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Surgical Diseases of the Kidney

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Surgical Diseases of the Kidney 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.
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