everything must depend on the amount of renal atrophy. A single kidney
may undoubtedly be completely atrophied by this as by any other lesion
without producing serious symptoms, since, as has been repeatedly
demonstrated, the other is sufficient to carry on the work under
ordinary circumstances; but if, as very frequently happens, both
kidneys are involved, there must come a time when the renal substance
no longer suffices, and the usual results of suppression of urine
follow. It is possible, however, for extensive changes to take place in
both kidneys before symptoms of insufficient secretion arise.
Hydro-nephrosis, in the entire absence of inflammatory symptoms and in
the presence of conditions likely to cause it known to exist in the
lower urinary passages, may be rather suspected than diagnosticated
until the appearance of a tumor. Some dull pain in the loins without
irradiations in any direction may exist, but so common a symptom can
have but little weight in diagnosis. For an early recognition of
swelling in suspected cases where nothing can be felt anteriorly, it
has been recommended that the patient be placed upon the hands and
knees, when the flank upon the affected side, instead of falling
slightly forward and leaving a shallow depression outside of the
erector spinæ, will remain full or protuberant. When an enlargement
evidently connected with the kidney makes its appearance after
obstruction to the passage of urine is known to exist, the diagnosis
may often be very simple; but if the tumor be the first phenomenon
observed, as may easily happen when the obstruction is situated high up
or even at the commencement of the ureter, it may require to be
distinguished from several other kinds of tumor occupying the lumbar
region, or, since hydro-nephrosis of a movable or misplaced kidney
sometimes takes place, from tumors of the abdomen in general. From
solid malignant tumors of the kidney the feeling of comparative
elasticity and fluctuation will in most cases distinguish it, though an
encephaloid kidney may be so soft as to render the second of these
points of {59} comparatively little value. Absence of hæmaturia and of
the cancerous cachexia, though not conclusive, would have much weight.
A hydatid cyst might counterfeit a hydro-nephrosis, but instances of
this affection having its primary seat in the kidney are of extreme
rarity. An ordinary cystic kidney is most likely to be connected with
chronic diffuse interstitial nephritis, which will have made itself
manifest by the usual symptoms, and is moreover unlikely to attain the
dimensions of a large or even moderate hydro-nephrosis. In a thin
person the ureter might, if felt dilated through the abdominal walls,
clear up the diagnosis. Extreme cases of cystic kidney with
comparatively little nephritis may, however, present great similarity
and cause difficulty in diagnosis.
From most other tumors of the abdominal cavity those of the kidney
present the important distinction that they are situated behind the
peritoneum, and consequently behind the intestines, so that the surface
of a renal tumor is likely to be crossed by a more or less extensive
area of percussion resonance, representing usually the large intestine.
This criterion is, however, not absolute, since a renal tumor may push
the colon completely to one side, or, on the other hand, tumors not
connected with the kidney may allow the intestine to come between
themselves and the abdominal wall.
An ovarian cyst is more manifestly attached to the pelvis, and its
history will disclose the fact of its having arisen from below. A
gravid uterus should also, when small, be manifestly connected with the
pelvis, and when larger be accompanied by the usual symptoms of
pregnancy. The same may be said of extra-uterine pregnancy, which may
be mentioned as among the conditions possibly giving rise to
difficulties in diagnosis.
The most efficient aid to diagnosis, when it is of importance that such
should be accurately made, is the aspirator-needle, which will procure
a fluid more or less characteristic of the tumor into which it is
thrust. In hydro-nephrosis the contents are a somewhat dilute urine,
with perhaps mucus; in a solid tumor, blood, with pieces of tissue
recognizable by the microscope; in a cystic tumor, fluid which is
perhaps somewhat urinous, but much more changed than in simple
hydro-nephrosis, and perhaps containing solid-looking bodies with
concentric and radiating striation; in hydatid cysts, hooks and
fragments of scolices; in ovarian cysts, the various contents, fluid
and semi-fluid, but not urinous, generally found therein.
With all these means, however, cases will occasionally arise in which
expert diagnosticians may be lead astray, and the difficulties become
considerably greater when the dilated pelvis is that of a displaced or
unusually-placed kidney. Such cases have been subjected to operation
under the impression that an ovarian cyst was present.
