Hematuria

“ The majority of the diseases from which the ancient Egyptians suffered, are those which still attack their successors; ophthalmia, affections of the stomach, abdomen, and bladder, intestinal worms, varicose veins, ulcers in the leg, the Nile pimple, and finally the "divine mortal malady," the divinus morbus of the Latins, epilepsy. Anaemia, from which at least one-fourth of the present population suffers, was not less prevalent than at present, if we may judge from the number of remedies which were used against hematuria, the principal cause of it. ”

“ In one of our fatal cases, with intense jaundice, hematemesis, inky black stools, and oedema of the feet and of the lungs, there was not a drop of urine secreted during the last four days of the initial paroxysm; death occurred on the eighth day, and the kidneys were found intensely engorged, of a deep blackish-blue color, with numerous ecchymoses in the cortex, due to impaction of the convoluted tubules with blood, while the renal epithelium was granular and swollen, and many tubules were filled with epithelial cells and granular matter. ”

“ Renal Hyperemia.—Active hyperemia is usually an early stage of acute nephritis, but may occur independently as a result of temporary irritation. The urine is generally decreased in quantity, highly colored, and strongly acid. Albumin is always present—usually in traces only, but sometimes in considerable amount for a day or two. The sediment contains a few hyaline and finely granular casts and an occasional red blood-cell. In very severe hyperemia the urine approaches that of acute nephritis.
[p. 133]
Passive hyperemia occurs most commonly in diseases of the heart and liver and in pregnancy. ”

“ Albumen is present in the urine, often in large amount, but its presence there is readily accounted for by the vaso-motor paralysis, and the impoverished condition of the blood, which is still further aggravated by this, its symptom. Casts are often found, but are usually small and medium sized light granular, and hyaline. Epithelial and fatty casts occasionally occur, but it is probable that, in these cases, renal disease had commenced before the chloral was used to excess. Hemorrhage from the kidneys and, indeed, from the whole urinary tract, is sometimes found. ”

“ When the combined percentage of globulins and serum albumin is subtracted from the total proteid percentage we have the percentage of nucleo-proteid.
Tests for Blood.—Very important in tests of the urine are those for blood. With an unaided eye a smoky colored urine, more or less reddish-brown in color, is suggestive in cases of haematuria, while in haemoglobinuria we usually have a more or less porter-colored, turbid fluid which, however, shows a clear haemoglobin-tinged fluid when centrifuged to throw down the haemoglobin casts and granular débris of the disintegrated red cells. ”

“ DISEASES OF THE KIDNEYS.—As has been abundantly proved by careful autopsies, inflammation of the retina may be developed during any form of Bright's disease, either with the enlarged mottled kidney of acute parenchymatous nephritis, the large white kidney, the amyloid kidney, or the cirrhotic kidney of chronic disease. In the vast majority of cases the retinal inflammation appears during the later stages of the last-named form of disease, and seems to be in some way dependent upon blood-poisoning, which has been caused by the degenerating kidney. ”

“ Hæmaturia is due to a variety of causes, which may be local or general. Local hæmaturia is caused by wounds, blows upon the kidney, or falls in which the kidney receives the force of the blow, as in striking the edge of a fence in falling; from cancer of the kidney, impacted calculus, parasites, embolism, acute Bright's disease; also poisoning from carbolic acid, cantharides, and mustard. General causes of hæmaturia are malaria, purpura, scurvy, blood-dyscrasias due to continued and eruptive fevers, especially typhus fever and smallpox, septicæmia and pyæmia, and cholera. ”

“ Rheumatism has never in my practice been dangerous, nor has it materially retarded convalescence, except when it affected the heart, causing pericarditis or endocarditis, when it involves great danger. Nephritis, if it be moderate, attended by little albuminuria and serous effusion, and by the occurrence of few renal casts in the urine, commonly ends favorably under judicious treatment, as we have already stated; but severe nephritis, with abundant albuminuria and casts and serous effusions, soon gives rise to alarming symptoms, and is the cause of death in a considerable number of instances. ”

