NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
51
EXAMINATION OF SPLENIC BLOOD.
In all cases where it was possible we obtained splenic blood by puncture
during life within a few minutes of -first seeing the patient. The particulars of
these observations are as follows :
—
Case XIX—An extremely mild case. Spleen punctured shortly after onset
o f h æ m o g l o b i n u r i a ( 8 t o 1 0 h o u r s ) a n d s h o r t l y b e f o r e i t s c e s s a t i o n .
Case XX.—A severe case. Spleen punctured about 4½ hours after onset
and 48 hours before hæmoglobinuria ceased.
Case XXII.—A severe case seen 30 hours after onset. Spleen punctured.
while hæmoglobinuria still continued.
Case XXIV .—A severe case seen on fourth day just before the hæmo
-globinuria ceased.
Case XXVI.—A severe case seen on 2nd day and about 36 hours before
hæmoglobinuria ceased.
Further details regarding these cases are given in Part III and in the appen
dix.
The same minute attention was given to these films as we gave to those of
the peripheral blood. The red cells, the intervening spaces, the leucocytes and
macrophages with their inclusions were in turn scrutinised, several days being
devoted to the examination of a single film .
Beyond such malarial parasites as are recorded later, and the presence of
malarial pigment, we failed to discover any foreign body. On the other hand, we
encountered large numbers of red cells engulfed in macrophages and leucocytes
many of which were absolutely normal in appearance ; and none of which showed
any contained parasite.
OBSERVATIONS WITH REGARD TO THE POSSIBILITY THAT A BLACK-WATER FEVER
PARASITE HAS BEEN MISTAKEN FOR THE MALARIAL PARASITE.—In, experi-
ments among pariah dogs with P. canis we frequently encountered infections
whi ch di d not gi ve r i se t o hæmogl obi nur i a ; we had al so been st r uck by t he f act
of the occasional quite decided, but superficial, resemblance of piroplasma to
certain young forms of the malarial parasite. The contention, that special para
- s i t e s h a d b e e n s o m e t i m e s s e e n b u t m i s t a k e n f o r m a l a r i a l , p a r a s i t e s s e e m e d t o
us therefore to have some slight possible foundation.
It was therefore necessary not only to carefully scrutinise any apparent
malarial parasite seen in Black-water Fever ; but also to ascertain if any parasite
not malarial occurred in the blood of persons living under Black-water Fever
52
conditions, or in, the natives living around them. I
n order to fit ourselves for
this we studied very
closely indeed the younger forms of the malarial parasites,
and especially the malignant tertian variety ; for the more advanced forms of
simple tertian and quartan it was impossible to consider anything but what they
seemed. The result of this study we hope to publish later.
It is sufficient for the present to state that our own cases of Black-water Fever
have shown typical examples of ordinary malarial parasites and in most of our
cases recent malarial pigment was present. These observations are in accord
with the results obtained by many other workers in whose recorded cases the
presence of malarial pigment seems to preclude the idea of the parasite being
other than malarial.
The study of a large number of blood specimens taken from the adults and
young children living in the immediate neighbourhood of the houses in which
Black-water Fever cases had just occurred likewise failed to demonstrate the
existence of any but undoubted malarial parasites.
The results of a number of such examinations are recorded below:—
BARADIGHI.
Babus
..
.
. ..
Babu I
..
..
.. Black-water Fever.
"
II
. .
..
..
" "
" III
. .
..
.. Simple Tertian parasites.
Bunyas ..
..
..
Male, 17 years
..
.. Quartan parasites. Later
had Black-water Fever.
„ 25 „
..
.. No parasites.
„ 20 „
..
.. Simple Tertian parasites.
Children in small groups of
huts near babus' houses.
Group I ..
3 years
.. Simple Tertian.
10 months ..
,, ,,
4 years
..
,, ,,
2 „
..
,, ,,
Group II
. .
4 „
..
,,
,,
6 months
..
,, ,,
4 years
.. Simple Tertian and crescents
3 " ..
