149 
5-  (Glomerular  haemorrhage  would  account  for  the  anaemia, 
sallowness,  and  watery  condition  of  the  blood  observed  in  blackwater 
fever. 
6.  Considerable  difficulty  is,  however,  experienced  when  an 
attempt  is  made  to  reconcile  the  theory  of  glomerular  haemorrhage 
with  the  pathological  conditions  observed  in  the  kidney  after  death. 
Lesions  in  the  glomeruli  would  be  expected,  and  occasionally 
haemorrhage  into  the  glomerular  cavities  extending  along  the  urin- 
iferous  tubules,  while  sometimes  blood  would  find  its  way  in 
considerable  quantities  into  the  urine.  Moreover,  if  we  suppose  the 
haemorrhage  to  be  due  to  malarial  parasites  in  the  blood  capillaries, 
these  parasites  would  scarcely  be  likely  to  be  confined  to  the 
glomeruli,  but  would  be  present  in  the  blood  vessels  of  the  kidneys 
elsewhere  and  would  cause  interstitial  as  well  as  glomerular 
haemorrhage.  Now  the  kidneys  have  been  so  far  free  from  these 
pathological  conditions.  In  fact  the  changes  in  the  kidneys  are 
exceedingly  slight  and  are  practically  confined  to  the  presence  of 
granular  material  in  the  tubules.  Other  changes,  such  as  degenera¬ 
tion  of  the  renal  epithelium  are  inconstant,  and  when  present  should 
be  regarded  as  complications  of  blackwater  fever  or  of  malaria,  and 
not  as  essential  factors  in  the  production  of  haemoglobinuria.  It  may 
be  remarked  that  superficial  haemorrhages  were  found  beneath  the 
capsule  of  the  kidney  and  in  the  mucuous  membrane  of  the  renal 
pelvis  of  Case  /a,  but  these  were  evidently  of  very  recent  date  and 
must  have  occurred  after  the  disappearance  of  the  haemoglobinuria. 
This  case  cannot  therefore  be  regarded  as  in  any  way  supporting  the 
hypothesis  of  glomerular  haemorrhage.  Case  2  (p.  178)  which  appears 
at  first  sight  to  give  some  support  to  this  hypothesis  also  fails  to  do  so, 
when  examined  more  critically.  As  already  mentioned  red  blood  cells 
were  present  in  the  urine  in  considerable  numbers  in  this  case,  so  as 
to  form,  on  standing,  a  layer  visible  to  the  naked  eye.  It  was  found, 
however,  that  the  red  cells  were  accompanied  by  a  number 
of  pus  cells,  there  being  one  pus  cell  to  about  eight  red  cells, 
while  the  urine,  which  was  neutral  in  reaction  to  litmus  paper  also 
contained  bacilli  when  voided.  When  haemoglobin  had  disappeared 
from  the  urine  it  was  found  that  pus  cells  and  bacilli  still  remained, 
and  the  previous  history  left  no  doubt  that  both  had  been  present 
before  the  attack  of  blackwater  fever.  It  is  clear,  therefore,  that  in 
