INFECTION IN INTERMEDIATE HOST: BLACKWATER 
213 
plasma. Usually, though not always, a 
hypocholesterinemia is present. The alkali 
reserve may be normal or show a decrease. 
Prognosis. The death rate in black- 
water fever is about 20 to 30 per cent and 
is about 10 per cent higher in the case of 
multiple attacks than in initial episodes. 
In approximately 65 per cent it occurs 
during the first week. Cardiac failure is 
usually assigned as the cause of death. 
Prognostic signs of bad omen are: (a) 
uncontrollable vomiting, (b) singultus, 
(c) anuria, (d) a marked degree of icterus, 
(e) a sudden drop in the temperature with 
prostration, (f) grave anemia and (g) 
coma. 
Pathology. The lesions found in black- 
water fever depend to some extent upon 
the stage of the disease at which death 
occurred. The liver is enlarged, congested 
and contains much bile. The bile capil¬ 
laries stand out distinctly. Hemosiderin 
and hemoglobin may be noted in the 
hepatic cells and malarial pigment is seen 
in the swollen endothelial cells. Necrosis 
of the parenchymal cells may occur. The 
spleen is swollen and shows much evidence 
of phagocytosis. Much pigment and red 
cell debris may be present, the venous 
sinuses are usually dilated and hyperplasia 
of the malpighian follicles is commonly 
seen. The kidneys may show some enlarge¬ 
ment. The epithelium of the convoluted 
tubules undergoes degenerative changes 
and the lumina contain casts made up 
largely of hemoglobin, erythrocytic and 
other debris and epithelium. The collect¬ 
ing tubules likewise contain casts, chiefly 
erythrocytic in origin. 
Treatment. The literature, unfortu¬ 
nately, is cluttered up with suggestions for 
the treatment of this disease but many of 
these have not been given adequate trial 
and will not be mentioned here. As yet no 
specific to control the hemoglobinuria is 
known. Absolute rest and good nursing 
are, of course, of primary importance. 
There would seem in most instances no 
good reason for, and some against, the use 
of quinine. In this circumstance atabrine 
may serve as an alternative although 
hemoglobinuria has been observed follow¬ 
ing its administration. The parenteral in¬ 
jection of saline if done judiciously appears 
to be of some value. Transfusions, perhaps 
several, are apparently desirable in cases 
of severe anemia. In the main, however, 
the treatment is essentially symptomatic. 
Recently Krishnan (1939) has reported the 
successful use of an adrenal cortex prepara¬ 
tion concurrently with ascorbic acid and 
glucose in seventeen patients. 
