will suffer from some degree of headache and stomach derangement. It is very remarkable to observe the change which takes place in many of these cases as age advances. Up to 30 or 35 the patient suffers almost constantly from some dyspeptic symptoms, and no matter what he eats, digestion, which is slow, is always accompanied by discomfort or actual pain. Not uncommonly the patient will tell you he is utterly miserable, and perhaps his sufferings are so great that he will assure you he does not care to live. About the age of 40 he, perhaps, begins to improve-is able to eat a pretty good meal now and then, and only gets upset occasionally. Although seldom feeling strong or vigorous, or contented and happy, life seems to be endurable. By the age of 50 probably all is changed. The patient enjoys good health, and is conscious of sensations which are quite new to him. His spirits are so good that he can scarcely believe he ever suffered from depression. His working power is greater than it ever was-he sleeps well, and, most wonderful of all, he can eat anything without discomfort, and in quantities which astonish him, and the despairing dyspeptic of early and middle life becomes cheerful and happy, and looks hopefully forward to a vigorous old age, and good health and strength to the end.

It has been assumed by some, that when phosphates were passing away the brain would suffer in nutrition, to prevent which phosphorus should be given. That so-called brain food is either required or can be supplied is an amusing fancy, but nothing more. Phosphorus used to be ordered some years ago in leucocythemia, upon the fanciful and quite unjustifiable hypothesis that deficiency of phosphorus in the blood interfered with the development of the red blood corpuscles. The only very decided effect I have seen resulting from the giving of phosphorus in any cases was, I regret to say, unfortunate. In one or two of my own patients there were pain and disturbance about the mouth and teeth, and in one, decided threatening of necrosis of the bone of the lower jaw.

When the phosphatic condition of the urine is only occasional, small doses of dilute acids in a bitter infusion before

meals, or the tincture of the perchloride of iron, will generally cause the urine to become healthy by improving the action of the stomach. Pepsin ("On Slight Ailments," 2d ed., p. 86), may also be given with advantage in some of these cases. Benzoic acid and benzoate of ammonia, in doses of from ten to thirty grains three or four times a day, between meals, for a month at a time, have also been prescribed, and sulphate of zinc, and extract of nux vomica, are favorite remedies. If the intestinal canal be loaded, and the patient has been living too well, as is not unfrequently the case, a little blue pill and compound colocynth pill will cure him.

Alkalies, as Dr. Owen Rees was the first to show, undoubtedly do good in some of these cases of phosphatic urine, probably by their action in promoting the normal chemical changes in the blood rather than by direct action upon the kidney or any part of the genito-urinary mucous membrane. Dr. Rees' explanation has been already referred to, p. 29.

When the phosphate in the urine has persisted for some time, and is accompanied with any symptoms referable to probable affection of the cord, especially if the bladder be irritable, and there be nervous twitching of the muscles, with tingling or numbness of the skin in any part of the lower half of the body, or diminished control over the voluntary movements, acids and tonics, with small doses of opium, should be given. The practitioner will meet with many cases where disease of the cord has been diagnosed, which nevertheless get quite well as soon as the general health is improved. Before treating such cases we must find out how the patient lives, and ascertain whether he has been troubled with mental anxiety, excitement, over-mental work, etc. The patient must not be led to suspect that he is suffering from any serious organic disease, for not unfrequently people are terribly nervous, and too prone to dwell upon every ache or pain they may have, and they are foolish enough to refer to medical books, with the view of ascertaining the nature of their ailments. The diagnosis in these cases should be very guarded, unless the symptoms clearly and positively indicate the real nature of the disease.

A patient for some time under my care, whose urine almost invariably yielded an abundant cloud of phosphates of lime and magnesia, on the application of heat, complained of a strange feeling of dread of some impending disaster. Whenever he heard of cases of fever or other disease in his neighborhood, he had the greatest difficulty to reason himself out of the conviction that he was about to have an attack. Although he admitted while talking to me that the probabilities were the other way, as soon as he got home and was alone the opposite conclusion took possession of his mind, and he suffered terribly from low spirits and a vague, indefinable fear or dread of something or other. When this patient's digestion and general health improved, the curious state of mental depression gradually disappeared, and he almost forgot that he had suffered from the symptoms which distressed him so much at the time.

OF BLOOD CORPUSCLES IN THE URINE-HÆMATURIA.

