MTIOLOGY 



1219 



93*8 per cent. Further, the presence of a haemolysin in malaria has been 

 demonstrated by de Blasi and others . 



The reply to these points is that the geographical distribution of blackwater 

 fever is only known in a very general way, and even this superficial know- 

 ledge is against the theory that it is due to malaria. Incidentally, we may 

 mention that no one has attempted, as far as we know, to make a spot-map 

 of a district where there is much blackwater fever, showing as far as possible 

 where the disease was really contracted, and to compare this with a similar 

 map made for the cases of malaria in that district. Nor, as far as we know, 

 has anyone attempted to show whether the epidemiological phenomena of 

 blackwater fever coincide with those of malaria. The West Coast of Africa 

 would appear to be a suitable place for these inquiries. 



The malarial theory is disposed of, in our opinion, in that it has many times 

 been recorded as occurring in persons who have never suffered from malaria ; 

 indeed, according to Craig, it has occurred in people who have not only never 

 been known to suffer from malaria, but in whom neither before, during, nor 

 after an attack have the parasites been found, and, finally, in whom a post- 

 mortem examination failed to reveal any evidence of malaria. Our opinion 

 is more or less confirmed by the fact that an attack of blackwater fever is 

 uninfluenced by quinine. However, at the present time, there are few advo- 

 cates of the theory that it is simply a malarial infection. Here, perhaps, may 

 be mentioned the fact that Donovan considers that it is malaria, but due to a 

 species of Laverania as yet unrecognized. Laloir's parasite requires confirma- 

 tion, and is in our opinion of doubtful value. 



2. Malaria, together tvith Some Other Factor. — As malaria by itself has proved 

 rather weak aetiologically, some other factor has been brought in to support it. 

 Thus Corre suggested chills, Berenger-Feraud mercury, and others acute and 

 chronic alcoholism, syphilis, severe muscular exertion, mental excitement, 

 and change of climate; but of all theories, that connecting malaria with 

 quinine has been the most popular. 



Malaria and Quinine. — Stephens has supported the theory that the disease 

 is partly of malarial origin, aided by a second factor — viz., quinine. In his 

 article in Osier's ' System of Medicine,' Stephens sums up his view : ' Blackwater 

 is not a disease per se, but rather a condition of blood in which quinine, other 

 drugs, cold, or even exertion, may produce a sudden destruction of red cells. 

 The condition is produced only by malaria, and generally by repeated slight 

 attacks, insufficiently combated by quinine. In such cases of chronic malaria 

 — i.e., in those suffering from anaemia, with repeated attacks of fever and 

 repeated doses of quinine — blackwater fever sooner or later almost certainly 

 supervenes — at least, in tropical climates,' 



These statements are too sweeping if genuine blackwater fever is meant, 

 otherwise the home of the disease would be Ceylon, whereas it is so rare that 

 we have never heard of a genuine non-imported case ; for in this island there 

 are Europeans and natives with just the conditions required by Stephens, 

 and yet they do not develop blackwater fever, because the only two cases 

 which we have met with or heard of in Ceylon in twelve years were most prob- 

 ably cases of quinine hsemoglobinuria. On the other hand, Stephens's 

 remarks are correct if applied to quinine haemoglobinuria. 



Stephens accounts for the difference between India and Africa as regards 

 the prevalence of blackwater fever by the common malarial parasite being the 

 tertian in India and the subtertian in Africa. Certainly the tertian is very 

 common in Ceylon, though the subtertian is also frequently found. Another 

 point which is difficult to explain is the frequency of the disease in Assam, 

 and the less frequent occurrence in other parts of India where malaria is 

 common. 



According to McCay, who has carefully investigated the action of quinine 

 in causing hsemoglobinuria, sulphuric acid and the sulphates cause a decrease 

 in the total inorganic salts of the plasma, which he thinks implies a 

 decrease in its osmotic tension. Water, therefore, passes into the red cells, 

 causing them to swell up, and, if the decrease in osmotic tension of the plasma 

 is suf&cient, to burst. 



