Compliments of the Author

The Relations of Movable Kidneyand Appendicitis to Each Otherand to the Practice of ModernGynaecology

BYGEORGE M. EDEBOHLS, A.M., M.D.

Professor of Diseases of Women, New York Post-Graduate School; Gynaecolo-gist, St. Francis’ Hospital; Consulting GynseeologisGSt,. John's Hospital

Reprint from the Medical! Record, March //, rSqy

NEW YORK

THE PUBLISHERS’ PRINTING COMPANY32, 34 Lafayette Place

i899

THE RELATIONS OF MOVABLE KIDNEYAND APPENDICITIS TO EACH OTHERAND TO THE PRACTICE OF MODERNGYNECOLOGY.1

GEORGE M. EDEBOHLS, A.M., M.D.,PROFESSOR OF DISEASES OF WOMEN, NEW YORK POST-GRADUATE SCHOOL;

GYNECOLOGIST, ST. FRANCIS 1 HOSPITAL ; CONSULTING GYNECOLOGIST, ST.John’s hospital.

During the fourteen years in which the writer was en-gaged in the general practice of medicine he occupiedhimself, among other things, with the then universallycurrent, and almost as universally unsuccessful, at-tempts to cure the special ills of womankind. Hepainted the vaginal vault, the exterior and interior ofthe cervix with iodine and other drugs; occasionallyeven ventured to attack the mucous membrane of theuterine body with applications of more or less criti-cally and judiciously selected medicinal agents; dis-tended the vagina to a greater or less degree withmedicated tampons of cotton, sheep's wool, etc,; fittedand refitted pessaries for ante-, retro-, and latero-flexions and versions and prolapsus of the uterus;solemnly prescribed more or less endless vaginaldouching with water, plain or medicated, at exactlysuch and such a temperature, etc. The end of treat-ment was never in sight for the unfortunate womanwho once began it; the “local treatment” habit be-came chronic or recurrent with many. Leaving out ofcount those cases cured by the surgical removal of ab-dominal and pelvic tumors, but a comparatively few ofthe luckier women escaped the endless slavery of thegynaecological chair by successful plastic surgery of

1 Read before the Medical Society of the State of New York,February I, 1899.

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the cervix, vagina, and perineum, and that only whenplastic surgery constituted the correct and only indi-cation in their particular case.

For the gynaecological sins of commission and omis-sion of this portion of his professional career the writerhas ever felt the most profound contrition—a slightand altogether inadequate atonement, but still theonly one that the nature of the case admits of. Inextenuation of his offences he can plead only the thenprevalent ignorance and misconception of the scienceand art of gynascology under which he in commonwith so many others labored.

Early in my career as a specialist, having entirelyabandoned general practice and devoting my time andenergies exclusively to the study and practice ofgynaecology and abdominal surgery, I became con-vinced and predicted that the development of gynae-cology in the immediate future lay in the direction ofsurgery. How completely this prediction has beenverified is matter of medical history. With attentionto major pelvic surgery, repair of genital lesions, cu-rettage, permanent correction of uterine and ovarianmalpositions by operative measures, etc., meeting theindications in each case more and more clearly andfully by the light of increasing skill in diagnosis,greater perfection of operative technics and con-scientious study of results, a proportionately greaterdegree of therapeutic success was obtained as com-pared with the local-treatment efforts of general prac-tice. Still it must, in all truth and humility, be ad-mitted that less than one-half of the women whopresented themselves as patients for gynaecologicaltreatment, and were properly accepted as such, couldbe made perfectly well by attention, even of the mostskilful order, to their pelvic organs, and full and satis-factory surgical correction of all disorders and abnor-malities thereof. In other words, a great many of thesymptoms usually regarded as pertaining to, or ema-nating from, the genital sphere, of which these womencomplained, persisted even after the condition of thepelvic organs was found unexceptionable by the most

