NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
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origin " because we have found no local infection, because the results of the
diagnostic methods employed have been negative, and because the patient
has recovered under expectant treatment only ;
or (4) The temperature chart shows a more or less high temperature each
day with or without remissions. The fever continues day after day, and no
malaria or other parasites are found in the blood. After a week or perhaps
two weeks the serum test for Malta fever or for typhoid fever is positive, and
other characteristic symptoms of one of these diseases appear ;
In this event we must be guided until the result of the serum test is
positive by the symptoms and by the negative results of the blood examina-
tions for malaria and other parasites. After a very few days we can definitely
exclude malaria because we know that as the patient has received no quinine
he could not continue to have high fever for more than two or three days
without our being able to find parasites in Ms blood, and we know also that
the temperature charts of cases of malaria in which quinine has not been
administered always show in a few days the intermittency and periodicity
characteristic of that disease ;
or (5) The temperature chart is continuous or remittent or intermittent and
may show a quotidian periodicity, but no malaria or other parasites are
found in the peripheral blood, and the serum tests are negative. The fever
continues day after day, and repeated examinations for tuberculosis, liver
abscess and other septic conditions have been negative.
In this event we shall think of the possibilities of the imperfectly known
continued fevers such as those of the paratyphoid group, and finally of kala
azar. Fevers of the paratyphoid group can be diagnosed, as a rule, only by
the results of serum test with cultures of the different paratyphoid bacilli or
better by the method of blood culture (see page 22). If the case is one of
kala azar we shall note rapid and progressive enlargement of the spleen until
it attains a size never reached in cases of typhoid or Malta fevers.
This brines us to the consideration of the class of diseases already enumer-
ated in which enlargement of the spleen may be very great. It often happens in
India that patients come to us for the first time with fever and with a spleen
so large that it extends to or beyond the level of the umbilicus. In such
cases the diagnosis, when chronic Bright's disease, cirrhosis of the liver and
syphilis have been excluded, usually rests between splenic leukaemia (which is
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rare), malarial cachexia, and kala azar. Splenic leukæmia, of course, is very
easily differentiated by a microscopical examination of the peripheral blood—
every field is crowded with leucocytes—but the differential diagnosis between
malarial cachexia and kala azar is not always easy, and as a rule we must admit
the patient into hospital if we wish to make the diagnosis accurately.
The chief differences between these two diseases may be tabulated thus:—
Malarial cachexia.
There are definite pyrexial and apyrexial
periods ; the pyrexial periods are of short
duration, and if a careful record of the
temperature is taken every four hours the
chart presents definitely the characters of
a malarial chart. Quinine stops the
fever.
Progressive emaciation is absent, and
between the pyrexial attacks the patient
is able to do his work.
The spleen is greatly enlarged; the liver
slightly or not at all enlarged.
Kala azar.
Fever is present for long periods ; it is
sometimes intermittent, but it presents
great irregularity. Quinine does not stop
the fever.
Great weakness and progressive emaciation
are always present.
The spleen and liver are greatly enlarged.
In order to confirm the diagnosis it may be necessary in a few cases to
puncture the liver or the spleen by the method already described.
The diagnosis of the pernicious attacks of malaria is sufficiently dealt with
in the descriptions on pages 61 to 63. In such cases it is seldom possible to
save the patient's life unless we are able to make an immediate examination
of the blood because until this is done the diagnosis is often obscure and the
treatment incorrect.
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CHAPTER IV.
Treatment and prevention.
Treatment
before the
diagnosis has
been made.
IN all diseases associated with fever an accurate diagnosis is essential for
successful treatment. During the period which sometimes elapses before
accurate diagnosis of the cause of the fever in a patient who complains of this
symptom can be made the following line of treatment should be adopted. The
patient should be admitted into hospital, sent to bed and given a milk-diet.
His temperature should be taken every four hours. Medicinal treatment
should be directed to the relief of symptoms ; a diaphoretic mixture and a
mild purge may be given if indicated, but during this period quinine must on
no account be used.
Routine treat-
ment for
adults.
