Jan., 1933] EDITORIAL 31

which would account for the discrepancy. Essentially, blackwater attacks those Indian Medical Gazette engaged in the rural areas?the case incidence per mille being 3.01 for those engaged in agri- culture, 2.83 for the mining industry, and 2.07 JANUARY for transport workers; 1.42 for rural areas, 1.32 for rural townships, and 0.28 for urban areas of over 1,000 population. RECENT researches on blackwater In summing up the first section of the FEVER memoir, on the distribution and incidence of the disease in Southern Rhodesia, Dr. Ross A veky which has important memoir recently writes as follows : appeared on the of blackwater fever is subject ' The essential fact which has in the that G. R. Ross Rhodesian Research emerged study by (1932), the realization of the intimate association of of and is, probably, Fellow the London School Hygiene of the disease with rural conditions. The higher inci- Tropical Medicine, entitled 'Researches on dence of the disease in rural inhabitants as compared Blackwater Fever in Southern Rhodesia with urban inhabitants generally, and the high incidence This memoir is both in its in those engaged in pioneer occupations, both help to very comprehensive, this of and in its establish fact. survey the previous literature The differential distribution in urban and rural carried _ ^ account of the investigations in Rhodesia districts deserves to receive emphatic mention, since it out It is an to the that the disease by the author and his collaborators. ^ encouragement hope may more of the four constitutes an extension of the now classical yet be fully controlled. This history urban centres shows that in the earlier of the memoir Thomson in 1924. big years by blackwater fever was not the The Rhodesia colony, always compara- white occupation of Southern tively rare disease that it is to-day. Perhaps the most dates from 1890 and the successful development illuminating part of the story of their achievement of of the country has been dependent on the two relative immunity is the realization that this has come primary industries of mining and about, not because of special control measures against producing the disease, but as part and parcel of their agriculture. The white numbers general population economic and municipal development. That this are 44,950, of which some 8 per cent, engaged should be so, is surely sufficient encouragement for the in mining industries, 17 per cent, in agriculture, belief that as development in the country districts we look for a and 75 per cent, in transport, industrial, com- proceeds may lowered incidence of the disease in the if not mercial and duties. This last next, in the present generation. professional Further, the application of methods of based element is in the four large control; largely concentrated on conclusions reached by the scientific study of the towns Gwelo and of Salisbury, Bulawayo, disease, must assuredly promise a speedier path to the Umtali in which approximately 47 per cent, of desired consummation. the white live. Males largely out- Thia definite distinction between urban and rural population areas must enter into the consideration of several number and to the immigration largely females, owing features of the distribution of the disease as revealed ?f of the white young adults the percentage in the preceding pages. Thus the fact that the incidence than population over 15 years of age is greater is greater in males than in females may be explained, it is in the standard British million. The native partially at least, by the fact that men are much more them Population numbers 933,899, of which likely to engage in the occupations which bring ' ' J60,301 into contact with primitive and undeveloped country. live in the native reserves and 173,598 live Farming, mining, prospecting and transport work which and work to the white in close proximity supply so large a percentage of the cases of the disease, population. are still almost entirely the undisputed territory of As the result of Thomson's work on the man in Southern Rhodesia. At the same time it must other female in in 1922 and 1923 be acknowledged that wives and relatives subject Southern Rhodesia the and a of blackwater do in many instances share hardships primitive standard system of notification environment under which these industries are conducted. not made fever cases was introduced (although There is no method of obtaining the relative figures of compulsory), and this greatly helped Dr. Ross females so placed or calculating the incidence of the cases of in data. Between the years 1914 disease in them, but the the disease recorded collecting in females for the have occurred almost and cases of blackwater period 1928 inclusive 679 in this class. fever Rhodesian exclusively were treated in Southern Another factor which may account for the difference of hospitals with 152 deaths, a case mortality in incidence in the two sexes is the fact that men are 22.2 per cent. The average death rate among much more careless in their habits and methods of life the between 1924 and than women. The flimsy and primitive housing European community the monotonous and 1928 was of which blackwater arrangements, inadequate dietary 9.25 per mille, that consists mainly of tinned and for 2.2 products ignores fever, notified