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critical expert. In still other words, the practice ofgynaecology as a specialty concerning itself exclusivelywith the pelvic organs, including as such the bladderand rectum, far from satisfying in its results toeither patient or physician. Very soon the importanceof the role played by a movablekidney in the perpetua-tion of symptoms usually ascribed to diseased condi-tions of the female pelvic organs began to dawn uponme. With the aid of nephropexy added to operativeprocedures more distinctly gynaecological in character,an increasing number of my patients were fullycured. A few years later still, after I had learnedhow to diagnosticate chronic appendicitis, the fre-quent association of that condition with symptom-pro-ducing movable right kidney, the apparent dependenceof the former upon the latter, and the important partplayed by the appendix in matters gynaecological,arrested my attention. With the added resource,when indicated, of appendectomy, I finally found my-self in a position fully and permanently to cure bysurgical measures almost every patient who came tome as a proper subject for gynaecological treatment,and who was willing to accept all the measures I con-sidered indicated to meet fully the requirements ofher case. Working along these lines and with theability acquired by increasing experience and observa-tion of results to establish clearly and from the begin-ning the indications presented in eacli case, moderngynaecology, so far as applied to the cure and relief ofexisting diseased conditions, has finally almost ap-proached the ideal of an exact science, and its practicehas become as completely satisfying as that of any otherbranch of the healing art.

The successful practice of modern gynaecology im-plies and presupposes a broad practical acquaintancewith all the ills human flesh is heir to in as great adegree, at least, as that demanded in the successfulpractice of any of the other so-called specialties. Aprevious training in general medicine and surgery isabsolutely essential to enable the gynaecologist to es-tablish clearly the sum total of the indications for

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treatment presented in each case, and to render him asafe guide and adviser of suffering womanhood.

To consider fully the relations of gynaecology togeneral medicine and surgery would be to write a text-book on the diseases of women. The object of thispaper is to call attention, and that in an outline waymerely, to the relations existing between the diseasesof women, in the limited sense, and the conditions ofmovable kidney and appendicitis, and incidentally tothe relations existing between the two last-namedaffections.

The Relations of a Movable Kidney and Appen-dicitis.—A consideration of the relations existing be-tween movable kidney and appendicitis will enable usto approach more intelligently and to grasp more fullythe relations existing between the two conditions namedand the diseases of the female pelvic organs. Thewriter has on two previous occasions called attentionto this subject, and to state the matter as succinctlyand briefly as possible will take the liberty of quotingthe summary of the latter of the two publications, re-ferring those w7 ho may wish to enter more fully intodetails and to judge of the validity of his conclusionsto the paper itself. The summary reads:

“ Chronic appendicitis, as proven by the writer’sclinical and operative work, is present in from eightyto ninety per cent, of women with symptom-producingmovable right kidney. This frequency constituteschronic appendicitis one of the chief, if not the chief,symptom of movable kidney.

“ Chronic appendicitis, by reason of its frequency,the protracted suffering and serious impairment ofhealth which it entails, and the dangerous possibilitiesof implanted acute attacks of appendicitis, may be con-sidered the most important complication of movableright kidney.

“ The writer’s statistics show: that twenty per cent,of all women have movable kidney or kidneys; thatfour per cent, of all women have symptom-producingmovable kidney or kidneys; that four per cent, of allwomen have appendicitis; that, while three and one-

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half per cent, of all women have both symptom-pro-ducing movable kidney and appendicitis, only one-halfper cent, of all women have appendicitis and well-anchored kidneys. The startling nature and impor-tance of the conclusions to be drawn from these statis-tics does not invalidate the latter.“Satisfactory investigation of the relations of mov-

able kidney and appendicitis became possible onlyafter the discovery and elaboration of the writer’smethod of palpation of the vermiform appendix. Itremains impossible to those not practically familiarwith the method.

“ Chronic appendicitis may be the only symptom ofmovable right kidney.

“Some of the symptoms commonly ascribed to mov-able kidney are often in reality due to the concomitantappendicitis.“The relations existing between movable right kid-

ney and chronic appendicitis are those of cause andeffect, for reasons detailed in the paper. A movableleft kidney never produces appendicitis.

“Movable right kidney probably produces chronicappendicitis by indirect pressure upon the superiormesenteric vein, the return circulation of the appendixbeing hampered by compression of the vein betweenthe head of the pancreas and the spinal column.

“Chronic appendicitis associated with movable kid-ney shows no tendency to resolution or spontaneouscure, with restoration of a normal appendix, while theright kidney remains movable. The only cure possi-ble, under these conditions, is by slow progress to ap-pendicitis obliterans.

“ In twelve of the writer’s cases of coexisting mov-able right kidney and appendicitis, the appendicitisapparently ended in resolution and remained perma-nently cured, after right or bilateral nephropexy, with-out any attention to the appendix.

“ Recovery from appendicitis after right nephropexymay only be expected in cases in which the associ-ated chronic appendicitis is of comparatively recentorigin.

