NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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Fatality of malarial fevers. Pernicious symptoms and causes of death.—
Malarial fevers cause much ill-health, and weakness and therefore interfere
greatly with the industrial success of people afflicted with them but,' even
when untreated, they are by no means very fatal, and among patients who
receive more or less adequate treatment a death is a rare event. The
following table shows the fatality of all kinds of malarial fevers among
European soldiers, Native soldiers, and Native prisoners treated in Indian
hospitals * during the five-year period from 1903 to 1907 :—
Years.
1903 to 1907
Class of patients.
European soldiers .
Native soldiers
Native prisoners
Number of
cases treated
in hospital.
63,597
144,728
189,534
Number
of deaths.
99
612
681
Case mortality.
•16 per cent. or 1 death in 642
cases.
•42 per cent, or 1 death in 236
cases.
•36 per cent. or 1 death in 278
cases.
The fatality of malarial fevers is higher among Native soldiers than
among Native prisoners because pernicious symptoms (which are the dangerous
ones) are more common in cases of malarial fever among the former class
than among the latter. For example during the five-year period ending
with 1907 the admission rate from malarial fevers of a remittent type (in
which it is well known that pernicious symptoms are common) among
Indian prisoners was only 1.8 per thousand as compared with a rate of 6.7per
thousand among Native soldiers. Some reasons for the relative infrequency
of pernicious symptoms among prisoners as compared with soldiers are (1)
when a prisoner feels ill he reports the fact at once, and if it is found that he
has fever he is immediately admitted into hospital and treated ; among
* A large number of cases of malarial fever in India are so mild that they can be
treated out of hospital; if the figures of these cases were added the case mortality figures
would, of course, be lower than those shown in the table. Among European troops
during the years 1906 and 1907 alone not many fewer than 10,000 cases of ague were
treated out of hospital, that is "in barracks." The practice has been objected to on
the ground that many of these patients are parasite-carriers and infect anopheline
mosquitoes in the barracks.
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Native soldiers, as among European, the practice of trying to carry on their
duties as long as possible without reporting sick is very common, and this
practice, of course, increases very much the liability that pernicious
symptoms will develop. (2) Quinine prophylaxis is very carefully and
thoroughly carried out among prisoners, and although it does not
always prevent infection it lessens the severity of the attack. If these
factors were not in operation we should expect the fatality of malarial
fevers to be much higher among prisoners than among Native troops
because among the former class there are large numbers of old and
infirm men and women in whom an attack of malaria is a much more
serious matter than in the younger and more robust European or Native
soldier.
As regards the fatality of the disease among other classes of people in
India we can add that among 3,402 cases which occurred among the wives of
European soldiers, and were treated in hospital during the ten-year period
ending with 1907, there were 37 deaths, a case mortality of about 1 per cent.,
and that among 5,128 cases occurring in the children of European soldiers
during the same period there were 86 deaths, a case mortality of 1.68 per
cent.
There are no Indian statistics which can be relied upon for calculating the
fatality of malarial fevers in patients who are untreated, but anyone who has
to study malaria in Indian villages cannot fail to observe that at any rate a
very large number of infants and young children pass through many attacks
of malarial fever without, apparently, being greatly affected by the disease,
and that such children gain an immunity to malaria which is of service to
them throughout their lives.
The statistics dealt with above include, of course, all forms of malarial
fever, but it is important to remember that serious symptoms and death
occur, as a rule, only in cases of infection with the Malignant Tertian
parasites. If the statistics of the ordinary intermittent fevers which are
produced usually by the Benign Tertian and Quartan parasites were
considered alone we should find that among European soldiers treated in
hospitals in India not more than 1 patient in every 850 dies, and among
Native soldiers not more than 1 in every 520. It is fortunate therefore
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that the Benign Tertian parasite is by far the commonest in most parts of
India.
Pernicious
symptoms.
The chief " pernicious " symptoms which may be met with in cases of
acute malarial fever in India are :—
Referable to the abdominal viscera and
alimentary system.
Severe epigastric pain.
Severe hepatic pain.
Severe splenic pain.
