The Home Medical Library, Volume 1 (of 6)

by Unknown

CHAPTER III

Malaria and Yellow Fever

The Malarial Parasite—Mosquitoes the Means of Infection—Different Forms of Malaria—Symptoms and Treatment—No Specific for Yellow Fever.

MALARIA; CHILLS AND FEVER; AGUE; FEVER AND AGUE; SWAMP OR MARSH FEVER; INTERMITTENT OR REMITTENT FEVER; BILIOUS FEVER.—Malaria is a communicable disease characterized by attacks of fever occurring at certain intervals, and due to a minute animal parasite which inhabits the body of the mosquito, and is communicated to the blood of man by the bites of this insect.

In accordance with this definition malaria is not a contagious disease in the sense that it is acquired by contact with the sick, which is not the case, but it is derived from contact with certain kinds of mosquitoes, and can be contracted in no other way, despite the many popular notions to the contrary. Mosquitoes, in their turn, acquire the malarial parasite by biting human beings suffering from malaria. It thus becomes possible for one malarial patient, coming to a region hitherto free from the disease, to infect the whole district with malaria through the medium of mosquitoes.

Causes.—While the parasite infesting mosquitoes is the only direct cause of malaria, yet certain circumstances are requisite for the life and growth of the mosquitoes. These are moisture and proper temperature, which should average not less than 60° F. Damp soil, marshes, or bodies of water have always been recognized as favoring malaria.

Malaria is common in temperate climates—in the summer and autumn months particularly, less often in spring, and very rarely in winter, while it is prevalent in the tropics and subtropics all the year round, but more commonly in the spring and fall of these regions. The older ideas, that malaria was caused by something arising in vapors from wet grounds or water, or by contamination of the drinking water, or by night air, or was due to sleeping outdoors or on the ground floors of dwellings, are only true in so far as these favor the growth of the peculiar kind of mosquitoes infected by the malarial parasites. Two essentials are requisite for the existence of malaria in a region: the presence of the particular mosquito, and the actual infection of the mosquito with the malarial parasite. The kind of mosquito acting as host to the malarial parasite is the genus Anopheles, of which there are several species. The more common house mosquito of the United States is the Culex. The Anopheles can usually be distinguished from the latter by its mottled wings, and, when on a wall or ceiling, it sits with the body protruding at an angle of 45° from the surface, with its hind legs hanging down or drawn against the wall. In the case of the Culex, the body is held parallel with the wall, the wings are usually not mottled, and the hind legs are carried up over the back.

When a mosquito infected with the malarial parasite bites man, the parasite enters his blood along with the saliva that anoints the lancet of the mosquito. The parasite is one of the simplest forms of animal life, consisting of a microscopical mass of living, motile matter which enters the red-blood cell of man, and there grows, undergoes changes, and, after a variable time, multiplies by dividing into a number of still smaller bodies which represent a new generation of young parasites. This completes the whole period of their existence. It is at that stage in the development of the parasite in the human body when it multiplies by dividing that the chills and fever in malaria appear. What causes the malarial attack at this point is unknown, unless it be that the parasites give rise to a poison at the time of their division. Between the attacks of chills and fever in malaria there is usually an interval of freedom of a few hours, which corresponds to the period intervening in the life of the parasite in the human body, between the birth of the young parasites and their growth and final division, in turn, into new individuals. This interval varies with the kind of parasite. The common form of malaria is caused by a parasite requiring forty-eight hours for its development. The malarial attacks caused by this parasite then occur every other day, when the parasite undergoes reproduction by division. However, an attack may occur every day when there are two separate groups of these parasites in the blood, the time of birth of one set of parasites, with an accompanying malarial attack, happening one day; that of the other group coming on the next, so that between the two there is a daily birth of parasites and a daily attack of malaria. In cases of malaria caused by one group of parasites the attacks appear at about the same time of day, but when the attacks are caused by different groups of parasites the times of attack may vary on different days. In the worst types of malaria the parasites do not all go through the same stages of development at the same time, as is commonly the case in the milder forms prevalent in temperate regions, so that the fever—corresponding to the stage of reproduction of the parasites—occurs at irregular intervals.

