[Reprinted from The Medical Recorder, Yol. Ill, No. 5, pages 122, 142,

v.

BY

ALBERT WOLDERT, M.D.,
TYLER, TEXAS.

Mr. President, Ladies and Gentlemen: Through a most
cordial invitation tendered me, I have the honor to speak to
you this evening on a subject which has engaged my undi¬
vided attention for upwards of eleven years. Long before I
began the study of medicine I became interested in this sub¬
ject, and after my graduation there seemed to be some kind
of fascination about the work which has kept me searching
here and there, in the nooks and dark corners, for any new
facts, any new truths which might be hidden in them.

Well do I remember an address given us students at the
University of Pennsylvania by that distinguished physician
and author, Dr. S. Weir Mitchell, in which he advised all
young practitioners of physic to take up spme kind of hobby
which would be profitable and wouldrj enrich their gray
hair with pride. He advised us students to take up some
line of investigation or research work in one of the sciences,
such as botany, geology, or any other kind of original work,
and to “ride that hobby hard.” He went further than this,
ind tried to stir up within us some feeling of restlessness,
some of the deeper sentiment which would formulate an ideal.
He wished us to read Ruskin, whose works had given him
more real pleasure than all other works he had read. It is
Ruskin who pours out to us the story of Athena, the Neith
of the Egyptians, the Athena of the Greeks, the Minerva of
the Latins, and who instils into us the four cardinal virtues
governed by Athena, prudence, justice, fortitude and tem¬
perance. It is Athena who wears two robes, the one of light,
and the one of darkness. It is always Athena that we hear
in the sound of trickling water, that we see in the golden
embroidered robe of the purple cloud; that produces the rust-

*An address (delivered by invitation) before the Bowie and Miller
County Medical Societies, Texarkana, Ark., March 9, 1906.

V 2

ling; of the leaves of the trees, for indeed it is Athena who is
“queen of the air.” Dr.' Mitchell desired ns to get out into the
world and seek for new ideas, believing with Wordsworth

that ;

11 Nature never did betray
Th,e heart that loved her; ’tis her privilege
Through all the years of this our life, to lead
From joy to joy; for she can so inform
The mind that it is within us, so impress
With quietness and beauty, and so feed
With lofty thoughts, that neither evil tongues,

Rash judgment, nor the sneers of selfish men,

Shall e’er prevail against us, or disturb
Our cheerful faith that all which we behold
Is full of blessings.”

So that if I have any hobby at all it must be the study of
mala *ial fever.

I am proud at this time to say that though there may be
some commercial rivalry between the cities of Texarkana and
of Tyler, medical science has risen above this motive in
life. Indeed science is universal and the work of an investi¬
gator in the remotest part of the earth cannot be lost, and new
discoveries in this day and time fly out swifter by far than
the wings of night, and within a day a discovery made in
Europe goes straight to India, or Japan, or America.

Medicine cannot be bound down by narrow and constricted
laws made by men, and if hedged in will burst the bands
asunder and forever grow. Medicine is non-sectarian, knows
no creeds nor dogmas; knows no “schools” nor “systems”
of nmdicine. The word “school” of medicine is set down in
the law books, and has become firmly fixed in the minds of
judges upon the bench, and no doubt enjoys the privilege of
keeping company with many “wise saws” with which we
have been told his head is filled.

There is in truth and in fact no such thing as a “school”
of medicine.

So that it has come about in this the twentieth century
that a professor of medicine or surgery, or therapeutics, in
any country in the world, can go abroad and feel at home
in any of them. I only have to remind yon that our own
Osier has within the past year been called to Oxford Uni¬
versity.

We find the same types of malarial parasites in Texas that
are found in Italy, in Africa, and in India.

3

If you have a case of malarial fever in Texas, and spread
a drop of that patient’s blood upon a minute piece of glass
and send it to Berlin, or Paris, or Rome, the doctor there
can inform you the type of that malarial parasite, and can
come pretty near telling you when your patient will have
his next chill.

The speaker is at this moment endeavoring to obtain speci¬
mens of malarial parasites from Panama.

The Origin of Malarial Fever — As to the origin of malarial
fever, it is best to at once dismiss from your minds once and
for all time the ancient idea that malarial fever or “malaria”
may be taken into the system of man through the medium of
air or water. The old idea that malarial fever originated in
stagnant water, or swamps, and that the night air was filled
with “dank humours” or malarial poisons blown from them,
was an idea fit for the almanacs, but not for the medical books
of the twentieth century.

It might be safely said that if one be protected from the
bite of an infected mosquito, that one might sleep for a thou¬
sand years immediately over the worst swamp in Arkansas
or Texas, and though he might drink all the stagnant water
in these marshes, he will never contract malarial fever by
such mode of living. I do not mean to say that the man who
so lives might not suffer at times from general body pains,
and perhaps fever, but I mean to say that in my opinion he
will never suffer from malarial fever. In other words, there
is no such thing in the world as “malarial poison,” and when
a person speaks of being “full of malaria” the term has no
meaning whatever, unless that person refers to the effects
produced by a living micro-organism living in his blood. It
is the germ that causes the malarial fever ; it is the germ which
may be easily seen with a good microscope, and it is the
germ that is killed by quinine. When this germ is destroyed
by quinine the patient is no longer “full of malaria.”

