Perhaps the most important form of hæmaturia and hæmoglobinuria resulting from general causes is that due to malarial poisoning. I prefer the term malarial to intermittent or paroxysmal, not only because it more precisely indicates the cause of the condition, but also because the condition itself is by no means always intermittent, sometimes continuing without interruption until checked by appropriate treatment; and I have known it to continue uninterruptedly for a year, in spite of all treatment.
The first complete report of an undoubted instance of this affection appears to have been published by Dressler in 1854,2 although incomplete and uncertain cases were reported prior to this date—one as early as 1832 by Elliotson.3 G. Troup Maxwell of Ocala, Florida, writes me, in 1883, that he first observed cases in Florida thirty years ago, and published an article on the disease in the Oglethorpe Medical Journal, Savannah, Ga., July, 1860. George Harley4 early contributed to our accurate knowledge of the subject in 1865, and since then numerous papers and reports of cases have appeared in English and American journals, the southern part of the United States being a fertile scene of the affection, while it is by no means rare in the Middle States.
2 "Ein Fall von intermittirender Albuminurie und Chromaturie," Virchow's Archiv, Bd. vi. S. 264, 1854.
3 "Clinical Lecture on Diseases of the Heart, with Ague (and Hæmaturia)," London Lancet, 1832, p. 500.
4 "Intermittent Hæmaturia," Medico-Chirurg. Trans. London, 1865.
Two degrees of the disease are met with—a milder form, in which other symptoms as well as the hæmaturia are less pronounced, and of which instances occur in the Middle States as well as the South and West of the United States. Of this kind seem to be the cases studied by Harley and other English physicians. In addition to this, there is a second, more malignant, form, attended by great prostration, vomiting, and yellowness of the skin, along with copious discharges of bloody urine. Instances of the latter are numerous in the Southern States of this country, where they have recently been studied with much care; also in the East and West Indies and in tropical countries generally. In neither degree of the disease is it necessary that the red corpuscles of the blood should be present. They may be represented by their coloring matters alone, when the condition is called a hæmoglobinuria or a hæmaturia.
The Milder Form.—The subjects, in my experience of eight cases, have been, with one exception, men, and I believe the experience of others included more men than women. They are generally able to recall a history of exposure to malaria, and often of distinct attacks of malarial fever, intermittent or remittent. The hæmaturia appears suddenly, and when paroxysmal may occur daily or on alternate days or a couple of times a week, or even at longer intervals. When the attacks occur at longer intervals, say of ten days or two weeks, if the disease is left alone the interval is apt to gradually diminish until the passage of bloody urine becomes daily. The urine in the morning may be perfectly clear, and at two o'clock is evidently bloody. It continues so through one or two acts of micturition, and then becomes clear again; or it may be bloody on rising and clear up by noon. Sometimes the bloody urine is preceded or accompanied by a sense of weariness and chilly feeling, or sometimes simply by cold hands and feet or by cold knees, or by pallor and blueness of the face, or by accelerated pulse, or by no other symptoms whatever. There is sometimes a sense of fulness in the region of the kidney and sacrum. The attacks are often induced by exposure to cold.
Harley states that in one of the two cases which he reported there was a slight jaundice, and in the second a "sallowness which appeared to be due to a disturbance of the hepatic functions," but in none of the cases which I have met was this symptom present. In the more malignant form occurring in the tropics and the Southern States of America, jaundice is a constant symptom.
While a majority of cases of malarial hæmaturia are intermittent, many are continuous, and of my eight cases only three were distinctly intermittent. One of these cases I published in a clinical lecture in the Philadelphia Medical Times as far back as September 1, 1871.
Negroes are not exempt from this milder form of the disease, as they seem to be from the more malignant form of the South. While writing this paper I was consulted by a negro thirty-one years old who had a true malarial hæmoglobinuria, which yielded promptly to the treatment by quinine. But this was the only negro out of seven cases.