BLACK-WATER FEVER 663 



gans can not keep pace with the destruction of the 

 erythrocytes. 



Trigeminal and supraorbital neuralgias and 

 periodic headaches occur sometimes as accompani- 

 ments of malarial infection, even when there is 

 little or no fever, and no parasites may be dis- 

 coverable in the blood. That they are malarial in 

 origin is concluded from the fact that they subside 

 under quinin treatment. In some forms, and par- cerebral and 

 ticularly in sestivo-autumnal fever, cerebral symp- symptmn*. 

 toms (e. g., coma) are marked by accumulations 

 of the parasites in the small vessels of the brain; 

 the vessels may be completely occluded. The con- 

 ditions are similar in the small vessels of the intes- 

 tines in malarial diarrheas. 



The so-called "black-water fever," or hemo- "Black-water 

 globinuric fever, is not a special form of malaria, 

 but a complication which, it is thought, is pre- 

 cipitated by insufficient or improper administra- 

 tion of quinin (Koch and others). It is most fre- 

 quent in the tropics, hence in aestivo-autumnal 

 fever, but may occur in the tertian and quartan 

 types. Various observers have found that in from 

 56 per cent, to 97 per cent, of the cases quinin 

 precipitated attacks. Stephens and Christopher 

 were not able to exclude quinin as a factor in any 

 of the cases they encountered. The essential proc- 

 ess is a massive destruction of the erythrocytes 

 which is entirely out of proportion to the number 

 of cells occupied by parasites; few or no parasites 

 may be present. The amount of hemoglobin thus 

 liberated is so great that it is excreted largely by 

 the kidneys; anuria may result from occlusion of 

 the tubules by pigment. How the quinin, or the 

 quinin plus parasites, produce this extensive hemo- 



