DISEASES OF THE URINARY SYSTEM
Diseases of the Kidneys
(Renal Hyperemia)
Definition.—An increase in the amount of blood to the vessels of the kidney. It is active hyperemia when there is arterial congestion, passive hyperemia when there is venous congestion.
Osteopathic Etiology and Pathology.—Active hyperemia may be caused by injuries to the renal splanchnics, especially the tenth to twelfth dorsal segments; injuries over and to the kidneys; exposure to cold when the body is very warm; poison given, as diuretics; eruptive fevers and pregnancy, or follow genito-urinary operations. Passive hyperemia may be caused by obstructive diseases of the general circulation, as chronic heart, lung and liver diseases, or by pressure on the renal veins by tumors, growths and the pregnant uterus. Thrombosis of the renal veins may produce passive hyperemia, but rarely.
Pathologically, in active hyperemia the kidney is swollen and slightly enlarged. Upon removal of the capsule, the kidney is found to be brown and mottled. On section the parts bleed freely, the Malpighian bodies are distended, and microscopical examination shows a cloudy swelling of the renal epithelium. In passive hyperemia the kidney is swollen, hard, firm and of a bluish red color. Later there is an overgrowth of connective tissue and some infiltration between the tubules. The Malpighian bodies occasionally become shriveled and the renal epithelium fatty.
Symptoms.—In active hyperemia the urine is scanty, of high specific gravity and of high color, containing some albumin and casts. Pain is experienced over the loins, following the course of the ureters, and the bladder is irritable. There are headache, nausea and vomiting. When from infection, fever may be present.
In passive hyperemia the symptoms are primarily those caused by the disease producing the disorder. There is weight over the loins and dropsy. The urine is diminished, of high specific gravity, highly colored, albuminous and occasionally shows a few hyaline casts.
Prognosis.—Active hyperemia.—Usually favorable if it can be treated in time. If prolonged, acute nephritis may develop. Passive hyperemia.—Depends on the cause. If the disease is prolonged, it terminates in interstitial nephritis.
Treatment.—Active hyperemia.—Absolute rest and thorough treatment to the renal splanchnics and treatment over the abdomen to the kidneys directly by carefully raising them. Adjust the lower ribs if found lesioned. Water should be drunk liberally and the patient encouraged to use vapor baths. Favorable hygienic surroundings, warmth and good food are indispensable. Warm applications over the loins are helpful.
Passive hyperemia.—The treatment largely depends upon the cause, but too much importance cannot be given to the treating of the vasomotor fibers of the kidneys from the eighth dorsal to the first lumbar. Textbooks state that the vasomotor fibers to the kidneys are from the ninth to the twelfth dorsal vertebræ, inclusive, but osteopathic experience shows we can affect vasomotor fibers slightly higher. Treatment here has a distinct effect on the blood pressure within the glomeruli. The renal epithelium is extremely sensitive to circulatory changes. Even the compression of a renal artery for only a few minutes causes marked disturbances. Hence any irritation or obstruction to the vasomotor innervation of the renal blood-vessels may result in serious conditions. The superior cervical ganglion of the sympathetic and the sciatic center have important bearing on the secretions of the kidney, through vasomotor fibers. Due attention should be paid to the bowels, and the patient required to take plenty of rest and a light diet.
Acute Parenchymatous Nephritis
(Acute Bright’s Disease)
Definition.—An acute, inflammatory process affecting the epithelium of the uriniferous tubules and due to the action of cold or toxic agents upon the kidneys, as well as to injuries to the renal splanchnics; is characterized by certain nervous symptoms with fever, dropsy, and scanty and highly colored urine. This inflammation involves more or less the whole kidney.
Osteopathic Etiology and Pathology.—This disease is caused by exposure to cold and wet while the body is warm and perspiring. Excessive use of alcohol may be a factor. May be caused also by infectious diseases, such as scarlet fever, diphtheria, measles, smallpox, acute tuberculosis and others; also by certain specific poisons which are eliminated by the kidneys, as turpentine, chlorate of potash, carbolic acid, phosphorus, ginger, cantharides and oil of mustard; also by pregnancy, as this is supposed to compress the renal veins, or through toxic agents. Syphilis may be an underlying cause. Blows and injuries to the back at the tenth, eleventh and twelfth dorsals are frequently the cause. Lesions are found from the sixth dorsal to the fourth lumbar. The lower three ribs may be at fault, while the innominate and muscular contractions have been found to be pathological factors. Lordosis may be a contributing cause. Loudon places considerable importance on cervical lesions and McConnell believes vasomotor disturbance plays an important causative role in the disease.
