II54 



THE MALARIAL FEVERS 



except, perhaps, a little pigmentation. The bone-marrow is generally hyper- 

 aemic and chocolate-brown in colour. The brain may appear normal, but in 

 the cerebral type of pernicious malarial fevers there will be marked changes. 

 In slight cases there may be only oedema without pigmentation or petechiae. 

 Sometimes there is brownish pigmentation without petechiae, and with or 

 without oedema. Typically, however, there are: — (i) Hyperaemia of the 

 leptomeninges, which may be cedematous and thickened; (2) brownish, or 

 even blackish, pigmentation of the cortex; and (3) punctiform haemorrhages 

 in the white matter under the cortex or elsewhere. The spinal cord exhibits 

 changes similar to those in the brain, while the retina shows numerous haemor- 

 rhages. 



Microscopical Examination.- — After death, parasites may be found in the 

 blood of the heart, spleen, bone-marrow, and at times in the capillaries of the 

 brain, intestines, pancreas, etc. 



The parasite, however, is much shrunken, and the typical forms seen during 

 life are not distinct after death. Thus the ring form shrinks and becomes a 

 rounded disc, with the chromatin particle situated at the periphery. The' 

 fully developed schizont is more typical, the merozoites being arranged in a 

 ring around the central pigment block. If the post-mortem is made quickly 

 this shrinking is not noted. The mononuclear leucocytes will be noted to 

 have pigment granules, while the polymorphonuclears may show phagocytosis. 

 In films from the internal organs macrophages with parasites and red cells 

 may be seen. 



In the heart there may be a few parasites, but very rarely the capillaries 

 will be found filled with red cells containing numerous parasites, and the heart 

 muscle laden with haemosiderin, as has been described in a pernicious cardiac 

 form of malaria, but may also be seen in cases of general infection. 



The lungs may contain parasites in all stages of their existence, as well as 

 pigmented macrophages and leucocytes. It is, perhaps, doubtful whether 

 there is a true form of malarial pneumonia, Bignami has stated that the 

 pneumococcus is always present, and that a pneumonia in a malarial patient 

 is a double infection. 



The capillaries of the liver are much enlarged, with swollen endothelial 

 cells often laden with pigment. These capillaries are filled with blood cells 

 containing parasites and leucocytes with pigment. The perivascular lymph- 

 spaces are swollen, and Kiipfer's cells contain pigment. The liver cells are 

 compressed between the dilated capillaries, and contain haemosiderin and bile- 

 pigment, and, in addition, isolated cells or groups of cells may be necrosed, 

 but this is rarely extensive. The portal canals are infiltrated with red cells 

 containing parasites in all stages of development. 



In the spleen the red cells of the pulp are seen to be filled with schizonts 

 and crescents, while pigment is present in leucocytes and macrophages. The 

 kidneys show pigmentation in the walls of the capillaries of the glomeruli, as 

 well as those lying between the tubules ; but parasites are rare in the former, 

 though common in the latter situation. Phagocytes are not uncommon, con- 

 taining pigment, red cells, and parasites. The cells of the glomeruli degenerate, 

 and are thrown off into the capsul^ along with exudation, and the epithelial 

 cells of the convoluted tubules degenerate, and are cast ofi into the lumen. 



The suprarenal capsule shows irregular areas of vascular dilatation full of 

 erythrocytes, many of which contain parasites, while macrophages may also 

 be present. 



The capillaries of the abdominal fat are often full of red cells containing 

 parasites. The bone-marrow is chocolate-coloured in the small bones, and 

 brownish-red in the long bones. Often it is soft and diffluent, and contains 

 sporulating parasites and, in particular, crescents (gametocytes), which are 

 thought to start their life here. 



When the intestine shows the choleraic appearances described above, the 

 capillaries of the mucosa and villi are filled -with parasites in all stages of 

 schizogony, and leucocytes with pigment masses. The epithelial cells are 

 necrotic, but the submucosa and deeper layers escape injury, and their blood- 

 vessels contain nearly normal cells. 



