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     When a relapse occurs the temperature again rises and the history of the
first attack is repeated.

     Splenic enlargement.—In all our cases there has been splenic enlargement.
In some cases there was a history of this condition being present before the attack,
and in two the spleen reached nearly to the umbilicus before the onset of the
Black-water Fever. In one case this organ was seen to enlarge very markedly
during the paroxysm; and in several others we have seen a reduction in the size of the
spleen take place (vide cases) as convalescence set in. In none of our cases has
splenic enlargement been absent.

     Epigastric pain.—This very characteristic symptom is practically always
present in greater or less degree. Pain is complained of not over the spleen and
liver, but over the pit of the stomach and behind the sternum. If there is a return
of the hæmoglobinuria, there is generally a return of the pain. The renal pain
mentioned by some authors has not been remarked by us.

      Increased pulse tension.—There is, with the onset of hæmoglobinuria, an
almost invariable increase in the pulse tension, which lessens as the paroxysm
abates. With a recurrence of the hæmoglobinuria the high tension pulse
returns.

    Icterus.—Icterus is rarely present until a certain time has elapsed after the
onset of the hæmoglobinuria. In some cases it may be confined to a slight yellow
tint of the conjunctivæ. It is associated with the existence of an intense
yellow colouring of the serum; but not with the presence of bile salts in the urine.
The icterus of Black-water Fever is generally very transient, lasting only a few
days after the cessation of the blood destruction; but sometimes a slight bronzing
of the skin may remain for a long period.

II.—URINE CHANGES.

     Hæmoglobinuria.—The first urine passed may be light red or quite dark.
In the latter case it often shows on the removal of the hæmoglobin by acidifying
and boiling a considerable amount of dark brownish pigment. The same brownish
yellow colour is sometimes seen in the urine passed at the height of the attack.
Later on, clearing by acidifying and boiling shows that this is not present, the
urine resembling ordinary high coloured febrile urine.

     When fresh urine passed early in the disease is examined by the spectroscope,
the bands of oxy-hæmoglobin are well marked, and can easily be reduced and re-
instated by shaking; but the band in the red indicative of met-hæmoglobin is
often very faint, and only becomes pronounced after the urine has remained standing