734 THE INDIAN MEDICAL GAZETTE [Dec., 1941

are BLACKWATER FEVER IN DARJEELING- inches. No regular anti-malaria measures TERAI adopted by the municipality except occasional of kerosene and crude oil mixtures in By JAGADISH C. BHATTACHARJEE, l.m.p. spraying the principal breeding places of the town during Darjeeling Himalayan Railway Hospital, Tindharia, the hot but the suburbs are always Darjeeling months, neglected. All the pernicious manifestations Within a of five years, 1935-39, the period of malaria are encountered, especially during cases of blackwater fever have come twenty monsoon months. under the writer's observation. The cases will be discussed from a clinical point of view with Incidence short notes on the treatment employed, as faci- From table I it will be noted that the maxi- lities for thorough laboratory investigations mum number of cases occurs in the winter in were not available in the locality. months, when there is a natural decline malaria incidence. This is borne out by other Topography and climatology practitioners of the town as well. The cases of this series have been encoun- tered in Siliguri, a subdivisional town of Dar- Table I jeeling district, Bengal, a place 300 feet above Showing incidence of cases month by month sea level and situated about 7 miles from the foot of the Himalayas. The locality is hyper- Number Number Month Month endemic for malaria, the spleen index amongst of cases of cases children under 12 years of age varying between 60 and 70 per cent. The climate is hot and moist in summer and cold and in the January July dry August winter. Rainfall is between June and February- heavy March September October and the annual rainfall averages 160 April [October May November June December

Total 20

Age and sex The disease is more common in adolescence Oi and males are more attacked. commonly 5 the cases 15 were males and twenty treated, oi females. The youngest patient was 4 years age and the oldest one 56. Average age of tin5 24 to 38 years. Of the twenty males as ne series, one person has been included twice had two attacks in two consecutive years. Table II Showing age incidence

Age groups, Number of years cases

1-10 10-20 20-30 30-40 40-50

Total 20

All the patients were middle-class Beng Hindus in various employments, such as ran household work, etc. &o services, agriculture, ^' of them are temporary residents of the p while others have been domiciled here for m than one Both these groups generation. D equally susceptible. So far no case has recorded amongst the Rajbansi community, original inhabitants of the sub-Himaiay plains of Bengal. Dec., 1941] BLACKWATER FEVER: BHATTACHARJEE 735

