Annual report on the Medical Research Institute / 1909-.

  • Nigeria. Medical Research Institute.
Date:
[1923]
    y for the year 1923. BLACKWATER FEVER, Blackwater fever, or Haemoglobinuric fever has been the subject of much controversy with regard to its causation. As experience has grown and careful observations and records have accumulated, the balance of evidence has swung more and more definitely to the malarial origin of the disease. Nevertheless, from time to time, new theories arise and other parasites are described as of pathogenic importance. Blackwater fever has one sign common to all cases, that is the passing of urine which is coloured some shade of red or brown according to the amount of blood-colouring matter it contains and dependent on the time at which the urine is voided after having reached the bladder. But the sequence of events, the nature of the onset, the number and the severity of the general signs and symptoms, the course of the disease, all these vary within fairly wide limits in different cases, in West Africa, at any rate. That these are dependent on individual idiosyncrasy and are influenced by the amount and degree of previous malarial infection, actacks, moreover, for the most part inefficiently treated, is probably the correct view, but this very lack of uniformity has led many observers to seek for other explanations. One of the most recent papers on the subject, contributed by Dr. Lefrou and Dr. Blanchard, describes the finding of spiroehaetes in the blood of several cases of blackwater fever, which occurred in French Congo. These observers, by using the method of triple centri¬ fugation of the blood, isolated Leptospira from the third deposit, which they were successful in transferring to guinea-pigs. During the year under review, an opportunity was afforded at Yaba of examining four cases of the disease by this method. Three of :hese occurred in Lagos (one was probably a simple haemoglobinuria) and one hi Abeokuta. The technique consists in withdrawing a certain quantity of the patient’s blood from a vein, into a measured amount of a solution of Citrate of Sodium of a definite strength, in a tube. The mixture is then centrifugalised, the rate and the time being controlled. The first sediment which consists mainlv of red and white c/ cells is discarded. The supernatant fluid is again centrifugalised during which the remainder of the red cells and most of the blood-platelets are brought down. The second deposit is afso thrown away, and the fluid is centrifugalised a third time. The deposit, on this occasion contains some blood-platelets and any spirocliaetes which may be present. In all the four cases investigated by this method, structures were readily found which by the dark-ground illumination of wet films closely resembled spirochaetes. The deposit in each case was submitted to <'J her tests, smears were fixed and stained by Giemsa’s process and also by Fontana’s preparation, cultures were made and guinea-pigs were inoculated. The staining methods failed to reveal spirochsetes, the attempts at cultivation in artificial media were negative, and although spirochsete-like structures were seen in the blood of the inoculated guinea-pigs, the animals themselves, with one exception showed no ill-effects. In the first case of blackwater fever five series of sub- inoculations were carried out from guinea-pig to guinea-pig, a similar number in the second and third cases, and four series in the last case. In the second case, one guinea-pig in the third series of sub-inoculations, showed a blood-serum stained distinctly pink after centrifugalisation. This however, was almost certainly due to artificial laking. The failure to demonstrate spirochaetes except by dark-ground illumination directed attention to the examination of the blood, in health and in disease both in human beings and in laboratory animals.
    9 About this time word was received that Dr. J. G. Thomson of the School of Tropical Medicine, London, was investigating the condition in Rhodesia and held the belief that the structures described wer^ “ pseudo-spiroehsetes ” and unconnected with the illness. The blood oi live Europeans was examined, two of whom had suffered from black- water fever in the past, one who was recovering from amoebic dysentery, and two who were convalescent from sub-tertian malaria. A native who harboured Filaria loa was also included. In addition to these, the blood of six monkeys and eight guinea-pigs was also examined. The “ pseudo-spiroehsetes ” were readily found in all cases. The slowness of their movements, the small number and irregularity of their spirals and the fact that they are not highly retractile draw attention to their non-parasitic nature. The structures' were of two main types, one short and thick with few curves, the other longer and thinner and with a wavy rather than a spiral outline. Latterly, some of the finer type were seen being detached from blood-platelets, and some of the shorter forms appeared to be formed from the red cells after these had been anchored to the slide and had thereafter been freed by currents in the film. In view of these findings and in complete agreement with Dr. Thomson’s conclusions, there appeared to be no adequate grounds for relinquishing the previously held belief that blackwater fever is dependent on previous malaria. Indeed the records of cases of this disease occurring in Nigeria during 1923, continue to add proof to the hypothesis. Reports of only twelve cases were received but five or six others occurred details of which for various reasons have not been furnished. The various data have been analysed as in previous years and the salient features are herewith presented. All the patients were male adults of British birth. Seven cases occurred in the Northern Provinces, four in the Southern Provinces and one in the British Cameroons. The towns in or near which the patients fell sick are Jos three, Onitsha two, and Ahoada, Bamenda, Ibadan, Ibi, Tvaduna, Kano and. Zaria, one case each. The months in which the disease was noted are January, February, March two cases, April, June three cases, August two cases, September and October. The age of the patient was twenty-four years (two cases), twenty- eight years (two cases), twenty-nine years, thirty-three years (two cases), thirty-four years, thirty-eight years, forty-five years, forty-nine years and fifty-five years. Six were Government Officials, three belonging to the Provincial Administrative Department, and three engaged on railway work. Of the non-officials two were in the tin-industry, three followed mercantile pursuits and one, banking. All the individuals had considerable previous tropical experience, except in one case, as is shown in Table I. TABLE I. Total time in Period resident Period in other parts of the tropics No. Nigeria. since leave. 1 4 years 11 months ... None. 2 17| months ... 17f months ... 3| months ... Rhodesia, Nyassaland, Congo Beige, 1 year. 3 3 years None. 4 2 years 6 months ... None. 5 11 years 12 months ... None. 6 3 years 16 months ... Salonika, Turkey, during the war. 7 3 months ... • . . None. 8 16 months ... • . • India, Arabia, during the war. 9 3 years 12 months ... India, 6 years. 10 '10 years 2 years None. 11 11 years 7 months ... None.