Simple vomiting.
Bilious vomiting.
Hæatemesis.
Pronounced constipation.
Simple diarrhoea.
Choleraic diarrhæa.
Dysenteric diarrhoea.
Melæna.
Jaundice.
Rupture of spleen.
Referable to the circulatory system.
Fainting attacks.
Sudden heart failure.
Progressive anæmia.
Referable to the respiratory system.
Dyspnoea.
Referable to the nervous system,
Severe headache.
Irritability.
Delirium.
Convulsions.
Epileptiform seizures.
Unconsciousness.
Coma.
Collapse.
Uncontrollable sweating.
Uræmia.
Hyperpyrexia.
Referable to the urinary system.
Albuminuria.
Nephritis.
Incontinence of urine.
Suppression of urine.
Hæmoglobinuria.
Although all these symptoms are highly important it is not possible in our
limited space to do more than refer very briefly to a few of them, and it
will be more profitable, I think, to give extracts from notes on actual cases
which have occurred recently in India than to deal with the subject in a
general way.
1. A European soldier was admitted into hospital on the evening of the 9th
November 1907 with a temperature of 103° F. He complained of intense headache.
The next morning his temperature was normal. The spleen was palpable and tender.
A blood examination showed the presence of numerous Malignant Tertian ring parasites.
At 10 P.M., the same evening his temperature rose to 105° F., and he became uncon-
scious. Shortly afterwards he became comatose, fæces and urine being passed involun-
tarily. The coma became more profound and ended in death. (Cerebral type with coma.)
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On the second day after admission the vomiting and diarrhæa stopped. (Choleraic
type.)
9. A European soldier was admitted complaining of dysentery. He had ten loose
motions containing pure blood mixed with black blood and mucus during the
day. There was no fever. Numerous crescents were found in a film of peripheral
blood. Quinine was injected intramuscularly, and he qaickly recovered. (Dysenteric
type.)
10. A Native soldier was admitted complaining of attacks of diarrhoea which had
come on regularly every week or ten days for a month. The motions were grass green
in colour. His temperature was 102.4°F. Many Malignant Tertian rings and crescents
were found in his blood. The fever and diarrhæa yielded readily to quinine given
intramuscularly. (Diarrhæic type.)
11. A Native soldier was admitted into hospital at Mauritius on 9th March 1906
with fever and a palpable spleen. He had typical attacks of ague daily, the chart being
of the double tertian type. Quinine was given hypodermically, but it had little or no
effect on the fever. On the 21st he had some oedema of the ankles and feet, and his
urine contained albumen. Quinine in various forms was tried, but he continued to become
more and more anæmic, and low fever continued. On 1st April 1907 he was profoundly
anæmic and extremely weak, and had some paralysis of the legs. A few days afterwards
he died from heart failure. (Type of chronic malignant fever with progressive
anæmia.)
12. A European soldier complained of colicky pains in the abdomen and fainting
fits. He was extremely anæmic and in a condition of collapse. Benign Tertian parasites
were found in his blood. There was abdominal distension and suppressian of urine.
Uræmic symptoms developed, and he died in a state of coma. At the post-mortem
examination it was found that the spleen had ruptured. (Spontaneous iupture of the
spleen.)
13. A European soldier was admitted into hospital at Ferozepore on 26th November
1907 suffering from fever of an irregular type and Jaundice. He had severe epigastric
pain, bilious vomiting, the vomit containing blood, loose hasmorrhagic stools and port
wine coloured urine. Blood examinations for malarial parasites were negative.
Later he had severe lumbar pains and passed blood-coloured urine. He got better,
but had a sudden attack of dyspnoea and died. (Hæmoglobinuric or Blackwater
fever.)
14. A Native soldier was admitted into hospital at Mauritius on 21st September
1906 suffering from fever and hæmoglobinuria. Quartan parasites were found in his
blood. Thirty grains of quinine were given daily for a week, but had no effect on the
temperature (which was typically of the quartan type) and aggravated the patient's
general condition. He developed intense anæmia and ædematous Swelling of the legs,
but ultimately recovered. (Hæmoglobinuric or Blackwater fever.)