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“In a minority of cases only of associated movableright kidney and chronic appendicitis will eithernephropexy alone, or appendectomy alone, meet allthe indications. The majority of patients requireboth operations to restore them to full health.

“ Both operations, right nephropexy and appendec-tomy, may be simultaneously performed through oneand the same lumbar incision extending along theouter margin of the erector spinae muscle from thetwelfth rib to the crest of the ilium.”

The Relations of Movable Kidney to Diseases ofthe Female Pelvic Organs. —Nearly every writerupon the subject of movable kidney has dwelt uponthe evident and unmistakable frequency of the associ-ation or coexistence of movable kidney with nearlyevery form of disease of the female pelvic viscera, re-troversion and its accompanying endometritis beingespecially well represented. Exacerbation of thesymptoms due to movable kidney at the menstrualepoch is also frequently noted, although the explana-tion of renal congestion with each menstruation ad-vanced by a number of writers is doubted by manyothers, among them the writer, who believes that thenervous manifestations of movable kidney, in commonwith all other nervous phenomena, are more apt to beaccentuated at the menstrual period. Equally far-fetched is the explanation of Landau, that malposi-tions of the uterus, notably retroversion and prolapsus,dislocate the kidney downward by traction upon theureter.

When we call to mind the essential pathologicalcondition underlying the development of movablekidney, its relations to posterior and downward dis-placements of the uterus do not appear difficult to un-derstand. The one thing settled about the etiologyof movable kidney is that it is due to a relaxation andstretching of the lamina fibrosa of the renal adiposecapsule, the tissue upon the integrity of which de-pends the retention of the kidney in its proper place.The same diseased action resulting in elongation andstretching of the essential supports of the other ab-

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dominal and pelvic viscera leads to enteroptosis, par-tial or general. When in the progress of the diseasethe supports of the uterus are attacked, and the round,broad, and other ligaments of the uterus lose theirtonicity and lengthen, the uterus becomes retrovertedand prolapsed. Glenard has pointedly and with allthe emphasis at his command called attention to thefact that mobility of the right kidney is the first stepin the delevopment of enteroptosis; that there is noenteroptosis without movable kidney, although theremay be, and frequently is, movable kidney withoutenteroptosis. Often and often has the writer wit-nessed and followed the successive development, inthe same woman, of mobility of the right kidney, mo-bility of the left kidney, and retroversion of the uterus,the first named of these three conditions almost inva-riably developing first, while either of the latter twosometimes preceded and sometimes followed theother.

While the connection between movable kidney andmalpositions of the uterus is, therefore, perfectlyclear, the association of movable kidney with otherdiseases of the female pelvic organs is probably sim-ply accidental, the frequency of the coincidence beingreadily explicable by the frequency both of movablekidney and of pelvic disease.

So much for the etiologic relations existing betweenmovable kidney and the diseases of woman’s specialorgans. From a practical point of view these rela-tions are of important and far-reaching significance.They explain, as already stated, why the most perfectsuccess in removing diseased states of the female pel-vic organs, and restoring these to practically normalconditions, so often fails of therapeutic relief, /ails tomake our patients fully well. An unsuspected, unde-tected, or disregarded movable kidney causing symp-toms will very frequently explain the discrepancybetween the opinion of the surgeon, after successfulpelvic surgery, that nothing further ails his patient,and the assertions of the patient herself that she feelsno better than before operation. It will explain, to

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cite only one instance, why a successful treatment ofretroversion of the uterus, or the repair of a laceratedcervix or perineum, may relieve the patient of a smallpart only, or even of none, of her multitudinous com-plaints. Of four women each having a movable kid-ney and movable retroversion, the symptoms in onemay be due exclusively to mobility of the kidney, inthe second exclusively to retroversion, in the third toboth movable kidney and retroversion, while thefourth woman may not suffer in any way from eithercondition. If you perform a retroversion operationin the first, or anchor a movable kidney in the second,you will have helped neither of them. If you do eitherof these operations alone upon the third, the result willbe at best but partial relief, while if you perform eitheror both of them upon the fourth, you will have beenguilty of an entirely unnecessary and uncalled-forprocedure.

