118 REVIEW — TROPICAL MEDICINE, ETC. 



Malaria— Ziemaiin and others who have been quoted. He also refers to several interesting facts not 

 continiced previously stated : — 



1. The Anopheles are never w.auting whore the fevers exist, but their quantity is not always iu direct proportion 

 to the intensity of the opidemy ; iu fact it is frcqueutly iu inverse proportion. On the other hand, there may be 

 microhcs imA A iiup/ieles without malaria developing itself, even when malarial patients arrive there from other 

 places, or some autochthonous or sporadic case of fever manifests itself there. Microbes and Anopheles may 

 therefore persist, and, notwithstanding this, the malaria may become attenuated and disappear. 



2. The number of Anopheles infected is always small, even iu the places and montlis most affected by the fevers. 

 The hereditary transmission of the infection from mosquito to mosquito has not been demonstrated up to now. 



3. There is no doubt that quinine acts in inverse proportion to the degree of development of the malarial 

 parasites in the blood stream ; that is to say, it acts best against the sporozoites directly they are inoculated and 

 least against the sexual forms destined to maintain the recurrent fevers, and little or not at all against the sexual 

 forms destined to propagate the species. Thus some fevers are pertinacious iu recurring in spite of the abundant 

 and protracted use of quinine, either alone or associated with iron and arsenic. In fact, these latter drugs under 

 whatever form and in whatever way administered have no value as direct anti-malarial remedies. 



4. Quinine, provided it be administered daily, is in average and even therapeutic doses better tolerated, and 

 for a longer time than, a priori, one could have believed ; that is to say, after the first two or three days it no 

 longer produces the least singing in the ears, and is not only completely innocuous but also acts as an aid to 

 nutrition and as a tonic to the digestive apparatus and muscles, thereby increasing the appetite and the power of 

 work. Quinine taken daily is always present in the blood, and thus prevents instead of produces the phenomena 

 of quinism. Further, there is not, perhaps, another example of a remedy so perfect, nor one which so rapidly 

 establishes itself, and can be prolonged for a long time (up to five or six months), and yet can be interrupted when 

 desirable without any disturbance, and without, although the organism is habituated to the small and average 

 doses, diminishing the curative efficacy of the large doses when they are necessary. 



5. Intolerance is rare if a salt insoluble in water such as the tannate of quinine be given. It is specially 

 indicated for young children, and it is important to give it in the form of comfits or chocolates. 



6. Dosage — 40 centigrams of the bisulphate, hydrochlorate or bi-hydrochlorate for adults and young 

 persons ; 20 centigrams of the same salts or 30 of the tannate of quinine for children. In districts with very 

 severe malaria, 50 to 60 centigrams of the bisulphate may be given. 



It will be seen that this method differs very considerably from the others quoted. 

 Certainly the statistics given by Celli speak well for its efficacy, but it must not be 

 forgotten that a procedure suitable for Italy may not be equally so for tropical Africa. At 

 the same time, I do not know that this Italian system of quinine administration has ever 

 been given a fair trial in the Dark Continent. 



Malta Fever. Most of the recent important work on this subject is embodied in 

 the Reports of the Special Commission which studied Malta Fever in all its aspects 

 at Malta. 



A useful resume is given by Bruce. ^ He mentions briefly the long course (average four 

 months), the extreme irregularity of the temperature curve, the exacerbations of the fever, 

 the presence of symptoms of a rheumatic or neuralgic character, and the extreme anaemia 

 and debility characterising the tedious return to health. 



He notes the disappearance of the disease from Gibraltar, and its occurrence in Malta, 

 Tunis, Alexandria, South Africa, Rhodesia (where it apparently followed the introduction of 

 goats), India, China, the Philippine Islands and America. He might also have mentioned 

 the Anglo-Egyptian Sudan, for it has been proved beyond all doubt to occur in this country, 

 chiefly, so far as I know, in the Kassala Province and the northern districts. I have been 

 able to confirm the diagnosis in at least one case by the agglutination test. The other 

 special points to which allusion is made may be tabulated : — 



1. Broadly speaking, the better the social position, the greater the liability to the disease. 



2. In Malta, the disease is prevalent all the year round, being commonest during the coldest and rainiest 

 months. It is markedly regular in its appearance, a large number suddenly cropping up in February, December, 

 or other of the cold and rainy months. 



3. Its distribution is general as regards the population of Malta. 



4. The principal path by which the Micrococcus melitensis leaves the body is the urinary tract. The urine 

 sometimes contains tlie organisms in enormous numbers. It may also quit the Ijody in the blood to a small extent 

 by the agency of mosquitoes and other blood-sucking insects. 



5. The micrococcus is fairly resistant to external influences. It can exist in a di-y condition in dust 

 or clothing for two to three months. It lives in tap-water or sea-water for about one month. It can live a week 

 even in urine which has decomposed and become markedly alkaline. Exposure to sunlight kills it in a few hours. 



6. No habitat outside the body, such as sewer air, dust, harbour water and other insanitary media could be 

 found. 



7. Infection by contact or by fomites was proved not to occur. 



' Bruce, D. (March, 1907). Journal of the Royal Army Medical Corps. 