I inform you that this small germ (which can only be seen
by aid of the microscope) and other forms of fevers in India
destroys the lives of upwards of 5,000,000 of her people every
year. But we need not go so far away to get statistics about
this disease. What would you say if I told you that according
to the statistics of the seven United States Army Posts in
Texas, and the statistics of three of the largest railway hos¬
pitals of Texas, go to show that at least one person in twelve

4

in this State each year suffers from malarial fever, and that
the expense to the people of Texas on account of malarial
fever amounts to the enormous sum of $5,000,000 to $10,000,-
000 a year? What would you think if I told you that basing
the statistics on that obtained from the city of San Antonio,
that in Texas every year over 3,000 people die from the ef¬
fects of this disease?

It is no wonder that the most influential newspaper in this
State ( Texas ( took me to task in its issue of June 21, 1904, after
I made that statement. It was not my statement, because it was
the records which spoke, and I did not make those records.
I find that this same paper in so far as the commercial as¬
pect of the question is concerned, has become converted and
so expresses itself in an editorial under date of March 5th,
1906. If we want to protect the commercial interests of Texas
we must first protect the health and the lives of all the people
living in it. And I must say that at the present time no or¬
ganized movement is on foot to protect the people against ma¬
larial fever.

On an average yellow fever kills about fifteen people a
year, and upwards of $42,000 is spent to prevent it; while
malarial fever kills about 3,000 people a year, and nothing is
done to prevent it.

Really this condition would almost be funny if it wasn’t
so serious.

Texas ought and must have a State Board of Health in
order to get rid of malarial fever.

Prom a commercial point of view we might say that some
of the best land in Texas, especially along the river bottoms
and districts subject to overflow, cannot be cultivated on
account of the danger from malarial fever. But again re¬
member, it is not because of the fact that water is present
that produces the chills and fevers. It is because that this
water is the breeding- ground for millions of malarial-carrying
mosquitoes. If you could keep all persons (negroes and ignor¬
ant people) suffering with malarial fever out of these swamps,
Lhere would be no malarial fever in those districts.

jNo'v this condition of things should not exist in Arkansas
an.j Texas, for the reason that it will be a plain business
proposition to get rid of the disease when the people become
thoLoughJy enlightened on this question. There is no reason
* 1 people of Arkansas or of Texas should be more fre-

5

quently affected by this disease than the citizens of New York
or Pennsylvania or Maine. One reason that we have not al¬
ready become alarmed over onr condition is that we have
grown accustomed to having chills and fevers. When a phy¬
sician is called to the country, especially to the home of one
of our colored brethren, it is no uncommon thing to be told
that the baby only “has de chills.”

As to the exact date of the first case of malarial fever that
ever occurred in the world, history will never explain any more
than we will ever be able to determine the exact date of the
first case of smallpox, the first case of yellow fever, or of
measles. We do not know where the first malarial parasite
came from. All that scientists are able to say is that one germ
came from some pre-existing germ, and that like begets like.
Therefore we can sum up in a few words all that is known
on this subject by saying that the first malarial parasite came
from some pre-existing malarial parasite.

Think of the millions of human lives, and the billions of
dollars this small microorganism has destroyed in the thou¬
sands of years of the world’s history, and then recall that sci¬
ence only discovered this parasite just twenty-six years ago !

It is a glorious thought for us in this the twentieth cen¬
tury to be engaged in putting such an arch-enemy of mankind
under our feet and to stay the hand of death from those we
love.

The Nature and Development of the Malarial Parasite —

Let us now get more closely acquainted with this germ of
chills and fever, and to do this we must call to our assistance
all of the skill of the zoologist, the biologist, the entomologist,
and the bacteriologist.

If we go to the zoologist for information he will begin by
saying that this little circular form or ring-shaped parasite
found in the red blood corpuscles of man belongs to the natu¬
ral order gymnosporidia, class sporozoa ; that it is divided into
different genera such as (a) Hemameba, and (b) Laverania;
into different species — hemameba malariae (quartan), hem¬
ameba vivax (tertian), and hemomenas precox (remittent
fever-Ross), and also into different sexes.

According to Marchiafava and Bignami of Italy, the ma¬
ture sexual forms (gameti forms) of malarial parasites are
termed gametes, the female sexual form being called macroga-

6

metes, and the cell which produces the male element is termed
the macrogametocyte.

If we draw a drop of blood from the ear or end of the
finger of a patient suffering with malarial fever, and allow it
to remain on a warm stage and in a moist air-tight compart¬
ment, for about fifteen minutes, it will be found that at the
end of this time a few of the fully developed forms of parasites
will have developed one to five flagellae or little arms which
wave about in different directions, and being sufficiently
strong to pull the parent microorganism around in different
positions of the microscopic field. In the course of time some
of these little arms or flagellae tear themselves loose and pene¬
trate other fully developed forms of parasites, and by this
means fertilizes them. These free flagellae which tear them¬
selves loose are called microgametes.

