REDDISH-BROWN DEPOSIT, LIKE BLOOD-INTERMITTENT HEMATINURIA. The variation in color of different specimens of urine passed within a few days by the same person is very remarkable, and seems to be due to varying conditions, internal and external, allied to those which determine great changes in the urea, uric acid, and other organic constituents of the urine. The alteration in color is mainly occasioned by chemical changes in the coloring matter of the red blood corpuscles. The ratio of disintegration and solution of these varies greatly at different times, and the character and intensity of the color produced is liable to great alterations. The deep color of the urine, irrespective of the presence of bile, in diseases of the liver, has been often remarked by physicians practicing in India; and my friend, Dr. Payne, made some interesting observations on this point, which will be found in the " Indian Annals of Medical Science" (Calcutta, Sept. 4th, 1858). In order to detect the coloring matter, Dr. Payne boils the urine, and then adds a drop of nitric acid. Various shades of color are produced, but at last the mixture becomes of a ruby red. The coloring matter of the blood corpuscles may be present in urine without any corpuscles. In many cases the serum is highly colored, and the dissolved coloring matter is excreted by the kidneys. Blood may escape from the vessels into the tubes of the kidney, the corpuscles may gradually become disintegrated, and the coloring matter be dissolved. Sometimes the coloring matter forms an abundant granular deposit containing also urates or uric acid, or large collections of granules and minute dark red angular particles, derived from the red blood corpuscles, may exist. That bile acids and their salts were powerful solvents of blood corpuscles was long ago proved by Hühnefeld, Plattner, and Simon; and it has been shown by Kühne that, by the action of the colorless biliary acids or their salts upon the blood corpuscles, the bilecoloring matter is produced. The bile acids themselves are not converted into the coloring matter, as Frerichs held, for they pass through the system unchanged. In certain cases where these processes are deranged it is very probable that the blood corpuscles are disintegrated in abnormal quantity, and rapidly converted into pigment, which escapes in the urine. The complicated mutual reactions which would ensue when varying proportions of biliary acids, hæmatine, and oxygen are presented to each other in the living blood, would fully account for the different characters and tints which the coloring matters in urine assume in various instances. Professor Vogel alludes to a case in which the color of the urine became very dark after the inhalation of arseniuretted hydrogen. Some experiments were made upon a dog, and it was found that the dark color was due to the disintegration of the blood corpuscles. Albumen was present, but no blood corpuscles could be detected. A similar disintegration of blood corpuscles seems to take place in typhoid fever, and in several other diseases. It is not uncommon to find distinct crystals of hæmatoidin amongst the brown coloring matter. These were no doubt formed in the upper part of the uriniferous tubes, where the coloring matter had remained quiescent for some time. Black Pigment.-Dr. Marcet, Med.-Chir. Trans., 1822, describes a black pigment which was present in the urine of a child. After the addition of an acid, some black flocculi were deposited. The coloring matter was dissolved by alkali, and Prout called it melanic acid. Professor Dulk gives a case in which a black deposit was separated from the urine by filtration. Other examples are recorded by Dr. Hughes. In three of these cases creasote had been taken internally, and in two, tar had been applied externally. In one case a dense black precipitate was thrown down by heat and nitric acid, which was examined by Dr. Odling, who found that by exposure it became converted into indigo blue. He draws attention to the close alliance between indigo and the creasote series of compounds, and suggests that, in the above cases, it was derived from the tar or creasote. (Guy's Hospital Reports, 3d Ser., Vols. II and III.) Dr. Stevenson refers to a case of melanuria in Vol. XIII of the third series of the Guy's Hospital Reports, 1867. The urine, which was black, and in thin layers brownish-black, like a mixture of India ink and water, was passed by a woman whose thigh had been amputated by Mr. Bryant. The stump had been dressed with a solution of carbolic acid. In most of the cases of black urine which have been reported, pitch, tar, or other substance containing carbolic acid, had been taken or applied externally. In this case, Dr. Stevenson proved that the color did not depend upon any compounds allied to albumen or hæmatine, and indigo blue was carefully sought for, but none could be detected. The coloring matter was freely soluble in potash. After the urine had been boiled with hydrochloric acid for some time, it acquired the property of reducing oxide of copper, and Dr. Stevenson therefore infers the presence of a substance capable of yielding sugar. This was probably a coloring matter allied to that formed by the action of concentrated acids on the extractive matters. Sometimes the urine is made black by remedies prescribed by the physician. If large doses of gallic acid be given, and the urine passed be tested with a solution of a salt of iron, a black color like ink results. Sometimes patients taking gallic acid pass urine of a dark color, and it has been noticed