15. A Native soldier was under treatment in hospital suffering from intermittent
malarial fever, the temperature ranging between subnormal and 104° to 105°F. He had
intense headache and diarrhoea, the motions being grass green in colour. Cerebral
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symptoms set in with the occurrence daily of an epileptiform convulsion which lasted
for some minutes. Malignant Tertian parasites were found in his blood. Quinine was
given hypodermically, but the disease was fatal. (Cerebral type with epileptiform
convulsions.)
The effects of long continued malarial infection.*
After a succession of attacks of untreated or insufficiently treated
malarial fever patients develop the condition which for many years has been
called in India "malarial cachexia."
Until recently the disease named
kala azar was almost invariably diagnosed as malarial cachexia, with the
result that signs and symptoms characteristic of that disease have
been recorded in reports and text-books as characteristic of malarial
cachexia.
It now appears that at any rate as regards natives of
India the true signs and symptoms of " malarial cachexia " are somewhat as
follows :—
(1) Enlargement of the spleen and anæmia are the obvious physical
signs.
(2) Serious symptoms are absent unless the patient is suffering from
some other disease in addition to malaria.
(3) The illness is not a continuous one ; periods of fever and
illness alternate with periods of apyrexia and partial
recovery.
(4) Chronic irregular " low " fever is not present ; during the pyrexial
periods the temperature chart, if the temperature has been
recorded every two or four hours, shows the intermittency and
periodicity characteristic of malarial fever.
(5) Patients suffering from this condition are not, as a rule,
emaciated, and unless another disease supervenes they do not
go from bad to worse, but after many relapses of fever slowly
recover.
* By long continued infection one means that the patient has had new attacks and
relapses for at least two years The comparatively rare cases of chronic malignant fever
with progressive anæmia, an example of which is recorded on page 63, are not included
in the class of cases usually diagnosed in India as "malarial cachexia " because as a
rule they are fatal within a few months or less.
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The diagnosis of malarial fevers,
The wrong
method.
When a patient complains or "fever we may attempt to arrive at a
correct diagnosis of his disease by one of two methods ; it is scarcely neces-
sary to say that one of these methods is wrong and the other right. The
7
wrong method can be disposed of in a few words. It exemplifies the com-
mon observation that in India and other tropical countries most patients
who complain of " fever '' express the opinion that the fever from which
they are suffering is " malarial," and that in these countries many medical
men all too frequently acquiesce in this diagnosis without taking pains to
ascertain its correctness. In such an instance the medical man, having
allowed the patient to make the diagnosis, proceeds to treat him more or
less vigorously with quinine. If, under this treatment, the fever disappears
in a few days the medical man regards the diagnosis as having been con-
firmed ; he has applied what is called the " therapeutic test." If the fever
does not decline within a few days the results of having adopted a wrong
method of diagnosis become apparent, and often several weeks elapse before
a correct diagnosis is arrived at.
The right
method.
The right method of setting about the diagnosis is the following. It is -
necessary to give this method in some detail, but it will readily be under-
stood that it is not possible in all cases to carry it out in its entirety. It is
seldom necessary to do so because if the principle of the method is followed
a correct diagnosis is usually made very quickly. Assistant Surgeons and
Hospital Assistants in charge of dispensaries in India have a very large
number of patients to attend to, and speedy diagnosis is important ; in such
cases, of course, and in cases where the requisite apparatus has not been
provided, all the details of the method cannot be carried out ; the procedure
must be modified, and accuracy of diagnosis and, therefore, efficient treatment
must be sacrificed.
The first note to be made regarding this method is that when in reply to
our question " Of what do you complain " the patient answers " fever "
we must endeavour to banish the thought of " ague " from our minds and
try instead to recall the various diseases which, not infrequently, have been
diagnosed under that heading. The list of these diseases is a long one, but
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its remembrance (or even the remembrance that such a list exists) will often
prevent mistakes in diagnosis. The list is as follows :—
Diseases relating to the respiratory system.
Pulmonary tuberculosis.
Pneumonia.
