ii86 



THE MALARIAL FEVERS 



3. Presence of mononucleosis in association with other features of 

 malaria. 



4. Pigmentation of the skin. 



5. History of old malarial infections. 

 Malaria should not be excluded by 



1. Absence of malarial parasites from the blood, even after repeated 

 examinations, especially in people who have taken quinine, and 

 unless the examinations have been repeated many times and at 

 varying intervals. 



2. Absence of mononucleosis. 



3. Absence of enlargement of the spleen. 



4. Absence of ' prompt reaction ' to quinine. 



The question of driving the malarial parasite from a hiding-place in some 

 organ into the peripheral blood by giving a small ' provocative dose ' of quinine, 

 injections of vaccines, of sterile milk, of strychnin, of adrenalin, by spleen 

 douches, violent exercise, by ultraviolet light, etc., has been attempted, but 

 reliance cannot be placed upon these methods as a practical aid to diagnosis. 



Splenic puncture, and the subsequent examination of the blood 

 obtained in this way, would help diagnosis considerably, but is not 

 devoid of risk. 



It is generally stated that a fever which within four days is not influenced 

 by quinine in full doses is not malaria. This is correct as regards malarial 

 fevers due to tertian and quartan parasites, but not always as regards those 

 caused by the subtertian parasite. We have met with cases in which the fever 

 has remained unaffected, while the parasite can be found in the peripiheral 

 blood, notwithstanding several weeks' quinine therapy by various methods. 



In malarial cachexia James has pointed out that the microscopical is inferior 

 to the clinical examination, drawing attention to the fact that a four-hourly 

 temperature chart carefully kept during one of the febrile attacks will often 

 show the typical curve of subtertian fever. In such dif&cult cases the clinical 

 signs, together with the reaction of the disease to quinine, must be utilized. 



In latent malaria the frequent increase of the urobilin in the urine may be 

 of some slight help in the diagnosis, as pointed out by Plehn, together with 

 indefinite periodical rheumatoid pains. Thomson has devised a diagnostic 

 method based on complement deviation, using as antigen a culture of malaria 

 parasites from a heavily infected case. The reaction, however, seems to be 

 positive also in cases of syphilis. Details may be found in Thomson's paper, 

 'British Medical Journal, December 7, 1918. 



The differential diagnosis of the various forms of malarial fever 

 should be confirmed, no matter how evident the clinical symptoms 

 may be, by microscopical examination. 



The most important diseases to differentiate from malaria are 

 typhoid, insolation, liver abscess, kala-azar, Malta fever, influenza, 

 yellow fever, dengue, and seven-days' fever. For the differential 

 diagnosis see Chapter LX. (p. 1511), which deals with the diagnosis 

 of a tropical fever. 



The pernicious forms of malaria, in whatever way they attack the 

 patient, will in most cases be readily diagnosed by blood examina- 

 tion, as will also the masked form of the disease. 



Fevers due to septicaemia caused by a streptococcus, the pneumococcus, 

 and the gonococcus, may resemble malaria, but can be excluded by bacterio- 

 logical examination, as can influenza when it gives rise to an intermittent 

 type of fever. 



