DISSECTING ANEURYSM.1

JamesB. Coleman
1898 The Lancet  
799 others containing bacilli of a crescentic form. The white corpuscles are greatly increased in number and there are also seen numerous giant white corpuscles with patches of black colouring matter in them. The pathology of this I take to be : (1) the crescentic bacilli of malaria invade the red corpuscles and proceed to absorb the hemoglobin, converting it into melanin, and they also multiply in number (these facts I have demonstrated by examining the blood of a patient subject to malarial
more » ... ver, but about three hours before an attack of rigors was expected) ; and (2) after a variable time the red corpuscles burst, setting free crowds of bacilli (this process I have found in blood taken at the period of rigors) ; the giant white corpuscles absorb the bacilli and apparently digest them, leaving only the melanin which .remains as black patches in the corpuscles (this process may be traced by examining the blood of a patient at intervals during a typical attack of fever). The -effect of the malarial poison shows itself differently in different individuals, the most usual form being that of high fever, the period of incubation being in most cases fourteen days, during which time the patient has a great feeling of bien aise. Towards the end of the incubation he becomes irritable and chilly, generally suffering from nausea, sometimes actual vomiting. At this period he begins to have a succession of rigors, which, however, gradually cease and he becomes feverish, with a full, bounding pulse. Without drugs this stage lasts from six to eight hours, when he begins to perspire, the temperature falls, and he sleeps for several hours, awakening without fever. After a length of time, varying from twenty-four hours to a week, if the person has not been placed under the influence of drugs the fever occurs again in exact similitude to the initial attack and this may recur at intervals for months. There is also a variety of malarial poisoning without much elevation of temperature, but with marked cerebral symptoms resembling meningitis. It is a most fatal variety and post mortem no signs of inflammation of the meninges can be seen. Residents in Rhodesia are also, I find, liable to attacks of dysenteric diarrhoea, which will not yield to opium or ipecacuanha, but rapidly gives way to tincture of perchloride of iron with quinine and arsenic. I have also seen what were apparently syphilitic ulcers, especially on the legs and thighs, which proved most obstinate to the usual specific treatment, but got well at once with the iron, arsenic, and quinine mixture, with a dusting powder of quinine locally. On healing these ulcers leave a permanent brown stain on the skin. I consider both diarrhoea and ulcers due to malarial poison and the brown discolouration of the skin is possibly the local deposit of melanin from the bacilli. The sequelæ of malarial fever are only what may be naturally expected, the first and most important being the intense anaemia which is so often found and which requires lengthy treatment by iron and arsenic with, if possible, change of air. This anaemia causes anasarca of the most dependent _parts-viz., legs and feet-but this cures itself as the .anaemia decreases, as also does the intense weakness, amonnting in some cases to temporary paralysis ; whilst another result of the poverty of red-blood corpuscles is shown in the dizziness, partial blindness, and flashes of light experienced by some on recovering from a severe attack. With regard to treatment every treatise on medicine and also the so-called popular handbooks describe quinine as a "sheet anchor" in malarial fever, but my experience tells me there is no greater mistake. The result is that nearly -everyone coming to Africa brings enormous quantities of -quinine tabloids, which they take ad lib., and also dose their friends, independently of any advice from a medical man, and they fully believe they are rendering themselves proof against fever. These large doses of quinine-and it is not uncommon to find persons taking from two to three drachms a day-produce an utter rottenness of the constitution. There is a distinct quinine cachexia, easily recognised by those who see it often, and when one of these individuals falls a victim to an attack of fever he generally has it badly. I have found the most successful treatment to be absolute rest in bed, a 15 gr. dose of antipyrin to begin with, followed in an hour by the following mixture : 10 minims of tincture of perchloride of iron, 5 minims of hydrochloric solution of arsenic, with water to 1 oz. 1 oz. to be taken every four hours with a 5 gr. tabloid of sulphate of quinine. At bedtime I generally give about 5 gr. of calomel, followed in the morning by a dose of some effervescent saline. In most ordinary cases of fever this treatment cuts short an attack under twenty-four hours and then I follow up with a tonic course of Easton's syrup in 1 clr. doses with 1 oz. of water three times a day at meals for a month, and I find that most individuals will thus enjoy an immunity from malarial fever for some months at least, although living in an unhealthy district. With regard to food stimulants are required, especially champagne. This will often stop the obstinate vomiting when even a mustard poultice at the pit of the stomach fails. During an attack I order milk and hot water in equal parts, and in some cases milk with a tablespoonful of brandy to each pint. When the temperature is normal and the paroxysm is over I give any food the patient fancies, and I find this answers well. I have one patient who after an attack of fever eats ravenously of cheese, enjoys it, and, what is more to the point, digests it. In the " cerebral apyrexial form " as I term that variety with low temperature and head svmptoms, which is veiy fatal, I find, so far, that the best treatment is calomel and sulphate of magnesia in full doses, producing free purgation, giving at the same time the quinine, iron and arsenic as in an ordinary attack. It is happily a rare form. I have only seen 6 cases, of which 1 was fatal ; the rest recovered, 3 completely and 2 with some mental aberration, which I am in hopes will prove only temporary. In Africa ice-bags" " are an impossibility, and yet how often one longs for them. Here, where medical men are rare, being often from 85 to 100 miles apart, it stands to reason that there are manv farmers and traders who when they get fever cannot obtain medical advice. For these Messrs. Burroughs, Wellcome, and Co. have prepared cases for me containing five bottles and a thermometer. These contain 25 (5 gr.) tabloids of antipyrin; 100 (5 gr.) tabloids of sulphate of quinine; 100 "Iron and Arsenic Co." tabloids; and 200 (1 dr.) tabloids of Easton's syrup. I order possessors of these when " shakes " begin to go to bed and take three 5 gr. tabloids of antipyrin and one hour afterwards to take one each of quinine and iron and arsenic tabloids, repeated every three hours until the temperature is normal ; then to begin with the Easton syrup tabloids, taking one three times a day for a month, and in every case I have been told that these drugs and directions have proved a boon ; and whereas the traders, &c., at outlying stations have previously suffered all the wet season from malarial ague, now the initial attack is all they experience for the season. To sum up, it must be remembered in every case that the malarial parasite destroys the red blood corpuscles, and one method of treatment is to replace them and so raise the vitality of the tissues that they may resist further invasions of the poison. Enkelctoorn, Ehodesla.
doi:10.1016/s0140-6736(01)82130-9 fatcat:rk36dtyuorgr7fiujslta3xh2y