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William H. (William Heiskell) Deaderick.

A practical study of malaria online

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be cadaveric lesions. Occasionally there are hemorrhagic
areas. Microscopically neither pigment nor parasites are so
evident as in certain of the other organs. The capillaries are
congested, sometimes thrombosed, and contain infected ery-
throcytes, phagocytes, which often show signs of degenera-
tion, and macrophages. The capillary epithelium may be swol-
len, but is only occasionally pigmented. The pleurae show
nothing abnormal.

The heart muscle is ordinarily pale and flabby, but the
muscular fibers do not usually afford degenerative signs. The
capillaries may contain parasites in greater or less number, and
the endothelium may be swollen. Cases in which the parasites
are very numerous in the cardiac capillaries, such as that of
Ewing, 181 are very rare.

In cerebral cases the meninges of the brain are deeply
hyperemic, and excess of serum is found in the meshes of
the pia, in the ventricles, and at the base of the brain. The
cerebral substance is commonly darkly pigmented and con-
gested, and may show hemorrhages, usually punctiform, occa-
sionally larger. The hemorrhages occur oftener in the cere-
brum, but may be present in the cerebellum. In the abdominal
form the brain may show but few pathologic changes. Micro-
scopically in the cerebral cases the capillaries are seen to be
filled, even to occlusion, with pigment, parasites, and phago-
cytes, the latter in the same or in different stages of schizo-
gony; gametes are seldom found. In some instances nearly
every red cell contains one or more parasites. Localization of
parasites are found not only in the cerebrum, but also in the
cerebellum and medulla. The capillary endothelium may be
swollen, pigmented, and undergoing fatty degeneration. Sec-
ondary changes, such as perivascular exudation, hemorrhages,
and necrosis, are not uncommon results of thrombosis. De-
generative changes in the ganglion cells have been detected.

The bone-marrow is of a dark color approaching that of
the spleen, and sometimes diffluent. Microscopic examination
reveals hyperemia, the capillaries being engorged with pig-
mented parasites and giant cells clinging to the vessel walls.
The parasites exist as free spores, schizonts, which are fre-
12



178 THE STUDY OF MALARIA

quently sporulating, and gametes in large numbers. Extra-
vascular parasites and free pigment are also found.

CHRONIC MALARIA

The spleen is always enlarged. The form is usually pre-
served. Its average weight is from 700 to 800 grams, though
it may attain four or five times this weight. In consistence
it is usually firmer than normal. The capsule is thickened,
especially at the convexity. Upon the surface are scattered
indurated whitish plaques of fibrous, occasionally calcareous,
consistence, evidences of perisplenitis. Adhesions to the
diaphragm or other parts are not infrequent. Subcapsular
infarcts are occasionally encountered. In section the paren-
chyma is usually found firm, only rarely is it of diminished
consistence. The color varies from that of muscular tissue to
slate color. The thickened trabecular, like white bands, are
very evident. The Malpighian follicles are sometimes con-
spicuous, sometimes indistinct. In old cases there is an over-
growth of connective tissue, particularly near the capsule. His-
tologically the chief changes found are trabecular hyperplasia
and venous dilatation. The process sometimes resembles a
hypertrophic cirrhosis. The fibrous trabecular are hypertro-
phied and there is formation of new connective tissue. The
venules are notably dilated, the walls thickened, and the blood
rich in pigmented leukocytes and macrophages. The deposition
of pigment is in general similar to that in acute malaria.
There is at times little change in the lymphoid tissue forming
the arterial sheaths and Malpighian bodies, but this may be
hyperplastic. Necrosis of the spleen pulp is observed, sur-
rounded by evidences of regeneration. These regenerative
processes consist chiefly of increased vascularization, forma-
tion of connective-tissue network enclosing giant cells, and
hyperplasia of lymphoid tissue beginning in the Malpighian
bodies.

The liver is not so constantly enlarged as is the spleen and
never attains so excessive a degree of hypertrophy. It may
weigh from 2 to 4 kilograms. In rare instances it is atrophic.
The consistence is firm, occasionally somewhat doughy. The



PLATE vn



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Fig. i.




