in which there was occasional bleeding from the gums, the urine contained blood during a period of nine months. In this case there was no loss in weight during the five years the patient was under observation.

When blood corpuscles are found entangled in casts, we may feel sure that they have escaped from capillary vessels in the cortical or secreting portion of the kidney, in most cases from the vessels of the Malpighian body. The blood is sometimes poured into the upper part of the uriniferous tube, while the cast is found in the lower; but more generally the blood escapes into the part of the tube where the cast is formed. The cast, however, is not composed of fibrin. If urine containing blood is acid, it has a dark, smoky appearance. This change in color, which is more marked when a small quantity of blood is very gradually mixed with a large amount of acid urine, is due to the action of the acid of the urine upon the hæmoglobin.

Hemorrhage from the kidney also occurs in the course of many forms of chronic disease. In such instances it is a favorable sign if the albumen is not to be detected after we have failed, upon microscopical examination, to find blood corpuscles. If the albumen, however, continues to be passed, in the absence of any blood corpuscles, we may feel sure that it has not been solely derived from the serum which escaped with the corpuscles through the ruptured capillary vessels. Its presence must be attributed to chronic renal disease. It is important to be able to determine whether there is more albumen than may be accounted for by the presence of the blood-whether the case is one of hemorrhage only, or of hemorrhage complicated with acute or chronic kidney disease.

When the kidney is injured by mechanical violence, hemorrhage occurs, and sometimes a violent shake appears sufficient to cause the rupture of some of the small vessels of the kidney, and the escape of a considerable quantity of blood in the urine. A gentleman of my acquaintance fell against a step, and his side and back came violently in contact with the edge. Much blood soon made its appearance in his water, and for several days the hemorrhage was severe. After the lapse of a fortnight the urine

still contained an abundant brownish deposit, in which a few altered blood corpuscles with numerous crystals of hæmatoidin were found. The blood effused in some of the tubes had probably remained in them a sufficient time for the crystals to be formed from the blood-coloring matter. I have seen similar crystals in sputum some time after hæmoptysis; also in the fluid outside hydatids of the liver, which sometimes escapes with the sputum; and oftentimes in clots in the brain two or three weeks after rupture of the vessel.

Hemorrhage from the kidney is not uncommon in cases of continued fever. Sometimes it occurs in the course of pneumonia; and I have seen it in several cases of acute rheumatism. In all these conditions the vessels of the kidneys and internal organs generally are highly congested.

Hemorrhage from the kidney and bladder always occurs sooner or later in the course of cancer of these organs. The diagnosis in the early period of the case is often very difficult, as there may be no pain and a complete absence of any definite symptoms. The persistence of the hemorrhage, however, its occasional increase in amount, the gradual emaciation of the patient, especially if he be upward of fifty, will lead the practitioner to suspect the real nature of the malady, and not unfrequently the detection of cancer cells in the urine proves beyond doubt the serious nature of the case. Fungus of the kidney or bladder is almost invariably accompanied by hemorrhage, which is sometimes very violent, and soon exhausts the patient; and this violent bleeding may be the first intimation to the patient of the existence of anything wrong. Hemorrhage from the prostate may be due to a very serious affection, and it is oftentimes one of the first symptoms of structural disease of that organ. Occasionally the veins of the gland become dilated and varicose, and at length rupture. The attack may last a few weeks, and then pass off, or it may continue, in spite of all treatment, until the patient's strength becomes exhausted.

I have known hemorrhage of a very decided character from the bladder, from the prostate, and from the urethra, occasioned by mere jolting over a rough road. Hemorrhage of this kind is

sometimes very troublesome, and continues for so many days that we begin to fear it depends upon actual disease. We must, therefore, press upon the patient the extreme importance of rest until the bleeding ceases. Citrate of potash and purgatives seem to be of use in many cases, and should be prescribed before gallic acid is given. The position of the calculus can sometimes be fixed by the discovery of epithelium from the pelvis of the kidney or from the ureter mixed with the blood or entangled in the meshes of small blood clots.

Hemorrhage from calculus in the bladder is often very considerable, and occasionally persists uninterruptedly for days or weeks; but more commonly it lasts only for a few days, and recurs after an interval. The patient should, of course, be carefully sounded.

Hæmaturia may depend upon a calculus being impacted in the kidney, in which case it may continue for a day or two, and then cease entirely for some time. In many cases it recurs constantly after unusual exertion or jolting. I have seen a case in which violent pain down the ureter, with retraction of the corresponding testicle, persisted for years during boyhood, after exertion.

