name is inseparably connected with renal pathology, and his opinion, the patient informed me, was in conformity with the views now expressed.

This man, B-, had several times, since he first came under my notice, presented himself with a return of his complaint. The hæmaturia, in June, 1856, lasted only three days. On the fifth day the urine was free from all trace of blood or albumen. Trouble and excitement preceded the attack. Six weeks afterwards he had another attack; and so dependent does the hæmaturia appear to be on mental excitement, that on this occasion a trivial dispute with his employer about the scale of remuneration for work was the exciting cause. On each of these attacks the symptoms exhibited the same peculiarity; a sense of weight and pain about the loins, but unaccompanied by any constitutional disturbance, by greater frequency of micturition, or inconvenience or difficulty in that act. It was thus, by the exclusion of all the symptoms of irritation characteristic of renal calculus, or of gouty inflammation; it was by the absence of all constitutional disturbance, whether febrile or dropsical; it was from the temporary character of the attack, the urine in a few days becoming free from blood, and from all morbid sediment, except a few scattered blood-discs, that we were led to exclude as the cause of the hæmaturia all those organic diseases in which hæmorrhage occurs as a prominent and leading symptom, and to attribute the hæmaturia to the operation of mental excitement.

I confess that but for the authority of such an observer as Rayer, or the support which this view received from the opinion of the eminent physician quoted above, that I had great difficulty in forming a satisfactory diagnosis of the cause of the hæmaturia. It was only by a patient observation of the sum of the symptoms exhibited by this patient over a period of more than eighteen months, and finding on each recurrence of the attack the strictly temporary state of the urine, the constant relation of this hæmorrhage to mental emotion, that I at last came to the conclusion that the case might be fairly classed with those which Rayer has mentioned

as 'hæmorragies renales essentielles' (sporadique), and that the exciting cause of the hæmaturia must be attributed to the rare and exceptional influence of mental excitement. I have been very desirous of keeping this patient under observation, with a view of testing the soundness of the opinion entertained up to this date.

This patient came again under my observation in May, 1857. He stated that it was more than six months since he last suffered an attack of hæmaturia; that during that period he had experienced many things to fret and worry him-quarrels with his wife, his brother gone to a mad-house; but, strange to say, these anxieties did not affect him so as to bring on bloody urine, as formerly.

The present attack was of three days' duration; and he stated that, for the first time, he felt some weight and uneasiness across the loins, with a settled fixed pain in the left hip, extending to the position of the anterior crest of the hip-bone. There was no numbness or pain in the leg, no retraction of the testicle, no frequency of micturition; he held his water through the night. The tongue was clean, appetite unimpaired, and the general health undisturbed; aspect of the patient healthy.

The urine was blood-coloured, albuminous, not deficient in quantity.

Under the microscope nothing but scattered blood-discs could be discovered.

On May the 18th, the urine had nearly lost its cherry tinge. The pain in the loins had abated. He derived apparently much benefit, so far as the subsidence of the hæmaturia, from the sesquichloride of iron.

During the summer and autumn he suffered several attacks, each passing off in three to four days, the urine becoming, he states, quite healthy in appearance. I have not, hitherto, been able to get the man to bring his urine for examination in these intervals of calm. On the 3rd of December he stated to me that now the urine becomes mixed with blood after much bodily exertion; and that when the urine is not bloody, it is turbid—

he said, milky-and throws down a sediment. On the 4th of December, he brought me some urine passed that morning. It was slightly turbid, a flocculent cloud was thrown down by subsidence, the clear portion was doubtfully hazy by heat and nitric acid. The sediment, when examined, was composed of pelvic epithelium, large, compound granule-cells, the smaller sized exudation-corpuscles (mucous pus-corpuscles), and a very abundant formation of oxalate of lime crystals (octohedra). I have rarely found them in greater abundance. (Pl. X, fig. 11.) The patient distinctly stated that the only inconvenience he felt was the pain in his loins, but not one sympathetic symptom, usually present in renal calculus, could be detected. The presence, however, of these inflammatory corpuscles in the urine is evidence of some irritation in the kidneys, and the, hæmaturia may hereafter be traced to some local source of mischief; but if this should ultimately be proved, the case presents very exceptional features. For more than two years the hæmaturia has been unaccompanied by any sympathetic symptoms, or by the slightest derangement of the health. Even now the aspect of the patient is most favorable; his looks are healthy, active, and undisturbed, and the lumbar pain passes away so soon as the blood disappears from the urine.

TEMPORARY AND INTERMITTING HEMATURIA.

The above case might almost be classified under this head. There are, however, cases, recently recorded by Dr. Harley,* in which the hemorrhage seemed in some to be traced to the effect of exposure to cold, in others to arise from the agency of a material poison.

Further observation is desirable on the sequel to these cases, as it may not be improbable that what at first seemed but a temporary and functional disturbance, eventually may terminate in organic disease.

'Med.-Chir. Trans.,' vol. xlviii, p. 161 et seq.

ENDEMIC HEMATURIA.

Attention has been recently directed to the prevalence of hæmaturia occurring to numerous individuals in certain localities, particularly at the Cape of Good Hope and in Egypt. It appears to be a symptom limited and indigenous to hot countries, and to arise from the ravages of a parasitic entozoa of the genus Distomum. It was discovered and first described by Dr. Bilharz, in Egypt, and out of compliment to him the parasite is now called the Bilharzia Hæmatobia.

A very interesting paper on this subject was communicated by Dr. John Harley to the Royal Medical and Chirurgical Society, and published in the 'Transactions,' for 1864 (vol. xlvii, p. 55). Dr. Roberts, in his work on "Urinary and Renal Diseases," also notices the disease. I have never met with an example; the reader is therefore referred to these works.

CHAPTER II.

URIC ACID IN EXCESS-GRAVEL OR RED SAND.

BEFORE describing the more serious and fatal forms of kidney disease which are developed by the gouty habit, it may be convenient to notice some of the conditions of the urine which are the usual precursors of the atrophied kidney, and which are -up to a certain stage-readily amenable to treatment.

Gravel or red sand from excess of uric acid, often inducing obscure symptoms of pyelitis, even hæmaturia and albuminous urine.

Urine containing excess of uric acid, which is rapidly and abundantly precipitated on cooling-in any of the crystalline forms which this acid assumes-will sometimes excite so great a degree of renal irritation, that grave doubts may be entertained whether the patient is not suffering from calculous nephritis. These doubts a microscopic examination of the urine will satisfactorily remove. The uric acid crystallizes from the urine so abundantly in these cases, that a deposit of what is called red sand, rapidly forms at the bottom and sides of the vessel, and is always accompanied by epithelium in abundance from all the urinary passages. Such urine therefore affords examples of epithelial cells from the bladder, ureters, and pelvis of the kidney. Epithelium from the tubuli uriniferi do not occur. When the amount of renal irritation is very great, large compound granule-cells are not unfrequent, and in very severe cases, where the symptoms differ in nothing but in