HEMOPHILIA 445 



organ but also an incision into the kidney, and a minute investigation of 

 the parenchyma. If the incised kidney is found to be anatomically unchanged, 

 it should be closed by suture and replaced. If this procedure affords no relief, 

 a secondary nephrectomy is to be performed. Primary extirpation is not 

 warranted in these cases. » 



How little data the exploration of an incised kidney in vivo may furnish, 

 Zondek recently demonstrated in a discussion before the Society of Internal 

 Medicine, when he arrived at the following conclusions : 



1. Even in a kidney laid open by operation the presence of a small stone 

 cannot be excluded with certainty. 



2. Even when surgical exploration of the organ gives a negative result, 

 inflammatory changes of the renal tissue may be due to a stone in a con- 

 cealed calyx. 



3. Complete proof of the diagnosis of angio-neurotic hemorrhage from the 

 kidney necessitates the most careful investigation of the entire kidney after 

 it has been removed from the body, and also of the ureter down to its point 

 of entrance into the bladder. 



Harris (Philadelphia Medical Journal, March 19, 1898) published two 

 cases of " essential " renal hematuria. In one of the patients the kidney was 

 exposed. In both cases the hemorrhage ceased. 



Harris has collected 16 similar cases from literature. The majority of the 

 patients were cured by simple nephrotomy. He comes to the following con- 

 clusions: 1. Eenal hemorrhages occur in which none of the usual causes, acute 

 nephritis, tuberculosis, sepsis, neoplasms, malaria, etc., are present. 2. The 

 pathological changes arising in the kidney are unknown to us. 3. These hema- 

 turias are not controlled by ordinary styptics. 4. If tonics, cold baths, etc., 

 are without effect, nephrotomy must be performed. 5. Primary nephrectomy 

 is in no wise indicated. 



J. Israel writes on the curative influence of renal incision in cases of uni- 

 lateral colic and unilateral renal hemorrhages in the obscure pathologic condi- 

 tion which up to the present has been called nephralgie, nephralgie hematurique, 

 renal hematuria without known lesions, essential or angio-neurotic renal hemor- 

 rhage, all of which, according to his investigations, most frequently depend upon 

 chronic inflammatory changes of the kidney. Up to the year 1898 he had oper- 

 ated upon 14 cases of this kind. Five kidneys were examined microscopically, 

 and four of these showed different forms of nephritis. In eight of the remain- 

 ing nine patients, microscopic investigation of the kidneys showed organic 

 changes. Of the fourteen cases treated by nephrotomy three died, of whom 

 two had severe bilateral nephritis ; six were completely and permanently cured ; 

 three after apparent recovery suffered from mild relapses of varying duration ; 

 in two patients the operation was designated as useless. 



Israel has summed up the important knowledge obtained from these obser- 

 vations in the following: 1. There are cases of unilateral nephritis. 2. There 

 are cases of renal colic due to nephritis which may completely simulate colic 

 from calculi. 3. There are cases of bilateral nephritis which produce only 

 unilateral colic. 4. There are cases of severe nephritis with absence of albu- 

 min in the urine and absence of casts. 5. The urine may be free from albumin 



