Vague Abdominal Discomforts Loose Kidney





After the vague pains around joints so commonly called rheumatic, and

which occur so frequently that probably there is no one over forty who

is quite ready to confess that he has not had rheumatism, the most

important source of vague discomfort is the abdominal region. This

occurs particularly in people who are engaged in a sedentary

occupation which prevents much exercise, keeps them indoors, and gives

them abundant opportunity as a rule for introspection and dwelling

upon their sensations. There are few people who live the intellectual

life who have not suffered from some of this abdominal discomfort,

which they presumed must mean some definite lesion, or portend some

serious development, and yet, as a rule, they have lived for years

afterward without any of their fears proving true.



Physicians are not spared from this source of worry and discomfort.

They suffer from it even a little more than others. Their knowledge of

the possibilities of serious pathological developments within the

abdomen, especially after the age of forty, makes them a little more

concerned as to the significance of these vague discomforts.



At least half a dozen times a year, for the last ten years, I have

heard physicians say that they were sure that some organ or other

within was not performing its function properly, and that there was

probably some organic lesion. The thought has usually been in their

minds for months, sometimes for years, and they have come to be

thoroughly examined. Sometimes they rather expect to be told that they

should go to a surgeon. They are usually half concealing a question as

to how soon they should set about putting their affairs to rights and

how serious the outlook is. As a rule, I am able to dismiss them

without any further treatment than the injunction not to think so

persistently about certain obscure feelings which they are allowing to

occupy their consciousness. Sometimes I know they take the

advice--even oftener, perhaps, I know they do not. Once it has got

hold of us, it is hard to get away from morbid introspection, and I

sometimes hear of them consulting others. All of these patients are

improved for a time after their consultation by the reassurance that

so long as they have a good appetite--which is the case with all of

them--and their bowels are regular--which unfortunately is not the

case with most of them--and so long as they sleep well and have no

acute pain, there is little likelihood of any serious latent abdominal

condition.



Such reassurance cannot be given until the abdominal region is

carefully palpated, and especially the right side explored as

thoroughly as possible. Here lies the appendix, the head of the

colon, which is sometimes the seat of trouble not necessarily

originating in the appendix. Just above them one may find a loose

kidney, for the right kidney is more likely to be movable than the

left, because of the overhanging liver, and finally the gall-bladder,

and the bile passages, so likely to be the seat of serious trouble. If

none of these organs are tender on deep palpation, if the kidney does

not come down when the patient is examined in the standing position,

if there are no serious derangements of digestion, except such as can

be attributed to nervous indigestion, and if there is no dilatation of

the stomach, and no enlargement of the spleen, there is no reason why

one should do anything but try to get the patient's mind off himself.



There is always the danger of overlooking an abdominal cancer, in

these eases, though with the care in diagnosis I have suggested this

is minimal. The best therapeutic test that I know to determine this,

if there should be any doubt, is to put the patient on an increased

diet and watch the scales. If he is able to digest the added food

well, and without trouble, and if he proceeds promptly to gain in

weight, there is much less than one chance in a hundred that he is the

subject of latent cancer in the abdominal region. The old farmer's

maxim is: "A sick hog don't get fat." When human beings properly

respond to increased feeding, it is probable, not only that there is

nothing serious the matter with them, but that the symptoms of which

they complained before may very likely have been due to lack of

nutrition. The digestive organs not having enough to occupy them, were

tempted to digest themselves, or at least to have their function

disturbed by the short circuiting of nervous energy looking for

something to do.



I have seen a number of these cases that had been operated on for

vague discomfort--some whose appendices had been removed, some whose

kidneys had been fastened up because they were slightly movable, some

whose gall passages had been examined for adhesions that were supposed

to exist, or perhaps for a stone that it was thought might be found

there, and except where some actual organic lesion was found and

relieved, none of them was materially improved when seen several years

after operation. I have heard reports of cures of these cases by

surgeons who felt that the removal of an appendix presumed to show a

catarrhal process, or a hyperemia, or an adhesion at its tip, had

meant the cure of vague abdominal discomfort which had continued for

many years and made the patient profoundly miserable. But these

reports were founded on the patient's condition at the end of

convalescence after the operation, and not on the condition that

established itself some months, or perhaps a year, later. Operations

on the abdomen, except for very definite indications, have, in my

experience, always done more harm than good, and I have seen serious

conditions--hernia, displacement of organs and disturbance of the

peristalsis of the intestines--develop subsequent to them.



