VOL. LIII. AUGUST. 1929. Authors are alone responsible for the statements made and the opinions expressed in their papers. of tbr (tommuntcattotla. THE MALARIA TREATMENT CENTRE-KASAULI. By MAJOR S. SMITH, Royal Army Medical Corp8. HISTORICAL. . . No. 2 THE Malaria Treathlent. Centre (M.T;(J.) was initiated early in 1924 in the hope of finding a really satisfactory treatment for chronic relapsiQg malaria, admittedly the most crjppling disease with which our Army in India has to cope. The first commanding officer was Major Siriton, V.C., O.B.E., LM.S., who had already gained considerable experience as the head of a civil" Quinine and Malaria Enquiry," which had been investigating various malaria problems amongst the jail and civil populations of Northern India and of which the M.T:C. might be called a military offshoot. In his selection of Kasauli as the site of the new venture, the D.M.S. (Major-General O. L. Robinson,' C.B., ,C.M.G.) was doubtless influenced partl y by the proximity of' the other scientific medical institutions at Kasauli and partly by the fact that this Hill Station, being 6,100 feet above sea level, is above the malaria belt (at this particular latitude) and, for this reason, the possibility of fresh malarial infections modifying or distorting the results could be ruled out of court. In other words he could be sure that any individual attack of malaria at the M.T.C: was due to the inadequacy of the treatment previously employed, and not to allY vagaries of the illOSquito, producing a fresh infection, for which previous treatment could not be blamed. .. In 1927, Major Sinton left the centre to take up the new appointment . of Director of the M:alar,ia.S1,lr,vey of Indif!,,:also !Lt Kasauli,and ·from his 6 Protected by copyright. on July 30, 2020 by guest. http://militaryhealth.bmj.com/ J R Army Med Corps: first published as 10.1136/jramc-53-02-01 on 1 August 1929. Downloaded from
Transcript
VOL. LIII. AUGUST. 1929.
Authors are alone responsible for the statements made and the opinions expressed in their papers.
~tlurnal of tbr
~rigitlal (tommuntcattotla.
THE MALARIA TREATMENT CENTRE-KASAULI. By MAJOR S. SMITH,
Royal Army Medical Corp8.
HISTORICAL. . .
No. 2
THE Malaria Treathlent. Centre (M.T;(J.) was initiated early in 1924 in the hope of finding a really satisfactory treatment for chronic relapsiQg malaria, admittedly the most crjppling disease with which our Army in India has to cope. The first commanding officer was Major Siriton, V.C., O.B.E., LM.S., who had already gained considerable experience as the head of a civil" Quinine and Malaria Enquiry," which had been investigating various malaria problems amongst the jail and civil populations of Northern India and of which the M.T:C. might be called a military offshoot.
In his selection of Kasauli as the site of the new venture, the D.M.S. (Major-General O. L. Robinson,' C.B., ,C.M.G.) was doubtless influenced partl y by the proximity of' the other scientific medical institutions at Kasauli and partly by the fact that this Hill Station, being 6,100 feet above sea level, is above the malaria belt (at this particular latitude) and, for this reason, the possibility of fresh malarial infections modifying or distorting the results could be ruled out of court. In other words he could be sure that any individual attack of malaria at the M.T.C: was due to the inadequacy of the treatment previously employed, and not to allY vagaries of the illOSquito, producing a fresh infection, for which previous treatment could not be blamed. ..
In 1927, Major Sinton left the centre to take up the new appointment . of Director of the M:alar,ia.S1,lr,vey of Indif!,,:also !Lt Kasauli,and ·from his
6
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headquarters, a fine and well-equipped building in the grounds of the Central Research Institute of India, he continues to keep a watchful eye on the M. T.e., acting in tbe advisory capacity of consulting malaria expert. vVe also receive very generous financial assistance from, tbe It Indian Research Fund AssociatiQn."
Our staff cQnsists Qfthe officer:-in-charge and an assistant surgeon provided by the Army (tbe M.T.C. is under tbe direct regis of A.H.Q., Simla), an experienced sub-assistant surgeon, a writer, laboratory a.ttendant and a sweeper paid for from funds supplied by tbe Indian Research Fund AssQciation. In addition, tbe Hill Depot, Kasauli, provides a serjeant clerk. Orderlies required for nursing duties and as clerks ar~ provided from the establishment of the M.T.C.
The malaria convalescents live in barracks, where accommodation is available for 150, and come under tbe officer commanding tbe Hill Depot for discipline, pay, messing, etc.
