212 
MALARIA 
hemoglobin in the renal tubules and was 
facilitated by any factor which interfered 
with secretion of water by the malpighian 
bodies. Occasionally a small amount of 
urine may be voided after anuria has set 
in; such a specimen may contain much 
albumin (solidifying on boiling) and may 
be free of hemoglobin. Ross (1932) sug¬ 
gested that this might indicate that the 
fluid is largely inflammatory lymph from 
denuded surfaces of the tubules. There 
may be considerable variation in the inci¬ 
dence of oliguria and polyuria from patient 
to patient; while many authors consider 
the latter a favorable sign, Ross (1932) 
noted it in two toxic fulminating attacks. 
The urine is usually light red to black 
in color and contains urobilin in irregu¬ 
larly increased amounts. Albuminuria has 
been recorded in degrees as high as 50 per 
cent and frequently persists for a few days 
after the hemoglobinuria. Bile pigment 
and bile salts are recognized as uncommon 
in blackwater fever urine. Ross stated that 
bilirubinuria was not observed in his 
patients unless the plasma yielded a direct 
Van den Bergh reaction to the extent of 
four units. The urinary sediment consists 
largely of blood pigment. This is present 
as (&) a majority of amorphous material 
and (b) casts which tend to increase in 
number as the disease progresses. Fre¬ 
quently they persist for some time and 
epithelial and hyaline casts may be seen 
later. The observations as to the presence 
of erythrocytes are conflicting. Some care¬ 
ful observers, however, have indicated that 
they undoubtedly have been seen in some 
instances. 
Icterus. The degree of icterus occurring 
in blackwater fever is, as one might reason, 
dependent upon (a) the extent of the 
hemolysis, (b) the amount of hemoglobin 
excreted by the kidneys and (c) the effi¬ 
ciency of the biliary system in excreting the 
extra production. Obviously, then, there 
is going to be a certain amount of varia¬ 
tion. Early, the Van den Bergh test gives 
the indirect reaction of hemolytic jaundice; 
later in anuria cases one may get the direct 
reaction characteristic of the obstructive 
type of jaundice. Icterus is infrequently 
absent, usually appears early and may be 
evident prior to the rigor or the detection 
of hemoglobinuria. It is marked in the 
fulminating toxic type of infection if the 
patient survives over 24 hours. Likewise 
icterus is usually quite definite when the 
hemoglobinuria is prolonged, either in the 
continuous or intermittent type of black¬ 
water fever. The greatest degree of jaun¬ 
dice, however, is noted in those with 
anuria. Ross (1932) makes an interesting 
point that gall-stones were frequent in 
those who had had either blackwater fever 
or severe malaria; that stones removed from 
such individuals invariably were composed 
entirely of calcium-bilirubinate. 
Blood. The destruction of erythrocytes 
is, of course, the outstanding feature in 
blackwater fever. The rate and amount of 
loss varies considerably and may be as great 
as one million red cells in 24 hours. Actual 
counts of less than a million erythrocytes 
per cmm and hemoglobin values as low as 
ten per cent have been observed. As the 
bone marrow responds, the immature forms 
in the erythrocytic series may be found in 
the smears. Anisocytosis, poikilocytosis, 
macrocytes and microcytes have been re¬ 
ported. The sedimentation rate is usually 
increased. There is much inconsistency in 
the different observations regarding the 
total leucocyte count and it is difficult 
therefore to determine possible correlation 
with clinical reaction. It is generally 
agreed upon, however, that an increase in 
mononuclear leucocytes is commonly, 
though not invariably, found and that 
there is frequently a lymphopenia. 
Nitrogenous retention may reach high 
values in patients with anuria, yet these 
persons usually do not show signs of 
uremia. Bilirubin in the blood plasma 
reaches its greatest concentration in the 
toxic or the anuric patients and may range 
from normal to 80 or more units. The 
color of the plasma is dependent upon the 
relative degree of hemoglobinemia and bili- 
rubinemia. Methemalbumin (Fairley 1939) 
is another pigment which occurs in the 
