Blackwater fever

“ In Africa, Europeans, Indians, and Chinese are attacked in great numbers, whilst the natives are said to enjoy an immunity. The immunity of the natives is probably not a racial immunity; more likely it is the immunity conferred by infection during childhood. In fact, negroes living in places which are free from blackwater fever contract the disease just like Europeans when they come within its reach. Plehn mentions a serious outbreak of blackwater fever among the blacks in the Cameroons, the disease especially attacking those who had come to the coast from the interior. ”

“ We know that the disease may remain latent for a considerable time, that those who have been infected may have relapses at long intervals, and that the clinical manifestations may appear for the first time far from the place in which the infection was contracted. It is a common belief among the older residents in British Central Africa that a change of district, particularly from one level to another, causes blackwater fever, an opinion based on the experience that many cases occur soon after such a change. ”

“ The blood of immune cattle in Texas fever regions, we know, contains, in small numbers, the babesia. Edington's experiments show that the supervention of a second infection, rinderpest, determines the multiplication of the latent babesia, and the explosion of the characteristic symptoms. May this not be in strict analogy with what happens in blackwater fever? The infection of blackwater fever may remain latent for considerable periods, until provoked into activity by some special agency, as cold, shock, quinine, or some additional infection, especially malaria. ”

“ Epidemiology.—There seems to be a consensus of opinion that when malaria is kept in check by proper and persistent quinine prophylaxis or by other antimalarial measures blackwater fever becomes mild in character or even nonexistent. It is those who are careless about quinine prophylaxis or those who expose themselves to depressing influences as cold, wet, excessive fatigue or alcoholic debauches in whom blackwater shows itself.
Overexertion leading to fatigue and chilling seem to be the most common exciting factors. Those in bad health from disease or lack of proper diet seem more susceptible. ”

“ Definition.—Blackwater fever is a disease of disputed etiology but recently there has seemed to be rather general agreement that it is connected with repeated attacks of malaria. It is prone to affect the old European residents of parts of the tropics where malignant tertian is rampant.
On the basis of lowered integrity of the red cells, by reason of repeated attacks of malaria, we may have extensive lysis of the red cells following the administration of a dose of quinine or as the result of refrigeration, excessive exposure to the sun or great fatigue. ”

“ It has its own peculiar distribution, and is absent or very rare in many places in which the various intermittent fevers are especially rife. It is exceedingly common amongst the few Europeans who live in tropical Africa; it is practically unknown amongst the many thousands of Englishmen who live in the fever haunts of India and elsewhere. It is quite true that blackwater fever generally occurs in persons who have previously suffered or are suffering from malaria ”

“ As regards the association of malaria and blackwater fever Stephens, in a study of 390 cases of blackwater, found that 73% of the cases showed malarial parasites on the day preceding the haemoglobinuria, 47.5% on the day of the attack and 23% on the day following the appearance of the dark urine. Other workers give higher figures as 95, 70 and 20%. ”

“ According to the modern school of tropical parasitology, blackwater fever is neither a form of malaria nor produced by quinine, but a specific disease due to a protozoal parasite akin to that which causes the redwater fever of cattle. ”

“ The idea that quinine might produce blackwater fever originated from a misinterpretation of the fact that the administration of quinine, even in small doses, may provoke the manifestation of blackwater fever in a patient in whom the infection is latent. As quinine, even in toxic doses, never produces blackwater fever in healthy people or in malaria patients elsewhere, its peculiar action in Africa had to be explained by a peculiar hypothetical idiosyncrasy an idiosyncrasy— which, curiously enough, is found only in certain malarious countries and not in others. ”

“ This chill, however, is more prostrating than those formerly experienced and upon passing his urine the patient notes its reddish to black coffee color and himself makes the diagnosis of blackwater fever. The attack comes on suddenly with a very severe chill, marked prostration and pain over the region of the kidneys. The temperature in a typical case rapidly goes up to 104° to 105°F.
Rather profuse sweating accompanies the fall of the fever and the patient is markedly debilitated after the subsidence of the fever. ”

“ As blackwater fever is more prevalent among those who have been for 2 or 3 years in highly malarious, tropical regions than among recent arrivals, the former should exercise the greater care as to errors in diet, alcoholic excesses, exposure to wet and irregularity in quinine prophylaxis. ”

“ In bilious remittent malaria an examination of the urine will suffice to exclude one of the characteristics of blackwater fever, namely, the presence of hæmoglobin. Moreover, the malaria parasite will be present in the blood throughout the fever until quinine has been administered. In yellow fever the initial rigor is rarely severe, the appearance of icterus is a comparatively late event, the spleen and liver are not usually enlarged, the urine is albuminous, and if blood be present the erythrocytes are abundant. ”

“ Some cases are so mild and transient, amounting, perhaps, to a single emission of hæmoglobinous urine, with little or no fever, that they are unattended with risk; on the other hand, a practitioner may encounter a run of severe cases in which nearly all die. Some old residents in Africa have passed through ten or more attacks with impunity. Taking one with the other, the case -mortality in blackwater fever may be put down at about 25 per cent. ”

“ The dark, porter-colored urine of blackwater is diagnostic even to the patient. The urinary sediment consists of granular débris with occasional haematoidin crystals. Albuminuria runs parallel with the haemoglobinuria. Pain in the loins, probably, from the plugging of the renal tubules by the detritus of red cell destruction, is a feature of blackwater fever. In blackwater fever we have the early appearance, even in a few hours, in a patient who is markedly asthenic and miserable, of jaundice, porter-colored urine and albuminuria. ”