In a not uncommon type of malaria the attacks occur every third day, with two days of intermission or freedom from fever. Different groups of parasites causing this form of malaria, and having different times of reproduction, may inhabit the same patient and give rise to variation in the times of attack. Thus, an attack may occur on two successive days with a day of intermission.

The reproduction of the parasite in the human blood is not a sexual reproduction; that takes place in the body of the mosquito.

When a healthy mosquito bites a malarial patient, the parasite enters the body of the mosquito with the blood of the patient bitten. It enters its stomach, where certain differing forms of the parasite, taking the part of male and female individuals, unite and form a new parasite, which, entering the stomach wall of the mosquito, gives birth in the course of a week to innumerable small bodies as their progeny. These find their way into the salivary glands which secrete the poison of the mosquito bite, and escape, when the mosquito bites a human being, into the blood of the latter and give him malaria.

Distribution.—Malaria is very widely distributed, and is much more severe in tropical countries and the warmer parts of temperate regions. In the United States malaria is prevalent in some parts of New England, as in the Connecticut Valley, and in the course of the Charles River, in the country near Boston. It is common in the vicinity of the cities of Philadelphia, New York, and Baltimore, but here is less frequent than formerly, and is of a comparatively mild type. More severe forms prevail along the Gulf of Mexico and the shores of the Mississippi and its branches, especially in Mississippi, Texas, Louisiana, and Arkansas, but even here it is less fatal and widespread than formerly. In Alaska, the Northwest, and on the Pacific Coast of the United States malaria is almost unknown, while it is but slightly prevalent in the region of the Great Lakes, as about Lakes Erie and St. Clair.

Development.—Usually a week or two elapses after the entrance of the malarial parasite into the blood before symptoms occur; rarely this period is as short as twenty-four hours, and occasionally may extend to several months. It often happens that the parasite remains quiescent in the system without being completely exterminated after recovery from an attack, only to grow and occasion a fresh attack, a month or two after the first, unless treatment has been thoroughly prosecuted for a sufficient time.

Symptoms.—Certain symptoms give warning of an attack, as headache, lassitude, yawning, restlessness, discomfort in the region of the stomach, and nausea or vomiting. The attack begins with a chilliness or creeping feeling, and there may be so severe a chill that the patient is violently shaken from head to foot and the teeth chatter. Chills are not generally seen in children under six, but an attack begins with uneasiness, the face is pinched, the eyes sunken, the lips and tips of the fingers and toes are blue, and there is dullness and often nausea and vomiting. Then, instead of a chill, the eyelids and limbs begin to twitch, and the child goes into a convulsion. While the surface of the skin is cold and blue during a chill, yet the temperature, taken with the thermometer in the mouth or bowel, reaches 102°, 105°, or 106° F., often. The chill lasts from a few minutes to an hour, and as it passes away the face becomes flushed and the skin hot. There is often a throbbing headache, thirst, and sometimes mild delirium. The temperature at this time, when the patient feels intensely feverish, is very little higher than during the chill. The fever lasts during three or four hours, in most cases, and gradually declines, as well as the headache and general distressing symptoms with the onset of sweating, to disappear in an hour or two, when the patient often sinks into a refreshing sleep. Such attacks more commonly occur every day, every other day, or after intermissions of two days. Rarely do attacks come on with intervals of four, five, six, or more days. The attacks are apt to recur at the same time of day as in the first attack. In severe cases the intervals may grow shorter, in mild cases, longer. In the interval between the attacks the patient usually feels well unless the disease is of exceptional severity. There is also entire freedom from fever in the intervals except in the grave types common to hot climates. Frequently the chill is absent, and after a preliminary stage of dullness there is fever followed by sweating. This variety is known as "dumb ague."

