5

IV.

THAT BLACK-WATER FEVER IS THE RESULT OF AN INDUCED CONDITION BROUGHT
ABOUT BY REPEATED MALARIAL INFECTION LASTING OVER A CERTAIN TIME.

   Most modern observers have accepted this view, first brought forward by
Stephens and Christophers (9) and later strongly supported by Panse (10).

   These observers, while agreeing so far with Koch that the morbid process con-
cerned cannot be considered as one bearing any true resemblance to a malarial
attack, formed the conclusion that it was exposure to severe and long continued
malarial infection which brings about the condition of unstable equilibrium in the
blood necessary before quinine, or any other determining factor, can bring about
an attack of the disease.

   Since then much confirmatory evidence has been amassed showing that Black-
water Fever is clinically most closely associated with malarial infection. But
this view of the origin of the disease is not universally accepted, and certain ob-
jections have been raised, more particularly by these who maintain that the .disease
is a specific one with no real relation to malaria. This being so it will be necessary
to pass in brief review the facts that have been ascertained in regard to the relation
of Black-water Fever to malaria, and to consider in detail the objections that have
been raised against the theory that it is of malarial origin.

GEOGRAPHICAL DISTRIBUTION.

   The geographical distribution of Black-water Fever we now know to be very
wide. In Europe it is recorded from Italy, Sicily, Sardinia, Greece, and Spain,
from Mery in Russia along the banks of the Danube, in the Caucasus and from
Turkey. In Italy as Stephens (11) points out it occurs more especially in South
Calabria, where the mortality from malaria, according to Celli., reaches 9 to 9.9
per 10,000, a rate double that in the Roman Campagna and more than ten times
that in Northern Italy.

   In Asia the disease has been met with in Cochin China, Tonkin, and Siam, and
it occurs also in India, Burmah, the Straits Settlements, Java, Sumatra, New Guinea,
and the New Hebrides; it has also been described as occurring among certain
communities in the more malarious parts of Palestine.

   Throughout Tropical Africa it is the chief cause of mortality among Europeans ;
and it is found also in Madagascar, Burbon, Mauritius, Reunion, and the Comorro
Islands.

   In the West Indies it was known to the early French observers; and in Nicara-
gua, Costa Rica, French, British and Dutch Guiana, Brazil, Central America, and
Cuba it has been recognised for a considerable time; while American physicians
227 H.D.