I have in mind two typical cases. One was a physician whom I had seen

on a number of occasions, and who complained of vague discomfort,

mainly in the right side of the abdomen, though never acute, never

accompanied by fever, nor even by any disturbance of pulse when he was

not in an excitable mood. His bowels were not always regular, and he

had had some disturbance of circulation as the result of thrombosis of

veins on that side after an attack of typhoid fever. My opinion

was that his discomfort was entirely due to the disturbance of

circulation. There was probably some interference with the normal full

circulation to the large intestine, in its ascending portion, that

gave him a feeling of uneasiness, or of consciousness of its function.

Eventually he became convinced that he was suffering from a chronic

form of appendicitis. After considerable persuasion he convinced a

surgeon friend that his appendix should be removed, and the operation

was done. I saw his appendix afterwards. It was supposed to be

thickened, but considering the normal limits of size of the appendix,

I could not think that it was beyond them in any marked way. At most

there was but a slight catarrhal inflammation.



For a time after operation he was much improved. He felt confident

that all his trouble has disappeared, and he took some pains to

impress me with the supposed fact that in these vague cases of

discomfort there was always some underlying organic lesion that needed

surgical treatment. During convalescence he had gained in weight, and

was looking very well. When I met him a year and a half later he said

that some of his discomfort had returned. He had grown thinner and was

feeling discouraged. Six months later he was about to submit to

another operation, this time for the breaking up of adhesions in the

neighborhood of his gall-bladder. He had become convinced that this

must be the seat of the difficulty. After this operation he was sure,

beyond peradventure, that his trouble was gone never to return. Two

years later I found him preparing to have his right kidney sewed up. I

had known that his right kidney was slightly movable, but it did not

move sufficiently to cause any disturbance of kidney function, and

certainly not enough to justify serious surgical intervention.



After this operation I met him once casually and he assured me that

now everything was surely all right. I have since heard that he

submitted to an operation either for the breaking up of some adhesions

around his stomach or in order to tuck up that organ for ptosis. It

had not been quite decided whether an adhesion caused a slight

hour-glass constriction of the stomach, with some dilatation of the

splenic end of the fundus, or whether there had been some actual

sagging. I am sure that after this operation, as after preceding ones,

with the strong suggestion that he ought to be better and an increase

of weight during convalescence, he lost his vague abdominal discomfort

for a time, though I have no doubt that it either has or will return.

When he gets something to so occupy his mind that he does not dwell

too much on his discomfort, he will not increase it to the extent that

makes it intolerable. Then he will remember that most people have some

discomfort, and he will learn to distract his mind, rather than allow

it to dwell on the thought of his particular ailment until it becomes

intolerable.



It has taken twelve years or more to develop this case to the point

where it is as instructive as it now is, and it is a typical example

of what may happen even to a physician. There are other cases in my

notes that are quite as instructive, two of them occurring in

thoroughly educated men, clergymen who were of good intellectual

capacity, but who became too much occupied with themselves. One of

these had more operations done on him than my friend the physician. He

first had his appendix removed, and was better for a time. Then his

kidney was fastened up, and improvement once more took place. After

this he lost in weight considerably and suffered so much from

headaches that a friendly surgeon suggested that there must be

adhesions between his dura and his brain. Accordingly a trephining was

done, and these adhesions, real or supposed, were broken up. For a

time he seemed to be better. Then he had some urinary trouble. A long

prepuce, though one that was never tight or adherent, and only

required a little attention to cleanliness to keep it from giving

bother, was removed. Some disturbance of his appetite led him to limit

his eating for a time, and then he suffered from constipation. This

was diagnosed by a specialist in rectal troubles as due to abnormally

developed valves in his rectum, and these were cut. He still

complained very much of abdominal discomfort at times. This was

diagnosed as ptosis of his organs, and an operation was done to tuck

these up. After this he developed a large ventral hernia, which had to

be relieved by a subsequent operation.



