EXAMINATION OF THE KIDNEYS, INSPECTION, PERCUSSION, PALPATION When pathological conditions of the kidneys are suspected it is necessary to examine not only the urine, the importance of which has already been emphasized at the beginning of this chapter, but the body as a whole. The methods of physical diagnosis will serve this purpose. They should include not only the examination of the diseased organ itself, but of the rest of the body, especially the heart, vascular system, and the funclus of the eye. Some of the physical methods of examin ing the kidney in infancy deserve to be employed more often than has been the custom hitherto. These methods are, besides inspection, pal pation, and percussion, the use of the X-ray, the cystoscope, the ureteral catheter, and the other methods of obtaining the separate urine from each kidney. It is true, however, that experience with these methods encourages their use only in older children, The local inspection, aecording to Strauss, is best made by compar ing from behind, one side with the other, first with the child prone, and afterwards in the erect position. In many cases of large renal tumor, or of hydronephrosis, bulging may be detected either at the side, behind, or in the abdomen. The presence of an (edematous swelling or of red dening of the skin near the loins is of value for the diagnosis of inflam matory processes in or near the kidneys, and of peri-, and paranephritie suppuration.
In regard to percussinn of the kidneys, Steffen says that it is quite possible in any child to determine the percussion limits of the kidneys above, below, and laterally. In diseases of the kidney, if daily exami nations are made, and recorded upon the skin with a colored pencil, thc variations in volume (increase and decrease) can be distinctly recog nized. Other observers believe that the results of renal percussion are of little value, and it is probable that in practice the method is only use ful in so far as it controls the results of palpation.
The palpation of the kidneys determines the local tenderness to pressure, changes in size, position, consistency, and mobility. It is best made with both hands with the patient in the dorsal position, and it is well to first have the bowels and bladder well emptied. Accord
ing to Israel. the best attitude in most cases is the semi-lateral, in which the patient lies midway between the dorsal and the full lateral position. so that the frontal plane of the body meets the plane of the table at an angle of 45 to 50 degrees. After the patient has been put in the dorsal or semi-lateral position, place the flattened finger tips immediately beneath the last rib, a little in front of the lateral edge of the longissi mus dorsi, and place the whole palm of the other hand, with the fingers fully extended, upon the surface of the abdomen 60 that the tips of the second and third fingers are beneath the tenth rib. In this manner, aceording to Israel, by gentle counter pressure. from above during deep inspiration, one may even feel small tumor masses of the posterior plane or the convex edge of the kidney glide down from beneath the twelfth rib. In adults, normal sized kidneys which are in their proper location can be felt only under the most favorable conditions, and there are probably only a few physicians who are able to palpate, as Israel does, the lower pole of any- normal kidney. In the case of children the conditions are more favorable since the kidneys extend lower towards the pelvis, and this is particularly true in regard to the babe. In babies of less than three months, Knopfelmacher recommends rectal palpation. "The procedure is as follows:--Place the left hand near the loins, and press lightly with the slightly bent fingers upon the muscles during the introduction of the well greased index finger into the rectum. Ac cording to the age, ancl the size and position of the sigmoid flexure, one will succeed in palpating one or both kidneys." It is generally easier to palpate the right than the left kidney, owing to its lower position on the right side. By this method the lower third or half of the kidney may be explored by the linger. The dorsal or semi-lateral position should be assumed by the child. or if the belly is too rigid, it may be done in the warm bath or under narcosis. While using this method, it is possible to confirm the observation of Iiiidinger, Israel, Litton, Wolkow, and others that the kidney under physiological conditions, MOVVS with the respiration.