When the blood has been withdrawn from the circula¬
tion by a special kind of mosquito (since all mosquitoes can¬
not convey malarial germs) known as the Anopheles, which
has spotted wings, this insect swallows red blood corpuscles
parasites and all into it stomach, where the same changes
occur as stated above. After a few hours the fertilized flag¬
ellated parasite, which is called the “vermicule,” pushes its
way outward through the epithelial cells or lining membrane
of the insect’s stomach or middle intestine, and later buries
itself in the muscular layer and outer surface of this organ.
After this phenomenon has occurred, the word “parasite” is
no longer applied to this germ, but it is now called by the
biologist the zygote oocyst, or sporozoon, all of which mean the
same thing.

After seven to ten days have elapsed it is found that these
zygotes will have developed within their interior hundreds of
small spindle-shaped thread-like bodies or sporozoites, or
spores, of the malarial parasite, and still later it will be found
that the parent zygote becomes so filled with these little spin¬
dle-shaped spores that it ruptures much in the same way that
the mother tick does when it sets free the seed-ticks, and these
spores are washed by the insect’s blood upward into its sali-
vary glands, to be poured out into the blood of man the mo¬
ment the insect bites, and in this way inoculates him with the
seed 01 the spores of malarial fever, which will within
the course of 2 to 14 days develop into the shape of round
bodies and so give the man a chill.

7

It should be remembered that the mosquito has no closed
system of blood vessels as occurs in man, but the blood (which
is white in color) is washed freely amongst all the tissues,
being pumped by means of the dorsal vein, which is nothing
more than a mere tube open at each end. Thus it will be ob¬
served that while the mosquito sucks into its body the full
grown or young form parasite which is round in contour, it
injects or inoculates into the blood of man a minute spindle-
shaped body from which again develops the full grown para¬
site. After these spindle-shaped spores are injected into the
circulation of man they at first attach themselves to the outer
surface of the red corpuscles, and I have many stained speci¬
mens showing them adhering firmly to the outer rim of the
corpuscles. Later these spores gain entrance into the interior
of the red cells, when they assume a ring shape. After from
2 to 3 days these intra-corpuscular parasites will have grown
to the size of a red blood cell, when they undergo sporulation,
and break up into from 8 to 20 small round segments or
spores. This process of sporulation occurring in the blood of
man is coincident with a chill, and hence observers by watch¬
ing in the blood these malarial parasites, have predicted when
a chill would occur.

Thus it is that the malarial parasite has chosen two hosts
to perpetuate its existence: one the body of man which acts
as the intermediate host, the other the body of the Anopheles
which acts as the definitive host, and one host is just as impor¬
tant as the other in the complete life history of this microor¬
ganism.

Thus it will be seen that malarial fever, or “ chills and
fever,” is a very “ catching” disease. This fact will be gradu¬
ally learned by the editor at his desk ; the banker in his count-*
ing room; the merchant in his store, and the farmer upon his
plantation. I should say that it will require many years to
complete the circuit.

The one who first discovered the fact that the mosquito
might act as the definitive host for the malarial parasite and
be the carrier of the malarial fever germ, was Dr. Ronald
Ross, now of the Liverpool School of Tropical Medicine, but
formerly surgeon in the British Army. Dr. Patrick
Manson of London was the first one to formulate a complete
theory regarding the disease, and Ross, after several years’
hard work, proved that the theory was true, by working out

ojL— g microscope: — You will observe — is tins specimen Elicit the
the life history ot the parasite in the mosquitoes he dissected.
In India Ross worked over his microscope two years without
finding anything to give him encouragement, but finally on
August 20, 1897, he succeeded in discovering the zygote of ma¬
larial fever developing in the mosquito, and the honor of the
discovery belongs to him.

After Ross came the Italian observers, Grassi, Marchiafava
and Bignami, and after them came Koch of Germany. Later
and in the summer of 1900, Dr. W. S. Thayer of Baltimore
succeeded in obtaining three positive results which, unfortu¬
nately, were destroyed (two of them by a laboratory servant),
and a few months later, on November 5, 1900, five years ago,
I had the honor of being the second in America of proving
that the Anopheles do act as the carrier of the malarial para¬
site. It is my pleasure this evening to exhibit before you this
specimen of zygote lying within the muscular walls of the
mosquito ’s stomach, or intestine, which I dissected by -means-
^zygote has carried with it from the blood of the patient suf¬
fering with malarial fever whom it had bitten, the hemoglobin
derived from the red blood corpuscle. This mosquito had
bitten, four days previously, a patient suffering with estivo-
autumnal fever, so that the zygote is 4 days old.

My friend, Dr. L. Napoleon Boston of Philadelphia, has
been kind enough to use my pen-and-ink sketches to illustrate
his book on “Clinical Diagnosis,” just out of press, which you
will observe shows the specimen more completely.

Eight years of work and upwards of half a million dol¬
lars have been consumed by the best workers of Europe to
prove all these different steps I have enumerated above, but
it is worth the cost a thousand times over.