A physical training staff is provided to help keep the men fit, and, during the winter months, all the station guards, necessary fatigues, etc., are performed by the convalescents.
Iu addition thirty beds are set aside at tbe British Military Hospital for those wbo suffer from a relapse of malaria whilst at tbe Depot.
ROD:TINE.
Every new arrival at the M.T.C. repQrts Qn the fQllowing morning to the B.M.H. for his initial medical examination, joining the 9.30 a.m. malaria parade for this purpose. On this, his first inspection, the fresh arrival receives a thorough general pbysical examination; a blood-smear (thick film) is examined, his blood-pressure, hremoglobin percentage, weight, and spleen are measured, and the results Qf these several examinations, together with his malaria histQry, record of service, etc., are entered on his chart, which is then filed and produced at his subsequent weekly inspections both for reference and for further entries to be made thereOll.
Men whose hremoglobin has been foulld to be ullder seventy per· cent (the proportion of these is small), have, during the past seaSQn, been ordered" liver diet" (i.e., eight Qunces of cooked sheep's or bullQck's liver in addition to the ordinary diet).
'1'hose with a hremoglobin percentage between 70 to 75, have been treated with iron and arsenic tonic for a month or until their hremoglobin percentage has risen above 85.
During his first week at the M.T.C. the convalescent is excused all duties; afterwards,if fit, he is marked "general duty,'" and becomes available for guards, fatigues, etc., and joins a physical training class.
After their primary medical examination all convalescents report weekly for: (1) determination of weight; (2) examination of blood-smear (thick film); and (3) examination of spleen and liver. The results in each case being entered on their charts and checked against previQus entries. In
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tbe case of tbose undergoing" liver " or tonic treatment, weekly boomoglobin estimatiolls are made, Hellige's apparatns bein!( used.
A small proportioll of cases of parasitic relapse unaccompanied by fever or symptoms is met with at the weekl y in spections. 'rbese weo, who may feel perfectly fit , are treated in exactly tbe same way as clinical relapses; they are admitted to bospital and receive tbe full course of routine treatment.
Each case of fever is detained in hospital, three blood-slides (thick film) are taken daily and examined, and only in the event of a positive blood-slide is the patient admitted to the malaria· wards, where, after a preliminary
Palpating the splccn. The wooden leg-rest pre,'ents soiling or the m30ttrc!lS by dirt.y boots , and ensures rela.xation of the abdomina.l muscles.
hremoglobin estimntion, be at once comes under one 01' other of the routine treatments.
Our treatments were, witb the two exceptions noted below, carried ant on a rigidly alternating system of: (1) treatment nnder trial, (2) control treatment (quinine), the patients for each treatment being taken in rotation, aud given serial numbers, without any special selection. The exceptions were :-
(1) Patients who had already relapsed on one form of treatment at the M.'l'.C., received some other drug, usually plasmochin, in the treatment of a subsequent relapse.
(2) The last plasmocbin series was not, in most cases, controlled by an alternating 11 quinine gronp," our wish being to test the severity and extent of any toxic symptoms that might arise dnring treatment with plasmochin
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in modified dosage (0'04 gramme daily) in as large a number of cases as possible before the end of the season.
The temperatures of all patients are recorded on four-hourly charts for the four or five days they are in hospital, blood-slides are examined three times daily until a definite diagnosis is arrived at, and the spleen is palpated daily, the results of the examination of the spleen and of the bloou-slides being entered on the charts. When the slides have been negative for two or three days and there is apparent clinical recovery, the patient is marked out to attend and excused duty until his course of treatment is completed. During the whole course of treatment, both in and out of hospital, the patient receives his medicine once, twice, or three times a day, as the case may be, under the direct supervision of the assistant-surgeon, subassistant-surgeon, or officer in charge; this expert supervision is specially valuable in the cases under treatment with plasmochin when toxic symptoms may be recognized early and promptly dealt with.
On the completion of treatment a second hffimoglobin estimation is made.
If possible, every convalescent remains at the M.T.c. for a full observation period of two months, or for two months following cessation of treatment if he relapses while under observation. In no case ,are we allowed to keep a convalescent for more than six months, at the end of which time he must be eitbflr returned to his unit or recommended for an invaliding board. '
During this observation period, as noted above, he reports to the British Military Hospital weekly for medical examination and for the various tests to be carried out, the results of these being entered on his chart, which thus acts as a very complete medical" dossier" during the man's stay at the centre.
