DIAGNOSTIC SIGNIFICANCE OF HEMATURIA FOLLOWING SLIGHT INDIRECT VIOLENCE.
The hmmaturia of injury does not require notice. The injury is direct, the history of the blow is generally obtainable, and the locality is usually obvious, but careful examination should elicit from the patient facts concerning the influence of slight indirect violence upon the production of a spontaneous hwmaturia.
If a slight indirect traumatism, such as a fall on the buttock, has produced in a youth or young adult a symptomless renal hwinaturia, which continues or intermits, it is probable that some pre-existing disease such as latent renal stone or chronic Bright's disease was present, and is now responsible for the obstinate persistency of the bleeding. In these cases the urine may reveal traces of the disorder in the shape of crystals or of casts, low specific gravity, and albumin.
In patients over forty (an arbitrary age depending upon statistics), with unsuspected softish malignant growth of the urinary tract, it is often a slight strain which appears to be the cause for the first attack of the hemorrhage. Some affirm that they feel or hear something "snap" or "give way" in making some slight exertion, such as lifting an article of furniture. In six of seventeen cases of malignant disease of the kidney which have been under my observation, some slight in direct violence had obviously induced the bleeding. In one-third of bloody urine. It proved to be due to the liberal use of the prickly pear. " Dr. Ilennen (" Military Surgery") quotes from Ellicot's Journal of his "Travels for De termining the Boundary of the United States :" "People ate very plentifully of this substance (prickly pear) at an island of the Mississippi (Kayoani), and were not a little surprised the next morning at finding their urine appear as if it had been highly tinged with cochineal. No inconvenience followed. * Rhubarb and senna in alkaline urine impart a red coloration to the urine. It is removed by adding acid, and returns on overcoming the acid with alkali. Analgen colors some urines a cherry-red.
the cases in my list of soft malignant vesical growth the initial hem orrhage had apparently some direct relation to a slight indirect trau matism. In two of the fifteen cases of carcinoma of the prostate the bleeding followed immediately on indirect violence. The small num
ber in the latter group probably depends on capsular protection.
Should, therefore, a light strain or a decided extra exertion be immediately or almost immediately followed in an adult over forty by a smart attack of hemorrhage, a friable pre-existing growth should be suspected to exist. It might be argued that the slight traumatism has been followed by a new growth; and that it stands to the growth in the relation of cause and effect. Not so. Though it is beside the question before us, I may remind the reader that the cystoscope has taught us that soft malignant tumor of the bladder may grow latently, unsuspected by either the practitioner or patient, and that cases have been examined within a week or so of the onset of lueraaturra and a large growth then discovered. Hence the onset of haamaturia does not herald the birth of a growth, but usually denotes a tear or degen erative change in the surface of one already formed.
Benign growths do not seem to be so often affected in this way, though when they have attained a large size they will often bleed upon some extra exertion being taken by the patient.
I account for this difference in the behavior of malignant and non malignant tumors when roughly shaken, by the structural differences of the stalk or base of these two varieties of growth, that of the benign type being less rigid and less friable than the malignant—for it is composed of tissue more approaching the normal in character. I would suggest that the surface of a purely benign growth, e.g., when covered by villous processes, is much less damaged by the succussious of the water in the bladder than is the easily tearable neoplastic base and surface of a carcinomatous tumor, for the latter is soldered on to the wall, and its attachment has to bear the strain of the stretching of the adjoining muscle as it yields before the momentum of the urine or bends before the compressing force of suddenly exerted infra abdominal pressure. My judgment has been often biased in favor of a malignant growth being present, when I have found that the onset hminaturia was apparently the result of slight indirect violence.