The child was full-grown for her age and well-nourished. She did not look ill. The abdomen was large and full, especially on the right side, and the superficial veins were distended. On palpation of the belly a large, oval, smooth mass was felt on the rit,dit side, reaching from the liver to the level of the brim of the pelvis. The fingers could be passed un der the lower border of the tumour, and above could be pushed a little way between the upper border and the liver, the edge of which could be distinctly felt overlapping the upper part of the mass. Anteriorly, the swelling reached beyond the middle line of the belly, and its limits could be distinctly felt rounded and resisting. Posteriorly, the tumour passed backwards into the renal region, and its boundaries in this direction could not be ascertained, although when the child lay on her left side the reso nance of the intestine could be made out posteriorly. In front the colon could be detected lying on the surface of the swelling.
The whole tumour was very slightly movable ; its surface was smooth ; its substance elastic, and it felt like a tense bag of fluid. There was no ascites ; no enlarged glands could be felt in the groins or elsewhere ; the edge of the liver reached two fingers' breadth below the ribs ; there was no enlargement of the spleen. In order positively to exclude fluid, an ex ploratory puncture was made into the tumour, but nothing but a little blood was withdrawn. The temperature remained normal after the puncture.
For a fortnight after the child's admission there was little change in her condition. Then, however, her temperature rose ; she vomited, and began to look ill and careworn, and a pneumonia developed in the base of the right lung. The urine became intensely acid ; it was loaded with urates, and deposited large amounts of uric acid ou standing ; there was also a trace of albumen. The liver enlarged ; the veins of the abdominal wall became engorged with blood ; cedema occurred in the lower limbs ; the face got dusky; aeneral convulsions came on, with epistaxis and bleed ing from the ears, and the child died in a few minutes.
On examination of the body a round-celled sarcomatous tumour, the size of a foetal head, was seen occupying the lower two-thirds of the right kidney, infiltrating its tissue. It was covered by the renal capsule. Its substance was of soft pulpy consistence in the centre, harder and firmer towards the circumference. There was one large haemorrhage into its lower part. The tumour pressed upon the inferior vena cava, which was dis tended by a large decolourised thrombus, perforated in the middle by a channel of the diameter of a goose-quill. The thrombus reached from the
level of the tumour upwards to the right ventricle of the heart. The liver and spleen were bath much congested.
This case may be considered a typical example of a renal tumour. The only doubt possible was as to the nature of the swelling, and this the exploratory puncture removed at once. Fluid being thus excluded, the rarity of any other form of solid growth made the diagnosis of sarcoma comparatively an easy one.
Sarcomatous tumours of the kidney generally grow rapidly, and the course of the disease is seldom protracted. Death often occurs within a year of the swelling being first discovered, and in the longest case life is rarely prolonged beyond eighteen months.
Hydronephrosis is almost invariably in children a congenital affection. It is often associated with some form of arrest of development, such as club foot, harelip, imperforate anus, or absence of the prostate gland. Both kid neys are more often affected than one alone, and the most common cause is impervious ureters or an imperforate urethra. According to Dr. Englisch, the obstruction may take its rise in the valvular folds, situated at the upper part of the 'ureter, or at its lower part ; and in five cases he referred the cause of the obstruction to a curving of the mucous membrane at the orifice of the urethra into a diverticulum.
In rare cases the disease is acquired during childhood from impaction of a calculus in the ureter. The other causes of acquired hyclronephrosis, viz., retroflexion and prolapse of the womb, etc., do not come into play until a more advanced period of life.
Whatever be the cause of the retention, the essence of the disease con sists in accumulation of urine in the pelvis of the kidney. The pressure of this fluid produces very serious consequences. Every degree of dilata tion of the parts is seen according as to whether the fluid can partially es cape or is wholly retained. In every case the renal pelvis is greatly dilated, but there are many degrees of alteration of the kidney substance, from mere flattening and toughening of the papillae to actual conversion of the organ into a membranous sac filled with fluid. If the obstruction is low down in the ureter, this tube is also dilated and its wall thickened. The fluid has a low specific gravity, and contains the elements of urine al though in feeble proportion ; i.e., urea, uric acid, urates, and often crystals of oxalate of lime. Its reaction is faintly alkaline. Its colour is clear amber or turbid, and may be yellow from pus or reddish from blood. Some times it contains epithelium, and in rare cases the consistence is increased to a thick fatty fluid.