98 Dr. Newman?Surgical Diseases of the Kidney

SURGICAL DISEASES OF THE KIDNEY: THEIR GENERAL SYMTOMATOLOGY AND PHYSICAL DIAGNOSIS?WITH ILLUSTRATIVE CASES.

By DAVID NEWMAN, M. D., Surgeon, Glasgow Royal Infirmary.

In this communication an endeavour will be made to study the special phenomena which form the symptoms of surgical diseases of the kidney, and various points will be illustrated by cases which have come under the observation of the writer. At the same time care will be taken to describe in detail and estimate the value of the physical signs which denote a departure from normal in size, form, consistence, situation, and sensitiveness of the kidney. The physical examination of the kidneys and ureters will be considered under the following heads :? I. Inspection. II. Palpation? 1. Abdominal. 2. Ballottement. 3. Rectal and vaginal. III. Rectal insufflation. IV. Percussion. V. Examination of the bladder with the cystoscope or the sound. VI. Collecting the urine separately from the two ureters. VII. Sounding the ureters. VIII. Roentgen ray photography. IX. Exploration by incision.

The symptomatology will be discussed under the following heads :? I. Symptoms referable to the kidney. 1. Increase in bulk of the kidney. 2. Increased sensitiveness on pressure in the renal region. 3. Spontaneous pain in the lumbar region. II. The presence of blood, pus, or other abnormal con- stituents in the urine. III. Anuria. IV. Evidence of vicarious action of other organs. their General Symptomatology and Physical Diagnosis. 99

Symptoms are the language of disease ; it is by reason of the subjective sensations of the patient, as described by him- self, that we are led to seek out the objective condition upon which the divergence from health is based. The diagnosis of the case is a complete understanding of the organic changes upon which the disturbance of function depends?it is not simply giving the disease a name. The different organs of the body, according to their situation and function, have different means of communicating to us the fact that they are disordered. This may be shown by suffering, by impairment of the function of the affected part, by alteration in its position or in its size, or by evidence of a portion of its task being taken up by other organs. Every organ, when diseased, has its own prodigy of morbid aspects and expressions. It is not desirable to enter into points of little significance, but rather to concentrate attention on the main and important facts, and endeavour to form a general conception of the characteristics of the diseases of the kidney in the treatment of which the surgeon's aid may be required.

Topographical anatomy and physical examination of the kidneys and ureters.?Physical examination of the contents of the thorax gives more exact results to percussion and auscultation than do the same methods applied to the abdomen ; but, on the other hand, the senses of sight and touch yield us more information to guide us towards the diagnosis of the disease in the abdominal organs. Un- doubtedly the artificial division of the abdomen into regions indicated by lines drawn on the surface of the body is very convenient for the description of the position and relation- ships of the viscera in the dead subject, but, in the living, the abdominal contents frequently fail to conform to the limits allotted to them by anatomists. The practical surgeon very soon recognises that the topography of the abdomen is uncertain, and the landmarks laid down are by no means accurate guides. In studying the morbid anatomy of the abdomen, not only is it necessary to map out the position of the kidneys in health, but it is requisite to bear in mind that many diseases of other organs may mimic, or may be simulated by morbid renal conditions; so closely allied, indeed, may be the symptoms and physical signs, that only by exploration can a definite diagnosis be made. Cases occasionally happen, even in the hands of the most accurate observers, where the peculiarity of the physical conditions and the obscurity of 100 Dr. Newman?Surgical Diseases of the Kidney: the symptoms have led to errors in diagnosis. Vidal cites cases where errors in diagnosis have been made by such distinguished masters in the art of surgery as Velpeau, Nelaton, and Gosselin, and when the renal enlargement is due to fluid accumulations, such as a hydronephrosis or a pyonephrosis, they have often been mistaken for ascites or for ovarian cysts, and have been operated upon as such by Meadows, Billroth, Goodell, Schelelig, Esmarch, Campbell, and " others. As Dickinson remarks, to suppose a solid renal tumour to be splenic, or a hollow one to be ovarian, are errors of no infrequent occurrence ; while a list of the enlargements, which have either been erroneously supposed to be renal, or for which renal swellings have been mistaken, would be little short of a complete catalogue of abdominal tumours." Viewed from the front, the kidneys occupy a position within the following limits:?Draw a perpendicular line from the ensiform cartilage to the symphysis pubis, and at right angles from it draw a horizontal line at the umbilicus. On the horizontal line, fix two points, one on the right side and the other on the left, 4 inches from the middle line, and from these points draw upwards two perpendiculars, 4 inches long, parallel to the middle line. Unite the upper extremities of these lines by a second horizontal line. Both kidneys will be included within the quadrangular space. On the posterior surface of the body the boundaries may be fixed as follows :?Draw a horizontal line at a level with the uppermost point of the spinous process of the eleventh dorsal vertebra, and a second line at the lowTer edge of the spinous process of the third lumbar vertebra. Let these lines extend 3? inches to right and left of the middle line, and join their extremities by two perpendicular lines. Both kidneys will be within the space so marked. While the measurements just given must be admitted to be only approximately correct, they are more reliable than the measurements taken from other anatomical landmarks. The kidneys being placed posterior to the peritoneum, when enlargement occurs the serous membrane is dissected, or pushed forwards from its posterior attachment, and the abdominal contents, being least resistent, are pressed for- wards, while the firm structures posterior to the kidney seldom yield so as to cause more than an indistinct fulness in the loin. Therefore, while the enlarged kidney is in close contact with the posterior abdominal wall, it is separated from the anterior by the contents of the peritoneal cavity. In health, the kidneys, except in lean subjects, cannot their General Symptomatology and Physical Diagnosis. 101 be easily limited by the ordinary methods of physical examination, but when the organs are increased in bulk by disease, or have departed from their normal position, inspec- tion, palpation, and percussion may give important clinical information, which may now be considered in detail.

