210 Transactions of the Society. 



The Hfemorrhagic Types of Malaria. — Near Skopolje, in 

 Serbia, in September 1915, an outbreak of so-called scurvy was 

 reported as occurring in a Serbian regiment, and 1 was asked to 

 investigate the condition. The patients were extremely pale, felt 

 very weak and languid, complained of pains in the loins and limbs ; 

 in most cases the whole body was covered with petechia?, and 

 tense indurated swellings due to large extravasations of blood 

 were present in several cases. In many of the patients bleed- 

 ing was taking place from the gums, which were swollen and 

 spongy, and from the nose ; in two cases there were haemorrhages 

 from the stomach and the intestine ; in one there was lipemorrhage 

 from the lungs and bronchi ; in another from the kidneys and 

 bladder. The exact diagnosis was most difficult, but the micro- 

 scope cleared it ; the blood was teeming with malarial parasites. 

 In none of the cases was fever noticed, but the presence of a large 

 indurated spleen in two of the patients, and the fact that I 

 had seen similar » cases in the Tropics, made me suspect malaria ; 

 the blood examinations made soon after revealed presence of 

 malarial parasites. All of the patients were put on quinine, and 

 the symptoms improved in a remarkably rapid manner, and dis- 

 appeared completely within three to six weeks. In some cases 

 I gave calcium lactate in association with quinine, but I soon 

 found out it was unnecessary. The diet was not changed in any 

 way. This hemorrhagic type of malaria must be distinguished 

 from the ordinary types of purpura, from scorbutus, also from 

 a peculiar hiemorrhagic affection, without jaundice, of spirochaitic 

 origin. 



Malaria may simulate Pernicious An/vmia Of this type I 

 have seen several cases, both in the Balkans and in tropical 

 countries. The appearance of the patient is (juite different from 

 an ordinary malarial cachexia, and there may be no history 

 and no sign pointing to a malarial infection. The patient is 

 generally a young man or woman with the typical pallor and the 

 lemon-yellow tint of pernicious anemia ; in some cases the liver 

 is slightly enlarged, or, more rarely, the spleen ; there is no fever, 

 or just 99 or 100° F, at night, which is quite common also in true 

 pernicious anaemia. The blood may be negative for malaria on 

 repeated examinations, and may show most of the common features 

 of pernicious ana?mia, such as poikilocytosis, nucleated red cells, 

 high colour index, relative increase of tlie small mononuclears 

 instead of the large mononuclears, as one would expect in malaria. 

 We had one such case for several months in 1918 at one of the 

 Uskub hospitals. The patient, a Serbian soldier aged twenty-one, 

 was fairly well nourished, but very pale, with a lemon-yellowish 

 tint ; he was always very languid and apathetic and stayed in bed 

 the whole time ; no fever, no enlargement of spleen or liver. Blood, 

 2,100,000 red corpuscles, marked poikilocytosis, some nucleated 



