MALIGNANT DISEASE OF THE KIDNEY.
Our knowledge of the varieties of malignant disease of the kidney in the adult is at present inexact; the clinical picture of the disease must, therefore, be uncertain. The commonest form of malignant dis ease in the adult kidney is encephaloid cancer, but it has been lately proved that sarcoma of the capsule of the kidney, as well as of the suprarenal body, is also not infrequent. The cases recorded of the latter diseases are too few in number, however, to settle definitely as to whether limmaturia is a delayed symptom in these sarcomata or not. I believe that in sarcomatous cases a renal tumor is discoverable before blood appears in the urine. In children, in whom probably most renal growths are sarcomata, the tumor is usually recognizable before the hmnaturia ensues. Thus Lebert, who has collected over fifty cases, notes that in thirty-six cases a renal tumor appeared first; and in nineteen cases lmmaturia was the first symptom.
Character of Hematuria in Malignant Disease of the Kidney in the Adult.—Onset : The patients are mostly men about the age of fifty. The ages of my cases were 64, 53, 53, 54, 44, 52, 42,. , 54, 62, 51, 49, 52, 60, 49, 47. In the large majority of patients whom I have seen there has been no warning, previous to the hemorrhage, that the kidney was diseased. In six cases out of seventeen the hemorrhage has been sudden, unexpected, and profuse, following almost directly upon some form of violence, such as a blow on the loin (two cases) ; severe exer cise (one case) ; severe coughing (one case) ; lifting a heavy weight (one case) ; bending down to open the lowest drawer of a bureau (one case). In the remaining eleven cases the hemorrhage has been spontaneous and usually bright in character at the very commence ment. In all cases rest in bed has promptly checked the bleeding, but on the patient returning to active habits it has recurred, sometimes to an alarming extent. Even travelling ill a jolting conveyance or a train has reinduced the hemorrhage. Clots of two forms appear early, or occasionally in the course of the disease—either the massy irregu lar clots which are formed in the bladder from the arterial blood poured into that viscus along the ureter, or the long worm-like clots, which are casts of the ureteral canal. I have seen these long clots only after traumatic rupture of the kidney and in malignant disease.
I believe they are rarely noticed in any other form of renal hemor rhage. Specimen No. 3601 A in the museum of the Royal College of Surgeons is an exception. It shows a right kidney laid open longi tudinally to display a large branched clot which in the recent state filled the pelvis and calyces and extended several inches down the ureter. The right renal vein was thrombosed, but the corresponding artery was patent. This specimen was removed from a woman aged thirty-six, whose urine became albuminous but not bloody shortly before her death, which occurred suddenly from pulmonary embol ism. In rare instances the ureteral casts have been found to be com posed of sarcoma cells and blood (St. George's Hospital Museum, 42 C) . Another similar case is recorded by Penrose." The bleeding often ceases abruptly, the water being heavily charged with bright red blood on one evacuation and at the next it is crystal-clear. This sudden change is due to temporary corkage of the ureter with a long vermicular clot. This clot will probably be grad ually decolorized and expelled at some subsequent urination in the shape of a worm of a whitish fawn-color, or even buff-colored or black. Of all renal hemorrhage, that which proceeds from a growth is by far the most alarming. In some cases it has been so profuse as quickly to blanch the patient, and to render him breathless on the slightest exertion; in one case the patient was blind for some days from retinal anaemia. The urine is colored variously from the admixture of blood, the color of thick cocoa or porter, dark red, bright arterial—in fact, every variety, with the possible exception of the tarry bleeding of malignant malaria, is simulated. Yet, notwithstanding this change of front, the urine will be usually clear between the at tacks, of fair specific gravity, and contain only a trace of albumin.* The profuse hemorrhage of renal carcinoma is sometimes rivalled by that of vesical malignant growth. In the latter, however, cystitis and the necrosis of the growth rapidly supervene and produce a typical stinking urine, which condition is never noticed, I believe, in uncomplicated renal cancer unless the practitioner has introduced septic material by catheterism, sounding, or injudicious washing.