MALARIAL FEVERS. By Surgeon-Majok M. D. O'Connell, m.d., Medical Staff,
In the official nomenclature of disease, issued by the College of Physicians, ague, remittent fever, and malarial cachexia are united in one sub-group under the heading " Malarial
Fevers."
In the
memorandum of the sub-committee
it is stated that the classification has been drawn up on the basis of etiology, and that within the groups, further division into sub-groups indicates closer alliances of causal on
classification,
relation.
While there are good reasons for uniting ague and malarial cachexia, there are not, in my
204
INDIAN MEDICAL GAZETTE.
opinion, equally good mittent fever in the
for including resub-group with these
reasons
same
diseases. The common belief in the profession Avas, when I first came to India as it is now, that ague and remittent fever owned a common origin. I shared the common belief, and after twenty years I find it is still the prevalent opinion. Twenty years ago enteric fever was almost unknown, or at least unrecognized in India, Gradually, however, it became- apparent that many cases hitherto looked on as malarial fever were really enteric, until, at the present time, enteric fever occupies the field almost to the exclusion of the term remittent fever in our army statistics. That in this we have erred and run into the opposite extreme is, I think, apparent from the lucid report of Sir Benjamin Simpson's Committee, who point out that while the number of admissions for enteric fever has increased considerably, there is 110 proportionate increase in the mortality from this disease; and they suggest it as a possible explanation that some portion at least of this increase is due to erroneous
diagnosis. Four
five years' residence in India, and of ague and remittent fever created a doubt in my mind as to whether these diseases could be due to the same cause malaria. or
experience
Seventeen years' residence in India have this doubt to a strong conviction that ague and remittent fever cannot possibly be due to the same cause, and that there is 110 stronger reason for grouping ague with remittent fever than for grouping it with enteric fever.
changed
which presents itself at the " " treating of malarial fevers is, that when we meet with this term, we do not know whether the author refers simply to ague, or remittent fevers, or to both. Some writers bring forward strong reasons for attributing malarial fever to the presence in the blood of a microorganism. If they refer to remittent fever, they The
difficulty
outset in
are
perhaps right.
Others bring forward equally strong evidence that malarial fevers are due to seasonal or climatic influence. If they refer to ague, they are perhaps right. When they differ, they are perhaps not referring to the same disease. It seems to me that, as long as we write of malarial fevers as a group without distinctly statinowhether we refer to ague or remittent fever 0? both, the result can only be confusion, and we shall get 110 nearer to answering Oldham's question : What is malaria ? But although we do not know what malaria is, it may not be unprofitable to examine what are the reasons for and against the popular belief that, it causes both ague and remittent fever. As far as I know, the facts which are thought
[July
1891.
to support the view that ague and remittent fever own a common origin are? Is*. That ague and remittent fever -prevail at the same time in the same locality.?Even if this be so, it cannot be considered a sufficient reason for believing that these diseases are due to the same cause. Measles and enteric fever may prevail together, but no one would say they are therefore due to the same cause. Having seen several severe outbreaks of ague, usually following local inundations, I may say that the occurrence of remittent fever during these out-
breaks
was very exceptional. That there is supposed to he some resem2nd. blance between a remission and an intermission of temperature.?So far from this being the case, however, I think, that the fact of there being a fever free period every 24 or 48 hours in one disease and not in the other would seem to indicate that they are quite distinct as to their origin. Judging from typical temperature charts of remittent fever, there would seem to be just as much, if not more, reason for grouping it with In ague the norenteric fever than with ague. mal temperature is reached every 24 or 48 hours, and maintained for one or more days before it again rises. In remittent fever, on the contrary, the temperature is never normal for from 15 In fact it may be said that to 20 or more days. and terminates natufull its runs course, ague rally in about 24 hours but it recurs, if active Remitmeasures are not taken to prevent it. tent fever takes at least 15 clays to run its course, and I have no hesitation in saying that there is no more tendency to its recurrence than there is to a relapse in enteric fever. I think another difference in the temperature of the diseases is that, it seldom reaches as high a point in remittent fever as it does in ague, and the range of temperature is seldom more than 2? or 3? F., while in ague it is usually 6? or 7* F. From the length of the period that the fever lasts then, as well as from the daily range of the temperature remittent fever would seem to be more closely allied to continued fevers than
to ague.
3rd.
That
one
disease
occasionally
changes into the other.?While I do this is
runs
or
not say that
I have never seen a case of ague change into a remittent fever. So I think it must at all events be rather a rare never so,
genuine
occurrence.