as such, accounted per such essentials as fresh milk or vegetables, and the cent, of the total deaths. The disease is nearly general disregard of comfort-making amenities, that so four times as common among European males often characterize life under masculine management, as but the are not tolerated by. women, if anything better is among European females, population and their influence in the ?f the in 1926 possible, raising general latter only numbered 17,366 standard of life cannot be minimized. That they insist on a standard be one reason * generally high may Ross, G. R. (1932). Researches on Blackwater why the incidence of the disease amongst them is less. in Southern Rhodesia. No. 6 of the Memoir As far as the age-distribution of the disease is zenesJever of the London School of Hygiene and Tropical concerned, attacks may occur at any age, but the figures Medicine. Price: cloth 10,s. 6d.; paper 8s. for the period have shown the disease to be rare in 32 THE INDIAN MEDICAL GAZETTE [Jan., 1933 those under 5 of and to be commonest in the years age whereas the curves for admissions for years of adult life, particularly from 15 to 34. The typhoid fever and show no such correlation- explanation of the low incidence in the years of child- pneumonia hood probably lies in the fact that much greater care ship at all. (This graph confirms and extends and attention are very naturally lavished on children an exactly similar set of observations recorded who are thus protected from unhealthy circumstances in Thomson's memoir of 1924.) Chart 12 in as far as and that the majority a large possible, spend the memoir shows an close proportion of their childhood in the schools which are again extremely mostly situated in the non-endemic urban areas. The correlationship between the prevalence of the increased incidence in adult years is probably accounted local anophelines, which reaches its maximum for by the fact that it is during these years that occupa- in March, and blackwater fever, which reaches tions are engaged in which spell risk as far as blackwater its maximum in The of Southern fever is concerned. April. The incidence of the disease in the Rhodesian-born Rhodesia is almost exclusively d^e to Plas?no- is illuminating in this connection, for it is seen that dium falciparum, whilst of the 14 species of the chances of contracting the disease are small until present, the two really important an reached when economic age is circumstances force ones are A. junestus and A. ga?nbice, whose them to seek employment, and to look after themselves. prevalence again shows a very close relation- The relationship of length of residence to the develop- to that of blackwater and which ment of the disease involves considerations which are ship fever, alone on dissections to be different from those discussed above, for the establish- mosquito proved ment of the fact that the disease only occurs after a malaria-infected. The work of Napier and certain length of residence is bound up with the question Campbell (1932) and of Knowles and Das of the aetiology of the disease in a more intimate way Gupta (1932) shows that hsemoglobinuric fever than the distribution of the disease amongst the various occur as a terminal event in of sections of the community. The figures obtainable for may monkeys Macaca mulatto, from the five years have shown that the greatest percentage species dying monkey- of first attacks occurs during the first five years of malaria, and again emphasises the close rela- residence, that the disease has been uncommon in those tionship between infections and with less than one year's residence. These findings are blackwater fever. in agreement with experience elsewhere, but it is hardly possible to discuss any explanation of why this should It must be admitted on the whole that the ' be so without reference to other considerations which malaria hypothesis' with regard to the etiology have not been discussed.' yet of blackwater fever now holds the field to the exclusion of other. reviewer has The author passes next to a consideration of any (The tried to hold an mind on this for the relationship of blackwater fever to meteoro- open subject now forced to the logical conditions in Southern Rhodesia. In years, but is conclusion that the correct The asso- general, the incidence of the disease reaches its this hypothesis is one.) ciation is with P. maximum about three months after the period usually falciparum infections, and that in an endemic or of maximum rainfall (October to March). hyperendemic area, Correlation with temperature is less but sometimes the other species are concerned. marked, stresses its though the incidence tends to be highest in Thus, Giglioli (1930) connection in British Guiana with P. vivax whilst those regions with highest temperature. infections, ' workers in the Dutch East Indies have found Viewing the subject as a whole, the impression it with P. malaria? infections. that is gained is that the influence that meteoro- associated logical conditions exert upon the disease is not If blackwater fever is a manifestation of a direct one, but is dependent upon the activity malaria, it is due however to malaria plus some of some other factor upon which they react \ other factor or factors. What this factor or these factors are at present