Figs, i, 2



PATHOLOGIC ANATOMY 1 79

capsule is tense and may be thickened. There may be present
whitish bands or patches, the results of perihepatitis. The
color varies from reddish to almost black. The cut surface
is usually found to be congested and may drip with blood. The
color is more or less dark red. There may sometimes be de-
tected on gross inspection an increase of connective tissue.
Microscopically the hepatic cells are seen to be hypertrophied
and hyperplastic, showing evidences of cloudy swelling and
necrosis, or atrophied as a consequence of vascular dilatation.
In certain areas there may be a complete disappearance of
hepatic cells, which are replaced by connective tissue, Kupffer's
cells, or beginning formation of new hepatic cells. The nuclei
are frequently multiple, and when single may be much larger
than normal and contain one or two nucleoli. The hepatic
cells may be charged with hemosiderin. . Pigment is contained
in the endothelial and Kupffer's cells, especially in congested
areas and in the periphery of the lobule. There is sometimes
diffuse overgrowth of connective tissue. The blood capillaries
are usually dilated and congested with blood rich in pigmented
leukocytes; the circulation is commonly sluggish. The bile
capillaries are ordinarily unaltered. The perivascular lymph
channels may be dilated. Amyloid degeneration beginning
apparently at the periphery of the lobules is not rare.

The kidneys are usually increased in volume and in weight.
The contracted kidney has been described in connection with
malaria, but there is some doubt as to the etiologic relation-
ship. The surface of the kidney is smooth, the color is dark
red, and the consistence is slightly increased. Upon section
the cortical substance is reddish gray. The pyramids are
markedly hyperemic, the red tint being most decided at the
border of the pyramidal substance. Upon microscopic ex-
amination the convoluted tubules and ascending limb of
Henle's loop are found dilated. The epithelium is swollen,
charged with hemosiderin, and may be undergoing degenera-
tion. In the collecting tubules the epithelium is, as a rule, only
slightly altered. These tubules rarely contain granular or
hyaline casts or desquamated epithelium. Bowman's capsule
presents changes similar to those of the convoluted tubules.



l8o THE STUDY OF MALARIA

The renal arterioles are congested and the capillaries are dilated
and gorged with blood rich in leukocytes, more marked in the
pyramidal than in the cortical substance. Melanemia is not
so decided in the kidney even when profuse in the spleen and
liver. There is generally little change in the connective tissue.
Here and there is a slight thickening of the intertubular con-
nective tissue. The blood-vessels, the glomeruli, and the walls
of the renal tubules may undergo amyloid degeneration. This
is more diffuse in the kidneys in chronic malaria than in the
other organs.

The alimentary tract may show evidence of amyloid de-
generation in the stomach or bowel and dysenteric lesions in
the colon.

In the lungs may be pigmentation and anemia, and in the
pleural cavity an effusion.

The heart is relaxed and often dilated and sometimes shows
evidence of degeneration of the musculature.

The bone-marrow is of firmer consistence and more deeply
colored than normal, especially toward the ends of the long
bones. There is usually a decrease of fat and a proliferation
of marrow cells, together with large cells, some undergoing
karyokinesis, lymphoid cells, and nucleated red cells. The
vessel walls are thickened. In some instances there is atrophy
of the bone-marrow.

The elimination of the pigment probably consumes three
or four months after the cessation of infection, though this
varies with the activity of the eliminative processes.

HEMOGLOBINURIC FEVER
The pathologic findings vary in proportion to the proximity
and intensity of the malarial attack. In addition to the changes
characteristic of malaria there are found, in blackwater fever
subjects, the results of hemoglobinemia and polycholia chiefly
in the kidneys and liver. Occasionally post mortems do not
reveal malarial evidences, as in two cases reported by Curry, 186
but this is very exceptional. The body is usually deeply jaun-
diced. There may or may not be edema. The muscular sys-
tem is often icteric.



PLATE VIII






m







Fig. i.



*X;



sStefc







Fig. 2.
Fig. i. — The kidney in chronic malaria with hemoglobinuria fever.
Fig. 2. — The kidney in malarise cachexia. (Kelsch and Kiener.)



