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286 The hæmoglobinuria may recur with each rise of temperature; or there may be only one or two out- bursts; it may continue for an hour or two only; or it may persist off and on for several days or even weeks.

In the more severe forms of hæmoglobinuric fever there is usually a very great amount of bilious vomiting, of intense epigastric distress, and of severe liver-and loin-ache. The urine may continue copious and very dark in colour; or, continuing hæmoglobinous, it may gradually get more and more scanty, acquiring a gummy consistence, a few drops only being passed at a time. Finally, it may be completely suppressed.

In severe cases death is the rule. It appears to be brought about in one of three or four ways. The fever may assume the typho-adynamic type; or suddenly-developed cerebral, hyperpyrexial, or algide symptoms may supervene. Singultus is said to be a fatal symptom. In other cases the symptoms may be like those consequent on sudden and profuse hæmorrhage— jactitation, sweating, sighing, syncope. Or it may be that suppression of urine, persisting for several days, terminates, as cases of suppression usually do, in sudden syncope or convulsions and coma. Or, more rarely, nephritis may ensue and the patient die from uræmic trouble three or four weeks after all signs of hæmoglobinuria and fever have disappeared. Recently I saw in London a case in which the fatal issue appeared to have been brought about by persistent hiccough— always a bad sign— hepatitis, and vomiting of blood,

The urine.— If the characteristic dark-brown, generally acid, urine of a hæmoglobinuric case be stood for some time in a urine glass, it will separate into two well-marked layers : an upper of a clear though very dark port- wine tint, and a lower—perhaps amounting to fine-half or one- third of the entire bulk— of a somewhat brownish-grey colour, and consisting of a sediment in which an enormous number of hyaline and hæmoglobin tube-casts are to be found, together with a large quantity of brownish granular material. Epithelium is also