The summer months are exceedingly busy at Kasauli, as at other bill stations; there is frequently a shortage of officers to carry on the routine work of the .station, and as my, functions included those of staff-surgeon and ordinary' routine hospital duties, the amount of time that could be devoted daily to the malaria convalescents was somewhat limited.
However,' we managed to carry out a certain number of investigations,. and those concerning the ,. trying-out" of the various forms of treatment have been fairly complete.
I have made a point of taking personal daily notes on all cases of malaria under the various forms of treatment, paying special attention to the pr~sence and duration of splenic enlargement, presence or absence of herpes labiaiis, duration of pyrexia, persistence of ,parasites in the peripheral blood, toxic symptoms (common in treatments with plasmochin), etc., as well as the ultimate effects of the various lines of treatment on the subsequent relapse rate. Our results have;been submitted in the form of monthly clinical reports to A.H.Q., and it is· from these I have largely drawn for this paper.. .
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~~I~~ Recei\'ed 011 Medicinal fit for I blood·smear remarks anJ signature General la_t attack recelyed Dietetic I ,
----- ----- ----- -- -----_. ------ ---------- ------, Fll.ir N. N. - - Liver E.D. I Neg. HE.O. =56'2 %. B.P. =138/75
" P.
" - Q.C.M. "
Hospital . i B.T. ,j:, , full tg
N. E. D. ,
Neg. H.B.0.=66 % " "
-" " I "
N. "
-" "
E.D. Neg. " =72'9 %
" N.
" -,
" " E.D. , Neg. " =89'5 %
N. 1 G. D. i Neg. " "
-, - I
N. .- 2 - G. D. I Neg. " " !
N. - 3 - , , " " I " I
B.T: 1, "
P. "
Q.C.M. P.M.Q. - Hospital , H.B.0.=74·3 %
i gametes ~g
" N.
" -"
- KD. Neg. !
" N.
" ,-
" - E.D. ! Neg.
" N. ,. - ,. - E. D. I Neg. H.B.0.=85·4 %
" N.
" - 1 - G.D.
" ,
- 2 .- : " " " " i "
SPECIMEN CHART.
Pte. R. of the Worcesters arrived in Kasauli 29.8.28. Hremoglobin percentage on arrival 56'2. He was put on to liver diet. He relapsed with malaria B. T. (1.0 parasites found in 20 fields of a thick film) on 5.9.28 and was admitted to hospital receiving a 21 days' course of quinine, citric acid and mag sulpho mist. (Q.C.M.). For three weeks after completion of treatment there was no relapse and he was performing full duties (G.D.). On 24.10.28 he again relapsed and received a 21 days' course of plasmochin and quiniue (P.M.Q.). His H.B.O. on commencement and completion of treatment with P.M.Q. was 74'3 % and 85'4 % respectively. By the 28.11.28 he was 2 weeks clear following cessation of treatment. After a further 6 weeks' freedom from relapse (noted on another sheet of chart) he had completed his 8 weeks' observation without relapse and was returned to his unit.
?:l ~ ~. <". ""-;::...
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In addition to our main terms of reference, i.e., the effects of various drugs given during varying periods on the malaria relapse rate, we have carried out a few subsidiary investigations dealing with: (1) hoomoglobin percentage; (2) blood-pressure; (3) weighi. These will now be shortly discussed.
H1EMOGLOBIN PERCENTAGE.
The Hellige hoomoglobinometer has been used throughout by the same individual (Sub-Assistant-Surgeon Di wan Chand). The initial readings may not have been accurate, but at least all readings have been consistent.
The instrument is an easy and satisfactory one to use, the standard tint corresponding very closely with the colour of the blood examined (when diluted with fo HCI); the error due to personal equation appears slight. I have frequently tested Diwan Chand's estimations and usually we are in agreement. This cannot, I think, be said for most other types of " tin tometer " used for hremoglobin estimations where the personal factor looms unduly large. The drawback of this instrument is that a goodly prick has to be made, 20 c.mm. of blood being required for the test .
. Ha1noglobin' est'imations are made (1) on all arrivals at and departures from the M.T.C.; (2) weekly on all cases whose hoomoglobin on arrival is under 75 per cent and who COllle automatically on either liver diet (under 70 per cent), or tonic treatment (70-75 per cent); (3) at the commencement and on completion of treatment in all cases of malaria relapse.
'With very few exceptions all cases have added considerably to their hoomoglobin percentage by the time of their departure from the station. The greatest gain has been recorded in most cases during the first ten to fourteen days of tbeir stay, and is in all probability part of the physiological polycythoomia that takes place in most normal individuals after a few days' residence at any considerable height above sea-level. .