Pathologically, at times the kidney alteration may be so slight as not to be recognizable by the naked eye, the appearance varying according to the stage and severity of the disease. The kidneys become enlarged, engorged and of a bright red color, and later have a mottled appearance; and when the capsule, which is non-adherent, is stripped off, the kidney is found to be soft and inelastic. In most of the cases in which the disease is due to toxic agents brought to the kidney through the blood-vessels, the glomeruli suffer first. The epithelium of the glomeruli and tubules is the seat of cloudy swelling and, in the later stages, of fatty change and hyaline degeneration. The tubules are clogged by altered cells, leucocytes and blood-corpuscles. In mild cases the interstitial tissue is simply inflamed, but in all cases it becomes more or less mixed with leucocytes and red blood-corpuscles. Osteopathic lesions produced upon animals in the region of the ninth to the twelfth dorsal, resulted in acute nephritis. The autopsy findings were distinctly typical.
Symptoms.—The onset is usually sudden, with moderate fever, pain in the back in the lumbar region and over the kidneys and following the ureters. Nausea and vomiting may be present. Dropsy soon appears, beginning with slight swelling or puffiness in the face below the eyes, later showing itself in edema of the abdominal walls and extremities. Uremic symptoms may develop. The urine is characteristic; is diminished in quantity and of high specific gravity; at first the sediment is copious and reddish brown in color, becoming less in amount and of high color. This sediment contains casts of the uriniferous tubules, free blood, epithelial cells, uric acid and urates. There are large quantities of albumin in the urine.
The presence of albuminous matter in the urine, even in large quantities, is not sufficient evidence to warrant a diagnosis of Bright’s disease nor is the amount a guide as to the severity of the case, for grave conditions often show a slight amount (Loudon).[98]
Diagnosis.—The general symptoms may be very slight, for the most severe cases may manifest slight edema of the feet, or there may be only the puffiness under the eyes and of the eyelids. In such cases the diagnosis must depend upon examination of the urine. With previous history, suddenness of the attack and character of the urine, ordinarily the diagnosis will be quite easy.
Prognosis.—Although this disease is generally grave, the prognosis is favorable and the majority of cases recover under judicious treatment.
Treatment.—Cases of acute nephritis require rest, quiet and warmth. Many cases recover under these conditions alone. It is absolutely necessary, however, that these conditions exist no matter what other treatment is used. A thorough treatment to the renal splanchnics cannot be overestimated for it is here (tenth to twelfth dorsal, inclusive) that a majority of the lesions producing acute nephritis occur. Besides correcting the vertebral and rib displacements in this region, a very effective treatment is to have the patient lie flat upon the back and then the osteopath, reaching around the patient with the fingers of one hand on either side near the spines of the lower dorsal vertebræ, raise the patient so that the entire body, except the shoulders and the feet, are lifted clear of the bed. Thus the treatment springs the spine anteriorly and produces a marked effect upon the kidneys through the renal vasomotor nerves. Occasionally lesions in the upper cervical region interfere with the normal activity of the renal nerve fibers passing to the kidneys by way of the superior cervical ganglion of the sympathetics.
Another very effectual treatment for the kidneys is treating them through the abdomen by a careful pressure upon the kidneys through the abdomen on either side of the umbilicus, thus lightly working each kidney outward and upward. This treatment relaxes any tissues about the blood-vessels, nerves and lymphatics to and from the kidneys that may be contracted and thus aids in establishing a normal activity of the involved organs. It also helps in relaxing tissues about the ureters and prevents the clogging up of the latter with debris. Bandel and Stearns report cases in which an impacted colon was an important factor in this particular.
The above means have for their object the direct relief of the congestion of the kidney. This is further aided by keeping the bowels active, which supplements the action of the kidneys, and by increasing the activity of the skin. This also aids in relieving dropsical effusions. The hot pack, in which the patient is wrapped in a wet sheet and then covered by a number of blankets, is an exceedingly good method to relieve the kidneys of some of the work and lessen their congestion, besides arresting uremic intoxication. This can be repeated daily if necessary. Where there is dropsy and scanty urine, the indications are to increase the secreting action of the kidney; besides treatment through the renal splanchnics, which contain the vasomotor nerves of the kidneys, stimulating treatment to the vagi will help to increase the urinary secretion. Hot fomentations, placed directly over the region of the renal splanchnics, is a valuable aid in cases which do not respond quickly to osteopathic stimulation. Treatment of the liver is important. Injections of cold water into the intestines will tend to stimulate the secretion of the kidneys, but this should be used with the greatest caution; in some cases tepid water would be better (see uremia).
The diet of the patient with acute nephritis is important. Give food that is easy of digestion and which contains a minimum amount of nitrogen. The stomach is quite likely to be irritable, consequently food that is adapted to it should be selected. Milk and weak animal broths are undoubtedly the best foods. The return to a solid diet, especially of meat, should be very slow. Suitable adjuvants to the milk diet are rice and farinaceous preparations. Loudon[99] recommends complete withdrawal of all foods for twenty-four to forty-eight hours and the reducing of nitrogenous foods to a minimum; a diet of milk and cream after the fast, followed by cereals and broths, then eggs and fish until albumin disappears from the urine. Alkaline mineral waters are useful to help maintain an alkaline urine, thus tending to withdraw exudates. The patient should be treated daily at first and later on every other day, for case reports show frequent treatments hasten recovery.