    There was thus a sufficiently long period of residence in malarious areas for each to acquire a malarial infection. In fact, with the exception of Case (7), there is a definite history of one or more attacks of malaria in all the subjects. As regards the exception, two attacks of dysentery were contracted in the three months’ period of his residence in Nigeria, but there was no history of any other illness. The details of each case are to be seen in Table II. TABLE II. Case (1) Six bad attacks of malaria. Often “slight fever” this tour. Case (2) Nine or ten attacks of fever this tour. Several in Nvassaland. «/ , Case (3) Two attacks of enteritis with malarial parasites in blood, this tour. Case (4) A number of mild attacks of malaria. Case (5) Had no malaria for years. Case (6) Many small attacks of malaria. Case (7) No history of malaria. Case (8) Frequent attacks of malaria. Case (9) Two or three small attacks of malaria in last two months. Case (10) Exceptionally healthy. Occasional malaria. Case (11) Several attacks of malaria, one within 14 days of illness. Case (12) Much fever. As regards quinine prophylaxis, this drug was for the most part neglected. Table III gives particulars. TABLE III. Case (1) Takes 10 grains thrice daily for a few days when he lias fever. Case (2) 5 grains quinine Hydrochloride daily. Case (3) Takes quinine regularly. Case (4) Takes quinine Bihydrochloride in varying doses at irregular intervals. Case (5) Took no quinine. Case (6) 5 grains Hydrochloride, very regularly. Case (7) 5 grains quinine irregularly. Case (8) 5 grains Hydrochloride, irregularly. Case (9) No quinine for one month before illness. Case (10) Took no quinine. Case (11) 5 grains daily, regularly. Case (12) 5 grains regularly for a year previous to illness, some¬ times 10 grains. These Tables (Tables II and III) show clearly that the patients (five, in all) who professed to take quinine regularly as a prophylactic against malaria were not thereby protected. The possible reasons for this lack of protection are many but the most likely explanations are some looseness in the use of the term “ regular ”, and a neglect of other precautions particularly the use of mosquito boots. In at least one case (Case 3) the inefficiency of the quinine was due to a chronic gastritis which interfered with the absorption of the drug. In the remaining seven cases, quinine was used either irregularly or not at all. It strongly emerges, from a study of the two tables that in eleven out of twelve cases there is a history of malarial attacks and inadequate quinine prophylaxis. It may be inferred that the malarial infection in several cases was inefficiently treated. The data respecting quinine as a possible precipitant or excitant of the actual condition of haemolysis are set out in Table IV.
    15 grains in solution
    In the above table, the third column “ Days ” refers to the period before the onset of black water, during which quinine was being taken. In the fourth column, in cases (2) and (6) the dosage is given ''from the first day to the last day of its administration. In the last column “ Interval” refers to the time which elapsed between the taking of the last dose of quinine and the first appearance of hsemoglobinuria. It will be seen that in two cases, the total amount of quinine taken within twenty-four hours of the appearance of black water, was 5 grains. In the first of these the patient was not in the habit of taking quinine, and in the second, it was the usual daily prophylactic dose. A definite history of previous attacks of blackwater fever was obtained in one case only, Case (12), one attack having occurred in 1902 and a second in 1903, both whilst the patient was in Rhodesia. In Case (2), however, there was information that whilst on active service in Russia during 1916, there was an illness lasting two weeks during which “ Red water ” was passed and jaundice was noted but no rise of temperature. He had then not been previously in .the tropics. There was complete recovery from the present illness in both of these cases. The premonitory signs and symptoms of the disease vary in the different reports. In some there was a period of malaise, which was usually attributed to malaria and led to the taking of quinine. This period varied from one to four days, but in two cases it had been a matter of weeks. In Case (1) the patient had been taking 10 grains of quinine twice daily for two days before the onset of hsemoglobinuria, so that presumably he had felt out of sorts. The history is similar in Case (2). There was fever for two days, for which quinine was taken. In Case (3) a long period of gastritis with vomiting and diarrhoea probably masked any prodromata. The previous history could not be obtained in Case (4), as when the patient was reached after some days’ travelling, he was delirious and his illness ended fatally. Somewhat similar circumstances explain the lack of information in Case (5). In Case (6) an attack of “fever” came on four days before the onset of blackwater, and the patient appeared to have completely recovered from this during the morning of the day in the evening of which hsemoglobinuria occurred. An “out of sorts” feeling preceded by three days the appearance of blackw7ater in Case (7) and on the actual day before, the patient thought he had a “ touch of sun.” In Case (8) there are no notes as regards onset. The patient in Case (9) had been in hospital under treatment for malaria for two days before hsemoglobinuria set in.