August 6: During the night, a profuse sweat.

3 a. m. : Violent headache, which disappeared toward morning. At present quite exhausted. Temperature, 36.4°; pulse 86; respirations, 28.

Still more dulness on the left side anteriorly in the second intercostal space. In the same place, undefined breathing, no rales. On the left posteriorly, alongside the scapula, a small area of dulness, with indefinite breathing. Sputum like yesterday.

4 p. m. : Temperature, 37.5°.

August 7: 8 a. m.: Temperature, 36°; physical signs in the lungs no longer perceptible. In the blood, apart from a few melaniferous leukocytes, nothing pathologic.

The patient left the hospital a few days later cured.

In cachectics pneumonia plays a much more striking and, we might say, legitimate role. As previously stated, cachectics suffer very frequently from chronic bronchitis, but show too an especial susceptibility to pneumonic infiltration.

It is a unanimous observation that cachectics suffer from pneumonia most frequently during the cold half of the year (Catteloup, Colin, Oldham, Roux, and others). In Algeria the majority of cases occur, according to Catteloup, during the months from November to March. Oldham saw numerous cases in Bahawulpur (East India), where differences of temperature of over 40° are not uncommon between day and night.

North winds in the malarial regions of the northern hemisphere carry with them the greatest danger to the cachectic.

The symptoms of pneumonia in cachectics have been studied most thoroughly by Catteloup. Later we had a magnificent treatise from Hadji Costa. The disease simulates in all details the pneumonia ordinarily seen in the old, the debilitated, drinkers, scorbutics, etc.

The initial chill and pain in the breast are frequently wanting;, likewise the rusty sputum; though again the sputum is intensely hemorrhagic. The flushing on one cheek is sometimes the only suggestion of its appearance (Colin). Slight stupor is often present, and severe prostration or a typhoid condition may dominate the picture from the beginning. As Maclean and other writers affirm, both lungs are frequently affected. Besides the areas of infiltration, which are discovered by percussion and auscultation, we often find areas filled with serum, presenting symptoms of partial edema of the lungs. The fever is ordinarily moderate, and is of an irregular remittent type.

According to Kelsch and Kiener, there is frequently a very troublesome feeling of constriction in the hypochondria, due to congestion of the liver and spleen. Loss of appetite, a subicteric discoloration, vomiting, diarrhea, meteorism, hematuria, and hemoglobinuria are not uncommon accompaniments. In addition, we usually see nervous symptoms, like delirium, agitation, carphologia, and adynamia.

The course is frequently protracted, and may last ten to twelve days. The physical signs continue often one to two weeks after the fever.

The termination is fatal. Colin estimated for Rome, 60 per cent, mortality. Kelsch and Kiener had in their material about 78 per cent., and Hadji Costa lost 7 out of 14 cases.

The pneumonia of cachectics shows a great tendency to go over into gangrene or abscess. Complications like pleuritis, pericarditis, and meningitis are relatively frequent.

Not rarely it terminates in chronic interstitial inflammation, with shrinking of the parenchyma and the formation of bronchiectases. The prognosis, therefore, is to be regarded as valde dubia.

Bronchopneumonia is likewise frequent in cachectics, and chronic interstitial pneumonia, with shrinking of the parenchyma and dilatation of the bronchi, very frequent. Heschl first drew attention to this latter, and since then other French writers have taken up the subject (Charcot, Lancereaux, Laveran, Grasset, and others).

The contraction of the lungs develops either insidiously, and is then perhaps the result of bronchitis and peribronchitis, or it occurs as the outcome of a pneumonia.

Yet in a number of published cases, as the autopsy records show (see, for instance, Grasset), tuberculosis played an undoubted role.

A peculiar disease of the apices of the lungs has been described by de Brun, which he often observed in Beirut in youthful malarial cachectics. Its symptoms were dry, often tormenting cough, dulness, bronchial breathing, yet no friction sounds and no rales. The condition came and went with the paroxysms of fever, though in other cases it remained for a long time with slight fluctuations of severity. Occasionally there was added a diffuse bronchitis with sonorous rales limited to the apex. Tubercle bacilli were never found, though Laveran's organisms appeared in the blood.

In two cases on which postmortems were made no changes were found in the apices, and de Brun assumes that the disturbances were entirely the result of congestion (?).

Unfortunately, he has published no complete case history, so that it is difficult properly to judge of his assertions.

Pleurisy occurs apart from pneumonia only accidentally, and is rarely a complication of malaria .

Hertz reports a case of tertian with pleurisy in which the friction rales disappeared on the apyretic days, though it is scarcely conceivable that the fibrinous deposit could be so rapidly absorbed. According to Steudel, blackwater fever is frequently accompanied by pleuritis sicca.

Tuberculosis of the lungs occurs in malarial patients at least as frequently as in the non malarial. The assertion made in former times that malaria and tuberculosis excluded each other (Boudin) doubtless depends on the fact that malarial regions, on account of their general climatic conditions, are more favorable to the respiratory organs. As a consequence, in these countries, tuberculosis plays a less dominating role. The smaller number of tuberculosis cases in Algeria in comparison with France is to be attributed, therefore, not to the malaria, but to the climate. The experience of the Roman pathologists is probably more correct, namely, that the debilitated malarial patients offer an especially favorable soil for tuberculosis. Others have arrived at the same conclusion.

Nor are all malarial countries spared tuberculosis. In India both diseases occur side by side; the same is true of Tongking, the Antilles, Guiana, etc. (see Jousset). Carsten actually asserts that phthisis is more frequent in the tropics than in temperate and cold climates.