globin unstable. When, therefore, its toxic influence is superadded to that of the specific cause of the hæmoglobinuric fever, it may be that it supplies the little that is required to determine an extensive liberation of hæmoglobin, which, had the quinine been withheld, might not have taken place. Bastianelli lays down the following sensible rules as to the use of quinine in hæmoglobinuric fever: (a) If hæmoglobinuria occurs during a malarial paroxysm and parasites are found in the blood, quinine should be given. (6) If parasites are not found in the blood, quinine should not be given, (c) If quinine has been already given before the hæmoglobinuria has appeared, and no parasites are found, its use should be suspended; but if parasites persist it should be continued.
Recommendations.— Patients who are suffering from or are threatened with hæmoglobinuria, or who have had this disease before, on the slightest indication of fever should go to bed at once, keep their skins warm and scrupulously protected from draughts, and take plenty of warm fluid if parasites are present in the blood, moderate doses— 5 gr.— of quinine every three or four hours (intramuscularly by preference) and a moderate dose of calomel should be given. Patients threatening blackwater should not be moved.
When the urine tends to be suppressed, diuretics must not be given with the idea of stimulating the kidneys. In these circumstances hot fomentations should be applied to the loins, plenty of bland diluents administered, and an exclusive milk diet ordered until all albumin has disappeared from the urine. Indeed, even in the mildest as well as the gravest cases, the free and frequent administration of fluid is a most important measure, whether the patient is thirsty or not, and should be insisted on from the beginning of the attack. When, owing to persistent vomiting, fluid cannot be retained by the stomach, enemata of warm physiological salt solution (much less irritating to the bowel, and thus far more likely to be retained than plain water) should be administered repeatedly, 6-8 oz. every half-hour or hour. If these are not retained, the salt solution (a teaspoonful to the pint
