448 THE HEMORRHAGIC DIATHESES 



they were unable to find any material or assignable cause for the hemorrhage; 

 while, from the circumstance that the hemorrhage ceased after operative in- 

 terference, whether by a simple exploration, a nephrotomy or a nephrectomy, 

 proof was given that the hemorrhage actually arose from the kidney in ques- 

 tion. For the explanation of the hemorrhage, therefore, the assumption of a 

 " local hemophilia " or an " angioneurosis " is in these cases held sufficient. 



If, however, the published clinical histories are critically examined, we 

 arrive at the conclusion that, as a matter of fact, in by far the majority of 

 cases, pathological conditions of the kidney or of the pelvis of the kidney 

 might have been determined which would explain the hemorrhage. Finally, 

 in the cases in which the kidney has been found apparently normal, the pos- 

 sibility was not considered that the starting point of the hemorrhage was not 

 in the kidney substance at all, but in the pelvis of the kidney, or in the ureter. 



Eovsing communicates four personal observations, in three of which patho- 

 logical changes were observed, and comes to the following conclusions: 1. 

 Many of the published cases of hemorrhage of nervous origin do not stand 

 the test of critical analysis, as in some of them pathological conditions were 

 actually present which very readily explain the hemorrhage, while in other 

 cases the investigation was not thorough enough to exclude other affections, 

 not only those of the kidney but also those of the bladder, as cystoscopy was 

 not performed to determine the origin of the hemorrhage from only one ureter. 

 2. There is no doubt that in a number of cases of hematuria from normal 

 kidneys, dislocation of the kidney with torsion of the pedicle or kinking of the 

 ureter plays an important role. ■ 3. The first case mentioned by Eovsing dem- 

 onstrates the fact, unknown till then, that lacing and the pressure of a corset 

 may directly cause very marked disease of the kidney. 4. After a careful 

 sifting of the cases a few still remain in which decided hemorrhage, which 

 was proved to originate from one ureter, disappeared permanently, although 

 the exploratory incision of the kidney in question showed no demonstrable 

 pathologic changes. 5. Such cases are so rare that they may be considered 

 purely as exceptions, and since serious disease can never be excluded clinically 

 as a cause for obscure cases of hematuria, in all doubtful cases an exploratoiy 

 lumbar incision should be made, especially since, according to experience, this 

 may have a curative effect upon the hematuria. 



In the first session of the Fourth French Congress for Urology (October, 

 1899) a symposium upon "essential hematuria" took place. Malherbe and 

 Legueu maintained that, besides hemorrhages occurring in tuberculosis, car- 

 cinoma, and lithiasis, a so-called essential hematuria had also been described 

 which is apparently independent of disease of the urinary organs. In an 

 accurate analysis of the cases published up to that time, particularly those cases 

 which had been pathologico-anatomically investigated, pathological changes 

 were almost invariably noted even though often slight, for example, calcareous 

 incrustation of a pyramid, or slight tuberculous disease. The most frequent 

 cause of so-called " essential hematuria " is evidently chronic nephritis. The 

 quite insignificant sclerosis of the renal parenchyma, as, for instance, after 

 contusion of the kidney, in floating kidney, and in pregnancy, may remain uni- 

 lateral, and not necessarily give rise to further symptoms of Bright's disease. 



