(2) The Shape of the information can be gathered by floating in water the clots which are passed by the patient.
Axiom i. : " Long, dark clots like earthworms* or quill-barrels indi cate bleeding from the renal pelvis, for they are casts or moulds of the ureter." ' All uncertainty is set at rest, however, if, after a tran sient cessation of the hemorrhage, long worm-like clots are passed partially decolorized, and if this is followed by a recurrence of the bleeding. It is thus demonstrated beyond doubt that the ureter has been completely plugged and the hemorrhage checked until shrinkage of the clot has loosened its hold and allowed of its expulsion from the canal.
Some years ago I happened to be examining with the cystoscope a patient who had suffered from profuse lammaturia, but in whom the bleeding had ceased abruptly three days before. I was able to demonstrate the right ureteral opening to a large number of medical • men. Partially extruded from that orifice and plugging it could be seen a long, gray, twisted clot. The patient himself had noticed that the reappearance of every attack had been heralded or had been ac companied by the presence of a long cylindrical black or grayish clot. To make the chain of evidence complete, I introduced an evacu ating catheter, directed its eye toward the right ureter, and applied the aspirating ball; then with a slight suction movement I swept the clot into the bottle. On immediately reinserting the cystoscope, streams of scarlet blood could be seen jetting out of the uncorked ori fice. I removed the kidney then and there, and found a small carci nomatous growth ulcerating into the pelvis.
But clots forming in the ureter are sometimes like thin red fishing worms, and concerning these there must be some uncertainty, for similar clots, though perhaps flatter and thicker, are moulded in the prostatic urethra.
Axiom ii.: " Large, irregular-edged, scarlet clots are derived from a bladder source if traumatism of the kidney and renal tumor are excluded." I have seen enormous clots of scarlet hue evacuated in cases of renal growth, so large indeed as to make one wonder that the urethra allowed of their transit, but these cases are uncommon, and usually the clots from carcinoma of the kidney are much darker. They are often described by those of the commoner class as being like blocks of bullock's liver.
Gelatination of Urine.—The late Professor called at tention to a condition of urine which he termed fibrinuria, and which he considered an important diagnostic feature in villous growths of the bladder. The urine, on being passed, is of a reddish-yellow color; it coagulates almost immediately into a jelly-like mass. Such
urine does not contain much blood, as shown by its color; hence the coagulum is not in proportion to the quantity of blood present in the urine.
Ultzmann's theory of the production of fibrinuria is that the spas modic contraction of the bladder checks the blood returning from the villi, and the vascular loops, therefore, become extremely turgid. If the blood pressure is very great the vessels rupture and hemorrhage ensues; if the tension is not sufficient to cause rupture of the vessels a transudation of plasma occurs, and its fibrin coagulates on the emission of the urine. This increased vascular tension also accounts for the presence of more albumin in the urine than would correspond to the quantity of blood and pus present.
Ullmann gives three cases in which he had observed this symptom. Willis ("Urinary Diseases and their Treatment," p. 169, 1838) men tioned a case : The urine gelatinized in the utensil, and when viewed by transmitted light was of a pale red-currant-jelly color." This condition must be rare. I have not met with a single well-marked instance in 150 cases of vesical growth.
(3) The Time at which the Blood Appears in the Stream.—Axiom: "Blood appearing toward or at the finish of clear urination denotes a vesical or a prostatic origin." This is a rule which can be safely relied upon. The cause of its production is obvious. The vesical muscles form contractile planes which are situated between two vascular surfaces, an external sub peritoneal layer and an internal mucous membrane. The external subperitoneal venous nets, which empty themselves into the internal iliac veins, receive the blood from the internal mucous membrane mesh, by means of vessels piercing the muscle planes. When the muscle planes contract, the external venous nets empty themselves, and are prevented by means of valves, from refilling by regurgita tion,' but the internal meshes become more turgid with blood as the contraction increases, for their efflux trunks are compressed by the muscles through which they pass on their way to join the external nets. The vessels underlying or abutting on any breach of surface such as an ulceration, or any thin-walled vessels such as those which form the basis of the structure of villous growths, will, therefore, have dangerous venous pressure placed upon them on contraction of the bladder. If to the force of an ordinary expulsive effort is added the extra stress of straining, the rupture of a congested, weakened, or thin-walled surface mesh is easily produced, and a little blood is ex pelled after or toward the end of the vesical contraction.