Table I shows the average hremoglobin percentage on arrival and departure with the average gain of a series of cases.
TABLE 1.
Numbers Average hremo- A vel'age hremo- Month of Average stay investigated globin per cent. globin per cent. departure ill Kasanli A verage gain
- (arrival) (d.parture)
-_._----------------------.-33 73'7 88'5 June, July 16-6 weeks 14·8 per cent. 28 79-3 87-2 August 9-5
" 7-9
" 29 76·4 88'4 September 10 " 12
" 3~ 80-0 92-8 October 10-4 "
12-8 " H 78-6 87·7 ~ November ,13
" 9-1
" 11 79-5 I
86-6 December 16 "
7-1 "
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S. Smith 87 Of 207 arrivals at the M.T.C. between the months March-November,
1928-3 bad an initial hffimoglobin under 60 per cent
23 between 60 and 70 per cent 89 71 and 80 per cent 84 81 and 90 per cent
8 over 90 per cent
One of the three with an initial h!Emoglobin percentage of 42'3, the lowest recorded during the season, was subsequently found to be suffering from a severe inter-current disease; another with an initial percentage of 54'8 was a severe case of chronic relapsing M.T, malaria from Bombay.
Of a series of 137 departures during the same period, only 11 (8 per cent) had an average hffimoglobin percentage on departure of less than 80, 11 (8 per cent) had become more anffimic and 9 (6'6 per cent) had failed to gain since arrival.
During the course of this investigation we have received striking proof of the fact that the pallor of a man's face is no guide to the extent of his anffimia. The most pallid individual met with, clinically a typical case of severe malarial anffimia, had a hffimoglobin percentage of 86'S, well above the average.
Anffimia (as judged by hffimoglobin estimation) to any serious extent would appear to be uncommon in chronic relapsing malaria, unless possibly at the commencement or during the course of an actual attack of malaria (especially M.T.) before effective treatment is instituted (vide tables IV and V).
Malarial cachexia, even after repeated relapses of malaria, is, as far as our experience goes, somewhat of a rarity in the case of the British soldier, and should not be diagnosed until all other causes of cachexia have been definitely negatived.
A white face and a history of chronic relapsing malaria do not constitute malarial cachexia.
A small series of cases was investigated to determine the effect, if any, of prolonged residence in India on the h!Emoglobin percentage. Our results appeared to indicate that residence up to six years had little ill-effect, but beyond this period there was a distinct tendency to a lowered hffimoglobin percentage.
That the number of previous relapses of malaria has little influence on the hffimoglobin percentage is suggested by the following figures! :-
Number of Previous Average hffiIDoglobin cases relapses percentage 17 1 79 20 2 78 24 3 77 10 4 81 :H more than 4 79'5
(average 6'9)
1 This observation is made in regard to the well, fed British soldier who receives adequate and early treatment for el1ch relapse.
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There are two fallacies in this series: (1) The data were taken entirely from the men's medical history sheets,
many mild relapses being missed,· In some cases medical history sheets· were lost, .
(2) In many cases the relapses were spread out over a number of years. It is probable that relatively few relapses spread out over a shorter period would produce a greater degree of ana3mia than a greater number of relapses occurring over a longer period,
BLOOD-PRESSURE (B.P).
The blood-pressure (systolic and diastolic) of all malaria convalescents is taken on arrival and shortly before departure.
The "Esska" sphygmomanometer, a German modification of the "Tycos" type, has been used throughout, and the auscultatory method (checked by palpating the radial pulse) has been made use of.
The ·average blood-pressure has remained remarkably constant from month to month and between arrival and departure, but there have been considerable fluctuations in the blood-pressure of individual cases from time to time (vide Table HA).
Below are tabulated the average blood-pressures of groups, of men taken on arrival at, and departure from, the station.
TABLE n,
Numbers Average blood- Average blood- Month of examilled pressnre. on pressure on departure A \"erage stay
arrival departnre 14 128'8 130'8 August 8'2 weeks 24 129-9 131'8 September 8'7 32 129-5 128'8 October 9'3 40 131'S 128'3 November 12'3 11 131'8 139 December 16
The systolic blood-pressure was taken of 167 men on arrival at the station; of these-
0-,- 0-0 per cent had blood-pressure under 100 mm, of Hg, 3- 1'8 between 100-110 mm, of Hg (both figures inclusive)
40-24'0 111-120 "
( 53-31'1 121-130
" " ( 46-27'5 131-140
" " (
22-13'2 141-150 "
( " 2- 12 151-155
" " (both 155)
1- 0'7 over 155 "
(160)
On the whole it was found that a slightly higher reading of the systolic blood-pressure was obtained by auscultation at the elbow than by palpation at the wrist.
