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TREATMENT of MALARIAL \ FEVER. with -Illustrating Chltrts J R Army Med Corps: first published as 10.1136/jramc-28-06-02 on 1 June 1917. Downloaded from 658 rrHE 'DIAGNOSIS, AND 'TREATMENT OF MALARIAL \ FEVER. With -Illustrating Chltrts, By CAPTAIN DAVID THO:M:SON, Royal Army Medical CM·ps. CONTENTS. , ' , ,(1)"PREFATORY NOTE. (2) THE DIFFERENT ',T,YPES OF, JliIALARIA. (3) THE CLINICAL' DIAGNOSIS OF MALARIA. (a) The Temperature. ' @ Splenic Enlargement. (c) Amemia and-Cachexia. (d),_(e), (fj'and (g) Amemia,' Jaundice, Rigors, Headache, Vomiting. (h) Quinine Diagnosis. , ,(i) Diseases 'liable to be confused with Malaria. (4) .THE, DIAGNOSIS OF' MALARIA BY MICROSCOPIC EXAMINATION OF THE 'BLOOD, Protected by copyright. (a) The Thin·Film Method. (b) The Thick Film Method. (c) The Number, of Parasites required to produce Fever. Jd) The Leucocytes. , _ (5) THE COURSE OF THE DISEASE WITHOUT QUININE TREATMENT._ , (6) THE COURSE OF'THE DISEASE WITH INSUFF~CIENT QUININE' TRE<\T~IENT. (a) Isolated Doses of Quinine (ten to twenty grains). (b) Five Grains of Quinine Daily. (c) Full Doses, (thirty grains daiiy) for an Insufficient Period (seven to ten days). ,,- , , ' , (7) THE CAUSE OF THE RELA'PSE~. (8) THE NECESSARY AND ~fINIl\IU~ SHORT QUININE TREATMENT REQUIRED TO http://militaryhealth.bmj.com/ OBTAIN A. REASO:i~'lABL,E GUARANTEE OF A. QURE IN RECENT CASES. (9) THE QUININE TREATMENT' OF JliIALARIAL CASES EXHIBITING PERNICIOUS SYMPTOMS, SUCH AS ,COMA AND PERSISTENT'VoMITING. (10) THE NATURljl; A,ND CAUSE OF THE PERNICIOUS SYMPTOMS. / . (11) THE BEST MODE OF GIVING QUININE AS A ,GENERAL CURATIVE ROU_TINH: TREATMENT. , (a) Amount of Quinine, Time and Mode of Administration. \. ,J (b) Respective Values of the Different Salts~ (c) The' Hypodermic and Intramuscular Injection Controversy. (d.} The Value of Intravenous Injection. (e) The Single Large Dose Method. , (j) Further Remarks on Routine Oral'Adminis,tration. on September 25, 2021 by guest. (12) OTHER:IMPORTANT P'OINTS IN TREATMENT iN 'ADDITION TO THE ADMINISTRA­ TION OF QUIN~NE. n3) THE bfPORTANC,E' OF EARLY AND THOROUGH QUININE ,TREATMEN,T. (14) THE NECESSARY AND'MINIMUlr-'QUININE TREATMENT, RE'QUIRED TO KILL' , OFF THE GAMETES IN MALARIAL CARRIERS, SO AS TO RENDER THE~r NON­ INFECTIVE TO MOSQUITOES; '/ o - \. J R Army Med Corps: first published as 10.1136/jramc-28-06-02 on 1 June 1917. Downloaded from , l' , , , 'David Xhdmson '659, (15) ,PSEUDO:RELAPSES IN M~ARIA. 1(16) THE'RARITY or QUININE RESISTANT CASES. '(17) THE :EFFECTS OF/THE CURATIVE DOSES OF QUININE ON THE SYSTEM AND , ' - , THE, AMOUNT OF QUININE THAT THE .t\ VERAGll: ~IAN CAN STAND. (18) THE INFERIORI;Y, O~ OTHER D'RTJGS COMPARED WITH QUININE. (19)' THE UNSATISFACTORY :'!'ACTS 'ABOUT ,QUININE PROPHYL.4.XIS. "(20) SOME NOTES ON BLACKWATER FEVER. (21) SYNOPSIS OF TREA:rMENT OF, MALARiA: , (22) fl,EFERENCES TO LITERATURE: (1) PREFATORY NOTE.", , OWING to th,e'great interest that h~s been aroused recently with " , regard t? the treatment of malarial fever, Lieutenant~Oolonel Sir Honald Ross has ~sked me to write the followingaceount of some extensive and car~ful res~arches on the subje,ct carried, out by us at the 'Liv~rp<?ol School of Ti·opical' Medicine and elsewhere,10f a ' continuous