stage the eyes are not congested and shining to the same degree; and, of course, the parasite is to be found in the blood.
Diagnosis from other types of paroxysmal fever.—— The following also are often mistaken for malarial fever: Cerebro-spinal meningitis; urethral fever; the fever attending the passage of gall-stones, or with inflammation of the gall-bladder; that associated with pyelitis and surgical kidney; lymphangitis, particularly that form of lymphangitis associated with elephantiasis and other filarial diseases; undulant fever; relapsing fever; trypanosomiasis; kala-azar, generally an irregular fever, though often quotidian, and almost invariably attended with enlarged liver and spleen and with anæmia; the fevers associated with tuberculous disease, with ulcerative endocarditis, with some types of pernicious anæmia, with splenic leucocythæmia, especially with visceral syphilis, with rapidly growing sarcoma, with forms of hysteria, and with many obscure and ill-defined conditions. The use of the microscope must not be neglected in such cases if there be the slightest doubt as to their exact nature.
It must not be concluded that, although unquestionable evidence of the presence of one or more of the foregoing has been obtained, malaria is absent. Malaria often concurs with these diseases. Malaria is a common complication in trypanosomiasis, for example, and it is often hard to pronounce as to whether in such cases any given rise of temperature be due to the trypanosoma or to the malaria parasite. The same may be said of tuberculosis, of syphilis, and, in fact, of any medical or surgical condition.
Typhoid and paratyphoid fevers.—— With out the microscope it is sometimes impossible to diagnose typhoid types of malarial fever from genuine enteric. In both there may be diarrhœa or constipation; in both there may be splenic enlargement; in both there may be typhoid tongue, delirium, and the entire range of typhoid symptoms. As a matter of fact, until recent years all typhoid in India was regarded and treated as malarial fever—— malarial
