Occasionally cases will be encountered in which blood issues first and is followed by clear or clearer urine. Care should be exercised in accounting for this somewhat unusual occurrence. In most cases the blood will be in the form either of a darkish clot or of dark fluid blood, and the reason why it precedes the stream of clear urine is because it has dropped to the orifice of the bladder just as it would settle down in a conical urine-glass. It is, therefore, shot out first. It is no certain sign, however, of prostatic or urethral origin. In the majority of cases it is from the bladder or from a renal source. Should brightish fresh blood issue at the commencement of the stream the origin is probably urethral.
A gentleman, aged fifty-two, was sent to me by Dr. Alexander of Paignton, in the hope that the clots which he was passing originated in the urethra. They were moulded like urethral clots, and preceded the stream. There was slight smarting three inches from the meatus when they were passed. On examination a largish right renal growth was discovered, which was removed. Doubtless the clots which col lected in the renal pelvis were gradually pressed down the ureter, finally dropped on to the lowest part of the bladder, and were swept away in the first part of the outrush.
Axiom: issuing from the meatus independently of mictu rition is from an urethral source." (4) On the Subsidence of the Blood in a Conical Glass.—R v. Jaksch asserts that "when blood-cells are intimately mixed with the urine in such a way that, though present in large quantity and deeply tinging the fluid, they do not form a sediment after many hours' standing, it may be inferred that the hemorrhage took place in the ,substance of the kidney or in the renal pelvis or ureters. If, under these circumstances, they are seen with the microscope to be pro foundly altered, having lost their coloring matter and presenting the appearance of pale yellow rings, the further conclusion results that the blood has been effused from the kidney itself, and the symp tom points to acute nephritis or to a fresh exacerbation in the course of chronic nephritis." Qualification,: Dr. James has pointed out that in some cases of alkaline urine a true hematuria may in the course of a few hours become a hemoglobinuria from the solution or disintegration of the red blood discs. This especially takes place in warm weather. In fact Dr. Tyson has known urine to be sent from southern parts of the United States, which when shipped contained blood corpuscles, but in which when received in Philadelphia no blood discs were dis coverable, only large amounts of blood-coloring matter. Such a con dition would render v. Jaksch's rule inaccurate.
(5) The Relationship between the Hcemoglobin and Albumin. Newman has shown that the relationship between the quantity of hemoglobin and the amount of albumin in the urine aids greatly in determining the seat of the hemorrhage. " Thus if the quantity of
hemoglobin and the amount of albumin determined by one or other of the recognized processes be compared, and if the ratio of albumin to hemoglobin is as 1 to 1.6, then it may be concluded," says Dr. Newman, "that the appearance of albumin is entirely due to the presence of blood; but if the quantity of albumin is much increased beyond the proportion just mentioned, the indication is in favor not only of an independent albuminuria, but also points to a renal affection as the cause of the hematuria." (6) Absorption Test.—It has been pointed out by Ultzmann that if potassium iodide solution is injected into the bladder, it is absorbed if any abraded surface exists and can be detected in the saliva. If there is no absorption of the iodide, it can be inferred that the continuity of the vesical.mucous membrane is intact.
(7) Microscopy.—Blood Casts : The presence of blood casts gives an accurate clue to the origin of the hemorrhage. I have met with one case of severe paraffin burn of the whole body in which the patient passed an ounce of perfect blood cylinders in eight ounces of secre tion. The cylinders fell at once to the bottom of the conical glass, and presented a very curious appearance. Death took place in a few hours. The kidneys were turgid with blood and in the first stage of nephritis.
Granular Casts : The presence of granular casts in the urine points in most instances to the kidneys as the source of the hemorrhage.
Growth : It is not an uncommon event (recorded in 19.3 per cent.. of vesical tumors) for the patient to pass visible pieces of growth. I have met with fragments which varied in size from a pea to a necrosed mass half the length of the little finger. Probably in most cases microscopic pieces are passed, chiefly consisting of the vinous processes. These, though they indicate a tumor, do not definitely settle the character of the growth.
Forty-one per cent. of vesical carcinomata have a surface-covering of villous processes,' while in half the cases of villous cancer villous papillomatous growths of the pure type apparently produced by irri tation coexist in the bladder with the carcinoma; 17 out of 46 cases of single carcinomatous tumors had villous coverings; 18 out of 36 multiple carcinomatous tumors had villous surfaces. Pure vil lous tufts coexisted in one-sixth of the cases of sarcomatous tumors, and one-fourth of the epitheliomata (Author, Pathological Society Transactions, 1888, Vol. XXXIX., p. 180, and Jacksonian Prize Essay, p. 144).
Eggs of the Bilharzia Ilmmatobia (Distoma Timmatobium) The yellowish, well-defined egg, furnished with its terminal or lateral spine, is readily recognizable.