I. Inspection.

Inspection should be made, not only while the patient is in the recumbent position, but also from the side and from the back, and in each position it is well to make the patient assume different attitudes, i.e., in the elbow-knee position, or with the knees flexed in the recumbent posture. By inspecting the abdominal wall in these different positions, we may mark irregularities on the surface and abnormal communication of the movements of respiration. These are specially noticeable when the kidneys are greatly enlarged or freely movable, as, for example, in cystic degeneration of the kidney, in hydronephrosis, or in movable kidney. The relationship of other organs to the kidney may also be ascertained.

II. Palpation.

1. Abdominal.?In diagnosing displacements and enlarge- ments, palpation is of great value. Except in thin persons, with lax abdominal walls, the normal kidney in its natural position can seldom be felt by bimanual palpation, and even under favourable circumstances all that can be made out with the hand is the lower border of the gland. In obese, muscular, or nervous patients, even an enlarged kidney may be difficult to examine without the aid of an anaesthetic. Palpation is most effectually carried out by placing the patient in the supine posture, with the knees drawn up and the chest slightly elevated, so as to relax the abdominal muscles. Occasionally it is necessary to palpate with the patient lying prone, turned on one side, sitting, or standing erect. It is always well to divert the patient's attention from the examination, and to make him breathe deeply and use the voice. By so doing, the muscles of the abdomen are rendered lax. The hands of the surgeon should be warm, and, to begin with, the examination should be made with the whole hand laid flat on the abdomen. With steady pressure gradually increasing in degree, but varying from time to time, not by a sudden push with the points of the fingers, one hand should 102 Dr. Newman?Surgical Diseases of the Kidney:

be pressed deeply into the interval between the crest of the ileum and the costal margins behind; while in front, the other hand is opposed to it, so as to grasp the parts, at first gently, afterwards firmly, between the two hands. By bimanual palpation, conducted in this way, the size, form, position, and consistence of the organ can be made out, or the presence of fluctuation ascertained. This examination should be made, first, with the patient lying on his back, afterwards lying upon his face, and if necessary in the elbow-knee position. If the kidney is easily felt by palpation, the conclusion may be come to that the organ is either enlarged or displaced. It is most easily felt during full inspiration. Generally, but not always, the presence or absence of fluctuation in the kidney can be ascertained, and on rare occasions friction of calculi may be detected. In cases of stone impacted in the ureter above the brim of the pelvis, much information may be gained by palpation through the abdominal parietes, provided the walls are flaccid and the patient thin. Not infrequently the ureters can be detected as hard rounded cords when they are thickened by disease. Examination should first be made without the use of an anaesthetic, in order to ascertain the degree of muscular resistance and the amount of tenderness or pain produced by pressure, and if there is much more muscular rigidity and pain over one kidney than over the other, the fact should be noted. Before examination, the bowel should be carefully cleared out by a laxative and by enemata, to remove fsecal accumulations in the ascending or descending colon, which may seriously interfere with the examination.

