The prognosis of malaria is so different according to the kind of infection, the climatic conditions, and individual circumstances that little in general can be said about it. Certain rules valuable in general pathology may be laid down here.
The robust and young, not broken down by alcohol, with healthy organs, when well nursed and properly treated, have naturally a better prospect even in the severe forms of malaria than feeble, old cachectics whose resisting power has been diminished by alcohol, overwork, or deprivation, and who fail to obtain proper nursing.
In addition we can state that infections with parasites of the first group give quoad vitam an almost absolutely favorable prognosis,* while infection with parasites of the second group may terminate unfavorably. The blood examination, therefore, gives important information in the prognosis.
In infections with parasites of the second group the prognosis is further influenced by the clinical symptoms, as well as the individual characteristics of the patient and of the "genius epidemicus."
We have already called attention to the usual mortality when discussing the more important pernicious forms. According to L. Colin, the fatality of the pernicious fevers in an ascending scale is: Icteric, comatose, delirious, cardialgic, algid, syncopal.
When giving a prognosis in pernicious cases, we must remember that one attack may be followed after a longer or shorter interval by a second, third, etc.
Fevers of the second group usually relapse in spite of quinin; fevers of the first group, rarely. Some authorities ascribe to quartan fever an obstinacy in this direction, though others, with whom I agree, deny this. Nevertheless it appears that the tendency of quartan to spontaneous recovery is very slight, and its bad reputation
* Even Celsus writes (Lib. iii, Cap. xv): " Nam quartana neminem jugulat; sed si ex facta quotidiana est, in malis seger est; quod tamen, nisi culpa vel aegri vel curantis, nunquam fit." probably comes from the time before the introduction of quinin. Moreover, though a positive and absolute cure usually follows the administration of quinin in cases of fevers of the first group, there are exceptions in which relapses occur in spite of the therapy.
We intend to introduce here a few figures from a large and mixed material which may serve to show the seriousness of malaria .
Beginning with Italy, since it is the most intensely infected civilized country, we find that in the years 1890, 1891, and 1892 there were 49,407 deaths from malaria , or 54 deaths annually among 100,000 inhabitants. In Rome alone there occurred-
In the year 1881 ...............................650 deaths.
" 1882 ...............................505 "
" 1892 ...............................139 "
.In the severely infected parts of Italy 8 per cent, of the inhabitants yearly fall victims to it. In the year 1895 the Italian army had 4856 malarial cases in hospitals, of which 13 died.
The Russian army showed, in 1881, 799,814 malarial cases, or 87.58 per cent, of the whole morbidity. Among these there were 279 deaths, or 0.35 per cent.
In the quinquennium from 1880 to 1884 the Russian army had an average morbidity of 75.83 per cent, from malaria (estimated from the whole force), with a mortality of 0.23 per cent.
According to Pampoukis, 14,000 malarial cases, among 40,000 admissions, were admitted to the hospitals in Athens in the course of five years. According to the same writer, one third of the morbidity throughout Greece was attributable to malaria . The mortality amounted to 4 :10,000. Seven per cent, of the cases were pernicious and showed a mortality of from 21 to 33 per cent.
The mortality of the different forms was as follows:
General mortality............................. 0.04 per cent.
Mortality from continued fever.................. 0.70 " "
Mortality from pernicious fever..................21.40 " "
Mortality from hemoglobinuria.................. 6.60 " "
According to the latest reports, the French garrison in Algeria showed 100 to 200 cases of malaria per thousand of the force: the mortality did not exceed 1 to 2 per cent. How much the severity of the disease has diminished in Algeria is evident from the fact that in the year 1833 the garrison of Bona had, among 5500 men, 4097 malarial cases requiring hospital treatment, 830 of which died.
That there are even yet severe malarial foci in Algeria is shown by Verdan's report from the station Wargla. Among the natives there was a general morbidity of 648, with a mortality of 122, of which 167 and 110 respectively represent the figures for malaria .
In the Department Ille et-Vilaine there occurred in 1873, among 10,089 inhabitants, 1696 cases of malaria , with 50 deaths.
In the Commune Bain alone, with 4266 inhabitants, there occurred, according to Dr. Blanche, 1866 cases (303 men, 596 women, 967 children); the above mentioned 50 deaths occurred entirely in this small commune. Among the 50 deaths, there were 25 children (Woillez) *
In the year 1878 the Department Morbihan had 452 cases, with 195 deaths (Herard); in 1880, 5705 cases, with 253 deaths; 1881, 2795 cases, with 191 deaths (L. Colin).
The English army in India, with a standing force of 64,137 men, showed, in the year 1892, a morbidity from "fevers" of 35,942 cases, with 474 deaths. Of these, 34,433 were malaria , with 98 deaths. The other deaths were due to "enteric fever," the majority of which were typhoid.
. The native army, numbering 127,355 men, showed 66,989 cases of intermittent, with 125 deaths and 1676 remittent, with 181 deaths: (Fayrer).
In Bengal 53,753 Europeans suffered from malaria . Among these there were 51,287 cases of quotidian type, with 646 deaths; 2097 of tertian type, with 12 deaths; and 369 of quartan type, with 2 deaths (Waring, quoted by Fayrer).
During the French campaign in 1895 malaria raged frightfully among the French as well as the native troops. In the French Army of Occupation the deaths reached in a few months the enormous figure of 6000 (almost one fourth of the entire force), so that Queen Ranavalo, of Tamatave, had reason to say: "The fever is my best general."
Segard observed in Madagascar 15 deaths among 24 pernicious cases.
According to Qu6taud, among a crew of 76 men on the ship "Thisbe" in Gabun (West Africa), 52 were attacked with malaria and 22 died.
Borius found in Senegal that one third of the pernicious cases ended fatally. Still, in certain places and at certain times milder forms occur, as is shown by the report of Cartier from Diego-Suarez in the year 1888. Among 1024 cases of malaria he had 4 deaths.
* We must add that the civil sanitary records give the data of the deaths, though not of the number of cases, reports of which are not compulsory. The latter are, therefore, approximate.
We will not add to these statistics, since it is already clear how different the mortality may be under different circumstances. Rapid intelligent treatment under otherwise favorable conditions will give the best results.