ii68 



THE MALARIAL FEVERS 



Remarks. — Only the bilious remittent will be considered here, as 

 malarial hcemoglohinuria will be treated in the next chapter on 

 Tropical Hsemoglobinurias, and the atypical subtertian fevers will 

 be described directly after bilious remittent fever. 



5. Bilious Remittent Fever. 



This is a type of subtertian remittent fever in which there is great 

 blood-destruction, and consequently much bile-production. We 

 have seen it repeatedly in Africa, and more recently in theBalcanic 

 Zone, and it is said to occur in all highly malarious districts. 



The attack begins as an ordinary remittent fever, but is asso- 

 ciated with jaundice, bilious vomiting, and usually bilious diarrhoea, 

 though in its place there may be constipation. The patient also 

 complains of pain and tenderness in the stomach and liver. After 

 a few days' illness the symptoms may gradually subside, or, with 

 or without hiccough, epistaxis, or haematemesis, the temperature 

 may rise considerably, and the patient, becoming comatose, dies. 



We have noted at times a curious intermission in the symptoms, 

 of short duration, after which high fever ensues, quickly followed 

 by coma and death [vide Yellow Fever-like Type, p. 1172). 



6. Mixed Infections. 



Mixed infections of L. malaricB with the other malarial parasites 

 are not uncommon, and lead to a type of quotidian fever which 

 can only be diagnosed accurately by an examination of the blood 

 and a differentiation of the parasites concerned. 



The blood may show only forms belonging to P. vivax at times, and only 

 forms belonging to L. malarics at other times. 



B. ATYPICAL SUBTERTIAN FEVERS. 



The causation of this group of subtertian infections is due to the 

 fact that Lav crania malaricB undergoes schizogony in the internal 

 organs, and is apt, at times, to specialize upon one particular organ, 

 which becomes seriously affected, not merely because it has to 

 bear the full brunt of the liberated toxins, but also because it suffers 

 from malnutrition, because its capillaries become blocked by 

 swollen endothelial cells belonging to their walls and by red blood- 

 corpuscles filled with malarial parasites, as well as by leucocytes 

 laden with pigment, and by the pigment and merozoites set free 

 during schizogony. 



This explains not merely the special character of the symptoms 

 exhibited in any case, but also the multiplicity of clinical types caused 

 by this parasite, and the peculiar conditions called masked malaria 

 or malarial mimicry. 



These various syndromes may for purposes of description be 

 arranged as follows : — 



I. Subtertian syndromes without localization, 

 11. Subtertian syndromes with localization. 



