75
Para. 41
that search for the parasites of malaria or for melanin should be carried out
where required for purposes of treatment.
These recommendations for diagnosis and management in paludism may be
collected in a more orderly manner, as follows :—
1. Search for the parasites of malaria or for melanin should he made when
required.
2. Early cases, in which the parasites are found by the microscope or are
inferred to exist from the presence of the typical fever, must he treated by large
doses of quinine (given if possible an hour or so before the birth of each fresh
generation of the organisms).
3. Quinine in smaller doses should be rigorously continued after the
febrile period, long enough to ensure the final extermination of the parasites
from the system.
4. In older cases, it is necessary to ascertain how far the parasites are
still present. If found, they must be exterminated as soon as possible by large
doses of quinine. If not found, we have still no right to infer that they are
absent ; and should, therefore, exhibit small doses of quinine daily for weeks or
months on the chance that some of them still remain.
5. Crescents do not produce fever ; continued small doses of quinine are
required when they only are present.
6. In other cases, we must always remember the possibility of any fever
which may exist being wholly or partly a secondary fever, especially if it
exhibit the characteristics given in paragraph 32, and if the spleen or liver are
enlarged. It should be treated by daily small doses of quinine to ensure
destruction of any parasites which may still be present, and by attention to the
state of the organs" to which this kind of fever appears to be due.
7. If the spleen be much enlarged, there is a presumption, as regards
natives of India, that the parasitic invasion is quite or nearly exhausted ;
and this presumption is strengthened if there be no more attacks of the typical
malarial fever. In such cases attention should be devoted particularly to the
state of the organs ; large doses of quinine will probably be found useless if not
harmful ; and we should depend on laxatives, tonics and good food—especially,
I think, fresh milk.
8. In the last stage, dieting and attention to the frequent intercurrent
complaints, such as diarrhoea, dysentery and worms, must be depended on.
9. In all cases of chronic malarial fever, microscopic examination of the
dejecta for the eggs of worms, especially of ankylostomes, is an absolute necessity.
And the examination should be repeated a week and more after vermifuges
have been given, in order to ascertain whether any worms remain. The employ-
ment of thymol in large doses without previous examination of the dejecta is
not as a rule defensible, unless the latter course cannot be adopted.
It will be perceived by the experienced practitioner that many of these
counsels are " counsels of perfection," which can more easily he written down
than followed ; nevertheless, an attempt can be made to follow them in a large
number of cases.
I have recommended the microscopical examination of the dejecta as a
routine, and of the blood when necessity arises. It may be objected that
these recommendations are impracticable and that medical men have no time to
carry them out.
The examination of the dejecta is an extremely easy process, requiring
only the humblest instruments and capable of being performed by all hospital
assistants. Any medical officer can easily train his subordinates in a few days
to do the work ; and after that only his superintendence will be required. The
technique is merely to place a small portion of the dejecta with a piece of stick
in a drop of water on a glass slide, to impose a cover glass, and to examine
with a medium power. The eggs of the different worms are figured in the
text-books [14 and 26]. In my experience, medical subordinates soon take
considerable interest in the task ; and, in short, there is little excuse for not
making these very necessary examinations.
The examination of the blood, however, requires high powers of the
microscope and some experience. Medical subordinates can do this work also,
as I have found ; but the medical officer must first be himself well acquainted
with the subject. Though I certainly do not think it necessary, or even possible
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