Blood examination: 1. Very many crescents and spheres of the same order. 2. A few melaniferous leukocytes. October 8, 9 a. m.: Temperature, 38.2°.

Blood examination: The same as yesterday, only somewhat fewer parasites; no small organisms. Hemoglobin, 70 per cent.; number of blood corpuscles, 3,217,000.

4 p. m. : Temperature, 38.3°.

October 10, 9 a. m.: Temperature, 36.2°.

4 p. m. : Temperature, 36.5°.

Blood examination: Numerous crescents and spheres of the same order, the latter frequently showing flagella, etc.

In this case, therefore, no ameboid forms were seen, only numerous crescents and their spheres. Of the latter, a very large number were flagellated.

K. has suffered every evening for two weeks from fever without a preceding chill. Violent headache, profuse sweats. Quite anemic; spleen enlarged to percussion, but not evidently palpable.

October 8, 1891, 4 p. m.: Temperature, 37.5°.

Blood examination: Numerous crescents and their spheres; no small organisms.

October 9, 10 a. m. : Temperature, 38.5°.

Blood examination: Very many crescents and their spheres, the latter frequently with flagella.

3 p. m. : Temperature, 38.3°. Hemoglobin, 60 per cent.; number of blood corpuscles, 2,988,000.

Blood examination: The same;- a strikingly large number of spheres with flagella. In the evening, 0.66 quinin.

October 10, 9 a.m.: Temperature, 35.8°.

5 p. m. : Temperature, 37°.

Blood examination: The same; still many flagellated spheres. October 11, 9 a. m. : Temperature, 36°. Blood examination: The same. 5 p. m. : Temperature, 36.2°.

October 12: The patient remained apyretic, though crescents and their spheres are still to be seen in lessened numbers in the blood.

In this case, too, the ameboid organisms were entirely wanting, while flagellate spheres of crescents, as well as crescents themselves, were present in large numbers. We wish to detail here finally a case of larval malaria .

A. E., aged fifty one, has suffered for fourteen days from typical tertian. The paroxysm occurred each time in the afternoon. The last paroxysm was yesterday. The patient is pale and cachectic looking; the spleen is evidently palpable.

September 25, 1891, 10 a. m.: Temperature, 36.2°.

Blood examination: Numerous crescents and their spheres.

4 p. m. : Temperature, 36.5°.

September 26, 9 a. m.: Temperature, 36.3°.

In the afternoon, about 2 o'clock, the patient was seized with an intense frontal headache on the right side, accompanied by prostration and chilly sensations.

3 p.m.: Temperature, 36.7°. Feverish feeling, with sweating.

Blood examination: Isolated crescents.

September 28: Yesterday apyretic and felt entirely well.

9 a. m. : Temperature, 36.5°.

Blood examination: Unchanged. Hemoglobin, 60 per cent.; number of blood corpuscles, 3,281,000.

2 p. m. : Attack of frontal headache similar to the day before yesterday.

3 p.m.: Temperature, 36.5°.

In the same way every second afternoon subsequently there was a paroxysm of frontal headache during which the supra orbital nerve was very sensitive to pressure. An elevation of temperature was never found.

Mixed Infection

In the previous sections it was repeatedly shown that not only several generations of one species of parasite might be present simultaneously, but even several different species. Combinations of any of the five species may seemingly take place, though the most frequent is that of the tertian parasite, with the different forms of the second group.

These combinations may sometimes be very complicated; for instance, Golgi once found in the blood of a man suffering from remittent fever three generations of quartan parasites and two of tertian. The elevations of temperature corresponded exactly with the outline that would be theoretically constructed for such a case.

The fever type in mixed infections is sometimes manifested by a coalescence of the different components, so that frequently continued, subcontinued, or even irregular types are seen, though sometimes, too, one generation so predominates as to make the fever simple. The following are examples of mixed infection:

W. G., aged forty three, states that he has suffered for three weeks from fever paroxysms. In the beginning these occurred daily, later irregularly, and at present every two or three days. The paroxysms show the classic features. The last occurred yesterday evening.

October 4, 1891: Infirm looking, anemic, and cachectic man. The spleen extends beyond the border of the ribs, about three fingerbreadths.

9 a. m.: Temperature, 37.7°.

Blood examination: 1. Innumerable non pigmented small parasites of signet ring form, and somewhat larger, round, ameboid parasites.

2. Isolated crescents. 3. Numerous brassy corpuscles (quotidian parasites). 4. Isolated large pigmented parasites, filling almost entirely the blood corpuscle; the pigment in them shows but little movement, and the infected blood corpuscles are frequently hypertrophic and decolorized (fully developed tertian forms).

