Nephritis constitutes one of the rarer sequelae, though observations as to its frequency are considerably at variance.
These differences are due, in the first place, apparently to endemic causes; in the second place, to the fact that the clinical diagnosis of nephritis is made on different grounds by different people. Albuminuria is regarded as nephritis by some, when it may be only the result of stasis or parenchymatous degeneration (cloudy swelling).
Frerichs, for instance, saw on the coast of Friesland, numerous cases of malarial cachexia with ascites, yet none with nephritis, while Bartels observed in Kiel numerous cases of parenchymatous nephritis in malarial patients coming from Schleswig-Holstein and the shores of the North Sea. Kelsch and Kiener investigated the subject in Algeria and found all forms and grades of the affection.
Rosenstein bestows considerable attention on malaria and kidney disease. He estimates that of the cases of Bright's disease observed by him in Danzig, 23 per cent, were due to malaria. In northern Holland (Groningen), in spite of the great prevalence of malaria, he found this complication rare; in southern Holland, very frequent. He mentions, too, that Heidenhain observed a series of intermittent fever epidemics in Marienwerder, with neither dropsy nor kidney disease following, while in the last epidemic there was scarcely a case without secondary nephritis.
Soldatow, who had the opportimity of making 350 autopsies on malarial cases in Dobrudja, found nephritis very frequent. Wood and Atkinson likewise assert its common occurrence. In Bamberger's statistics of nephritis malaria plays a very secondary role. Among 623 cases of secondary nephritis only 13 could be attributed to malaria, yet he adds that this may be because malaria plays at most an unimportant role in Vienna.
Blackwater fever seems to be followed by nephritis no more frequently than the common forms. This is remarkable since, in addition to the noxious influence of the parasite, there is the irritation produced by the excretion of the dissolved hemoglobin. The form of nephritis produced by malaria varies.
Acute nephritis, according to Rosenstein, sometimes occurs during the course of quotidian fever, especially when the sweating stage is absent and is manifested by its usual symptoms (oliguria, blood, albumin, casts, edema, etc.), though the edema may be wanting. Rosenstein makes its duration two weeks to four months. He saw no case become chronic and no case end fatally.
Kelsch and Kiener likewise observed acute nephritis, and usually in the first period of malarial intoxication. It developed either during the course of the fever paroxysms or during convalescence, probably provoked by cold. According to them also the duration is from several weeks to several months. In the majority of cases the typical symptoms were present, together with the common sequelae on the part of the circulatory apparatus. Fatal cases were observed repeatedly.
Subacute nephritis in the common form, represented by the "large white kidney," has been reported by Rosenstein as especially frequent in association with or following malaria . In regard to it he says: "Particularly after intermittent, I have observed typical cases which, without further examination, would certainly be regarded as amyloid. Investigation of the anamneses showed that the preceding fever occurred usually in three different forms: In the first the paroxysms were incomplete in that, in case of a tertian type, there was a cold and a hot stage, but no sweating stage. In the second the paroxysms were complete, of tertian or quartan type, but few in number. After three or four such paroxysms an interval of several weeks occurred, during which the patients showed but slight general disturbances, in spite of the continuance of the fever in a latent form. They returned to their work until dropsy appeared simultaneously with albuminuria or preceding it. In the third, fever paroxysms of varying type occurred almost uninterruptedly for months (in one case even two years), and only with their cessation did dropsy and albuminuria come on. Dropsy is a constant symptom that I never saw wanting in nephritis produced by intermittent. The urine shows the characteristics belonging to the large white kidney, oliguria, high specific gravity, considerable albumin, and, among the formed elements, lymphocytes, fatty granular cells, and granular casts. I must mention as a peculiarity that the urine contains considerable urates, and, therefore, on account of its small volume, may appear, when cold, cloudy and loamy. The casts are frequently granular, due to impregnation with urates, and, on the addition of acetic acid, the rhombic crystals of uric acid become conspicuous."
Kelsch and Kiener likewise often observed the "large white kidney" following malaria (described by them as "nephrite a granulations forme aigue").
Chronic nephritis in the form of secondary contracted kidney is not rarely seen in cachectics. It is regarded as a terminal form of the two previously named conditions. The uremic symptoms accompanying it may give rise to difficulties in diagnosis. The course of malarial nephritis is distinguished in no way from that of neph riticles in general.
For the prognosis, we may refer to the observations just mentioned. Still we may add that Bohn rarely observed Bright's disease following malaria in children, yet when it did occur, it was always fatal.
In the section on Cachexia we have already referred to this subject. We may add here that the gangrene usually runs its course entirely without pain. It may be limited to a relatively small area, and recover under scar formation, or may spread rapidly to the mons veneris or the inner surface of the thigh, when the prognosis becomes serious.
Malarial orchitis has been described especially by French military physicians (Maurel, Girert, Calmette, Charvot, Bertholon, Schmit, and others). According to Martin, who saw a number of cases in Sumatra, we have to do in these cases with "a foudroyant inflammation of the male sexual organs (testicle and epididymis)." The testicle and epididymis are almost simultaneously affected by the inflammation under marked remittent fever. Cachectics and men who suffered previously from malaria are the victims. No trauma comes into play, nor does acute or chronic gonorrhea. The pain is more intense than in gonorrheal orchitis. Moreover, in the latter, the epididymis is usually primarily affected, and only later the testicle. The swelling may be marked, and not rarely reaches the size of a child's head. Under proper treatment it disappears more quickly than the gonorrheal orchitis, though it may lead to extensive suppuration of the testicle.