1224 



THE TROPICAL HEMOGLOBINURIAS 



like the skin. The temperature rises quickly to 103° or 104° F., 

 and the pulse is regular, rapid, small, and compressible. At first 

 the urine may appear normal, but sooner or later the characteristic 

 stout-like colour appears, with pains in the back and burning sen- 

 sations in the urethra. On the other hand, this may be the first 

 feature of the attack, and causes the patient to send at once for the 

 doctor, though he may not at the time feel ill, or it may occur at 

 the height of the fever, as Kelsch points out. 



The mind may be clear or the patient may be brought to the 

 hospital quite unconscious, and may remain so for days, or delirium 

 may set in. After a few hours perspiration appears, and the 

 temperature remits to about 100° F., the urine clears, and a mild 

 case may recover, while in a severe case, instead of the remission, 

 hyperpyrexia, coma, and death may ensue. 



Usually, however, after the remission the temperature again 

 rises (post-hsemoglobinuric fever), and the shiverings, vomitings, 

 and pains return, while diarrhoea, with motions full of bile, and 

 sometimes also with blood or haemoglobin, comes on. A motion 

 with haemoglobin may present a most striking appearance, being 

 mainly green in colour, with a reddish deposit on the surface. 



This second paroxysm may be the last, or it may be succeeded 

 by several others, after which the patient may recover. On the 

 other hand, he may die during these attacks from exhaustion, or 

 from hyperpyrexia and coma, or from anuria and uraemia. 



Convalescence. — ^After the attacks the patient is exceedingly 

 weak, and convalescence is protracted, and is liable to be compli- 

 cated at any time with anuria, leading to fatal uraemia. 



Varieties. — Kelsch and Kiener recognize two distinct types — a 

 mild and a severe, of which the latter is subdivided into three — 

 viz., the ordinary severe, the fulminating with a rapidly fatal 

 issue, and the uraemic type. 



Complications. — ^The most usual complication is the passage of 

 haemoglobin or blood per anum, giving rise to ' dysenteric motions,' 

 as they are often called. Muco-pus is, however, generally absent. 

 Inflammation of the tonsils and salivary glands has been noted. 



Sequelae. — ^There is nearly always grave anaemia and much weak- 

 ness as the result of an attack, with often stomach and intestinal 

 derangements, but of all, the most serious is nephritis, leading to 

 uraemia. 



Diagnosis. — ^Blackwater fever is easily recognized, as a rule, the 

 diagnosis being based on the heBmoglohinuria with high fever and 

 jaundice, and the severity of the symptoms. 



The differential diagnosis has to be made from yellow fever, in 

 which, however, there is never haemoglobinuria. Acute yellow 

 atrophy of the liver and Weil's disease are easily distinguished by 

 the urine, which does not contain haemoglobin, and by the presence 

 of the peculiar spirochaete in the blood and urine of the latter 

 disease. 



Quinine haemoglobinuria is not a serious disease, and can be readily 