Predisposing conditions rise of temperature without other signs and symptoms of blackwater fever. The urine A lowered state of general health, over-exer- clears up as the temperature returns to normal. tion and exposure to chill were the exciting Though a high rise of temperature is the rule causes, but a history of frequent short attacks yet haemoglobinuria has been observed in a ?f fever was given in every case. patient whose temperature rose only to 100?F. Onset Urine.?There is always a tendency for dimi- nution in the amount of and in a The onset of hemoglobinuria is always sudden, urine, severe case the in 24 hours be and it usually appears within the first few days quantity passed may less than 15 ounces. In bad there of the occurrence of fever; in several cases it very cases, be total In has been found to occur with the first bout of may suppression. typical cases, the fever. urine is dark, coffee-coloured in the beginning and, passing through different shades, Table III finally becomes tarry. In mild cases, the urine is Showing the day of appearance of hcemo- passed freely, it is bright red in colour, gradually globinuria turning to brown, after which it clears up quickly. It always contains haemoglobin in Number of solution. Albumin is in severe cases Day of fever present cases and epithelium, hyaline, granular and haemo- globin tubular casts are found in the centrifu- In our series of the 1st day galized deposit. cases, duration of was 7 2nd ? longest haemoglobinuria days a 3rd ? and the shortest, few hours. The average was 4th ? 2.85 days. 5th ., Gastro-intestinal tract Nausea, bilious vomiting, and jaundice are Total .. 20 found in all the typical cases. Vomiting is always a distressing complication and seriously 1 Relation with quinine interferes with the administration of nutrition and medicaments by the mouth. In one of the . Out of the twenty cases, intramuscular injec- the to tion of quinine has been responsible for preci- patients, tendency vomiting persisted even after he was cured and pitating an attack of hsemoglobinuria in 3 cases; apparently rectal and intravenous had to be whereas 7 cases had taken quinine either as feeding glucose to for and tablets jar in mixture, during the first few resorted days together. Hiccough oays of fever before the onset of hemoglo- epigastric pain are also common accompani- ments. binuria. In one case, administration of one Jaundice sets in and lasts several dose of 5 grains of quinine sulphate was respon- early days after the urine is clear. The liver is often ten- sible for precipitating an attack, but the urine on account of the extra strain to cleared up quickly, soon after the quinine was der, perhaps with the set free in the blood. withheld. The remaining 10 cases (50 per cope haemoglobin had not taken in any form during ^ent) quinine Blood the particular attack of fever. Blood was examined for malaria parasites in History of previous attacks altogether 15 cases of which 6 showed presence of P. falciparum 2 cases showing cres- Of these 20 4 gave a history rings, cases, patients as well. This a 40 cent ?f a attack before came under cents gives per positive previous they my In those who had taken this number includes the second finding. cases, quinine observation; before under observation, no parasite attack of the case that was counted twice in this coming be found in of examinations. series. could spite repeated Clinical manifestations Table IV The patient may have a previous attack of Showing result of blood examination fever lasting for several days, and then a rise of tempera- Total Total M.P. ^dden superimposed abrupt Percent- a shiver- cases blood found ture, 104 ?F. to 105 ?F., accompanied by age treated examined lrig fit, pain in the loins and region of the spleen positive and liver and severe vomiting of bilious matter. are certain cases, though their There however Cases having pre- 10 5 had no of dumber may be small, who history vious quinine. fever; the patient has a sharp chill, Cases without 10 10 60 ^evious the limbs and having previous followed by severe rigor, pain in He has quinine. loins, and a high rise of temperature. a micturition and then desire for 40 strong Total .. 20 15 Passes dark red urine. In a few cases, transient hemoglobinuria has followed a high 736 THE INDIAN MEDICAL GAZETTE [Dec., 1941

