7 p.m.: Temperature, 39°. Received 0.33 quinin.
August 13, 5 a. m. : 0.33 quinin.
9 a. m.: Temperature, 37.6°.
Blood examination: 1. Numerous non pigmented organisms, endowed with ameboid movement. 2. An extremely large number of "brassy corpuscles," in some of which the parasites show active ameboid movement. In no corpuscle is there any pigment, only here and there a hemoglobin granule.
10 a. m. : 0.66 quinin.
4 p.m.: Temperature, 39.2°.
Blood examination: 1. Very numerous ameboid organisms. 2. A like large number of brassy corpuscles. 3. One sphere of the crescent class.
7 p. m. : Temperature, 40.5°; 0.33 quinin. August 14, 5 a. m. : 0.33 quinin. 9.30 a. m. : Temperature, 37.2°.
Blood examination: 1. A smaller number of ameboid non pigmented organisms; several with hemoglobin inclusions. 2. Isolated crescents. 7 p. m. : Temperature, 39°; 0.66 quinin.
August 15: Patient complains of exhaustion and pains in the limbs; he appears completely prostrated.
9 a. m.: Temperature, 37°; 0.66 quinin.
Blood examination: 1. Isolated non pigmented organisms. 2. Isolated crescents.
7 p. m. : Temperature, 39.3°; 0.66 quinin.
August 16, 10 a. m. : Temperature, 35.8°; profuse sweat.
Blood examination: 1. A scanty number of small organisms. 2. Isolated crescents.
After this the patient remained apyretic.
The type of fever was pure quotidian, though from the anamnesis and the commencement of the curve it was preceded by a continuous one.
The pigment perceived in the leukocytes in the first days probably originated from the crescents, for there was not the slightest pigment to be seen in all the innumerable ameboid organisms.
This variety was separated from the other forms by Marchiafava and Bignami. In its morphologic evolution it is closely related to the pigmented quotidian parasite, from which it can scarcely be differentiated in many stages of its development. According to Marchiafava and Bignami, the principal differential points are the following:
1. Its cycle of development lasts forty eight hours.
2. The pigment sometimes shows oscillatory movements, never seen in the quotidian parasites.
3. The parasite reaches a much larger size, filling at the time of sporulation one half to two thirds of the blood corpuscle.
4. Even the markedly pigmented stages are actively ameboid.
5. The non pigmented stage lasts twenty four hours or longer. The following differences exist between it and the ordinary tertian parasite:
1. It is in all corresponding stages smaller.
2. It frequently assumes a ring form, never seen in Golgi's parasite.
3. The pigment is more scanty and only exceptionally shows movement.
4. Infected red blood corpuscles show an inclination to shrink, while in the case of ordinary tertian, they swell.
5. The spores are smaller, and on an average not so numerous (8 to 15).
6. It forms crescents, which the other never does.
After the statement of these differences from the other forms, it is unnecessary to give a detailed description of the pernicious tertian parasite. (For the temperature curve produced by these parasites see subsequent paragraphs.)
Examination of the blood before the paroxysm reveals pigmented forms that usually take up about half the blood corpuscle. At the beginning of the paroxysm no parasites at all may be found, the new generation making its appearance only after the paroxysm has lasted some time. These new forms, as previously mentioned, remain un pigmented for twenty four or even forty eight hours, so that they may be seen eight to ten hours before the paroxysm still unchanged, or they may become so quickly pigmented that the close of the paroxysm will show pigmented organisms.
According to the discoverers, the peculiar fever curve is due to the fact that sporulation does not occur all at once, but intermittently. As in the other small forms, sporulation takes place almost entirely in the internal organs. The crescent formation likewise shows no differences. It is worthy of mention that the two investigators have found the relapse in this case following usually the type of the initial fever, though often more pronounced.
The majority of writers (Grassi, Feletti, Thayer, Hewetson, etc.) refuse to accept the malignant tertian parasite as a separate species. I am not prepared to deny, with the absoluteness of these writers, Marchiafava and Bignami's deduction, for I have met a not inconsiderable number of patients suffering from tertian fever who showed parasites corresponding to their description.
My attention was attracted to malignant tertian fever in the summer of 1891, before Marchiafava and Bignami had yet come forward with their publication, and only the desire of studying it more accurately detained me from publishing my conclusions at the time. In the summer of 1892, after further cases, I was able to affirm the certain existence of this fever.
The following are two histories of such cases:
K. W., aged forty two, has suffered daily for six days from prolonged violent chills, followed by fever and sweating. The paroxysms occurred at about 2 a. m., though occasionally at 8 a. m. Intense headache, pain in the limbs, anorexia, diarrhea, a subicteric discoloration of the skin, stupor, dry tongue. Spleen evidently palpable, painful.
August 22, 1891, 11 a. m. : Temperature, 41.5° (the chill occurred at about 4 a. m.).
Blood examination: Very many ameboid organisms, some very small, others somewhat larger, all non pigmented. 4 p. m. : Temperature, 39.8°.
Blood examination: 1. Numerous very small and somewhat larger ameboid organisms, without pigment; plural infection of a blood corpuscle frequent. 2. Very many brassy corpuscles, the parasites of which contain fine pigment. 3. One melaniferous leukocyte.
7 p. m. : Temperature, 38°. During the night, a profuse sweat.
August 23, 9 a. m. : Temperature, 36.4°.
Blood examination: 1. Very numerous small forms, filling about one fourth of the red blood corpuscle. They are but slightly motile. Many of them show a little pigment, which is always at the margin. 2. Very many brassy corpuscles, with parasites usually pigmented and in ring form.
About 2.45 p. m., chill.
3.30 p. m. : Temperature, 40°.