Statistics as to the results of different methods of treatment of malarial hemoglobinuria are of only relative value, since among the differently treated cases there would be a large percentage of individuals with quinin intoxication.
Moreover, as mentioned by Corre, the results of treatment fluctuate within wide limits, according to time and place, even under exactly similar therapy; in other words, the matter is complicated by an unknown factor, the interference of which cannot be avoided. Nevertheless, we intend to introduce a few of these statistics, since better are wanting.
We take the following statistics from Berenger-Feraud. To make them intelligible we must say that this physician believes in energetic treatment with quinin. He gives 3.5 to 4.0 quinin pro die, together with quite large doses of opium. The letters standing before the different rows indicate military medical men under whose assistance the treatment was carried out. The cases occurred in West Africa.
* In one case Livio Vincenzi was unsuccessful with this combination.
Number of Patients.
Quinin in very small doses. Calomel.
Quinin in moderate doses.
Calomel in very small doses.
Quinin in very small doses.
Calomel and other purgatives
as a basis of treatment.
Quinin in large doses.
Tyson had, among 24 cases, 33.8 per cent, of recoveries with quinin, and 25 per cent, of recoveries without quinin; Webb, among 33 cases, 69.6 per cent, of recoveries with quinin, all deaths without quinin.
Steudel (East Africa), who recommends large doses and employs in the first days of the disease 8.0 quinin (once even 10.0 quinin), had among 18 cases 3 deaths, or 16 to 17 per cent.
In contrast to these favorable data the following seem to show the opposite for the treatment with quinin:
Daniel reckoned, among 93 cases, 82 per cent, of recoveries and 18 per cent, of deaths by treatment without quinin, and 59 per cent, of recoveries and 41 per cent, of deaths with quinin.
Albert Plehn (Kamerun) had, among 53 cases, 5 deaths, or 9.8 per cent, mortality, under moderate treatment with quinin. This last named authority formulates the following principle for the treatment of blackwater fever
"1. Quinin is superfluous, because the enemy which it is to combat succumbs in a short time from its own activity.
"2. Quinin is in the highest degree dangerous, on account of its tendency to produce new paroxysms by renewed disorganization of the blood after the first have happily passed."
After reading the very interesting and instructive anamneses of Plehn, we cannot resist the impression that many of his cases of blackwater fever were nothing else than quinin intoxication. According to Plehn's own statement, among the 53 paroxysms observed by him, 48 were "produced" by quinin, or, at least, followed its administration.
We cannot agree, therefore, with his conclusions for the following reasons:
Almost all of his cases took quinin either on account of general indisposition or fever. Although after this (omitting the fact whether it was only post hoc or actually propter hoc) a paroxysm of hemoglobinuria occurred, the quinin exercised, nevertheless, its antiparasitic effect. For only in this way can be explained the very small number of parasites which Plehn found in the majority of the cases that he examined. After these patients had been restored to health it was impossible to say that they would have recovered without quinin, but only that the small doses which they took before the paroxysm had been sufficient. Plehn's view that the parasites succumb after they are liberated by the destruction of the corpuscles may be correct, but it is also true that the quinin could act more readily on these than on the intraglobular parasites, and so exercise, in smaller doses, a more marked effect than ordinarily.
Moreover, we understand, from Plehn's histories, that he permitted the paroxysm of hemoglobinuria to pass under purely symptomatic treatment, yet when fever occurred again which he found himself unable to master, he turned every time to quinin, and with advantage.
Altogether, it seems to be determined that a rational therapy requires strict attention to both infection and idiosyncrasy to quinin, as well as a thorough study of the individual case from these points of view. The treatment of blackwater fever is one of the most difficult and serious problems of the tropical physician. On account of the uncertainty surrounding these cases, especially when the examination of the blood is ignored, different methods of treatment arose.
Still, some of these manifest much that is good, since they are based on the symptomatic indications, which are of considerable importance. The patients suffer, for instance, excruciating torments, which naturally call for relief.
Therefore we do nothesitate to introduce several of these methods. Though we must refer at the same time to a subsequent section for the further symptomatic treatment of malaria .
Quennec obtained good results in 22 cases, with the following treatment: In addition to moderate doses of quinin, he administered 4 to 6 gm. chloroform pro die, in the following combination:
Gummi arab., q. s.
Of this, the patient takes a swallow every ten minutes. The vomiting and singultus are favorably influenced, and the diuresis relieved.
He recommends also saline purges, together with high cold injections into the intestine (sodium chlorid 10; water 1000). Hebrard obtained good results in two cases from the same treatment.
Range recommends the following therapy: At the beginning of the first paroxysm, six wet cups to the lumbar region and an injection of quinin hydrobromate, with three drops of ergotin. Internally, infus. sennse with manna and three glasses of boiled Kinkelibah (see below). He claims that after forty eight to sixty hours the urine regularly becomes clear.
We cannot conceal that with the already severe destruction of the blood we consider blood letting decidedly contraindicated.
Segard observed good results from 1 or 2 gm. tannin pro die, administered internally during the paroxysm. He gave quinin only after the hemoglobinuria had passed. Cazes recommends no quinin, and instead, applications of moxa and Vienna caustic paste to the renal and hepatic regions.
Guillaud's "method of treatment" (1887) is offered to show that medical science has not yet passed its middle ages. In addition to giving large doses of ipecac and quinin-60 grams (!)-he applied blood leeches and wet cups to the renal region (he did this repeatedly on the same patient).
In the tropics calomel and ipecac are administered in superabundance in this as well as other forms of malaria ; in our opinion, too routinely and without sufficient indication.
The transfusion of blood, recommended by Steudel, as well as the inhalations of oxygen practised by Baccelli, are worthy of the warmest commendation.
It is possible, too, that subcutaneous infusion of salt solution would be of advantage. Plehn warns, and correctly, against the employment of alcohol during the paroxysm. Some writers express doubt as to whether, in cases of uncontrollable vomiting associated with tormenting thirst, the patient should be allowed to drink, since, as a rule, the drink is immediately vomited. It seems to us that rectal infusions or subcutaneous injections of salt solution are most adapted to replace the loss of fluid in the tissues. The relieving of the thirst by iced drinks is no more than an act of humanity. Unfortunately, the necessary ice is not rarely wanting.