This line of treatment will be continued until the diagnosis is assured
when, if necessary, it will be changed to one more likely to cure the disease
which has been recognised as the cause of the fever. In these notes we have
bo consider the treatment of those patients only in whose cases a diagnosis of
malarial fever has been made. It is well known that quinine is a true
specific, that is, an infallible remedy, for this fever. Its administration
should be begun immediately the diagnosis is assured, irrespective of the
stage of the attack or the height of the fever. A good routine practice in
the treatment of adult patients is to give a dose of 15 grains of the sulphate
dissolved in two or three ounces of water (with the aid of a sufficient
quantity of dilute hydrochloric acid) just before the morning meal and a
similar dose before the evening meal, and to continue these doses daily for
five days. It is a good practice to give a purgative on the clay that the
treatment is begun. If it has been possible during the first stage, that is
during the days before the diagnosis has been made, to ascertain the time of
the day or night at which the paroxysm is to be expected, the times of giving
the doses of quinine should be altered, one dose being given about four hours
before the expected paroxysm and the other about 12 hours later. Exps.
rience has shown that, provided the doses of quinine are not vomited or
are not passed through the intestine without being absorbed, there is hardly any
form of true malarial fever which fails to yield to this treatment within a
few days and if at the end of five days, the patient's fever continues as
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before, we may be almost sure that our diagnosis is wrong, and that the
fever is not due to malaria. In the great majority of cases the parasites
will disappear from the blood, and the fever cease in from 24 to 72 hours,
after the beginning of the administration of the regular doses of quinine,
and in these cases the patient may be allowed to be up and about before the
end of the five days, although, of course, the daily doses will be continued
for that period.
Routine ireat -
ment for
children.
The treatment of children should be carried out in the same manner as
that of adults, but the doses of quinine should be regulated according to the
ages of the children, and as the doses are less the treatment may have to be
carried out over a longer period before the parasites are eradicated. The
dose should be to the amount of one grain twice a day for each year of age up
to 5 years of age. From 5 to 10 years of age a dose of 5 grains twice a day
is sufficient, and from 10 to 15 years a dose of 10 grains twice a day. After
15 years of age the same closes as for adults may be given. Euquinine
which has only a slight taste can be easily given to children. It is weaker
than quinine, and the doses given should be half as much again as those
of the sulphate. It must be given in the form of the powder, as, if dissolved
with the aid of acids, its bitter taste returns,
These routine methods of treatment, which are the best for all ordinary
Cases of intermittent fever, can be improved upon in certain cases. The
most important point to remember in connexion with the administration of
quinine is to give it at such a time that it will be in the blood and organs
when the parasites are sporulating so that it can act on and kill the merozo-
ites before they have entered the blood corpuscles. In ordinary Benign
Tertian and Quartan fevers it is easy to find out the time of sporulation of
the parasites and, as we have just mentioned, the doses in such cases should
be given about four hours before the febrile attack, but in some " pernicious "
fevers the parasites sporulate so irregularly that we cannot fix a definite time
for giving the doses of quinine. In such cases the best plan to follow
is to give small doses of quinine at frequent intervals. A dose of four
grains of quinine should be given every two hours throughout the daytime
and at such times (but not more frequently than every two hours) during
the night as the patient is awake. As a rule not more than three grammes
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of quinine (45 grains approximately) should be given during the 24 hours
to any patient suffering from malaria. The plan of administration just
described is sometimes called the fractional method of Nocht, and very good
results have been obtained by it in the treatment of ordinary intermittent
fevers as well as in the remittent types.
Again, there are certain cases of malarial fever—those, for example, in
which vomiting is a symptom and some obstinate cases of frequent relapse—in
which it is preferable to administer the drug by intramuscular injection.
For this method of treatment the following articles are necessary—(1) an
all glass hypodermic syringe ; (2) a spirit lamp, a tripod stand and a
porcelain dish ; (3) tablets of a salt of quinine which is soluble in water ;
quinine bi-hydrochlorate (Burroughs, Wellcome & Co.) or the bichlorate of
quinine and urea (Parke Davis & Co.) are suitable salts ; (4) alcohol and lint ;
(5) a pair of forceps. Eight grains of the soluble salt given once a day is
generally an effectual dose in this method of treatment, but since the dose
is given only once a day it is especially necessary that it should be given
at the proper time—about four hours before the febrile attack. It
sometimes happens that intramuscular injections given in the evening
have little or no effect upon the fever, but immediately become effectual
when the time of administration is changed to early morning. It the
infection is very severe we should, of course, give two or three or even more
injections of eight grains during the day. The dose should be injected into
the muscle of the buttock, the place selected being first thoroughly cleansed
with alcohol. It is scarcely necessary to say that the operation must be
carried out with strictly aseptic precautions ; the syringe and needle must
be thoroughly boiled, the needle must be fitted to the syringe with the aid
of the sterilized forceps—not with the fingers—and the tablets must be
dissolved in boiled water. The stab should be made deeply into the gluteal
muscle, and the little wound made by the needle should be covered with
collodion. It is the experience of most medical officers in India that injec-
tions given intramuscularly are preferable to those given subcutaneously.
A point of practical importance in connexion with intramuscular
injections is that it is not necessary to attempt to dissolve the salt of quinine
in the least possible quantity of water ; it is far better that the amount of
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liquid injected should be unnecessarily • large than that the salt should
crystallize out while the injection is being made.
