I2l8 



THE TROPICAL HEMOGLOBINURIAS 



In Europe it is found in South Italy, Sicily, Sardinia, Macedonia, 

 Greece, and Southern Russia. In Africa it occurs in Algeria, and 

 through the whole of the tropical area of West, Central, and East 

 Africa. In Asia it is well known in India, especially in the Duars, the 

 Terai, Assam, the Jeypore district of Madras, and the Canara district 

 of Bombay. It is also found in China, Cochin China, and Farther 

 India. In America cases have been recorded in the southern regions 

 of the United States, in Central and South America — especially 

 Brazil — and the West Indies. It occurs in the Anglo-Egyptian 

 Sudan, but there are many other parts of the tropics from which 

 it has not been reported. Too much trust must not be placed upon 

 this distribution, as confusion exists between the mild attacks of 

 quinine haemoglobinuria, as well as the atypical subtertian malarial 

 form. True blackwater fever can exist in epidemic form, and is a 

 very fatal infection. 



Etiology. — ^The causation of blackwater fever has been much 

 complicated by the confusion arising from the non-recognition of 

 quinine and malarial hsemoglobinurias, but when these conditions 

 are admitted there is still the serious disease, ' blackwater fever,' to 

 be explained, and its causation appears to us to be some protozoal 

 parasite as yet unknown. 



The various theories which have been advanced to explain the 

 aetiology of blackwater fever are: — 



1. The malarial fever. 



2. The theory of malaria, together with some other factor. 



3. Malarial anaphylaxis theory. 



4. An unknown agent theory. 



5. Bite of an unknown arthropod. 



1. The Malarial Theory. — All the old writers on the aetiology of black- 

 water fever attributed its cause to malaria, in much the same way as they 

 classed most tropical fevers under the same term. 



When these fevers came to be differentiated, blackwater fever was assigned 

 to the action of Laverania malaricd ; but of late years cases have occurred in 

 which this parasite has not been found, but only Plasmodium malaria or 

 P. vivax, because these parasites are very commonly met with in the 

 tropics. 



The older writers maintained that blackwater fever existed wherever there 

 was severe malaria, and that it was not found where this was absent, and they 

 instanced Southern Italy, where malaria causes a mortality of 7 to 10 per 1,000, 

 as a region where blackwater fever is common, and compared it with North 

 Italy, where the malarial mortality is only i per 1,000, and where blackwater 

 fever is rare. Further, it was pointed out that the people attacked with 

 blackwater fever had always previously suffered from malarial fever, and 

 had generally had several attacks. This view may be said to have been 

 supported by Stephens, who states that the blood of persons examined during 

 the day preceding the haemoglobinuria contained parasites in 95*6 per cent, 

 of cases, while during the day of the attack these parasites were found in 

 only 6i'9 per cent., and during the day after the attack in only lyi per cent. 

 Stephens and Christophers point out that, though they only found malarial 

 parasites in i2'5 per cent, of all their cases, still they found evidence of malarial 

 infection, as exemplified by the presence of pigment in the leucocytes or by 

 an increase in the percentage of the large mononuclear cells, in no less than 