I have seen a wise of enteric fever begin with a paroxysm of ague, that is, after a considerable rise of temperature lasting 24 hours, the normal temperature was reached and maintained 24 hours when it again rose and ran the ordinary course of enteric. This did not lead tne to believe that ague sometimes changes to enteric, and that they are therefore due to the same
cause;
but that
a
person about
to
suffer
July
O'CONNELL ON MALARIOUS FEVERS.
1891.]
from enteric and
pened
living
in
a
malarial district
to contract malaria also.
hap-
It also frequently happens in the fourth week of enteric fever that the temperature assumes a distinctly intermittent type. It is not reasonable to assume from these facts that ague and enteric fever are due to the same cause. Then, why are we justified in assuming from similar facts that ague and remittent fever own a common origin ? 4tli. That quinine is a specific for remittent as tvell as for intermittent fever.? If this be so, it is certainly a strong argument for the popular belief in the common origin of ague and remittent fever. I have not, however, found that it is a specific for remittent fever, or that it has an effect anything at all like what it certainly has in ague. It may, if given in considerable doses, reduce the temperature perceptibly, but it never arrests the disease as it does in ague. In ague it is an undoubted specific. In my own experience it has proved useless if not harmful in the treatment of remittent. I have seen it given to the extent of thirty or forty grains daily for nearly a fortnight, and the last state of the patient was worse than the first as can be easily
imagined. As
reasons
for
mittent fever
are
considering not
due
that ague and
to the
re-
same cause
may be noted :? ls?. Their relative prevalence.?Ague is a very common disease in India, and gave 21,783 admissions amongst the British troops in the year 1888. Remittent fever is nothing like so common a disease, and only gave 419 admissions It amongst British troops in India in 1888. can scarcely be supposed if these two diseases are due to the same cause, the difference in the number of admissions for each would be so great. Lyons writing of fevers in the Crimea says: " It is certain at all events that in the past campaigns this disease (remittent fever) has not by any means played so important a part as it has on former occasions." (Report on Pathology of Diseases of the Army in the East). Yet Hirsch in his Handbook of Geographical and Historical Pathology refers to the Crimea as the home of remittent fever. When we find statements like the above made by such world-wide authorities as Lyons and Hirsch, one can only conclude that very little is known regarding remittent fever. 2nd. Their maximum prevalence.?It ofteu happens that ague and remittent fever attain their maximum of prevalence at the same time. But it also not unfrequently happens that remittent fever reaches its greatest prevalence in most is while August, prevalent in Novague ember or December. 3rd. Their mortality.?Ague seldom kills directly, but death from remittent fever is not so uncommon. Tlius in the year 1888 there were 11 deaths from ague amougst British troops
205
in India out of 21,783 admissions, whilst there were 37 deaths from remittent fever out of only 419 admissions. 4th. Liability to recurrence.?Ague recurs. Can there be a Remittent fever does not, reason for doubting that they own a stronger The oftener a person is attackcommon origin? ed by ague, the more liable is lie to be again attacked. On the contrary, recurrence if not absolutely unknown in"remittent fever, is so rare This (remittent) in unthat Maclean writes, healthy climates is often the first form of fever that attacks new comers, but such are seldom exposed to second attacks ; in other words, there is less liability to a recurrence than in the intermittent form." I would add that an attack of ague does not protect from remittent fever, nor does the latter protect from ague. 5th. The great difference of ague and remittent fever as regards their amenability to treatment by quinine.?This has been previously referred to. 6th. Complications and sequela.?In remittent fever, there is usually hepatic disturbance, pain and tenderness, with an icteric tint of the conjunctiva and urine. In ague there is splenic pain and tenderness, which are not usually found in remittent fever. After remittent fever the liver may be seriously perdamaged. After ague the spleen may be " manently enlarged. I am not aware that ague cake" ever follows remittent fever. Again, it is not apparent that leucocythgemia or pigmental deposit in organs ever follow remittent fever, although they frequently are found after ague. In the foregoing remarks I attempt to put forward some facts which seem to me to tell against the popular view that ague and remittent fever are due to the same cause, viz., malaria, and that, therefore, they are rightly united iu one sub-group in the nomenclature of disease. I do not, however, offer any opinion as to what malaria may really be. In a second paper, however, I will make an attempt to demonstrate that seasonal or climatic influences are quite sufficient to explain the occurrence and recurrence of an intermittent The occurrence of remittent fever, howfever. ever, cannot be explained in the same way. '
In the official nomenclature of disease, issued by the College of Physicians, ague, remittent fever, and malarial cachexia are united in one sub-group under the heading " Malarial
Fevers."