Another method of administering quinine which is sometimes of advan-
tage in the treatment of children is to administer the drug per rectum. For
this method the rectum should first be cleared out by giving a simple enema
and then 15 or 20 grains of quinine in mucilage of gum arabic with 10 or 12
drops of Tincture of opium should be injected as high as possible.
"After treat-
ment."
The next subject to which attention must be directed is the so-called
" after treatment " of the patient. This is very important and must on no
account be neglected. We will suppose that the patient has undergone
during five days the routine treatment by doses of 15 grains of quinine twice
daily, and that he has recovered and is doing his work again. He may now be
left for eight days without any quinine. At the end of this period he should
receive a dose of 15 grains of quinine each morning on an empty stomach
during three successive days. Then should follow another interval of eight
days during which no quinine is given. Then treatment during three days
followed by a third interval of eight days, and this by a third period of treat-
ment ; and so on, treatment for three days alternating with freedom from
treatment for eight days, during a period of three months. It is unlikely that
during these three months the patient will suffer from a relapse or from a
fresh attack, but if he does he will be re-admitted into hospital, and the whole
course of treatment will be carried out again from the beginning.
Hints.
Finally, we may deal briefly with the treatment of some of the pernicious
attacks already described, but before doing so a few remarks which I
regard as being of some importance may be made. (1) In reading over the
methods of treatment adopted in Indian hospitals one cannot fail to notice
the great frequency with which phenacetin is used, especially in hospitals
for Native troops, as a diaphoretic in malarial fever. I cannot but think
that this drug, which in many cases exerts so depressing an effect upon the
heart and has no action upon malaria parasites, should be used very rarely,
if ever, in the treatment of malarial fevers. (2) Every hospital should be
provided with a good syringe and with tablets of a suitable salt of quinine for
the administration of quinine intramuscularly. The syringe should be kept
for this purpose alone, and the requisite apparatus, etc., should be ready
always. (3) Records show that the administration of quinine subcutaneously
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is largely used. Experience has now shown that better results would be
obtained if this method of administration were given up in favour of
administration intramuscularly into the gluteal muscle. (4) Quinine when
given intramuscularly is not absorbed so rapidly as when given by the mouth,
but its absorption extends over a longer period ; therefore intramuscular
doses do not act so quickly as those given by the mouth, but their action is
more prolonged. It is this prolongation of action that makes the method so
valuable in chronic relapsing cases. (5) The intensity of action of quinine
when given intramuscularly is probably less than when given by the mouth,
so that, theoretically, intramuscular doses should be larger than doses given
by the mouth. But in practice it is often difficult to give a larger dose than
eight grains intramuscularly, and experience teaches that this dose is usually
effectual. (6) It will be inferred from what has just been said that it is not
always better to give quinine intramuscularly than by the mouth ; it is
seldom better to do so. (7) To patients who do not remain in bed during
treatment larger doses of quinine must be given than to those who do so.
(8) Quinine when taken in powder or in the form of compressed tablets
should be followed by a wine-glass of water acidified with three or four
drops of hydrochloric acid.
Pernicious
attacks.
As regards the treatment of pernicious attacks it is not necessary to add
much to what has already been said in the foregoing pages. In cerebral
attacks a smart purge should be given along with the first dose of quinine,
and a dose of at least 10 grains of a soluble salt of quinine should be given
intramuscularly in addition to that which is given by the mouth. Hyper-
pyrexia should be treated by cold baths, rectal injections of iced water and
ice bags to the head—never by the administration of powerful diaphoretic
or depressing drugs, which are very likely to cause profound collapse when
the temperature falls with profuse sweating.
In cases when there is no time to be lost quinine should be
administered intravenously. If the solution of quinine is at the correct
temperature [100°F.), if the quinine is thoroughly dissolved, and if complete
aseptic precautions are taken, there is no danger in this operation. Fifteen
grains of quinine bi-hydrochlorate should be dissolved in 30 or 40 minims of
normal saline solution. The skin over the bend of the elbow should be
rendered aseptic. A rubber tube is wound round the arm on the proximal
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side of the median basilic vein. An incision is made through the skin along
the course of the vein, and the vein is carefully dissected free until it is well
exposed. Care being taken that the needle of the syringe is completely
filled with the quinine solution, the anterior wall of the vein is picked up
with a fine forceps and pierced by the needle. The solution is injected
slowly, the needle withdrawn and the wound closed. The dose may be
repeated twice during the first 24 hours if it seems necessary.*
In attacks where there is much restlessness or violent delirium ¼th grain
of morphia should be given hypodermically. If a patient with a choleraic
attack is seen at the beginning of the attack twenty grains of quinine injected
intramuscularly is the correct treatment. The vomiting usually prevents
any drug being given by the mouth. If the patient gets worse an injection
of two pints of normal saline solution should be made into the loose
subcutaneous tissue of the axilla. If the patient is not seen until collapse
has set in intravenous infusion of two or three pints of normal saline
solution in which has been dissolved 20 grains of quinine bi-hydrochlorate
should be resorted to. The method of carrying out this treatment is des-
cribed in books on operative surgery.