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In a small proportion of cases ,the pulse could not be auscultated at the bend of the elbow (probably owing to some anatomical peculiarity) although there might be a good radial pulse.
In some few others the dia'ltolic pressure could not be gauged with any accuracy; but these eases formed a very small proportion of the whole and in the great majority the auscultatory method proved quite satisfactory.
The blood-pressure was invariably taken on the right arm, the patient lying at full length on a comfortable mattress with his arm fully extended during the reading of the manometer.
That there may be marked variations in the blood-pressure (both systolic and diastolic) of individuals"when a series of estimations at varying int6rvals is made, is shown by the accompanying table (Table IIA).
Of the two, the diastolic pressure (the difference between the systolic and pulse pressures in the subjoined table) tends to show less variation than the systolic.
TABLE HA.
Blood-pressure Initial blood- Bloon-pressure Blood-pressure Final blood- Greatest Greatest pressure pressure on variation in variation in Case No_
(in mm. of Hg) after 1 week aft.r 1 month departure blood-pressure pulse pressure
1. The patient was in hospita.l with a. severe a.ttack of urticaria when the above low systolic reading" 80" was obtained.
Figures in brackets are the pulse pressure, i.e., difference between systolic and diastolic readings.
In certain cases marked (?) the diastolic pressure could not be ascertained with-any a.ccuracy.
The above small group does not represent a continuous ~erie.s, but was abstracted from a larger similar series of seventy-five cases and shows the greatest variations in the larger group. The average greatest variation in blood-pressure for the whole group was 17:3 mm. of Hg.
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Most malaria convalescents have shown a satisfactory gain in weight during their stay at Kasauli. The average gain or loss of weight with the average duration of stay is tabulated below :-
Numbers l\Ionth of Average gain or Average duration examined departure loss of weight 01' stay
33 June and July -1'9 lb.' 16'6 weeks 28 August +4'5 lb. 9'5 30 September .. +4'4 lb. 10
38 October (only 4 lost weight)
+3'6 lb. 10'4 (4 lost weight)
42 November (4 failed to gain) I. +4'2 lb. 13 (3 lost weight)
11 December (3 failed to gain)
+6'6 lb. 16 (none failed to gain)
1 The loss in weight recorded for those who joined their units duriog June and July is explained partly by the fact that a proportion of these men had wintered in Kasauli and were merely throwing off their winter fat and clothing; June and July also were hot and oppressive and khud climbing during these months is not conducive to gain in wp.ight.
CLINICAL.
Two hundred and forty malaria convalescents have joined the malaria treatment centre since the beginning of the year. Of this number 77 have relapsed with benign tertian and 5 with malignant tertian malaria (total relapse, rate 37 per cent) while at the centre, and have been admitted to hospital. In addition, 2 had a combined ,malignant tertian and benign tertian infection. No ca~es of quartan malaria have occurred,
Of a series of 78 cases of malaria benign tertian 'relapse admitted to hospitals, 54 (69'4 per cent) only had one relapse, 20 (25'6 p~r cent) had a second relapse and 4 (5'1 per cent) had three relapses while at the centre.
Of the 5 cases of malignant tertian relapse, 3 had one relapse and:2 each had four relapses. Both of these latter had become primarily infected in the South (1 Kirkee, 1 Bombay) where a type of malignant tertian malaria more virulent and less amenable to treatment than the Punjab variety is said by some to occur.
ENLARGED SPLEEN.
Of a series of 104 malaria convalescents joining the centre only four (3'8 per cent) were noted to have clinically enlarged spleens on arrival. . Of this number two had benign tertian parasites in their peripheral blood and suffered a clinical relapse on the evening of their arrival in Kasauli.
These figures suggest that clinical enlargement of the spleen .is not commonly met with in cases of chronic relapsing malarIa between the relapses, if they are treated early and efficiently in each attack (vide footnote p. 87).
It is important to remember that malaria is not the only cause of enlarged spleen even in those with a long malarial history.
Leukremia, splenic anrem'ia, kala-azar, and tuberculosis are among a
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long list of other possible causes of an enlarged a nd tender spleen in an apyrexial patient.
