Page:EB1911 - Volume 15.djvu/815

Rh tubercle in two ways; ascending, in which the primary lesion is in the testicle, epididymis, or urinary bladder, the lesion travelling up by the ureter or the lymphatics to the kidney; descending, where the tubercle bacillus reaches the kidney through the blood-vessels. In the latter case, miliary tubercles, as scattered granules, are seen, especially in the cortex of the kidney; the lesion is likely to be bilateral. In primary tuberculosis, and in ascending tuberculosis, the lesion is at first unilateral. Malignant disease of the kidney takes the form of sarcoma or carcinoma. Sometimes it is dependent on the malignant growths starting in what are spoken of as “adrenal rests” in the cortex of the kidney. Sarcoma is most often seen in the young; carcinoma in the middle-aged and elderly. Carcinoma may be primary or secondary, but the kidney is not so prone to malignant disease as other organs, such as the stomach, bowel or liver.

Cystic Kidneys.—Cysts may be single—sometimes of large size. Scattered small cysts are met with in chronic Bright’s disease and in granular contracted kidney, where the dilatation of tubules reaches a high degree. Certain growths, such as adenomata, are liable to cystic degeneration, and cysts are also found in malignant disease. Finally, there is a rare condition of general cystic disease somewhat similar to the congenital affection. In this form the kidneys, greatly enlarged, consist of a congeries of cysts separated by the remains of renal tissue.

Parasitic Affections.—The more common parasites affecting the kidney, or some other portion of the urinary tract, and causing disease, are filaria, bilharzia and the cysticercus form of the taenia echinococcus (hydatids). The presence of filaria in the thoracic duct and other lymph-channels may determine the presence of chyle in the urine, together with the ova and young forms of the filaria, owing to the distension and rupture of a lymphatic vessel into some portion of the urinary tract. This is the common cause of chyluria in hot climates, but chyluria is occasionally seen in the United Kingdom without filaria. Bilharzia, especially in Egypt and South Africa, causes haematuria. The cysticercus form of the taenia echinococcus leads to the production of hydatid cysts in the kidney; this organ, however, is not so often affected as the liver.

Stone in the Kidney.—Calculi are frequently found in the kidney, consisting usually of uric acid, sometimes of oxalates, more rarely of phosphates. Calculous disease of the (q.v.) is generally the sequel to the formation of a stone in the kidney, which, passing down, becomes coated by the salts in the urine. Calculi are usually formed in the pelvis of the kidney, and their formation is dependent either on the excessive amounts of uric acid, oxalic acid, &c., in the urine, or on an alteration in the composition of the urine, such as increased acidity, or on uric acid or oxalate of lime being present in an abnormal amount. The formation of abnormal crystals is often due to the presence of some colloid, such as blood, mucus or albumen, in the secretion, modifying the crystalline form. Once a minute calculus has been formed, its subsequent growth is highly probable, owing to the deposition on it of the urinary constituent forming it. Calculi formed in the pelvis of the kidney may be single and may reach a very large size, forming, indeed, an actual cast of the interior of the expanded kidney. At other times they are multiple and of varying size. They may give rise to no symptoms, or on the other hand may cause distressing renal colic, especially when they are small and loose and are passed or are trying to be passed. Serious complications may result from the presence of a stone in the kidney, such as hydronephrosis, from the urinary secretion being pent up behind the obstruction, or complete suppression, which is apparently produced reflexly through the nervous system. In such cases the surgical removal of the stone is often followed by the restoration of the renal secretion.

The symptoms of renal calculus may be very slight, or they may be entirely absent if the stone is moulding itself into the interior of the kidney; but if the stone is movable, heavy and rough, it may cause great distress, especially during exercise. There will probably be blood in the urine; and there will be pain in the loin and thigh and down into the testicle. The testicle also may be drawn up by its suspensory muscle, and there may be irritability of the bladder. With stone in one kidney the pains may be actually referred to the kidney of the other side. Generally, but not always, there is tenderness in the loin. If the stone is composed of lime it may throw a shadow on the Röntgen plate, but other stones may give no shadow.

Renal colic is the acute pain felt when a small stone is travelling down the ureter to the bladder. The pain is at times so acute that fomentations, morphia and hot baths fail to ease it, and nothing short of chloroform gives relief.

For the operative treatment of renal calculus an incision is made a little below the last rib, and, the muscles having been traversed, the kidney is reached on the surface which is not covered by peritoneum. Most likely the stone is then felt, so it is cut down upon and removed. If it is not discoverable on gently pinching the kidney between the finger and thumb, the kidney had better be opened in its convex border and explored by the finger. Often it has happened that when a man has presented most of the symptoms of renal calculus and has been operated on with a negative result as regards finding a stone, all the symptoms have nevertheless disappeared as the direct result of the blank operation.

