Marked and persistent vomiting and hiccough are very unfavorable signs. In particular, however, it is anuria that gives us our greatest concern in the care of a case. A severe attack is followed by a marked anaemia and convalescence is usually protracted.
Prophylaxis and Treatment
Prophylaxis.—The view now generally entertained is that where malarial prophylaxis is properly carried out there will not be any blackwater fever. In persons who have had a previous attack of blackwater fever quinine prophylaxis should be with quinine tannate or quinine base, avoiding the acid salts of quinine.
In particular any exposure to chilling influences or conditions which lower resistance should be avoided. 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.
Treatment.—There is less unanimity of opinion as to the advisability of giving quinine during an attack of blackwater fever than exists as to any other therapeutic measure.
Of course if it be true that quinine base is devoid of haemolytic influence the fear of increasing haemolysis by giving quinine would not have to be considered. At any rate any red cells containing parasites will surely be destroyed in the general haemolysis and with them their contained parasites, so that it does not seem reasonable to give quinine during the first day or two of the attack. Quinine, if given, should not be by mouth for fear of increasing the nausea and vomiting. The majority of authorities hold that if parasites persist after two or three days from the onset quinine is indicated. Some give quinine during the first day if parasites are present but otherwise they withhold quinine.
Absolute rest in bed, avoidance of chilling and good nursing are the prime considerations in treatment.
The patients should be given alkaline waters freely, as Vichy or water containing 30 grains of bicarbonate of soda to the pint. Cracked ice often tends to lessen the nausea and vomiting. Albumin water or barley water may be retained better than milk or broths. As the condition is so asthenic one cannot disregard the nourishment of the patient during the first two or three days as is true of the sthenic first stage of yellow fever. Hot fomentations to the loins are indicated for relief of pain and the effect on the renal congestion.
Saline enemata are of particular value and may suffice in mild cases. In severe cases subcutaneous or intravenous saline injections are necessary. Sorel recommends the intravenous injection of lactose or glucose solutions in quantities of about 300 cc. (Crystallized glucose 47 grams, water 1000 cc. or C. P. lactose 92.5 grams, water 1000 cc.) He also uses these sugar solutions as enemata. Dry cupping or hot fomentations over the loins are the usual remedies in threatened suppression of the urine. If blackwater fever should be shown to be accompanied by diminished alkalinity of the serum then the intravenous injection of a 1 or 2% solution of bicarbonate of soda would be indicated. Some have recommended calcium lactate in doses of 20 grains every four hours. There is little evidence however to indicate that it is of value. Transfusion of blood has been practised but reports of such treatment indicate that while temporary improvement occurs yet this is followed by a return of haemoglobinuria. From Dudgeon’s work it would seem that the existing haemolysins would destroy the foreign red cells.