Having had the good fortune to see a case which operation disclosed to be one of a large vascular hypernephroma, the writer believes that the following fairly complete history and findings in the case previous to operation should be helpful to the general practitioner who may run across such a case and be puzzled by the apparent contradictions of the symptomatology.
The patient was man 53 years of age, married, of sedentary habits during the last ten or eleven years, but a milkman by occupation for ten or more years prior to that. Family history negative throughout, father and mother both alive and in the seventies, and no deaths in family as yet anywhere. Patients habits always good, no dissipation for the last ten years, and at present not even smoking. Teeth had been attended to a year ago, seven crowns in all.
The occupation of milkman followed for ten years or more had been one of hard work and patients first sickness was noticed five years after giving up the milk business and going into an office.
Seven years previous to date of consulting the writer he was seized suddenly with a severe pain in the back down the outside of the hip but not at all following course of ureter. At this same time his urine looked dark. He went to bed and stayed there a week, then when the backache left him and the urine became clear he got up.
He was well for a year after that when suddenly another attack of backache and dark urine came on, which lasted for two days.
Another year went by and again he had an attack lasting a few days. After three years he had attacks twice a year for three successive years. In the sixth year he had five or six attacks, and in the seventh year attacks every now and then hence the consultation with the writer.
At present the backaches are not severe but the urine is much more bloody than ever before noticed. It hurts him on the left side when in bed. He is most comfortable in bed when lying on his back or half way on his stomach. Has backing cough, especially in winter, but no tickling and doesnt raise any sputum. Has recently had night sweats. Appetite not good but tongue clean. Belches a good deal. Breath offensive.
As regards the urinary symptoms the urine is normal between attacks of pain, but at those painful times is bloody, and, of late, has been bloody even when the pain has not been marked. Recently he has found himself unable to void urine while in the erect posture, and has to lie down to urinate. There is no pain, no burning or straining. No stoppage of the stream while urinating. Sometimes while standing up he feels a “bearing down” in the genital organs.
The urine at times looks, as he described it, like the water in which beets have stood. Long liver – like looking clots are passed. The long stringy clots have been passed for three years.
On being asked why he did not attend to the bleeding long before this, patient rather reluctantly admitted that once a surgeon wanted to remove the left kidney but that he (the patient) preferred to try Christian Science, which, proving unsuccessful after a years thorough trial, he now consulted a medical man again. He claimed that cystoscopic examination had been positive, “something” having been found, he didnt know what, but that X-ray of the kidneys and bladder was negative.
Physical examination by the writer showed an undersized person who, if younger, would have been suggestive in appearance of renal tuberculosis. He was only five feet, one inch tall, maximum weight 145, present weight only 125 pounds, the fifteen pounds having been lost in the last two years. There was no pain or sensitiveness on pressure over either kidney an never had been. He rises only once or twice at night to urinate.
His temperature was 98.5*; his pulse 115, small and regular; his blood pressure, systolic, 115; there was no enlargement of the left ventricle, no accentuation of the aortic second sound.
The urine analysis was interesting and as follows: Quantity of urine in 24 hours only 340 cc. eleven ounces. Specific gravity 1020, reaction acid, fifty – three degrees. per cent. of urea, ammonia and phosphates high, 2.7, 0.1 and 0.19, respectively. Uric acid and chlorides low (presumably because of diet, avoiding meat?). Indican reaction moderate, acetone negative, sugar negative.
The urine was dark in color, plainly suggesting blood in appearance. The albumin was small in amount plainly due to blood. Less than one – half of the first mark on the Esbach tube was obtained.
Microscopically, the urine showed at a glance that the blood came from the kidneys. There were a few uric acid crystals and only, a few leucocytes, the mass of the field being renal blood. There were many and large clots in the urine. One object looked like the fragment of a granular tube cast, but casts were not present in number sufficient to identify.
Patient was given a gentle but firm order to consult a surgeon at once for cystoscopic examination with catheterization of ureters. Was told he “might” have a stone, but his family was warned that the possibility of a malignant growth must be considered.
After due diagnostic precautions operation was undertaken and a large, highly vascular hypernephroma of the left kidney removed. Patient made good recovery.
We take pleasure in announcing that Dr. E.H. Grubbe, the pioneer roentgenologist of Chicago, will contribute a series of papers on X-ray therapy for this department, beginning with the subject of cancer of the uterus.
We are also promised a paper or two from Dr. Leroy Thompson, from whose article on iritis we present excerpts in the present number. Dr. Thompson specializes in eye, ear, nose and throat.