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M AT, AR T A 
with heterologous strains might be indis¬ 
tinguishable. We (Boyd, Stratman-Thomas 
and Kitchen 1936a) have observed that a 
patient convalescent from an infection with 
one strain of P. falciparum may, when re¬ 
inoculated with a second (heterologous) 
strain, develop an equally severe attack. 
Many of the pernicious infections which 
are said to develop suddenly during a 
relapse, may well be the result of a rein¬ 
fection with an heterologous strain of the 
parasite. 
Mannaberg states that: “In order to 
diagnose chronic malaria the following 
clinical symptoms must be present: (a) 
occasionally recurring paroxysms of ma¬ 
laria for months (relapses) which may be 
normal or latent, (b) a certain degree of 
anemia, (c) enlargement of the spleen and 
eventually enlargement of the liver, (d) 
the same species of parasites in the blood 
throughout the whole period, (e) general 
characteristic appearance.” (These condi¬ 
tions could easily be met by reinfections.) 
Under appearance he cites the tawny color 
of the skin with its pallor and not infre¬ 
quent icteric tint. He refers also to the 
anemia and its accompanying dyspnoea and 
palpitation on exertion. The patients fre¬ 
quently complain of malaise, headache, 
vertigo and insomnia. 
It is difficult, and sometimes impossible, 
to. differentiate between what some authors 
describe as chronic malaria and others as 
malarial cachexia. Some consider them as 
synonymous. Again, some authors (James 
1922; Hehir 1927) divide malarial cachexia 
into two types, acute and chronic. The 
acute type, as described, would not seem 
to differ greatly from the condition fre¬ 
quently seen following some of the severe 
types of malarial infection. James (1922) 
feels that under endemic conditions “ ‘ca¬ 
chexia’ is only exceptionally an accurate 
term to apply to the condition of patients 
who have suffered for a long time from 
repeated malarial infections and reinfec¬ 
tions. ’ ’ Severe anemia and marked spleno¬ 
megaly are the out-standing symptoms. 
Dyspnoea, weakness, emaciation and di¬ 
arrhoea are usual and there may be oedema 
of the lower extremities, possibly ascites. 
A description of this syndrome, credited to 
Dr. R. E. Little of Quincy, Florida, ap¬ 
peared in McGown’s (1894) text. The 
latter author noted that “. . . this cachec¬ 
tic condition ... (in certain areas) . . . 
is most frequently the sequelae to malarious 
diseases.” 
Complications and sequelae. Complica¬ 
tions are not infrequent in estivo-autumnal 
malaria, particularly in highly endemic 
areas and in individuals debilitated by 
repeated infections with P. falciparum. 
Indeed, in so far as the latter group of 
individuals is concerned, malaria may be 
said to be a disease of complications. Often 
the form of the intercurrent disease is 
modified by the malarial infection. Re¬ 
spiratory infections frequently complicate 
the picture; of these, bronchitis, pneumonia, 
and influenza may be mentioned. When 
the latter, under epidemic conditions, at¬ 
tacks patients with malaria, the mortality 
rate is high. Manson-Bahr (1931) stated 
that ‘ ‘ pulmonary tuberculosis is very prone 
to supervene in cachectic cases, ’ ’ but March- 
iafava and Bignami (1901) do not agree 
on this point. It is likely, however, that 
malarial infections tend to cause a tuber¬ 
culous focus to extend. The last-named 
authors are of the opinion that it induces 
a miliary form. Staphylococcic and strepto¬ 
coccic infection may occur. These, though 
local at first, may take the septicaemic form. 
Dysentery and cholera occasionally become 
associated with malarial infections. Rup¬ 
ture of the spleen when due to trauma, as 
it usually is, may be regarded as a com¬ 
plication. The usual outcome is fatal and 
death, due to the hemorrhage, is rapid. 
Kala-azar and ankylostomiasis are other 
diseases which not infrequently complicate 
estivo-autumnal malaria. There are many 
other, though less frequent, infections 
which may supervene. 
Among the sequelae that have been noted 
following malaria are certain psychic dis¬ 
turbances. These may amount to frank 
psychoses, more or less prolonged. James 
(1922) quoted Porot and Gutmann as ob- 