Malignant Tertian and
crescents.
1 year
.. Simple Tertian and
crescents.
3 years
..
Simple Tertian.
Group III
..
Male, 45 years
Nil.
" 25 "
Nil.
Boy, 12 „
Nil.
53
Children in Santal lines near babus'
houses and banya's shop.
\
2 years
.. Simple Tertian and Quartan.
4 months
.. Simple Tertian.
8 "
.. Malignant Tertian swarming.
6 "
.. Simple Tertian.
2 years.
..
" "and Quartan.
5 "
..
" "
2 "
..
" "
7 "
..
Nil.
3 months
.. Simple Tertian and crescents.
1 year
.. Quartan.
2 years
.. Simple Tertian.
1 year
.. Quartan.
2 years
.. Simple Tertian.
Woman, 30 years .. Pigmented leucocytes and single
small ring.
Man, 20 years
Nil.
Children in Nagpuri lines near bunya's
shop.
1 year
.. Simple Tertian and crescents.
7 years
.. Simple Tertian.
5 "
. . Quartan.
6 "
.. Simple Tertian.
Servants' lines near bunya's shop
Boy, 18 years .. Quartan.
" 1year .. Simple Tertian.
" 2 years ..
" "
" 8 "
..
Nil.
BARONS.
Lines near assistants' bungalow
.
'
5 years
.. Simple Tertian.
1 year
.. Nil (but enlarged spleen and
anæmic).
2 years
.. Simple Tertian.
3 "
.. Quartan.
6 "
. . "
1 0 "
.. Simple Tertian.
2 "
.. Quartan.
5 "
.. Malignant Tertian rings.
2 "
.. Nil (new cooly).
5 "
. . Quartan.
1 1 "
.. Crescents.
1 year
. . Simple Tertian.
3 year s
..
" "
3 "
.. Nil (mononuclear increase).
4 "
.. Quartan.
6 "
.. Simple Tertian.
6 "
. . Quartan.
227 H. D.
O
54
BENTGURI.
Manager's bungalow servants
. .
Mohamedan
30 years, large spleen, no parasites
, ,
32 „ ,, ,, ,,
Cooly class
18 ,, no spleen ,,
,,
25 ,, ,, ,,
Syce (Bengali)
enlarged spleen ,,
Assistant's bungalow servants
. .
Mohamedan
32 years, Black-water Fever.
, ,
20 ,, Simple Tertian. Intensely
anæmic
Syce (Bengali)
18 ,, Simple Tertian. Intensely
a n æ m i c .
Waterman
Malignant Tertian. Fever at times.
European. Aged 40. No parasites. Living at manager's bungalow.
European. Aged 25. Anæmic. No parasites. Living until recently at assistants'
bungalow.
The examination, also of a number of babus living under Black-water. Fever
conditions, the results of which are given a little later;. showed the presence of none
but typical malarial parasites.
These observations appear to us to exclude the possibility that Black-water.
Fever is due to a human piroplasmosis.. They do not, as we are aware, absolutely
preclude the existence of a special parasite in Black-water Fever ; but they tend
to show that the hypothesis which puts this view forward must confine itself to
the suggestion that the disease is not an ordinary piroplasmosis, or due to a blood
parasite visible to critical microscopical examination. W i t h t h i s m o d i f i c a t i o n o f t h e
specific disease theory we shall deal later.
55
• CHAPTER IV.
SPECIFIC RELATION OF BLACK-WATER FEVER TO MALARIA.
It is sometimes stated in recorded cases of Black–water Fever that the patient
had not previously suffered from malaria; this statement, if true, is evidently a strong
argument against Black-water Fever being the direct outcome of constant malarial
attacks. Our own experience has led us to doubt very much whether such histories
are trustworthy. For reasons already given we think it is very improbable that a
man could live for several years in any Black-water Fever country known to us
without contracting malaria ; the ordinary European does not take precautions,
and infection with malaria is one of the conditions imposed by residence, which few,
if any, can escape, but which shows itself more prominently in some than in others.