PATHOLOGIC ANATOMY l8l

The spleen is enlarged, often enormously so, and congested.
The surface color varies from grayish to reddish brown, almost
black. The capsule is thickened and usually strips easily, but
may be adherent. The consistence of the organ is often so
diminished that it appears like a pulpy sac. The trabecular
are thickened and fibrous ; the pulp is decidedly increased. The
Malpighian corpuscles are usually hypertrophied, sometimes
giving the appearance of sago spleen. Pigment is usually
abundant. It is contained within the cells or lying between
them. The cells of the Malpighian bodies show the greatest
quantity and largest masses. The large mononuclear cells and
giant cells are pigmented. The leukocytes lying external to
the walls of the small veins may show more pigment than those
scattered here and there throughout the pulp. The color of
the pigment varies from yellow to almost black, and may con-
sist of hemosiderin or melanin. The walls of the smaller
vessels are thickened, and the lumen may be obliterated. The
sinuses may be obliterated with pigmented and other cells.
The endothelial cells may be proliferating, and often contain
granules of pigment. Parasites and pigmented leukocytes may
be present in the spleen when not discoverable in the general
circulation. There may be round cell infiltration around the
trabecular.

The liver is enlarged, congested, and surcharged with bile.
It varies in color from a decided yellow to a dark brown. The
capsule is slightly adherent. The surface is usually smooth,
but there may be subcapsular nodules from the size of a pin-
head to that of a pea, which on section exude a thick, cheesy
matter. There is abundant pigmentation, often rod-shaped,
especially of the endothelial cells, macrophages, and leukocytes.
The course of the capillaries may be well marked by the pig-
ment contained in the endothelial cells and that between the
wall and the adjacent liver cells. Both the yellow and black
pigments are found, the former especially, in the liver cells.
Pigmentation is often more pronounced in the center of the
lobule. Thrombi of pigmented cells in the capillaries and sub-
lobular veins occur, with cloudy swelling and fatty degenera-
tion of liver cells. These retrogressive processes are in the



l82 THE STUDY OF MALARIA

form of islands. The biliary injection, more intense in the
center of the hepatic lobule, may extend to the smallest
branches. Regenerative efforts on the part of the liver cells
are very much more common than in pernicious malaria ( Mar-
chiafava and Bignami). Karyokinetic barrels and manasters
predominate. This is interpreted by Bastianelli as evidence
of hyperfunction of the liver. Marchiafava and Bastianelli
both agree in believing that this multiplication of the hepatic
cells is an attempt on the part of the liver to meet the in-
creased demands for work in eliminating the detritus of hemo-
globin (Thayer). The gall-bladder is usually distended with
bile.

The kidneys are generally congested, weigh more, and are
softer than normal. The capsule is loosely attached. On
section the cortex is often yellowish ; the pyramids may present
brownish streaks, more intense toward the apices. In the
cortex may be found wedge-shaped hemorrhages with bases
toward the capsule and apices pointing toward the medulla.
The medullary pyramids may show minute hemorrhages. The
glomeruli often escape undamaged; there is rarely any pig-
mentation of the cells within Bowman's capsule ; there may be
cloudy swelling, and slight epithelial desquamation. The
epithelia of the convoluted tubules usually show cloudy swell-
ing, fatty degeneration, or coagulation necrosis. There may be
pigmentation of the epithelial cells. The lumina are often
plugged with hemoglobin casts holding the epithelia in place.
The changes in the straight tubules are similar, but casts are
more numerous. The epithelium of Henle's loops is better
preserved, but the lumen is usually choked with casts of hemo-
globin and epithelial detritus from the convoluted tubules.
Biliary pigment also occurs here. Karyokinesis is sometimes
seen in the epithelium of Henle's loops and of the convoluted
tubules.

The stomach and intestines may be negative. The serous
coat may be pale, the mucous membrane congested and bile-
stained, especially near the opening of the common bile-duct.
There may be isolated hemorrhages, excoriations, and pigmen-
tation. The pancreas is normal.



