6g 
III.  THE  RELATION  OF  HAEMOGLOBINAEMIA  TO 
HAEMOGLOBINURIA  IN  BLACKWATER  FEVER. 
In  the  preceding  sections  it  has  been  shown  that  the  haeino- 
globinuria  of  blackwater  fever  cannot  be  attributed  to  the  direct 
action  of  quinine  on  the  red  cells  contained  in  the  blood,  nor  is  it 
associated  ordinarily  with  the  possession  of  a  haemolytic  power  by 
the  patient’s  blood  plasma.  These  two  possible  factors  in  the 
mechanism  of  production  of  haemoglobinuria  having  been  excluded, 
the  way  is  clear  for  the  consideration  of  the  relationship  of  haemo¬ 
globinuria  to  haemoglobinaemia.  Upon  this  point  there  is  no 
consensus  of  opinion  among  writers,  nor  have  different  observers 
obtained  concordant  results  respecting  the  existence  of  haemoglobin¬ 
aemia  in  blackwater  fever.  Berthier*  and  Hymans  van  der  Berght 
were  unable  to  observe  red  tinted  serum  during  blackwater,  though 
on  spectroscopical  examination  oxyhaemoglobin  bands  were 
obtained ;  A.  PlehiiJ  found  dissolved  haemoglobin  and  also  bile 
pigment  in  the  blood  plasma  during  blackwater  ;  Bignami§  found  no 
dissolved  haemoglobin  in  the  blood  plasma  during  blackwater ; 
Murri,^  who  is  of  opinion  that  haemoglobin  cannot  pass  through  the 
kidneys  until  the  renal  epithelium  has  undergone  changes,  states  that 
haemoglobinaemia  may  persist  for  hours  before  haemoglobinuria 
appears.  Stephensll  states  guardedly:  ‘Not  infrequently  the  serum 
shows  no  trace  of  haemoglobin,  although  the  haemoglobinuria  may 
be  actually  increasing.  Haemoglobinaemia  does  however  occur.’ 
No  quantitative  determination  of  the  amount  of  haemoglobin  in  the 
blood  plasma  in  blackwater  fever  appears  to  have  been  made  by  any 
observer,  however,  and  the  views  held  in  this  connection  appear  to 
have  been  based  entirely  upon  inspection  of  the  serum.  The  only 
*Quoted  by  Marchiafava  and  Bignami,  Malarial  Haemoglobinuria,  Twentieth 
Century  Practice  of  Medicine,  London,  igoo,  Vol.  ig,  p.  483. 
t  Bydrage  tot  de  kennis  der  Zwartwaterkort.s,  Nederl.  Tydschrift  voor 
Geneeskunde,  1904. 
J  Aliologie  unci  Pathologenese  des  Scbwarzwasserfiebcr.s.  Virch.  Arch..  1903. 
B.  174,  S.  509. 
^  Marchiafava  and  Bignami,  loc.  cit. 
ITQuoted  by  Marchiafava  and  Bignami,  loc.  cit. 
||A  System  of  Medicine.  Allbutt  and  Rolleston,  Vol.  II,  Pt.  2,  p.  297, 
London,  1907. 
