SECTION I. DISEASES OF THE KIDNEY. CHAPTER I. ROUTINE EXAMINATION OF A UROLOGICAL CASE; SUMMARY OF METHODS. I. History. A. ROUGH GENERAL OUTLINE.-The onset symptom-the course, its duration, whether continuous or marked by intermittent attacks-the attacks, whether increasing or decreasing in severity and frequency-does the present attack resemble others in the past ?-any former diagnoses and treatments, any instrumentation, any injury. B. DETAILS OF PRESENT AND PAST ATTACKS. Pain. Its positions-starting points-lines of radiation. Its character-dull or sharp-mild or severe-continuous or intermittent. Relation to movement, to micturition, to hæmaturia, to position. Is there anything which relieves it or makes it worse? Frequency of micturition.-During the day and at night— Manner of micturition.-Power, volume, continuity, direc- Cloudy urine. Is it cloudy when passed, or after standing? Is it offensive when passed? Passage of sand and calculi, clots, fragments of growth, etc. General history.-Age, occupation, ever abroad. Habits Venereal history.-Gonorrhoea, syphilis, chancroids. Family history.-Tuberculosis, calculus, gout, congenital Special systems-General states.-Wasting, oedema, rigors and fever, specific fevers. Alimentary system.-Thirst, appetite, nausea and vomiting, state of bowels. Nervous system.—Headache, fits. Respiratory system.-Phthisis, chronic cough, dyspnoea. Cardiac and vaso-motor.-Palpitations, dyspnoea, giddiness, faints, flushings. II. Physical Examination. A. Inspection, palpation, and, if necessary, percussion of each structure, proceeding in Anatomical order and from System to System. 1. Genito-urinary System in anatomical order. Penis and external palpation of urethra. Scrotum. Rectal Examination (usually after abdominal). Ex- Kidneys: Inspection, palpation (see p. 58). B. URINE-Physical tests.-Colour, smell, density, quantity in twenty-four hours. Chemical. Acidity, albumen, urea, chlorides (phosphates, uric acid), sugar, blood, and pus. Microscopic.-Crystals, casts, blood, pus, bacteria. Bacterial-Microscope, culture, inoculation. C. OTHER SYSTEMS.-Routine physical examination. Heart and vasomotor. Size of heart, condition of arteries, systemic blood pressure, ophthalmoscope. Blood. - Anæmias, leukæmias, hæmophilia, purpuras, toxæmia, septicemia. Nervous system.-Tabes, epilepsy, disseminated sclerosis, paraplegias, etc. Skin.-Nutrition, dry or moist, diseases. Skeleton.-General type, individual bones, joints. SPECIAL METHODS OF EXAMINATION. Urethra.―Janet's irrigation method and the glass tests (see p. 371), collection of pus and threads from anterior urethra and posterior urethra (microscope and culture on blood agar). Urethroscope. Bougies, dilators. Prostate.-Secretion obtained by massage (after irrigation of the anterior urethra followed by micturition). Vesicula.-Secretion obtained by massage (after irrigation of the anterior urethra followed by micturition). Bladder.-Cystoscope. Catheters (sound). Ureters.-Meatoscopy. bougies. Bougies. X-ray and iron oxide Kidneys.-Ureteric catheters. Urines collected, with or without experimental polyuria, injection of phloridzin, injection of coloured substances, etc. Surgical exploration. X rays. After a complete collection of facts the diagnosis is made by considering them as a whole. 1. The organ or organs affected-kidney, ureter, bladder, urethra, prostate, penis, testicle, vas, vesiculæ. 2. The nature of the local disease. 3. General effects. THE DIAGNOSIS OF KIDNEY DISEASE is concerned with two factors: 1. The anatomical condition of each kidney. 2. The physiological condition of each kidney. 1. ANATOMICAL CONDITION. A. To prove the presence of two kidneys (when the question of nephrectomy arises). 1. Both kidneys may be palpable. 2. If no stigmata of congenital defect are present, and if there is no family history of defect, then the presence of two normally placed ureters as seen by the cystoscope, secreting urine (as proved by inspection or the ureteric catheter), is sufficient evidence for practical purposes (see p. 30). 