Further practical applications of the facts adducedand to be adduced, on which the making or losing ofprofessional reputation largely hinges, lie in the di-rection of diagnosis, the proper establishment of in-dications for treatment, and prognosis. Given a pa-tient with movable kidney or kidneys, various disor-ders of the pelvic viscera, and perhaps chronicappendicitis, it goes without saying that it is first ofall of vital importance to be able to diagnosticateeach and every one of these conditions. Next, as tothe proper establishment of rational indications fortreatment, it is essential that we learn how to analyzethe patient’s symptoms, so as to be able correctly torefer each of these symptoms to the special pathologiccondition causing it. Then first will we be in a posi-tion to apply intelligently the proper remedy—not toanchor, for instance, a movable kidney when that con-dition is producing no symptoms, but the sufferings ofthe patient are due to chronic appendicitis, diseases ofthe pelvic viscera, etc., or vice versa. Often, indeed,will it be necessary to correct all the pathologic con-ditions named before full therapeutic success is ob-tained and the patient is made entirely well.

9This analysis of the symptoms presented by a given

patient, with their correct reference to the specific ab-normality causing each of them, is not quite so easyand simple a matter as the discovery or diagnosis ofthe various existing pathologic conditions themselves.It requires training, close observation, correct induc-tion, experience, and a judicial cast of mind joined tohabitual, painstaking, full and complete routine ex-amination of every patient presenting, to reach itshighest development and greatest capabilities. Onceacquired, however, this faculty of correct analysis ofsymptoms becomes the richest possession and greatestpower for good of the gynaecologist, or, for that matter,of the general practitioner. With it, diagnosis in itsfullest sense and prognosis approach the dignity ofexact sciences. Its possession and correct applicationwill enable the surgeon to determine at the start if thecase is one requiring several operations to be per-formed at different sittings, will restrain him frompromising a complete cure after performance of a partonly of the surgical work required, and will preventhis losing the confidence of his patient after the firstoperation or series of operations, as the case may be.On the contrary, possessing a full and intelligentgrasp of the patient’s entire condition and all the thera-peutic requirements called for in her case, he willinform her that such and such of the symptoms shepresents are due to such and such of her pathologicconditions, and such and such other symptoms to suchand such other abnormalities; that after the operationsimmediately contemplated she may expect to be rid ofcertain specified complaints, but that the rest of hersymptoms will disappear only after all the remainingabnormalities producing symptoms in her case havebeen finally corrected. The confidence of the patientis thus retained when she finds her attendant’s predic-tions come true after her first operation or operations,and she unhesitatingly follows his further lead towardperfect health.

To be specific, I may state that in my own practiceI have never required more than two sittings to cor-

rect by operation all the pathologic abnormalities pres-ent at my first examination in the abdomen and pelvisof any one woman. An extreme case, though by nomeans a very infrequent one, is the following takenat random from among a number of similar ones onmy records: A married woman, aged thirty-one years,had a large, heavy uterus, retroverted, tied down byadhesions; there were multiple lacerations of the cer-vix; an extensive cicatrix following a childbirth tearof the left vaginal vault and left parametrium; chronicappendicitis, and movable right and left kidneys—eachof the pathologic conditions named being responsiblefor one or another or several of the numerous symp-toms complained of, and each requiring correction be-fore a complete therapeutic success could be hoped for.She was informed of her condition, and that a numberof operations to be performed at two sittings would berequired for her relief. On February 16, 1898, at thepatient’s home, I performed curettage of the uterus, am-putation of the cervix, and vaginoplasty for the removalof the vaginal and parametric scar; then, through afive-centimetre incision through the right rectus ab-dominis muscle, I performed inversion of the appen-dix and liberation of the uterus by breaking up theadhesions binding it down posteriorly, concludingwith inguinal shortening of the round ligaments. Atthe second sitting, exactly four weeks later, bilateralnephropexy was performed. Smooth convalescencefrom both series of operations, primary union of allwounds, and a patient perfectly cured and remainingcured of all her many previous complaints, resulted.Again, in another somewhat similar case, bilateralnephropexy for movable right and left kidneys, andinversion of the appendix for chronic appendicitisthrough the lumbar right nephropexy incision, wereperformed at the first, and the pelvic surgery requiredin the case, curettage of the uterus, amputation of thecervix, and shortening of round ligaments at the sec-ond sitting.

When such a large number of operations demand-ing two sittings are required in a given case, it fre-

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quently becomes a nice matter to determine whichseries of operations is the more important and urgent,and should be first undertaken. Experience and thedemands of surgical technics will prove the bestguides in determining the proper course. One rule,however, should probably hold almost inflexibly good:When the appendix is involved and its removal be-comes necessary, appendectomy should be included inthe first series of operations. The risks of delay inappendicitis should not be assumed without grave andcogent reasons.