This must be exceedingly clear to all who have experience of the countries in
question.
But since the reasons on which we base this view do not seem to be generally
recognised it is desirable to emphasize them.
There are three conditions tending to obscure the frequency of malarial
attacks in a highly malarious country—
(1) Familiarity of the patient with attacks which cause him altogether to
ignore their importance.
(2) Refusal under certain circumstances to acknowledge the disease.
(3) Non-recognition.
It frequently happens that when European residents in an intensely malarious
country are questioned as to whether they have suffered from malaria or have had
any recent attacks they give a denial to the direct question, but on more closely
cross-questioning them they admit a history of repeated " bilious attacks,
" " h e a d a c h e s , " t o u c h e s o f t h e s u n " o r f i t s o f r e t c h i n g , o r d y s p e p s i a .
Without going into further detail we may say that, in our experience of mala
– r i o u s c o u n t r i e s , " b i l i o u s n e s s , " " r e t c h i n g " " v o m i t i n g , " " h e a d a c h e , " " t o u c h e s o f
the sun," and even " influenza " and " colds " are not necessarily "masked" malaria
but as a rule the symptoms of typical though more or less mild attacks of the disease.
In one case a medical man in Africa told one of us that he was feeling a " bit bilious";
on examination of his blood a considerable malignant tertian infection was found.
We could, were it advisable, multiply such instances by the score ; though such
a want of recognition we feel bound to state has not been a feature in the Duars
where several of the medical men use the microscope freely in diagnosis. We may,
however, refer to cases and histories which arc self-contradictory.
56
Our motive for entering into a somewhat long discussion on this point is to em-
phasise the fact that histories of Black-water Fever patients, who profess not to
have suffered from malaria, are to be treated with grave caution.
In all of our cases we have every reason to believe that, prior to the Black-water
Fever, the patient had for some considerable time been suffering from repeated.
malarial infection.
In the great majority there is very strong probability, as shown by the history,
that an actual attack of malaria immediately preceded the Black-water Fever.
This view was amply confirmed, wherever early examination of the patient was pos-
sible, as will be seen from the following tabular abstract of our cases :
—
Previous history.
Prodromata.
Under 24 hours
of onset.
Between 24
and 48 hours
of onset.
Third day and
l a t e r .
Case I.—Babu .. Had been getting fever for which
he had been taking quinine.
....
. .
..
3rd day.
Pigmented leucocytes.
Case II.—Coolie Was being treated for fever and
spleen by Dr. babu.
. . . .
. .
. .
Abundant recent malarial
pigment in organs.
Case III. —Babu's
servant.
Not known ..
..
.. Came to garden looking for
work. Seen to be ill.
. .
..
Abundant recent malarial
pigment in organs.
Case IV.—Dhoby Dr. babu makes special note of
much fever dating back three
months at least.
Complained of fever four or
five days preceding the
black-water.
A single malignant
tertian ring.
48 pigmented leuco-
cytes in a count
of 500 cells.
No parasites.
87 pigmented
leucocytes
in count of
500 cells.
3rd day.
Two or three pigmented
leucocytes.
Case V.—Babu .. Had been getting fever and was
being treated for this with in-
sufficient doses of quinine.
Had fever 10 days previously ;
also fever 10 days after
attack with malignant ter-
tian parasites.
Malignant tertian
parasites. Later
in day much re-
duced in number.
No parasites.
Case VI.—Bearer States he has had no fever this
year, but was taking quinine
(insufficient) to prevent fever.
But his statement is contra-
dicted by his master who says
that he has had fever.
Slight fever for two days prior
to black-water.
. .
No parasites.
4 pigmented
cells in count
of 500.
Case VII.—Babu Had to go to Calcutta for a change
on account of constant fever.
Was taken with fever in the
train for which he took
quinine.
. .
..
Mononuclears 28 .5 per
cent.
Case VIII. —
Babu.
Had been getting fever
..
Had an attack before black-
water. Fever for two days
before attack.
Malignant tertian
rings.
