A system of practical medicine. By American authors. Vol. 4

by Unknown

⁴ Arch. für Klin. Chirurg., 1879.

There can be no doubt that in many cases the symptoms are more severe than might be supposed from the ordinary descriptions, and are very unfairly characterized as hysterical. On the other hand, many cases are attended with but the mildest form of the symptoms just described, and the patients, ignorant of any tumor either from its discomfort or from having felt it, live in health and comfort for many years.

DIAGNOSIS.—The diagnosis of this condition, if the physician keeps in mind the possibility of its occurrence, is usually not difficult. In many cases a tumor has been felt by the patient which when called to the attention of the physician is recognized by its shape. In some cases in thin persons the form of the kidney, even to its hilus with the strongly-beating artery, can be made out. It glides easily from between the fingers, and can be moved more or less remotely from its normal position, to which, however, it returns without difficulty, especially when the patient assumes the recumbent position. The excursions are of course limited to a certain length of radius, of which the origin of the renal vessels is the centre, and seldom go much beyond the median line toward the side opposite to that on which the movable organ belongs.

The usual statement of text-books, that a depression or lessened resistance is to be felt in the loins of the side from which the kidney is absent, and a diminution of the normal dulness, which returns again when the organ is replaced, rests, as regards the majority of cases, rather upon theoretical considerations than on actual observation. The thickness of the lumbar muscles, upon which the kidney rests, is such that the dulness on percussion is not capable of much change. In most persons the outer limit of dulness in this region is not that of the outer edge of the kidney, but of the extensor dorsi communis. Palpation and percussion therefore in the renal region are not likely to be of much value in diagnosis, although an occasional case appears to justify the ordinary statement. The hand-and-knee position described above would be more likely than any other to show an existing depression.

Palpation for the purpose of finding the tumor, if it be not at once evident, or for examining it after it is found, should be bimanual, one hand being placed in the space between the ribs and the crest of the ilium of the supine patient and pressed strongly upward, while the surface rather than the points of the fingers of the other hand should be carried and pressed with some firmness into the relaxed abdominal parietes. In this way the kidney may be caught between the two hands and examined more or less completely according to the thickness of the abdominal walls. Sometimes the kidney can be partly grasped between the finger and thumb of one hand. In this way the size, shape, and sensitiveness of the tumor can be determined, as well as its position and movability.

A movable kidney may of course present some difficulties of diagnosis from other abdominal tumors. The liver is sometimes, though very rarely, movable, and never to the same extent as a wandering kidney, and as it is pushed downward discloses its much greater bulk. The base of the gall-bladder may occasionally be quite movable, but its excursions are of a more limited radius, being of course executed only by the base and not the whole organ.

The spleen, when it descends so as to be distinctly felt below the ribs, is much less movable, and if it descends deeply without great enlargement, its absence from its proper place is demonstrable by percussion. The splenic tumor is also larger, firmer, and more closely applied to the abdominal walls than the floating kidney. The left kidney, it should be remembered, is less frequently movable than the right.

A small ovarian tumor might be mistaken for a movable kidney low down in the abdomen, or vice versâ. The latter error has actually been committed, and has led to an attempted removal of the supposed cyst. The more easy movability of the kidney upward and of the ovary downward or laterally, as well as the shape, and in many cases the result of a vaginal examination, should be sufficient to make the distinction, which, if an exact diagnosis be absolutely necessary, may be confirmed by aspiratory puncture.

A malignant omental tumor might at the first examination present points of difficulty in diagnosis, but even if it were single and counterfeited with considerable accuracy the shape of the kidney, neither of these conditions would be likely to continue for any length of time.

TREATMENT.—The treatment usually suggested for this affection is based partly on the fact that many cases are hysterical, and also on that other more important one, that very little can be done to restrain the vagaries of the offending organ.