The work of Dr. Ronald Ross in the beginning was not a
mere caprice or holiday pleasure. Science with an all-con¬
suming flame for new things, sapped from him both health
and money. Thus in one of his letters to me, dated October
1st, 1900, he spoke of having gone to Wales, and in his words,
“The constant work on one subject has almost driven me wild,
as you imagine.” In a later letter to me Ross says: “Unfor¬
tunately I am already ruined (financially) by scientific work.”

ibis discovery of Ross threw a new glamour about the
study of yellow fever, and it was only two or three years later
when our own countrymen, Reed, Carroll and Lazear (the

O^cJL

9

latter of whom died that others might live) with Agramonte
of Cuba, proved that the mosquito, Stegomyia fasciata, acts
as the sole carrier of yellow fever. Do you not believe that
if Eoss had not made the discovery that mosquitoes act as the
disseminator of malarial fever, that we would still each year
be confronted with the danger from yellow fever, through
useless fumigation and shotgun quarantine?

Let us reflect for a moment in this race of life and try to
discern whether or not this discovery of Eoss may not have
had some influence on the commercial interests of the Amer¬
ican nation. Let us recall the fact that the French nation
many years ago endeavored to link the oceans together with
their Panama canal. What happened? The answer is, as
doctors know full well, that too little interest was paid to
the question of the public health, andThousands^of tl^eir peo¬
ple died, and the enterprise, costing ^40,OOOtOOO, was a mis¬
erable failure. The building and maintenance of the Panama
canal is not a question of politics, nor of a sea level, nor of a
lock canal: it is a question of public health. If it had not
been for Dr. C. A. L. Eeed and a few others, the American
Government would have perhaps made the same fatal blunder
as did the French Government. (See Journal American Medi¬
cal Association, March 11, 1905). But now a strip 50 miles
in width and running through Panama — thanks to the ever-
vigilant Dr. Gorgas — is as healthy, he states, as the country
between Philadelphia and New York City.

Think of it! We are told (Gorgas — Journal American
Medical Association, February 3, 1906) that under French
occupancy 20 years ago, that many employes of the canal were
found dead along the roadside, and it is uncertain just how
many died along the line. At Ancon every Frenchman con¬
tracted yellow fever, and more than half of them died. Three
members of the medical staff died in one day, and nine within
one month. Of thirty-six sisters brought over as nurses,
twenty-four died of yellow fever. Of eighteen young French
engineers who came over in one vessel, within a month all
had died but one.

At the end of many fleeting years which shall have gone ;
in the distant future when there will be no such thing as
yellow fever and malarial fever, and when these two diseases
will no longer menace the health and the lives of the inhabi¬
tants of India, of the United States and of other nations; at

10

that time when the farmer at his plowshare can till the soil
with no fear of impending danger; and when men upon the
mightiest battleship and lightest ocean craft shall smile at
Nature’s undoing as they sail under the brow of old Culebra,
and whose freighted vessels shall churn the watery link at
Panama, I feel sure that no name will be held in greater vene¬
ration and esteekn than that of Ronald Ross, the discoverer
of the life history of the germ which has slain its millions,
and rendered such an undertaking as this canal an absolute
reality. Surely it was a beautiful tribute to genius and
perseverance, when the appropriate committee recently
awarded to him the Noebel prize of $40,000 for “eminent ser¬
vice to mankind.”

And yet he is not through with his labors. Only within
the past two weeks a letter has come to me from him inform¬
ing me of the good work now being done in regard to malarial
fever in Ismailia and the Federated Malay States.

The Diagnosis of Malarial Fever — If by means of a rather
large size needle we prick the lobe of the ear, or end of the
finger of a patient who has chills and fever, and spread this
blood on a piece of glass, and stain it with either the Nocht-
Romanowsky, or Wright, or other stains composed of some
form of aniline dye, and examine this stained blood with a
microscope which magnifies the red blood corpuscles from 800
to 1300 times, one may observe the malarial fever germs
which have been stained in two different colors, and lying
within the red blood corpuscles. This is the quickest, the
surest, and the best way for the physician to obtain sufficient
evidence by which he is able to say to his patient, that he
either has, or he has not malarial fever. Ofter the physician
must show this stained malarial parasite to his patient before
he fully understands that such a simple thing as chills and
fever is due to a germ, and that this germ lives in his blood.

I will leave it to the conscience of the individual doctor
who cannot stain this micro-organism, and who is unfamiliar
with the microscope, whether he is doing his full duty towards
his patient in doubtful cases of malarial fever.

In continuing I may say that after the blood has been
spread out on a piece of clear glass as stated above, and
after having been stained, it will be found that the small
merozoite, or the very youngest form of malarial parasite,
or that young body which has been injected in the spore

11

form by the malarial-carrying mosquito, may be seen adher¬
ing, or somewhat overlying the rim of the red corpuscle as
though it was clinging onto the corpuscle for dear life, and
that the body or protoplasm of this small parasite is stained
a deep blue color, while at the other end of it we may see a
small red or garnet colored dot, which is the chromatin or the
staining portion of the nucleus of the parasite. It thus ap¬
pears that the spindle-shape spore injected by the mosquito
changes its shape as it passes through the system of man.

Through a letter received during the last two weeks, I
learn that the Leishman method of staining the malarial para¬
site is a very popular one in England, but whatever method is
used, we should be able to see both protoplasm and nuclear
figures.