The medical TREATMENT of hydro-nephrosis is nil. In many cases nothing
is demanded by the immediate necessities of the case, and atrophy, if
it be probable that only one kidney is involved, may be allowed to take
place without interference. It is possible that in some instances
manipulation of the tumor might relieve the obstruction and allow the
tumor to subside when a slight twist or angle in the ureter is the
cause. The fact of an occasional spontaneous subsidence of such a tumor
shows that something of this kind has taken place.
{60} The surgical treatment of affections of the lower urinary
passages, as both a prophylactic and therapeutic measure, has already
been spoken of under the head of Pyelitis. It would, however, be only
in a minority of cases of pure hydro-nephrosis that the seat of
obstruction could be efficiently reached by surgery.
Puncture and aspiration of the sac may very properly be resorted to,
and may prove of value--in the first place, as a more or less temporary
relief; and secondly, as a means of re-establishing the flow through
the natural passages by the relief of pressure and consequent opening
of the valvular fold, which has occasionally been observed at the
junction of the ureter with the pelvis.
In a case where the obstruction is known to be irremediable, and where
the hydro-nephrosis, if existing only on one side, is likely to
increase, it is not desirable to make the puncture too early or to
repeat it too frequently, since by allowing the pressure to increase
the atrophy of the kidney will be more rapidly accomplished, and the
need of frequently emptying the sac will not arise so often in the
future. On the other hand, if there is a prospect of a restoration, if
both kidneys are affected, or if the kidney not involved in the
hydro-nephrosis is known to be seriously impaired in function, and it
is desirable to preserve the secreting structure as long as possible,
the punctures should be so arranged as to keep the pressure at its
minimum. This must, however, be regarded as a temporary expedient. The
puncture may be made either from the back or front, though in most
cases the latter position, if the puncture be made with a small clean
needle, would be the more convenient, and equally safe notwithstanding
its traversing the peritoneum.
A hydro-nephrosis may be treated either by removal or by drainage. Both
of these methods have been resorted to, and are to be employed
according to the circumstances of the individual case. A pyo-nephrosis
naturally demands interference more peremptorily and more promptly than
a simple hydro-nephrosis, because it exposes the patient to the dangers
not only of its pressure and of its tendency to destruction of the
renal substance, but to those more urgent ones of purulent infection or
of perforation and perinephritic abscess. Removal is to be undertaken
by the ordinary rules of laparotomy. Drainage has been arranged in
cases where removal was impossible or unadvisable by stitching the
edges of an opened sac to the external wound. It is possible that the
choice between the two operations can be made only after the primary
incisions and explorations have advanced sufficiently to enable the
extent of adhesions and the amount of healthy renal substance to be
approximately determined.
Staples of Dubuque states, on the basis of 71 cases collected by him,
that "63 per cent. of patients operated on are cured by lumbar
nephrectomy, 68 per cent. by open methods in general, and up to date
100 per cent. by either lumbar incision and drainage or the creation of
a fistula."
Malignant Growths.
As pathological rarities only, and having but little clinical interest,
may be mentioned, as occurring in the kidneys, fibroma, lipoma, {61}
myxoma, anginoma, and adenoma. Malignant growths originating in or
involving the kidneys, sarcoma or carcinoma, are, however, more
frequent and more important.
Sarcoma, primitive or secondary, of the kidney is a somewhat rare
occurrence, but most frequent in children. The whole kidney may be
transformed into a mass occupying its place and somewhat resembling it
in form, but many times exceeding it in bulk and weight. Such a tumor
may largely distend the abdominal cavity and compress its contents.
Upon section we often find a substance varying greatly in consistence,
from almost fibrous hardness to cavities filled with grumous material
broken down by fatty degeneration and often colored by hemorrhage. In
the interior may be found remains of the pyramids and cortical
substance occupying their usual relative positions, but as it were
distended, these portions being surrounded by a much thicker layer of
purely abnormal neoplasm, probably connected with the capsule and its
surrounding fat. In other cases all traces of normal form and structure
may have disappeared. The microscopic structure of such a growth
presents no peculiarity except so far as the arrangement of cells in
the normal gland may be followed to a certain extent in the
less-altered portions of the tumor. Besides this total destruction of
the kidney, it is not uncommon to find nodules involving a part of one
or both the organs, and more or less distinctly marked off from the
healthy portion.
