The icterus has again increased. Temperature, morning, 39.6°; evening, 38.6°. Deep adynamia. Mucous membrane of the mouth and throat very dry. Total aphonia, bilious vomiting, involuntary fecal evacuations. A quinin clyster was thrown off. In the morning and evening a subcutaneous injection of 0.60 quinin mur. and 0.01 morph. mur., in order to quiet the vomiting. In the evening, a mustard plaster to the epigastrium.
September 28: Morning temperature, 37.4°; general condition still becoming worse. Pulse very small and rapid. Stupor more marked, adynamia, continued bilious vomiting, singultus. The extremities are cool; the pupils contracted. General hyperesthesia, especially on the skin of the abdomen. Subcutaneously, 1.0 quin. mur. Tea with rum,, wine. Evening temperature, 38.9°.
September 29: Condition still worse, though no new symptoms have appeared. Temperature: morning, 38°; evening, 39°.
10 p. m. : Exitus letalis.
The autopsy* showed especially a soft, diffluent tumor of the spleen, associated with an intense brown pigmentation; marked enlargement of the liver, associated, too, with brownish pigmentation and diminished consistence. The biliary passages were patulous; the gall bladder showed considerable dark green bile. Several areas of lobular pneumonia in the inferior lobes of the lungs.
Isolated scattered petechias, as well as epistaxis, hemorrhages into the posterior chamber of the eye, etc., occur not infrequently in different forms of malaria , especially the bilious.
An acute malaria , associated with marked hemorrhages, simulating the picture ol morbus maculosus Werlhofii, or scorbutus, or a combination of both, is rare, though such cases have been undoubtedly observed (Eisenmann,,Wenmarning). Marchiafava and Bignami report two cases, one of which was extremely severe. Tchouprina reported a case of a child with hemorrhages from the nose and gums and numerous petechise. The child came from a location where,, according to the father, numerous children manifested the same symptoms.
In these cases it is always necessary to examine carefully for a complication of the malaria with one of the blood diseases. These complications should be thought of in poorly nourished individuals living in damp dwellings and poorly constructed caserns, especially when other persons manifest, at the same time, similar hemorrhages without malaria. In campaigns in the tropical regions such mixed infections are often observed in large epidemics. Haspel reported these mixed forms in Algeria, and described them under the name "Fievre putride, scorbutique, epidemique."
* Here detailed in abstract.