SHALL HEALTH BOARDS SELL ANTITOXIN IN COMPETITION WITH THE REGULAR DRUG TRADE?

There is no more interesting question now before the medical profession than that of obtaining pure antitoxin and pure vaccine virus. The recent action of the New York County Medico-Pharmaceutical League in connection with this subject brought to light some things that ought to be sufficient at least to make it apparent that there should be some safeguard thrown around all institutions that manufacture serums, to insure that nothing but trustworthy goods should be placed on the market. We are very positive that serums which are manufactured under the direction of health boards should not come in competition with those manufacturers who make a business of it for the purpose of money-making, for we believe that one of the greatest safeguards in this matter is good, honest competition. No individual or firm that has a large amount of capital invested can afford to send out from his laboratories an inferior article of this kind, as he would ruin his business and of course lose his investment.

Professor Reynold Wilcox, in speaking of the testimony given before the Legislative Committee at Albany two years ago, said that one of the Health Commissioners of New York City admitted that inferior antitoxin, such as was not good enough for use in New York, was sold at reduced rates in Chicago. It was also ascertained during this investigation that the stable in which the horses were kept was the basement of a veterinary hospital. To say the least of it, the New York Health Commissioners who were controlling the output of the antitoxin at the time did not find it necessary to borrow any nerve, as theirs seems to be the kind with the brand burnt in. Such evidence as the above is sufficient to satisfy the most exacting that health boards should not manufacture serum for sale, and that the public health demands thorough protection against the manufacture of impure serums and vaccine virus.

THE

VOL. XXXIII.

“NEC TENUI PENNÂ.”

LOUISVILLE, KY., MARCH 15, 1902.

No 6.

Certainly it is excellent discipline for an author to feel that he must say all he has to say in the fewest possible words, or his reader is sure to skip them; and in the plainest possible words, or his reader will certainly misunderstand them. Generally, also, a downright fact may be told in a plain way; and we want downright facts at present more than any thing else.-RUSKIN.

Original Articles.

LATENT MALARIA.*

BY GEORGE B. YOUNG, M. D.

Passed Assistant Surgeon, United States Marine Hospital Service.

The great advances made during recent years in our knowledge of the clinical hematology of the malarial fevers have cleared away many of the obscurities that had hitherto surrounded the subject of the atypical and obscurer phases of the manifestations of malarial infection, but there are, among others, one aspect of the question of which we have, as yet, but very imperfect knowledge. I allude to the question of latency. It therefore occurred to me that a very brief resume of the questions presented in that connection, and of some of the suggested solutions, might be of interest-not that I have any original contribution to make to your knowledge on the subject, but because it might offer an interesting topic for discussion by the Society as a whole.

By "latent malaria " I mean the condition existing in those cases in which, following an infection differing as far as we can determine in no respect from one producing in the usual time some clinical manifestation of malaria, there arise no clinical symptoms at all, or their onset is delayed for weeks or months, although the parasites. may be more or less constantly present in the circulation, following, as far as we can determine, the normal life-history characteristic of their intra-corporeal existence.

In a sense, such cases may be roughly grouped into two classes; first, cases of long incubation but followed eventually by clinical

*Read before the Louisville Clinical Society, February 11, 1902.

For discussion see page 219.

manifestations arising without any apparent immediate exciting cause; and second, cases in which there are, as far as we can see, no clinical manifestations, or if such do occur their onset seems to be determined by some existing cause entirely independent of the malarial infection. Of course no hard and fast line can be drawn between these two classes, but in a general sort of a way it may be said that there are clinical reasons for the distinction-possibly a third class might be made of cases presenting relapses after exceedingly long periods, separated by a condition of apparently perfect health.

The older clinicians used to recognize a disposition to malarial attacks in certain individuals under conditions which our present knowledge shows precluded the chance of recent infection; and while "malaria in the system" was (as indeed it still is) very often a cloak for ignorance, there is now known to be a scientific basis for such a diagnosis.

