mal hæmoglobinuria; 2, bilious remittent malaria; 3, yellow fever; 4, icterus gravis. If it be borne in mind that rigor, hæmoglobinuria, pyrexia, are all in evidence at the outset in black water fever, and also that black water fever is acquired only in certain countries, an error in diagnosis is improbable.
As regards paroxysmal hæmoglobinuria occurring in the tropics, a diagnosis might be impossible. Both diseases have the same symptoms. Paroxysmal hæmoglobinuria, as a rule, is of a milder type. In bilious remittent malaria an examination of the urine will suffice to exclude one of the characteristics of blackwater fever, namely, the presence of hæmoglobin. Moreover, the malaria parasite will be present in the blood throughout the fever until quinine has been administered. In yellow fever the initial rigor is rarely severe, the appearance of icterus is a comparatively late event, the spleen and liver are not usually enlarged, the urine is albuminous, and if blood be present the erythrocytes are abundant. The same remarks apply to icterus gravis.
Treatment.— Having regard to the frequency with which hæmoglobinuric fever concurs with malarial infection, and the well-established fact that quinine may precipitate or determine a hæmoglobinuric attack, the question of the administration of that drug in hæmoglobinuria becomes an important point. Some practitioners of experience recommend the exhibition of the drug in heroic doses, giving it every two hours in divided doses to the extent of 120 gr. a day; this they keep up till convalescence is established. On the other hand, hæmoglobinuria may come on while the patient is cinchonized. The Plehns, Koch, and others, after trying quinine in these cases, and carefully comparing the results of treatment both with and without quinine, abandoned its use. So long as the hæmoglobinuria continued they treated the case symptomatically, cautiously resuming the specific if the case merged into and concluded as a simple intermittent. There can be no doubt that in large doses quinine exercises a certain amount of destructive action on the blood corpuscles, rendering their hæmo-
