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Dr. G. W. Moody: “I would like to ask Dr. Lee if he ever discovered any constitutional effect after the local use of phenacetin?”

Dr. M. H. Lee: “Never have."

MALARIAL HEMATURIA.

ROBERT WHITE BARTON, M.D., MARION, ARK. “The Treatment of Malarial Hematuria,” by Dr. W.P. Barton, Malone's Landing, Miss., as quoted by The Medical World from MEMPHIS MEDICAL MONTHLY, has attracted my attention, and I beg for space in your valuable journal to recite my experience with the disease.

Malaria hematuria occasioned more uneasiness, both to practitioners and patrons, when I located in this county, than all other malarial diseases. The doctor answered the call as a matter of duty, and often frankly admitted to those in charge of patients that he had no views upon the treatment of the disease. This feeling existed with the older practitionersmen competent and experienced—and it is useless to say that the writer felt the same way. For eight years I have devoted much careful study to this disease, and submit the followingthe results of that experience—to whom it may concern :

Malarial hematuria is a malarial disease, or, to define more comprehensively, is a diseased condition caused by the continuous (chronic) action, or the frequent recurring acute action of malaria, of both the intermittent and remittent varieties, in which the number of red blood corpuscles is decreased and, to a limited extent, destroyed, and the white corpuscles increased; in which also, the functions of the liver are disturbed, and in a few cases suspended, thereby causing speedy death from pernicious congestion ; in which the liver is always enlarged and engorged, sometimes indurated; in which the spleen is enlarged and sometimes indurated, and in which the functions of the kidneys are so deranged, that the disease is improperly classed, by some, as a disease per se of that organ.

It may be intermittent, simple or pernicious; or remittent, simple or pernicious. The quotidian and tertian types are the most frequently seen as in ordinary intermittent malarial fever,

yet the double quotidian and tertian types have been in a few instances, treated by the writer, and a tendency to relapse, by return of paroxysm, every seventh day for a greater or less length of time, after convalescence, noticed. I have observed the following causes of death, viz.: congestion, heart failure and uremic poisoning. The congestion may be of the general capillary variety, or it may be elective (to coin a term), selecting the stomach, liver, kidneys, spleen, bowels, etc., as a special object of attack. Malarial hematuria could not be properly classed as any other than a blood disease, if any other malarial disease can be classed as such. Besides the evidence of this being the correct classification, we find in the paroxysm, with its cold, hot and sweating stages (in the intermittent variety), and in the remittent variety the diurnal rise and fall of the temperature, with more or less coldness and congestion periodically, followed by dry, hot skin and high temperature; we have the further evidence furnished by the character of serum found in blisters made upon the body of hematuric patients. In at least ninety per cent. of cases treated in intensely malarial districts, the congested, swollen and indurated condition of the liver and spleen can be hastened in their restoration to a more normal size and function, by a cantharidal blister, of sufficient size. The serum from these blisters is of some dark port wine color, known to be the characteristic color of the urine in malarial hematuria. I have never seen serum otherwise colored, except in two cases, when it was of a deep orange or lemon color.

In these two cases, the discoloration of the eyes was also of a brighter yellow than in other cases.

The existence of the above conditions, which observant practitioners could not overlook, in this disease, show the indications for quinine. While I give quinine in stimulating doses, at least, in all cases, the following rule guides me in its administration. The greater evidence you have of congestion, and the more certainly you can diagnose intermittent variety, the nearer anti-periodic doses of quinine must be given. Dr. Barton says, “malaria produces the condition, and in some cases possibly the disease, but is now passive, and what we are to dread is uremia.” While the danger of uremia is an alarm

ing and probable one, and there is an asthenic condition in hematuria that is now more generally observed, yet when you study the problem as to the relations of the terms, conditions and disease, in this disease, we find that the condition is the result of repeated attacks of acute malaria, or the result of long-continued chronic malaria. While a person may not necessarily be a sufferer from chronic malaria to fall a victim of malarial hematuria, the disease always attacks either such subjects, or those suffering from repeated recurrent attacks of acute malaria.

Death from heart failure may be the result of uremia caused by suppression, or it may be from general nervous prostration and inanition, days and weeks after the urine has been restored to its natural color.

