SEQUELS IN MALARIAL FEVER 49 



subtertian malaria. The effect of the substances toxins 

 liberated when the red corpuscles containing the para- 

 sites break up, is irregular but more or less continuous. 

 The tendency is for a considerable but variable proportion 

 of the parasites to be fully developed and therefore to rup- 

 ture the corpuscles which contain them about the same 

 time. The toxic effects, as instanced by the pyrexia and 

 vomiting, will then tend to show slight periodicity. 

 Other evidence of toxaemia, such as haemolysis, is 

 variable. In some cases, even when the fever is high, 

 there is little or no haemolysis, in others it is marked. 

 When the infection has continued for a long time there 

 is always anaemia, but not necessarily severe anaemia. 

 Of probable toxic causation are certain further symptoms 

 which are more common in some places than in others, 

 though morphologically the parasites in the different 

 places are indistinguishable. These include (a) Albu- 

 minuria, which may be transient, appearing and dis- 

 appearing with each attack of fever, or occurring much 

 as it does in scarlet fever, as a definite sequela of the 

 disease. (6) Neuritis, which may be general or may occur 

 mainly in the legs, and lead to a paresis with loss of 

 knee-jerks, muscular tenderness, and rapid wasting of 

 the muscles. In some of these cases there is some 

 disturbance of the higher cerebral functions, such as 

 loss of memory. These cases are often confounded with 

 alcoholism, and may be associated with it. Rapid im- 

 provement takes place under quinine. 



Diagnosis. On the clinical symptoms alone, even 

 during the stage of pernicious attacks, certain diagnosis 

 is impossible ; suspicion only is warranted. Certainty 

 one way or the other is essential, as for any case 

 persistent treatment, and for severe cases energetic 

 treatment, is necessary. It is also essential that the 

 possibility of malaria should be excluded in many cases, 

 as without this time will be wasted before the real 

 disease, possibly tractable, is diagnosed. The only 

 satisfactory method is by blood examination. With 



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