Pyelitis.—Inflammation of the pelvis of the kidney is generally produced by the extension of gonorrhoeal or other septic inflammation upwards from the bladder and lower urinary tract, or by the presence of stone or of tubercle in the pelvis of the kidney. Pyonephrosis, or distension of the kidney with pus, may result as a sequel to pyelitis or as a complication of hydronephrosis; in many cases the inflammation spreads to the capsule of the kidney, and leads to the formation of an abscess outside the kidney—a perinephritic abscess. In some cases a perinephritic abscess results from a septic plug in a blood-vessel of the kidney, or it may occur as the result of an injury to the loose cellular tissue surrounding the kidney, without lesion of the kidney.

Hydronephrosis, or distension of the kidney with pent-up urine, results from obstruction of the ureter, although all obstructions of the ureter are not followed by it, calculous obstruction, as already noted, often causing complete suppression of urine. Obstruction of the ureter, causing hydronephrosis, is likely to be due to the impaction of a stone, or to pressure on the ureter from a tumour in the pelvis—as, for instance, a cancer of the uterus—or to some abnormality of the ureter. Sometimes a kink of the ureter of a movable kidney causes hydronephrosis. The hydronephrosis produced by obstruction of the ureter may be intermittent; and when a certain degree of distension is produced, either as a result of the shifting of the calculus or of some other cause, the obstruction is temporarily relieved in a great outflow of urine, and the urinary discharge is re-established. When the hydronephrosis has long existed the kidney is converted into a sac, the remains of the renal tissues being spread out as a thin layer.

Effects on the Urine.—Diseases of the kidney produce alterations in the composition of the urine; either the proportion of the normal constituents being altered, or substances not normally present being excreted. In most diseases the quantity of urinary water is diminished, especially in those in which the activity of the circulation is impaired. There are diseases, however, more especially the granular kidney and certain forms of chronic Bright’s disease, in which the quantity of urinary water is considerably increased, notwithstanding the profound anatomical changes that have occurred in the kidney. There are two forms of suppression of the urine: one is obstructive suppression, seen where the ureter is blocked by stone or other morbid process; the other is non-obstructive suppression, which is apt to occur in advanced diseases of the kidney. In other cases complete suppression may occur as the result of injuries to distant parts of the body, as after severe surgical operations. In some diseases in which the quantity of urinary water excreted is normal, or even greater than normal, the efficiency of the renal activity is really diminished, inasmuch as the urine contains few solids. In estimating the efficiency of the kidneys, it is necessary to take into consideration the so-called “solid urine,” that is to say, the quantity of solid matter daily excreted, as shown by the specific gravity of the urine. The nitrogenous constituents—urea, uric acid, creatinin, &c.—vary greatly in amount in different diseases. In most renal diseases the quantities of these substances are diminished because of the physiological impairment of the kidney. The chief abnormal constituents of the urine are serum-albumen, serum-globulin, albumoses (albuminuria), blood (haematuria), blood pigment (haemoglobinuria), pus (pyuria), chyle (chyluria) and pigments such as melanuria and urobilinuria.

Effects on the Body at large.—These may be divided into the persistent and the intermittent or transitory. The most important persistent effects produced by disease of the kidney are, first, nutritional changes leading to general ill health, wasting and cachexia; and, secondly, certain cardio-vascular phenomena, such as enlargement (hypertrophy) of the heart, and thickening of the inner, and degeneration of the middle, coat of the smaller arteries. Amongst the intermittent or transitory effects are dropsy, secondary inflammations of certain organs and serous cavities, and uraemia. Some of these effects are seen in every form of severe kidney disease, and uraemia may occur in any advanced kidney disease. Renal dropsy is chiefly seen in certain forms of Bright’s disease, and the cardiac and arterial changes are commonest in cases of granular or contracted kidney, but may be absent in other diseases which destroy the kidney tissue, such as hydronephrosis. Uraemia is a toxic condition, and three varieties of it are recognized—the acute, the chronic and the latent. Many of these effects are dependent upon the action of poisons retained in the body owing to the deficient action of the kidneys. It is also probable that abnormal substances having a toxic action are produced as a result of a perverted metabolism. Uraemia is of toxic origin, and it is probable that the dropsy of renal disease is due to effects produced in the capillaries by the presence of abnormal substances in the blood. High arterial tension, cardiac hypertrophy and arterial degeneration may also be of toxic origin, or they may be produced by an attempt of the body to maintain an active circulation through the greatly diminished amount of kidney tissue available.

Rupture of the kidney may result from a kick or other direct injury. Vomiting and collapse are likely to ensue, and most likely blood will appear in the urine, or a tumour composed of blood and urine may form in the renal region. An incision made into the swelling from the loin may enable the surgeon to see the torn kidney. An attempt should be made to save the kidney by suturing and draining; unless