Page:EB1911 - Volume 15.djvu/814

Rh and the effects of the kidney-lesion on the body at large. Affections of the kidney are congenital or acquired. When acquired they may be the result of a pathological process limited to the kidney, in which case they are spoken of as primary, or an accompaniment of disease in other parts of the body, when they may be spoken of as secondary.

Congenital Affections.—The principal congenital affections are anomalies in the number or position of the kidneys or of their ducts; atrophy; cystic disease and growths. The most common abnormality is the existence of a single kidney; rarely a supernumerary kidney may be present. The presence of a single kidney may be due to failure of development, or to atrophy in foetal life; it may also be dependent on the fusion of originally separate kidneys in such a way as to lead to the formation of a horse-shoe kidney, the two organs being connected at their lower ends. In some cases of horse-shoe kidney the organs are united merely by fibrous tissue. Occasionally the two kidneys are fused end to end, with two ureters. A third variety is that where the fusion is more complete, producing a disk-like mass with two ureters. The kidneys may be situated in abnormal positions; thus they may be in front of the sacro-iliac articulation, in the pelvis, or in the iliac fossa. The importance of such displacements lies in the fact that the organs may be mistaken for tumours. In some cases atrophy is associated with mal-development, so that only the medullary portion of the kidney is developed; in others it is associated with arterial obstruction, and sometimes it may be dependent upon obstruction of the ureter. In congenital cystic disease the organ is transformed into a mass of cysts, and the enlargement of the kidneys may be so great as to produce difficulties in birth. The cystic degeneration is caused by obstruction of the uriniferous tubules or by anomalies in development, with persistence of portions of the Wolffian body. In some cases cystic degeneration is accompanied by anomalies in the ureters and in the arterial supply. Growths of the kidney are sometimes found in infants; they are usually malignant, and may consist of a peculiar form of sarcoma, which has been spoken of as rhabdo-sarcoma, owing to the presence in the mass of involuntary muscular fibres. The existence of these tumours is dependent on anomalies of development; the tissue which forms the primitive kidney belongs to the same layer as that which gives rise to the muscular system (mesoblast). Anomalies of the excretory ducts: in some cases the ureter is double, in others it is greatly dilated; in others the pelvis of the kidney may be greatly dilated, with or without dilatation of the ureter.

''Acquired Affections. Movable Kidney''.—One or both of the kidneys in the adult may be preternaturally mobile. This condition is more common in women, and is usually the result of a severe shaking or other form of injury, or of the abdominal walls becoming lax as a sequel to abdominal distension, to emaciation or pregnancy, or to the effects of tight-lacing. The more extreme forms of movable kidney are dependent, generally, on anomalies in the arrangement of the peritoneum, so that the organ has a partial mesentery; and to this condition, where the kidney can be moved freely from one part of the abdomen to another, the term floating kidney is applied. But more usually the organ is loose under the peritoneum, and not efficiently supported in its fatty bed. Movable kidney produces a variety of symptoms, such as pain in the loin and back, faintness, nausea and vomiting—and the function of the organ may be seriously interfered with, owing to the ureter becoming kinked. In this way hydronephrosis, or distension of the kidney with urine, may be produced. The return of blood through the renal vein may also be hindered, and temporary vascular engorgement of the kidney, with haematuria, may be produced.

In some cases the movable kidney may be satisfactorily kept in its place by a pad and belt, but in other cases an operation has to be undertaken. This consists in exposing the kidney (generally the right) through an incision below the last rib, and fixing it in its proper position by several permanent sutures of silk or silkworm gut. The operation is neither difficult nor dangerous, and its results are excellent.

Embolism.—The arrangement of the blood-vessels of the kidney is peculiarly favourable to the production of wedge-shaped areas of necrosis, the result of a blocking by clots. Sometimes the clot is detached from the interior of the heart, the effect being an arrest of the circulation in the part of the kidney supplied by the blocked artery. In other cases, the plug is infective owing to the presence of septic micro-organisms, and this is likely to lead to the formation of small pyaemic abscesses. It is exceptional for the large branches of the renal artery to be blocked, so that the symptoms produced in the ordinary cases are only the temporary appearance of blood or albumen in the urine. Blocking of the main renal vessels as a result of disease of the walls of the vessels may lead to disorganization of the kidneys. Blocking of the veins, leading to extreme congestion of the kidney, also occurs. It is seen in cases of extreme weakness and wasting, sometimes in septic conditions, as in puerperal pyaemia, where a clot, formed first in one of the pelvic veins, may spread up the vena cava and secondarily block the renal veins. Thrombosis of the renal vein also occurs in malignant disease of the kidney and in certain forms of chronic Bright’s disease.