Irregular and Severe Form—Chronic Malaria.—This occurs in those who have lived long in malarial regions and have suffered repeated attacks of fever, or in those who have not received proper treatment. It is characterized by a generally enfeebled state, the patient having a sallow complexion, cold hands and feet, and temperature below normal, except occasionally, when there may be slight fever. When the condition is marked, there are breathlessness on slight exertion, swelling of the feet and ankles, and "ague cake," that is, enlargement of the spleen, shown by a lump felt in the abdomen extending downward from beneath the ribs on the left side.

Among unusual forms of malaria are: periodic attacks of drowsiness without chills, but accompanied by slight fever (100° to 101° F.); periodic attacks of neuralgia, as of the face, chest, or in the form of sciatica; periodic "sick headaches." These may take the place of ordinary malarial attacks in malarial regions, and are cured by ordinary malarial treatment.

Remittent Form (unfortunately termed "bilious").—This severe type of malaria occurs sometimes in late summer and autumn, in temperate climates, but is seen much more commonly in the Southern United States and in the tropics. It begins often with lassitude, headache, loss of appetite and pains in the limbs and back, a bad taste, and nausea for a day or two, followed by a chill, and fever ranging from 101° to 103° F., or more. The chill is not usually repeated, but the fever is continuous, often suggesting typhoid fever. With the fever, there are flushed face, occasional delirium, and vomiting of bile, but more often a drowsy state. After twelve to forty-eight hours the fever abates, but the temperature does not usually fall below 100° F., and the patient feels better, but not entirely well, as in the ordinary form of malaria, where the fever disappears entirely between the attacks. After an interval varying from three to thirty-six hours the temperature rises again and the more severe symptoms reappear, and so the disease continues, there never being complete freedom from fever, the temperature sometimes rising as high as 105° or 106° F. In some cases there are nosebleed, cracked tongue, and brownish deposit on the teeth, and a delirious or stupid state, as in typhoid fever, but the distention of the belly, diarrhea, and rose spots are absent. The skin and whites of the eyes often take on the yellowish hue of jaundice. This fever has been called typhomalarial fever, under the supposition that it was a hybrid of the two. This is not the case, although it is possible that the two diseases may occur in the same individual at the same time. This, indeed, frequently happened as stated, in our soldiers coming from the West Indies during the Spanish-American War—but is an extremely uncommon event in the United States.

Pernicious Malaria.—This is a very grave form of the disease. It rarely is seen in temperate regions, but often occurs in the tropics and subtropics. It may follow an ordinary attack of chills and fever, or come on very suddenly. After a chill the hot stage appears, and the patient falls into a deep stupor or unconscious state, with flushed face, noisy breathing, and high fever (104° to 105° F.). Wild delirium or convulsions afflict the patient in some cases. The attack may last for six to twenty-four hours, from which the patient may recover, only to suffer another like seizure, or he may die in the first. In another form of this pernicious malaria the symptoms resemble true cholera, and is peculiar to the tropics. In this there are violent vomiting, watery diarrhea, cramps in the legs, cold hands and feet, and collapse. Sometimes the attack begins with a chill, but fever, if any, is slight, although the patient complains of great thirst and inward heat. The pulse is feeble and the breathing shallow, but the intellect remains clear.

Death often occurs in this, as in the former type of pernicious malaria, yet vigorous treatment with quinine, iron, and nitre will frequently prove curative in either form.

Black Water Fever.—Rarely in temperate climates, but frequently in the Southern United States and in the tropics, especially Africa; after a few days of fever, or after chilliness and slight fever, the urine becomes very dark, owing to blood escaping in it. This sometimes appears only periodically, and is often relieved by quinine. It is apparently a malarial fever with an added infection from another cause.

Chagres Fever.—A severe form of malarial fever acquired on the Isthmus of Panama, apparently a hemorrhagic form of the pernicious variety, and so treated.