3. If congenital stigmata are present "iron-oxide " bougies should be passed up each ureter and a radiogram taken. If the course of the ureters appears normal, and especially if a shadow outline of each kidney can be obtained, then the evidence is sufficient. 4. If doubt remains, exploration of each kidney by the lumbar route is justifiable. 5. A fused kidney may be found at exploration (see p. 30). There can then be no doubt that no other kidney is present. B. The morbid condition of each kidney.-This is determined by a consideration of all the signs and symptoms, general and local, and especially the analyses of the separated urines, and the X-ray examination. 2. PHYSIOLOGICAL OR FUNCTIONAL CONDITION. The power of one or both kidneys may be normal, diminished, absent, or increased. The normal healthy kidney has a large reserve of power, which does not depend on an anatomical basis, for if one kidney has to be suddenly excised after a severe crushing injury, the opposite kidney is able to take on at once the work previously carried out by both kidneys. Anatomical hypertrophy is a later phenomenon (see p. 36). In progressive destruction of the kidney the limits of hypertrophy are reached after a long time and compensation fails. When this is so definite symptoms begin to appear, but before that there are no symptoms to show that the reserve power is lessened or that hypertrophy has occurred. Whether kidney substance be destroyed, or the function be depressed slowly or suddenly, there is a stage of latency or tolerance, during which no signs appear, followed by a period of "uræmia" during which some or all of a definite series of signs may be revealed. When compensation begins to break down, it may break down completely and for good and all, or the patient may continue to live on the border-line for a considerable time, showing signs of failure if submitted to excessive strain, losing the signs as soon as the strain is removed, and the minimum amount of work thrown on the damaged organ. These signs of failure are grouped under the term “Uræmia.” URÆMIA. Etiology. The condition is not due to the retention of urinary products in the blood, such as urea, nor has it been possible to prove that it is due to the cutting off of a hypothetical internal secretion of the kidney. It has been suggested that the kidney in health excretes toxic metabolites, which in disease accumulate in the blood and produce uræmia, or that when the kidneys are diseased abnormal metabolites formed by the tissues enter the blood, but attempts to isolate such bodies and prove that they produce the symptoms of uræmia have so far been unsuccessful. Certain facts for which no complete explanation can as yet be given seem to be fairly well established and throw light on many clinical phenomena. (1) Destruction of kidney substance leads to a profound disturbance of the alimentary system, producing thirst, loss of appetite, nausea, vomiting and attacks of diarrhoea (gastritis and colitis). (2) The late symptoms of acute uræmia, such as convulsions, paralyses, drowsiness, delirium, coma, Cheyne-Stokes' respiration, the extreme height of the general blood-pressure are due to oedema of the brain. (3) In many cases of advanced destruction or degeneration of kidney substance there is a persistent raising of the general blood-pressure with hypertrophy of the muscular walls of the systemic arteries and the left ventricle of the heart. SIGNS AND SYMPTOMS OF URÆMIA IN SURGICAL CASES. Alimentary system.-Thirst that cannot be satisfied is one of the earliest symptoms, even when the tongue is moist and clean. The tongue in surgical cases is often surprisingly moist and clean, and only in the late stages does it become tremulous, dry and coated with heavy white or yellow fur, in common with the rest of the mouth and throat. Nausea and sporadic attacks of vomiting, especially in the mornings, are amongst the earliest and most characteristic symptoms. When accompanied by epigastric pain and hæmatemesis from high blood-pressure the resemblance to gastric ulcer is sufficiently close as to lead to mistakes if the urine be not tested carefully. Constipation is the rule, alternating with attacks of diarrhoea. |