Passive congestion of the kidneys occurs in heart-diseases and lung-diseases, where the return of venous blood is interfered with. It may also be produced by tumours pressing on the vena cava. The engorged kidneys become brownish red, enlarged and fibroid, and they secrete a scanty, high-coloured urine.

Active congestion is produced by the excretion in the urine of such materials as turpentine and cantharides and the toxins of various diseases. These irritants produce engorgement and inflammation of the kidney, much as they would that of any other structures with which they come in contact. Renal disturbance is often the result of the excretion of microbic poisons. Extreme congestion of the kidneys may be produced by exposure to cold, owing to some intimate relationship existing between the cutaneous and the renal vessels, the constriction of the one being accompanied by the dilatation of the other. Infective diseases, such as typhoid fever, pneumonia, scarlet fever, in fact, most acute specific diseases, produce during their height a temporary nephritis, not usually followed by permanent alteration in the kidney; but some acute diseases cause a nephritis which may lay the foundation of permanent renal disease. This is most common as a result of scarlet fever.

Bright’s disease is the term applied to certain varieties of acute and chronic inflammation of the kidney. Three forms are usually recognized—acute, chronic and the granular or cirrhotic kidney. In the more common form of granular kidney the renal lesion is only part of a widespread affection involving the whole arterial system, and is not actually related to Bright’s disease. Chronic Bright’s disease is sometimes the sequel to acute Bright’s disease, but in a great number of cases the malady is chronic from the beginning. The lesions of the kidney are probably produced by irritation of the kidney-structures owing to the excretion of toxic substances either ingested or formed in the body; it is thought by some that the malady may arise as a result of exposure to cold. The principal causes of Bright’s disease are alcoholism, gout, pregnancy and the action of such poisons as lead; it may also occur as a sequel to acute diseases, such as scarlet fever. Persons following certain occupations are peculiarly liable to Bright’s disease, e.g. engineers who work in hot shops and pass out into the cold air scantily clothed; and painters, in whom the malady is dependent on the action of lead on the kidney. In the case of alcohol and lead the poison is ingested; in the case of scarlet fever, pneumonia, and perhaps pregnancy, the toxic agent causing the renal affection is formed in the body. In Bright’s disease all the elements of the kidney, the glomeruli, the tubular epithelium, and the interstitial tissue, are affected. When the disease follows scarlet fever, the glomerular structures are mostly affected, the capsules being thickened by fibrous tissue, and the glomerular tuft compressed and atrophied. The epithelium of the convoluted tubules undergoes degeneration; considerable quantities of it are shed, and form the well-known casts in the urine. The tubules become blocked by the epithelium, and distended with the pent-up urine; this is one cause of the increase in size that the kidneys undergo in certain forms of Bright’s disease. The lesions in the tubules and in the glomeruli are not generally uniform. The interstitial tissue is always affected, and exudation, proliferation and formation of fibrous tissue occur. In the granular and contracted kidney the lesion in the interstitial tissue reaches a high degree of development, little renal secreting tissue being left. Such tubules as remain are dilated, and the epithelium lining them is altered, the cells becoming hyaline and losing their structure. The vessels are narrowed owing to thickening of the subendothelial layer, and the muscular coat undergoes hypertrophic and fibroid changes, so that the vessels are abnormally rigid. When the overgrowth of fibrous tissue is considerable, the surface of the organ becomes uneven, and it is for this reason that the term granular kidney has been applied to the condition. In acute Bright’s disease the kidney is increased in size and engorged with blood, the changes described above being in active progress. In the chronic form the kidney may be large or small, and is usually white or mottled. If large, the cortex is thickened, pale and waxy, and the pyramids are congested; if small, the fibrous change has advanced and the cortex is diminished. Bright’s disease, both acute and chronic, is essentially a disease of the cortical secreting portion of the kidney. The true granular kidney, classified by some as a third variety, is usually part of a general arterial degeneration, the overgrowth of fibrous tissue in the kidney and the lesions in the arteries being well marked.

The principal degenerations affecting the kidney are the fatty and the albuminoid. Fatty degeneration often reaches a high degree in alcoholics, where fatty degeneration of the heart and liver are also present. Albuminoid disease is frequently associated with some varieties of Bright’s disease, and is also seen as a result of chronic bone disease, or of long-continued suppuration involving other parts of the body, or of syphilis. It is due to irritation of the kidneys by toxic products.

Growths of the Kidney.—The principal growths are tubercle, adenoma, sarcoma and carcinoma. In addition, fatty and fibrous growths, the nodules of glanders and the gummata of syphilis, may be mentioned. Tuberculous disease is sometimes primary; more frequently it is secondary to tubercle in other portions of the genito-urinary apparatus. The genito-urinary tract may be infected by