In the course of previous remarks we have repeatedly alluded to the frequent affections of the bronchi in malaria . Here we need recall only the common symptoms, dry cough, dyspnea, and sub crepitant rales, that occur in the course of an acute intermittent and the chronic bronchial catarrh of cachectics.

The pulmonary complications vary in frequency with race and local conditions. Fayrer states that they are frequent among the natives in India; Partridge and F. Plehn, the same in Assam and in West Africa; Triantaphyllides found bronchitis in 7 per cent, of the cases in Batum.

The bronchitic symptoms of acute malaria are usually only slight, and continue for only a few hours after the paroxysm, or cease with it.

Still there are cases in which the bronchitis comes into the foreground on account of excessive secretion or a cough. I remember a case, for instance, in an old lady living in a malarial region. She repeatedly manifested, with a tertian intermittent, so intense a bronchitis, that the physicians were always deceived and diagnosticated bronchitis, influenza, etc., until the further course, characterized by typical paroxysms and the prompt reaction to quinin, placed the diagnosis beyond doubt. The expectoration was exceedingly copious and mucopurulent. Over both lungs, but most marked over the lower lobes, medium sized moist rales were audible. The percussion note was normal. The pleurae never seemed to participate-at least, pain and pleuritic friction rales were absent. The bronchitis persisted during the apyretic intervals, but was then slighter. It disappeared with the paroxysms or a few days later. It may be worth noting that this case manifested a marked inclination to diseases of the respiratory tract in general. In the course of two years the patient passed through two attacks of croupous pneumonia and frequently suffered from a mild bronchitis.

Similar observations have been made by other writers. Heine mann frequently saw in Vera Cruz coryza, catarrhal bronchitis, and marked dyspnea go hand in hand with acute malaria . After repeated attacks of this kind the bronchitis may become chronic, and, separated from its original cause, progress independently.

Triantaphyllides observed a number of cases with asthmatic symptoms in which the blood showed malarial parasites, though neither asthma crystals nor eosinophile cells could be found in the sputum.

Grasset has collected in his thesis several cases of this kind. In some, emphysema of the lungs occurred, which, in my opinion, should not be considered the result of the malarial bronchitis (Grasset to the contrary notwithstanding), but of a natural predisposition. At least it is difficult to imagine that a complete emphysema with barrel shaped thorax could develop, as in one of his observations, on account of a bronchitis of two to two and one half months' duration.

The question of the frequency of chronic bronchitis in cachectics has been discussed.

Although catarrhal affections of the bronchi are more numerous, pneumonia is of more interest on account of its greater pathologic dignity.

Pneumonia may complicate malaria in any of its stages, though it is most frequently associated with the cachexia, in which it constitutes one of the chief dangers.

In order to prevent misunderstanding, we wish expressly to insist that there is no proof that the malarial virus can produce a croupous infiltration of the lungs. In the section on Pernicious Fevers we described the pneumonic remittent and intermittent. In these we found only a swelling of the mucous membrane, associated with profuse secretion of mucus, serum, and even blood into the fine bronchioles, but no deposit of a fibrinous exudate.

The cases of intermittent pneumonia described in the old literature-i. e., not with an intermittent fever, but with the disappearance of all objective and subjective symptoms during the apyretic interval, and a recurrence during a new paroxysm-are regarded by modern observers of the widest experience (Colin, Jaccoud, Roux, and others) as errors due to defective methods of examination. It is scarcely possible to conceive that a solid infiltration of a lobe would vanish in a few hours and return as quickly.

In Grisolle's "Traite pratique de la pneumonie" (1841) may be found the old literature on this subject. Injustice has been done to Grisolle by the assertion that he defended the occurrence of intermittent pneumonia. Grisolle states that he himself observed no such case. All he does, therefore, is give an intelligent resume of the observations of others. He expressly affirms that the crepitant rales may cease during the apyrexia, to appear again during the paroxysm, but denies that the hepatization could retrogress within hours, to appear again suddenly with the corresponding physical signs.

From recent times we have no communications relative to this- at least, none that would stand criticism. Tartenson's view that the majority of croupous pneumonias are due to malarial infection is mentioned only as a literary curiosity of to day.

Malarial pneumonia must not be confused with the uncommon croupous pneumonias that show, instead of a typical continued, an evident intermittent or remittent fever. These pneumonias have nothing to do with malaria , and I cannot agree with Tartenson when he asserts that "this form is observed in its full development only at the time of an epidemic of intermittent fever." I have several times seen these cases in individuals entirely free from malaria , and living in non infected regions. Further details relative to these pneumonias may be found in the works of Gerhardt, Jaccoud, Bertrand, and Clark.

As previously stated, all types of malaria may be complicated with croupous pneumonia, yet these pneumonias are always mixed infections.

The complication of an acute malaria with pneumonia is no frequent occurrence, yet in regions in which malaria is endemic an epidemic of pneumonia may occur at the time of a malarial epidemic, and then both affections associate readily (Constant, Grifouliere).