NATURE 



381 



MALARIA AND ITS TREATMENT. 

 [1] Malaria in Macedonia: Clinical and Haemato- 

 logical Features and Principles of Treatment. 

 By P. Armand-Delille and others. Preface by 

 Prof. Laveran. Translated by Dr. J. D. Rolles- 

 ton. Edited, with a preface, by Sir Ronald 

 Ross. Pp. XXX +115. (London: University 

 of London Press, Ltd., 1918.) Price 65. net. 

 (2) Anti-Malaria JVork in Macedonia among 

 British Troops. By Dr. W. G. Willoughby and 

 L. Cassidy. Pp. x + 68. (London: H. K. Lewis 

 and Co., Ltd., 1918.) Price 45. 6d. net. 

 i) T^HIS work deals with the parasitology of 

 J- malaria, the associated clinical manifes- 

 tations and the treatment, the main and more im- 

 portant part being the clinical. In the section on 

 parasitology the authors enlarge on the importance 

 of parthenogenesis of the gametes as the cause of 

 the persistence of the infection and of the relapses. 

 As J. D. Thomson has pointed out, the so-called 

 parthenogenesis of the malarial parasite is based 

 on a misconception of Schaudinn's of vvhat the 

 term "parthenogenesis" is, and on an error in 

 interpreting the facts observed by him. 



The greater prevalence of subtertian infections 

 during the summer, and of benign tertian during 

 the autumn and winter months, is in accordance 

 with the findings of British workers on the Struma 

 and Doiran fronts, and seems to bear some rela- 

 tion to the seasonal preponderance of different 

 species of anophelines. 



As stated, the chief portion of the work is de- 

 voted to the clinical aspects of the disease. Judg- 

 ing from the number of symptoms and complica- 

 tions described, it would appear that a considerable 

 amount of work has been devoted to these points. 

 Unfortunately, the authors give us no information 

 of the number of malaria cases' observed by them, 

 or of the number of cases of the various clinical 

 types they describe. They divide malaria clinically 

 into two categories, primary and secondary palu- 

 dism, with an intervening apyrexial period asso- 

 ciated with relapse and complications. 



Primary paludism may manifest itself as a slight 

 febrile attack, or as a febrile gastric derangement, 

 and it may also simulate typhoid, paratyphoid, or 

 what is designated "Mediterranean dengue." 

 Associated with this stage may be anaemia, varying 

 in severity from a barely perceptible pallor to 

 pronounced anaemia, with wasting and jaundice, 

 and, perhaps, complicated with oedema or haemor- 

 rhages, especially epistaxis, which is described as 

 being fairly common. Petichiae have also been ob- 

 served. Whereas haemorrhagic symptoms im- 

 proved under quinine administration, oedema 

 seemed to be unaffected by the drug. 



A great number of symptoms and complications 

 are described as being associated with primary 

 paludism. These are arranged in order according 

 to the organs involved. A condition called "in- 

 fective icterus," bearing a close resemblance to 

 NO. 2542, VOL. lOl] 



Weil's disease, but being less fatal than the latter, 

 IS described. "Suprarenal insufficiency" appears 

 to have been encountered several times. Acute 

 cachexia was found only in connection with sub- 

 tertian infections. Albuminuria was present only 

 in a few cases ; a definite acute nephritis was rarely 

 seen. Although a few patients developed " hjemo- 

 globinuric fever" early in the disease, this con- 

 dition generally became manifest during the course 

 of secondary paludism. 



The authors state that they have not observed 

 a true amaurosis in connection with malaria or 

 its treatment with quinine ; they consider the con- 

 dition so exceptional as to be no contra-indication 

 to treatment with large doses of quinine. They 

 are also sceptical as to quinine deafness, but they 

 have noted disturbance of the equilibrium, with 

 excitability of the vestibular nerve, in two cases. 



Pernicious attacks of malaria are attributed to 

 invasion by large numbers of parasites in indi- 

 viduals whose resistance is diminished. They vvere 

 met with only in Plasmodium falciparum infec- 

 tions, and generally in men suffering from great 

 fatigue following overwork. The term "defaced 

 paludism" is given to various atypical forms of 

 malaria. "Masked paludism" includes cases in 

 which the visceral manifestations are unaccom- 

 panied by febrile phenomena. 



Secondary paludism, characterised by "disci- 

 plined " attacks, occurs in patients not exposed to 

 reinfection by mosquito bites, and is that clinical 

 form met with in cases which have returned to 

 non-malarial countries. Under this heading are 

 described all the ague attacks and their associated 

 clinical phenomena. A short account of hsemo- 

 globinuric fever is given. 



The diseases most commonly found complicating 

 malaria w^ere typhoid, dysentery, and "recurrent 

 fever." For the treatment of paludism, quinine 

 hydrochloride is recommended as the most efficient 

 salt. It should be given in 3-gram doses, and 

 may be combined with urethane or antipyrin. The 

 best method of administration, according to the 

 authors, is by intramuscular or subcutaneous in- 

 jection. Oral quinine is rarely considered advisable 

 owi«g to the gastric disturbances generally present. 

 Intravenous quinine should be given only as an 

 extreme measure and where there are suitable con- 

 ditions, as in large hospitals. The drug should be 

 given daily during the febrile attack, six to eight 

 hours before the attack is expected. In mild- re- 

 lapses 2-gram doses are advised, and in bad 

 relapses 3-gram doses. In pernicious attacks 

 great reliance is placed on adrenalin — 2 milli- 

 grams in 500 to 1000 normal saline. Quinine 

 in relapsing cases should be suspended between 

 the attacks. During treatment absolute rest in 

 bed, substantial diet, and the administration of 

 iron and arsenic are recommended. The authors 

 do not say how long quinine should be continued 

 after the last febrile attack. 



The impression left on the reader by this work 

 is one of some confusion, but possibly this may be 

 partly due to the diflicuhies of translating technical 

 scientific points. Such expressions as "infective 



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