xiii, b. 6 Haughwout : Endemic Malaria 295 



he mentions as a rare but possible complication. He also speaks 

 of cases of malaria that simulated appendicitis so closely as to 

 bring the patient to the operating table. 



The frequent failure of protozoan parasites to play the game 

 according to the rules is a constant source of perplexity to phy- 

 sicians and parasitologists. It has long been an accepted rule 

 that an attack of malaria might be expected to develop in from 

 ten to fifteen days after the bite of an infected anopheline. 

 Garin(iO) dissents from this, and cites his evidence to the con- 

 trary, secured through a study of conditions in Macedonia. He 

 produces evidence of a clinical and microscopical nature, tending 

 to show that persons may become infected with malaria but 

 remain in perfect health for a more or less indefinite period, 

 until the introduction of some extraneous factor causes the 

 infection to light up and become active. 



This behavior on the part of the parasite he attributes to the 

 possession of a partial and variable degree of immunity on the 

 part of the host. This immunity he believes to be partly natural 

 and partly acquired, the acquired immunity having developed 

 as a result of the prolonged use of quinine as a prophylactic. 

 He believes the disease may become active in patients of this 

 type following upon severe muscular fatigue, wounds, surgical 

 operations and chloroform anaesthesia, overexposure to the sun, 

 or even typhoid inoculations. 



Kaminer and Zondek (17) report having found parasites in the 

 blood of apparently healthy persons. They say of these persons 

 that at least they were free from fever, and complained of 

 nothing worse than a little headache and a feeling of lassitude. 



Of interest in this connection is the observation of Delanoe(6) 

 in an epidemic of malaria in the Oulad Hassoun, Western Mo- 

 rocco. A remarkable feature of this outbreak was the early 

 appearance of a large number of gametocytes in the blood of 

 persons stricken with malaria. Similar phenomena have been 

 recorded by other observers, which should serve as an indication 

 that primary malaria must be strictly dealt with, especially in 

 localities where conditions for transmission are favorable. 



Malaria as a problem may be regarded from three distinct 

 standpoints: First, there is that aspect of malaria that most 

 frequently comes under the notice of the physician — the active 

 manifestation of the disease, which may express itself in a more 

 or less typical, clinical picture. There are the familiar benign 

 and malignant tertian fevers, with exacerbations occurring about 

 every forty-eight hours; the less frequently observed quartan 

 fevers, with attacks every seventy-two hours; double tertians 