I had followed the case carefully during many years, seeing him at

times, and I was always opposed to the idea of operation and fully

confident that none of the operations were really needed. He could not

be persuaded that what his case needed most was occupation of mind

with something besides his condition. Whenever I could persuade him of

this I had seen him gain in weight, get into much better spirits and

be almost able to take up his work again. Then he would become

discouraged, and before long I would hear of another operation that

was planned, or was about to be performed. During the course of one of

his many progressive losses in weight as a consequence of depression

of mind, he developed tuberculosis. He resisted this very well, but

eventually died rather suddenly of an empyema. A careful autopsy

showed nothing but the traces of former operations, and no reason why

they should have been done.



Another case: A friend, also a clergyman, had three operations done,

one of them circumcision, the second an appendectomy and the third on

a supposed floating kidney. None were indicated, so far as I could

see, by any definite symptoms, or justified by his condition. He had

vague abdominal discomfort, and this continued to bother him in spite

of treatment by various specialists, and his mind became so much

occupied with it that he was ready to submit to anything in order to

be rid of his burden of discomfort. At no time was it an ache, nor did

he ever speak of it as a pain. He had some tendency to dilatation of

the stomach and at times, when much occupied with indoor work and

neglecting muscular exercise, there was probably some delay of

digestion. His appetite was good whenever he would let it be; his

bowels were regular whenever he was eating sufficient to stimulate

them to normal function; he slept well, except when unnerved by

something, but the presence of this abdominal discomfort disturbed

most of his waking hours. He could stand it so far as it had gone, but

he was sure that it would become so much worse in the future that it

would be unbearable. He dreaded that cancer or some other awful

development would come after a time.



As a matter of fact, the main portion of the discomfort in these cases

is the dread of what may happen. It is a dread, just as misophobia or

claustrophobia or acrophobia or any of the other dreads that we

discuss in the chapter on that subject. The constant occupation with

this dread apparently inhibits to some degree the flow of nerve

impulses to the abdominal organs, and digestion, already disturbed, is

still more impaired. Indeed, the whole of the discomfort seems

to be a consciousness of stomach and intestinal function rather than

anything more serious. The stomach will take two or three pounds or

even more of mingled liquids and solids at a meal and pass them on to

the intestines without forcing itself into the field of our

consciousness. Anyone who is aware what a thin-walled membranous bag

the human stomach is--what it most nearly resembles is perhaps the

familiar bladder of the cow--may well be surprised that, though it is

supplied with many sensitive nerves, it gives so little sign of the

load that is often placed in it. It may, however, be brought rather

poignantly into the sphere of consciousness by concentration of

attention on it.



The intestines function usually with the same lack of reflex. They

proceed to pass on this quantity of food, store up two or three days'

rations, digest what is nutritious and eliminate what must be

rejected, without rising into consciousness. If either stomach or

intestines once begin to attract attention, then it will be difficult,

unless care is exercised to distract the mind from them, to replace

and keep them back in the sphere of the unconscious once more.

Peristaltic movements are constantly taking place in the digestive

tract. Various things may interfere with peristalsis, and the

disturbance of it will almost surely cause some sensation. It may not

be serious, and digestive processes may continue, yet there may be

discomfort. If there is delay in the passage of food, gas accumulates

in the stomach, presses up against the diaphragm and interferes with

the heart action. This will give rise to many bothersome sensations,

some of which are felt in the heart region itself; others much lower

down on the left side, where it is rather hard to recognize just what

the real seat of them may be. A good deal of the abdominal discomfort

of which people complain, is due to such functional disturbances,

emphasized by the fact that digestive action has come into the sphere

of consciousness and now attention is being concentrated on it, to the

detriment of digestion itself, as well as to the increase of the

annoyance which the discomfort may occasion.



Operations for abdominal discomfort are quite contra-indicated, unless

there are very definite localizing symptoms of some pathological

lesion that can surely be relieved by operative intervention. To

operate on general principles is sure to emphasize the patient's

concentration of attention on his abdominal discomfort, if it does not

relieve it, and in most of these cases it utterly fails. The strong

suggestion of an operation will relieve for the time being, just as

operations for epilepsy seemed to relieve when that procedure was

first introduced, though now, unless there are definite localizing

signs, there is no question of such an operation.





Toxic Factors.--Tea.--A very interesting phase of abdominal

discomfort seems to be associated with the taking of nerve stimulants.