Death from uremic poisoning is always the result of suppression, which never exists if the periodicity—in other words, if the recurrence of the paroxysm is prevented. If paroxysm does occur, of course the kidneys are congested actively, their eliminative function is thereby suspended, and may remain so, the patient succumbing to uremia, from the effects of poisonous material which are in too excessive quantity for the deranged organs to eliminate. The assumption of the existence of an organic lesion taken by Dr. Barton is unwarranted. In the majority of cases, no organic lesion exists. Nephritis of mild character usually exists, as evidenced by albumin found in all true malarial hematuric urine. A further evidence that no organic lesion of the kidneys existed in the cases referred to by Dr. Barton, is his statement “that death from malarial hematuria treated therefor is a curiosity.” My experience is based upon the treatment of thirty-two

Fourteen were treated before I had any settled views upon etiology or treatment of the disease, with a loss of fifty

The remaining eighteen cases were treated, as related in this article, with two deaths, or eleven and one-ninth

In the fatal cases, of the fourteen, death invariably occurred on the third day of the disease, from uremia, often accompanied by convulsions. The treatment of these cases varied, and consisted of calomel, in large or small doses, qui

cases.

per cent.

per cent.

nine in large and small doses, nitro-muriatic acid, quinine, buchu, digitalis, etc.

The treatment given below has been used in eighteen cases. Death occurred in two cases, one of which, a boy aged four, had been treated twice-twelve months and six weeks respectively—before the fatal attack. The complication of double pneumonia, occasioned by severe change in temperature, added to his danger, and, although urine became of natural color for days, large quantities of albumin were present to the last. In the latter days of the case, the presence of tube casts and pus globules, and a large painful tumor in the region of the right kidney, justified the belief that an organic lesion of the kidney existed. The other fatal case, a woman aged forty-four, had the third paroxysm (quotidian) before calling medical aid; she died suddenly within thirty-six hours from the beginning of treatment, from uremia. She had suffered with jaundice and chronic malaria for months previous to the attack, and was in a profoundly anemic condition when taken.

My treatment is divided into specific, symptomatic and local. The specific remedies used are quinine (preferably the bisulphate) and soda hyposulphite, both of which remedies are universally used for their anti-malarial properties.

Under the head of symptomatic treatment, I would name free and frequent draughts of fresh cool water for its soothing and antipyretic effects, to cleanse the stomach by emesis, and to get its valuable diuretic effects; alcoholic stimulants, as indicated by the condition of the pulse, which is always too rapid and noticeably wanting in tension.

If capillary congestion demands it, atropine or fluid extract of belladonna should be used. At the approach of the hour when the return of the paroxysm is expected, a patient should be placed under influence of morphine (one-fourth grain) and atropine sulphate (1-60 to 1-100).

If congestion is alarming and persistent, the use of belladonna, for its vis a tergo action, should be alternated with bromide of potassium, for its effect in contracting the capillaries, just as they would be in this condition not occurring as a complication of malarial hematuria. The hyposulphite of soda and quinine should be repeated immediately if vomited. Vom

iting at first is the natural and chemical sequence of taking hyposulphite of soda in this disease. There are always present viscid acid secretions and frequently food undigested and in a state of fermentation in the stomachs of these patients. When the hyposulphite of soda comes in contact with the acid contents of the stomach a chemical change immediately is effected, and large quantities of sulphuretted hydrogen gas is produced, which may be sufficient to cause almost instantaneous evacuation of the stomach by expansion of that organ and the esophagus,causing vomiting mechanically. This action of hyposulphite of soda suggested the remedy for colic (myself the patient) from overeating, at a vegetable dinner. Vomiting was almost instantaneous, on taking a teaspoonful dose, and relief was prompt. I use it in preference to all other remedies with young babies suffering from indigestion accompanied by colic.

Local treatment: A cantharidal blister over the liver and spleen, the degree of counter-irritation to be desired determining how severely the remedy should be allowed to act. Mustard foot baths, mustard plasters on extremities; and sometimes to arrest vomiting. The above remedies, like remedies I have classed as symptomatic, are not used in a routine manner, but employed, if indicated and as indicated.

After the urine has “cleared,” and the fever disappeared entirely, or you recognize the fact that you have a remittent type of malarial fever, and a bloodless patient to treat, the doses of quinine should be tonic; hyposulphite of soda used only to unload the bowels when they fail to move daily; aromatic sulphuric acid, stimulants and a buttermilk diet used until the temperature is normal. The temperature is normal much sooner than the pulse, which continues weak and rapid a long time, particularly so in the intermittent variety.

On the return of every seventh day-from the first paroxysm noted—until the return of health and strength, large doses of quinine should be given to prevent what is often called a relapse, which is, in fact, a recurrence of a malarial paroxysm, which may or may not be accompanied by hematuria. After aromatic sulphuric acid has been used long enough to perceptibly increase the red corpuscles of the blood, then

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