Copyright
William H. (William Heiskell) Deaderick.

A practical study of malaria online

. (page 25 of 36)
Online LibraryWilliam H. (William Heiskell) DeaderickA practical study of malaria → online text (page 25 of 36)
Font size
QR-code for this ebook


Icterus intense, early, always pres- Icterus usually slight, begins on
ent. third or fourth day; may be ab-

sent.
Conjunctiva jaundiced. Usually congested at first.

Hemoglobinuria. Albuminuria or hematuria.

Blood may show malarial parasites, Absent,
pigmented leukocytes, and mono-
nuclear leukocytosis.
Bilious vomiting. Vomit clear or black.

Hemorrhages uncommon. Relatively common.

Spleen usually much enlarged. Enlargement slight.

Increasing pulse. Pulse retards with stationary or in-

creasing temperature (Faget's
sign).
Albuminuria from beginning. , Usually appears from second to

fourth day.

A rather striking coincidence is the relative immunity of the
negro to both diseases.

Certain cases of bilious remittent fever present points of
striking similarity. This is well illustrated by the following
case which was represented to me by the messenger and by
the family on my arrival as one of "hematuria" :



DIAGNOSIS 291

A. H., white, male, aged thirty-nine, timberman, lived in a
malarial country eighteen years. Never had hemoglobinuric
fever. He had been having chills at intervals all summer and
fall, slight fever, "dumb chills," and slight jaundice for three
weeks ; no quinine for two months ; badly salivated from seven
large doses of calomel taken several days ago. Examination
November 29, 1906, four and a half hours after first passage
of "bloody water." Temperature, 99 4 / 5 ; pulse, 92; marked
jaundice of skin and sclera; has been vomiting; liver region
tender ; spleen extends to anterior superior spinous process and
to within \y 2 inches of the umbilicus. Blood examination
showed two large pigmented, intracorpuscular parasites, hemo-
globin 65 per cent. Urine "port wine" color, acid 1.014; nitric
acid test for albumin negative, biliary coloring matter abun-
dant, no hemoglobin. Microscopic examination negative. Un-
der quinine treatment the urine cleared in thirty-six hours and
the fever left in a few days, going no higher than ioi l / 2 . The
anemia and enlarged spleen were yet present when I last
saw' the patient, two weeks after the attack.

The following scheme will help to differentiate hemoglobin-
uric fever and bilious remittent fever:

Hemoglobinuric Fever. Bilious Remittent Fever.

Onset sudden. Onset slower.

Jaundice develops rapidly and be- Jaundice develops more slowly and

comes intense. is not so intense.

Parasites frequently absent. Parasites usually present.

Albuminuria constant. Albuminuria not constant.

Urine colored by hemoglobin or its Urine colored by bile.

derivatives.

The differential diagnosis, as attempted by some writers,
from "quinine poisoning in malarial subjects" is futile and im-
possible, as this condition is a mode of hemoglobinuric fever.



CHAPTER VII



PROGNOSIS



Spontaneous Recovery. — It is a familiar fact that malaria,
after the manner of other infectious diseases, not infrequently
undergoes what is termed spontaneous cure. Physicians in
malarial regions often see patients whose paroxysms, typic and
with characteristic periodicity, have ceased without medication
or after nothing but a purgative dose.

It is doubtful, however, whether this cessation may with pro-
priety be termed a cure. In the majority of instances relapses
follow at shorter or longer intervals. It is better, therefore,
for practical purposes to consider this but a transition from
active malaria to latency. The greater frequency with which
gametes are found after the so-called spontaneous recovery
justifies this assumption.

Spontaneous cure occurs more frequently in tertian and
quartan infections. This statement applies merely to the tem-
porary cessation of paroxysms and not to the tendency to re-
lapse.

It is more frequently observed in the negro than in the white
race, permanent cures occurring not rarely in the former race
in the absence of all medication.

Sex may exert a slight influence upon the tendency to spon-
taneous recovery, the female, on account of less severe exposure
to deleterious influences, probably manifesting a greater dis-
position.

The discontinuance of paroxysms may be sudden or more
often gradual, the accesses becoming less severe or the interval
longer, or in infections with more than one generation of para-
sites one may be suddenly destroyed, the others later.