Pleurisy.
Bronchitis.
Influenza.
Diseases relating to the genito-urinary
system.
Pyelitis.
Chronic Bright's disease.
Syphilitic fever.
Gonorrhæal and urethral fever.
Diseases relating to the alimentary system.
Tonsillitis.
Gastro-enteritis.
Appendicitis.
Hepatitis.
Abscess of the liver.
Affections of the gall bladder and bile
ducts.
Fever due to infection with intestinal
worms.
Diseases relating to the circulatory
system.
Ulcerative endocarditis.
Splenic leukæmia.
Lymphangitis.
Other diseases.
Rheumatic fever.
The initial fever of small-pox and other
exanthemata.
Heatstroke.
Dengue fever.
Malta fever.
Typhoid fever.
Relapsing fever.
Filarial fever.
Cerebro-spinal fever.
Simple continued fever.
Septic conditions.
Kala azar.
It will be obvious that the first thing to be done in order to exclude the
majority of these diseases is to make a thorough search for a sufficient cause
of the fever in some local infection in the respiratory, alimentary, circulatory,
genito-urinary, or other system. Those who make this their first diagnostic
rule will be surprised how frequently it happens that a sufficient cause of the
fever is found in the respiratory system or, failing this, in the alimentary
system. It is ten years since Professor Thayer wrote that "the one process
above all others which is confounded with malarial intermittent fever is
pulmonary tuberculosis " and, despite the lapse of time, it is safe to say that
this is still true. If any sign of tuberculous disease is found a specimen of
the sputum should be taken for microscopic examination. (See page 22.)
If there are no facilities locally for the examination the film must be sent to the
nearest laboratory.* When the respiratory system has been examined carefully
* This applies also to films of blood, to specimens for the serum reaction test and to
any other material which must be examined for diagnostic purposes.
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without result, attention will be directed to the alimentary system and an
endeavour made to find or to exclude a local infection there. In this case
the search will be begun in the mouth (including the teeth, gums, and tongue),
and the pharynx and fauces will be examined. A general examination of the
abdomen by inspection, palpation and percussion will then be made and
afterwards a special examination, by palpation and percussion, of the stomach,
the liver and gall-bladder, the spleen and the intestines. A specimen of the
fæces should be examined microscopically for the eggs of intestinal worms.
(See page 22.) The physical examination of the genito-urinary system will be
concerned chiefly with the palpation of the kidneys, with the physical,
chemical, and microscopical examination of the urine and with a search
for signs of gonorrhoea or syphilis. The examination of the nervous
system will be conducted with the object chiefly of excluding heat stroke and
cerebro-spinal meningitis. By a careful examination of each system in this
manner—and it is necessary to mention that the examination of the ear, the
throat, and the nose (especially for septic conditions) must not be omitted—we
shall have narrowed down considerably the limits of our enquiry. Hitherto
we shall have been occupied in attempting to arrive at a correct diagnosis of
the cause of the fever by a process of exclusion ; we shall have found that
the cause does not lie in a local infection in any of the systems examined.
We have excluded, let us say, all except the following diseases :—
The initial fever of small pox
and other exanthemata.
Dengue fever.
Heat stroke.
Simple continued fever.
Cerebro-spinal fever.
Malta fever.
Typhoid fever.
Relasping fever.
Filarial fever.
Malarial fever.
Splenic leukæmia.
Kala azar.
Malarial cachexia.