We have then in the first class cases, in which weeks or months after infection, the host remaining meantime in apparently perfect health, there is a sudden development of symptoms due to presence of the organism. How long such periods of incubation may last no one knows. Bloxall reports one case of forty-eight days' incubation, and another of one hundred and eighty-four. In these instances the cases occured on shipboard after a definite, limited exposure. Craig reports a case presenting apparently an incubation period extending from September until some time in March. This was an officer who left Cuba in September after having fever, and remained well until March, the time being spent in New York and San Francisco. Since Craig's book was published the existence of infected mosquitoes has been demonstrated at the Presidio, but even so, they would hardly have been active during even a San Francisco winter. I have notes of a case extending from September to the following May. This was the case of a sailor who in October, 1898, went on board a lightship off the Delaware capes. She was fully four miles from the nearest point of land, and the patient remained continuously on board until February, 1899. In the terrific storm that occurred at that time the lightship was torn from her moorings by the ice and carried to sea. She was towed in and lay at a pier for about a month; but it was the coldest winter for years, ice in the harbor five feet thick, so infection at that time can be excluded. Except at this time patient was never ashore until the middle of May, when he was brought ashore with a typical malarial attack, lasting a

few days, the æstivo-autumnal parasites being quite abundant. In the second class, we have cases in which persons live for long periods in perfect health and then following some unusual exposure to the elements, or some shock to the general system, as a fall from a horse, a broken leg, or the receipt of other injury, will immediately blossom out into a typical malarial paroxysm. The following is an illustration from my own observation :

A gentleman long employed on the Congo was invalided home, and came out to Virginia, residing in the mountains, where malaria was unknown. He went to visit a relative at a distance of about thirty miles, and having to cross a river was compelled to wait some hours or so, after a hard day's ride, in a damp, cold mist, while the ferryman was being found, getting thoroughly chilled. In the morning he had a severe paroxysm, the first for months. Again, we have all seen operations for one thing or another in patients apparently well immediately followed by sharp attacks of malarial fever. Now, if in the mosquito season in a malarial section, the question might be raised whether the manifestation was not a simple coincidence, but in the cases mentioned above this can be excluded, except possibly in Bloxall's cases. Unquestionably cases in which the parasites exist in their for some reason latent or non-symptom producing state are much more numerous than formerly reported. Koch, for instance, found parasites in the blood of a large proportion of the people in certain sections of German West Africa, especially in children. Craig reports that forty per cent of the soldiers admitted to the Presidio hospital without malarial symptoms had parasites in their blood. There were fifty-six cases in all admitted for various reasons during nine weeks. Of course, as these were all in patients admitted for other disease, some may have had the malarial symptoms masked by such disease, and almost certainly some of the diarrheas and dysentery were probably malarial, still there is no doubt that many were cases of true latency.

Now, what is the explanation of this latency? Briefly, there have been so far offered (at least as far as I know) but two hypotheses; and I have a third, which perhaps should not be called a hypothesis, but rather an explanation of the first hypothesis. These two hypotheses are, first, that the parasites lie dormant in the spleen or bone marrow; second, that for some cause the parasites multiply to such a slight extent that they fail to produce a febrile reaction. This last is the opinion of Thayer, accepted by Mannaberg. It is quoted by Marchiafava and

Bignami, who cite certain facts in support of it, but do not commit themselves to either view. Manson seems rather inclined toward the former view.

For myself, if I may venture upon holding any opinion differing from the unquestioned leaders in the malarial field, I am inclined to believe that under certain circumstances the apparent dormancy of the parasites may be due to their following, under the influence of conditions not at all understood, an entirely different life cycle, this opinion being, as stated before, simply a variant of the first hypothesis. The advocates of the second hypothesis urge in its defence the frequent finding of parasites in the blood of persons apparently entirely well, and the fact that in a few such cases serial observations have shown such parasites passing through the regular changes of their life history. The evidence, it must be confessed, is strongly suggestive of the interpretation put upon it, and unquestionably those cases in which relapses occur a few days after a change of altitude (a very common occurrence), or following a chilling, etc., can be explained by the theory that the depression of the patient's resistance gives the circulating organisms a chance to multiply more rapidly, and so bring about a paroxysm. That is to say, that while under previous conditions only a small number of parasites survived to maturity, under the more favorable conditions offered by the reduced condition of their host they survive in sufficient number to produce a paroxysm; but it is to be observed that the paroxysms arising thus only occur after sufficient time has elapsed to cover the normal period of incubation of the particular type of organism present.

This has been verified numbers of times; I have seen it repeatedly, while there seem to be cases in which the paroxysm follows the exposure in considerably less than the normal period of incubation. I think I have seen such, and heard of others; vide, the gentleman from the Congo, referred to above.

The shortest period of incubation is with the tertians, so even if the exposure to depressing influences occurred just before the time at which a group of parasites were ready to mature it would be about forty-eight hours before the increased number of parasites surviving as a result of the depression of their host could pass through their life cycle, mature, and cause a paroxysm; while if the exposure occurred just after the time for maturing, two cycles would have to be lived through before a paroxysm could occur, i. e., the scanty survivors.