Prognosis. — This is influenced to some extent by locality.
It is manifest that in regions where only the tertian and quartan

292



PROGNOSIS 293

infections are prevalent the mortality is less than where severe
estivo-autumnal fevers are widespread. There is, furthermore,
quite a difference in the mortality rate in countries where the
estivo-autumnal infections are equally distributed.

Race as a factor in the mortality of malaria has already been
dealt with.

A majority of deaths from malaria occur in children. There
is no doubt but that many children die of malaria which has
not been diagnosed in time. In the young pernicious symptoms,
especially cerebral, are prone to supervene, or the attack may
be followed by extreme anemia and dropsies. Malaria is like-
wise much more serious in advanced age than in the interme-
diate ages.

Occupation and social conditions play a part in prognosis.
Excessive toil and exposure may render pernicious attacks
otherwise benign, and timely treatment, usually resorted to by
the better classes, enhances the chance of recovery.

The outlook is probably more favorable in attacks occurring
without the malarial season than within.

Manifestly the condition of the patient with reference to the
results of previous disease is of importance. Anemia, alcohol-
ism, dysentery, and other conditions not fully recovered from
contribute gravity to the prospect.

The type of malarial infection is of the greatest importance.
In the tertian and quartan types it is only very rarely that
serious symptoms result. It is not yet certainly known in
which variety of estivo-autumnal infection the prognosis is
most grave. While Marchiafava and Bignami 162 and Manna-
berg 141 hold that the tertian estivo-autumnal infections are
most often attended with danger, Craig 70 and Wright 38 main-
tain the opposite view.

Postponement and anticipation of the paroxysms were for-
merly regarded as favorable and unfavorable, respectively.
However, owing to the irregularity of the estivo-autumnal
fevers, these can be said strictly to be properties of tertian
and quartan infections only, and are consequently of little prog-
nostic import. Violent headache, somnolence, sighing respira-
tion, slight mental aberration, defective articulation and vision,



294 THE STUDY OF MALARIA

cold surface, and rapid, feeble purse are some of the symptoms
which forebode evil.

The prognostic value of the microscopic examination of
the blood is limited. While, as a general rule, the severity of
the attack is in proportion to the number of parasites, these
are sometimes scanty in the peripheral circulation even in grave
cases. Sporulating and advanced stages of estivo-autumnal
parasites are rarely seen in the superficial blood except in
extremely severe cases.

Delaney 346 regards a reduction of leukocytes to or below
1,500 as of grave prognostic value. The writer is unable to
verify this from his experience, since in his cases of pernicious
malaria there has existed a leukocytosis.

While in tertian and quartan infections a paroxysm may be
predicted approximately from the results of blood examination,
such an attempt with estivo-autumnal malaria may prove mis-
leading. An impending paroxysm dependent on mature para-
sites in the visceral circulation cannot be foretold.

Intercurrent diseases complicating malaria aggravate the
prognosis. This is especially the case in chronic malaria and
cachexia, with which pneumonia, dysentery, and other diseases
form frequently fatal associations.

The gravity of pregnancy as a complication of malaria has
been considered.

In nephritis of malarial origin the prospect is, as a rule,
good. If, however, the patient is repeatedly subjected to
malaria or other harmful influences the prognosis is not propi-
tious.

The prognosis of the nervous sequelae is ordinarily favor-
able. The various paralyses and mental symptoms are gener-
ally transitory, but may occasionally become persistent. Bulbar
symptoms are usually slow to disappear.

The course of chronic cachexia may be extended for years ;
acute cachexia runs a more rapid course. In mild cases a
change of climate and tonic treatment do a great deal for the
patient; advanced cases rarely recover. Death may occur
from exhaustion, but is more commonly due to pernicious
malaria and to complications, of which the most frequent are



PROGNOSIS 295

pneumonia and nephritis. Hence the danger to the cachectic is
not confined to the malarial season, but he is in danger through-
out the entire year.