period, of nearly fouryears_(1910-1913), , A(ter this laborious and 'Prolong~d3esearch\ it 'was very gratify~ Protected by copyright. ing 'to learn thatpracticaUy.aIL. of our conclusicms 'were strongly supported by the!American school of clinicians and pathologists on the Panama Canal Zone. it must be admitted ,that the opinions of the latter carried great weight, since, during a' period of ten years, -they h~d acbumu1ated in the hospitals on the Canal ·Zone" careful records (clinical and pathological), of. over, 100,000 cases. The ,same physicians; ,mqreover, had been in charge' of the .hospitals "there during practically the whole of that period.' , , - Our views, on the other: hand, were obt!i;ine9. chiefly from some 200 'cases and our opinions therefore carry v,ieight,:not' from the' http://militaryhealth.bmj.com/ immensity of numbe~s, but from the' care w~th whiqh each was i,nvestigatedfor the sole purpose of obtaining_the maximum am~unt of information possible. Nearly all .of our' cases were kept· in , ' hosp'ital for a much longer period' than was necessary, quinineand Qth~r drrigsw,ere given for varying periods 'and , fhen withh~la, the clinical-resu;lts' and the results of, bloodexamihation by special ", enumerative method!? being careiully,charted daily in every case. Some6,OO(J blood examil1ations were m,ade on these 200 cases alone. The numbers of pi],rasites and leucocytes were estimated , ,often severalt~nies daily, and" carefu1recor~s ,were kept, of the on September 25, 2021 by guest. hremoglo~in percentage, Sltc. " , ,\ Special inves,tigations were, made 'Yith regard:to "?rescent and gamete carriers" as this was verY.impo,rtant :with regard ',to. the transmission of 'the disease., ~./ . • I " J R Army Med Corps: first published as 10.1136/jramc-28-06-02 on 1 June 1917. Downloaded from 660 'Diagnosis and Treatment of Malarial Fever ' - - , \. " Our cases did not come from' o'ue locality only, but frbm many ,~ , :, parts; of the world, including the Southern United -States, Central AmeDica, the Amazon Valley and other parts of S'outh America, -al~o West Africa, East Africa" India, China, etc. ,They cQmprised - , "malignant tertianriHtlaria, benign tertian~ a few cases of quartan and some mixed cases. Some were very acute and recent cases, ' some 'were ~subacute, and scim~ 'wer~ chronic cases of long durati'on. Several'~cases cameo,under our care in a coinatose condition, and finally some had biackwater fever. _ We dealt therefore with maiaria} feverfromI)1anycountries, in all its phases. ' Our researches have already been -published with mal).y scientific " details 'in several paper~ written by us during the four years pedod of our work. As the informati,on, however, is more or .less scattered and inaccessible to the average army clinician, we have considered it necessary to 'give here a c.oncise account of O1;lr conclusions, more especiaJly with rega'rd to the riiininnlm treatment ,which we found nec'essary in or(1er to~ give a reasonable guarantee of a ,permanent , cure of the disease. " ," Protected by copyright. t ' (2) THE DIFFERENT TYPES OF MALARIA. / / ''-'Thereare threetarieties of malaria-benign tertian, malignant , . tert'ian and quartan. :These can be distinguished from each 'other­ clinically as well as by the microscopic e;xamination 'of the blood. ' (a) Benign tertian.