Treasurer, George G. Cattermole, Professor of Diseases of Children in Colorado School of Medicine. Senators, W. C. Hollopeter, Professor of Diseases of Children in Medico-Chirurgical College of Philadelphia; H. M. McClanahan, Professor of Diseases of Children Medical Department of the University of Nebraska, Omaha; F. R. Gilbert, Professor of Diseases of Children Kentucky Medical College, Louisville, Ky. The program in part is here presented: Address of Welcome, Arthur D. Bevan, Chicago. Address of the President, Samuel W. Kelley, Cleveland, Ohio. The Teaching of Pediatrics as Seen by an Inspector of Medical Colleges, "Frederick C. Zapffe, Chicago, Ill. "The Fallacy of Attempting to Teach Pediatrics in the Chair of Practice," John A. Witherspoon, Nashville, Tenn. "The Teaching of Pediatrics in the European Schools," H. E. McClanahan, Omaha, Neb. "The Teaching of Pediatrics in the Medico-Chirurgical College of Philadelphia," W. C. Hollopeter, Philadelphia, Pa. "The Doctrine of Difficult Dentition," Theodore J. Elterich, Pittsburg, Pa. Anatomical Peculiarities of Infants and Children," Richard B. Gilbert, Louisville, Ky. "Unciniariasis in the Southern States," J. Ross Snyder, M. D., Birmingham, Ala. Paper, Wm. W. Butterworth, New Orleans. "Some Points on Infants' Clothing," Alfred C. Cotton, Chicago, Ill. Papers by Robert A. Black, Chicago, Ill., Wm. J. Butler, Chicago, Ill., and J. W. Van Derslice, Chicago, Ill. Deaths C. T. Grover, of Orwell, died recently. Katherine Burns, of Canton, O., died March 23. S. R. Walker, aged 40, died suddenly at Aurora, O., April 19. Wm. E. Warner, a retired physician of this city, died April 17, aged 79 years. O. F. Prochaska, 3323 East 55th St., Cleveland, died March 29, aged 39 years. C. A. Force, of Attica, O., aged 49, died March 23, after undergoing an operation. Howard S. Straight, a well known specialist of this city, aged 50, died in New York City, April 14, while returning home from abroad. Charles J. Aldrich, Professor of Nervous and Mental Diseases in the Cleveland College of Physicians and Surgeons, and one of the leading physicians of this city, aged 47, died April 19 at Lakeside Hospital, after a prolonged illness. The Cleveland Medical Journal VOL VII JUNE, 1908 Essential Hemorrhage of the Kidney By F. E. BUNTS, Cleveland, Ohio No 6 In October, 1904, a patient was referred to me for operation for supposed stone in the right kidney. She brought with her a radiograph which, her physician said, showed distinctly the stones in the kidney. She was 48 years of age. Her father died of typhoid fever; her mother and one brother were living and well; three brothers were dead, one of epilepsy, one of cancer, and the other of septicemia. No history of tuberculosis in any member of the family could be obtained. Patient had had the usual diseases of childhood, and stated that she had had three attacks of typhoid at 11, 20 and 30 years, respectively. She had had tonsillitis frequently and had an attack of enteritis three years previously. She had had a pain in her right side for four years, not constant but recurring at varying intervals, but since January, 1904, it had been almost constant. In March, 1904, she first noticed blood in the urine, and it had been nearly constantly present though varying much in quantity, at times rendering the urine very dark in color; occasionally she had pain on urination. Aside from this trouble the patient was in very good physical condition, appetite good, bowels regular, and she was gaining in weight. Urinary examination before operation: Acid reaction; sp. gr. 1029; a trace of albumin; no sugar; a few granular casts; red blood-cells, epithelium and leukocytes. Ureteral catheterization and report by W. E. Lower: Read before the Academy of Medicine of Cleveland, April 17, 1908 Amount obtained from each kidney, 6 cc. Color: Right clear amber, left bloody. Freezing point: Right 89, left 105. Reaction: Right very slightly acid, left acid. Albumin: Faint trace right, present left. Microscopic findings: Right, ureteral epithelium, few leukocytes; left, red blood-cells. Although the subjective symptoms seemed to point to the right kidney, the ureteral examination was so positive in its result that it was decided to operate upon the left kidney on the assumption that there was either a stone or possibly a polyp in the pelvis of the kidney. An observation of the radiograph which she brought me showed that the supposed stones in the right kidney were really shadows from the vertebrae in the kidney region. At the operation I could not discover any stone or growth by palpation. The kidney was somewhat larger than normal, otherwise natural in appearance, with the exception of a central zone which was dark colored as though the site of a venous congestion. The kidney was split from pole to pole and down to the pelvis but no stone or growth could be found and no macroscopic evidence of disease, except the central congestion, could be found. The kidney was sutured with No. 2 chromic catgut mattress sutures and the wound in the loin was closed with a gauze drain. Immediately following the operation there was a large amount of blood present in the urine but at the time of her discharge, November 20, there was no macroscopic evidence of blood, and microscopic examination showed only a few blood-cells. pain had disappeared. The I saw the patient again on September 18, 1905, at which time there was no blood in the urine. There was general improvement in her physical condition, with a decided increase in