I have many of these young morozoites clinging to the red
blood corpuscles which I shall be pleased to show to anyone
sufficiently interested.

After this small merozoite has remained attached to the
rim of the red cell for sometime, it finally gains entrance to
the corpuscle which it continues to devour, constantly break¬
ing down the hemoglobin, and assumes a “ring” shape. Now
this “ring” shape form is a most important stage to remem¬
ber, because we will run across them perhaps more frequently
in the pernicious type of fever — estivo-autumnal fever — than
any other form of the parasite. Often this ring-shape form of
parasite has a slight swelling around one of its parts, at which
place the ring is broader, and thus gives what Ewing calls a
“signet-ring” appearance. If this ring-form of parasite con¬
tains two red chromatin dotlets in opposite poles of the ring,
and if such forms predominate over any others, or if we find
crescent-shaped parasites, we may be sure that the patient
has a case of estivo-autumnal fever, or a pernicious type of
fever. Though I would have you to believe that the tertian

malarial fever might perhaps be as “pernicious” as any other
form. I have found tertian rings containing two dotlets of

chromatin granules, but they are not common.

Often these ring-shaped malarial parasites may be found
attached to the rim of the corpuscle and be of wide diameter.
Frequently we have to look for them as long as half an hour
before finding one, but I have the pleasure this evening of
showing you a specimen of blood taken from a case of black

12

jaundice, in which you may see as many as 50 to 100 of these
rings, and sometimes as many as four of them in one corpuscle
the most parasites which I have ever seen in any specimen.
It is stained by my modification of the Nocht-Romanowsky
stain, and shows the blue protoplasm, and the red chromatin
dotlet of the parasite which may be easily differentiated.

But I must inform you that after the onset of hemoglobinu¬
ria occurs malarial parasites are seldom found. In 16 cases of
black jaundice which I have studied during the past year,
malarial parasites were only found in two of them. After
many hours this small merozoite will have grown to a larger
size, at which stage some writers speak of it as the micro-
gametocyte, while if it lives a little longer it is called the
macrogametocyte.

In the case of the very youngest form of parasite we cannot
differentiate between the tertian and the quartan form of
fever by an examination of the blood. Frequently, however,
we can tell at a mere glance the kind of malarial fever with
which we are dealing.

As stated above, often we can within a few moments tell the
kind of fever by the characteristics of the ring-forms of para¬
sites. The tertian and quartan types are best distinguished
in their later stages or after the microorganisms have become
microgametocytes, and macrogametocytes. In these stages the
tertian parasite causes the red blood corpuscle in which it is
contained to become swollen or of wide diameter, while the
parasite exhibits a tendency to spread out in various directions
all over the corpuscle, while the pigment granules are quite
black and in very fine granules.

Regarding the quartan parasite Ewing says that the ring
partakes of the “general character of the tertian ring, but
smaller, more compact, and more richly and coarsely pig¬
mented. ” * * * And “on account of the tendency of the

quartan parasite to complete its life cycle in the general cir¬
culation, quartan pre-segmenting bodies are relatively much
more numerous in the stained specimens than are the similar
forms of the tertian organism.” And further: “In some
specimens taken several hours before the chill the majority v
ol the organisms (quartan) found may present the markedly
itdiculated structure indicative of approaching division. These
coarsely reticulated, relatively small, and richly pigmented
(large granules) bodies, lying in markedly shrunken cells,

13

are very characteristic and not readily confused with any
other form of malarial parasite commonly found in the peri¬
pheral blood.” Sometimes the estivo-autumnal parasite may
be seen within the shrunken red cell, but in the case of this
type the pigment granules are of very much smaller size than in
the quartan form. Ewing says that the quartan rosette forms
are more frequently found in the peripheral blood than any
other type, and may be readily recognized by the small num¬
ber (six to twelve) and comparatively large size and geomet¬
rical arrangement of the spores.

Whenever we see these rosette bodies forming in the blood
we c$,n inform our patient that he will soon have a chill or a
paroxysm of fever, since after this rosette body breaks up
into numerous segments in any of the forms of malarial fever,
the parasite elaborates a certain amount of poison or toxin
which is poured out into the blood, and on reaching the cen¬
tral nervous system produces a chill.

This method of making a quick diagnosis of malarial fever,
and so clearing up points of contention in many continued
types of fever is of supreme importance when it comes to
making a differential diagnosis beteween malarial fever and
yellow fever. True it is that a person may have both malarial
fever and yellow fever at the same time, but to say the least
such a condition would be very uncommon.

As to the co-existence of malarial fever and typhoid fever,
I believe Thayer and Heweston in Baltimore found only one
such instance in 616 cases of malarial fever, so that the term
‘ ‘ typho-malarial fever” should have passed out of the text
books 20 years ago, and is no longer used by the up-to-date phy¬
sician. I will admit that during the recent war with Spain a few
soldiers suffering with typhoid fever were returned home,
and within a week or two after their recovery malarial para¬
sites were found in the blood. But it is the concensus of opin¬
ion that when the two diseases are coexistent that the typhoid
runs its course before the evidence of malarial fever is mani¬
fested.