that if iron is administered at the same time the urine is occasionally perfectly black. My friend, Dr. George May, of Reading, sent me a specimen of urine passed by a patient who was taking lactate of iron and gallic acid. The urine was almost as dark as ordinary writing ink. It not unfrequently happens that the urine contains a redbrown and bulky deposit much resembling blood in its general appearance, but of a browner and more dull color. Upon microscopical examination not a blood corpuscle is to be found, and the deposit is seen to consist entirely of brown, granular matter. The older observers invariably called this deposit blood, from its color. No blood corpuscles are present, but no doubt the deposit is derived from the red blood corpuscles, by some disintegrative process. These cases are quite distinct from those in which the coloring matter of the red blood corpuscles is dissolved and excreted in a soluble form, as occurs in the course of exhaustive fevers, etc. The cases to which I have now to direct attention are those in which the coloring matter found in unusual quantity exists, in great part, in an insoluble form. In many of them there is a reddish-brown, bulky deposit, which varies in amount, and is only occasionally present. As I have remarked, no blood is present, and in the majority of the cases not a blood corpuscle can be found after the most careful search through many specimens of the deposit, examined by the twelfth of an inch objective. Albumen may be present in considerable quantity, or the merest trace may be detected. Albumen may be found in the urine before the characteristic color appears. It usually is present in considerable quantity while the hæmatinuria lasts, and persists for some time after the attack has passed off. The cases in which this brown, blood-like deposit occurs, which is completely free from blood corpuscles, are spoken of as intermittent hæmaturia, or hæmatinuria, or hæmoglobinuria. The brown, granular coloring matter is derived from the blood corpuscles by disintegration, but precisely where the disintegrative process takes place, and the exact conditions under which it is effected, are questions still surrounded by much uncertainty. The deposit only occurs now and then, sometimes not oftener than once in six months, but in some cases once in two or three weeks. Between the attacks the patient seems to be quite well, and his urine perfectly clear. It may be altogether free from albumen, or this substance may be always present in small quantity. The cases in which this deposit occurs are characterized by a train of very remarkable and definite symptoms. The disease may last for many years, or the patient may suffer from one or two attacks, and then get quite well. The symptoms by which the attack of hæmatinuria is ushered in, the general look of the patient, the temporary relief always following the use of large doses of quinine or cinchona, or both, favor the opinion formed by many who have studied the disease, that it is nearly related to intermittent febrile conditions, though the real nature of the malady cannot be said to have been ascertained up to the present time. From ten to twenty grains of quinine may be given twice or three times daily. In one very bad case of this affection Sir William Gull prescribed with great benefit quinine and every kind of bark in the Pharmacopoeia. The patient's strength must be sustained by a nourishing, easily digestible diet, and when the paroxysm is coming on, and during its occurrence, it is often necessary to give stimulants. Ammonia seems to relieve the malaise and depression in some cases. The attack usually begins with a feeling of chilliness and malaise, sometimes heightened to a distinct rigor. Not only is there severe lumbar pain, but pain down the back; coldness of the hands and feet, pallor, and blueness of fingers and toes, and not unfrequently of the face and lips. Indeed, the look of the skin of the extremities reminds one of the appearance and coldness in the collapse stage of cholera, so very marked is it. The tongue is often furred, and the digestion much deranged, but there is seldom more than slight fever, and in many cases the temperature is not above the normal. These symptoms are often associated with nausea, a complete distaste for food, intense weakness, and a longing to go to bed and get warm; and this longing should at once be gratified. In fact, the phenomena which usher in an attack of intermittent hæmatinuria are essentially the same as those which many have frequently experienced, only in a very slight degree, when an ordinary cold or a bilious attack is about to come on, and precisely accord with those which characterize decided agues and various intermittent febrile affections. In intermittent hæmatinuria exposure to cold when the circulation is weak has, I think, much to do with the initiatory symptoms. As regards the pallor, lividity, and slightly yellow color of the skin, it must be remarked that it is very common to meet with these changes in people who are generally considered, and consider themselves, to be in good health. One, two, or more fingers of one or both hands become very cold and pallid, the capillary circulation being very much lowered, or completely checked for the time. This state may last for minutes only, or for hours. The circulation may be restored by a little gentle friction, or the blood may not be caused to return to the surface by any efforts that may be made for the purpose of effecting this object. The state of the vessels of the cold skin is, of course, G |