For treatment of acute uremia in Bright’s disease, see uremia. Complications should be treated as affections independent of the renal disorder.
Chronic Parenchymatous Nephritis
Definition.—A chronic inflammation of the kidney, involving the epithelium, glomeruli and interstitial tissue, characterized by dropsy, increasing anemia, albuminous urine and acute uremia.
Osteopathic Etiology and Pathology.—It may be the result of acute nephritis. It follows the same diseases as already mentioned in acute nephritis. More often it follows the same diseases as already mentioned in the acute form, syphilis, tuberculosis, purulent conditions, focal infections (streptococcus), alcohol, scarlatina and pregnancy contributing the greater number. It is more common in the male sex and in early adult life. Habitual exposure to cold and dampness; chronic lesions of the spine, chiefly in the lower dorsal region, are causative factors.
Pathologically, the large white or a yellowish white kidney is the most common kidney lesion. In this form the kidney is enlarged, often to twice its normal size, is smooth, and the capsule very thin. The tubes, on microscopic examination, are found to be choked with broken down granulated epithelium and fibrinous casts. The capillaries show hyaline changes. The interstitial tissue is increased everywhere, but not to an extreme degree. Catarrhal swelling and hyperemia (to a slight degree) are found in the pelvis of the kidney.
In the second stage—that of the small white kidney—there is a reduction in the size of the organ, due to the destruction of the renal epithelium and the contraction of the overgrown connective tissue. Some hold that this may be a primary, independent form and not always preceded by the large white kidney. The organ is pale in color, rough and granular, the capsule being thickened and somewhat adherent. There is an accumulation of fatty epithelium in the convoluted tubules, constituting marked areas of fatty degeneration and giving the organ a white or whitish yellow appearance. It is this which gives the name of small granular fatty kidney to this form. There are extensive interstitial changes, degeneration of tubules and destruction of great numbers of the glomeruli.
Chronic hemorrhagic nephritis is a variety associated with this stage. The organ is enlarged, and scattered throughout the cortex are found brown hemorrhagic foci due to hemorrhages into and about the tubes. Otherwise the changes are similar with those found in the first form.
Symptoms.—It usually begins as a chronic affection and the symptoms slowly become apparent. Failing health and loss of strength, dyspepsia and anemia, waxy appearance with puffiness of the face, dropsy and increased arterial tension with hypertrophy of the left ventricle, gradually make their appearance. Uremic symptoms are common, while dropsy is marked and persistent. Vomiting and sometimes profuse diarrhea occur; in fatal cases there is sometimes found to be ulceration of the colon. The urine, as a rule, is diminished in quantity, is often very scanty, although it is frequently normal in color and appearance. There is an abundance of albumin, heavy sediment, hyaline and granular tube casts, epithelium from the kidneys and pelvis, leukocytes and often red blood-corpuscles. If fatty degeneration takes place, there will be fatty casts and oil globules. In the later stages the urine is abundant, low specific gravity, considerable albumin, and many casts.
Diagnosis.—In the inflammatory stage, where there is enlargement of the kidney, extreme pallor, scanty urine, albumin, and tube casts, history of infections, pregnancy, or exposure to cold and wet, and lesions in the lower dorsal region, the diagnosis is clear.
Prognosis.—Always give a guarded prognosis; relapses are frequent, but cases have been cured. There is always a tendency for the subchronic forms to become chronic.
Treatment.—The treatment requires persistent work, especially over the renal splanchnics, and strict attention on the part of the patient to hygienic principles. The lower dorsal lesions are very apt to be refractory owing to extensive fibrotic changes of the deep muscles and capsular ligaments. But repeated effort will usually secure results. Care should be taken as to exposure to cold and overexertion. The quality of the blood should be improved, as it is anemic and contains various toxic products. Strict attention should be paid to the diet. Iron is largely used for anemic conditions, but this principle we hold to be wrong. It is not more iron that is wanted, but an ability of the system to assimilate the iron which it has. Relative to diuretics von Noorden says: “It would be the greatest paradox to economize the renal work to the utmost in one direction (diet, sweating, etc.) and on the other hand excite them to increased activity by means of the strongest stimulants we possess, (drugs). I regard such prescribing as radically wrong.” The diet should be carefully selected and of minimum amount. The pure milk diet is undoubtedly the best. The use of meat seems to favor uremic convulsions.
The digestive organs should be kept in as good condition as possible, particular attention being paid to the liver and bowels. The use of suitable clothing is important; wool should be worn next to the body. The skin is a powerful adjuvant to kidney elimination, and the suppression of the action of the skin throws extra work on the kidneys. Possibly stimulation of the lung function would aid in the elimination. Rest, with a proper amount of fresh air and outdoor exercise, is essential.
In conditions calling for attention to the skin and bowels the treatment will be the same as in acute parenchymatous nephritis. There is a ganglion on each side of the umbilicus within a radius of an inch that sends fibers to the kidneys (Dr. Still). Just what is the function of these ganglia is unknown. The treatment of the complications is independent of that for the renal trouble. For direct treatment to the kidneys see acute Bright’s disease.
