Loose Kidney.—Movable kidney is responsible for many of these cases of abdominal discomfort. Where it exists to a marked degree it may be relieved by operation. It occurs much more frequently in women than in men because, for physiological reasons, the kidneys are normally more movable in women and this is particularly true of the right kidney, which would otherwise perhaps be injured by pressure between the pregnant uterus and the liver. It is probable that many of the cases of the kidney of pregnancy are really due to an abnormal fixity of the kidney to a particular place, so that the growing uterus interferes by pressure with its circulation and its function. Slight movability of the kidney, then, should not be considered pathological.
I have seen a number of these cases. They seem to occur particularly in women who have lost weight. The fat around the kidney is somewhat absorbed during the course of loss in weight, and this leaves this organ more movable and also less protected and consequently more liable to irritation. One sees it rather frequently in many unmarried women who have some strenuous occupation. Many of these young women come back from their vacation at the end of the summer having gained fifteen or twenty pounds in weight. If there has been any kidney sensitiveness or movability before, [{308}] both have usually disappeared. The kidney is well held in place because there is much more fat within the abdomen, all the organs are better cushioned, yet without any interference with their function.
During the course of the year these patients, school-teachers, stenographers, and daily workers of various kinds, lose in weight. When they have lost ten pounds the kidney begins to be sensitive again and somewhat movable. By the time they have lost fifteen to twenty pounds there is serious complaint in the right upper quadrant of their abdomen extending at times over toward the navel, and the kidney becomes quite movable. At this time the treatment must consist in holding the kidney as firmly in place as possible, for dragging downward will be followed by reflex symptoms in the stomach and intestines. Disinclination to food, loss of appetite, and even the occurrence of some nausea, as well as some constipation, are easily traced to kidney reflexes. During the night there is no trouble, because while the patient is lying down the kidney falls into its proper position. On arising in the morning the kidney drops down out of place. If a corset is put on at this time the kidney may be forced still further out of place, giving rise, after a couple of hours, to considerable discomfort. New shoes can be borne at first, but after a time the pressure they produce shuts off circulation and causes intolerable discomfort. To a less degree this happens to the kidney if thus compressed and this explains the course of symptoms in many cases.
Mechanical Treatment.—If the corset is adjusted before the patient rises, and fits reasonably snugly, but not too tight, the contents of the abdomen will all be kept in place, and the kidney will maintain its normal position. When the corset is not sufficient to retain the kidney in place, a simple pad, a towel or a napkin or, if there is much sensitiveness, something more elaborate, especially adapted to conditions, can be placed over the kidney, and when held firmly by the corset will keep the kidney in its place. At first the kidney is usually sensitive to this on account of having been pressed upon during the preceding weeks or months. The patient must bear some little inconvenience at first, must get accustomed to the new conditions in which the kidney is kept in place, and must not expect complete relief at once. Any improvement must be considered a step forward, and further amelioration can be confidently promised. As in all other cases of the use of apparatus or mechanical aids—spectacles, false teeth or crutches—the patient must be content to grow used to the new order of things, before expecting satisfying relief.
This is the palliative treatment. The natural treatment of many of these cases is to have the patient maintain such weight as will hold the kidney in place, because of the fat within the abdomen, without any necessity for external aids. This can be done more readily than is often thought to be possible. These patients insist that they lose their appetite when they settle down to work, but what they really lose is the habit of eating a definite amount at stated intervals. Very often it will be found that breakfast, which they took abundant time to eat during vacation, is rushed. The luncheon suffers in the same way and is small in quantity. They take only one good meal, and one good meal is not sufficient to maintain normal weight.
Question of Operation.—When a kidney is so movable as to deserve the adjective "floating," so that it moves considerably from its place and, perhaps, even sags and may be felt in the subumbilical region, it should be fastened up [{309}] by surgical means. There is a choice between two evils. The fastening of the kidney in the loin does not restore the normal condition, but puts it in an artificial condition. The kidney supports are of such a kind that it was evidently meant to be slightly movable. When it is fastened firmly in the loin, it is likely to feel every jar, and certain post-operative cases that I have seen, in which firm adhesions had supposedly taken place, complained considerably of the discomfort occasioned by this. In a certain number of cases, even after the operation, the kidney is still somewhat movable, because the adhesions yield and some of the old distress returns. All this must be realized before there is any question of an operation. There must be not merely a little discomfort, but enough of actual ache and of reflex disturbance that can be traced directly to the kidney to warrant the operation.
No floating kidney should be operated upon in a patient who has lost much in weight and has developed a sensitiveness of the kidney since the reduction of weight. Definite efforts should first be made to bring about increase in weight, so as to see whether this will not restore the previous condition of reasonable comfort. At times it is said that the disturbance of the stomach, that is reflex to such a floating kidney, prevents the patient from taking and assimilating enough food to restore normal weight. This will be true if attention has been called to the condition very seriously, and if the patient is persuaded that this is the reason why there is no appetite and poor digestion. Ordinary palliative measures, such as a binder, or a specially made corset, will be sufficient to prevent the kidney from producing reflex disturbance of the stomach, and will exert a strong suggestion to this effect under the influence of which the patient will usually gain in weight.
Intermittent Discomfort.—The discomfort that comes with a loose kidney may be quite intermittent. I have known patients to be bothered by it for months, and then quite free from it for several years, only to have their discomfort renewed so that they become quite worried. Some definite local or mechanical condition can generally be found for these variations in feeling.
In thin people a jolting ride over a rough road or stepping off a car will occasionally be the beginning of the trouble, and as this also is likely to cause a stone in the kidney to give its first manifestations, there may be serious suspicion of a more grave pathological condition than is really present. If this discomfort continues only the X-ray can absolutely decide the question.
Once the mechanical conditions which cause the discomfort are understood by the patient, the actual ache becomes much more easy to bear. Apprehension makes it almost intolerable. Attention exaggerates it, and makes diversion of mind difficult. Understanding helps all the conditions and lessens the pain, not actually but mentally, until after a time very little attention is paid to it.