The symptoms of this double infection are naturally made up of the symptoms of the two components. There are added, therefore, to the symptoms of the malarial affection, pain in the side, tormenting cough, rusty sputum, and other physical signs.

The course of the fever in these double infections deserves some attention. This is irregularly remittent, rarely intermittent. Ordinarily the two fevers are so interwoven that the curve fails to separate them. These are the cases for which Torti employed the expression, " proportionata," yet it sometimes happens that the curve shows a comparatively high level, with regular intermittent dentations. Marchiafava and Guarnieri and Antolisei observed pneumonias complicating acute malaria that ran their ordinary fever course.

The subjective symptoms are usually marked. They increase on the occurrence of an intercurrent malaria paroxysm, the three phases of which may be sometimes, but not always, recognized. The objective signs of pneumonia are not altered, whether or not a malarial paroxysm is in progress, and these continue until the pneumonia has passed.

The sputum is usually markedly hemorrhagic, and shows sometimes, besides the diplococcus of pneumonia, malarial parasites (as I have observed in one case). The parasites pass into the sputum with the red blood corpuscles. According to Bignami, the parasites occur in the sputum but seldom, because the infected blood corpuscles adhere to the walls of the lung capillaries, in the same way as in the cerebral vessels. That malarial parasites are found in the blood scarcely needs mention.

With timely diagnosis, the malarial infection may be broken up by quinin, while the pneumonia runs its ordinary course unhindered. The pneumonia appears either simultaneously with the malaria , when the first chill may mark the beginning of both diseases, or only after several malarial paroxysms have passed. In the latter case the pneumonia may set in with some of its characteristic symptoms absent, and develop under such slight subjective symptoms as to be readily overlooked, especially when the lungs are not examined daily.

The two greatest investigators of malarial pneumonia, Catteloup and Morehead, advise, therefore, that malarial patients be examined even as thoroughly and diligently as patients suffering from other severe diseases, otherwise the most serious mistakes are inevitable. In some cases it may be very difficult to decide whether the malaria or pneumonia began first.

The prognosis of this complication is naturally worse than that of pneumonia or of malaria taken separately-in fact, experience shows a rather considerable mortality. In special cases the age and constitution of the patient are of importance, as well as the extent of the infiltration and the kind of malarial infection. If the last is by parasites of the second group, and if other severe symptoms arise, the prognosis is naturally aggravated. The prognosis is especially unfavorable when the malaria is in itself pernicious; if, in other words, a comatose algid or choleraic pernicious fever is complicated with croupous pneumonia. In such cases a fatal termination is almost inevitable.

Our own case-double tertian with croupous pneumonia:

Ferd Safer, aged forty five, admitted to the hospital at Esseg August 4, 1892. He states that he has had daily for four days, about midday, a violent chill, followed by fever, but no sweating. Likewise, for the same length of time, a cough without expectoration. He complains, besides, of intense headache and pains in the limbs.

Status proesens at 4 p. m.: Medium sized, pretty robust man; temperature, 40°; pulse full, 112; respirations, 40. Patient very restless, turning from side to side in bed. Pupils contracted. A mere touching on the bones, especially in the region of the knee joint, is very painful. On percussing the tibiae the patient draws himself together with the pain.

On the left, anteriorly from the clavicle down, dulness, with somewhat of a tympanitic note; otherwise percussion normal. Over the area of dulness loud bronchial inspiration and expiration, with moderately profuse, sonorous rales. Vocal fremitus is increased. Over the aorta a systolic and diastolic murmur. Splenic dulness extends to the border of the ribs. Palpation of the organ was unsuccessful on account of the superficial breathing.

In the blood, numerous tertian parasites in two generations. The first fully developed, large; the second, about twenty four hours old, and filling only half the blood corpuscle. Enormous numbers of flagellate organisms. Active pigment and ameboid movement. Many fragmented fever forms.

7 p.m.: 0.33 quinin mur.

August 5: During the night, a profuse sweat. Morning, 6 a. m., 0.33 quinin mur. Temperature, 8 a. m., 36.4°; pulse, 85; respirations, 30. Dulness similar to yesterday, the rales more numerous, subcrepitant. No expectoration.

In the blood, numerous large parasites, some vacuolated, with immo tile pigment, a few dropsically enlarged, with actively swarming pigment. Numerous intraglobular parasites, one half to three fourths the size of a red blood corpuscle, completely immotile, and with pigment likewise at rest. Further isolated torn forms.

One sporulation form with scattered pigment; four large spores and numerous small granules.

Midday, 1p.m.: A very mild chill.

3 p. m.: Temperature, 37.2°. Patient expectorated for the first time on coughing. The expectoration consisted of large, yellow, consistent clumps, intensely hemorrhagic, sometimes bright red, again brownish red.

Microscopically in the sputum, besides diplococci, very many well preserved blood corpuscles, with between them, here and there, a shrunken parasite, and large cells filled with rough granules or yellowish flakes, together with pigment and dead parasites. In one of these a parasite was found with actively swarming pigment.

In the blood many deformed large parasites in the act of disintegration; likewise isolated sporulation forms. The pigment which they contained was at rest, or showed very little movement. Many broken up quinin forms. Isolated parasites half developed, also motionless. Since quinin was administered, no flagellate organism was seen. Therapy each morning and evening, 0.33 quinin mur.