weight. This case, which no doubt might be classed under the vague title of essential hemorrhage from the kidney, was the first one in which I had an opportunity to cut down upon and examine the kidney. Having done so and having found nothing, and having seen the subjective as well as the objective symptoms disappear after an operation which had no definite aim except to establish the fact that there was no stone or tumor, suggested the desirability of reviewing the literature of essential hemorrhage of the kidney to see whether there was anything definitely determined regarding its pathology and treatment. The literature is rather voluminous and the opinions widely different. Boursier, writing in 1900, thinks that this hemorrhage may be the only symptom of renal lithiasis, stating that in some cases the determining cause was uric acid crystals and in others oxalate of calcium crystals. These crystals are so frequently present in urine that it would seem quite as much coincidence as a cause. Albarran draws attention to the excessive hemorrhage which may come from limited tuberculosis and small neoplasms in the cortex of the kidney, and to what seems to be of particularly important significance, the fact that in certain conditions of the kidneys the least lesion of nephritis is capable of determining the vascular or angioneurotic modification capable of leading to bleeding. He mentions the frequently observed abundant hemorrhages following cutting a kidney in which nephritis is present. Fenwick reports two cases which he thinks demonstrate the reality and power of nerve control over the renal blood-supply, and draws attention to the extremely small source from which an uncontrollable hemorrhage may come. Elterich reports a case of hematuria which was paroxysmal in character and seemed to occur most frequently after some mental excitement. Schenck, in reporting a case of renal hematuria of unexplained origin, adopts the view of Israel and of Rovsing, that there is an undiscovered cause of the bleeding, rather than that the bleeding comes from an anatomically sound kidney. Guthrie relates 12 cases of hematuria occurring in closely related persons, but thinks this form is hereditary and distinct from the essential renal hematuria of Debairieux. Schede thinks that the nervous theory of this form of hematuria is tenable in part, but doubts Israel's conclusion, that there is no such thing as bleeding from anatomically unaltered kidneys. Wulff examined microscopically a section from a kidney which had been bleeding. From the presence of blood corpuscles between the tuft and the wall in the glomeruli, the spaces being larger than normal between tuft and wall, he thought it pointed more clearly to an essential origin than in any other cases reviewed, for not only were there no evidences of nephritis, unless the presence of hyaline casts in the straight tubules be taken as such, none being found in the urine, but the red corpuscles were in such situations as to preclude in all possibility that the bleeding could be due to rupture of the blood-vessels. If they had been found in only one glomerular space this might have been probable, but as they were found in many it is not probable. Regnes sums up his review of the subject by saying, "A priori one can say that there is no essential hematuria; its existence would be contrary to all the laws of general pathology. It is necessary to believe that there is in reality a cause, but that the present condition of our scientific methods of investigation does not permit us to discern it." Schuller analyzes the cause of renal hematuria of apparently essential origin in cases recorded by different men as follows: 1. Congenital abnormalities. Large vascular cord diagonally across the renal pelvis. When the pelvis became full the cord became kinked and circulation was obstructed with resulting hematuria (Rovsing). 2. Diffuse bilateral nephritis (Israel, Rovsing). 3. Diffuse or partial (circumscribed) unilateral nephritis. (Israel and Rovsing, four cases each; Pousson and Senator, and Poirier and Oliver, two cases each; Forsell, Salbatier, Tuffier, one case each.) 4. Glomerulonephritis (Hofbauer, Péan, Desmous). 5. Extreme fibrous degeneration of the fatty capsule, dense thickening of the capsule propria, which showed inflammatory processes and circulatory disturbances (Israel, six cases; Rovsing, two). 6. Mechanical lesions and their consequences (chronic nephritis from compression). A typical case of "Schnürniere" (kidney compressed by lacing?). A case of torsion of the kidney "pedicle" behind an adherent lobe of the liver (Rovsing, both cases). 7. Sandy incrustation of a papilla (Abbé). It is not known why we find diffuse nephritis with severe hemorrhage on one hand, and a much more severe grade of diffuse nephritis and no hemorrhage on the other, nor why, with contracted kidney, severe bleeding should occur. In Schuller's own case, in which there was no apparent cause for hematuria of renal origin, the microscopic examination of a portion of the kidney removed showed the presence of parenchymatous nephritis. He thinks that in "essential" renal hematuria. the bleeding is entirely due to mechanical causes. I have collected from the literature of this subject 70 cases and have attempted to analyze them from various standpoints. 1. Sex: I find that there are recorded 30 males and 37 females, suggestive at least that occupation and exposure were not predisposing factors. 2. Age: This varies from five years to 65 years, and the |