Mortality. — The true mortality of malaria is difficult to
estimate. While statistics are not lacking, the different condi-
tions under which they are compiled must be considered, some
being from charity hospitals, some from private practice, some
from military practice, from various localities, etc. It is, fur-
thermore, undoubtedly true that a considerable proportion of
malarial cases does not come to the notice of physicians. The
variety of forms which malaria assumes is another obstacle.
It is probable that many cases ascribed to complications, fan-
cied or real, are due to malaria.

Bearing these points in mind, the following figures are pre-
sented, showing a mortality of 2.89 per cent. :

Author. Locality. Cases. Deaths.

Laveran 1 Turko-Russian War . . 140,000 1,092

Laveran 1 Constantine 1,310

Laveran 1 Italian Army 4,856 13

Schellong" 2 New Guinea 1,954 22

Ross" 8 Greece 960,048 5,916

Ross 349 Hong Kong 7,352 984

Ewing 27 Camp Wikoff 605 39

Smart 76 Civil War 1,373,355 15,423

Travers 38 Malay States 3,397 348

Terburgh 84 Dutch Indies 2,308,128 114,490

Cardamatis 68 Athens 22,618 15

Koch 34 Grosseto 281

Koch 172 East Africa 63 2

Hagen 350 Papua 301 23

British Colonial Reports 351 . British Colonies 12,617 618

Wright 38 British Malaya 17,468 680

Haw 352 Baberton 449 l 4

Hope 40 North Bengal 1,784

Laveran 3 " Algiers 98,774 7,432

Gorgas 354 Panama 1,055 5

Erni 81 Dutch Indies 116,879 73*

United States Marine Hospital 35 ". .General 6,618 20

Various Hospital Reports Southern States 1,294 30

German Protectorate Reports 356 ... German Protectorates 5,003 32

Malaria Society 37 Italy 22,792



120



5,109,001 148,055

Prognosis of Pernicious Malaria. — The prognosis of per-
nicious malaria is extremely grave. It depends upon the physic
condition and age of the patient, the type and severity of the
attack, and the promptness and efficiency of the treatment.



296 THE STUDY OF MALARIA

Anemia from previous attacks of malaria or other causes,
alcoholism, or organic disease of important viscera add to the
gravity of the case. The cerebral types are less serious in the
young and vigorous, very fatal in the aged. As a rule, patients
seen early and treated skilfully and energetically have a better
chance for life, but many cases end fatally in spite of the best
and most timely treatment.

The number of parasites in the peripheral circulation is not
always a reliable guide as to the severity or progress of the
attack. With apparent amelioration of the symptoms the
physician should be circumspect in his prognosis and bear in
mind the possibility of further paroxysms.

In the writer's opinion, the algid type is the most lethal,
the typhoid and the dysenteric least so, though this is not
exactly in accord with Colin, 291 who arranges the types accord-
ing to the following descending scale of gravity : Syncopal,
algid, cardialgic, delirious, comatose, icteric, choleraic. Schel-
long 92 regards the comatose as the most dangerous, and Le
Dantec, 26 the delirious and algid.

Parry 357 states that average mortality of pernicious malaria
is 1 out of every 8 cases; Wharton 358 estimates it as 1 of every
12 or 15; Haspel 86 and Borius, 149 one-third; Pampoukis, 86
21.4-25.4 per cent.; Le Dantec, 226 20-50 per cent, and Cres-
pin," 4 20-70 per cent. The algid type is said by Pampoukis S6 to
be fatal in 55.5 per cent, of cases. Cardamatis 287 states that
the comatose variety is fatal in 20-40 per cent. ; Bergeand 309
believes the mortality of this type to be 50 per cent.

The following list of 27,039 cases of pernicious malaria,
compiled from the literature, shows a mortality of 26.6 per
cent. The first column of figures shows the number of cases,
the second the number of fatalities :

Number of Number of
Cases. Deaths.

Laveran 1 104 53

Bailly 360 886 341

Nepple 86 14 6

Antonini and MonarcT -. 39 9

Maillot 80 186 38

GralP 6 117 75

Burot and Legrand 212 210 142

Smart 70 16,209 4.164

Travers 38 260 81



PROGNOSIS 297

Number of Number of
Cases. Deaths.

