remittent and, doubtless, often with disastrous results. In circumstances in which the Widal test or blood culture is available, either is an invaluable supplement to microscopical examination of the blood.
Typho-malarial lever.—— One important fact in connection with the diagnosis of typhoid in malaria must ever be kept in mind. In individuals who have previously been subjected to malarial influences and who, perhaps, have suffered at one time from well-marked malarial fever, the oncoming of typhoid is often preceded by three or four paroxysms exactly like those of ordinary ague. This may occur even when the patient has been for some time in a nonmalarial country, as England. In such cases quinine is usually given early in the attack; its failure to check the disease should lead to careful prognosis and the avoidance of too active purgation. Similarly, well-marked malaria-like fluctuations of temperature and the appearance of the parasites in the blood in the course of a continued fever do not exclude typhoid. These cases are probably typho-malarial, and have to be treated as such as typhoid with a malarial complication.
Necessity for microscopical examination of blood in pernicious attacks.—— Without the microscope it is sometimes impossible to diagnose, in time to direct appropriate treatment, pernicious comatose malarial attacks from heat-stroke or, if algide in character, from ordinary apoplexy; malarial dysentery, which must be treated with quinine, from ordinary dysentery, which must be treated with emetine, or ipecacuanha, or with the sulphates; algide malarial attacks, from cholera; certain types of malarial fever occurring, as they are very apt to do, in the puerperal state, from puerperal fever; malarial pneumonia, from croupous pneumonia; malarial aphasia, from the aphasia of organic brain disease; and so on.
It is manifest that the revelations of the microscope have enhanced our powers of diagnosis in malarial affections enormously, and, therefore, our powers of treatment. Every doubtful case must be