we do not know. Chapter IV of the memoir deals with the There may be exaltation of the virus by constant relationship of blackwater fever to malaria, and passage tribes in the here we reach the crux of the whole through aboriginal locality question. who have become habituated to it be The accumulated evidence in this chapter is it; may associated with certain groups of conclusive that blackwater fever is a manifes- transmitting it be tation of malaria. Deeks and James (1911) anophelines; may precipitated by (but not so in all it may be in Panama were the first to stress this necessarily cases); perhaps due to or biochemical causes in the in German East Africa biological point. Schilling (1911) individuals concerned. The future of also drew attention to it. In some areas, such study the disease in may as the and the we experimental monkeys help Punjab Philippine Islands, us in these factors. intense malaria without blackwater investigating get fever, With to the association of blackwater but in the malaria is seasonal regard former, strictly fever in Southern Rhodesia with in its incidence and the is nftt malaria, population exposed Dr. Ross writes as follows :?? to infection the whilst in the throughout year, ' latter, malaria control and continued treatment As far as Southern Rhodesia is concerned the between malaria and blackwater are fairly well enforced. In Rhodesia malaria relationship existing fever in that territory must be regarded as adding is not a notifiable and disease, very many considerable weight to the argument that the latter cases do not come to hospital On the other disease is a manifestation of infection with malignant hand chart 14 of the memoir shows how tertian malaria. It has been seen that the greatest extremely close is the correlation between incidence of blackwater fever occurs in those classes of the and in those areas in which the incidence admissions for the 1924-1928 population hospital years of malaria is greatest, that freedom from malaria and and those from from malaria blackwater fever, blackwater fever go hand-in-hand, that the seasonal Jan., 1933] EDITORIAL 33

Part II of the report deals with the bio- . ? luuiutJiiut; ui tut; t>v*~> ui^ . ??nnTll...,, v , v of the blood and urine in ?s chemistry blackwater of malarial infection n intimate previous ? j fever. there is an admirable case of blackwater fever and and on Here, again, ox ac of all work and and association between an attack that^ge,^wpieht of summary previous views, co e The Qf a volume of work on. attack of . the orj.ance large original reported these facts must surely emphasize It is to summarise this section of . impossible of the diseas can malaria in the genesis mrasite the since it is itself of the nature of a of the report, tion with other varieties blackwater fever "J?of ,. and should be read in the original predispose to the development obtainable review, by cannot be determined from the alone all workers interested in the disease. Part III info1'^^ter 1 malaria from where malignant seen, of the memoir is concerned with clinical Rhodesia, ma ' types accounts for all cases of treatment. practically of?[ the ep ^Vmioloeydemio!log: of the disease, its prophylaxis and If one takes certain features dis Such are as mild to moderate the two the types exemplified diseases, particularly similarity, the seasonal incidence, a and uncomplicated, fulminant and toxic types, and - population be P which has been demonstrated might An0-n}ieles the anuric type, the continued and intermittent common vector. Thus the black- Of 118 cases the duration of the hsemo- trans(.mls?lonf,ti?Pticalof a type. (lambice or Anopheles funestus was as : to tte alarial 'parasite, globinuria follows water-fever virus, in addition ^ of bot {Mlana^ would the absence and 24 . . . . 29 explain w absent Up to hours these mosquitoes districts in which o diseases 1?2 . . .. 28 the occurrence of the phases however, days epidemic > an assump , at the same time of year. Such -n 2?3 days . . 27 cannot the infrequence con- explain blafW^t ?t 3?4 . . 16 the first of residence or its development days year from a^con^ after removal or 4 or . . 18 siderable intervals in v}rus days longer region unless one qualities postulates ^or of a most nature. can., freauency were not per agent unique or the Relapses infrequent?10 cent., immunity of the native inhabitant the?rec^c? attacK as compared with a figure of 13 per cent, for with an of malaria precedes which attack a series of cases in Uganda. The opinion is of blackwater fever. nam Deeks ( ' often expressed that blackwater fever The conclusion reached by Welshman /1924),( patients Thomson should not be moved to as this and James (1911), Stephens (1915), ^ & hospital increases a ? blacks , i run. and many other observers that ^e the risk Dr. Ross finds that the reverse is one , manifestation of malarial toxicity the case substantiate. is the case; mortality among those results of the investigation present moved to hospital was 27 per cent, as against Dr. 32 cent, for those not the With regard to the role of quinine, per moved; greater which gc nursing facilities in a good more than reports in all on 162 cases, hospital compensate for the risk incurred in the following history : moving one patient. No quinine taken for at least onset o With regard