Diseases of the Kidney

Its early stages pass unrecognized, though it may well be looked for in hearty eaters where a habit of high arterial tension exists. Of the early manifestations, increased arterial tension is the most important. Close following it we find hypertrophy of the left ventricle, with eventual enlargement of the entire organ, and corresponding changes in the character of the apex beat. A systolic murmur, heard at the apex and transmitted to the left, may develop later. The central nervous changes are those noted under uraemia*. Retinitis, choked disc, and amaurosis are frequent ocular symptoms, and ringing in the ears and sudden deafness may occur.

Gastro-intestinal symptoms such as anorexia, nausea, vomiting, and diarrhea are almost always present in greater or less degree. The tongue is generally coated. It may be red, dry and cracked, or moist and glazed, or covered in brownish scum, or furred and foul. Uraemic, and often cardiac, dyspnoea is of frequent occurrence; bronchitis is a very regular accompaniment; oedema of the lungs is often seen toward the last; and oedema of the glottis may occur. Eczema, dry and itchy skin, ‘pin and needles’, cramp, numbness, and other cutaneous and nervous manifestations occur although oedema is rare. Where present it is generally merely a slight puffiness in the feet and ankles. -pg. 934-935.

Polyuria, persistent low specific gravity, and the presence of a few hyaline casts constitute the urinary signs of this disease. Albumin may or may not be present in small quantity. -pg. 646.

Butler, G. R. (1902). The Diagnostics of internal medicine: a clinical treatise upon the recognised principles of medical diagnosis. New York: Appleton.

Entered by: Erin Choi, 06/11/2020

(a) Bilateral tumors in the renal regions, which may increase in size under observation. They may cause great enlargement of the upper zone of the abdomen. The colon and stomach are in front of the tumors, on the surface of which in very thin subjects the cysts may be palpable. (b) Haematuria, which may recur at intervals for years. (c) The signs of a chronic interstitial nephritis—(1) pallor or muddy complexion; in rare instances a bronzing of the skin; (2) sclerosis of the (3) hypertrophy of the heart with accentuated second sounds; (4) urine abundant, of low specific gravity, with albumin, and hyaline and granular tube-casts, and in one of my cases there were cholesterin crystals. […] A rare event in rupture of a cyst with the formation of a perinephric abscess and peritonitis. […] Occasionally the kidneys and liver present numerous small cysts scattered through the substance. The spleen and the thyroid also may be involved, and there may be congenital malformation of the heart. The cyst in the kidney are small, and neither so numerous nor so thickly set as in the conglomerate form, through in these cases the condition is probably the result of some congenital defect.

Osler, W. (1909). The Principles and Practice of Medicine (7th ed.). London: Appleton and Co. Pg. 716.

Entered by: Erin Choi, 7/17/2020

Definition.- Dilatation of the pelvis and calyces of the kidney with trophy of its substance, caused by the accumulation of non-purulent fluids the result of obstruction.

Symptoms.—When small, it may not be noticed. The congenital when bilateral usually prove fatal within a few days; when unilateral, the tumor may not be noticed for some time. It increases progressively and has all the characters of a tumor in the renal region. In adult life many of the cases, due to pressure by tumors, as in cancer of the uterus and enlargement of the prostate, etc., give rise to no symptoms.

There are remarkable instances of intermittent hydronephrosis in which the tumor suddenly disappears with the discharge of a large quantity of clear fluid. The sac gradually refills, and the process may be repeated for years. In these cases, the obstruction is unilateral; a cicatricial stricture exists, or a valve is present in the ureter, or the ureter enters the upper part of the pelvis.

The examination of the abdomen shows, in unilateral hydronephrosis, a tumor occupying the renal region. When of moderate size it is readily recognized, but when large it may be confounded with ovarian or other tumors. In young children it may be mistaken for sarcoma of the kidney or of the retroperitoneal glands, the common causes of abdominal tumor in early life. Aspiration alone would enable us to differentiate between hydronephrosis and tumor. The large hydronephrotic sac is frequently mistaken for ovarian tumor. The latter is, as a rule, more mobile and rarely fills the deeper portion of the lumbar region so thoroughly. The ascending colon can often be detected passing over the renal tumor, and examination per vaginam, particularly under ether, will give important indications as to the condition of the ovaries. In doubtful cases the sac should be aspirated. The fluid of the renal cyst is clear, or turbid from the presence of cell elements, rarely colloid in character; the specific gravity is low; albumen and traces of urea and uric acid are usually present; and the epithelial elements in it may be similar to those found in the pelvis of the kidney. In old sacs, however, the fluid may not be characteristic since the urinary salts disappear, but in one case of several years’ duration oxalate of lime and urea were found.

Perhaps the greatest difficulty is offered by the condition of hydronephrosis in a movable kidney. Here, the history of sudden disappearance of the tumor with the passage of a large quantity of clear fluid would be a point of great importance in the diagnosis. In those rare instances of an enormous sac filling the entire abdomen, and sometimes mistaken for ascites, the character of the fluid might be the only point of difference. The tumor of pyonephrosis may be practically the same in physical characteristics. Fever is usually present, and pus is often found in the urine. In these cases, when in doubt, exploratory puncture should be made.