Detection.—To the well-educated physician is now open an exact method of determining the existence of malaria, and of distinguishing it from all similar diseases, by the examination of the patient's blood for the malarial parasite—its presence or absence deciding the presence or absence of the disease. For the layman the following points are offered: intermittency of chills and fever, or of fever alone, should suggest malaria, particularly in a patient living in or coming from a malarial region, or in a previous sufferer from the disease. In such a case treatment with quinine will solve the doubt in most cases, and will do no harm even if the disease be not malaria. Malaria is one of the few diseases which can be cured with certainty by a drug; failure to stop the symptoms by proper amounts of quinine means, in the vast majority of cases, that they are not due to malaria. There are many other diseases in which chills, fever, and sweating occur at intervals, as in poisoning from the presence of suppuration or formation of pus anywhere in the body, but the layman's ignorance will not permit him to recognize these in many instances. The quinine test is the best for him.

Prevention.—Since the French surgeon, Laveran, discovered the parasite of malaria in 1880, and Manson, in 1896, emphasized the fact that the mosquito is the medium of its communication to man, the way for the extermination of the disease has been plain. "Mosquito engineering" has attained a recognized place. This consists in destroying the abodes of mosquitoes (marshes, ponds, and pools) by drainage and filling, also in the application of petroleum on their surface to destroy the immature mosquitoes. Such work has already led to wonderful results.[11] Open water barrels and water tanks prove a fruitful breeding place for these insects, and should be abolished. The protection of the person from mosquito bites is obtained by proper screening of habitations and the avoidance of unscreened open air, at or after nightfall, when the pests are most in evidence. Dwellings on high grounds are less liable to mosquitoes. Persons entering a malarial region should take from two to three grains of quinine three times a day to kill any malarial parasites which may invade their blood, and should screen doors and windows. Patients after recovery from malaria must prolong the treatment as advised, and renew it each spring and fall for several years thereafter. A malarial patient is a direct menace to his entire neighborhood, if mosquitoes enter.

Treatment.—The treatment of malaria practically means the use of quinine given in the proper way and in the proper form and dose. Despite popular prejudices against it, quinine is capable of little harm, unless used in large doses for months, and no other remedy has yet succeeded in rivaling it in any way. Quinine is frequently useless from adulteration; this may be avoided by getting it of a reliable drug house and paying a fair price for the best to be had. Neither pills nor tablets of quinine are suitable, as they sometimes pass through the bowels undissolved. The drug should be taken dissolved in water, or, more pleasantly, in starch wafers or gelatin capsules. When the drug is vomited it may be given (in double the dose) dissolved in half a pint of water, as an injection into the bowels, three times daily. Infants of a few months may be treated by rubbing an ointment (containing thirty grains of quinine sulphate mixed with an ounce and a half of lard) well into the skin of the armpits and groins, night and morning. Children under the age of two can be best treated by quinine made into suppositories—little conical bodies of cocoa butter containing two grains each—one being introduced into the bowel, night and morning.

During an attack of malaria the discomfort of the chill and fever may be relieved to considerable extent by thirty grains of sodium bromide (adult dose) in water. Hot drinks and hot-water bottles with warm covering may be used during the chill, while cold sponging of the whole naked body will afford comfort during the hot stage. In the pernicious form, attended with unconsciousness, sponging with very cold water, or the use of the cold bath with vigorous friction of the whole body and cold to the head are valuable. The effect of quinine is greatest during the time of birth of a new generation of young parasites in the blood, which corresponds with the time of the malarial attack. But in order that the quinine shall have time to permeate the blood, it must be given two to four hours before the expected chill, and then will probably prevent the next attack but one. A dose of ten grains of quinine sulphate taken three times daily for the first three days of treatment; then a dose of three grains, three times daily for two weeks; and finally two grains, three times daily for the rest of the month of treatment will, in many cases, complete a cure. If the quinine cause much ringing in the ears and deafness, it will be found that sodium bromide taken with the quinine (in twice the dose) dissolved in water, will correct this trouble. If the patient is constipated and the bowel discharges are light colored, a few one-quarter grain doses of calomel may be taken every two hours, and followed in twelve hours by a dose of Epsom salts, on the first day of treatment, with quinine. It is no use to take quinine by the mouth later than two hours before an attack, and if the patient cannot secure treatment before this time, he should take a single dose of twenty grains of quinine.