The origin of sarcomata involving the kidneys may be the subperitoneal
cellular tissue or the neighboring organs. As a primary disease sarcoma
of the kidneys is very rare.
True cancer or carcinoma of the kidney is not a common disease, and is
said to have been found 12 times in 447 cases of cancer of various
organs. It may be primary or secondary, and a description of the gross
appearances would be essentially the same as that of the sarcoma. The
tumor does not, however, usually attain so large a size, and the amount
of degeneration of neighboring organs and of ulceration is greater.
Calculi are often found in cancerous kidneys.
The SYMPTOMS produced by either sarcoma or carcinoma may be none at all
for a time. Dull pains in the loins or referred to the
hypochondrium--which, however, from their indefiniteness can have but
little diagnostic importance--are among the early phenomena. Pains like
nephritic colic may appear. The urine usually shows little of
importance. There may be sympathetic disturbance of micturition, but
unless hemorrhage occurs there is not likely to be anything in the
urine discoverable by the microscope to fix the nature of the trouble.
Fragments of cancer-structure in the very rare cases in which they are
said to have been found would of course be conclusive, but evidence
based on the alleged discovery of cancer-cells in the urine must be
received with the utmost caution, recollecting the great variety of
shapes and sizes assumed by the epithelium of the urinary passages.
Hæmaturia is a symptom occurring in only a portion of the cases, its
appearance in a given case evidently depending on the way in which the
tumor invades the kidney and increases in size. If growing in such a
way as to compress the ureter at an early stage before any erosion of
the mucous membrane has taken place, blood, even if set free in the
pelvis, cannot reach the bladder. If hæmaturia is present before any
tumor can be felt, it has {62} only a subordinate value, but if
occurring after the discovery of such a tumor, the combination is of
the highest significance. At a later period all the symptoms of
compression of other abdominal viscera arise--anorexia, vomiting,
jaundice, oedema, ascites, emaciation, and death.
When a tumor has become evident, it is to be diagnosticated from cystic
disease and from hydro-nephrosis, with which it agrees in position and
possibly in form. From the former of these its hardness and rapid
growth, the invasion of other organs, and the cachexia will serve to
distinguish it. Hæmaturia is not present in cystic disease. From
hydro-nephrosis or pyo-nephrosis the diagnosis has already been stated.
On the right side it might not in every case be easy to distinguish a
morbid growth of the kidney from one affecting the liver, and a similar
difficulty might arise on the other side with the spleen. The diagnosis
is to be made by a careful location of the tumor by palpation and
percussion and the absence of symptoms likely to occur in connection
with affections of the organs named. In children psoas abscess and
degeneration of the lumbar lymphatic glands should also be considered.
A sarcoma of the kidney has been mistaken and punctured for an empyema.
A sarcoma behind the kidney, pushing it forward, is very difficult to
distinguish from a similar growth affecting the organ itself,
especially as it is likely to give rise to signs of renal irritation
discoverable by the microscope. A slight pyelitis, distinguished by pus
and the absence of any cellular elements to indicate an origin at a
lower point, has been observed in such a case.
The results of exploratory puncture have been before alluded to. If a
piece can be brought away large enough to be examined microscopically,
it may settle the diagnosis, not only as to a malignant growth, but
also as to its kind.
The distinction between carcinoma and sarcoma cannot always be made
during life, nor indeed, without a microscopical examination, after
death. It is of importance chiefly with reference to prognosis after
operation for removal of the organ. A more rapid growth, a greater
tendency to invade other organs, and a more marked cachexia would speak
in favor of carcinoma, while a tumor gradually attaining a very large
size, and not spreading beyond the kidney and its immediate envelopes,
is more likely to be a sarcoma.
