'50 
this  case  it  could  not  be  asserted  that  the  red  blood  cells  came  from 
the  kidneys,  but  it  is  more  probable,  since  cystitis  was  present,  that 
the  red  cells  came  from  the  situation  in  which  pus  cells  were  being 
discharged.  The  difliculty  of  reconciling  the  hypothesis  of  glomerular 
haemorrhage  with  the  pathological  findings  is  so  great  that  from  this 
standpoint  alone  this  hypothesis  must  be  disregarded. 
7.  As  regards  pyrexia  and  associated  constitutional  disturbance 
both  hypotheses  stand  on  the  same  level.  The  symptom  of  haemo- 
globinuria,  whichever  hypothesis  is  adopted  to  explain  its  causation, 
does  not  in  itself  necessarily  imply  accompanying  constitutional 
disturbance. 
The  conclusion  which  follows  from  the  above  discussion  is  that 
the  hypothesis  of  haemoglobinuria  in  blackwater  fever  being  due  to 
primary  glomerular  haemorrhage  is  untenable  ;  because  this  theory 
( t)  would  not  account  for  the  haemoglobinaemia  which  accompanies 
blackwater,  (2)  nor  would  it  furnish  a  satisfactory  explanation  of  the 
mechanism  of  suppression  of  urine,  while  (3)  it  is  out  of  harmony  with 
the  pathological  findings  in  cases  of  blackwater  fever  in  which  rleatli 
has  occurred  on  the  day  of  appearance  of  haemoglobinuria.  On  the 
other  hand  the  hypothesis  of  a  primary  haemoglobinaemia  furnishes 
a  satisfactory  explanation  not  only  of  the  pathological  findings,  but 
also  of  the  main  symptoms  of  blackwater  fever,  namely  the  appearance 
of  haemoglobinuria  and  of  granular  casts  in  the  urine,  which  the 
experiments  on  rabbits,  recorded  in  Table  35,  prove  to  be  a  necessary 
consequence  of  haemoglobinaemia  in  such  degrees  as  were  observed 
in  blackwater  fever  cases  (Table  34,  p.  75).  In  the  light  of  all  these 
facts  it  may,  therefore,  be  confidently  asserted  that  the  haemoglobin- 
uria  of  blackwater  fever  is  dependent  primarily  upon  haemoglobin- 
aemia  and  is  not  due  to  renal  haemorrhage.  The  site  of  the  laking 
of  red  cells,  causing  haemoglobinaemia,  remains  to  be  ascertained 
The  mechanism  of  the  rise  of  temperature  and  accompanying 
symptoms  is  also  left  une.xplained.  The  former  problem  will  now  be 
considered;  the  latter  is  not  capable  of  elucidation  in  the  present 
state  of  our  knowledge. 
Concerning  the  site  in  whicli  laking  takes  place,  there  are  a  limited 
number  of  data  available.  .Such  laking  may  occur  in  the  blood  in  the 
peripheral  circulation  or  in  internal  organs. 