Differential count always revealed increase in alkalinity of blood and urine, which should be mononuclear leucocytes, sometimes exceeding tested each time it is passed. 20 per cent. If vomiting is persistent and the patient can- Toxccmia.?If the urine is free, the conscious- not retain sufficient fluid by the mouth, rectal ness is undisturbed, but, in cases with suppres- saline with 5 per cent glucose should be enjoined. sion of urine, severe toxaemic symptoms are Injection of 25 to 50 c.cm. of 25 per cent glucose noticed. In the only fatal case in the series, the solution, intravenously several times a day patient had continued suppression for 3 days. according to the severity of the case, is very She was delirious at first, but later died of efficacious in maintaining the heart and circula- 1 of coma, perhaps due to uraemia. tion and inducing diuresis. Five to 10 c.cm. a 10 per cent solution of calcium gluconate of Diagnosis may be combined with the first injection the active In practice, the only condition with which it glucose solution in the morning during of If is imminent can be confused in the stage is bilious phase haemolysis. suppression early 2 cent remittent malaria. In the latter the calcium may be replaced by per sodium condition, with onset is slow, an enormous quantity of bile is bicarbonate solution intravenously glucose, and this be as often as necessary. present in the urine, and jaundice is slow in may repeated saline and normal saline also appearance. A simple test is found in the text- Hypertonic may be to indications. I have books : if a quantity of urine is shaken in a injected according not of sodium foam on the in black- tried large doses bicarbonate bottle, pink appears top by water it is in bilious remittent solution intravenously as recommended urine; yellow other malaria. Manson (Manson-Bahr, 1935). Amongst measures, mention may be made of high rectal hot Treatment with warm water, dry cupping and lavage, of The main principle of treatment consists fomentation over the loins. Liquid extract of :? punarnava and liquid extract of Cassia beareana in drachm doses also to maintain the (i) removal of specific cause; we must at may help flow of urine. present accept malaria parasites to Of much has been attached be the cause, late, importance to administration of infusion of leaves of Vit (ii) maintaining the flow of urine and com- in the treatment of blackwater bating toxaemia, and peduncularis fever 1940). The is (in) relieving distressing and urgent symp- (Measham, plant popularly known as In several toms. ahoi plant in the locality. cases of varying degrees of severity, we have The patient should be put to bed and all used fresh decoction made from freshly "collected quinine therapy, including derivatives leaves and found that, if it can be retained by quinine but and combinations containing quinine, should be the patient, it acts as a powerful diuretic, stopped at once. For controlling malarial infec- unfortunately even in moderately severe cases tion, synthetic acridin derivatives, such as its administration is complicated with extreme atebrin or and nausea and and the can hardly (Bayer) quinocrine (May vomiting patients ls Baker), should be administered. In this series stand no result it; therefore, therapeutic no of 20 cases, I have used atebrin with uniformly achieved in those cases. It appears to have good result and no untoward effect, except that effect on temperature and malaria parasites^ evidence of gastric irritation, has been noticed fol- nor does it stop haemolysis. lowing atebrin administration. As a routine For heart and circulation, pitui" maintaining and measure it was exhibited in full doses in all cases trin, adrenalin, coramine, cardiazol, caffein whether showing malaria parasites or not. sodium benzoate, and injections of glucose In severe cases, atebrin musonate, 0.2 to 0.3 solution, normal saline, and where possible blood gm., was injected intramuscularly during the transfusion may be resorted to according first two consecutive days; this was supplemen- indication. Some recommend injection of live? ted by oral administration of atebrin tablets of extract as a routine measure, as a disturbance o^ to 0.1 gm., twice or thrice daily for one or two the function of the liver is also supposed p^ days following. In mild cases atebrin was given a part in the genesis of blackwater fever by mouth. Atebrin is mainly excreted through (Nocht and Mayer, 1937). This being a power' the kidneys; hence in a case with a tendency to ful stimulant to the haemopoietic system diminution in the amount of urine, the dose helps in the renewal of blood, which can be con- should be the tem- iron and arsenic com' carefully adjusted. By this, siderably promoted by in perature usually returns to normal on the third pounds, good nutrition, and adequate rest or fourth day, when the urine becomes clear. bed. To promote the flow of urine and combat toxaemia, plenty of fluid in the form of barley, Result of treatment glucose, soda and green coconut water, etc., One patient died out of 20, giving a mortal^) ie, should be enforced from the beginning. The rate of 5 per cent. Manson-Bahr (1935) 25 cen bowels should be kept open by saline purgatives. corded average mortality rate of per be in to maintain Alkalis should given plenty (Concluded on opposite page) (Continued from previous page) and Rogers and Megaw (1930) from 10 to 40 Per cent. The writer fully recognizes that the Percentage of mortality in such a small series has but little significance. Moreover, in an attack of blackwater fever, often there is one hffimoclastic crisis and the treatment is just to help the patient to tide over it; in most attacks, the hemoglobinuria ceases after a few hours of Jts own accord and all conclusions, therefore, re- garding the value of any particular form of treatment have to be drawn with the greatest reserve. The only advantage we have over the elder method of treatment is that since the in- troduction of synthetic anti-malarial drugs the control of malarial infection in cases of black- water fever has been easier. Summary 1. Twenty cases of blackwater fever have been treated in the plains of Darjeeling-Terai, With one death. 2. The features common to the cases are : tever, hemoglobinuria, vomiting, jaundice and a tendency to diminution and suppression of Urine. 3. The treatment employed mainly consists of administration of fluids, alkalis, non-irrita- ting diuretics, intravenous glucose, plus atebrin Parenterally and/or by mouth. . Acknowledgments I record here sincere thanks to Mr. G. P. ^ my *~]ackett, general manager, and Dr. S. K. PJswas, head of the Medical Department, Dar- Jeeling Himalayan Railway, for the facilities ?btained during the treatment of these cases. I arn especially grateful to Dr. Biswas for his eilcouragement in sending this note to the press. REFERENCES ^ivson-Bahr, P. H. Manson's Tropical Diseases. > (1935). Cassell and Co., London. iJeasham, J. E. (1940). Indian_ Med. Gaz., 75, 25. ?cht, B., and Mayer, Malaria. John Bale Medical (1937). Publications, London. Rogers, L., and Megaw, Tropical Medicine. J. and A. W. D. (1930). Churchill, London.