102 TROPICAL MEDICINE AND HYGIENE 



main dangers of the disease. The failure to recognize 

 these essential features has caused the adoption of in- 

 jurious measures from time to time. 



The disease is not a haemorrhagic one ; it is a haemolytic 

 one. The actual disease occurs in the blood-vessels, and 

 the red corpuscles, once broken up, set free the haemo- 

 globin in the plasma, and there it is injurious and has to 

 be disposed of. The liver and other organs can absorb 

 it in part only, but the capacity of these organs is limited 

 and the greater proportion is discharged with the urine. 

 This discharge must not be checked, but aided by the 

 free supply of water. If considered as haemorrhage it 

 would be natural to attempt to diminish this discharge. 

 The patients themselves notice that they fill chamber- 

 pot after chamber-pot with what looks like almost pure 

 blood, and are anxious that the loss should be diminished, 

 as they fear that they are bleeding to death. The medical 

 attendant requires a firm faith in the soundness of his 

 pathological views, and his action should be to main- 

 tain, and if possible increase, the total amount of the 

 bloody urine discharged. The dilution of the urine 

 makes no obvious difference in its appearance, and, from 

 the point of view of the patient and his friends, the 

 measures that should be taken will only increase the loss. 



Free administration of water is necessary to maintain 

 this flow, otherwise there is danger of such extensive 

 blocking of the renal tubules that suppression will occur; 

 the coagula and debris formed in the convoluted tubules 

 may remain there, but usually are carried along and block 

 the tubules in the pyramids, so that extensive areas of 

 the kidneys are unable to discharge their secretion. This 

 process commences \vith the onset of haemoglobinuria, 

 and probably always, even in the mild cases, some of the 

 tubules in the pyramids are blocked. It is essential that 

 the treatment, by encouraging the flow of urine by a free 

 supply of water, should start as soon as the disease occurs. 

 The drugs used have belonged to many classes. Haemo- 

 statics, such as ergotin, have been extensively used, but 