A practical point relating to prognosis, which it iswell to bear in mind, is that large abdominal tumorsand the pregnant uterus in the later months form thebest possible contrivances or splints to support in itsproper place a movable kidney, and while doing so tokeep in abeyance all the symptoms of the latter con-dition, Consequently, we must be prepared for therecurrence or even the new development of symptomsof movable kidney after the termination of pregnancyor theremoval of large ovarian and uterine tumors, anexperience which the writer has encountered on nu-merous occasions.

The Relations of Appendicitis and Disease of theFemale Pelvic Organs.—This part of my subject hascome to be more generally and better understood andacted upon by gynaecological surgeons as a wholethan the two subdivisions already discussed. I canlimit myself, therefore, to an attempt at indicatingmerely a few of the practical aspects of the relationsexisting between appendicitis, acute and chronic, andthe various disorders of the female pelvic organs. Toconsider them in exte7iso would far exceed the limitsof an ordinary paper.

In the first place no examination of the pelvic vis-cera should be regarded as complete that does not takenote of the appendix and determine whether that organis in normal condition or inflamed. This can be read-ily established in practically every woman, the verystoutest and those having abdominal tumors only ex-cepted, by properly executed palpation of the appen-

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dix. It is unnecessary to say another word upon theimportance of the knowledge thus obtained.

Appendicitis and inflammatory diseases of the ute-rine adnexa and of the pelvic peritoneum are veryfrequently found associated. The inflammation maybe primary in either the appendix, the adnexa, or thepelvic peritoneum, and one or both of the other twoof the three tissues mentioned may become secondarilyinvolved. Generally it is not difficult to determinefrom the history of the case, as well as from the find-ings at coeliotomy, the order of involvement of thevarious organs. Practically the condition of the ap-pendix should always be investigated by inspectionon the occasion of coeliotomy for diseased adnexa orpelvic inflammation. Should any doubt be enter-tained in regard to the perfect health of the appendix,the latter must invariably be removed. The writer,in his own practice, has carried this rule still furtherand inverts the normal appendix on the occasion ofcoeliotomy undertaken on any indication, providedalways that such inversion does not call for enlarge-ment of the incision required to do the other work inhand, and that the patient’s condition is not so criti-cal that her safety is jeopardized by the additionaltwo or three minutes required for inversion. Inver-sion of the entire, unopened, normal appendix can beperformed in two or three minutes; is in itself, if prop-erly performed, entirely devoid of risk; does not addto the dangers of whatever other operation may havebeen undertaken, and absolutely insures the patient’sfuture against a possible appendicitis. The premiumpaid for such insurance, two to three minutes’ prolon-gation of anaesthesia, is insignificant when comparedwith the amount of future suffering from a possiblechronic appendicitis, or the risk of a possible acuteappendicitis, which it covers. As already stated, fourper cent, of all women whom I have examined duringthe past six years had appendicitis. To be absolutelycertain of not being one of the four per hundred isworth something to any woman. As a matter of factI know of at least five of my patients who at periods

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more or less remote following a coeliotoray performedby myself, and at which coeliotomy the appendix wasfound normal, acquired appendicitis, acute or chronic.This experience has led me to live up to the followingrule: The abdomen should never be opened anywherewithin a finger’s length of the appendix without inves-tigation of the condition of the latter. If the appen-dix is found diseased, it should be removed, even if itis necessary to enlarge the incision for this purpose.If found normal it should be inverted entire and un-cut, if this can be done without enlarging the incisionor imperilling the patient’s chances of recovery fromthe operation or operations in hand.

The diagnosis between appendicitis and diseases ofthe right uterine adnexa, particularly their variousinflammations and new growths, forms an interestingtopic, which, however, time will not permit me to gointo at length. The general rule for guidance, which,however, frequently fails, is that adnexal diseases aremore pelvic, appendicular inflammations more ab-dominal, in location. The history of the case formsan important element in diagnosis, but is likewisesusceptible of misinterpretation. An inflamed andeven gangrenous appendix may have taken up itsabode in the depths of Douglas’ sac, or other parts ofthe pelvis, as well as in unusual places in the abdo-men. In one case of abscess situated in Douglas’ sacthe writer was able to diagnosticate the tumor as prob-ably appendicular in origin, from the fact that carefulpalpation proved the appendix to be absent from itsnormal site. Operation verified the correctness of thediagnosis. In other doubtful cases the writer hasbeen able repeatedly to exclude appendicitis by pal-pating a normal appendix occupying its normal situ-ation above the suspected tumor mass.

