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THE DIAGNOSIS OF MALARIA.
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scopic diagnosis became impossible. Even the differentiation of the two main forms of malaria—for instance, the benign, which seldom, if ever, kills—from the subtertian, which proved to be responsible for nearly SCO deaths in 1918, should alone justify the adoption of Audi alteram partem." I am a microscopic diagnosis in every case of pyrexia. to grant that a very small proportion of cases willing THE DIAGNOSIS OF MALARIA. may not be diagnosed on one microscopic examination alone owing to scantiness of the parasites in the periTo the Editor of THE LANCET. pheral blood or the early stage of the disease ; but one’s of a from letter Colonel SIR,—The publication in issue of Feb. 28th and your chances are greatly increased if a three-slide rule on Mathew O’Connell your three separate occasions, or even the thick film method, annotation upon the probability-diagnosis of malaria is It was by the institution of a routine of from as it was calls for some reply myself, my article thisadopted. kind that were many benign cases (some 3000 in upon the necessity for early diagnosis and early treat- retained for further service near the front lineall) instead ment of malaria in armies in the field which prompted of being sent to hospital at the base, as would otherwise this correspondence. In the first place, I think it is a have been the case. cold should throw water at the that anyone pity Colonel O’Connell quotes me as saying that three prtsent moment upon microscopic diagnosis, which cases originally diagnosed as sunstroke, five as dysenhas been proved to be the most important and necessary were afterwards found to be suffering from &c., tery, and reliable means of diagnosis in malaria with a view subtertian malaria—a very small number in so large to treatment; for if this is not the object of Colonel I quoted no force. This is hardly correct. a O’Connell’s letter I fail to understand the issue that numbers of the total misdiagnoses, but only gave is at stake, nor can I see how the classical experiments where the discovery was made too lateof Sir Patrick Manson have any bearing upon micro-’ instances I would like to cite on the post-mortem table! as medicine to scopic diagnosis military applied during in this connexion. instance After the occupain the war Palestine. I am sure Colonel O’Connell will 11 out of 15 of Damascus one reported pathologist admit that, by instituting a system of microscopic diag- tion isolated as dysentery, and 30 out of 45 diagnosed in nosis the field, many valuable lives were saved which in one would otherwise have been lost through non-adminis- as influenza were in realitysubtertian malaria, field ambulance alone. This by no means exhausts an of I tration estimate how much quinine, nor can extensive list of critical medical and even surgical cases military disability was thereby avoided. There can be in which the diagnosis and treatment were made clear no question, I submit, that everyone who served with examination. I have seen three by simple microscopic the armies in the East during the war fully appreciated that a microscope and an expert pathologist-for a cases sent down as lunatics, two of which were fatal subtertian infections, and one man under arrest for microscope without a trained eye behind it is of little suspected drunkenness for the same reason. use-are as essential a part of the field ambulance equipAfter the adoption of the diagnosis station scheme in ment as are surgical instruments, stethoscopes, or the inevitable cholera outfit which is so carefully treasured, the E.E.F. I find from my records of over 100 autopsies but seldom used. How many hundred diagnoses of on malarial cases that in no single instance had the existence of the infection been missed during the malaria, which would otherwise have been missed on victim’s lifetime. This certainly was not the case clinical grounds, were made during these epidemics of subtertian malaria I would not like to guess, but when- before the adoption of the scheme. I do not think it is claiming too much to say that ever the clinical diagnosis became unsatisfactory in the in midst of phlebotomus fever, influenza, relapsing fever, field laboratories more than justified their existence in making a the at assisted E.E.F. ; rate, any they and enteric, the man with a microscope scored every diagnosis in at least 80 per cent. of medical cases. time. The amount of work they got through was phenomenal. I remember standing in a casualty clearing station In the last laboratory to which I was attached two one morning in December, 1917, when a large number of sick filed past bearing upon their field cards such officers and three men were responsible for over 62,000 on blood and faeces, including over 500 blood varied diagnoses as debility, bronchitis, influenza, reports examinations for malaria in one day, during the year of the heart, and what not, 1918. One of the pleurisy, disordered action great advances in clinical medicine and how I found on microscopical examination no less has undoubtedly been our ability to diagnose malaria infections with the 22 virulent subtertian than were infections with precision, and, again, I hope that parasite. This rapid examination occupied less than Colonel O’Connell’s letter will not