II74 



THE MALARIAL FEVERS 



skin and mucosae of the nose, bronchi, intestines, stomach, and 

 generative organs, during the attack, but not during the intermission. 



This condition rapidly produces acute grave anaemia, with 

 thready pulse, coma, delirium, convulsions, and death, or may 

 become the milder type, in which fever is not a marked symptom 

 {vide p. 1 1 69). 



Hydrophobia-like Type. — Signs of hydrophobia associated with 

 fever, a large spleen, and malarial parasites in the blood, call for 

 energetic quinine treatment, when the symptoms disappear, unless 

 it is true hydrophobia in a malarial patient. 



Kussmaul Coma-like Type. — Signs of Kussmaul's coma coming 

 and going every alternate day and associated with fever in a diabetic 

 patient call for quinine therapy, even if the spleen is not enlarged, 

 the blood free from malarial parasites and mononucleosis. Occa- 

 sionally after the exhibtion of a small dose of quinine, parasites may 

 be found in the blood. 



Diaphoretic Type. — In this type the sweating of the third stage 

 of an attack is so exceedingly copious that not merely is the bed 

 saturated, but a pool may even form on the floor. Such excessive ex- 

 cretion of sweat is dangerous, as the patient becomes more and more 

 exhausted as it goes on, and a most dangerous collapse may ensue. 



Comatose Type, — ^This may begin suddenly or slowly. If the 

 latter, there may be weakness, sleepiness, headache, disturbance of 

 vision, stupor, or delirium, which ends in coma. But more often 

 the patient is brought to the hospital quite comatose. He lies flat 

 upon his back, with usually no paralysis and no alteration in the 

 reflexes. The pupils may be contracted and give the idea of opium- 

 poisoning, while the patient cannot be roused to answer questions, 

 but will only frown or groan. 



Haemorrhages may be found on the skin and in the retina. The 

 urine, which may have casts and a little albumen, is usually passed 

 involuntarily, as are the motions. The heart is dilated, and the 

 pulse, at first slow, soon becomes quick, and towards the fatal ter- 

 mination very quick and thready. Respiration may be quiet or 

 noisy. If death is to take place, the patient becomes colder and 

 colder, the tongue dry and thick, and respiration ceases. 



If he is about to recover, the coma will gradually pass away; he 

 will be able to answer questions when roused, and after a time 

 gradually recovers consciousness. The speech is at times most 

 peculiar, being scanning in character. 



The coma may be present one day, but the next day the patient 

 maybe slightly better, with a subnormal temperature and a slower, 

 fuller pulse; towards evening, however, the temperature rises, and 

 the coma returns. This second attack is, as a rule, fatal. The 

 fever may be remittent or intermittent. In the latter case it 

 returns before death. Quinine treatment by injection and other- 

 wise appears to be of no avail at times, and after two or three days 

 of coma, even when the parasites have disappeared from the peri- 

 pheral blood, the person may die. 



