INFECTION IN INTERMEDIATE HOST: QUARTAN 
195 
largely responsible for the considerable 
amount of chronic nephritis he found. He 
believed long-continued, unchecked fever to 
be the cause. Manson-Bahr (1931) re¬ 
marked that there was ‘ ‘ some evidence that 
quartan malaria is more prone to be asso¬ 
ciated with subacute nephritis than are the 
other forms of malaria.” In a study of 
plasma proteins, Boyd and Proske (1941) 
found that in 2 patients with quartan ma¬ 
laria, albuminuria;, to the extent of a trace, 
was associated with a depression in the 
plasma albumin, and that oedema occurred 
at the time of such depression; when the 
plasma albumin was depressed to 2 grams 
per cent, oedema occurred unless a com¬ 
pensatory increase in globulin was devel¬ 
oped. In both of these instances a nephro¬ 
sis had developed. 
Icterus. In one of 4 of our artificially 
inoculated patients who developed jaundice, 
this symptom did not appear until after 
termination of the primary attack. 
Duration, remissions and chronicity. 
This disease is notorious for its persistence 
and is the most chronic of the three classical 
malarial fevers. It comprises a primary 
attack which is usually followed by one or 
more remissions and secondary attacks and 
has been reported to last one or more years 
in the known absence of opportunity for 
reinfection. In our artificially induced, 
spontaneously terminating infections the 
duration varied between 19 and 169 days 
with a mean duration in the case of white 
patients of 81.2 days, and in the case of 
negroes, 53 days (in patients receiving spe¬ 
cific medication which might have been ex¬ 
pected to interfere with the natural course 
of the infection, there was observed a varia¬ 
tion of from 16 to 303 days with a mean of 
98.6 days. This suggests that these patients 
might otherwise have had longer and more 
severe attacks). In naturally inoculated 
white patients the mean duration of the 
course has been 170 days. The compara¬ 
tively long duration of attacks in quartan 
malaria is of interest in view of the slow 
development of these infections (this in¬ 
verse relationship is notably the opposite 
of that which obtains in P. falciparum 
malaria; here the organism grows rapidly 
and the infections are less given to chronic¬ 
ity than even those due to P. vivax). 
While remissions, in our experience, have 
shown much variability both as to number 
and length, we have not observed renewed 
activity following a quiescent period which 
lasted as long as 53 days. Boyd’s (1940b) 
study of remissions showed that: (a) their 
mean duration varied directly with the 
length of the attack, (b) most of them of 14 
days or less duration were spontaneous in 
origin but the majority of the longer ones 
followed interference, and (c) about 40 per 
cent of the spontaneous, and about 56 per 
cent of induced remissions occurred within 
50 days of the onset of the illness. 
Prognosis. Quartan malaria is not prone 
to develop pernicious symptoms and the 
parasite density has rarely exceeded 20,000 
per cmm in our patients. Twenty nine per 
cent of our artificially, and 60 per cent of 
the naturally, induced infections came to a 
spontaneous stop. James (1910) recorded 
spontaneous recovery in 25 per cent of his 
patients and described the disease as milder 
in tropical than in temperate zones. Craig 
(1909), however, felt that . . in tropical 
regions the prognosis in the quartan infec¬ 
tions, especially, should be guarded. . . .” 
None of our 5 naturally induced infections 
terminated fatally but 3 of the 38 artificially 
inoculated patients died. Of these 3, in 
only one case did it seem likely that the 
quartan infection was a major factor in the 
fatal outcome. This species has ordinarily 
been quite readily controlled with quinine 
when necessary. Interference (usually em¬ 
ploying small doses of quinine) was prac¬ 
tised in 23 of our patients, largely to con¬ 
trol the severity of the infection. On the 
other hand, interruption was indicated 
when the patient was not supporting the 
infection well or when some intercurrent 
condition developed. Frequently after brief 
interference it was possible for a patient to 
carry on to a spontaneous termination and 
no recurrence was encountered following 
intensive quinine treatment, given either to 
terminate the attack or subsequent to spon¬ 
taneous cessation. No sequelae have been 
observed in any of our patients. 