An intramuscular injection of eight grains of quinine daily is the best
treatment for chronically relapsing attacks and for chronic cases with
enlargement of the spleen. Good food, tonics and often a sea voyage or
chancre of climate are essential for recovery.
In the treatment of all cases of fever it is important to remember above
all that it is quite wrong to continue giving large doses of quinine daily for
many days if the drug is obviously not doing good. Quinine is essentially a
drug which if it is going to do good at all does so very quickly. There are
records of many patients in India having received 30 or 40 grains of quinine
daily for a month without any apparent effect on the temperature having been
produced; in all probability such patients were not suffering from malaria
at all, and at any rate it is certain that whether they were suffering from this
* The details are given in this manner for the sake of those who have never attempted
to administer quinine intravenously ; those who have practised the simple operation of
withdrawing a few cubic centimetres of blood from a vein will know, of course, that the
preliminary dissecting out of the vein is not often necessary.
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disease or not the quinine should have been stopped after the first week and
the effect observed.
The prevention and extirpation of malarial fevers.
The different methods which have been recommended with the object of
preventing or extirpating malaria may be divided into two classes, namely:—
(I) Methods in which quinine is used.
(II) Methods in which quinine is not used.
I.
The methods of class (I) comprise firstly Dr. Robert Koch's plan for the
eradication of malarial fevers by the use of quinine, and secondly the different
plans for the prevention of malarial fevers by the use of quinine.
A.—The eradication of malarial fevers % the use of quinine.
The eradica-
tion of
malaria by
the use of
quinine.
Dr. Robert Koch's scheme is for the extermination of all malaria parasites
by the systematic treatment of all infected individuals with quinine. He
compares the campaign against malaria to that which is carried out
against cholera. Just as in cholera it is necessary to search out all the
sick, the convalescent, and the healthy who harbour the cholera vibrio and
to isolate and disinfect them, so in a campaign against malaria it is neces-
sary to search out and disinfect all people who harbour the malaria parasite.
The method is carried out in the following way. The blood of all the
inhabitants of the district which it is desired to free from malaria is system-
atically examined, and all those in whom infection with malaria is found are
treated by the following plan for " the disinfection of the infected." A dose
of 15 grains of quinine is administered on each of two or three successive
days and repeated at intervals of eight days throughout a period of three
months. If during the course of the treatment the individual gets a relapse of
fever, or if, even without a relapse, malaria parasites are found in his blood, he
receives five consecutive days' treatment with quinine given in the following
doses :—On each of the first and second days 30 grains of quinine (15 grains
in the morning and 15 grains in the evening), and on each of the third, fourth
and fifth days 15 grains. The after-treatment is then continued in the same
way as before, viz., 15 grains on two or three successive days every eight
days for three months.
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By this method Dr. Koch and his assistants have obtained successful
results in a number of malarious districts under different conditions, but in
order to carry out the method a staff of trained observers is necessary, and
for this and other reasons it has not been widely adopted in India. It is
important however that the principles of the method should be known if
only that the differences may be clear between it and the subject of the
prevention of malarial fevers by the use of quinine. The plan is applicable
only in isolated areas in which the inhabitants are under control, and in
describing in more detail the procedure to be adopted we may assume that
the scheme is being attempted in a small jail situated at least half a mile from
the nearest inhabited area. In such a case the following steps would be
taken:—
(1) an accurate name roll of the inhabitants (men, women and
children) in the jail and within its precincts would be
obtained;
(2) a sample of the peripheral blood of each of these persons would be
taken;
(3) these specimens would be examined by the special staff of observers,
either locally or at a central laboratory, and a list of all persons
in whose blood malaria parasites had been found would be sent
to the medical officer of the jail;
(4) the medical officer would segregate all these people (who would be
called " malaria-carriers ") and would subject them to the course
of treatment with quinine just detailed. The course for each
person would last three months, and during this period specimens
of their blood would be taken frequently. If at any time one of
the malaria-carriers got an attack of fever, or if, even in the
absence of a rise of temperature, malaria parasites were found
in his blood, he would be subjected to the five days' course of
treatment and to the course of "after-treatment." If from
any cause the treatment of one of the " malaria-carriers"
was interrupted for more than 10 days the whole three months'
course would have to be recommenced from the date the
patient again came under treatment •