to be week prior to the ^ symptoms, rigor may blackwater . ? absent?48 cases, may precede the haemoglo- binuria?104 cases, or follow it?10 cases. The Patients taking prophy- " regularly ' ' ^ ? no on lactic quinine ? administration of. quinine has effect the One of taken pyrexia accompanying the hsemoglobinuria or close only quinine ? ' upon '?the prior to the onset of blackwater ^ post-hsemoglobinuric pyrexia developed aftei pyrexia itself being apparently a manifestation Hsemoglobinuria had several doses of quinine ^ of the hsemolytic process. Hiccough is common a ? ? in the cases and is beenUCC11 takenLCIIVC11 anuric and toxic very grave symptom. Lumbar pain is very frequent ' in the The obvious gQand would seem to be definitely of renal origin. irregularity wri > of to the attack', he Pain over the area and spleen may also quinine a exinp-? hepatic great a number of cases presents p be complained of. Splenic enlargement is we are to qui usual but not invariable in the disease. problem if regard - -g of actual g important factor in the With to treatment, there are so . many , ' regard blackwater fever and suggests treatments'^ in vogue that it be said at is may vv liti tuv effect pro rnechanism*?v>vuaiiism tu) the once that none of them has merit. wTliereby' any special 9.a onmnlpv nnhirp i J ^ complex nature? subsidiaryThe mortality in the disease remains at a figure The author deals next with o not outof about 25 per cent., no matter what treatment cases do factors. The Rhodesian is of haemostatic of as' adopted. Injections sera, exposure to cold or fatigue , of and ^ d familialhorse serum, antivenene, blood trans- a we* In some instances . to v ue duefusion have all been advocated, but the benefit was obtained this history (but ofthe all seems doubtful. Calcium chloride may same family members of the attacksbe is anti-haemolytic in the test tube, but it is same A of pre^ house). history pnorted moreor than doubtful whether the amount injected of 192 cafles common?73 out ported,could achieve the same effect in the human 38 per cent. It is well known Intramuscular or body. injections of caffeine a ^^ction, fever is frequently household a^y sodiumone benzoate were tried out in a series of the of house being type concerned ting mos-the Rhodesian cases, but of 20 cases so treated for ' that affords ideal facilities 8 died. The conclusion reached by most quitoes. 34 THE INDIAN MEDICAL GAZETTE [Jan., 1933

observers who have had to undertake the treat- With regard to prophylaxis, the position is ment of blackwater fever is, undoubtedly, that the same as that with regard to malaria. In we possess no remedy which can be accepted the tremendously widely scattered rural areas as having demonstrable influence on , of Southern Rhodesia larval species control is and this conclusion is reflected in the fact that an immensely difficult problem; and individual the treatment most generally employed in the measures (amongst which the prophylactic 1 disease is purely symptomatic \ administration of plasmoquine for its crescen- ' To endeavour to produce diuresis is un- ticidal' effect will certainly take its place) doubtedly physiologically soundwrites the seem to be more feasible. The screening of author. Sodium bicarbonate has been used houses is not merely advisable, but is a neces- in the treatment of the disease for In this connection Dr. Ross writes as extensively ' sity. a variety of reasons. The alkaline treatment follows : fever has received most of blackwater extensive ' It is obvious that no malaria can and there is some danger of its campaign against publicity being be planned without knowledge of topographical circum- as a One regarded panacea. fact, however, stances, of the distribution and nature of the exposed deserves emphasis. Despite the number of population, the habits of the carrier mosquitoes, and authors who have published their findings the the economic problems involved. In Southern Rhodesia we an extensive total number of cases covered their have to deal with territory in which by reports the is and is small There is thus exposed population small, widely scattered, ample justifica- consists mainly of two races differing greatly in their tion for the critical to wonder whether the habits and circumstances. Moreover, it has been shown ordinary probability of recovery is sufficiently that the disease is essentially rural in its distribution allowed for If alkaline is used, and that it exhibits a seasonal periodicity which is therapy related to the of the oral or rectal route is to be to the closely prevalence Anopheles gambice preferred and funestus. It has further to be remem- intravenous. Intravenous Anopheles injections of large bered that the country is still in the initial stages of quantities of sodium bicarbonate are un- its growth and development, and that, however great, doubtedly dangerous and may cause tetany and the desire to be rid of malaria, there is a limit to the can devoted to even death In Southern Rhodesia the expenditure which be the object. Taking these facts into consideration, it does not seem probable intravenous of bicarbonate in cases in injection that extensive anti-larval measures will be instituted which symptoms of suppression were present in the near future. If the problem were the elimina- was attended