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v] Care must therefore be exercised in advising and in performing even the slightest operations on patients of this class.

Intestinal and pulmonary affections.—— In addition to the troubles mentioned, we find that the subjects of malarial cachexia are apt to be dyspeptic; to suffer from irregularities in the action of the bowels; to suffer from morning diarrhœa, at first of dark bilious, and later, perhaps, of pale, copious, and frothy stools. They are also very liable to a low and highly fatal form of pneumonia. Cachexia associated with functional and with organic lesions.—— There may be said to be two degrees or kinds of malarial cachexia. In one there is merely anæmia with congestion of the portal system; this may be quickly recovered from on the patient being removed from endemic malarial influences and subjected to specific and proper treatment. In the other there is, in addition to anæmia, organic disease of the abdominal viscera—— of the liver, spleen, and kidneys ——the outcome of long-standing congestion of these organs. These tissue changes not only keep up the anæmia, in spite of removal from malarial influences, but, in the long run, inevitably progress to a fatal issue.

Pathology and pathological anatomy.—— The pathology of malarial cachexia is virtually, in the first instance, that of acute malarial disease. There is blood destruction by the direct action of the malaria parasite and of its toxins, eventuating in oligocythæmia and in the deposit of hæmozoin and of hæmosiderin (yellow pigment) in the tissues. The activity and persistence of the process lead to congestion which ultimately determines organic changes in liver, spleen, kidneys, and probably in the bone marrow.

Splenic enlargement.—— The spleen may become so enlarged under repeated attacks of the congestion attending a succession of fever fits, or in consequence of a less active and perhaps feverless hæmolysis, that it may come to weigh many pounds, and so to increase in bulk as to occupy nearly the entire abdomen. The