Finally, x-rays afford very convenient means of diagnosis under many circumstances, although mistakes have occurred from misinterpretation of shadows. Nevertheless, when a well-taken picture shows unmistakable evidence it may be considered as quite reliable.
Diagnosis.
—In the matter of diagnosis few diseases, as Hunner has shown, present such protean symptoms. Between calculous nephritis and tuberculosis the only positive indication is the discovery of bacilli in the urine or the reproduction of the disease in animals by inoculation. Blood occurs in both, but is more likely to be influenced by exercise in cases of stone. Pus occurs also in both, while pain is unreliable. Palpation shows nothing, unless it may reveal thickening of the ureter in the female as felt through the vagina. In pyelitis the presence of a stone may cause any of these conditions, or it may develop because of them. If trouble have begun soon after an acute infection, or during pregnancy, it is more likely to be a case of infected kidney. When tumor is suspected, urinary examination is the best guide. The sudden occurrence of hemorrhages, with their abrupt cessation, rather favor diagnosis of tumor, as does also the absence of pus. Still the latter may be absent when the ureter is obstructed. Intermittent hydronephrosis is usually due to kinking of the ureter connected with a movable kidney. During the attacks the kidney will be enlarged and misplaced, while blood may appear. With return to place comes subsidence of enlargement, while increase in the amount of urine is characteristic. Idiopathic hematuria or “renal epistaxis” is sometimes connected with the chronic interstitial forms of nephritis. The urine shows blood, if dealing with renal calculus, and bile if with biliary calculus. In the former pain is more likely to radiate down the ureter, while in the latter it is upward and backward. In biliary trouble the gall-bladder may be enlarged and movable or even pendulous. Kelly has suggested a method of differential diagnosis by catheterizing the ureter, and forcibly injecting into the pelvis of the kidney a bland, sterile solution. If the pain which it produces be identified by the patient as the same which is usually suffered it may be regarded as diagnostic; if somewhat different, then the actual attacks are more likely to be biliary. A normal renal pelvis should hold about 7 to 8 Cc. before the patient begins to complain.
Treatment.
—In the milder cases, and those where small concretions are repeatedly passed, medicinal treatment may be given a trial. While the alkalies, especially the lithium preparations, have repute in certain quarters, there is probably nothing superior to piperazin in its power of dissolving small uric calculi. Its physical properties and its expensiveness, however, make it disadvantageous to use. It is so sparingly soluble that part of the benefit obtained from it may be due to the volume of fluid ingested with it, and to the consequent dissolving and washing down of small particles. Glycerin is also an analgesic here, as in biliary calculi, and a half-ounce, administered every two or three hours, will often give relief. Attention to the diet is also necessary, especially in acute and uric acid patients.
When there is reason to believe that the kidney contains a calculus which cannot be passed, and especially when an x-ray picture reveals such a condition, then surgical treatment alone offers prospect of complete relief. This includes nephrotomy and what has been named nephrolithotomy, i. e., exposure and opening of the kidney and removal of its contained concretions. When these are easily felt the procedure is simple. However when only a small concretion has been shown in the skiagram, and it is not easily palpable, even with the kidney between the fingers, it is sometimes a difficult matter to locate. One method of doing this is with a small needle, passed repeatedly in the direction of the supposed calculus—used, in other words, as a probe. When such a stone is thus recognized it should be removed.
In cases of long-standing, renal pelves are dilated into relatively large sacs, containing numerous concretions, or sometimes a large stone in branching form, resembling coral. If a considerable degree of pyonephrosis or of disintegration accompany such a stone a complete nephrectomy should be made. It remains, then, for the surgeon’s judgment to decide as between nephrolithotomy or nephrectomy, a question which will be settled, in large measure, by what has been ascertained regarding the condition of the other organ. If considered fully competent little hesitation need be felt in removing the diseased one; if its condition be distrusted, then it were best to not carry out the surgical indication, but to substitute for it good general treatment.
MOVABLE AND FLOATING KIDNEY.
In most of the serious and in many of the milder degrees of unnatural mobility of the kidney to which the adjectives “movable” and “wandering” are applied, the surgeon has to deal with a somewhat anomalous condition, which, while it attains serious and alarming symptoms during life, leaves little evidence after death. Thus, Ebstein found it in only 5 out of 36,000, and yet it is said to occur in at least 20 per cent. of all women examined. In women and children the kidneys lie lower and deeper in the gutter on either side of the spine, beneath the seventh to the tenth cartilage, the upper end of the left kidney belonging at the level of the ensiform cartilage. The kidneys are supported by perirenal fascia, by the renal vessels, by pressure of the surrounding viscera, their anterior peritoneal covering playing but small part. Abnormal mobility below the twenty-fifth year of age is rare; its etiology is still obscure, it being found in women at least six times as often as in men; more commonly in those who have borne several children, or who have become suddenly emaciated after long illness, while in men it is most common on the left side. The kidney is afforded a small, distinct peritoneal covering, the so-called mesonephron, which, with its other supports, may be more or less lax, permitting differing degrees of abnormal mobility, the milder being spoken of as movable kidney, the more serious as floating kidney. As Belfield has shown, in every case of functional disturbance of the urinary organs the possibility that a floating kidney may be the cause of the trouble should be borne in mind.