Interstitial Nephritis
Definition.—A chronic inflammation of the kidney in which there is reduction in its size due to an extensive destruction of the tubular substance, with an overgrowth, and later a contraction, of the connective tissue elements. Cardio-vascular changes, arteriosclerosis and cardiac hypertrophy are usually associated.
Osteopathic Etiology and Pathology.—Osteopathic lesions to the renal splanchnics are important predisposing causes. The disease may follow parenchymatous nephritis; or it may be caused by a continued passive congestion due to valvular heart disease. Gout; cystitis (often following gonorrhea), the inflammation extending up the ureters to the kidney; heredity; old age; long continued worry, anxiety or grief; chronic alcoholism, overeating; syphilis; tuberculosis; focal infections, especially of streptococci; chronic mineral poisoning (as from lead), and alterations in the renal ganglionic centers are causes. It chiefly occurs in males during middle life.
Pathologically, both kidneys are involved (although one may be more affected than the other), and reduced in size, often to less than half their normal size. After removing the capsule, which is thickened and adherent, the surface is found to be uneven, or granular and containing small cysts. The kidney is hard, tough and resistant, the color varying from a darkish brown to a yellowish gray. The cortical portion is especially reduced in size. On microscopic examination, the connective tissue appears greatly increased; this contracts, compressing the tubules and blood-vessels, causing their destruction. There is general arterial sclerosis, and the left side of the heart is hypertrophied. There are frequent nasal and retinal hemorrhages, due to the brittleness of the arterial walls which predispose them to rupture; hence, apoplexy is a frequent termination. The ganglionic centers, being interfered with, undergo fatty degeneration and atrophy. There are marked retinal changes—retinitis, fatty degeneration of the retinal tissues and sclerosis of the nerve fiber layers.
Symptoms.—The onset is insidious. In most cases the symptoms are latent. The general health is disturbed; there are frequent micturition, gastric disturbances, tense and bounding pulse, hypertrophy of the left ventricle, high blood pressure, disorders of vision, sleeplessness, headache, furred tongue, slight swelling of the feet, dry skin, scurvy and shortness of breath. The urine is increased in quantity, of acid reaction, light in color, low specific gravity, with a small amount of albumin, a few hyaline casts, and some epithelial cells. There is increased thirst and the patient may have to urinate two or three times during the night. There is well marked mucous cloud, slight sediment, and as the disease advances the urine may be diminished, the albumin increased and the casts become more numerous, while occasionally blood cells will be found.
Much importance should be attached to the blood pressure condition.
Diagnosis.—The early stages are not always recognizable. Later, while there is high arterial tension, thickening of the arterial walls and marked hypertrophy of the heart, the urine should be examined very carefully both night and morning, as the diagnosis will greatly depend upon the condition of the urine, which is increased in quantity, of low specific gravity, with a trace of albumin, narrow hyaline and pale granular casts, making the diagnosis usually easy.
Prognosis.—It is generally incurable, but favorable so far as the power to prolong life is concerned, provided the diagnosis be made early in the case, and the patient lives a quiet life. The case usually terminates with convulsions, coma and death. Apoplexy is frequently associated with chronic nephritis. In all forms of chronic nephritis some intercurrent infectious disease is quite possible, which is apt to be serious owing to the cachectic state.
Treatment.—The dietetic and hygienic treatment is the same as in chronic parenchymatous nephritis. The nerve and vascular supply to the kidneys should be treated as in acute parenchymatous nephritis. Freedom from worry and overwork, and if possible change of climate, should be prescribed. Frequent bathing, with friction of the skin, should be insisted upon and the bowels kept regular by a treatment of alkaline water. In all kidney cases special attention should be given the liver. The alkaline water is a good diuretic; besides it flushes the kidneys and helps to remove the debris.
These cases invariably present a rigid spine which should be carefully but thoroughly treated, traction being one of the methods that give comparatively quick and excellent results. Overcoming spinal immobility, correction of the dorsal area, attention to the chest rigidness, and frequently raising the abdominal organs will often considerably reduce the blood pressure.
The accidents and complications which so often endanger the patient, must be treated as they arise.
Amyloid Kidney
Definition.—A pathological state of the kidney in which there is a peculiar infiltration into the kidney structure of an albuminoid material of a waxy appearance.
Etiology and Pathology.—This is associated with Bright’s disease and other wasting diseases. It is most frequently caused by profuse and long continued suppuration, especially of the bones, by syphilis, tuberculosis, cancer, lead poisoning and gout.
Pathologically, the kidney is large and pale, but it may be normal in size or even small, pale and granular. The capsule is not adherent, the surface of the kidney, after removing the capsule, is pale and anemic. On section the cortex is seen to be enlarged. It is homogeneous, anemic, pale, waxy and resisting. On microscopic examination there is found to be an infiltration of a homogeneous or wax-like material. This progresses until all parts of the organ are infiltrated. As the result of this pressure the structures of the kidney undergo an atrophic degeneration, the kidney becoming contracted, smaller, rough and even distorted in shape. The cortex becomes narrowed and the capsule adherent. If a section of an amyloid kidney be stained with a solution of iodine, numerous mahogany red points appear.