No parasites.
Pigmented
leucocytes.
57
—
Previous history.
Prodromata.
Under 24 hours.
of onset.
Between 24
and 48 hours
of onset.
Third day and
later.
Case IX.—China-
man.
Has had two previous attacks of
black-water.
Had fever for about three
days before attack.
Malignant tertian
ring. Scanty pig-
mented cells.
Case X.—Police-
man.
Six months on duty out in dis-
trict. Himself, wife, and
daughter all suffered much from
malaria.
Fever a fortnight before
attack. Evidently at the
time he took quinine he
thought he was coming in
for fever.
..
Two pigment-
ed leucocy-
tes.
Case XI.—Babu Came to a new garden three
months before. Ever since
coming has suffered from con-
stant and severe fever, not
less than an attack once a fort-
night.
....
No parasites.
15 pigmented cells
in 500.
Case XII.—Coolie Not known ..
..
.. Had " bad fever" for which
he was given quinine.
. .
..
3rd day.
No pigment.
Mononuclears 24.6 per
cent.
Case XIII. —Eu-
ropean child.
Fever frequent
..
..
. . . .
Quartan parasites.
..
Case XIV.—Po-
liceman.
Vide Case X—History of con-
stant fever.
. . . .
..
. .
3rd day.
No parasites.
4 pigmented leucocytes.
Case XV.—Babu Wife and himself have been suf-
fering from constant fever.
. . . .
. .
..
4th day.
No parasites.
No pigment.
Case XVI.—Eu-
ropean.
Constant fever
..
. .
. . . .
. .
2nd or 3rd day
(?). Mononu-
clears 17.7
per cent.
58
Case XVII.—
Babu.
Doubtful previous attack of black
water.
Fever for three or four days
before attack.
. .
Pigmented leu-
cocytes.
4th day.
No pigment.
Case XVIII.—
Babu.
Frequent fever
..
.. Slight fever for some days
before. Of two other babus
on this garden one had black-
water (Case XVII); the
other, a new-comer, simple
tertian fever.
..
. .
5th day.
No evidence on microsco-
pical examination of
malaria. ( Vide spleen.
)
Case XIX.—Ser-
vant.
Living under extremely bad mala-
rial conditions. Fellow ser-
vants fever-stricken.
Was treated for fever a week
before and had fever on
the day before his attack
which intermitted.
No microscopical
evidence of mala-
ria. His three
fellow servants
all had malarial
parasites in their
blood.
Case XX.—Babu History of fever and three months
ago had an attack of "liver"
with yellowness of his eyes.
Was being treated for three
days before attack for fever.
Abundant malarial
pigment in splenic
macrophages.
Case XXI.—Eu-
ropean.
Living in house that even in the
dry season was much in-
fested with anopheles.
Had been seedy for a fort-
night. States that he was
well when he took the dose
of quinine preceding his
attack.
Mononuclears 20
per cent.
No parasites.
No pigment.
. .
Case XXII.—
Shop-keeper.
Repeated attacks of fever during
the whole of the nine months
he has been in the Duars.
Feverish a fortnight before.
A few days before attack
had high fever which remit-
ted. The fever came on
again and he passed black-
water.
Crescents in spleen
and abundant
recent pigment.
Case XXIII.—
Coolie.
Doubtful
. .
. .
.. Had fever (temp. 104) day
before black-water.
. .
. . Seen only on 6th day.
No microscopical evidence
of malaria.
59
—
Previous history.
Prodromata.
Under 24 hours
of onset.
Between 24
and 48 hours
of onset.
Third day and
later.
Case XXIV.—
Chinaman.
Doubtful
..
..
.. History vague and uncertain
. .
. .
No evidence of malaria in
peripheral blood.
Abundant malignant ter-
tian pigment and a
sporulating parasite in
the spleen.
Case XXV
.. Repeated fever
. .
. .
. . . .
. .
. .
Seen 5th day.
Films not yet examined.
Case XXVI .. Repeated fever
. .
. .
. . . .
