BLACKWATER FEVER 89 



Ocean and the Solomon Islands. In these places it is 

 more common now than formerly. It also occurs in 

 Cyprus, and outbreaks, sometimes called epidemics, have 

 occurred in Greece, Sardinia, &c. 



The main types are: (i) slight or ambulant cases; 

 (2) severe attacks ; (3) relapsing forms in which the 

 attacks, whether mild or severe, recur with a short 

 interval intermittent form or without any interval, 

 where the urine is free from haemoglobin remittent 

 form. 



The clinical course of the severe simple type of 

 the disease varies, but the course can be conveniently 

 divided into five stages : 



(1) Prodromal stage, usually febrile. 



(2) Onset of more characteristic symptoms haemoglo- 

 binuria and jaundice. 



(3) Continuance and disappearance of the haemoglo- 

 binuria. 



(4) Secondary pyrexia. 



(5) Convalescence. 



(1) The prodromal stage is usually taken for an 

 ordinary attack of malaria, and in cases where blood 

 examination has been made in this stage malaria parasites 

 subtertian in most instances have been found. The 

 fever need not be severe, in fact the patient is often able 

 to travel and walk about, and is rarely so ill as to be 

 rigidly confined to bed. Sometimes yawning, pallor, and 

 pains in the limbs precede the attack. Occasionally, but 

 very rarely, no symptoms at all are observed, and the 

 prodromal stage may then appear to be absent. 



(2) The actual onset appears to be sudden and is 

 frequently marked by a severe rigor and high tempera- 

 ture, and pain usually in the region of the liver, but 

 sometimes in the loins. This pain may be very severe, 

 or may be little more than discomfort ; in the majority 

 of instances it is transient. The patient is seized with an 

 urgent desire to micturate, and finds his urine to be of 

 a deep black colour, but when shaken up in a bottle the 