We may now allow ourselves to proceed by the alternative method and
to think of the possibilities of the fever being due to one or other of these
diseases. Assuming that our patient is suffering from only one disease—we
cannot, of course, deal in this small book with complicated cases—it will be
seen that the diseases just enumerated can be divided into two classes,
namely, (1) those in which the spleen may be very greatly enlarged (splenic
F 2
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leukæmia, kala azar, and malarial cachexia), and (2) those in which the
spleen may be not at all or only slightly enlarged (the remainder of the
diseases in the list). Let us deal first with the second class, which is the
largest. There are in this class ten diseases, but some of them, such as heat
stroke, dengue fever, cerebro-spinal fever, and typhoid fever, are not very
frequently met with among natives of India, and the diagnosis of others such
as small-pox can seldom be difficult, so that without doubt at this stage of
our diagnostic procedure it is justifiable to think first of malarial fever and to
see if by questioning the patient we can confirm this diagnosis. If we are
convinced from the answers of the patient that the fever from which he
suffers show definitely a Quartan or Tertian periodicity we may regard our
provisional diagnosis of malarial fever as being confirmed, and we are justified
in commencing suitable treatment at once. If, however, the patient's
answers show that his fever is of a continuous type or presents a Quotidian
periodicity or if it began only a short time before he has sought our advice
the difficulties of diagnosis may be very great. We will suppose that our
patient is being examined on the second day of his illness, that his temper-
ature is 102° F., that his spleen is not at all or only very slightly enlarged,
and that we have been able to find no other signs which will aid us mate-
rially in our diagnosis. In such a case the correct course to pursue is as
follows : (1) the patient should be admitted into hospital ; (2) he should
be given a milk diet ; (3) his temperature should be taken every four hours ;
(4) two specimens of his blood should be taken—one on a slide for the exami-
nation for malaria and other parasites, the other in a blood capsule for the
serum reaction tests with cultures of the Malta fever and typhoid fever bacilli
(see pages 10 and 21); (5) if thought desirable a diaphoretic mixture, not
containing quinine, and a mild purgative may be prescribed, but this is the only
medicinal treatment permissible. On no account should quinine be given.
Our course of procedure is now an expectant one ; we must wait and watch
for positive symptoms and signs which will afford a clue to the correct diagnosis.
As soon as possible we shall examine carefully the specimens of blood taken. If
it happens that we find the parasites of malaria or of relapsing fever or of
filarial fever in the blood film our task of diagnosis is ended, and we can proceed
at once to treat the patient appropriately. But such a fortunate event by
HO means always happens, and it may be several days or a week or even more
( 69 )
Before, as the result of a positive microscopical examination of the blood or a
positive serum re-action test or the appearance of characteristic signs and
symptoms, a sure diagnosis can be made.* During this period, however, the
patient can come to no harm, for he is being treated as though suffering from
the most serious of the diseases mentioned, namely, typhoid fever.† Every
day until the diagnosis has been made we shall take a specimen of blood to
be examined for malaria and other parasites, and every week a specimen for
the serum re-action tests. We shall invariably adopt the rule not to give
quinine until the diagnosis is established. If this definite plan is pursued it
will be found that—
(1) after a day or two the temperature chart shows definitely the charac-
ters of interrmttency and periodicity, and malaria parasites are found in the
patient's blood ;
or (2) The temperature chart does not present features of definite diagnostic
significance, but malaria parasites or filaria embryos or the spirochete organ-
isms of relapsing fever are found in the blood ;
in both these events the diagnosis is established by the results of the
blood examination ;
or (3) The temperature is irregular, but shows a tendency to fall from the
first or second day. It has fallen to normal, and the patient has recovered
in five or six days or less. No malaria or other parasites are found in the
blood, and the serum tests are negative;
In this event the diagnosis of the true cause of the fever is doubtful, and
in the present state of knowledge we shall return such cases under the heading
"simple continued fever " or under the heading "pyrexia of uncertain
* In many cases the period occupied in diagnosis can be reduced greatly by employ.
ing the method of blood culture described on page 22. In cases of typhoid fever the
diagnosis can be made by this method on the first or second day of the disease, and it
may be said also that in cases with symptoms simulating typhoid but in which the
results of this method of diagnosis with a specimen of blood taken during the first three
days of the fever have been negative typhoid fever may be excluded.
† The teaching that, having obtained specimens of blood, we should begin at once
to treat the patient with quinine "on the chance" that he may be suffering from
malaria is wrong. A patient with malarial fever is not in danger until the parasites
become so numerous that they can be found almost immediately the eye is applied to
the microscope, and for the patient's sake the advantages of waiting until an accurate
diagnosis can be made far outweigh any which could be brought forward in favour of
giving quinine at an earlier stage.