The disease, being comparatively rare in this latitude, is sometimes overlooked on this account. Of the 8 cases which I have noted during sixteen years, 5 originated in Pennsylvania, 1 in New Jersey, 1 in Delaware, and 1 in North Carolina.
TREATMENT.—The treatment is distinctly that of malarial disease, and I have seldom seen more brilliant and satisfactory results than have followed the use of quinine in a case accurately determined, although such success is not invariable; and I have known the disease to resist for a long time the most thorough and judicious use of anti-malarial remedies. Usually, however, I take hold of a case of this kind with considerable confidence. When there are distinct remissions my practice has been to administer 16 to 20 grains of sulphate of quinia in the usual manner of anticipation of the paroxysm in intermittent fever—from 3 to 5 grains every hour until the required amount is taken; the whole amount may be taken in two doses, or even in one dose. Where there is no distinct remission I more usually direct 3 to 5 grains every three hours, until the hemorrhage ceases or decided cinchonism is produced.
The advantage well known to accrue in malarial disease from the combination of mercurials with quinine applies to hemorrhagic malaria as well, although I usually reserve the mercurial until I have ascertained whether the simple quinine treatment answers the purpose. If the usual method fails, I give 8 or 10 grains of calomel in the evening, followed by a saline in the morning, before reinstituting the quinine treatment. In the case of the colored man alluded to who had malarial hæmoglobinuria 36 grains of quinine failed to break the attack; but the same quantity, given after 10 grains of calomel had acted, succeeded.
Where these means failed I have not found the other methods of treatment commonly resorted to in obstinate malarial disease to be any more efficient. I allude to the treatment by arsenic or by iron and arsenic. Indeed, in the only two cases in which, after failure with the quinine treatment, iron and arsenic were used at my suggestion, they failed absolutely. In the one case, under the care of James L. Tyson, this treatment was carried out most faithfully. After four weeks' treatment with quinine without effect, Fowler's solution was given, at first in 5-drop doses three times daily, subsequently increased to 10 and 15, along with 20- and 30-drop doses of tincture of the chloride of iron, until oedema of the eyelids occurred, when the arsenic was discontinued, but the iron continued. In two or three days the arsenic was recommenced in 3- and 4-drop doses for three or four weeks longer without effect. Fluid extract of ergot in 20-drop doses was then substituted for the iron, alternating with the arsenic for two weeks longer, when some slight favorable change was apparent, but it was temporary. Repeatedly throughout the treatment the patient complained of weariness and backache, cold feet and knees, headache and acceleration of pulse, and a feeling of utter wretchedness; and then again he would feel quite comfortable for a day or two, but with little or no change in the urine, except occasionally in the morning, when it would sometimes be quite light-hued, but after breakfast would again assume its bloody character. A sojourn at the seaside for two weeks was without effect.
It will appear from the above that ergot, which has been found useful in some forms of hæmaturia, is of little service here, as is attested by two other cases in which I tried it faithfully. At the same time, it is a remedy which should be tried in case of failure with others.
The usual astringents, mineral and vegetable, of known efficacy in the treatment of hemorrhagic conditions, should be used alone or in conjunction with the specific anti-malarial treatment after the latter has been found of itself insufficient. To this class of remedies belong the mineral acids, persulphate of iron, acetate of lead, alum, gallic acid, catechu, kino, the astringent natural mineral waters, etc.
Rest is certainly an important adjuvant in the treatment of this form of malarial disease. I have known a recurrence to take place after a long drive.
It is claimed for many natural mineral waters that hemorrhage from the kidneys is one of the affections cured by their use. Chalybeate and alum springs might be expected to be of advantage by the local action of these astringents in their transit through the kidneys, and they frequently are. The following case illustrates their efficiency: The patient was a lawyer who consulted me in June, 1881, at the suggestion of W. W. Covington of North Carolina. He had frequently had chills, and a congestive chill in 1873. Three months before I saw him he began to pass bloody urine. He had no other symptoms, except a soreness and weakness in the neighborhood of the sacrum, extending into the outer part of the left thigh. The urine passed for me at the time of his visit was dark reddish-brown in color, acid in reaction, had a specific gravity of 1028, highly albuminous, and deposited a sediment of almost tarry consistence, which was made up almost entirely of blood-corpuscles. There were no tube-casts. He had been a dyspeptic since seventeen years of age, and medicines disagreed with him; but he was treated faithfully with quinine, iron, arsenic, ergot, benzoate of lime, all without the slightest effect. At the end of about a year from the time he consulted me he heard of the Jackson Spring, located in Moore county, North Carolina, fifteen miles distant from Manly Station on the Raleigh and Augusta Railroad. He went there, and remained one week. He stated that for the first two or three days the water acted decidedly on his kidneys, and he voided a number of clots of blood. On the third day all traces of blood disappeared, and it recurred but once since, on a very cold day in November last, but again disappeared after a day or two in the house. Unfortunately, no precise analysis of this water seems to have been made, but from what my friend writes it evidently contains iron and sulphur, and magnesia is also said to be present. It is promptly diuretic. Since this occurred I have used the water of alum springs in other instances with advantage.13
13 See the report of a case treated successfully by Rockbridge alum-water by Radcliffe, Med. News, Jan. 12, 1884.
The following are some of the chalybeate and alum springs the waters of which may be expected to be of service in hæmaturia: Orchard Acid Springs, New York; Rockbridge Alum Springs, Pulaski Alum Springs, Bath Alum Springs, Stribling Springs, and Bedford Alum Springs, all in Virginia. In all of these waters iron and alum are both present, accompanied, in many instances, by free sulphuric acid, by which their efficiency is increased. In one of my cases the hemorrhage disappeared temporarily under the use of the water from the Bedford Springs, Penna., but again returned. These waters contain a little iron, but no alum. Subsequently, the same patient was promptly relieved by quinine, which had not been previously tried.