..
Abundant re-
cent pigment
in spleen. Peri-
pheral blood
not yet exa-
mined.
Case XXVII .. Repeated fever
. .
. .
. . . .
. .
Films not yet
examined.
60
61
It is impossible to overlook the fact that in the majority of these cases
malarial infection has been present, and that this has disappeared in the pro-
gress of the attack.* Of ten cases seen on the first day six showed actual parasites
and two more showed abundant recent pigment. Of the seven observations on the
second day, none showed parasites ; but in six there were pigmented leucocytes.
On the third day out of five observations three showed a few pigmented leucocytes,
none showed parasites. Of five observations on the fourth, fifth and sixth days
only one showed evidence of malaria and this on splenic puncture. In both of
the cases, where we have been able to study the organs, abundant recent pig-
ment was present in the macrophages and leucocytes of the spleen and liver, though
parasites had then disappeared.
These observations do not stand alone ; they reproduce very closely the
relation shown by Stephens (55) in his summary of observations upon this point.
Stephens' tabulation is as follows :—
Observer.
DAY BEFORE ONSET.
DAY OF ATTACK.
DAY AFTER ONSET.
Total.
Positive.
Total.
Positive.
Total.
.
Positive.
A. Plehn
.. ..
. .
5
5
5
3
10
2
F. Plehn
.. ..
. .
0
0
21
18
10
3
Koch
..
.. ..
5
5
8
6
6
1
Stephens and Christophers
..
1
1
9
2
16
0
Daniels
.. ..
. .
3
3
3
1
2
0
Panes
.. ..
..
9
8
17
9
20
5
TOTAL
..
23
22
63
36
64
11
Percentage positive
..
..
95.6 per cent
61.9 per cent
17.1 per cent.
* Note.—Cases XXV
are not included as films have not yet been adequately examined.
Similarly treated a tabulation of our cases shows :—
— DAY BEFORE ONSET.
FIRST DAY.
SECOND AND THIRD
DAY.
FOURTH TO SIXTH
DAY.
Neg.
Pos.
Neg.
Pos.
Neg.
Pos.
Neg.
Pos.
Parasites ..
..
Nil
10
6
7
0
10
1 †
† S p l e n i c p u n c t u r e , a s i n g l e p a r a s i t e .
227 H. D.
Q
62
—
DAY BEFORE ONSET.
FIRST DAY.
SECOND AND THIRD
DAY.
FOURTH AND SIXTH
DAY.
Neg.
Pos.
Neg.
Pos.
Neg.
Pos.
Neg.
Pos.
Percentage positive ..
. . . .
60 per cent.
0 per cent.
10 per cent.
Parasites and pigment
Nil
10
8
7
6
10
4
Percentage
. .
. . . .
80 per cent.
85.7 per cent.
40 per cent.
Classifying the parasite finds the preponderance of malignant tertain is very
noticeable—
Malignant tertian
..
. .
..
..
. .
.. 6
Benign tertian ..
..
. .
. .
. .
..
.. 0
Quartan
. .
..
. .
. .
. .
. .
.. 1
It is obvious that the significance of these observations depends upon whether
such an amount of evidence for malaria would be found in any indiscriminately
selected persons of the same race and class. Our experience of blood finds in
adults opposes such a supposition.
The examination of forty-five babus and their servants in August, Septem-
ber and October, the most malarious part of the year, gave as follows :—
Not infected
. .
. .
. .
..
.. 34
Benign tertian
. .
. .
. .
..
.. 5
Quartan
. .
. .
. .
. .
. . 2
Malignant tertian
..
. .
. .
. .
. . 4
Total 24.4 per cent, infections.
Of five babus examined in May and June, one showed malignant tertian
infection.
The examination of sixteen babus in January gave :—
Benign tertian
..
. .
. .
..
.. 0
Quartan
..
. .
. .
..
.. 0
Malignant tertian
..
. .
. .
. .
.. 1
Pigmented leucocytes ..
. .
. .
..
.. 1
No evidence of malaria
. .