5 p. m. : Temperature, 38.5°. Patient feels exhausted and complains of constriction in the region of the spleen.

Blood examination: 1. Isolated crescents. 2. Isolated melaniferous leukocytes. Hemoglobin, 42 per cent.; number of red blood corpuscles, 2,217,000. Patient receives since yesterday morning 1.0 quinin daily in three doses.

4 p.m.: Temperature, 38.4°.

October 6: Profuse night sweats.

10 a. m. : Temperature, 36°.

Blood examination: 1. Isolated crescents. 2. Numerous leukocytes with large pigment granules. 4 p. m. : Temperature, 36.4°.

October 16: Since the last note he has remained apyretic. Hemoglobin, 65 per cent.; number of red blood corpuscles, 3,087,000.

The infection consisted, therefore, of crescents, quotidian and one generation of ordinary tertian parasites. The two latter yielded to the quinin, leaving only the crescents. The type of fever was quotidian, though for two days there was no absolute apyrexia, since the morning temperature of 37.5° and 37.7° indicated, in the cachectic patient, fever temperatures.

F., aged twenty nine, states that he has had a paroxysm in the afternoon daily for eight days. This consisted of a mild chill, several hours of fever, and slight sweating. Excruciating headache.

September 24, 1891: A tawny,, subicteric discoloration of the skin. The spleen extends two fingerbreadths beyond the border of the ribs.

5.30 p. m. : Temperature, 38.7°.

Blood examination: 1. Numerous actively motile, small ameboid organisms, with very fine pigment granules, many of them showing the signet ring form. 2. Moderately large, pigmented, actively motile, endo globular organisms. 3. Isolated, quite large sporulation forms containing many spores within hypertrophic and decolorized blood corpuscles.

7 p. m. : Temperature, 41.2°.

September 25, 11 a. m. : Temperature, 36°; profuse night sweat. Blood examination: The same as yesterday, only no sporulation forms, yet large, endoglobular, fully developed forms.

4 p. m. : Temperature, 40.5°; in the evening, 0.66 quinin.

September 26, 9 a. m.: Temperature, 36°; 0.66 quinin.

Blood examination: A very few pigmented and non pigmented forms.

4 p.m.: Temperature, 38.2°.

Blood examination negative.

September 30: Since the twenty sixth the patient has been apyretic, although he sweats considerably and has become pale.

Blood examination: Numerous crescents and their spheres. Hemoglobin, 53 per cent.; number of blood corpuscles, 3,066,000.

October 6: Still apyretic. Blood examination negative.

Table III.-General Summary Of The Characteristics Of The Different Species Of Parasites

Time of Development.

Motility.

Pigment.

Form of Maximum Size. Sporulation.

Number of Spores.

Crescents.

Change in the Infected Blood corpuscles.

1. Quartan parasite.

72 hours.

Slight motility.

Large granules slightly or not at all motile.

Size of the red Daisy shapes, blood corpus- i n d i v i d u al cle. spores oval, with evident nucleolus.

6 to 12.

Scarcely ever decolorized ; usually darker in color. Normal in size or shrunken.

2. Ordinary tertian parasite.

48 hours or less (in the anticipating type).

Active ameboid motility in the young and likewise the middle aged forms.

Finer granules in active movement in the younger forms,though often, too, in the large forms.

Size of the red Sunflower or blood corpus- grape cluster cle, some- form; indi times larger. vidual spores small, round; nucleolus seldom visible.*

15 to 20

(often less).

Frequently hypertrophic. Decolorize rapidly and almost completely.

3. Pigmented quotidian parasite.

24 hours.

The non pigmented young forms very actively ameboid; after the deposition of pigment, but slight motility.

Very fine; concentrates itself in one or two clumps. No movement.

One fourth to Irregular one third the masses, size of the red blood corpuscle.

6 to 8 (sometimes more).

+

Frequently shrink when they are either darker (old brass) or completely decolorized (veil).

4. Non pigmented quotidian parasite.

24 hours or less.

Very active ameboid motility.

None.

One fifth to Star form or one fourth irregular the size of masses, the red blood corpuscle.

6 to 8.

+

Frequently shrink and become darker.

5. Malignant tertian parasite.

48 hours.

Active motility seen also in the pigmented forms.

Moderately fine; shows frequently os cillatory movements.

One half to Irregular two t h i r d s masses, the size of the red blood corpuscle.

10 to 12; less frequently, 15 or 16.

+

Frequently sh rink, become darker, or may be decolorized.

* In the unstained condition. When stained, it is always visible.

The infection consisted in this case of two generations of common tertian parasites and of pigmented quotidian parasites. The fever was quotidian in character.