To children may be given a daily amount of quinine equal to one grain for each year of their age. In the severe forms of remittent and pernicious types of malaria it may be necessary for the patient to take as much as thirty grains of quinine every three days or so to cut short the attack. But, unfortunately, the digestion may be so poor that absorption of the drug does not occur, and in such an event the use of quinine in the form of the bisulphate in thirty-grain doses, with five grains of tartaric acid, will in some cases prove effective. Chronic malaria is best treated with small doses of quinine, together with arsenic and iron. A capsule containing two grains of quinine sulphate, one-thirtieth grain of arsenious acid, and two grains of reduced iron should be taken three times daily for several weeks.

YELLOW FEVER.—This is a disease of tropical and subtropical countries characterized by fever, jaundice, and vomiting (in severe cases vomiting of blood), caused by a special germ or parasite which is communicated to man solely through the agency of the bites of a special mosquito, Stegomyia fasciata.

Distribution.—Yellow fever has always been present in Havana, Rio, Vera Cruz, and other Spanish-American seaports; also on the west coast of Africa. It is frequently epidemic in the tropical ports of the Atlantic in America and Africa, and there have been numerous epidemics in the southern and occasional ones in the northern seacoast cities of the United States. The last epidemic occurred in the South in 1899. Rarely has the disease been introduced into Europe, and it has never spread there except in Spanish ports. The disease is one requiring warm weather, for a temperature under 75° F. is unsuitable to the growth of the special mosquito harboring the yellow-fever parasite. It spreads in the crowded and unsanitary parts of seacoast cities, to which it is brought on vessels by contaminated mosquitoes or yellow-fever patients from the tropics. Havana has heretofore been the source of infection for the United States, but since the disease has been eradicated by the American army of occupation, that danger has been removed. Yellow fever is not at all contagious in the sense that a healthy person can contract the disease by contact with a yellow-fever patient, or with his discharges from the stomach, bowels, or elsewhere, and is probably only communicated to man by the bite of a particular kind of mosquito harboring the yellow-fever organism in its body. Both these facts have been incontestably proved,[12] in part by brave volunteers from the United States Army who submitted to sleep for twenty-one days on clothes soiled with discharges from patients dying of yellow fever, and escaped the disease; and by others living in uncontaminated surroundings who permitted themselves to be bitten by infected mosquitoes and promptly developed yellow fever.

Development.—After a person has been bitten by an infected mosquito, from fourteen hours to five days and seventeen hours elapse before the development of the first symptoms—usually this period lasts from three to four days. With the appearance of a single case in a region, a period of two weeks must elapse before the development of another case arising from the first one. This follows because a mosquito, after biting a patient, cannot communicate the germ to another person for twelve days, and two days more must elapse before the disease appears in the latter.