The outlook in hydronephrosis depends much upon the cause. When single, the condition may never produce serious trouble, and the intermittent cases may persist for years. The latter are the most hopeful and Frederick Taylor mentions an instance in which, after the fifth or sixth subsidence, in the course of two years, a calculus was discharged. Occasionally the cyst ruptures into the peritoneum, more rarely through the diaphragm into the lung. A remarkable case of this kind is at present under the care of my colleague, Halsted. A man, aged twenty-one, had, from his second year, attacks of abdominal pain in which a swelling would appear between the hip and costal margin and subside with the passage of a large amount of urine. In January 1888, the sac discharged through the right lung. Reaccumulations have occurred on several occasions since, and on June 9, 1891, the sac was opened and drained.

The sac may discharge spontaneously through the ureter and the fluid never reaccumulate. In bilateral hydronephrosis there is a danger that uraemia may supervene. There are instances, too, in which blocking of the ureter on the sound side by calculus has been followed by uraemia. And, lastly, the sac may suppurate, and the condition change to one of pyonephrosis.

Osler, W. (1892). The principles and practice of medicine: Designed for the use of practitioners and student of medicine. New York, NY: D. Appleton and Company..

Entered by: Erin Choi, 06/11/2020

There is a sharp pain about the region of the kidneys, with some degree of fever, and a stupor or dull pain in the thigh of the affected side. The urine is at first clear, and afterwards of a reddish colour ; but in the worst kind of the disease it generally continues pale, is passed with difficulty, and commonly in small quantities at a time. The patient feels great uneasiness when he endeavours to walk or sit upright. He lies with most ease on the affected side, and has generally a nausea or vomiting, resembling that which happens in the colic. This disease, however, may be distinguished from the colic by the pain being seated farther back, and by the difficulty of passing urine, with which it is constantly attended.

Buchan W. (1793). Domestic Medicine, or, a treatise on the prevention and cure of diseases by regimen and simple medicines. (14th Ed., pp. 246). Boston : Printed by Joseph Bumstead, for James White, and Ebenezer Larkin.

Created by: Sara Ahmed, 06/08/2021

Entered by: Rachel Johnson, 07/19/2021

1. Renal colic
It is characterized by agonizing pain, which starts in the flank of the affected side, passes down the ureter, and is felt in the testicle and along the inner side of the thigh. The pain may also radiate throughout the abdomen and chest and may be very intense in the back. In severe attacks there are nausea and vomiting and the patient is collapsed. The perspiration breaks out upon the face and the pulse is feeble and quick. A chill may precede the outbreak, and the temperature may rise as high as 103 o . […] Micturition is frequent, occasionally painful, and the urine, as a rule, is bloody. There are instances in which a large amount of clear urine is passes, probably from the other kidney. 

2. When the calculi remain in the kidney
(1) Pain, usually in the back, which is often no more than a dull soreness, but which may be severe and come on in paroxysms. It is usually on the side affected, but may be referred to the opposite kidney, and there are instances in which the pain has been confined to the sound side. It radiates in the direction of the ureter, and may be felt in the scrotum or even in the penis. […] (2) Haematuria.- Although this occurs most frequently when the stone becomes engaged in the ureter, it may also come on when the stones are in the pelvis. […] It is aggravated by exertion and lessened by rest. Frequently it only gives the urine a smoky hue. […] (3) Pyelitis.- There may be attacks of severe pain in the back, not amounting to actual colic, which are initiated by a heavy chill followed by fever, in which the temperature may reach 104 o or 105 o , followed by profuse sweating. The urine, which has been clear, may become turbid and smoky and contain blood and abundant epithelium from the pelvis. Attacks of this description may recur at intervals for months or even years […] (4) Pyuria.- There are instances of a stone in the kidney in which pus occurs continuously or intermittently in the urine for many years.

Osler, W. (1909). The Principles and Practice of Medicine (7th ed.). London: Appleton and Co. Pg. 711-712

Entered by: Erin Choi, 6/9/20

The diagnostic symptoms of pyelitis are local pain or uneasiness referable to the lumbar region on one side or on both sides; the presence of pus in the urine, with mucus and sometimes a little blood, together with epithelial cells from the pelvis of the kidney. The pus does not appear suddenly in more or less abundance, as in cases of renal abscess; at first small in quantity, it gradually increases, rendering the urine opaque, and subsiding to the bottom after a specimen has been allowed to remain undisturbed. The urine, if there be no obstruction, generally gives an acid reaction.

Pyelitis is attributable to calculi when it is preceded or accompanied by attacks of pain caused by the passage of calculi from the pelvis of the kidney to the bladder, especially if the inflammation be unilateral and on the same side as the colic.

Flint, A. (1879). Clinical medicine: a systematic treatise on the diagnosis and treatment of diseases ; designed for the use of students and practitioners of medicine. London: Churchill. Pg. 431.

Entered by: Erin Choi, 6/19/2020