Pyrexia and rigor apart, the two most important and constant physical signs met with during a clinical relapse were enlarged spleen and herpes labialis. The diagnostic value of the latter, when present, as an early sign in malaria is not, I think, fully appreciated. In many febrile conditionsamong others, fevers of the enteric group-herpes labialis is uncommon and its occurrence in a doubtful case is decidedly against the latter diagnosis and in favour of malaria.
Enlarged and tender liver was but seldom met with (one only in this series), probably on account of the small number of cases of malignant tertian treated.
Of a series of 119 relapses of malaria admitted to hospital during June to November, 1928, fifty-seven (48 per cent) were noted to have enlarged spleens at some period during the attack, usually on the second or third day.
In the same series thirty-one (26 per cent) were noted to have herpes labialis. The monthly distribution of those with enlarged spleens was as follows :-
10 occurred in 24 cases of active malaria, i.e., 41'7 per cent during Jttne 8 20 " 40'0 hly
5 occurred in 24 cases of active malaria, i.e., 20'8 per cent during June 6 20 " 30 0 July 8 25 " 28'0 August 2 24 8'3 September 6 15 "40'0,, October 4 11 " 36'3 " November 2 4 " 50'0 December
It will be noted that the monthly distribution of herpes labialis in this small series of cases was much more "patchy" than that of enlarged spleen. There appeared to be no more than a casual tendency for enlarged spleen and herpes labialis to occur together in the same patient; nor did the splenic rate appear to be influenced, except possibly to some extent in an inverse ratio, by the number of previous relapses.
Thus of a series of !j5 cases who were admitted to hospital with active malaria, 27, with an average relapse rate (before joining M.T.C.) of 2'4 attacl{s, were noted to have enlarged spleens, 28 cases, with an average relapse rate of 3'3 previous attacks, had no splenic enlargement. Of 10 cases with a history of more than 4 previous attacks only 20 per cent had splenic enlargement during a subsequent attack at the M.T.C.,
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The above results suggest that the incidence of splenic enlargement during an attack of malaria is not to any extent influenced by the number of previous relapses. In fact, for the small series examined those with a high relapse rate (more than four relapses) had the least tendency to splenic enlargement during a subsequent relapse.
That the mere finding of malarial parasites in the blood o£apyrexial patient does not rule out the co-existence of some other disease is well shown by the following case :- .
Case l.-Gunner '1'. was admitted to the B.l\:LH., Subathu, on May 14, 1928, with a two days' history of nausea, vomiting, and headache, and a
~ ~-OATE. 13 14 15 16 17 16 19 20 21 1.1 23 14 25 26 17 28 29 30 31 I 2 3 4 :; () ., a 10 11 1 I 14 I 16 17 16 DAY Of OIS 3 4 5 6 ., 8 , 10 11 I 13 14 IS 16 1"/ 18 19 20 1.1 Z1 23 24 25 26 Z7 16 l~ 30 31 n 33 34 35 36 31 3e 39
temperature of 100° F. Benign tertian rings were found in a blood-film and bis spleen was palpable. Tbe temperature dropped after the administration of quinine and remained normal for five days, On the sixth day there was a sudden rise of temperature to 101'4° F., he had a rigor, bis spleen, wbich bad receded during the apyrexial period, again became enlarged and tender, and benign tertian rings were found in a blood-slide .. He continued to run an irregular temperature in spite of quinine. After a week's pyrexia bis temperature again fell abruptly to normal and remained so for a week, at tbe end of which there was a third abrupt rise to 102° F. : benign tertian rings were again present in a blood-film. In spite of the
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continued administration of quinine by the mouth, much of which he vomited, and by intramuscular. injection, he continued to run an irregular pyrexia and was transferred to the B.M.H., Kasauli,on June 15, as a case 'of resistant malaria. He ran an irregular pyrexia for a further fifteen days, during which time frequent blood-slides were negative. Bacillus typhosus was isolated from his stools on June 27, the twenty-third day of his third pyrexial attack. After a further apyrexial period he suffered a further mild relapse lasting eight days. .
It is interesting to conjecture in this case to which bout of fever should be ascribed the primary attack of typhoid. It was considered that the first two febrile attacks were in all probability uncomplicated malaria, somewhat resistant to quinine on account of the continuous vomiting. During the third more prolonged pyrexial attack typhoid fever was grafted on to an attack of malaria; the fourth pyrexial attack was a mild typhoid relapse.
(To be continued.)
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ilitaryhealth.bmj.com
/J R
Arm
y Med C
orps: first published as 10.1136/jramc-53-02-01 on 1 A