In the
memorandum of the sub-committee
it is stated that the classification has been drawn up on the basis of etiology, and that within the groups, further division into sub-groups indicates closer alliances of causal on
classification,
relation.
While there are good reasons for uniting ague and malarial cachexia, there are not, in my
204
INDIAN MEDICAL GAZETTE.
opinion, equally good mittent fever in the
for including resub-group with these
reasons
same
diseases. The common belief in the profession Avas, when I first came to India as it is now, that ague and remittent fever owned a common origin. I shared the common belief, and after twenty years I find it is still the prevalent opinion. Twenty years ago enteric fever was almost unknown, or at least unrecognized in India, Gradually, however, it became- apparent that many cases hitherto looked on as malarial fever were really enteric, until, at the present time, enteric fever occupies the field almost to the exclusion of the term remittent fever in our army statistics. That in this we have erred and run into the opposite extreme is, I think, apparent from the lucid report of Sir Benjamin Simpson's Committee, who point out that while the number of admissions for enteric fever has increased considerably, there is 110 proportionate increase in the mortality from this disease; and they suggest it as a possible explanation that some portion at least of this increase is due to erroneous
diagnosis. Four
five years' residence in India, and of ague and remittent fever created a doubt in my mind as to whether these diseases could be due to the same cause malaria. or
experience
Seventeen years' residence in India have this doubt to a strong conviction that ague and remittent fever cannot possibly be due to the same cause, and that there is 110 stronger reason for grouping ague with remittent fever than for grouping it with enteric fever.
changed
which presents itself at the " " treating of malarial fevers is, that when we meet with this term, we do not know whether the author refers simply to ague, or remittent fevers, or to both. Some writers bring forward strong reasons for attributing malarial fever to the presence in the blood of a microorganism. If they refer to remittent fever, they The
difficulty
outset in
are
perhaps right.
Others bring forward equally strong evidence that malarial fevers are due to seasonal or climatic influence. If they refer to ague, they are perhaps right. When they differ, they are perhaps not referring to the same disease. It seems to me that, as long as we write of malarial fevers as a group without distinctly statinowhether we refer to ague or remittent fever 0? both, the result can only be confusion, and we shall get 110 nearer to answering Oldham's question : What is malaria ? But although we do not know what malaria is, it may not be unprofitable to examine what are the reasons for and against the popular belief that, it causes both ague and remittent fever. As far as I know, the facts which are thought
[July
1891.
to support the view that ague and remittent fever own a common origin are? Is*. That ague and remittent fever -prevail at the same time in the same locality.?Even if this be so, it cannot be considered a sufficient reason for believing that these diseases are due to the same cause. Measles and enteric fever may prevail together, but no one would say they are therefore due to the same cause. Having seen several severe outbreaks of ague, usually following local inundations, I may say that the occurrence of remittent fever during these out-
breaks
was very exceptional. That there is supposed to he some resem2nd. blance between a remission and an intermission of temperature.?So far from this being the case, however, I think, that the fact of there being a fever free period every 24 or 48 hours in one disease and not in the other would seem to indicate that they are quite distinct as to their origin. Judging from typical temperature charts of remittent fever, there would seem to be just as much, if not more, reason for grouping it with In ague the norenteric fever than with ague. mal temperature is reached every 24 or 48 hours, and maintained for one or more days before it again rises. In remittent fever, on the contrary, the temperature is never normal for from 15 In fact it may be said that to 20 or more days. and terminates natufull its runs course, ague rally in about 24 hours but it recurs, if active Remitmeasures are not taken to prevent it. tent fever takes at least 15 clays to run its course, and I have no hesitation in saying that there is no more tendency to its recurrence than there is to a relapse in enteric fever. I think another difference in the temperature of the diseases is that, it seldom reaches as high a point in remittent fever as it does in ague, and the range of temperature is seldom more than 2? or 3? F., while in ague it is usually 6? or 7* F. From the length of the period that the fever lasts then, as well as from the daily range of the temperature remittent fever would seem to be more closely allied to continued fevers than
to ague.
3rd.
That
one
disease
occasionally
changes into the other.?While I do this is
runs
or
not say that
I have never seen a case of ague change into a remittent fever. So I think it must at all events be rather a rare never so,
genuine
occurrence.