There is no TREATMENT known to be of value in cancer or sarcoma of the
kidney, except so far as it may diminish pain or regulate the
secretions. Surgically, removal of the diseased organ is the only
expedient to be thought of. Although nephrectomy has been shown to be a
perfectly practicable operation, and one that is usually well borne
when the other kidney is sound, it has not proved very successful with
malignant growths, even as a temporary expedient. This is partly at
least to be accounted for by the difficulties lying in the way of
diagnosis in the earlier stages, and the reluctance with which so
serious an operation would naturally be resorted to until hopes based
either on the uncertainties of diagnosis or mistaken reliance on
medical treatment have been given up. Cases, however, have been
reported where patients have recovered from the operation, and the
disease has not returned for some months. When an operation has been
resorted to, the tumor has usually become too large to be extracted
through the loin, and laparotomy has been the course {63} pursued.
According to Billroth,[22] out of 33 operations for tumors of the
kidney, 13 have been cured.
[Footnote 22: _Mittheil. der Aerzte in Nieder Oesterreich_, Bd. x. p.
161 _et seq._]
Cysts.
Three kinds of cysts are met with in the kidney besides those connected
with the growth of parasites.
Kidneys congenitally affected with cystic degeneration contain a large
number of sacs lined with a vascular membrane, among the partitions of
which are found the remains of secreting structure. Both kidneys are
equally affected, and are enlarged and more or less lobulated. They are
occasionally so large as to constitute an obstacle to labor, and
various operative procedures, even evisceration, have been required to
accomplish the delivery of the foetus affected. The cysts are filled
with fluid of various degrees of darkness of color from almost perfect
limpidity to almost black. The fluid in the smaller cysts, at least,
contains some of the urinary solids. The slighter degrees of this
affection do not render a child necessarily non-viable, but with the
larger some accident is likely to happen.
The formation of these cysts has been referred to an intra-uterine
chronic nephritis, but another theory accounts for them by a vice of
development. The fact that when the lesion is unilateral, as sometimes
happens, there is apt to be a deficiency of some other part of the
genito-urinary apparatus on the same side, and that several infants
with cystic degeneration have been born of the same mother, speaks
strongly in favor of the latter theory.
Serous cysts of later origin do not usually attain so large a size, or
rather the kidney does not, on account of their smaller number. They
are lined with a thinner membrane, and their contents are nearly clear,
but coagulable, comprising uric acid, carbonate of lime, and
cholesterin. Occasionally a single cyst attains considerable dimensions
and produces by its pressure atrophy of part of the kidney. These cysts
are supposed to arise in consequence of the blocking of a tube.
The third class of cysts closely resemble the first in appearance and
in form, and contain more or less serous or gelatinous fluid, with
albumen, blood-corpuscles, and pus, as well as the peculiar colloid
bodies previously mentioned. They undoubtedly arise from the distension
of tubes and of Malpighian bodies. These cysts are usually associated
with chronic interstitial nephritis, and in fact they are rarely absent
in cases of this kind, although the extreme degree--that is, where the
cysts assume the most prominent position while the contracting
nephritis falls into the background--are less common. In these latter
cases the organ may be almost transformed into a mass of rounded bodies
somewhat resembling a bunch of grapes.
The SYMPTOMS of the first two of these conditions--that is, of the
cysts which are not connected with an active nephritis and attract
attention simply as tumors--depend on the pressure they exert; and a
diagnosis is to be made by a knowledge of their history and by the
rules already given. The symptoms and diagnosis of the third variety
are involved in those of chronic interstitial nephritis.
{64} There is no reason to suppose that any drug has any therapeutic
action on such kidneys, so far as the cysts are concerned. It should
always be remembered that a kidney may contain a large number of cysts,
and yet scattered portions of secreting substance enough be left to
carry on the function indefinitely.
It might under some circumstances be justifiable to remove a cystic
kidney on account of the pressure exercised on other organs, but as the
cysts do not increase rapidly in size, punctures several times
repeated, so as to empty a number of them, would in most cases prove as
effectual an operation, and, what is of greater importance, would not
involve the loss of any portion, even if small, of secreting structure
which may be left.
