Boudin's notion that typhoid and malaria locally exclude each other is contradicted by the facts. Over the earth there are a large number of foci in which both diseases are endemic, among which we may mention India, Indo-China, Algeria, and Italy. In a restricted sense they may be said to exclude one another, inasmuch as malaria occurs by preference in the country, typhoid in the cities; yet, as is obvious, this would have little influence in a concrete case.
Moreover, there is in the individual no exclusive opposition to the two diseases. Malaria immunizes against typhoid fever no more than the reverse.
There are numerous reports of autopsies in which the signs of malaria and typhoid fever were found together. Laveran observed several cases of typhoid in persons who had previously suffered from malaria, and still manifested traces of the disease. Malarial cachectics likewise are not at all protected against typhoid.
The most interesting question is, whether an individual can suffer from both diseases at the same time.
Omitting the older observations, as those of Frison, we have others from Kelsch and Kiener, Laveran, Thompson, and Gancel that make a positive answer highly probable.
Laveran several times saw soldiers admitted to the hospital for intermittent fever contract typhoid while there. He further observed that the malarial parasites disappeared from the blood during the typhoid, to reappear after it. Even in the symptoms malaria was scarcely noticeable, the scene being dominated entirely by the typhoid.
Kelsch and Kiener likewise observed cases of typhoid in the course of which malaria manifested itself by producing at intervals irregularities in the fever, marked anemia, and enlargement of the liver. They even endeavored to combine the characters of the two diseases under the name of "proportionate," in Torti's sense.
It is remarkable that the combination of these two diseases has not yet been seen in Italy (Baccelli, Ascoli), although both are endemic and there is no lack of the best observers.
The diagnosis of typhosa proportionata demands the greatest caution, for even when everything is taken into consideration-for instance, the parasitology-mistakes are made both during life and postmortem.
I consider a clinical diagnosis in its old sense to be absolutely unreliable, and, unfortunately, the majority of cases reported so far were diagnosed in this way.
The close clinical resemblance that may exist between subcon tinued typhoid malaria and genuine typhoid fever has been mentioned on page 278. Moreover, every physician in practice has seen typhoid fevers that manifest an external resemblance to malaria on account of beginning intermittently with chill and sweating, on account of a continuous remittent course, or on account of septic temperature movements coming on at the close.
Colin, having observed such cases, he considered them at the beginning malaria , but when the continued fever developed, with all the symptoms of typhoid, he concluded that the malaria had been "transformed" into typhoid fever.*
This idea of Colin's, which cannot even be considered in the light of our present knowledge, has not ceased to produce confusion. Fayrer himself, with all his rich experience and his capability of unprejudiced observation, is not free from Colin's influence. In his clever and careful way he says: ". . . I believe that miasmatic poisoning under certain undefined modifying circumstances may give rise to continued or remittent fever, which becomes practically indistinguishable from specific enteric fever."
Woodward looked at the question from another point of view. He found a number of feverish affections which he could place in the category neither of typhoid nor of malaria , and, supported by clinical observation, he concluded that there was a mixture of the two infections, for which he proposed the name " typhomalarial fever." By this name he intended to describe the simultaneous occurrence of the two diseases in the form of a specific hybrid infection arising from the combined action of both.
If the designation "typhomalarial fever" was always employed in Woodward's sense, there would be no objection to it, though
* Colin writes ("Traite des maladies epidemiques," p. 807): "C'est sur les malades atteints de remittente palustre que nous avons vu alors se manifester surtout la fievre typhoide, trouvant a l'autopsie d'une part la rate fortement pigmented de la fievre pernicieuse, d'autre part les ulcerations des glandes de Peyer."
Woodward himself was not in a position to give anything like convincing proofs that a mixed infection existed in his cases (which occurred during the War of the Rebellion*), and the great majority of cases published since, especially by physicians in the tropics, are also based on inadequate grounds. But it is now more or less customary to describe acute infections which cannot be clinically diagnosed either typhoid or malaria , with the compromise name, "typho malaria" (Maget).
Naturally, it is impossible to reproach the tropical physicians; on the contrary, we can only feel grateful for their scientific endeavors under the most difficult conditions. The exact diagnosis of a typhomalaria would have its difficulties in a well supplied clinic; how much more so in a field lazareth in Africa.
Still we must insist that the diagnosis of the combined infection can be assured only when both malarial parasites and typhoid bacilli have been demonstrated, or when, at least, instead of the latter, the Widal reaction is positive.
From the literature that I have seen Vincent is the only one who demonstrated the simultaneous presence of malarial parasites and typhoid bacilli in the same individual. Unfortunately, the original paper is not at my command.
Since dysentery and malaria are frequently endemic in the same places, it is readily intelligible that an individual might be attacked by both of these protozoan infections at the same time. As a matter of fact, these mixed infections have been frequently observed (see Moursou's extensive treatise).