Symptoms.—There are similar changes in the liver, spleen and often the intestinal canal. There is a profuse, watery diarrhea, due to amyloid changes in the intestinal canal, with loss of flesh and strength, edema of the lower extremities, and ascites. There is an increased flow of pale, watery urine, of low specific gravity; albumin is abundant and usually hyaline, often fatty or finally granular tube casts occur.
Prognosis.—As a rule the prognosis is decidedly unfavorable and it must be controlled by the disease with which it is associated.
Treatment.—The primary disease demands attention, otherwise the measures of treatment indicated are those of chronic parenchymatous nephritis, with special attention to the general health and surroundings of the patient. Give a generous diet and be persistent with the treatment.
Pyelitis
Pyelitis is inflammation of the pelvis of the kidney. When a suppurative inflammation extends into the interstitial tissue of the organ, it produces a condition called pyelonephritis. The inflammation usually starts in the pelvis of the kidney, the infection being carried there either by the circulation or the urinary tract, but it soon involves the rest of the kidney. Pyelitis is usually secondary to some other conditions such as urethritis, cystitis, or ureteritis. “Infection of the kidney rarely takes place through the blood and only when the vital membrane of the kidney is impaired.” It may start from within the organ in the interstitial tissue, caused by infectious embolism or traumatism, or the tubules may become obstructed by concretions.
Osteopathic Etiology and Pathology.—Retained decomposed urine due to pressure upon the ureters by tumors or bladder disease; calculus concretion, kinked ureter, displaced kidney, traumatic agencies, as falls, blows, strains, kicks or penetrating wounds; nephritis, pregnancy, cold and wet, are causes. Pyelitis may follow cystitis, the inflammation extending up the ureters to the pelvis of the kidney and thence to the substance of the organ, inducing pyelonephritis. Tuberculosis, focal infections, and intestinal disorders (colon bacillus), are other causes. Lesions from the ninth dorsal to second lumbar or lower, and malnutrition are predisposing factors.
Pathologically, the mucous membrane of the pelvis is usually the first affected, the inflammation generally extending from below upward. It is swollen and sometimes visibly congested and of a gray color. The pelvis and calyces are more or less dilated, while the papillæ are flattened. There is a gradual dilatation of the calyces and atrophy of the kidney substance, until the whole organ may be converted into a pus sac. If complete obstruction occurs, the fluid portion may be absorbed and the pus become inspissated and cheesy. The ureter is often dilated. In tuberculous pyelitis the apices of the pyramids are also invaded, the kidney substance is broken down and the result is the same. In the pyelitis caused by cystitis, the infection passes up the tubules or is carried by the lymphatics. The abscesses extend along the pyramids, burst through the papillæ and calyx into the pelvis of the kidney, and thus also the kidney becomes a purulent sac.
Symptoms.—Pain and tenderness over the region of the kidney first appear. In a few cases cystitis will be the only symptom. The suppurative stage is marked by high fever and a chill or a succession of chills. The general condition of the patient denotes prolonged suppuration. There is failure of health and more or less wasting and anemia. The urine is characteristic, contains pus, which varies in quantity greatly, and where only one kidney is affected, may be suppressed for a time and there will be a sudden outflow of the pus, due to the breaking of the sac. Blood is also very constant, but hardly ever of sufficient quantity to be seen by the naked eye. The urine is usually diminished in quantity and the color pale; the specific gravity is low on account of the small amount of urea present. The reaction of the urine is acid. Pus and blood render the urine slightly albuminous. Casts from the kidney, and even portions of the kidney, may be present.
Diagnosis.—From nephritis by the absence of much albumin, tube casts and dropsy. From cystitis, by the history, lumbar pains and acid urine. In cystitis the urine is always alkaline. From perinephritic abscess, by the absence of edema over the lumbar region. The urine may be normal and there are lumbar pains and hectic fever. In tuberculous pyelitis there is a history of tuberculosis in other organs and there are tubercles in the urine. Malaria or typhoid may be suspected. The X-ray and cystoscope should be employed. An exploratory incision may be necessary.
Prognosis.—Depends altogether on the cause and extent of kidney involvement. In simple cases and some tubercular, recovery may occur, although there is a tendency in all cases for the disease to become chronic.
Treatment.—Depends upon the cause, but thorough treatment along the lower dorsal, the lumbar and sacral regions will be of considerable benefit in controlling the catarrhal process in the kidney, its pelvis, the ureter and the bladder. If pathology permits, gently raising the kidneys, ureters and neighboring organs, knee-chest position, will materially assist circulation and drainage. Fresh spring waters for diluents and restricting the diet to light food, preferably milk, are indicated. Rest is important and warm applications locally are sometimes helpful. The general health must be carefully watched as there is always considerable drain upon the system. A timely operation may materially lengthen the life in many cases. Attention to the bladder, urethra and prostate is necessary.