lead to the diminished half an hour, but it is more than possible, since malaria use of the microscope in malaria diagnosis ; even in the had not been suspected at that season of the year, that case of patients in this country I know of cases in all these men would have been evacuated down the for want of a microscopic examination, the real which, line and would not have received specific quinine treatcause of death or illness-malaria-has been overment till some two or three days later, and possibly one looked. I am. Sir. vours faithfnllv. or more would have succumbed. PHILIP MANSON-BAHR. One has only to glance at the official report upon Weymouth-street, W., March lst, 1920. malaria in Palestine during 1918 in order to convince oneself that the early microscopic diagnosis of malaria THE SITE OF INOCULATION IN SYPHILIS. helped to conservethe man-power of Allenby’s force To the Editoi, of THE LANCET. during that fateful summer, and T do not think it is an to claim a division of that European exaggeration nearly SIR,-Having read the investigations on syphilis troops was spared by these means for the great advance which have been conducted by Dr. P. Fildes and in September of that year. From official sources it is Surgeon-Lieutenant Commander R. J. G. Parnell at known that no less than 35,439 cases, or one-tenth of the Haslar Hospital (Medical Research Committee, Special total force, were microscopically diagnosed as malaria Report Series, No. 41 and 45 [see p. 614]), I asked the during 1918, and of these no less than 24,748 were writers if they could supply me with data regarding verified by eight laboratories and diagnosis stations the sites of inoculation of their patients. In response primarily near the front line, 14,842 being benign and Dr. Parnell has most kindly supplied me with the 9906 subtertian infections. The total number of blood data of 2743 consecutive cases of the Haslar series. examinations undertaken by these field laboratories and It will be seen that 68’7 per cent. of patients are diagnosis stations was 111,261, a third of the total infected on the prepuce, glans, or meatus (4’4 per cent. under a phimosed prepuce), 10’6 per cent. on the body fighting force, in a period of less than six months. During the advance into Syria the number of cases of or root of penis or on the scrotum, 19 per cent. unstated severe or malignant malaria reached the colossal figure or combined lesions, and 1’7 per cent. extragenital of 1800 fresh infections a week. Even this figure lesions. cannot be taken as comprising the total number, as These facts were supplied with the permission of the owing to the rapidity of the advance complete micro- Medical Director-General of the Navy ; and, as I think
Correspondence. "
one
patients
scopic diagnosis became impossible. Even the differentiation of the two main forms of malaria—for instance, the benign, which seldom, if ever, kills—from the subtertian, which proved to be responsible for nearly SCO deaths in 1918, should alone justify the adoption of Audi alteram partem." I am a microscopic diagnosis in every case of pyrexia. to grant that a very small proportion of cases willing THE DIAGNOSIS OF MALARIA. may not be diagnosed on one microscopic examination alone owing to scantiness of the parasites in the periTo the Editor of THE LANCET. pheral blood or the early stage of the disease ; but one’s of a from letter Colonel SIR,—The publication in issue of Feb. 28th and your chances are greatly increased if a three-slide rule on Mathew O’Connell your three separate occasions, or even the thick film method, annotation upon the probability-diagnosis of malaria is It was by the institution of a routine of from as it was calls for some reply myself, my article thisadopted. kind that were many benign cases (some 3000 in upon the necessity for early diagnosis and early treat- retained for further service near the front lineall) instead ment of malaria in armies in the field which prompted of being sent to hospital at the base, as would otherwise this correspondence. In the first place, I think it is a have been the case. cold should throw water at the that anyone pity Colonel O’Connell quotes me as saying that three prtsent moment upon microscopic diagnosis, which cases originally diagnosed as sunstroke, five as dysenhas been proved to be the most important and necessary were afterwards found to be suffering from &c., tery, and reliable means of diagnosis in malaria with a view subtertian malaria—a very small number in so large to treatment; for if this is not the object of Colonel I quoted no force. This is hardly correct. a O’Connell’s letter I fail to understand the issue that numbers of the total misdiagnoses, but only gave is at stake, nor can I see how the classical experiments where the discovery was made too lateof Sir Patrick Manson have any bearing upon micro-’ instances I would like to cite on the post-mortem table! as medicine to scopic diagnosis military applied during in this connexion. instance After the occupain the war Palestine. I am sure Colonel O’Connell will 11 out of 15 of Damascus one reported pathologist admit that, by instituting a system of microscopic diag- tion isolated as dysentery, and 30 out of 45 diagnosed in nosis the field, many valuable lives were saved which in one would otherwise have been lost through non-adminis- as influenza were in realitysubtertian