2. Ballottement.?At the Congres de Chirurgie Fran^aise, 1886, M. Guy on called attention to this sign as a valuable indication of tumours of the kidney, but equally applicable to all forms of enlargement. Ballottement is simply a refined method of palpation, and it must be admitted to be in some respects superior to bimanual palpation as generally carried out. The patient, lying upon his back, is instructed to relax the muscles of the abdomen and to breathe freely with the mouth open. The surgeon then places his hands as for making bimanual palpation, the fingers of the hand in the lumbar region are pressed gently forwards, and the patient asked to rest upon them without straining; the other hand is then used to press the anterior abdominal wall slightly backwards?enough to diminish the space separating it from the kidney, but not sufficient to allow the two to come in contact. The surgeon then gives a short, sudden jerk from their General Symptomatology and Physical Diagnosis. 103 behind, and as he does so the kidney, if increased in size or unduly mobile, is projected forward and lightly touches the anterior abdominal wall?a movement readily perceived by the hand in front. In this way the observer may, with a little practice, be enabled to appreciate not only an increase in the size of the kidney, but may also make out its form and consistence; and this may be done at a time when palpation, conducted in the ordinary way, may not show much change in the bulk or in the form of the gland. The jerks given with the hand from behind must be abrupt, their suddenness must be such as to take the muscles by sur- prise, and also, in order to communicate the ballottement to the anterior hand, the pressure in the lumbar region must be sustained until the kidney has touched the anterior abdominal wall. The phenomenon is most easily got in enlarged movable kidney; but the movement of itself is not evidence that the organ is unduly mobile, as it can be developed in many cases where the attachments are normal, the kidney being enlarged only.

3. Rectal palpation has been employed in the diagnosis of renal lesions and in ascertaining the condition of the ureters, It is most applicable to the left kidney. The patient must be an adult with an enlarged or displaced kidney, and to conduct the examination the aid of an anaesthetic is neces- sary. The hand, which must not be a large one, is slowly and gradually passed into the rectum while the other hand presses the abdominal wall in front. A bimanual examination is made, and, in some instances, very useful information may be obtained. Vaginal palpation may be employed in a similar way, and is especially useful in cases of stone impacted in the lower part of a ureter.

III. Rectal Insufflation

with air may not be resorted to in routine practice, but only in exceptional cases. It has been employed for the purpose of distinguishing an intra-abdominal swelling from an enlarged kidney. The patient is placed upon his back, and, the colon having been previously cleared, the dull area in the renal region is carefully mapped out and marked. A long tube is then introduced into the rectum, and through it air is passed until the whole colon is slowly but fully distended. 104 Du. Newman?Surgical Diseases of the Kidney.

The abdomen is then again percussed, and the change and resonance noted. If the swelling is intraperitoneal the if it is renal a dulness may be diminished only, whereas clear note can be got all over the front of the abdomen.

IV. Percussion.

While in most persons the healthy kidneys cannot easily be limited by percussion, at least with anything like accuracy, in lean patients a dulness corresponding with the inferior and outer border of the kidney can be mapped out, and found to extend lower during a full inspiration. The proximity of the kidneys to the liver or the spleen, their position in front of thick muscles, as well as their envelope of fat, all render percussion of the normal kidney difficult; but in the absence of one kidney, and in disease associated with enlargement, percussion is of value. In the former the atrophy of the organ, or its absence, will be indicated by a clearer note being obtained over the corresponding renal region behind. If one kidney has been removed by operation, a distinct difference may be observed in the resonance of the two sides, partly on account of compensatory hypertrophy of the remaining kidney. If the morbid process has caused enlargement or distention of the kidney, the normal resonant area of the loin will be en- croached on from behind. The patient should be examined recumbent, in the ventral position, or standing erect. The renal swelling can very often be accurately limited by percussion, but in some instances?for example, in cystic kidney?a resonant note may be obtained even where the enlarged kidney is felt the easily with hand; and while it is very easy to fix a clear limit by palpation, an area of diminished resonance may gradually pass to that of complete dulness. Again, a colon distended with gas may pass over the enlarged kidney from above on downwards, or, the other hand, percussion may fail to betray the presence of bowel in front of the swelling, on account of the intestinal gas having been expelled by pressure. {To be continued.)