I have frequently found that patients who complained of vague

abdominal uneasiness, sometimes rising particularly at night to the

height of colicky feelings but always on the left side, were indulging

to excess in tea or coffee. In one case, a woman was taking, she

thought, about a dozen cups of tea a day. Just how much more than this

she actually was taking I do not know, for it is almost incredible the

amount of tea that middle-aged women who are alone may take. I once

found by actual count made for me, that a woman was taking almost a

score of cups of tea in each twenty-four hours.







Just as soon as there is a reduction in the amount of tea taken in

these cases, relief is afforded the patient. This relief will not,

however, be absolutely satisfactory because the craving for the tea

stimulation makes the patients irritable, and it takes but very little

to cause them to complain that they still have their old discomfort.

In the course of three or four days they realize that the root of the

trouble has been reached. If the discomfort has continued for a good

while, a sort of habit seems to be formed, and the attention of the

mind gives a sense of uneasiness, if not discomfort, in the left

abdominal region. Usually it is in the upper left quadrant and seems

to be stomachic in origin. The discomfort is apparently due to the

presence of air, or gas, which is not properly expelled because of

some lack of co-ordination of muscles, and then the warmth of a room

or of the bed at night, or the presence of some slightly irritant

substance makes the discomfort more noticeable. In the patient's

over-stimulated condition, there is inability to withstand it

patiently. In none of these cases is there a fever, though in all

there is some disturbance of the pulse as if the heart's action were

interfered with and the organ resented it.





Coffee.--In some cases the same vague abdominal discomfort occurs as

a consequence of taking too much coffee. This is seen in men more than

in women. The tea topers are nearly all women, though my attention was

first called to this vague discomfort, that made life miserable for a

tea tester, who spent most of his day tasting tea, though drinking

very little of it. With regard to coffee, individual idiosyncrasy is

an extremely important matter. Some men seem to be able to take five,

six or even more cups of coffee in the day without inconvenience; some

cannot take even a small cup of coffee after six o'clock at night

without being kept awake for several hours; others cannot take a large

cup of coffee in the morning without having considerable discomfort,

which is usually attributed to indigestion. I have known large, strong

men, who were much better for not taking any coffee, or at the most a

tablespoonful of it in a cup of milk in the morning to satisfy the

taste.





Loose Kidney.--Movable kidney is responsible for many of these cases

of abdominal discomfort. Where it exists to a marked degree it may be

relieved by operation. It occurs much more frequently in women than in

men because, for physiological reasons, the kidneys are normally more

movable in women and this is particularly true of the right kidney,

which would otherwise perhaps be injured by pressure between the

pregnant uterus and the liver. It is probable that many of the cases

of the kidney of pregnancy are really due to an abnormal fixity of the

kidney to a particular place, so that the growing uterus interferes by

pressure with its circulation and its function. Slight movability of

the kidney, then, should not be considered pathological.



I have seen a number of these cases. They seem to occur particularly

in women who have lost weight. The fat around the kidney is somewhat

absorbed during the course of loss in weight, and this leaves this

organ more movable and also less protected and consequently more

liable to irritation. One sees it rather frequently in many unmarried

women who have some strenuous occupation. Many of these young women

come back from their vacation at the end of the summer having gained

fifteen or twenty pounds in weight. If there has been any kidney

sensitiveness or movability before, both have usually

disappeared. The kidney is well held in place because there is much

more fat within the abdomen, all the organs are better cushioned, yet

without any interference with their function.



During the course of the year these patients, school-teachers,

stenographers, and daily workers of various kinds, lose in weight.

When they have lost ten pounds the kidney begins to be sensitive again

and somewhat movable. By the time they have lost fifteen to twenty

pounds there is serious complaint in the right upper quadrant of their

abdomen extending at times over toward the navel, and the kidney

becomes quite movable. At this time the treatment must consist in

holding the kidney as firmly in place as possible, for dragging

downward will be followed by reflex symptoms in the stomach and

intestines. Disinclination to food, loss of appetite, and even the

occurrence of some nausea, as well as some constipation, are easily

traced to kidney reflexes. During the night there is no trouble,

because while the patient is lying down the kidney falls into its

proper position. On arising in the morning the kidney drops down out

of place. If a corset is put on at this time the kidney may be forced

still further out of place, giving rise, after a couple of hours, to

considerable discomfort. New shoes can be borne at first, but after a

time the pressure they produce shuts off circulation and causes

intolerable discomfort. To a less degree this happens to the kidney if

thus compressed and this explains the course of symptoms in many

cases.