Tuberculosis.
The tubercles which are found in the kidney in cases of general miliary
tuberculosis have usually no clinical interest, since the kidney is
not, even in children, one of the points where tubercular localization
is most intense, and renal tubercles are consequently but little
advanced when death takes place from the extension of the disease in
other organs. They present no symptoms which are perceptible among the
much graver ones attending the progress of the disease elsewhere.
In the disease known as tubercle of the kidney, caseous nephritis, or
nephro-phthisis, masses of caseous material are deposited in the renal
parenchyma which may soften, break down, and communicate with each
other and with the calices and pelvis. In some cases it is probable
that the disease originates in or immediately underneath the mucous
membrane of the urinary passages. This process of breaking down
continues much in the same way as that of a phthisical lung, until the
kidney becomes little more than a hardened, irregular, knobby shell
enclosing a ragged, ulcerated cavity with thickened, pus-secreting
walls and filled with pus, more or less blood, and débris of
kidney-structure and tubercle. In such portions of renal substance as
may remain it is not unusual to find miliary tubercle. If obstruction
of the ureter exists, a pyo-nephrosis may exist in addition. Rupture
into the peritoneal cavity or into the intestine has occurred.
It is probable that in this affection are included two processes,
differing in pathology and etiology and to some extent in clinical
history. It is probable that true tubercle may originate in the kidney
as a result of either tubercle or cheesy inflammation elsewhere, as in
the lungs, bodies of the vertebræ, or scrofulous glands. In this case
there are no marked symptoms until the process of softening and
breaking down has reached the mucous membrane of the pelvis. Besides
this, renal phthisis sometimes succeeds, as a more local invasion, to
tubercle or cheesy inflammation of the urinary passages, and in this
case the symptoms appear simply as aggravations of those already
present and depending upon ureteritis and pyelitis. Renal phthisis is
seldom if ever an independent disease. It is often associated, besides
the affections already named as standing in etiological relationship
with it, with cheesy inflammation of the testicle, vesiculæ seminales,
and much less frequently of the ovaries and Fallopian tubes.
{65} The DIAGNOSIS of tubercle in the kidney before it has reached the
pelvis is probably impossible. Pain in the back or slight albuminuria,
as has been already stated, is of no diagnostic value except as
pointing to some renal irritation, as to the cause of which it tells
nothing. In the presence of tubercle elsewhere it might be regarded as
suspicious.
After cavities have become connected with the pelvis or have extended
from it, the symptoms become more marked. In the urine are to be found
pus, some blood, epithelium of the urinary passages and often of the
kidneys, in many cases in the form of casts; and it is claimed that
masses of caseous matter as large perhaps as the head of a pin may be
found, which will of course make the diagnosis almost a matter of
certainty. If the urine containing such a deposit is acid, it is almost
certain that the lesion is mainly in the kidney and that the bladder is
but slightly if at all affected. It is also stated that the bacillus of
tubercle has been found. The presence of this parasite will not only
testify as to the presence of the clinical condition known as phthisis
of the kidney, but will also make it sure that the affection depends
upon tubercle in the strictest pathological sense, and will influence
the prognosis accordingly. Inoculation of purulent sediment from the
urine of a patient suffering from tuberculosis of the urinary passages
has produced tubercle in the iris of the rabbit. This procedure has
been suggested as a means of diagnosis as to the character of a chronic
catarrh of these passages before the appearance of tubercle
elsewhere.[23]
[Footnote 23: Ebstein, _Centralblatt für die Med. Wiss._, 1882, p. 918,
from _Deutsch. Arch. f. klin. Med._, xxxi. S. 63.]
If pyelitis have already been present, the change in the appearance of
the urine will be less characteristic, but there may be a marked
aggravation of symptoms when the contents of softened masses are added
to the secretions of the mucous surface. There is likely to be much
fluctuation in the quantity of débris present from day to day. Urinary
fever of the hectic or subcontinued type, with anorexia, nausea, dry
tongue, and diarrhoea, is present. In some cases the enlarged and
irregular kidney may be felt.