Simple hemorrhage, not dependent upon organic disease, sometimes takes place from the mucous membrane of the bladder, as well as from other mucous membranes, as those of the nose, throat, air-tubes, stomach, intestines, etc.; but it must never be forgotten that slight hemorrhage is often the very first symptom of very serious changes, and the practitioner should, therefore, in a doubtful case, always give a very guarded opinion, and see and examine the patient a few times before he commits himself to a diagnosis.

When blood is found in the water pretty frequently, after the age of 60, the observer should be very careful not to commit himself to an opinion until he has examined many specimens of water, at intervals of a week or two, as the blood may be due to the commencement of malignant disease. Every now and then a few cancer cells may be found if carefully searched for.

Small quantities of blood are sometimes passed day after day

It

by apparently healthy persons, just as micturition ceases. seems as if the effort to expel the last drop of urine had caused the rupture of a few capillaries about the membranous part of the urethra or neck of the bladder. The hemorrhage usually ceases after a time, if the patient rests. Usually no special treatment is necessary, but it may be desirable to give a saline purge. In some of the cases which have fallen under my notice the bleeding was certainly caused by an undue sexual indulgence. Occasionally a few blood corpuscles are found in the urine, although not a trace of albumen can be detected in it. Sometimes the blood remains for some time in some part of the urinary passages before it escapes, and the serum and all the soluble constituents are absorbed, the red blood corpuscles in certain cases not being so much altered as is usual.

Blood Clots assume various forms, and if they have been retained for many days in the bladder, undergo great changes in color and form, so that there may be considerable difficulty in identifying them. They have been mistaken for portions of mucous membrane, entozoa, and other things. Clots of extraordinary forms are often passed by patients suffering from renal calculus. Sometimes these clots are of very curious shapes, and occasionally upon the surface will be found a depression, evidently from the stone over which the blood had coagulated. By careful microscopical examination, without disturbing the clot, small crystals may sometimes be seen, which have been detached from the surface of the stone. Epithelium, which may sometimes be identified without difficulty, is often entangled in the blood clot. The ova of entozoa are also occasionally found. By careful examination of the blood clot, in short, we may often gain very important information which is of the greatest assistance to us in forming a conclusion as to the nature of the case.

Hemorrhage caused by Entozoa in the Kidney.—The presence of entozoa in the kidney is occasionally the cause of the escape of large quantities of blood from the renal vessels.

these cases there is bleeding to an alarming extent.

In some of

The patient becomes blanched and very feeble, and his case is diagnosed as soft cancer of the kidney or bladder, until the urinary deposit is

carefully examined, and then ova or fragments of the envelope of the ovum of Bilharzia are discovered (Bilharzia Hæmotobia, "100 Urinary Deposits," Pl. VIII, Fig. 112). This entozoön occurs in Egypt, the Mauritius, and many parts of the East. Dr. John Harley has discovered the ova of this entozoön in the urine of several persons from the Cape, where the disease was contracted. Dr. Harley considered that the ova came from a particular species of Bilharzia, which he named Capensis. See "The Transactions of the Medico-Chirurgical Society, 1864," and following year. Strongylus is another entozoön which gives rise to much hemorrhage in the very rare cases in which it

occurs.

Intestinal worms are sometimes passed into the vessel containing the urine, and the patient not unfrequently affirms that they come from the bladder. Various species of acari are frequently met with in urine. It need hardly be said they were not formed

in the urinary organs. Insects and their larvæ are, from time to time, brought to us in specimens of urine. Patients will positively assert that larvæ of the common flesh; fly have been passed through the urethra. I have, on many occasions, had specimens of the common maggot and cheese maggot forwarded to me, with the positive assurance that they have been voided by the patient. The presence of the tracheæ in every part of the body proves the creature to be an insect, and it need scarcely be said that an air-breathing insect could not have been developed in any part of the urinary organs. These insect larvæ will pass through the entire tract of the intestinal canal in a living state. See "The Microscope in its Application to Practical Medicine," and references to papers by Dr. Brinton and Mr. Blood.

Treatment of Hæmaturia.—In acute febrile conditions, as has been already remarked, the kidneys are apt to become congested, and sometimes considerable quantities of blood may be lost. The symptom generally passes off after a few days, but in one case of acute rheumatism, it persisted for three weeks, producing an anæmic condition; cupping over the loins and several remedies were tried, but did not seem to produce any immediate effect upon the hemorrhage, which, however, gradu