From these researches it appears that malarial cirrhosis, at least from a clinical point of view, possesses no special characteristics, but, on the contrary, presents as many differences in the symptom complex as cirrhosis due to other causes.

Icterus, tumor of the spleen, hypertrophic and atrophic liver, ascites, gastro intestinal and cholemic symptoms, hemorrhages from passive congestion or from an icteric hemorrhagic diathesis, dominate the picture in different combinations and in varying severity.

Whether the peculiar liver cirrhosis of children, endemic to India (Gibbons, Jogendro Nath Ghosk, Mackenzie), has anything to do with malaria , is very questionable. It is at present attributed, though not without opposition, to the bad nourishment of the children.

Amyloid degeneration of the liver will be discussed later.

Spleen

The splenic tumor which develops in acute malaria decreases in size after the disease has passed, yet the organ scarcely ever becomes again normal in size, and we frequently meet people with enlarged spleens acquired years before from a mild malaria of short duration. This persistent splenic tumor is described as "ague cake." This enlargement, under ordinary circumstances, causes no disturbances. These set in only when the tumor is uncommonly large, or when it sinks down on account of its attachments becoming loose.

The size of the splenic tumor may be extraordinary. Cases in which it reaches to the umbilicus are seen daily. It can scarcely, be called a rarity when it reaches to the pelvis and is supported on the pelvic bones. Under these circumstances the weight of the tumor-its pressure on the intestine, on the ureters, on nerve trunks, etc.-causes various symptoms. The most frequent are: A feeling of dead weight in the left half of the abdomen on walking, standing, and riding, and pains in the left leg, sometimes associated with a coxitis position of this extremity.

When its attachments become loose, the organ may become movable to a varying degree and so cause various disturbances. As a rule, the organ sinks down only a little and then produces only slight disturbances or none at all. Still, cases have been described in which the spleen sank clown into the small pelvis and produced symptoms of intestinal obstruction.

Severe symptoms of a violent character usually appear when the long drawn out pedicle of the spleen is twisted. The symptoms are those of an acute peritonitis or acute intestinal obstruction. The diagnosis is readily mistaken.

The wandering spleen is most frequently observed in the emaciated and run down; in women who have borne many children and have flabby abdominal walls, when it is usually in association with general enteroptosis.

Perisplenitis is a very frequent complication, and is the cause of the pain in the spleen complained of by many malarial patients, especially during the paroxysm. In some cases it occasions no disturbances, even when sufficiently marked to produce audible or palpable friction murmurs.

It sometimes develops only a long time after the malarial infection has passed. I observed a case in which the splenic tumor and the perisplenitis arose some time after a malaria and produced absolutely no disturbance. The patient succumbed to an intercurrent affection. The capsule of the spleen was thickened to a bony like shell, over one centimeter thick, so that a saw was necessary to open the organ. The perisplenitis may lead to the excretion of a slight amount of fluid exudate into the peripheral cavity or even give rise to general acute peritonitis.

A condition, almost always fatal, though fortunately rare, is rupture of the spleen. It occurs almost exclusively in chronic splenic tumors, and is even then, in the majority of cases, the result of trauma. It has been observed several times in cases where patients in delirium threw themselves from a window and fell on the left side.

In one case of Haspel's the rupture occurred on vomiting, brought on by an emetic. Faunce saw a drunken man tumble on the street and so rupture an old ague cake.

The rupture is favored by different circumstances. Among the first of these we may mention a relaxation of the splenic tissue, such as accompanies acute infections (T. Colin), and relapses, especially in people with a chronic tumor. In the second place a marked inequality in the thickening of the capsule, on account of which the splenic substance is forced by the thicker to the thinner portions, which prove incapable of resisting the pressure. Finally, adhesions of the spleen to the diaphragm and ribs, on account of the non yielding in case of a grave trauma from above or below.

The result of rupture of the spleen is hemorrhage into the peritoneum, the severity of which depends on the size and depth of the tear and other circumstances. If the capsule is not broken,-in other words, if only an internal rupture of the spleen occurs,-a subcapsular hematoma arises. E. Colin observed a case in which, on account of extensive adhesions, the blood failed to pour into the peritoneum, but instead made a track for itself through the diaphragm into the left pleural cavity.

The diagnosis of rupture of the spleen is associated with no great difficulty. The history of the preceding trauma, the tumor of the spleen, the sudden collapse with rapidly increasing pallor, the development of dulness in the dependent parts of the abdomen, the general tenderness on pressure over the abdomen, are sufficiently characteristic.

Death is usually rapid on account of the hemorrhage. In cases not immediately fatal a general peritonitis frequently develops. In some instances life has been preserved by a timely laparotomy.

Splenic abscess is a rare sequel. Fassina could find only seven cases in the literature up to 1889. To these he added two of his own. On account of this very small number, little can be said about its occurrence. Almost all cases were in cachectics. The symptoms were variable. In some cases localized violent pain, doughy edema, and redness of the skin, a fluctuating tumor, a pyemic fever refractory to quinin, suggested the diagnosis. In others pain was less pronounced and only symptoms of general emaciation, irregular fever, diarrhea, and voracious appetite were present. In one case of Mallet's the abscess ruptured externally. Lancereaux reported a case that showed metastases in the lungs and brain.

The course is principally dependent on whether a proper diagnosis has been made and timely surgical interference undertaken. In case there are good grounds for supposing an abscess, a trial puncture may be made in the hope of striking the chocolate colored or red wine like pus.

Left to itself, the abscess is cured only when it ruptures externally or into the gastro intestinal canal.

Zuber observed two and Doue one perisplenitic abscesses in old malarial patients. Hertz describes an abscess of the spleen that originated from an extravasation of blood. E. Colin calls attention to the fact that circumscribed hematomata of the spleen shut off by adhesions may be mistaken for abscesses.

Partial gangrene of the spleen has been observed by E. Colin in two cases. Necrotic shreds and even large sequestra of spleen tissue, without gangrene, have been frequently found in splenic abscesses.

Embolic infarcts are not uncommon, and during life occasionally cause severe symptoms (fever, chill, pain).