Mechanical Treatment.--If the corset is adjusted before the patient

rises, and fits reasonably snugly, but not too tight, the contents of

the abdomen will all be kept in place, and the kidney will maintain

its normal position. When the corset is not sufficient to retain the

kidney in place, a simple pad, a towel or a napkin or, if there is

much sensitiveness, something more elaborate, especially adapted to

conditions, can be placed over the kidney, and when held firmly by the

corset will keep the kidney in its place. At first the kidney is

usually sensitive to this on account of having been pressed upon

during the preceding weeks or months. The patient must bear some

little inconvenience at first, must get accustomed to the new

conditions in which the kidney is kept in place, and must not expect

complete relief at once. Any improvement must be considered a step

forward, and further amelioration can be confidently promised. As in

all other cases of the use of apparatus or mechanical

aids--spectacles, false teeth or crutches--the patient must be content

to grow used to the new order of things, before expecting satisfying

relief.



This is the palliative treatment. The natural treatment of many of

these cases is to have the patient maintain such weight as will hold

the kidney in place, because of the fat within the abdomen, without

any necessity for external aids. This can be done more readily than is

often thought to be possible. These patients insist that they lose

their appetite when they settle down to work, but what they really

lose is the habit of eating a definite amount at stated intervals.

Very often it will be found that breakfast, which they took abundant

time to eat during vacation, is rushed. The luncheon suffers in the

same way and is small in quantity. They take only one good meal, and

one good meal is not sufficient to maintain normal weight.





Question of Operation.--When a kidney is so movable as to deserve

the adjective "floating," so that it moves considerably from its place

and, perhaps, even sags and may be felt in the subumbilical region, it

should be fastened up by surgical means. There is a choice

between two evils. The fastening of the kidney in the loin does not

restore the normal condition, but puts it in an artificial condition.

The kidney supports are of such a kind that it was evidently meant to

be slightly movable. When it is fastened firmly in the loin, it is

likely to feel every jar, and certain post-operative cases that I have

seen, in which firm adhesions had supposedly taken place, complained

considerably of the discomfort occasioned by this. In a certain number

of cases, even after the operation, the kidney is still somewhat

movable, because the adhesions yield and some of the old distress

returns. All this must be realized before there is any question of an

operation. There must be not merely a little discomfort, but enough of

actual ache and of reflex disturbance that can be traced directly to

the kidney to warrant the operation.



No floating kidney should be operated upon in a patient who has lost

much in weight and has developed a sensitiveness of the kidney since

the reduction of weight. Definite efforts should first be made to

bring about increase in weight, so as to see whether this will not

restore the previous condition of reasonable comfort. At times it is

said that the disturbance of the stomach, that is reflex to such a

floating kidney, prevents the patient from taking and assimilating

enough food to restore normal weight. This will be true if attention

has been called to the condition very seriously, and if the patient is

persuaded that this is the reason why there is no appetite and poor

digestion. Ordinary palliative measures, such as a binder, or a

specially made corset, will be sufficient to prevent the kidney from

producing reflex disturbance of the stomach, and will exert a strong

suggestion to this effect under the influence of which the patient

will usually gain in weight.





Intermittent Discomfort.--The discomfort that comes with a loose

kidney may be quite intermittent. I have known patients to be bothered

by it for months, and then quite free from it for several years, only

to have their discomfort renewed so that they become quite worried.

Some definite local or mechanical condition can generally be found for

these variations in feeling.



In thin people a jolting ride over a rough road or stepping off a car

will occasionally be the beginning of the trouble, and as this also is

likely to cause a stone in the kidney to give its first

manifestations, there may be serious suspicion of a more grave

pathological condition than is really present. If this discomfort

continues only the X-ray can absolutely decide the question.



Once the mechanical conditions which cause the discomfort are

understood by the patient, the actual ache becomes much more easy to

bear. Apprehension makes it almost intolerable. Attention exaggerates

it, and makes diversion of mind difficult. Understanding helps all the

conditions and lessens the pain, not actually but mentally, until

after a time very little attention is paid to it.





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