Uremia
The name applied to a series of manifestations resulting from the retention of poisonous materials in the blood, which should have been removed by the kidneys. Uremic symptoms may occur any time during an attack of nephritis. In chronic cases it seems likely that extensive destruction of renal tissue is the principal factor that leads to the toxemia. They may also occur when the circulation of the blood in the kidneys is interfered with or the ureters are obstructed. They are not due alone to the urea (which is found to be increased in the blood), but more probably several poisons that are retained in the blood. Traube’s theory is that acute cerebral edema with anemia accounts for the symptoms. Halbert says: “A more recent and more plausible claim is to the effect that a poison is developed in the body as the result of nephritis,” for retention of effete matter or ligation of renal arteries and ureters or impaired renal activity does not fully explain the cause of the stupor, coma, convulsions, sometimes paralysis, and gastro-intestinal disorders.
Symptoms.—Loss of appetite, nausea, vomiting, headache and drowsiness are the initial symptoms. Headache is usually at the back of the head and may extend down the neck. The next symptom is coma, alternating with convulsions which may range from only a slight twitching to violent epileptiform spasms. These spasms may occur without the slightest warning and are often followed by blindness which may last for several days. These attacks of coma and convulsions are sometimes ascribed to localized edema of the brain.
Transient paralysis is also due to congestion or edema of the brain and it may be of the cord. There may be mania which comes on abruptly, although the delirium is not at all violent, while profound melancholia may be found. There may be nervous symptoms develop, such as numbness in the hands and fingers, itching of the skin and cramps in the muscles—especially those of calves of the legs. Pulmonary symptoms are sometimes continuous—dyspnea, paroxysmal dyspnea and Cheyne-Stokes’ breathing. These attacks of dyspnea may be as distressing as true asthma. Cheyne-Stokes’ breathing may be present without coma.
Uncontrollable vomiting may set in with great abruptness, followed by hiccough and purging. There may be a catarrhal or diphtheritic inflammation of the colon with diarrhea. The breath has a urinous odor and the tongue is often very foul. The pulse is slow and full, with a temperature below the normal, although during convulsions the pulse may become rapid and the temperature rise. Occasionally there are atypical forms of uremia which may be very confusing and obscure.
Diagnosis.—The history, subnormal temperature, the urinous odor of the breath, high arterial tension and increased second sound of the heart will distinguish the condition. Feeling of numbness, palpitation, headache, restlessness, mental wandering are not infrequently early symptoms. The phenolsulphonephthalein test for the secreting power of the kidney, and the examination of the urea in the blood are of great aid in diagnosis.
Prognosis.—Extremely grave, but one should always be very careful in his prognosis, for there is a possibility of recovery, even after the most serious symptoms have been manifested.
Treatment.—As impermeability of the kidneys produces uremia, by not allowing the various poisons to be eliminated by the renal path as they should be, the treatment must be applied directly to the kidneys. Elimination is demanded and if treatment through the abdomen to the kidneys directly and to the renal splanchnics does not bring about prompt and thorough elimination of the intoxicating properties, the bowels and skin must be made active. The vapor or hot air bath or hot pack should at once be used. An ice-bag to the head will be beneficial. An increase in the quantity of urine may be brought about by the displacement of a part of the mass of blood, which is in relative stagnation in certain parts of the vascular system. Forcing it into the main circulation in order to increase the pressure within the vessels of the kidney, is the treatment indicated. This great stagnant mass of blood is found in the arterial capillaries of the portal system in the liver and splenic tissues and should be manipulated into the general circulation in order to increase the arterial tension of the kidneys and thus favor elimination. The treatment should mainly be applied to the vasomotor nerves of the portal system, from the fifth to the ninth dorsal, and directly over the abdomen, liver and spleen.
The introduction of water, from 110 degrees to 120 degrees, or even 150 degrees, into the colon by means of injections, is useful; warm irrigations increase renal secretion, bowel action and sweating with a decrease of tension. Cold drinks will stimulate the abdominal vessels and induce absorption of a certain quantity of water to still further increase diuresis. Cold irrigation increases blood pressure temporarily, but later it lessens the pressure; it should be used only with great caution. Milk is one of the best drinks to be used. Secretions of the liver must not accumulate. The bile must be expelled so that its toxicity will not be added to the other poisons.
The food of the patient is an important matter. A milk diet is best; avoid meat and nitrogenous foods and any food that leaves much residue. In this way the nutrition of the patient is kept up with a minimum of urea formation and, besides, there will be very little intestinal putrefaction. Emergency measures not mentioned above are repeated high normal salt enemata (two to three pints), the alcohol sweat and venesection (about one pint). When the attack is broken the condition resolves itself into the renal disorder, generally acute Bright’s disease.
This disease illustrates one phase of the uselessness of drugs; for when the impermeability of the kidney has become such that it ceases to have the power of eliminating toxic substances formed by the organism, there is then retained the medicinal substances. The kidney is as impermeable for therapeutic poisons as for the natural poisons and the employment of toxic medicines in such cases has often no other effect than to bring an association of medicinal intoxication with an uremic.