“ The kidneys often getting into a relaxed state, cannot retain the urine, but, becoming dilated, they allow the blood and other thick matters to escape from the veins. The kidneys often discharge blood periodically like hemorrhoids; and when evacuated they are relieved, in which cases we must not rashly interfere, if the bleeding immediately stops; but, if it continue, we must bleed in the arm, and use for hemorrhage of the kidneys and bladder those remedies which are recommended for hemoptysis and other hemorrhages ”

“ The Genito-urinary System.—The dark colored urine is pathognomonic of the disease and gives it its name. The reddish to almost black color is due to haemoglobin and not to bile. Bile pigments do not appear in the urine. There is but rarely a red cell to be found in the granular débris with occasional haematoidin crystals which forms the urinary sediment, hence it is haemoglobinuria and not haematuria.
The urine resists decomposition for a long time. Albumin is present in large amount and comes on with the onset of haemoglobinuria. Casts are abundant and urobilinuria is marked. ”

“ Thrombosis of the renal vein also occurs in malignant disease of the kidney and in certain forms of chronic Bright’s disease.
Passive congestion of the kidneys occurs in heart-diseases and lung-diseases, where the return of venous blood is interfered with. It may also be produced by tumours pressing on the vena cava. The engorged kidneys become brownish red, enlarged and fibroid, and they secrete a scanty, high-coloured urine.
Active congestion is produced by the excretion in the urine of such materials as turpentine and cantharides and the toxins of various diseases. ”

“ A slight exciting cause is all that is necessary to produce their rupture. The primary cause is the false membrane, and, in some cases, vascular granulations, which have rapidly formed, perhaps in twenty-four hours—conditions eminently favorable to the production of hemorrhage. In cancerous, tubercular, and dyscrasial conditions of the blood, the blood-vessels are especially weak and easily give way, owing to the defective nutritive properties of the blood itself, just as, in typhoid fever, we have nasal and intestinal hemorrhage, and in typhus, petechiæ. ”

“ If the demand be for the red cells owing to loss from hemorrhage or any of the anaemias, the fatty marrow is rapidly replaced by cellular elements; this is mainly an active proliferation of the nucleated red cells, and gives rise to the erythroblastic type of marrow. If the white cells be required, as in local suppurating abscess, general septicaemia, acute pneumonia, &c., there is an active proliferation of the myelocytes to form the polymorpho-nuclear leukocytes, so that we have in this condition a leucoblastic transformation of the fatty marrow. ”

“ Certain persons have isohaemolysins in their blood which dissolve the red cells of other persons and in paroxysmal haemoglobinuria autohaemolysins may be present which can destroy the patient’s own red cells. This auto-haemolysis seems operative only when a low temperature is followed by a high one. When haemoglobinaemia exists the liver converts it into bile pigment causing bilious stools and jaundice. If one-sixth of the red cells are destroyed haemoglobinuria results. ”

“ The anaemia in liver abscess is not so great as the muddy complexion would indicate. The emaciation is greater than the anaemia.
Haemorrhages
The loss of blood through haemoglobinuria and haematuria has been taken up under the urine. The haemoglobinuria is the pathognomonic symptom of blackwater fever. There is also recognized a haemorrhagic form of pernicious malaria with epistaxis and alimentary tract haemorrhages. Moderate haemoglobinuria may be found in severe cases of malignant tertian infections. ”

“ Lymphocytes are formed in the lymphoid tissues, including that of the bone-marrow. They constitute, normally, 20 to 30 per cent. of all leukocytes, or about 1000 to 3000 per c.mm. of blood. They are more abundant in the blood of children.
The percentage of lymphocytes is usually moderately increased in those conditions which give leukopenia, especially typhoid fever, chlorosis, pernicious anemia, and many debilitated conditions. A marked increase, accompanied by an increase in the total leukocyte count, is seen in pertussis and lymphatic leukemia. ”

“ The patches of congestion, so characteristic of this disease in other organs, are not here observed. This may depend upon the peculiar disposition of the capillary system of the kidney. The blood has to pass through the Malpigian tufts, and may be purified, or altered in character, before it reaches the proper venous system of the organ.
In cases where purulent infection of the blood has been purposely produced, portions of the kidney will not unfrequently be found inflamed and firmer than natural ”