The Quinine or So-called “Therapeutic Test — That day
has passed away when one can make' the claim that malarial
fevel* is or is not present when based on the administration
of quinin. This has been called the “therapeutic” test for
malarial fever, and was a subject worn threadbare by con-

14

tending physicians before the microscope came into general
use. To expose the fallacy of the reasoning involved in such a
question the plainest proposition possible should be formulated
which would run about as follows: “After excluding other
diseases, and if to a case of fever quinin be given and the
fever disappears, the results prove that the patient had ma¬
larial fever.” I have thought over the matter a good deal,
and this is about the simplest proposition I can get out of it.
It would be just as logical to say that if to another case of
fever quinin be given, and the patient dies, that therefore, the
quinin killed him. Either proposition would be full to over¬
flowing with fallacies and would not stand in any court in this
or any other country. How much more convincing it would
be to say that this or that patient has malarial fever, and
“that here is the stained malarial parasite for you to look at,
gentlemen.”

Moreover, I have many specimens of malarial parasites
from the blood of patients who have taken over 100 grains of
quinin, and I shall show you some colored plates which repre¬
sent malarial parasites which still lived in the blood for sev¬
eral months, though upwards of 200 grains of quinin had been
taken.

The Diagnosis of Malarial Fever Based on the Occurrence

of Chills — The question may often be asked: “Doctor, why
do you have to go to so much trouble as to stick your pa¬
tient’s finger or ear and get a drop of blood, and stain this

blood, and examine it with a microscope magnifying a thou¬
sand times'? Can’t any ordinary doctor tell when a person
has a chill?” To the latter question I would be apt to say
yes, but also remember, my dear sir, that only 60 per cent
of the cases of malarial fever we ordinarily meet with (ter¬
tian) have any distinct “shake,” while the other 40 per cent

oi the cases would probably not be diagnosed without the

microscope.

Thayer and Heweston tell us that out of 189 cases of
estivo-autumnal fever treated in Baltimore, only 52 per cent
ox them had “chills,” while one sixth of that number com-

4^-xiiod vhilv of headache, pains in the back, limbs, etc.,

mo symptoms ordinarily accompanying an acute infection.”

1 eannot understand just where the benefit to the patient
oomld come m if we depend upon the “therapeutic” test, or

15

wait for rigors or “shakes” to determine our diagnosis of
malarial fever.

Prevalence of the Different Types of Malarial Fever in
Texas and Elsewhere — From statistics which I have carefully
gathered from the seven different United States Army posts
along the western border of Texas, and from one of the largest
railway hospitals in this State, the prevalence of the different
types of malarial fever is as follows: “Thus in the United
States Hospital Posts “quotidian” fever occurred in 62 per
cent; tertian 11 per cent, and remittent 22 per cent. At the St.
Louis Southwestern railway hospital formerly located at Tyler,
Texas, the tertian was about 66 2-3 per cent, quotidian, 16 2-3
per cent, and quartan about 1 per cent. In several years’
practice in Philadelphia I never met with a single case of quar¬
tan fever, and have so far observed but one case in Texas.
Thayer and Heweston in their splendid book entitled, “Ma¬
larial Fevers of Baltimore,” give the following percentages
for Baltimore : Out of 531 cases of malarial fever there were
of tertian 62 per cent, estivo-autumnal 35 per cent, and quar¬
tan 4-10 per cent.

Where Does the Malarial Parasite Go During the Winter
Months, and Why Do Chills and Fevers Become More Preva¬
lent from Spring to Fall? — Considering all the facts which
have been enumerated above, one’s mind will In spite of him¬
self go back to this thought: “Observing no cases (or at
most, few cases) of malarial fever during midwinter, when
there are, presumably, no mosquitoes, how can the malarial
parasite grow and develop, and flourish during the frost, and
ice, and snow? To get at the tap-root of this proposition,
we must reflect that the malarial parasite of man is a highly
complex form of parasite, and being so, feeds on something
which it does not produce. In other words, it requires a highly
albuminous food on which to exist. Moreover, it requires
warmth, and moisture, and darkness, all of which it finds in
the blood of man. Finding that the malarial parasite will

stow and clove lop. nnd form spores in endless time in the
blood of man, it will be discovered that if we killed every

mosquito in the world, that we would, for a time at least, still
have cases of malarial fever. But you will observe from what
has been previously said that this malarial fever would never
afflict anyone else than those who already have it, because
there would be no medium of conveyance — all mosquitoes be-

ing dead. I might add that I have kept mosquitoes alive in
glass jars for as long a period as two months.

If we go carefully into the history of these cases of malarial
fever which occur in the early spring (and for some reason
which I cannot explain, generally in February and March)
when there are, presumably, no mosquitoes, we will learn that

practically every one of such cases either had shaking chills,
or else some form of fever during the previous fall. And if
we are very careful in obtaining this history, we can some¬
times tell from whom the patient caught the disease. After
the malarial-carrying mosquito comes out of its hiding places
in May and June, it is an easy matter to understand how chills
and fever are spread from person to person.