Renal Calculus
Renal calculi are concretions formed by precipitation of solids derived from the urine, and are found in the kidney or its pelvis. If large, they are called stones; the smaller masses are known as gravel or sand, according to their size. When the stones attempt to pass through the ureters, it brings on an attack of renal colic; rarely are they voided without this symptom.
Osteopathic Etiology and Pathology.—The affection occurs at all ages, more commonly, however, in children and in old people. The male sex is more liable than the female. Sedentary habits, gout and excessive meat eating are predisposing causes. Heredity seems to be a predisposing cause in some families. Inflammation of the pelvis of the kidney, caused by derangement of the ribs and vertebræ of the tenth, eleventh and twelfth dorsals or first lumbar, is an important etiological factor.
Pathologically, the chemical varieties are:
(1) Uric acid and urates are the most common. The stones are usually smooth or lobulated; are hard and of a reddish color. Usually in these stones, both uric acid and urates are to be found. This material may be passed in the form of sand or large stones. The sediment in the urine may be the nuclei of the stones; as may foreign matters, such as the mucus or desquamated epithelium caused by the inflammation of the pelvis of the kidney, blood clots, or, in fact, any foreign matter that may reach the urinary passages. Individuals passing a small amount of urine, and old people are the principal subjects. “As a consequence of concentration and high acidity of the urine, the uric acid and urates are readily separated in solid form and held together by the albuminous matrix.”
(2) Phosphatic Calculi are white in color, soft and mortarlike. They are composed of phosphate of lime, ammonia and magnesium phosphate. These are found more often in the bladder than the kidney. Disease of the bladder is the cause.
(3) Oxalate of Lime are a mixture of oxalate of lime and uric acid. They are dark in color, very hard and uneven, with hard, pointed projections. On account of their uneven shape they have been named mulberry calculi. These stones produce great pain as they pass through the ureters.
There are other concretions of rare occurrence.
Symptoms.—There is pain in the back in the region of the kidneys with more or less tenderness. The pain may be severe and paroxysmal. There may be bleeding, which is seldom profuse; this will give the urine a smoky hue, but may be present to such a small degree as to be only apparent by the use of the microscope. The stone may obstruct the ureter and cause pyonephrosis or hydronephrosis. Pyelitis of a catarrhal character is common. In pyelitis there may be intermittent fever of several degrees, then sweating. There may or may not be pus in the urine.
Renal Colic is caused when the calculus attempts to pass through the ureter so that ureteral spasms result. The stone, however, may become lodged at the entrance to the ureter. There is a sudden onset and great pain which starts in the back, radiating downward into the groin, down the side of the thigh and into the testicle and glans penis. The testicle is often retracted, the face pale, the features pinched, and there is frequently vomiting. There are cold sweats and the pulse is weak. The paroxysm may last only a few minutes or extend over several hours. If uric acid is found, it points to uric acid or oxalate of lime calculi and the urine is acid in reaction. If alkaline phosphatic stones may be suspected, examination of the urine directly after the attack aids greatly in diagnosis, for at other times the urine is usually negative.
Diagnosis.—Biliary Colic.—The jaundice in biliary colic comes on very soon after the obstruction begins. The stools are without bile and the pain extends from the right hypochondriac region to the upper abdomen and the right shoulder. The urine is negative and a stone may be passed in the stools. Renal colic is often simulated when the ureter is obstructed from any cause whatever. It may be compressed from a floating kidney or tumor, or obstructed by a clot of blood, fragments of hydatid cysts or plugs of mucus. Lumbo-abdominal neuralgia, intestinal colic, and renal tuberculosis may simulate renal colic. The X-ray plate is of decided value.
Prognosis.—As complications may arise, it is best to give a guarded prognosis, but the prognosis is generally favorable. It is a disease that is very apt to recur when strains or falls affect the innervation to the kidney, but many cases have been permanently cured. If the stone is large, its passage along the ureter may prove fatal unless surgical interference is instituted at once, but if it is renal sand it may be easily voided in the urine and thus the prognosis will be favorable.
Treatment.—Treatment should be given toward overcoming the cause producing the calculi, which will often be found at the tenth rib. Treat the kidneys thoroughly, both through the renal splanchnics and directly through the abdomen, anteriorly. But direct abdominal treatment should be given very cautiously. Treatment here corrects disorders and seems to release some solvent that acts upon the various forms of calculi and disintegrates the ones already formed and prevents the formation of others. Possibly this solvent is an internal secretion of some gland; possibly like the splenic secretion is to the biliary calculi (Dr. Still.). Dr. Still held that one of the functions of the suprarenal capsule was to prevent the formation of these concretions.