by disappointing results. Used tion of malaria from such towns as Salisbury and in the strength of 150 grains to the pint, the Bulawayo one would not hesitate to recommend such schemes for favourable consideration, but when the injection of 1 and 2 pint amounts was ineffec- main endeavour must be to protect the scattered rural tual in the of preventing development suppres- population economic problems are likely to cause the sion in three cases of the anuric type '. Further, postponement of a national effort to a more prosperous in blackwater fever, although there has been a time. This applies most particularly to drainage loss in the corpuscular volume of the blood schemes, the value of which is not challenged, and where individuals or are in a to there has been no loss in the companies position corresponding embark on such schemes the expenditure would and there do not to be plasma, appear special undoubtedly be justified. indications for intravenous saline injections. Alternative methods of larval control involving the to Blood transfusion would appear be much employment of such larvicides as oil or Paris green better. Treatment after the cessation of seem more suitable to the requirements of the country. resolves itself into treatment The investigations on mosquito .prevalence in Rhodesia hemoglobinuria that such measures are essential of the and of the suggest only during resulting debility. the rainy season and for a short period at the commence- are Iron and arsenic universally employed in ment of the dry season, and they may be recommended this condition, whilst treatment of the anemia as more likely to achieve a quicker and more extensive with liver extract is also worthy of trial. result under present conditions than any other anti- larval measure. to the vexed of With regard very question While the merit of anti-larval measures remain? of is whether the administration quinine advis- unquestioned, it would appear that considerable time able or justifiable during blackwater fever or must elapse before such measures will effect any in the it seems to give a definite considerable reduction mosquito population of not, impossible the and the inhabitants in The collection of figures on colony, that, meantime, opinion. largest rural districts must depend upon more methods Thomson personal this point is that given by (1924) of prophylaxis. from the statistics of and compiled Deaderick_ While on the whole, the standard of education in the Cardamatis: in cases treated with 1,931 quinine colony is such that the elementary facts of the mosquito- was in 898 the mortality 25 per cent., whereas malaria doctrine do not require stressing, there is cases treated without quinine the mortality was urgent need for the instillation of a more wholesome of 10.3 per cent. (It seems possible that in respect for the consequence malarial infection. The general attitude towards the disease is much too atebrin we may now possess a drug which will complacent. It is regarded as a demon not half so clear the malaria infection the up underlying black as terroristic medical men would paint it, and its blackwater fever without any danger of increas- exorcism by an occasional dose of quinine as a matter ing the haemolysis.) After recovery from the of simple household therapeutics. Until such time as attack of blackwater anti-malaria treat- the individual is brought to realize that malaria is an fever, treacherous and must be or the will a insidious, death-dealing disease, only ment given, patient get a half-hearted response may be expected from those of malaria or of blackwater relapse?either whose co-operation is an essential in any campaign fever, against it. Jan., 1933] SPLENECTOMY: CONNOR 35

Much greater attention should be given to the References of building sites and the construction ^oice Deeks, W. E., and James, W. M. (1911). A Report proof sites situated as fai houses. The choice of on Hcemoglobinuric Fever in the Canal Zone. Mount possible from breeding g > ^as possible anopheles Hope, C. Z., p. 177. clearing of scrub vegetation, and the: removal of native compounds to a distance of at least 4 y Giglioli, G. (1930). Malarial Nephritis. Messrs. J. & leeward side are whic should A. London. elementary precautions , Churchill, observe. As far as actual construction and Das B. M. A the necessity of screening part of the ^ Knowles, R., Gupta, (1932). Study j-,e of and Its Transmission should be recognized, while mosquito-ne^"11^ Monkey-Malaria, Experimental to 301. regarded as an essential Man. Indian Med. Gaz., LXVII, p. * furnishing.' * * * Napier, L. E., and Campbell, H. G. M. (1932). The London School of Hygiene and tropica Observations on a Plasmodium Infection which causes Medicine is to be on the p < Hemoglobinuria in Certain Species of Monkey. Indian congratulated Med. 246. tion of this admirable report. ithin Gaz., LXVII, p. pages it summarises our present-day kn g Schilling, C. (1911). In Ross' Prevention of Malaria. of blackwater fever, with special ie eie London. Pp. 451?474. rural the lacunae 1 areas, and emphasises Thomson, J. G. (1924). Researches on Blackwater knowledge. It should serve as a startingII Fever in Southern Rhodesia. London School of Tropi- irom which further investigation will cal Medicine: Research Memoir Series, Vol. VI, London, p. 149.