The malarial parasite does not make a distant excursion
and forage for its food, but may stay in the blood of man all
winter (and perhaps in the infected mosquito), and not give
trouble until the following spring, when to perpetuate its very
existence seemingly, it goes on sporulating, constantly in¬
creasing in number until the man comes down with a shiver
or distinct chill followed by high fever. In one instance at
least (American Journal Medical Sciences, March, 1903) I
think I have been able to prove that a patient had brought her
malarial parasites with her all the way from Tennessee to
Texas, a distance of over a thousand miles.

(Later — I can now add that I have found malarial para¬
sites in the blood of man in every month from September to

A Case of Malarial Fever, in Which the Parasite
Lived in the Blood Throughout the Winter Months— Mrs. B.,

aged 36, white, large and plethoric, the mother of two chil¬
dren^ on October 24, 1905, developed “dumb” chills at 10
a.m. On October 26 she had another “dumb” chill at 2 p.m.
I he tertian paroxysm now changed into the quotidian type,
and she had a shaking chill on October 27 at 3 p.m., and
a; so a shaking chill on October 28 at 11 a.m. A drop
i blood was obtained on this day (October 28) at 4 p.m.
ana stained by means of my modification of the Nocht-Roman-

ov.sky method, and two distinct groups of tertian parasites
,v found, hence the case was one of double tertian infection
i; daily paroxysms. I have this specimen in my possession.
m poking around over the walls of this house I had no trouble
Cu. ■ i chin g upwards of half a dozen Anopheles quadrimacu-

17

lata, or malarial-carrying mosquitoes. In fact the malarial-
carrying mosquitoes in this house were more abundant than
the common house mosquito (Culex). Mosquitoes sleep during
the day time and may be easily caught by placing a bottle with
a large mouth over them. The Anopheles can be easily identi¬
fied by the fact that all species of this genus have spotted
wings, and when they rest on the wall their body projects
almost at a right angle from the surface on which they adhere.

As soon as these malarial parasites were found in the blood
I put the patient upon quinin, given in the way suggested by
Professor Robert Koch, which consists in combatting the para¬
site in its different cycles of development, which seems to
occur every seventh, fourteenth or twenty-first day. Koch
tries to kill the young merozoites and other forms by giving
quinin for four days, then leaves it off three days, then four
more days of quinin, then three days without quinin, and
finally four more days of quinin. This is the only case of
malarial fever I have treated by this plan which does not seem
to have been cured.

I feel sure that my friend, Dr. C. A. Smith, will be apt to
have me indicted for heresy, and for going abroad for a
method of treating malarial fever, because he is in the habit
of giving quinin in hydrochloric acid- solution, which is a
splendid method, and one which I also use in obstinate cases.

After the administration of quinin the patient got up out
of bed and seemed as well as usual for two months, but
in January she began to manifest peculiar nervous symptoms,
such as twitching about the mouth, general tremors, a feeling
as though the blood was rushing to the head, and a fear of
impending cj.eath. At this time she had no fever.

Two weeks ago, or February 26, 1906, she had a “dumb”
chill at 3 p.m., the fever going to 101%, and accompanied with
general body pains. On March 28, or two days later, at 2 p.m.,
she had a slight shaking chill, followed by fever which at 5
p.m. rose to 102 3-5. At this time she complained of general
body pains, notably in left side of chest over heart, and in the
dorsal ana abdominal regions. As the weather for some days
previously had been variable and as colds were very preva¬
lent, my first thought was that she was suffering from grippe.
However, a drop of blood was obtained about 5 p.m. on Feb¬
ruary 28, 1906, or ten days ago, and after being stained by

*

means of my modification of the Nocht-Romanowsky method,

18

much to my surprise I found my old enemy, the tertian para¬
site, in two distinct groups (double tertian infection) still
lurking in this patient’s blood, where they had been all win¬
ter. I have taken the trouble to paint some of these parasites
in colors, which you will observe on the card specimen passed
around.

I also have with me the stained specimen which I shall be
glad to show to anyone interested.

An interesting point in this case is the fact that this
patient, during her attack of malarial fever in October of last
year, had taken tonics and upwards of 200 grains of quin in,
but these parasites which I show you were not destroyed.

So far as I am aware this is the first observation of this
kind which has been made in Texas proving that the malarial
parasites may survive the winter in the blood of man.

I also found the malarial parasites present in this patient ’s
blood on March 1, 1906, or nine days ago.

In these colored plates yon will observe that the protoplasm
or the body of the gametocyte stains distinctly blue, and is
highly pigmented, while the chromatin granules are stained
red, showing that the nucleus seems to be somewhat pushed
outward to one side of the parasite. In the upper specimen
observe the large size of the ring, and that it only contains
one chromatin granule corresponding with the nucleus. The
clear area around the chromatin granule is called by Ewing
the “milky” zone.

Can Malarial Parasites Always Be Found in the Blood of
Patients Suffering with Malarial Fever? — In this case of ma¬
larial fever detailed above, in which I observed the malarial
parasites moderately abundant in the blood on February 28,
1906, I must also inform you that at an examination made
two days previously, in two specimens examined and by two
different methods, I found nothing. I have repeatedly found
that in selecting the blood, when I used two slides or cover
slips, that one of these would show the parasites, while the
other one with which the blood was spread would show noth-
-ng. Therefore we should always select at least three or four
specimens of blood for such an examination. Sometimes at
1 ho height of the paroxysm of fever if we select the blood we
wdl^find nothing, because at this stage these sporozoa (except
01 quartan) have a tendency to seek the internal
mgans such as the spleen, or bone marrow, where they un-

MALARIAL PARASITES— DOUBLE TERTIAN INFECTION.