I have seen a wise of enteric fever begin with a paroxysm of ague, that is, after a considerable rise of temperature lasting 24 hours, the normal temperature was reached and maintained 24 hours when it again rose and ran the ordinary course of enteric. This did not lead tne to believe that ague sometimes changes to enteric, and that they are therefore due to the same
cause;
but that
a
person about
to
suffer
July
O'CONNELL ON MALARIOUS FEVERS.
1891.]
from enteric and
pened
living
in
a
malarial district
to contract malaria also.
hap-
It also frequently happens in the fourth week of enteric fever that the temperature assumes a distinctly intermittent type. It is not reasonable to assume from these facts that ague and enteric fever are due to the same cause. Then, why are we justified in assuming from similar facts that ague and remittent fever own a common origin ? 4tli. That quinine is a specific for remittent as tvell as for intermittent fever.? If this be so, it is certainly a strong argument for the popular belief in the common origin of ague and remittent fever. I have not, however, found that it is a specific for remittent fever, or that it has an effect anything at all like what it certainly has in ague. It may, if given in considerable doses, reduce the temperature perceptibly, but it never arrests the disease as it does in ague. In ague it is an undoubted specific. In my own experience it has proved useless if not harmful in the treatment of remittent. I have seen it given to the extent of thirty or forty grains daily for nearly a fortnight, and the last state of the patient was worse than the first as can be easily
imagined. As
reasons
for
mittent fever
are
considering not
due
that ague and
to the
re-
same cause
may be noted :? ls?. Their relative prevalence.?Ague is a very common disease in India, and gave 21,783 admissions amongst the British troops in the year 1888. Remittent fever is nothing like so common a disease, and only gave 419 admissions It amongst British troops in India in 1888. can scarcely be supposed if these two diseases are due to the same cause, the difference in the number of admissions for each would be so great. Lyons writing of fevers in the Crimea says: " It is certain at all events that in the past campaigns this disease (remittent fever) has not by any means played so important a part as it has on former occasions." (Report on Pathology of Diseases of the Army in the East). Yet Hirsch in his Handbook of Geographical and Historical Pathology refers to the Crimea as the home of remittent fever. When we find statements like the above made by such world-wide authorities as Lyons and Hirsch, one can only conclude that very little is known regarding remittent fever. 2nd. Their maximum prevalence.?It ofteu happens that ague and remittent fever attain their maximum of prevalence at the same time. But it also not unfrequently happens that remittent fever reaches its greatest prevalence in most is while August, prevalent in Novague ember or December. 3rd. Their mortality.?Ague seldom kills directly, but death from remittent fever is not so uncommon. Tlius in the year 1888 there were 11 deaths from ague amougst British troops
205
in India out of 21,783 admissions, whilst there were 37 deaths from remittent fever out of only 419 admissions. 4th. Liability to recurrence.?Ague recurs. Can there be a Remittent fever does not, reason for doubting that they own a stronger The oftener a person is attackcommon origin? ed by ague, the more liable is lie to be again attacked. On the contrary, recurrence if not absolutely unknown in"remittent fever, is so rare This (remittent) in unthat Maclean writes, healthy climates is often the first form of fever that attacks new comers, but such are seldom exposed to second attacks ; in other words, there is less liability to a recurrence than in the intermittent form." I would add that an attack of ague does not protect from remittent fever, nor does the latter protect from ague. 5th. The great difference of ague and remittent fever as regards their amenability to treatment by quinine.?This has been previously referred to. 6th. Complications and sequela.?In remittent fever, there is usually hepatic disturbance, pain and tenderness, with an icteric tint of the conjunctiva and urine. In ague there is splenic pain and tenderness, which are not usually found in remittent fever. After remittent fever the liver may be seriously perdamaged. After ague the spleen may be " manently enlarged. I am not aware that ague cake" ever follows remittent fever. Again, it is not apparent that leucocythgemia or pigmental deposit in organs ever follow remittent fever, although they frequently are found after ague. In the foregoing remarks I attempt to put forward some facts which seem to me to tell against the popular view that ague and remittent fever are due to the same cause, viz., malaria, and that, therefore, they are rightly united iu one sub-group in the nomenclature of disease. I do not, however, offer any opinion as to what malaria may really be. In a second paper, however, I will make an attempt to demonstrate that seasonal or climatic influences are quite sufficient to explain the occurrence and recurrence of an intermittent The occurrence of remittent fever, howfever. ever, cannot be explained in the same way. '
