Still we usually find an outspoken chloranemia-i. e., a diminution in the hemoglobin and in the number of erythrocytes, the decrease in the former being disproportionately great in comparison with the latter. The red blood corpuscles vary in size, microcytes being most frequent. A slight poikilocytosis may also occur, and isolated nucleated normoblasts may be found.

The leukocytes are regularly diminished in number, both relatively and absolutely. Kelsch and Kiener found in 33 cases of chronic malaria the proportion of the red to the white blood corpuscles constantly altered in favor of the former. This fluctuated between 1:800 to 1:2000, yet with a relapse or an acute complication leukocytosis usually occurs.

Enlargement of the spieen is rarely absent, and the more frequent the relapse, the largervit becomes. The organ frequently extends several finger breadths beyond the border of the ribs. Its consistence is moderately firm. It is often the seat of spontaneous pain, sometimes of a lancinating, again of a dull, pressing or constricting character. The pain may radiate to the spinal column. The spleen is frequently sensitive to pressure. According to Duboue (de Pau), when an enlargement to percussion is not evident, the spontaneous pain will indicate the existence of malaria , though in our opinion too great weight should not be placed on this circumstance. The splenic tumor usually increases in volume during a relapse and no longer returns to normal during the interval.

The liver is likewise frequently enlarged, though this is always more difficult to determine, especially when the patient was unknown to the examiner previously. It is generally recognized that this organ may show quite well marked differences in size in response to physiologic conditions. An extension beyond the border of the ribs two or three finger breadths may in one case indicate an enlargement, in another, be physiologic. It may also be painful and manifest subjective disturbances similar to those in the spleen.

The blood examination during the relapse, as well as immediately before and after, is always positive. During the intervals there may be no trace of a parasite in the peripheral blood, or only organisms of the crescentic order and melaniferous leukocytes.

Occasionally in the intervals, as especially Vincenzi has shown, ameboid forms, even in the act of sporulation, are observed. The fact that no fever symptoms are manifested may be due to a certain habituation of the organism or the vasomotor centers.

The parasites may be of one species, when they usually belong to the second group, or may be of different species-most commonly a mixture of ordinary tertian parasites with parasites of the second group.

The finding of parasites is essential to the diagnosis of a relapse, since chronic malaria , as well as malarial cachexia, shows conditions associated with fever that are not dependent on the malarial infection. We will discuss these conditions later on.

The general appearance depends in great part on the degree of anemia and hydremia.

The skin is usually tawny, not only in places exposed to the sun, but over the whole body. This peculiar color is made up of pallor and pigmentation, to which is often added a slight icterus, and is encountered at every step among the inhabitants of malarial regions. Occasionally a more intense degree of melanosis of the skin is observed. In contrast to this, however, there are cases with only a slight pallor of the lips, and even this may be wanting if no relapse has occurred for a long time and the blood has had time to recuperate.

Edema not rarely accompanies the hydremia. In this stage of the disease it is usually slight, confined to the legs, and transient in contrast to the edema occurring during the cachexia.

Corresponding to the severity of the anemia the pulse is frequently hastened. After physical effort, palpitation, a feeling of oppression, and dyspnea often occur just as in anemic persons generally.

Kelsch and Kiener maintain that, in addition to the anemia, the hyperemia of the spleen and of the liver and the increase in function of these organs (the removal of the pigment) throw extra work on the heart. In 80 autopsies of chronic malaria they found more or less hypertrophy of the heart 34 times. As a rule, this was slight and limited to the left ventricle. Even during life the hypertrophy of the heart is not rarely perceptible in a stronger impulse (Julie).

Bronchitic disturbances are frequent. They sometimes disappear with the relapse, but again obstinately persist, when they may lead to capillary bronchitis or pneumonia.

The digestive tract is not regularly affected, yet patients often complain of general disturbances, like sensations of pressure and constriction after meals, an inclination to constipation, diarrhea, pyrosis, etc.

In addition patients complain frequently of malaise, headache, vertigo, and sleeplessness. Their voice shows alterations; they become ambitionless, surly, and peevish.

In the absence of complications, the urine contains no abnormal constituents, though frequently urea and urobilin are increased (Kelsch and Kiener).

Chronic malaria may be cured. This is best accomplished by a change of residence to a healthy climate, though this is not a guarantee of eventual cure. There are many cases of relapses-even pernicious relapses with fatal terminations in salubrious regions, for it must not be forgotten that the patient carries the parasite with him.