From a case of tertian malatial fever, in which the parasites had
existed in the blood throughout the winter months, and had resisted
tonics, and upwards of 200 grains of quinin.

Stained with Woldert’s modification of the Nocht-Romanowsky stain,
and showing the red chromatin granules of the nucleus and the blue
protoplasm of the malarial parasites.

Initial attack of fever began October 24th, 1905; recurrence Feb¬
ruary 26th, 1906.

19

dergo segmentation. I have seen in microscopic sections
malarial parasites which were literally packed in the blood
vessels of the brain. Sometimes during the first day or two
of the onset of the fever the parasites may be few, and we
may fail to find them.

Again, if one gives qninin it will surely kill many of the
parasites, and while only a few may be present in the peri¬
pheral circulation, none may be present in the minute drop,
of blood on the cover slip. If in selecting the blood a very
fine needle be used to prick the skin the blood may not flow
out easily, and if one should squeeze the parts they would
be apt to press out the oil from the skin, and also watery
portions of the blood and tissue juices, and by this means a
poor specimen would be obtained which might show nothing.

In selecting the blood one should always use a needle of
large size and go deep enough for the blood to come to the
surface quickly, and without the necessity of using too much
pressure. In certain cases of chronic malarial fever in which
quinin has been taken there may be very few parasites in the
blood, and none may be found.

In making a microscopic examination of the blood it is
absolutely essential that we should know how to spread the
blood, and to always be sure that the glass is cleansed and
highly polished. Slightly warming the slide as by breathing
on it once or twice aids the blood in spreading.

Hasty examinations should never be made, and as a rule
one should not give up the search until twenty or thirty min¬
utes have been consumed.

And lastly, the stains which we use may not be working
just right, and by this fault we may fail to find the
parasites.

So that it is found that there may be at least nine differ¬
ent reasons why we may not find the parasites in certain
cases of malarial fever.

But bearing these sources of error-in mind, one ought to be
able to diagnose correctly perhaps as high as 90 per cent of

his cases of malarial fever, while by clinical methods he cannot
perhaps do better than to correctly diagnose 50 per cent of
such sases.

The Prevention of Malarial Fever — In an address on mala¬
rial fever which I had the honor of delivering before the Mc¬
Lennan County Medical Society and Business Men’s Club at

20

Waco, September 12th, 1905, 1 referred at length to this sub¬
ject; but I have transgressed my time so far that I cannot
go into this phase of the question as much as it deserves.
In that address I reported a case of malarial fever who, at my
direction, in order to prevent the disease, had about twelve
days previously and during a period of two or three days,
taken 12 grains of quinin as a prophylactic, but which did
not keep off the attack of this disease. I stained the parasites
by several different methods and have them with me.

I should very much like to also tell you something of my
work done during the fourteen months time spent in the
study of the habits and nature of the malarial-carrying mos¬
quito, and how after dissecting dozens of these insects under
the microscope, and how after cutting them into 600 pieces, I
was able to learn the complete anatomy of the mosquito, col¬
ored plates of which I exhibit before you this evening;

But I must press hurriedly on and summarize in a few
words just how to get rid of malarial fever, by saying that
the direct way would be to destroy all the malarial parasites
in the blood of man, or else to adopt the indirect way by
destroying all mosquitoes. The best way to accomplish the
latter would be to adopt a thorough system of drainage, and
supply every two or three weeks to the breeding-ground of
mosquitoes, abundant petroleum.

Individually we can do but very little, but such work must
be done by an efficient State Board of Health, which Texas
needs badly, and must have.

Malarial fever should be classed as a highly infectious
disease, such as yellow fever, and every case should be re¬
ported to the health department of villages, towns and cities.
Patients suffering with malarial fever, as in the case of yellow
fever, should be enclosed, especially during the night hours,
bv means of closely-fitting mosquito bars. It is only neces¬
sary to remember that the malarial-carrying mosquito gener¬
ally seeks its food during the night hours.

Ever keeping before us the high ideals to which we as
physicians wish to attain, and remembering that this our dread
enemy malarial fever — annually in this grand State of ours
causes the destruction of 3,000 human lives, and millions of
dollars in loss of time from illness alone; and being conscious
n t that our medical profession is the only profession
under the dome of heaven whose own combined efforts in

21

getting rid of disease tends to destroy its devotees ; but looking
around and observing the havoc of disease and death, of
the desolation created by it in the homes of neighbors and
friends, and of the sick infant, too, in its mothers arms, who
is too frequently the first to be swept away by malarial fever,
let us go forth and give battle against our enemy, to the end
that our accomplishments will in the course of time permit
the mantle of protection to fall upon those who shall live after
us, and who may thus reap the legacy which we shall leave to
them, consisting of earth’s richest blessing of long life, full
of prosperity and unbounded happiness.