232 THOMPSON YATES AND JOHNSTON LABORATORIES REPORT 
Koch has so strongly advocated the quinine factor in blackwater that it 
appeared at first as if he denied its malarial origin, but this is not so, as is quite clear 
from his later writings. He holds that quinine is the immediate exciting cause, but 
that a predisposition, determined by many attacks of malaria, is necessary. 
Many of those who hesitated to give their assent to these views now acknowledge 
that there is such a thing as quinine haemoglobinuria occurring in malarial cases. This 
acknowledgment amounts to a recognition of the quinine origin of blackwater fever, 
for the two conditions are absolutely indistinguishable. We have ourselves seen cases 
which were to us clearly of this nature, and our views are summed up by saying that 
blackwater fever is a disease malarial in origin, and dependent on blood changes 
occurring after many malarial attacks, and generally, if not always, in relation to an 
actual attack, but that, also, it is undoubtedly almost invariably induced by the taking 
of quinine in this state. 
It has been argued that if quinine is the cause of blackwater fever it is a dan- 
gerous drug, and should not be used in malaria, but this argument is not a good one. 
It is, as we believe, in the malarial chronic that blackwater almost always occurs. We 
believe that in such a oerson quinine is dangerous. If, however, quinine is efficiently 
used as a preventive of malaria, no fear need be held of it. It is inadequate quinine 
treatment, because malaria is thereby not really combated, which is the danger. 
While then we consider that the malarial origin of blackwater fever has been 
established by us on a basis of microscopical evidence, yet we may briefly consider 
some other aspects of the question, as it will enable us also to answer some of the 
objections of a purely general character, which have hitherto been raised against its 
malarial origin. 
I . It has been urged that the distribution of blackwater fever and malaria is not 
the same. Even if this statement were true, it must not be forgotten that the distri- 
bution of mild malaria and severe malaria is by no means the same. Thus, the 
mortality from malaria in the few still remaining foci in Northern Europe is in no way 
comparable to that of the Roman Campagna, nor, again, is the severity of malaria in 
Northern Italy comparable with that in the South. W T e cannot, indeed, speak of the 
distribution of malaria as a whole. If, however, we confine our remarks to regions 
of intense malaria we believe that the distribution of blackwater fever will be found 
to tally exceedingly closely with that of malaria. The distribution of blackwater fever 
is, we believe, considerably wider than is generally supposed. Thus in the Bengal 
Duars, in India, blackwater was found by us to be as common as in Africa, a fact to 
which the literature of the distribution of blackwater fever gave us no clue. 
Further, in Madras we discovered the existence of blackwater fever, the 
existence of which was quite unknown, even to medical men in India. We believe, 
in fact, that there is rather a very close and even exact parallel between the distri- 
bution of blackwater fever and severe malaria. 
