This condition is intimately associated with malaria, since malarial parasites have been found in 95 per cent. of the cases investigated, but as the condition of hxmoglobinuria which characterises it is only seen in a small number of severe malarial fevers, it is obvious that some unknown factor capable of producing dangerous hiemolysis must be also present when the condition known as blackwater fever supervenes. Whether this is a toxin produced in the patient's body or whether it is a toxin elaborated by some unrecognised malarial or other parasite cannot he at present demonstrated.
The disease is not produced by quinine, since blackwater fever has been repeatedly found in patients who had never taken this drug in any form, but quinine may precipitate an attack when the hxmoglobinuric condition is present, hut which is not of sufficient intensity to produce the characteristic symptoms of the disease, unless renal inadequacy is present.
The patient should be at once put to bed and the fever treated by diaphoretics, and symptoms relieved by approved remedies as they arise; thus vomiting may be met by Morphia hypodermically, the liver and loin pains will require hot fomentations or dry-cupping, and the bowels should be opened by a smart saline purgative. The serious question at once arises: Should Quinine be administered ? Some answer this in the affirma tive and commence the treatment of the disease in a routine way by ad ministering 5-ro grs. Quinine every 6 hours; others, believing that the drug has no specific effect over the hiernoglobinuria in its acute stage, hesitate to employ it in this stage; whilst probably all are agreed that the drug must be resorted to for the cure of the disease after the pressing urinary symptoms have been relieved. The writer has had the experience of four typical and severe cases of the disease occurring in individuals just arrived from the tropics, and three of whom bore quinine well. Unfor tunately the quinine difficulty is not the most serious consideration for the physician; the great danger to the patient is that of suppression of the urine, and as a rule this is a graver complication than the height of the fever.
The urinary suppression is due to mechanical obstruction of the tubes by large epithelial casts. This mechanical plugging causes more or less renal congestion, and unlike what occurs in ordinary paroxysmal hamo globinuria the urine shows red blood-cells in half the cases where sup pression is about to occur. This fact has a most important bearing upon
the treatment. The patient must be poulticed or cupped over the loins, and the skin made to act by the hot bath or by the hot-air bath as in acute Bright's Disease where uremia is threatening. A large enema of Saline solution should he administered with the view of diluting the toxin in the blood and of flushing the urinary tubules. When the enema is rejected or in desperate cases, in addition to the enema Saline should be injected into a vein as in hemorrhages, or into the subcutaneous areolar tissue in different parts of the body, 4 or 6 pints being employed, and there can hardly be a doubt that in some cases life may be by this means saved. In one patient seen by the writer this procedure certainly appeared to save life. A strong Saline purgative or a dose of Croton Oil should be administered as soon as the hypodermic injection of the saline solution has been given.
The immediate after-treatment, once the danger of suppression of the urine has been combated, must consist of Quinine, and Stephens affirms that the cure cannot be considered as complete till the patient has been enabled to take i grs. without any ill-effects. Any salt of the alkaloid may be given. Celli advocates the tannate by the mouth; others adminis ter the hydrochloride by the bowel in doses of 5-2o grs., whilst many authorities prefer to give 5-so grs. of the acid hydrochloride by the skin. Should the hsemoglobinuria have followed the use of quinine in the first instance the drug must be cautiously tried in half the above doses, or its administration postponed for 48 hours. It is advisable not to administer the sulphate, as all sulphates tend to favour hremolysis.
Vincent has shown that the hypodermic administration of Calcium Chloride renders the employment of quinine safe, and it is a good routine to add the calcium salt to the normal saline solution injected into the bowel, subcutaneous tissue, or veins in the treatment of threatening suppression, though the drug appears to possess no influence over the paroxysms of ordinary non-malarial h=oglobinuria.