malaria, field ambulance alone. This by no means exhausts an of I tration estimate how much quinine, nor can extensive list of critical medical and even surgical cases military disability was thereby avoided. There can be in which the diagnosis and treatment were made clear no question, I submit, that everyone who served with examination. I have seen three by simple microscopic the armies in the East during the war fully appreciated that a microscope and an expert pathologist-for a cases sent down as lunatics, two of which were fatal subtertian infections, and one man under arrest for microscope without a trained eye behind it is of little suspected drunkenness for the same reason. use-are as essential a part of the field ambulance equipAfter the adoption of the diagnosis station scheme in ment as are surgical instruments, stethoscopes, or the inevitable cholera outfit which is so carefully treasured, the E.E.F. I find from my records of over 100 autopsies but seldom used. How many hundred diagnoses of on malarial cases that in no single instance had the existence of the infection been missed during the malaria, which would otherwise have been missed on victim’s lifetime. This certainly was not the case clinical grounds, were made during these epidemics of subtertian malaria I would not like to guess, but when- before the adoption of the scheme. I do not think it is claiming too much to say that ever the clinical diagnosis became unsatisfactory in the in midst of phlebotomus fever, influenza, relapsing fever, field laboratories more than justified their existence in making a the at assisted E.E.F. ; rate, any they and enteric, the man with a microscope scored every diagnosis in at least 80 per cent. of medical cases. time. The amount of work they got through was phenomenal. I remember standing in a casualty clearing station In the last laboratory to which I was attached two one morning in December, 1917, when a large number of sick filed past bearing upon their field cards such officers and three men were responsible for over 62,000 on blood and faeces, including over 500 blood varied diagnoses as debility, bronchitis, influenza, reports examinations for malaria in one day, during the year of the heart, and what not, 1918. One of the pleurisy, disordered action great advances in clinical medicine and how I found on microscopical examination no less has undoubtedly been our ability to diagnose malaria infections with the 22 virulent subtertian than were infections with precision, and, again, I hope that parasite. This rapid examination occupied less than Colonel O’Connell’s letter will not lead to the diminished half an hour, but it is more than possible, since malaria use of the microscope in malaria diagnosis ; even in the had not been suspected at that season of the year, that case of patients in this country I know of cases in all these men would have been evacuated down the for want of a microscopic examination, the real which, line and would not have received specific quinine treatcause of death or illness-malaria-has been overment till some two or three days later, and possibly one looked. I am. Sir. vours faithfnllv. or more would have succumbed. PHILIP MANSON-BAHR. One has only to glance at the official report upon Weymouth-street, W., March lst, 1920. malaria in Palestine during 1918 in order to convince oneself that the early microscopic diagnosis of malaria THE SITE OF INOCULATION IN SYPHILIS. helped to conservethe man-power of Allenby’s force To the Editoi, of THE LANCET. during that fateful summer, and T do not think it is an to claim a division of that European exaggeration nearly SIR,-Having read the investigations on syphilis troops was spared by these means for the great advance which have been conducted by Dr. P. Fildes and in September of that year. From official sources it is Surgeon-Lieutenant Commander R. J. G. Parnell at known that no less than 35,439 cases, or one-tenth of the Haslar Hospital (Medical Research Committee, Special total force, were microscopically diagnosed as malaria Report Series, No. 41 and 45 [see p. 614]), I asked the during 1918, and of these no less than 24,748 were writers if they could supply me with data regarding verified by eight laboratories and diagnosis stations the sites of inoculation of their patients. In response primarily near the front line, 14,842 being benign and Dr. Parnell has most kindly supplied me with the 9906 subtertian infections. The total number of blood data of 2743 consecutive cases of the Haslar series. examinations undertaken by these field laboratories and It will be seen that 68’7 per cent. of patients are diagnosis stations was 111,261, a third of the total infected on the prepuce, glans, or meatus (4’4 per cent. under a phimosed prepuce), 10’6 per cent. on the body fighting force, in a period of less than six months. During the advance into Syria the number of cases of or root of penis or on the scrotum, 19 per cent. unstated severe or malignant malaria reached the colossal figure or combined lesions, and 1’7 per cent. extragenital of 1800 fresh infections a week. Even this figure lesions. cannot be taken as comprising the total number, as These facts were supplied with the permission of the owing to the rapidity of the advance complete micro- Medical Director-General of the Navy ; and, as I think
Correspondence. "
one
patients