In the uric acid tendency, the free use of alkaline mineral waters for the solution of uric acid may be helpful. Much may be done by dieting. The amount of nitrogenous food should be limited, eating a minimum amount of meat and using plenty of milk and vegetables. In the phosphatic tendency, diluted drinks freely used are helpful. Meats are indicated. Milk and vegetables should not be used freely as they tend to make the urine alkaline. In all instances care of the general health and avoidance of beer drinking and excessive meat eating are demanded.
During an attack of renal colic, when a stone had lodged in a ureter, one may be able, by very careful manipulation, to aid the stone in its progress downward, (somewhat after the manner of manipulating gall-stones), but do not delay surgical measures too long. By inhibiting the nerve force of the spinal nerves along the lumbar and sacral regions (chiefly tenth dorsal and first lumbar), relief may be given. The nerves of the ureters are derived from the inferior mesenteric, spermatic and pelvic plexuses. Employ the hot bath; this may relax the spastic condition. Cloths wrung out of hot water and applied locally are of aid. Occasionally a change of posture will give relief. Even inversion of the patient is sometimes followed by immediate cessation of the pain. The patient may drink freely of hot lemonade or water. An anesthetic may be of aid in the manipulation of a renal calculus in the ureter, as the anesthetic will relax the tissues over the abdomen, making it much easier for one to get near the impacted calculus, but be cautious. Morphine may be necessary. During the intervals the patient should lead a quiet life and avoid sudden exertions of any kind. It is important to keep the urine abundant, consequently have the patient drink a large quantity of distilled water. “Renal calculus is brought about by lesions affecting the suprarenal capsule of the kidney, or spinal lesions from the tenth dorsal to the first lumbar, affecting the lower ribs.”
Movable Kidney
This means a distinctly mobile condition of the kidney (almost always acquired, but may be congenital), due to the lax condition of the tissues which support it and to the elongation of the renal vessels which allow the kidney to move in certain directions. Rapid loss of tissue that absorbs the fat surrounding the kidney is a cause. There are almost invariably lesions in the dorso-lumbar region that predispose to an abnormal mobility of the kidney. These lesions undoubtedly weaken the innervation to the surrounding and supporting kidney structures. A posterior spine, with consequent downward and constricting displacement of the floating ribs, is common, although lateral and anterior spines (dorso-lumbar region) may be found. Strains, heavy lifting, and various violent exertions are important exciting factors. Tight lacing, pregnancies, an enlarged liver and gastro— and enteroptosis are also important factors. This condition is found more commonly in women, and undoubtedly is a frequent cause of direct, gastro-intestinal, reflex, and obscure disturbances. There are very different degrees of mobility in different cases. It may be so slight as hardly to be recognized or so great that it can easily be felt by the hand through the abdominal walls, resembling a movable tumor in the abdomen.
Symptoms.—Often there are no noticeable symptoms. Sometimes when the displacement and mobility of the kidney are most marked, the reflex symptoms are not noticeable. The right kidney is the one usually affected, on account of its relation to the liver which moves during the respiratory act. Usually there is pain in the lumbar region and the patient experiences a heavy, dragging pain in the abdomen, which especially manifests itself while standing and walking. There may be intercostal neuralgia. Various colicky and other gastro-intestinal pains, and nervous symptoms as neurasthenia, melancholia, hysteria and headache are common. There may be obstinate indigestion, palpitation of the heart, flatulence and cardialgia; also, an irritable bladder, due to pressure. At times the kidney becomes tender and swollen as a result of twisting of the renal vessels or of the ureter (Dietl’s crises), causing engorgement of the organ; this may be associated with agonizing pain and symptoms of collapse. Hydronephrosis may be manifested.
Diagnosis.—The shape of the tumor, marked mobility, and lessened resistance on percussion of the renal region will make the diagnosis. The disorder very rarely proves fatal. In doubtful cases utilize the X-ray.
Treatment.—Many cases rarely give trouble directly, but may be a source of reflex and obscure symptoms. Attention to the general health of the patient and persistent treatment of the dorso-lumbar region greatly strengthen the relaxed tissues about the kidney and cure a number of cases. Having the patient attempt to replace the organ after he goes to bed will be of value. Treatment of the abdomen to strengthen the walls and lessen any liver congestion and to keep the bowels active is very beneficial. Teach the patient how to stand and walk correctly, especially holding the abdomen in and up. A liberal diet to the point of increasing the weight is worthy of trial. The use of supports is not always satisfactory. Surgical treatment for fixing the kidney is of permanent value, but do not advise operation unless absolutely indicated. (See Prolapsed Organs, Part I).
To determine the presence of a movable kidney, it is best to have the patient in the dorsal position, the head slightly lowered and the abdominal walls relaxed by flexing the thighs moderately upon the abdomen. Then with the left hand in the lumbar region behind the eleventh and twelfth ribs, and the right hand in the hypochondriac region, the kidney can usually be detected after full inspiration followed by complete expiration; or, have the patient in a standing posture with the body bent slightly forward and the hands placed upon a table, then perform bimanual palpation; or, perform the manipulation in the knee-elbow position. When in this position (knee-elbow), if the kidney has become dislodged, a resonant note will be obtained by percussion over the normal location of the kidney.