The morbid anatomy is scarcely more precisely defined. Ponfick9 goes so far as to say that the exudation of hæmoglobulin is not possible without the concurrence of marked diffuse nephritis. Recently Lebedeff10 has sought to investigate the more minute alterations of the kidney in hæmoglobin exudation, but without very definite results. These, however, on the whole, seem to confirm Ponfick's view as to the presence of an inflammatory process, as also do those of Litten11 and Lassar.12
9 "Ueber die Gemeingefährlichkeit der essbaren Morchel," Virchow's Archiv, Bd. lxxxviii. S. 476, 1882.
10 "Zur Kenntniss der feineren Veränderungen der Nieren bei der Hämoglobinausscheidung," Virchow's Archiv, Bd. xci. S. 267, Feb., 1883.
11 "Verhandl. des Vereins für innere Medicin," Deut. Med. Wochenschr., No. 52, Dec. 29, 1883.
12 Ibid., No. 1, Jan. 3, 1884.
DIAGNOSIS.—The diagnosis of this condition is not usually difficult. We have first to determine whether the hemorrhagic discharge is from the kidney rather than the bladder or ureters. The former is the case when tube-casts are found. But tube-casts are not always present even when the hemorrhage is from the kidneys. The absence of clots and of vesical irritation, and of pain in the course of the ureters, is characteristic of blood from the kidneys. Finally, all hæmoglobinurias are renal.
It being certain that the blood comes from the kidney, we have to distinguish it from that due to cancer, to calculus-irritation, and to cachexias, as purpura and scurvy; or to grave forms of infectious disease, septicæmia, pyæmia, etc.; or, finally, to poisonous substances introduced into the blood, such as arsenic, iodine, arseniuretted hydrogen, carbonic acid and carbonic oxide gas, and even certain species of edible fungi.
The diagnosis is greatly aided if it is found we have to do with a hæmoglobinuria rather than a hæmaturia. For although the former condition is produced by toxic and septic agencies of another kind, the attending symptoms, when it is thus produced, are so characteristic that it is not likely that error can be made.
To aid in distinguishing it from cancer we have the history of malarial exposure, and often that of other forms of malarial disease; and, notwithstanding the seeming drain upon the system, none of the cases I have ever seen present the profound anæmia of cancer. The bloody discharge in cancer of the kidney is always a true hæmaturia; there are always blood-discs in the urine. There is often pain in the region of the kidney in cancer, but never in malarial hæmaturia.
In calculous disease there is almost always pain before or during the hæmaturic attack, and characteristic crystalline sediments often appear in the urine.