FLATE IX




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Fig. 2.
The kidneys in blackwater fever (Werner).
Fig. i. — Occlusion of the straight tubules.
Fig. 2. — Iron reaction with potassium ferrocyanide.



PLATE X




The kidneys in blackwater fever (Werner).
Fig. i.— Degenerative changes in the epithelium of the convoluted tubules.
Fig. 2. — Dilatation of the lumen of the convoluted tubules.



PLATE XI




Ficr. !.




Fis



The kidneys in blackwater fever (Werner).
Fi g- T- — Different characters of included masses in the glomeruli, the convoluted

tubules, the straight tubules, and the intercalary portion.
Fig. 2 . — Different characters of coagula in the ascending and descending limbs

of Henle's loops.



PATHOLOGIC ANATOMY 1 83

The pleurae may show punctate hemorrhages and the cavity-
may contain a quantity of serous fluid. The surface of the
lungs may show slaty specks and striae. The cut surface is
very pale, and exudes a very small amount of very pale, frothy,
serous fluid. There may be an ashy discoloration in the course
of the vessels, hypostatic congestion, and edema.

The pericardium may contain from a few drams to several
ounces of a clear or sanguineous fluid, and may present hemor-
rhages varying in size from that of a millet seed to that of a
cent. The heart is pale and often flabby. The muscular
fibers are easily separable; the walls may be very thin. The
left ventricle is usually strongly contracted, the right collapsed.
Auricles and ventricles may contain coagula or thrombi.
Microscopically the fibers stain well and show striations per-
fectly; there are some areas of slight pigmentation and some
of connective-tissue proliferation; the nerve trunks in the
transverse section show marked degeneration; empty nerve
sheaths are seen, and some connective-tissue proliferation into
funiculus (Goltman and Krauss).

The brain is usually pale and unpigmented; the latter ven-
tricles may contain an excess of fluid. The convexity of the
pia may show slight cloudiness in the course of the vessels.
The puncta vasculosa may be scarcely visible. The bone-
marrow shows the usual changes of malaria. Melanin, hemo-
siderin, and proliferating normoblasts may be found.



CHAPTER V

CLINICAL HISTORY

The simplest and most logic classification of the malarial
fevers is, according to the form of the several parasites caus-
ing them, into tertian, quartan, and estivo-autumnal. The en-
deavor to affiliate the tertian and quartan parasites with the
intermittent fevers and the estivo-autumnal with the remittent
is fruitless, for a remittent temperature is by no means a
characteristic of estivo-autumnal infections. Neither is the
division into quotidian, tertian, and quartan consistent. Quoti-
dian paroxysms may be due to estivo-autumnal infection,
double tertian, or triple quartan. Tertian paroxysms may be
produced by estivo-autumnal parasites or by simple tertian.
The three forms of malaria will be studied in their acute and
chronic courses, larvated or masked forms, with the complica-
tions and sequelae.

ACUTE MALARIA

Incubation. — The period of incubation varies within very
wide limits. It may be stated as a general proposition that the
incubation period is longest in quartan infections and shortest
in the estivo-autumnal. The average period is, for quartan,
twelve to eighteen days; tertian, six to fourteen days, and
estivo-autumnal, two to ten days. Much longer periods, run-
ning into several months, have been reliably recorded. These
must be regarded as cases of chronic malaria where the latent
stage precedes the active, and are analogous to those cases of
syphilis in which the secondary manifestations occur without
recognized primary lesion, and are to be explained satisfactorily
only by parthenogenesis.

General Description of a Malarial Paroxysm. — The forms
of acute malaria have so many points in common that it is
convenient to describe first the typic malarial paroxysm.

184



CLINICAL HISTORY 1 85

Prodomata may be perceived by the patient. They may
correspond to the last few parasitic sporulations preceding that
which causes the paroxysms or may occur only a few hours
before the access. They are ill-defined, but usually consist of
languor, anorexia, headache, aching of the loins and hips,
thirst, epigastric distress, a disposition to stretch and yawn,
and chilliness along the course of the spine. These symptoms
may be so slight as to escape attention. The typic malarial
paroxysm comprises three well-marked stages : the cold stage,
the hot stage, and the sweating stage.