Symptoms.—During the night or morning the patient has a chill (or feels chilly) and experiences discomfort in the stomach, with sometimes nausea and vomiting. There is pain through the forehead and eyes, in the back and thighs, and often in the calves. The face is flushed and slightly swollen—particularly the upper lip—and the eyes are bloodshot, and gradually, in the course of thirty-six hours, the whites become yellowish. This is one of the most distinguishing features of the fever, but is often absent in children. The tongue is coated, there are loss of appetite, lassitude, sore throat, and constipation. In the beginning the temperature ranges from 101° to 103° F., or in severe cases as high as 105° or 106° F., and the pulse from 110 to 120 beats a minute. The fever continues for several days—except in mild cases—but the pulse usually falls before the temperature does. For example, the temperature may rise a degree during the third day to 103° F., while the pulse falls ten or more beats at the same time and may not be over 70 or 80, while the temperature is still elevated. This is another peculiar feature of the disease. Vomiting often increases on the second or third day, and the dreaded "black vomit" may then occur. This presents the appearance of coffee grounds or tarry matter and, while a dangerous symptom, does not by any means presage a fatal ending. The black color is due to altered blood from the stomach, and bleeding sometimes takes place from the nose, throat, gums, and bowels, with black discharges from the latter. The action of the kidneys is usually interfered with, causing diminution in the amount of urine. It is extremely important to pay regard to this feature, because failure of the patient to pass a proper amount of urine calls for prompt action to avert fatal poisoning from retained waste matters in the blood. The normal amount of urine passed in twenty-four hours in health is over three pints, and while not more than two-thirds of this amount could be expected to be passed by a fever patient, yet in yellow fever the passage of urine may be almost or wholly suppressed. The course of the disease varies greatly. In children—especially of the Creoles—it is frequently so mild as to pass unnoticed. In adults the fever may only last a few hours, or two or three days, with gradual recovery from the various symptoms, and yellowness of the skin lasting for some time. This is not seen readily during the stage of fever when the surface is reddened, but at that time may be detected by pressure on the skin for a minute, when the skin will present a yellow hue on removing the finger before the blood returns to the pressure spot. With fall of fever, and abatement of symptoms after two or three days, the patient, instead of going on to recovery may, after a few hours or a day or two, again become very feverish and have vomiting—perhaps of blood or black vomit—yellow skin, feeble pulse, failure of kidney action with suppression of urine, delirium, convulsions, stupor, and death; or may begin to again recover after a few days. Mild fever, slight jaundice, and absence of bleeding are favorable signs; black vomit, high fever, and passage of little urine are unfavorable signs. The death rate is very variable in different epidemics and among different classes; anywhere from fifteen to eighty-five per cent. Among the better classes it is often not greater than ten per cent in private practice. Heavy drinkers and those living in unfavorable surroundings are apt to succumb.

Prevention.—Yellow fever, like malaria, is a preventable disease, and will one day be only a matter of historic interest. Dr. W. C. Gorgas, U. S. A., during 1901, by ridding Havana of the mosquito carrying the yellow-fever organism through screening barrels and receptacles holding water, and by treating drains, cesspools, etc., with kerosene, succeeded in also eradicating yellow fever from that city, so that in the following year there was not one death from this disease; whereas, before this time, the average yearly mortality had been 751 deaths in Havana. Spread of the disease is controlled by preventing access of mosquitoes to the bodies of living or dead yellow-fever patients; while personal freedom from yellow fever may be secured by avoiding mosquito bites, through protection by screens indoors, and covering exposed parts of the face, hands, and ankles with oil of pennyroyal or spirit of camphor, while outdoors.

Treatment.—There is unfortunately no special cure known for yellow fever such as we possess in malaria. The patient should be well covered and surrounded with hot-water bags during chill. It is advisable to give a couple of compound cathartic pills or a tablespoonful of castor oil at the start. Two, or at most three, ten-grain doses of phenacetin at three hours intervals will relieve the pain during the early stage. Cracked ice given frequently by the mouth and the application of a mustard paper or paste (one part mustard, three parts flour, mixed with warm water and applied between two layers of thin cotton) over the stomach will serve to allay vomiting. Cold sponging (see Typhoid Fever, p. [232]) is the best treatment for fever. The black vomit may be arrested by one-quarter teaspoonful doses of tincture of the chloride of iron, given in four tablespoonfuls of water, every hour after vomiting. The bowels should be moved daily by injection of warm soapsuds. The patient should not rise from his bed, but should use a bedpan or other receptacle. In addition, a pint of warm water, containing one-half teaspoonful of salt, should be injected into the bowel night and morning and, if possible, retained by the patient. The object of the latter is by its absorption to stimulate the action of the kidneys. The diet should consist of milk, diluted with an equal amount of water, broths, gruels, etc., and only soft food should be given for ten days after recovery. Iced champagne in tablespoonful doses at frequent intervals, or two teaspoonful doses of whisky in a little ice water, given every half hour, relieves vomiting and supports the strength.

FOOTNOTES:

[11] See Volume V, p. 76, for detailed methods.—Editor.

[12] See Frontispiece, Vol. V.