“ Where one utilizes the methods of examining for increased percentage of large mononuclears or for melaniferous leucocytes, in those cases not showing malarial parasites, the percentage of evidence of malaria is greatly increased. It is necessary to understand that a small percentage of cases diagnosed as blackwater fever do not show evidences of malaria at autopsy and cases are recorded where blackwater has attacked persons who had never had malarial fever, such instances, however being exceptional. ”

“ In 1898 Sambon suggested, because of the striking analogies that its distribution, course, symptoms and morbid appearances have with the hæmoglobinuric fevers of cattle, horses, dogs and sheep, that blackwater fever might be a form of babesiasis. This view, which has been adopted by Blanchard and others, deserves consideration. It is quite reasonable to expect to find in man parasites belonging to this genus of the hæmoprotozoa, so abundantly represented amongst the animals most intimately associated with him. ”

“ Only small quantities of food should be given at a time. Rest in bed is very important, and the patient must be careful when he is allowed to get up owing to the danger of heart failure. Tonics are required during convalescence.
Blackwater Fever.
Blackwater fever is probably a pernicious complication of malarial fever, and derives its name from the colour of the urine. It must be remembered that dark-coloured urine is usual in all fevers; it is scanty during the height of the fever, especially if there is much sweating. ”

“ He affirmed, however, that the unhealthfulness of the climate was the most serious obstacle; and, since it was late in the season for us to put up a mosquito-proof dwelling before the rainy and unhealthy season came, he thought it best for us to select a place and then go south until the rains were over. Otherwise we might be stricken with fever, a deadly type of which, known as black water fever, is common in this section of the country. ”

“ Thus, persons long resident in a badly-drained house, although frequently ailing in various ways, may never be laid up with typhoid fever; a certain immunity has been obtained by the slow adaptation of the system to bad air, but at the sacrifice of vigorous health. But if a new and healthy family move into the same house a deadly outbreak of typhoid or diphtheria may at once result. ”

“ Water from rivers and streams running near where many people live is likely to be made impure and is sure to bring sickness and death to some of those who use it. Water from a small stream at Plymouth, Pennsylvania, running past a house occupied by a typhoid patient, gave the fever to over a thousand persons in one month. The water from a small stream at Ithaca, New York, gave the fever to over thirteen hundred people in one season, and an almost equal number caught the fever in a few weeks at Butler, Pennsylvania, by drinking water from a small creek along which some sick persons lived. ”

“ Three butchers only, out of nearly one hundred who remained in the city, died with the disease. Many of them attended the markets every day. Two painters, who worked at their business during the whole time of the prevalence of the fever, and in exposed situations, escaped it. Out of forty scavengers who were employed in collecting and carrying away the dirt of the streets, only one was affected by the fever and died. ”

“ While continuing his experiments with mosquito bites, Dr. Reed was carrying on a rigorous test of the theory that infected clothing and bedding was the transmitting agent of the fever — a theory unquestioningly accepted by the medical profession and acted upon in framing and enforcing quarantine regulations. The very name given to these infected articles, supposed to be capable of passing on the flame of infection— "fomites," a word derived from the Latin term for "tinder" — indicates how seriously they were regarded as a means of spreading the flames of the fever. ”

“ The leading physicians and pathologists, in regions where these fevers prevail, are now convinced that they are not malarial fevers, but are simply more or less typical varieties of typhoid fever—a disease due to a specific bacillus and which is commonly contracted as a result of the ingestion of contaminated water or food. The error in diagnosis, upon which the inference has been based that malarial fevers may be contracted through drinking water, has been widespread, in this country, in Europe and in the British possessions in India. ”

“ Though these illnesses may usually be checked so easily, their frequent return affects the body greatly, and makes it more and more susceptible to injurious climates and atmospheric influences, so that the slightest change is often sufficient to bring back the fever. Still, all the diseases produced in these regions by an alteration in the surface of the ground are less dangerous than in any other part of the United States, which may be chiefly ascribed to the free unimpeded motion of the air, and the fact of no large swamps or standing waters existing here. ”

“ It must be acknowledged, however, that there is no direct proof of the existence of malaria or miasmata, much less of their nature.
CAUSE OF INTERMITTENT FEVERS. That preventive of ague, draining the land, must affect the water of a district quite as much as it affects the air, and there is direct evidence to prove that intermittent fever has, at all events in some cases, been caused by drinking the water of marshes. ”

“ I have seen so many instances of filth and 277 crowding in ships and hospitals in the West Indies, without contagion being produced, and which in Europe could hardly have failed to produce it, or to render it more malignant, that I am convinced there is something in tropical climates unfavourable to the production and continuance of infectious fevers55. The ships which bring this fever from Europe in general get rid of it soon after arriving in a warm climate; and nothing but the highest degree of neglect can continue or revive it. ”

“ Secondly, It sometimes happens that men, under the influence of this infection, are more apt than others to be affected with symptoms peculiar to the climate upon their first arrival. A very striking instance of this has been mentioned in the case of men that 381 were pressed into the Formidable at New York, some of whom had the common ship fever on the passage; others, upon our arrival at Barbadoes, were seized with the yellow fever, and were the only men in the fleet who had it at that time. ”

“ Some people resist powerfully the encroachment of all infectious diseases, while others seem fated to have an opportunity of testing in their own person every prevailing malady. Experience teaches, however, that typhoid fever, unlike many other diseases of the group, is favored in its development by unhygienic surroundings. Bad air, bad food, uncleanliness, and over-population of a house or quarter of a city, create a condition in the system favorable to a rapid and virulent development of the fever after an infection by the germs. ”