The frequent involvement of the appendix in vari-ous pathologic conditions affecting the female pelvicorgans should always be taken into account in arriv-ing at a decision as to whether a given case of diseaseof the pelvic organs requiring operation is to be ap-proached by the vaginal or by the suprapubic route.

Palpation of the appendix should always be practisedbefore operation in each such case. If the appendixis found normal, the vaginal route may be selected.If the appendix, on the contrary, is found inflamed oreven not entirely above suspicion, suprapubic abdomi-nal section is indicated, as enabling one to deal withthe appendix as well as to perform the other work re-quired. This point is so evident that to dwell uponit longer would be waste of time.

Appendicitis complicating pregnancy and labor isa subject that has lately come in for a fair share ofdeserved attention, which, I might add, it shouldhave received long ago. I merely mention it, as itdoes not come, strictly speaking, within the limita-tions of my theme.

The relations of movable kidney, appendicitis, andthe diseases of the female pelvic organs are of interestand importance alike to the general practitioner, thesurgeon, and the gynaecologist. Among the womenconsulting the latter a large number present two, orfrequently even all three, of the conditions named,though suffering only from the symptoms caused by oneor more of them, and healthy in all other respects. Thislarge class of women can be relieved of their multi-tudinous complaints and be made perfectly well andhappy by the physician who possesses both the powercorrectly to analyze their symptoms and the surgicalskill necessary to perform properly the operations in-dicated. Nothing short of malignant disease shouldbaffle him in this class of cases. He must not, ofcourse, perform nephropexy when the movable kidneyor kidneys produce no symptoms, as is the case inabout eighty per cent, of all women having movablekidneys, nor should he operate upon the pelvic organswithout making certain that they are the cause of thewoman’s complaints. The appendix, if diseased, hewill never go amiss in removing.

A certain number of these patients will need ne-phropexy, appendectomy, and surgical correction ofabnormalities in the genital sphere to restore them tocomplete health. With a large experience based upon

constant study of these cases for a number of yearspast and critical observation of results, I have nohesitation in saying that the indications in each casecan always be fully and clearly established. Basingmy actions upon this fact, I now decline to accept fortreatment any patient, unless with the proviso and ex-press understanding that she will have all the opera-tions indicated in her case. I act thus both in theinterests of the patient herself and for the protectionof my professional reputation, which is not enhancedby the fact of a patient upon whom I have operatedstill going about in quest of complete relief and cure.

The writer has seen quite a number of cases in whichall the symptoms the patient ever complained of, allof which had been referred to disease of the pelvicorgans, persisted, with now and then a new one added,after complete removal of uterus, tubes, and ovaries.The patient’s complaints after operation were some-times referred by the operator to sudden establishmentof the menopause, sometimes to the fact that both ova-ries had been entirely removed, and again to the cir-cumstance that a remnant of ovary had been allowedto remain. Several of these cases were restored tocomplete health by subsequent nephropexy, by re-moval of a diseased appendix, or by both operationswhen indicated. It is superfluous to add that thegenital organs had been needlessly sacrificed.

A list of the author’s previous publications upon thetopics above treated of is appended. It will serve toillustrate the evolution, in his practice, of the princi-ples enunciated and the gradual steps by which hispresent position was reached.

1. “Movable Kidney; with a Report of CasesTreated by Nephrorrhaphy.” American Journal oj theMedical Sciences , March and April, 1893.

2. “Diagnostic Palpation of the Vermiform Appen-dix.” American Journal oj the Medical Sciences, 1894,n. s,, cvii., 487.

3. “A Clinical Lecture on Palpation of the Vermi-form Appendix.” Post-Graduate, 1894, ix., 154.

4. “Notes on Movable Kidney and Nephrorrhaphy.

Part 111. The Relations of Movable Kidney andAppendicitis.” American Journalof Obstetrics, 1895,xxxi., 161.

5. “Inversion of the Vermiform Appendix.”American Journal oj the Medical Sciences, 1895, n. s.,cix,, 650.

6. “ Wanderniere und Appendicitis; deren haufigeCoexistenz und deren simultane Operation mittelsLumbalschnitt.” Centralblatt Jiir Gyndkologie, 1898,xxii., 1084.

7, “ Chronic Appendicitis the Chief Symptom andMost Important Complication of Movable Right Kid-ney.” Post-Graduate, 1899, xiv., 85.

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