The cold stage presents itself with the rapid intensification
of the prodromata described. The sensation of coldness spreads
to every part of the body. The skin becomes pale, especially
the lips, the ears, and the nails, and the papillae of the skin
stand out, forming the so-called "goose-skin." The patient
shivers, sometimes so violently that he shakes the bed; he
covers up, his teeth chatter, and he looks and feels cold. The
slightest motion of the body or of the bedclothing increases
the vehemence of these phenomena. Notwithstanding these
evidences of coldness, the thermometer shows an elevation of
internal temperature. The fever may even precede the cold
stage. The patient complains of a tight headache, a backache,
precordial oppression, and dyspnea. He often complains of
general soreness, as severe as if having been beaten. He may
suffer with nausea and vomiting of bile. There is apt to be
frequent micturition of small quantities of limpid urine. The
respiration is rapid and tremulous. The pulse is accelerated,
diminished in volume, and increased in tension. The cold stage
may last from a few minutes to two or three hours.

With the onset of the hot stage hot flashes alternate with
cold until, the sense of heat becoming general, the patient
presents a very different picture from that of the first stage.
He begins to uncover, the skin is flushed and hot, the pulse
full and bounding, the respiration deeper, and the urine is
scanty and high colored. There may be constipation or
diarrhea. The tongue is coated, bulky, and usually shows
indentations produced by the teeth. Herpes appears upon the
lips or nose. The spleen is enlarged and the upper half of the



i86



THE STUDY OF MALARIA



abdomen is tender on pressure. The headache, soreness,
nausea, and vomiting continue, there is often great thirst and
epigastric pain, and the temperature continues to rise.

When the temperature is at its height the sweating stage is
ushered in by crisis. Beads of perspiration begin to appear
upon the face, then a universal sweat breaks out, and the skin,
which was first cold and rough, then hot and dry, now becomes
moist and natural. The temperature falls to normal, often a
little below; the pulse and respiration resume their normal



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features. The soreness disappears, the thirst ceases, and the
patient often feels so comfortable that he takes a short nap.

Such is the typic procession of one of the most remark-
able events in the category of disease. The conspicuous
changes, the swift succession of stages, and the punctual pe-
riodicity of paroxysms are unparalleled in pathology.

In some paroxysms, however, one or two stages may be
missing. The temperature may rise unaccompanied by a cold
stage or may fall to normal unattended by sweats. This con-
stitutes the so-called dumb chill. The cold stage is the least
constant, the hot stage the most so. The cold stage is most



CLINICAL HISTORY



187



constant in quartan fever, least so in estivo-autumnal infec-
tions.

Simple Tertian Infection. — Infection with a single brood
of simple tertian parasites causes a paroxysm every other day.
The parasites being in the same stage of development causes
great regularity in the course. From the beginning of one
paroxysm to the beginning of another is almost precisely forty-
eight hours. When the interval is not quite so long, as some-
times happens, the paroxysms are said to anticipate; when




Fig. 52. — Double tertian infection.

longer, as is more rarely the case, they are said to postpone or
to retard. Postponing is usually regarded as evidence of abat-
ing activity.

In more than half the simple tertian cases the infection is
double ; that is, there are two distinct generations of parasites.
These generally mature on alternate days; two paroxysms on
one day with an intervening day of apyrexia being extremely
rare. The paroxysms may occur at the same time every day
and be similar in every respect. Usually, however, there is a
perceptible difference between the paroxysms of successive
days, a difference consisting of time of onset, severity, and



1 88 THE STUDY OF MALARIA

relative length of the stages of the paroxysms. It very rarely
happens that the paroxysms are so lengthened, and one so
anticipates that its onset occurs during the latter stage of the
preceding paroxysm. They are styled subintrant attacks.

A change of type from quotidian to tertian paroxysms, or
vice versa, is commonly observed. The change from quotidian
to tertian may be spontaneous or the result of incomplete medi-
cation or improvement in hygienic conditions, one group of
parasites perishing. A change from tertian to quotidian may



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Online LibraryWilliam H. (William Heiskell) DeaderickA practical study of malaria → online text (page 15 of 36)