Martirano 150 19 9

Pezza 84 2 1

Tanzarella 84 31 8

Thayer and Hewetson 29 3 2

Plehn 5 10 1

Maillot 362 7 6

Theophanidis 362 5 2

Cardamatis 363 3 2

Pampoukis 362 52 20

Billet 161 40 2

Segard 79 24 15

MaureP 156 77

Caccini 147 135 56

Martirano 147 6 3

Charity Hospital, New Orleans 361 8 6

Neer 166 3 3

Celli 83 8,032 1,879

Cardamatis 68 So 9

Colonial Reports 351 252 133

Kelsch and Kiener 178 89 51

Albini 82 87 _ii

27,039 7,205

Six hundred and eighty-nine cases of specified type give
the following respective mortalities :

Comatose. Delirious. Algid. Typhoid. Ataxic.

Maillot 86 77-14 61-12 48-12

Schellong" 7-6

Plehn 5 10-1

Maillot 362 .... 7-6

Theophanidis 362 .... 5-2

Cardamatis 363 .... 3-2

Pampoukis 287 52-20

Billet 151 .... •••• 40-2

MaureP 279-103 .... 78-23 .... 22-17

Neer 156 3~3

Total 428-147 61-12 141-45 40-2 22-17

34% 20% 32% 5% 77%

The Prognosis of Hemoglobinuric Fever. — The prognosis
of hemoglobinuric fever is grave, and should be "guarded and
Delphic." Probably the most valuable prognostic sign is the
quantity of urine ; the chemic analysis and microscopic exami-
nation are not of great value in prognosis. Anuria, the most
dreaded symptom, is to be feared if the daily quantity of urine
falls below 200 cc. If suppression supervenes the outlook is
extremely serious and is unfavorable in proportion to early
onset. When a patient is tided over a period of suppression,



298 THE STUDY OF MALARIA

as occasionally happens, he usually dies during convalescence
of exhaustion, subsequent nephritis, or embolism.

Excessive and uncontrollable vomiting is a bad omen, ex-
hausting the sufferer and interfering with nutrition and medi-
cation. Diarrhea is probably in many cases, with suppression
or a tendency thereto, a life-saving measure, and may be par-
tially responsible for the relative rarity of uremic symptoms
under these circumstances. Singultus is present in a majority
of fatal cases, and when obstinate is always unfavorable. Re-
mittent or intermittent temperature is usually favorable. Som-
nolence, with diminishing amount of urine ; coma, especially of
early onset, petechias, epistaxis or other hemorrhage, and algor
forebode evil.

Thrombus formation in the heart or large vessels may cause
sudden death when the patient is thought to be progressing
favorably. Plehn 5 believes that loud heart murmurs accom-
panied with weak, irregular pulse denote heart thrombus. This
condition is almost certainly fatal, usually in five to eight days.

The larger the share partaken by quinine in the etiology of
the individual case the better the prognosis, provided the case
is not further aggravated by quinine.

Cases occurring in victims of malarial cachexia or of com-
plications are usually more serious.

The mortality varies unaccountably from year to year, some
seasons evincing a series of mild cases, others an appalling
mortality. In a certain parish of Louisiana in 1867 many
cases are said to have occurred, of which not less than 95 per
cent, died. 366 Fisch, 191 who placed the mortality on the Gold
Coast at 20 per cent., states that until two or three decades
previously nearly all who were attacked died. On the other
hand, Banks 210 makes the well-nigh incredible statement that
he treated over 100 cases in the Congo State without a death.

Pampoukis 96 gives the mortality of blackwater fever as
6.6 per cent. ; Crosse, 4 20 per cent. ; Kanellis, 867 22.4 per cent. ;.
Berenger-Feraud, 96 23.1 per cent.; Barthelemy-Benoit, 96 25
per cent. ; Bertrand, 229 25 per cent. ; Carre, 191 27 per cent. ; Cas-
san, 96 32.1 per cent. ; Michel, 368 33 to 50 per cent. ; Schellong", 191
42 per cent. ; Reynolds, 367 50 per cent. ; Scott, 367 60 per cent.



PROGNOSIS 299

The following list of 6,037 cases, with 1,268 deaths, shows
a mortality of 21 per cent. It is compiled from various sources.

The first column of figures shows the number of cases, the
second the number of deaths:

TREATED WITH QUININE, 1821 CASES, 472 DEATHS, 25.9%

Number of Number of

Cases. Deaths.

