" ' The two diseases, cholera and fever, supposing them to be distinct, certainly masked one another so effectually that diagnosis was extremely difficult at times. The people, by the end of October, began to show the exhausting effects of the epidemic fever: enlarged spleen, anemia, debility, jaundice, and the usual sequela? told fatally on their enfeebled constitutions.

" 'This specific fever was strictly confined to the city and to those only who had to go inside on duty.' "

After reading this account there is no doubt in my mind that this was an epidemic of choleraic pernicious, for Dr. Ross' description of the sequelae (dropsy, anemia, splenic tumor, etc.), as well as that of Dr. Duke, who arrived only after the principal epidemic, is very evidently one of malarial cachexia. Whether true cholera existed at the beginning of August, before the choleraic pernicious, as Dr. Ross believes, cannot be judged, on account of the shortness of the report.

Choleraic pernicious is by no means limited to the tropics. Sire dey, for instance, reports six such cases, one of which ended fatally in Montaut (Basses-Pyrenees) in 1884.

The chief symptoms of choleraic pernicious fever are profuse diarrhea and vomiting.

The stools are in the beginning somewhat yellowish, later serous, and sometimes slightly sanguineous, and finally clouded by small mucous flakes, desquamated epithelium, etc., giving them the character of rice water stools. Not uncommonly there is pain in the epigastrium or abdomen generally.

When the condition continues, algid symptoms appear, as coolness of the skin, cyanosis, cramps in the calves of the legs, threadlike pulse, etc., so that the picture simulates more and more the algid stage of cholera.

As a differential diagnostic point between them Torti mentions the fever. He writes: " Uno verbo, omnia accidentia, qua? Choleram morbum comitarti solent, a quo tamen clistinguenda est ha?c affectio quasi cholerica, inquantum est merum symptoma febris supra con suetam intensionem adauctum, et febris ipsius periodum, ac motum subsequens, velut umbra corpus."

When the patient had previously one or more paroxysms of fever and the temperature in the rectum is found elevated, the diagnosis, even apart from the blood examination, is easy. If the attack begins with a chill, the diagnosis is evident at once; in the rarer cases that begin with vomiting and diarrhea and rapidly show algid symptoms, with eventually death, confusion with cholera morbus is difficult to avoid.

When the clinical symptoms leave in doubt, the blood examination becomes the only means of a positive diagnosis. So far there have been but few cases of choleraic pernicious in which a blood examination was made, yet the following one, from Marchiafava and Bignami, shows that even here numerous parasites may be found in the peripheral blood. It is to be hoped that the future will gather more information.

A mixed infection of malaria and cholera can be proved only by the simultaneous finding of malarial parasites and cholera vibrios. As far as I know, no such case has as yet been reported.

According to Kelsch and Kiener, the algid symptoms seldom last longer than twelve hours, and from their experience, the prognosis is not extremely serious. Still the condition shows striking variations in different localities and individuals.

Marchiafava and Bignami describe the following case:

C. G., aged fifty four, a cook from Porta S. Giovanni (Capannello), was brought in a wagon to the hospital on September 5, 1890, at 2 p. m., accompanied by a watchman. The disease began on September 2. The patient was in a condition of anxious excitement, and became delirious when left to himself. Facial expression anxious; pupils dilated; skin cold and covered with a viscid sweat; cyanosis of the lips and extremities ; pulse frequent and thready; spleen slightly enlarged. He had a profuse diarrhea, and in the morning vomited, even on the street. In the hospital he manifested a cholera like diarrhea and nausea. The blood examination showed numerous non pigmented ameboid parasites. He was given 2.0 quinin by injection and the same by the mouth. Friction, injection of ether, camphor, etc.

8 p. m.: Profuse sweat. Skin still cool; delirium has ceased, and is replaced by continuous lamentations. Pulse small and rapid. Diarrhea continues.

During the night the diarrhea lessened, the skin became warmer, and he had several hours' rest.

September 6: Morning, considerable improvement. Pulse, 90, strong; the algor has passed; temperature, 36.6°. The cyanosis has disappeared. Still a few diarrheic evacuations. Quinin, 2.0; cardiac stimulants and wine. In the blood only a few ameboid, non pigmented parasites.

6 p. m.: Apyretic. Pulse strong; diarrhea has ceased; pallor and prostration continue. Quinin, 1.0.

During the following days progressive improvement. Strength returned gradually; appetite increased; the parasites disappeared from the blood and there was no further fever.

Dysenteric Pernicious

In this form the fever paroxysm is accompanied by bloody and mucous stools and tenesmus. There are abdominal pain, stomachache, and, in one word, all the symptoms ordinarily seen in dysentery. Algor is rare, and "the prognosis is, therefore, more favorable than in choleraic pernicious forms.

Some observers of experience (for instance, Colin) deny that the symptoms of dysentery can be produced by malaria alone, and claim a mixed infection in these cases. This is a problem for parasitology, We have preserved dysenteric pernicious on account of a series of publications which would otherwise be valueless.

Torti differentiates still another form that may come in here, namely, subcruent or atrabilious pernicious (sanguineous or black bilious pernicious).

This is characterized by profuse diarrhea, first yellowish and serous, later sanguineous, following which algid symptoms appear. The blood is intimately mixed with the stools and may be either fluid or coagulated. It must, therefore, come from the upper part of the intestine. This form is differentiated from the choleraic by the absence of vomiting and the bloody stools; from the dysenteric, by the absence of tenesmus and the inclination to algor.

Recent writers have bestowed no further attention on this symptom complex,* though Torti's precise description leaves no doubt as to its occurrence.