EXAMINATION OF THE PATIENT FOR THE SOURCE OF HEMATURIA OR HAEMATURIA.
1. Physical Examination.—The physician will do well to make a thorough examination of all accessible parts of the urinary tract before instituting any instrumental exploration as to the cause of 11maturia. I hold very strongly that it is culpable for instrumenta tion of any form to be carried out before all other methods of research are exhausted. My reasons for this hard and fast rule will be given subsequently.
Kidneys.
The renal region must be palpated to ascertain the existence of any undue tenderness, enlargement, or displacement of the kidneys. Is rael's method of palpation is a very satisfactory one. A line parallel with the middle line of the abdomen is drawn from the middle of Pou part's ligament to the margin of the ribs. The finger-tips, placed two finger-breadths below the margin of the ribs and upon this line, are directly over the lower extremity of a kidney in place. In order to feel this kidney we must avoid poking with eager hooked fingers, or the abdominal muscles will contract in resentment. The tips of the straight extended fingers are placed upon the point indicated while the patient lies supine, with flexed legs, upon a hard bed or table. The other hand now lifts the loin gently toward the opposed fingers. At each expiration which the patient makes the fingers upon the abdomen are pressed a little farther toward the kidney, and it is not long before the fingers easily recognize the object sought for. If the patient now takes a full breath, a wandering kidney will be forced far under the finger-tips. I believe every renal tumor is one-third larger than we think it is.
Tenderness.—Rough palpation elicits varying degrees of pain in any kidney which has some portion of its substance inflamed. Simple or ulcerating pyelitis, chronic abscess of the kidney, inflamed cyst, acute suppurative nephritis,—in all these, tenderness can be elicited by deep pressure. It is a mistake, then, to consider that pain can be evoked by palpation only when stone is present. I will admit that, in most cases of long-standing of stone imbedded in the cortex or a deep calyx, or in cases of stone iu the pelvis large enough to press apart the walls of this cavity, there is a characteristic stabbing pain on percus sion over the front of the kidney, but this " stab" is not elicited in all cases of renal calculus by percussion. Its absence, therefore, does not exclude stone. The inflamed kidney always tends to be drawn
upward under the ribs. This change of position must be allowed for in palpation and percussion.
Enlargement.—In unusually thin people the tail or lower end of the kidney can be easily examined. But a kidney which is not markedly movable and which can be readily felt in its entire extent by the palpating fingers is abnormally large. It may not be diseased but merely hypertrophic, for it has often been demonstrated that when one kidney is atrophied the fellow-gland has become correspondingly enlarged in doing double duty. Perceptible enlargement of the non mobile kidney without a history of a previous traumatism to the opposite loin, coexisting with blood in the urine, is a condition which should at once arrest attention.
The questions raised by enlargement are : Is it a tough kidney irritated by the presence of a large stone? Is intermittent hydro nephrosis present? Are tubercular changes in progress? Is it a growth; a carcinoma or sarcoma; or is the kidney merely mobile? It is noteworthy that calculi, even those of large size, sometimes remain latent in the kidney except for an occasional lematuria. I believe this mostly happens in the young adult. Primary chronic tubercular disease of the kidney occurs usually in patients over twenty years of age with a family history of phthisis. The kidney, before perinephritis has set in, is hard, rounded, smooth, usually mov able, and very tender. It rarely, in my experience, reaches the size of a large closed fist without inducing inflammatory adhesion and thickening around it. This fixes the and draws it slightly upward under the ribs, whence it is pushed downward in the third and last stage by abscess accumulation—a grade marked by elevated temperature and other signs.
Sarcoma of the child's kidney is too rapid in its growth and too characteristic to require notice. The uninflamed sarcomatous and carcinomatous tumors of the kidney (in patients over forty-five years of age) are usually large, smooth, insensitive, and movable long after the hemorrhage has appeared, unless an injury has started the hxma turia in the earlier stages.
It sometimes happens that a kidney is so freely movable behind the peritoneum that its excursions may occasionally kink the ureter and produce intermittent hydronephrosis, When the attack conse quent upon the backward pressure subsides by the straightening of the ureter, blood may appear in the urine.