“ Hemorrhoids of the bladder due to obstructed circulation is not infrequently the source of the bleeding. The amount of blood transuded varies very greatly, though it is seldom so great as to prostrate the patient. In all cases when it is considerable it is of great importance to localize the bleeding point. The urethra can be excluded if there is no bleeding between the acts of micturition. The differential diagnosis between hemorrhage from the bladder or kidney is less easy. ”

“ In acute cases the stool may be almost pure blood with only an admixture of mucus.
Vesical tenesmus may be present and the urine may be diminished in amount.
There is a toxic effect on the heart so that the pulse tends to become accelerated and weak. Bacillary dysentery may show a moderate [181] leucocytosis with increased polymorphonuclear percentage instead of a large mononuclear one as with amoebic dysentery.
At times, however, the lymphocytes may be the leucocytes showing the greatest relative increase. ”

“ In many instances it is probably independent of any secondary infection, since it occurs in both ulcerative and non-ulcerative cases. It seems to be more common in sarcoma than in carcinoma. Very large counts are rarely noted.
[p. 161] (c) Post-hemorrhagic.—Moderate leukocytosis follows hemorrhage and disappears in a few days.
(d) Toxic.—This is a rather obscure class, which includes gout, chronic nephritis, acute yellow atrophy of the liver, ptomain poisoning, prolonged chloroform narcosis, and quinin poisoning. Leukocytosis may or may not occur in these conditions, and is not important. ”

“ Uraemia is of toxic origin, and it is probable that the dropsy of renal disease is due to effects produced in the capillaries by the presence of abnormal substances in the blood. High arterial tension, cardiac hypertrophy and arterial degeneration may also be of toxic origin, or they may be produced by an attempt of the body to maintain an active circulation through the greatly diminished amount of kidney tissue available. ”

“ The rare and rapidly fatal anemia which has been described under the name of aplastic anemia is probably a variety of pernicious anemia. Absence of any attempt at blood regeneration explains the marked difference in the blood picture. Red corpuscles and hemoglobin are rapidly diminished to an extreme degree. The color index is normal or low. The leukocyte count is normal or low, with relative increase of lymphocytes. Stained smears show only slight variations in size, shape, and staining properties of the red cells. ”

“ Toxic elements in the blood affect the kidneys in a greater or less degree, and there produce changes at first unnoticed,—at least, as long as the kidney can perform its function,—but the day arrives when, as described by Fothergill, blood depuration is imperfect, and we get many diseases which are distinctly uræmic in character, and ending in any of the so-called kidney diseases, Bright’s disease being one of the most common. ”

“ Myelocytes are rare.
The red corpuscles show the changes usual in severe secondary anemia. Erythroblasts are seldom abundant. Blood-plaques are decreased.
3. Pseudoleukemia (Hodgkin's disease) resembles lymphatic leukemia in that there is marked and progressive enlargement of the lymph-nodes. There is, however, no distinctive blood-picture. The changes in hemoglobin and red cells resemble those of a moderate symptomatic anemia, with rather low color-index. The leukocytes are commonly normal in number and relative proportions. ”

“ Kidneys undergoing this process of degeneration [p. 49] often furnish up to a short time before death a normal, or even more than normal, amount of urine, and one is often astonished to find how little disturbance of elimination has been caused in cases where the true kidney-structure seems to the naked eye to have been almost entirely destroyed.
The DIAGNOSIS of a calculus remaining in the pelvis of the kidney depends chiefly on the determination of hæmaturia and pyelitis for which no other cause can be found, and upon the presence of pain in one loin. ”

“ Very constant also is a marked absolute, and often a relative, increase of eosinophiles and basophiles. Polymorphonuclear neutrophiles and lymphocytes are relatively decreased.
[p. 210] The red cells show the changes characteristic of a severe secondary anemia, except that nucleated reds are commonly abundant; in fact, no other disease gives so many. They are chiefly of the normoblastic type. Megaloblasts are uncommon. Blood-plaques are generally increased.
2. Lymphatic Leukemia.—This form may be either acute or chronic. There is marked loss of hemoglobin and red corpuscles. ”