1.1 
1  lio  enquiry,  which  has  sonic  bearing  upon  the  prophylaxis  of 
suppression,  presents  itself ;  is  it  necessary,  in  order  that  this 
plugging  may  occur,  that  the  flow  of  urine  should  be  diminished? 
Obviously  if  the  flow  were  very  rafiid  the  tendency  to  accumulation 
of  granular  material  in  the  tubules  would  be  diminished,  and  with  it 
also  the  tendency  to  Irlocking.  I  he  question  turns  largely  u|ion 
whether  the  granular  material  whiclr  is  present  becomes  denser 
through  the  absorption  of  water  by  the  epithelium  of  the  tubule.s.  If 
this  occurs  the  formation  of  dense  plugs  is  evidently  parti}- 
conditioned  by  the  relation  subsisting  between  the  rate  of  flow  of 
glomerular  fluid  on  the  one  hand  and  the  rate  of  rcnio\'al  of  water 
from  the  lumen  of  the  tubules  on  the  other  hand.  If  the  latter  is 
sufficiently  rapid  no  retardation  of  the  former  may  be  required  in 
order  that  plugging  ma)?  take  place. 
In  view  of  the  mechanical  blocking  of  the  kidneys  in  suppression 
of  urine  in  blackwater  fever,  it  is  astonishing  that  this  process  should 
still  be  attributed  to  a  purely  functional  disturbance,  a  nervous  reflex 
or  vasomotor  inhibition  of  secretion  of  urine,  a  view  which  is  no\N- 
chiefl}^  of  historical  interest.  By  A.  Plehn*  a  nervous  inhibition  of 
glomerular  secretion  is  regarded  as  the  primary  and  essential  factor 
in  this  condition. 
Another  point  of  interest  in  connection  with  suppression  of  urine 
m  blackwater  fever  is  the  enquir}'  whether,  when  once  suppression  has 
been  established,  the  plugs  ma}^  }’et  be  dislodged  and  the  flow  of  urine 
re-established.  As  a  matter  of  fact  such  cases  occur  :  four  cases  are 
referred  to  by  Werner,!  in  which  after  two  or  more  days  anuria  secre¬ 
tion  of  urine  was  re-established.  In  Cases  /a  and  ii  (pp.  [95  and  217) 
it  has  already  been  mentioned  that  dislodged  plugs  were  constantly 
'-V  Atiologic  und  I’athogenese  de.s  Schwarzwasserfiebers,  N'irch.  Arch.,  u/'J, 
Ii.  T74,  S.  509.  Oil  page  519:  “das  plotzliche  Stocken  der  t’rinsekrction  slelll 
aufangs  vielleicht  ebenfalks  einen  rein  functioneller  t'organg  dar,  und  es  folgt 
erst  sekundar  die  mechanisclie  t’erlegimg  dci  flarnk.aniilchen  durcli 
( 'oagulieren  der  k'.i wejssiiberladenen  l  Uissigkeil.'’  J.  de  Ilaan.  Die  nieren 
beim  .Schwarzwas.serfieber,  Arch.  f.  Schiffs-  und  'rropenhygiciie,  1905,  It.  9,  .S.  ->2. 
explain.s  snppres.sion  as  in  part  due  to  mechanical  obstruction  by  renal  plugs,  in 
part  due  to  low  glomerular  pre.ssure  in  consequence  of  which  the  pre.ssure  of  the 
urine  is  insufficient  to  drive  out  the  plugs  (pp.  jo-ji).  Our  observaiion.s  on 
experimental  haenioglobinuria  do  not  afford  any  evidence  of  the  occurrence  of 
clotting  in  the  tubiile.s;  on  the  contrary  the  con.stituents  of  the  blood  which  lead 
to  clotting  do  not  pa.ss  through  the  kidney,  haemoglobin  alone  being  elimin.ited. 
tl-.oc.  cit.,  p.  14. 