Vieth 8 14 3

Dryepondt 8 28 1

Mense 234 22

Powell 234 9 7

Gelpe 234 3 2

Diesing 234 2 2

Hagge 234 7 2

Schellong 234 7 3

Reynolds 234 1 1

Doering 187 6

Hanley 184 13 3

Moffatt 263 '.. 9 2

Gorgas 354 20 3

Steudel 96 18 3

Malone 389 120 14

Brem 215 14 2

Coste 370 IS 7

Steggall 371 3

Woldert 240 5

Otto 63 1

Schlayer 222 1

Austin 372 1

Herrick 261 8

Curry 186 1 1

Burot and Legrand 225 3 1

Cardamatis 208 1,352 354

Broden 242 12 7

Theophanidis 373 23 14

Oeconomou 373 18 5

McDaniel 374 _8_5_ 35

TREATED WITHOUT QUININE, 1006 CASES, 112 DEATHS, 11.1%

Number of Number of

Cases. Deaths.

Tomaselli 232 30 6

Navarre 8 2

Henric 376 2

Kohlstock 376 48 8

Koch 172 16 3

Hopkins 260 6 1

Bertrand 229 21 2

Ollwig 49 15

Wittrock 49 4 1

Ziemann 49 12 4

A. Plehn 1 " 53 5

Kleine 223 15 1

Krauss 199 15

McElroy 214 25 4

Goltman and Krauss 1 '" 12 9



300 THE STUDY OF MALARIA

TREATED WITHOUT QUININE, 1006 CASES, 112 DEATHS, 11.1%

Number of Number of

Cases. Deaths.

Malone 369 35

Coste 370 10 4

Hearsey 266 15 4

Seal 258 6 1

Ruge 239 1

Dryepondt and Vancampenhout 228 1

Howard 218 1

Ketchen 238 1

Masterman" 1 1

Herrick 251 1 1

Curry 186 1 1

Cardamatis 206 456 33

Ensor 377 « I

Broden 242 25 2

Pancot 242 7 z

Theophanidis 373 9

Oeconomou 373 31 2

McDaniel 374 93 16

F. Plehn 6 25 1



TREATMENT MIXED OR NOT RECORDED, 3210 CASES, 684

DEATHS, 21.3%

Number of Number of

Cases. Deaths.

Kanellis 232 ' 20 4

Poole 8 56 15

Rothschuh 8 20 18

GuioF 8 185 49

Gouzien 370 53

Meixner 49 40 6

Hofft 49 14 6

Wendland 49 10

Daniels 67 184 41

Wellman 56 34 5

Ipscher 90 20 1

Krueger 90 n 2

Simon 90 17 3

Kerr Cross 380 27 9

Osborn 14 10 5

Berenger-Feraud" 286 66

O'Neill 98 50 2

Burns 235 16 6

Shropshire 267 177 35

Dempwolff 381 17 2

Lipari 202 19 5

Gouducheau 245 IS 4

Cochran 382 642 158

Kelsch and Kiener 178 109 35

Bolton 383 175 38

Grail 256 113 13

Forde 384 2 1

Grenet 373 68 8

Rousseau 373 • 22 6

Carmouze 373 30 9

Mericourt 373 22 3

Koryllos 373 28 5

Pampoukis 373 156 35



PROGNOSIS 301

TREATMENT MIXED OR NOT RECORDED, 3210 CASES, 684
DEATHS, 21.3%

Number of Number of
Cases. Deaths.

Cardamatis 385 30 6

Parathyris 373 23 3

Prout 38S 24 8

Jacobs 387 147 16

DeCruz 388 13 6

DeBlasi 389 3

Orme 390 2

Thompstone 391 27 5

German Protectorate Reports 356 293 45

Total 6,037 1.268

F. Plehn 5 asserts that mortality is highest in first attacks,
but the following table of Daniels 57 does not bear him out :

Of 136 first attacks 31 or 22.7 per cent, were fatal

Of 33 second attacks 8 or 24.0 per cent, were fatal

Of 15 third or fourth attacks. 2 or 13.3 per cent, were fatal



CHAPTER VIII



PROPHYLAXIS



The immortal discovery of Ross is to the prophylaxis of
malaria what that of Laveran is to the diagnosis, and, although
recent, has already been instrumental in saving untold suffer-
ing, incalculable economic loss, and thousands of human lives.