The significance of blood in the urine must engage the consideration of every practitioner in medicine and surgery. The presence of blood may mean that a little has escaped from the vessels of some part of the urinary mucous membrane, of no more consequence than a very slight nose bleeding. On the other hand, a little blood in the urine may be the first evidence of the presence of stone, or of a very serious organic change which will almost certainly result in death.

As in cases of hæmoptysis, the practitioner cannot be too careful about committing himself to a definite opinion until he has well thought over all the facts of the case. Without care,

and especially in cases where the patient or his friends may be inclined, as is said, "to insist" upon having the "candid" opinion of the practitioner at once, is there danger of asserting that a case of slight bleeding, which turns out to be serious, is nothing, or, of affirming that one which is of no consequence at all is the commencement of a terrible and necessarily fatal disorder. In many cases where blood is present in the urine, it is even more difficult to come to any positive conclusion on first seeing the patient, than it is in cases of hæmoptysis, hæmate

mesis, or bleeding from the bowels, to decide whether the bleeding is serious or only of trivial consequence.

It is of the first importance to insist upon rest in any case of hæmaturia-especially so in cases where the patient has passed the age of 45 or 50. Even when you are pretty sure that the blood comes from the urethra, in a young and apparently healthy man, it is nevertheless most desirable to act upon the cautious side, for by making the patient rest at once, you may save him from a somewhat severe illness, or from the occurrence of pathological changes which may result in stricture, abscess, or some other serious and troublesome lesion. Even where bleeding occurs from an inflamed surface of mucous membrane, where there is continued irritation and movement of the parts, the discharge is often followed by the pouring out of lymph, which results in thickening and formation of fibroid tissue. This change is especially damaging in the case of the mucous membrane of the ureters, bladder, or urethra. In cases of hemorrhage we cannot be too strong in insisting upon rest for a few days or a week, or until we feel pretty certain that all danger of a repetition of the discharge of blood has ceased.

Blood Corpuscles usually form a red or brownish-red granular deposit, which sinks to the bottom of the vessel; but a few corpuscles are usually diffused through the urine. If the urine be perfectly neutral, or slightly alkaline in its reaction, the color of the blood will be bright red; but in those instances in which the reaction is decidedly acid, it will be found of a brown color, imparting to the supernatant fluid a "smoky" hue. When the urine has a decidedly "smoky appearance" it will often be found that the blood is derived from the kidney. If, however, the urine is decidedly alkaline, the blood will retain its florid red color. In the majority of cases in which the mixture of blood and urine is bright red, it is probable that it has escaped from the mucous membrane of the bladder, or from the prostate or urethra. If blood globules remain long in urine, they become much altered in form, the outline appearing irregular and ragged, and the surface granular. Sometimes, however, they appear swollen and very much enlarged. These changes are, no doubt, due to F*

physical actions. The characters of blood corpuscles are represented in "100 Urinary Deposits," Pl. VIII, Fig. 100. As a single grain of blood contains three hundred million blood corpuscles or more, it must be obvious that only one drop diffused through a pint or more of urine would yield corpuscles enough to be discovered by microscopical examination, if time were allowed for the sediment to subside.

If blood remains for some time stagnant in the uriniferous tubes, or in the capillary vessels, before it passes into the urine, crystals of hæmatoidin are often found. From five days to two weeks probably elapse before the crystals in question result. Blood in the urine may be derived from any part of the genitourinary mucous membrane. In the female, it often escapes from the vessels of the uterus or vagina. At the time of the menstrual discharge a good deal of blood is, of course, found in the urine. For some days afterward a few blood corpuscles and disintegrated blood corpuscles may often be detected. In some cases it would appear that small quantities of blood get entangled in the mucus and amongst the papillæ of the mucous membrane of the os and cervix, or in folds or depressions of the mucous membrane, for in some cases we find blood corpuscles in the water for many days after the catamenial discharge has ceased. Some of these cases are put down as renal calculus, while in others the blood corpuscles are regarded as evidence of the existence of ulceration of the os uteri. From the urine of some females, who nevertheless enjoy excellent health, blood corpuscles are hardly ever absent, and are almost always to be detected if a considerable quantity of the urine be allowed to stand for some time, and the slight deposit which subsides is submitted to microscopic examination.

Blood may come from the kidney,-in consequence of recent inflammation or old-standing disease, causing distention and rupture of the vessels of the Malpighian body, or its escape may depend upon that peculiar condition of system in which there is a tendency to capillary hemorrhage in all parts of the body, a condition which is now known as Hæmophilia (atua, blood, yeλía, love, friendship, fondness, "predisposition for "). In one case