442 THE HEMORRHAGIC DIATHESES 



these may undergo the characteristic changes which occur in the extraTasa- 

 tions, or they may disappear without these changes. 



LOCAL HEMORRHAGES UPON A HEMOPHILIC BASIS 



In the last decade a number of cases have been published in which the 

 common characteristic was a more or less profuse hemorrhage from a kidney, 

 the absolute integrity of the organ being determined either by clinical observa- 

 tion or by operation. In these important cases the question arises: What 

 factor is the cause of the hemorrhage? Although Lauenstein published his 

 fundamental case in the year 1887, and a large number of similar observations 

 followed (those of Sabatier, Schede, Anderson and Leguen in the years 1889 

 and 1890), only Senator's article ("Eegarding Eenal Hemophilia," 1891) can 

 be accorded scientific, authoritative importance. I shall therefore give a 

 synopsis of the case : 



A girl, aged nineteen, in the year 1887, noted blood in the urine immedi- 

 ately after menstruation. The examination of the voided hemorrhagic uriae 

 at that time showed a large amount of hemoglobin although no red. blood- 

 corpuscles. After the lapse of two years, during which time decided debility 

 and periodic cough gave rise to the suspicion of tuberculosis, the hemorrhage 

 recurred ; this time it was more profuse, and lasted with slight intervals more 

 than six months. The analysis of the urine showed actual hematuria; the 

 blood discharged through the kidneys differed but very little from pure un- 

 mixed blood. Toward the end of February, 1890, Senator determined the 

 following: Patient is well formed, very pale, no trace of emaciation. The 

 internal organs present nothing abnormal; lungs and kidneys apparently 

 healthy. Urination painless, perhaps somewhat more frequent than normal, 

 but without tenesmus. The urinary sediment consists exclusively of erythro- 

 cytes; crystals, pus and other pathologic constituents are absent. No fever. 

 The examination carried out under an anesthetic shows no changes, neither 

 in the kidney nor in the bladder nor in the sexual organs, but it was demon- 

 strated by means of the cystoscope that the blood flowed from the right ureter. 

 After the usual causes of hemorrhage, such as stone, tumor and tuberculosis, 

 had been excluded, Senator made a diagnosis of hemophilia which was con- 

 firmed by the history. It was ascertained that the patient was a member of 

 a family in which hemorrhages occurred frequently. Four sisters, and a 

 brother aged seventeen, showed great tendency to epistaxis; the father, who 

 at the time was quite healthy, as a child had been frequently attacked by 

 nose bleed and hemoptysis without showing any pulmonary lesions. Eleven 

 brothers and sisters of the father suffer or have suffered from epistaxis; an 

 uncle of the patient, who for a long time suffered from epistaxis, in his 

 twentieth year had an attack lasting twenty-four hours, after which purpura 

 appeared over the entire body and hematemesis occurred; the disease ended 

 fatally after fourteen days. A second uncle is the father of two children 

 who have inherited epistaxis from him. The mother of the father, up to 

 the time of her death, menstruated profusely. Unquestionably, therefore, the 

 patient was a member of a bleeder family. Although no symptoms of heme- 