. .
..
.. 14
Total 12 5 per cent, infections.
63
As we have already noted, Black-water Fever is frequently seen in babus
long resident in the Duars ; our cases have been as follows :—
Under 5 years
..
..
..
..
. . 3
Five years or over
..
..
..
..
. . 7
Ten years or over
..
..
..
..
. . 3
Since therefore the length of residence has played but a small part in this
incidence of Black-water Fever the series of cases of Black-water Fever in babus
is comparable with that of the series examined for malaria, quoted above.
We have therefore evidence of a
—
(1) Greater incidence of malaria among Black-water Fever cases than the
rest of the community.
(2) A special relation to the course of the attack shown by the disappear-
ance of the signs of malaria during the progress of the disease.
Granting the relation of malarial infection to Black-water Fever, which seems
to us established, there are but two explanations possible, either that the
malaria has a causal relationship to the Black-water Fever, or that the attack of
Black-water Fever, on the analogy of Red-water in Rinderpest, by lowering the re-
sistance brings on an attack of malaria in a subject already containing parasites
in his system. We can only judge of the relative probability of these alterna-
tives. If Black-water Fever only induces a malarial attack it is difficult to see
why the latter disease should always precede the former, and be already
over before the morbid process which called it forth has disappeared. It is obvious
also that the conclusions in regard to the malarial origin of Black-water Fever are
not altogether dependent on the proof of the association of the disease with an attack
of malaria, which is the point demonstrated by the facts just given. The conclusion
that Black-water Fever has a malarial origin is largely bound up in considerations
given by us in preceding chapters, questions of similar distribution and intimate
association. That some cases should yield no evidence of malaria on microscopical
examination, or even be unassociated with an attack, is no bar to the view that they
have come about as the result of much antecedent malaria.
CHAPTER V.
CONCLUSIONS IN REGARD TO THE FACTORS ENGAGED IN BRINGING ABOUT BLACK-
WATER FEVER.
A consideration of the facts presented forces us to the conclusion that in Black-
water Fever we are dealing not with a specific disease, but some stage in the progress
of malarial infection long continued and constantly repeated. Stephens has already
voiced this conception when he says that malarial infection displays its intensity in
Black-water Fever, men dying in Africa not from malaria, but from the resulting
Black-water Fever. This conception is also in harmony with the ideas suggested by
Marchiafava and Bignami (56-a) in their description of malarial hæmoglobinuria.
That in Black-water Fever, though induced by malaria, we see a distinct
morbid process, and not a mere malarial attack, is shown by the relation of the
condition to malarial infection. It is impossible to discard the evidence proving this
relation ; and once this view, that in Black-water Fever we have a disease, not
malaria, but malarial in origin is admitted, every known fact in regard to it is em-
braced in the theory : a statement which cannot be made of any other hypothesis.
As we have thus unhesitatingly decided in favour of the malarial origin of Black-
water Fever, that is of its being the outcome of the malarial conditions pictured in
our second chapter, it may be thought that we have done so in face of a certain
number of objections. This we do not allow : for a careful consideration of the
facts regarding Black-water Fever show no real objections ; but, on the contrary,
the closer such apparent objections are studied the more obvious does the truth of
the malaria view appear.
Numberless objections have been raised on the misconception that Black-water
Fever is in some way an attack of malaria. Such for example as that differences
in the clinical manifestations of the two diseases prove Black-water Fever not
to be malarial ; or that a disproportion between the number of malarial para-
sites and the hæmoglobinuria showed that the presence of the former bore no rela-
tion to the latter.
These objections are foreign to the point at issue, and apply only to theories of
the disease no longer held by any recent worker on the subject.
The series of objections that relate to alleged want of coincidence between geo-
graphical distribution and seasonal incidence of Black-water Fever and malaria
we have shown do not exist. It cannot be suggested that in recent researches too
much has been taken for granted in relating Black-water Fever to malaria ; the
more pleasing solution would undoubtedly be the demonstration of a specific
227 H. D.
R