167 
by  Stieda*  (1893),  Marchiafava  and  Bignamit  (iQOi).  A.  Plehni 
(1903),  De  Haan§  (1905),  and  WernerU  (1907)-  In  some  of  the  cases 
recorded,  in  which  death  took  place  on  the  day  on  which  haemo- 
globinuria  first  appeared,  it  is  possible  if  not  probable  that  the 
condition  of  the  kidneys  would  have  led  to  suppression  of  urine  if  life 
had  been  prolonged.  The  changes  to  be  considered  may  be  grouped 
under  four  heads  :  the  presence  of  granular  material  in  the  lumen  of 
the  renal  tubules ;  degenerative  and  other  changes  in  the  renal 
epithelium  ;  fluid  distension  of  the  renal  tubules  ;  interstitial  changes. 
The  first  condition  was  always  present  in  more  or  less  marked  degree. 
The  state  of  the  renal  epithelium  is  not  described  alike  by  all 
observers,  some  finding  the  epithelium  quite  normal,  others  meeting 
with  cloudy  swelling,  coagulation  necrosis  or  fatty  degeneration,  01 
again  the  epithelial  cells  were  found  loaded  with  coloured  granules. 
Distension  of  the  renal  tubules  was  usually  absent ;  Wernerll  describes 
four  cases  (Cases  4  and  5  and  to  less  extent  Cases  2  and  6)  in  which 
this  condition  was  present,  but  these  are  not  improbably  cases  in 
which  suppression  of  urine  would  have  been  observed  if  the  patients 
had  survived.  Interstitial  changes  (presence  of  epithelioid  cells  and 
leucocytes)  were  rarely  met  with. 
In  any  attempt  to  apply  the  above  observations  to  the  elucidation 
of  the  enquiry,  what  is  the  condition  of  the  kidneys  in  blackwater 
fever  during  simple  haemoglobinuria,  it  is  necessary  to  distinguish 
between  the  changes  in  the  kidney  which  are  necessarily  present  and 
those  which  when  present  are  to  be  regarded  as  secondary  or 
additional  pathological  changes.  We  are  on  safe  ground  when  we 
infer,  from  the  condition  of  the  urine  during  blackwater  and  from 
post-mortem  observations  in  blackwater  fever  and  in  experimental 
cases,  that  granular  material  is  present  in  the  renal  tubules  during 
haemoglobinuria  whether  dependent  upon  blackwater  fever  or 
produced  experimentally.  If  haemoglobin  is  eliminated,  not  by  the 
*  Einige  histologische  Befunde  bei  tropischer  Malaria,  Centralbl.  f.  a.  Path. 
11.  p.  Anat.,  1898,  B.  4,  S.  321. 
+  Malarial  haemoglobinviria,  Twentieth  Century  Practice  of  Medicine,  I.ouclon, 
1900,  Vol.  19,  p.  483. 
t  Die  Nieren  beim  Schwarzwasserfieber,  Arch.  f.  Schiffs-  und  Tropenhygiene, 
1903,  Bd.  7,  S.  270. 
S  Die  Nieren  beim  Schwarzwasserfieber,  Ibidem,  1905,  Bd.  g,  .S.  22. 
IF  Uber  die  Nieren  beim  Schwarzwasserfieber,  Ibidem,  1907,  Bd.  n,  S.  3. 
II  Loc.  cit.,  pp.  9-1 1 . 