It has been explained how the parasite is abstracted by cer-
tain species of mosquitoes with the blood of infected indi-
viduals, undergoes essential changes in the body of the mos-
quito, and is then inoculated into healthy persons. It is, there-
fore, evident that if this cycle be broken at any point infection
cannot occur, and that if it were universally interrupted during
a sufficiently long period of time the disease would be annihi-
lated. Hence prophylactic measures may be directed against
the destruction of the malarial parasites within the body of
man, the destruction of the mosquitoes which are capable of
transmitting the parasites, and the prevention of mosquitoes
gaining access to man. The parasite may be opposed either in
man or in the mosquito. The mosquito may be combated
either in its aquatic or in its aerial stage. Prophylaxis may
be conducted by a community or by an individual, may be
public or private, offensive or defensive.

As is well known, malaria is now almost or entirely absent
from regions in which it was formerly very prevalent, and in
other places is rapidly diminishing. In the regions in mind the
change was independent of designed efforts for the eradication
of the disease; in fact, it occurred in most instances before the
discovery of either the malarial parasite or of the role of the
mosquito in the dissemination of the disease, and was an un-
expected result of the progress of civilization. This uncon-
scious prophylaxis was probably the product of several factors,
which may be classed as agricultural, therapeutic, and hygienic.

302



PROPHYLAXIS 303

I. Lowering of the ground water and consequent diminution
of breeding pools through drainage for reclamation of swamp
lands, clearing and cultivating of lands, construction of levees,
etc. 2. More radical cures of malaria by means of cinchona
bark and its derivatives, lessening the number of cases of
latent malaria, thereby diminishing the sources from which
parasites might be obtained. 3. Improved hygienic conditions,
better homes and food, the installation of water and sewerage
systems, improved road and street grading, the use of screens,
mosquito bars, etc. For very few other diseases has uncon-
scious prophylaxis done so much as for malaria. This is still
exemplified in regions where malaria is yet endemic; those
who live under the best hygienic conditions suffer least from
malaria, though they may even be ignorant of the manner of
its propagation.

With the tediously attained and in many cases incomplete
results of this unconscious prophylaxis are in decided contrast
the consequences of well organized and vigorous sanitary
measures directed toward the prevention of malaria. Many
instances could be adduced where within a comparatively short
space of time highly malarial localities have been almost com-
pletely freed from the disease, but a few examples will suffice.

One of the most successful campaigns against malaria was
that at Ismailia, a town of about 8,000 inhabitants, near the
middle point of the Suez Canal. The town was founded in
1862, and was celebrated for its salubrity until 1877, when
malaria was introduced and spread rapidly; in 1886 nearly
all the inhabitants were attacked. In 1901 the president of
the Suez Canal Company, learning something of the results
of modern prophylactic methods, dispatched Pressat, a member
of the medical staff, to Italy to study the subject, and invited
Ross to inspect the place and advise upon the most suitable
manner of conducting the campaign. In September, 1902,
Ross arrived in company with MacGregor and with Pressat
returning from Italy. An abundance of anophelines were
found in the houses of the employes, and the larvae, especially
in small, brackish marshes, in the sand, and in some of the
waters of irrigation, but not in the main canal, where they



304 THE STUDY OF MALARIA

were probably destroyed by fish. It was evident that mosquito
reduction was to be the chief end, though old cases of malaria
received vigorous treatment. Marshes were filled with sand
and the irrigation channels were deepened or treated with oil.
This preliminary work was conducted with a brigade of only
four men, though many others were employed later for the
extensive permanent work. From 1885 until 1902 inclusive
the number of cases of malaria at Ismailia had averaged nearly
1800 annually. In 1903 there occurred 214 cases; in 1904.
90, and in 1905 only 37. It is said that it is now possible to
sleep with comfort in the place without nets. The cost of the



Online LibraryWilliam H. (William Heiskell) DeaderickA practical study of malaria → online text (page 25 of 36)