Hemorrhage from the bladder may be also caused by the injudicious intro duction of the sound, or catheter. Prostatic hemorrhage is rare ; disease of this gland is chiefly indicated by constant difficulty in emptying the bladder, and its condition must be ascertained by examination per rectum ; in hemor rhage from the urethra the blood is not passed at the time of micturition, but flows without awv attempt to empty the bladder. Both these affections are regarded as surgical.
c. As an accompaniment of purpura, blood, when present in the urine, is generally of considerable amount and bright color; the diagnosis rests on the other signs of the altered condition of the blood which it exhibits. Memo turia is comparatively very rare as an idiopathic disease; it is important to inquire into the previous existence of other hemorrhages, of which it may be vicarious, such, for example, as piles ; or of epistaxis and copious bleeding from slight wounds, -which may be taken as evidence of the hemorrhagic diathesis.
d. In chronic disease of the kidney the urine is often tinged of a smoky color by the intermixture of a small quantity of blood, which has been altered in appearance by the action of the acid present in the urine. When the urine is alkaline, the color has a pinkish hue; it has seldom the florid look of un altered blood. Exactly the same appearances are often found in the urine passed after an attack of scarlatina when dropsy occurs.
In both cases the .distinguishing feature of the disease with which this form of hemorrhage is associated is that there is a much larger amount of albumen present in the urine, as proved by chemical reagents, than could have been derived from simple admixture of the actual quatrtiby of blood necessary to produce the red or brown color.
These observations all tend to show that luematuria Is almost constantly a symptom, though a casual one, of disease in some portion of the urinary ap paratus ; and all the points which have been alluded to require further study, if more than a mere guess at its cause be sought far. In giving it a place among the hemorrhages, we only seek to point out its accidental and uncer tain character, and that it is rather to be regarded in many instances as an intercurrent disorder, making its appearance in the course of some more severe malady.
§ 5. Intestinal Hernerrliage.—When blood is passed by stool, it is necessary to determine whether there be haemorrhoids, internal or external. In their absence, we must proceed to inquire into the constitutional aad precursory symptoms. Whether it have
been preceded by haematemesie, by fever, by diarrhoea, or by dysentery, the color of the blood will aid in determining from what portion of the canal it comes. The darker in color, the higher up is its source; the brighter, and the more nearly it ap proaches to the ordinary color of blood, the nearer is its point of discharge to the anus ; black and pitchy after luematemesis, it is bright and florid in dysentery.
When not from the stomach, its most common source is ulceration of the mucous membrane in some part of the canal. It is not unfrequently present in purpura, and sometimes appears to depend on a state of simple debility and extreme re laxation of the mucous membrane; but when such cases terminate favorably, there must always remain a doubt whether ulceration did not exist.
§ 6. Uterine Hemorrhage may occur in seemingly perfect health, or as a consequence of disease; the mere fact of the continuance or frequent recurrence of hemorrhage is not of itself any sufficient indication of disease of the organ. The character we would assign to it, as distinguished from menorrhagia, is the irregularity of the periods of its occurrence; but so great is the tendency to periodi city in this organ, that such a rule is liable to error. Menorrha gia, properly so called, consists in an inoreasd flow of the men strual discharge, the actual quantity being greater, the time of its duration longer, and the intervals of repose shorter, but all per fectly regular in their recurrence, and gradually developed. Hemorrhage, again, comes on suddenly, and is quite independent of the menses; if it happen at one period, it does not follow at the next, but may again recur at some future one, or at any intermecliate time.
a. -When it is found in apparent health, it is generally the con sequence either (1) of sudden alarm, especially soon. after the usual menstrual period, or (2) of abortion:. in such cases it may continue at intervals for weeks or months afterwards, from want of care and proper management,.
b. As a consequence of disease, it is most commonly associated with (1) polypus or fibrous tumors; (2) fungoid growths and can cer; (3) sometimes with the hemorrhagic diathesis, when it is fol lowed by intense ancemia, and may even prove fatal. The local diseases which give rise t,o hemorrhage from the uterus must be ascertained by tactile examination ; their consideration will be resumed at a later part of our inquiry. (See Chap. %XXIII., Diseases of the Uterus.)