-'J'he classical temperature curve, with a shai'p rise every third day as indicated on Chart 1 is. very characteristic. I The rise of temperature is very o~ten~ ac~ompanied by'a sever'e http://militaryhealth.bmj.com/ rigor which may las~ for half, an hour or more., puring this time the patient feels ,very ill and cold. After the fever h,as reacited its heigh~ profuse perspiration occurs, accompanied bya sudden fall in temperature. ,The diagnostic feature is the sudden ri~eand fttII of , the temperatuie,-the whole paroxysm being over as a 'rule in some - eight hours. Benign terti~n malaria is not ,often accomp~nied, by pernicious symptoms such ,as com~, and it is very seldom followed by blackwater fever. The benign tertian parasite (Plasmodium vivax) is the larg'est of the 'three: "It circulates in the peripheral blood in all its s'tages' on September 25, 2021 by guest. ,.froni the young ring forms to, the full-grown sporulating forms. The infected red-ceils -are markedly'stippled and they' are usually. much larger than th~ norma~ uninfected corpuscles'. \. \ The number of spores produced ~s a rule is sixteen, ang these / ·",1 J R Army Med Corps: first published as 10.1136/jramc-28-06-02 on 1 June 1917. Downloaded from / , .David Thcnnson 661 - " spores or young riilgs are m-uch larger than those oftlie malignant, tertian parasite.' " ' ", , ,(b) Malig1'~ant Tertian Mala~ia:-'T/his is ayery good name as this type is, as a rule, much more severe on the patient'than the, , beni~n tertian variety, and)t is also very li,able'to be accompanie4 ' by pernicious symptoms such as coma., severe vomiting, etc. OHART~l. Benign tertian mal~ria (classi~al type), .. •. ~-::? M E M, E M' E' M M M M E' E E E ~ f9 c: ·~-'f ~ , t. ,.~ t, ~' ):, 'i , 105° '~'! - " r; , .... ,,~ 11) 11) ~ ~ " ; 104°' ~, , i· . .' . -.~ ~ 0 t , ,I.; \J :t: - " 103° .. I CC " \ , . u 102° " - , ~ , .. 101 ° Protected by copyright. .. .. _1' 100° .. -, , , 99° ,& ' 98° la "- ~ " ~\ , , \ J \ ,J / ~ V \' ' .. I J 97° "' , .. " , ~ r"" • .. ~ote ,'that' ,spor~lation is synchronous ~ith' the 'rigor and ~ise of temperature, and that all stages of the parasite are found in the peri­ http://militaryhealth.bmj.com/ _ pheralblood. " ' If we _compare~ ,the typical benign t(jrtlan fever curve (Chart 1) w'ith'the typical m:align~nttertian fever curve, (Chart 2) it is' easy to see why_ the latter is more severe. At a glarlce we note that the fall of temperature does not occur quickly as ,in the case' of benign ,tertian. It falls as a'rule abou,t half a degree and then rises again, 'so that the complete paroxy'sm lasts for some eighteen to twenty hours. Clinically this is the most 'diagnos~ic feature, of, , 'maIigna,nt tertian malaria, v!z., the long duration of the fever' paroxysm. It ,must be remembered, however" that one, ,does on September 25, 2021 by guest. , occasionallJ get ,short paroxysms iit· malignant tertian, producing a chart ,indistinguishaqle from that· of benign, tertian fever (vide Chart 4). Typical rigors are more common in the benign than III tl?-e malignant tertian ;variety. I , \ " J R Army Med Corps: first published as 10.1136/jramc-28-06-02 on 1 June 1917.
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