NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
( 36 )
able, with one or two adequate doses of quinine given at the proper
time, to cut short the attack almost at once. We should also be
in a position to tell our patient exactly what type of malarial fever
he was suffering from, how long he would have to continue
treatment in order to completely eradicate the parasites, and how
to protect himself from future relapses. All these points are very
1
mportant, because it must be remembered that malaria, like syphilis,
requires many months of continuous treatment for its eradication, and
for this reason requires the same care and accuracy in diagnosis.
As soon as the diagnosis of malarial fever is assured, it is best
to begin treatment with quinine at once, irrespective of the stage of
the fever, and to keep the patient slightly cinchonised * by repeated
doses of the drug until he is cured.
We should note, however, that quinine acts most effectively on
the parasite when it has escaped from the red blood corpuscles in the
act of sporulation. As we have already learnt, this corresponds in
point of time with the onset of the paroxysm (the cold stage), and
whatever other closes of quinine we give the patient during the day
we should always make sure that he receives one large dose (say of
20 grains) shortly before his paroxysm is expected. One dose given
at this time will, in the ordinary regular Tertian and Quartan
fevers, probably stop all future paroxysms, though it will not of
course prevent the one which is actually impending (see Chart I).
Euchinin which is tasteless, is quite as effective as ordinary
quinine and can be easily given to children. It must be given in the
form of the powder, as, if dissolved with the aid of acids, its bitter
taste returns,
Quinine is much more effective if given hypoclermically than in
any other way. Tabloids of the bi-hydrochlorate or some other
soluble salt should be used, dissolved in distilled water. A new
syringe, kept solely for the purpose, should be employed, and great
care taken to thoroughly boil the needle, syringe, and solution and to
render the skin thoroughly aseptic before carrying out the operation.†
* The first symptoms of cinchonism are buzzing noises in the ears and
deafness.
† A convenient case containing all necessa"ies for the hypodermic administra-
tion of Quinine can he obtained from Messrs. Burroughs, Wellcome & Co., London.
( 37 )
From two to five grains is usually a sufficient dose hypodermically,
given, if possible, just before the onset of the paroxysm, tut
as much as ten or fifteen grains may be given and repeated on the
same or subsequent days as may be necessary. It is easier and
better to give the quinine hypodermically than intramuscularly, but
care must be taken to get the point of the needle actually under the
skin and not between its layers, or a painful lump will result. Arsenic
has no action on the malaria parasite and is only of use as a tonic
after the attack is over.
As in syphilis, continuous treatment is necessary for some months
after all symptoms have passed off to ensure freedom from relapses.
It is probable that a very large number of the cases of malarial
fever admitted into our hospitals are relapses, the result of insuffi-
cient treatment during and after a first attack, and the practice
which pertains in our hospitals of sending a patient out as " cured "
almost as soon as the fever has left him, is no doubt responsible for
the large number of cases of chronic malarial cachexia that occur in
India.
Prophylaxis.
Under this heading two closely allied, yet quite distinct, sub-
jects must be considered, viz. :—
(1) The prevention of malarial fevers.
(2) The extirpation of malarial fevers.
In considering first the prevention of malarial fevers we may
recall these facts :—
(1) Anopheles mosquitoes are the carriers of the disease.
(2) People with malaria parasites in their blood are the
source from which anopheles mosquitoes become
infected and able to carry the disease.
Attempts at prevention may, therefore, be directed either
against the carrier, (anopheles mosquitoes) or against the source,
(infected people) or against both.
The chief methods of prevention that have been recom-
mended are as follow :—
(1) The extermination of anopheles mosquitoes,
( 38 )
(2) The protection of everyone from the bites of anopheles
mosquitoes.
(3)
Segregation.
(4) The use of prophylactic drugs.
Methods (1) and (2) are directed against the carrier of the
. disease and method (3) against the source. Method (4) is an
empirical one and disregards both the carrier and the source.
The plan of attempting to exterminate or to reduce the number
of anopheles mosquitoes in malarious districts, was initiated by
Major Ronald Ross, I. M. S., the discoverer of the facts upon which
all modern systems of prophylaxis are based. This method may,
therefore, be called the method of Ross.
The plan of attempting to protect everyone from the bites of
infected anopheles mosquitoes, by covering in the doors and
windows of houses with mosquito-proof netting has been chiefly
. advocated by Professor Celli in Italy, and it may, therefore, be
appropriately called the method of Celli.
The third plan, that of segregation, differs from segregation
measures usually carried out in the case of other contagious diseases,
in that it has for its object not the segregation of the sick but that
of the healthy. It has been chiefly advocated for the protection of
Europeans who are obliged to live in malarious districts, and it has
its foundation in the fact that natives, and especially native child-
ren, in malarious countries form the chief source of infection of
anopheles mosquitoes. It assumes also that such mosquitoes do not
habitually fly more than half a mile, and that they bite only at
night-time. On these grounds it is advocated that no European
house should be built within half a mile of a malarious town or
village, and that no native servants or their children should be
allowed to sleep at night in the compounds of European bungalows,
but that their quarters should be placed as far as possible from the
bungalow.
This method of prophylaxis goes by the name of " The segrega-
tion of Europeans", and was initiated by Drs. Stephens and
Christophers, who consider it to be the most efficient way of
protecting Europeans from malaria in certain parts of Africa.
As regards the fourth method it may be said at once that the
( 39 )
only drug which is of any service as a prophylactic against malarial
fevers is quinine, and that the correct way to employ it for this
purpose is to administer a dose of 15 grains on two successive days
every 9th and 10th days throughout the time the individual
remains in a malarious place.* Small doses of 3—5 grains taken
every day, as recommended by some authors, are of little or no use
in preventing new infections, though perhaps such doses, if taken
continuously, would serve to ward off relapses of old attacks.
Having thus briefly summarised the different methods of
prophylaxis recommended, we may now apply our knowledge to
the following particular cases: —
(1) Prophylaxis as applied to the individual.
(2) Prophylaxis as applied to any particular body of
individuals such as a regiment of soldiers.
(3) Prophylaxis as applied to communities.
1. Prophylaxis for the individual.—In considering the preven-
tion of malarial fevers from the point of view of the individual
it is necessary to distinguish carefully between two points which are
frequently confused, viz.:— (1) the prevention of first or new
infections; and (2) the prevention of relapses of former attacks.
There is no doubt that any individual who wishes to do so, may
effectually protect himself from a first or a new infection, wherever
he may be living, by taking measures to prevent himself from
being bitten by mosquitoes. This fact has been thoroughly proved,
and at the present time is not doubted by anyone who is capable of
forming an impartial opinion on the matter.
The chief precautions to be taken are:—
(1) Never go to sleep except under a good mosquito
curtain.
(2) Never go out in the evening or sit in the house or
verandah without wearing sufficient clothes to
protect the whole body from mosquito bites.
Especial care should be taken to protect the feet and ankles by
wearing high boots or putties. The reason for this precaution will
be obvious to anyone who has lived any time in the tropics.
Theoretically it would also be necessary to protect the hands by
* The method of Dr. Robert Koch.
( 40 )
wearing gloves and the face and head by wearing a gauze net
covering ; but in actual practice it is unnecessary to take these
extreme precautions, because most people, except during sleep, take
care to prevent mosquitoes from biting their face or hands.
Anyone who carries out the principle of always protecting
himself from mosquito bites by the simple method outlined above,
can live in the most malarious country with impunity. There are,
however, certain additional safeguards for the individual which no
wise man would neglect.
The chief of these is an application of the prophylactic method
known as the "segregation of the European" which has already
been referred to, and which of course is equally applicable to any
individual native who chooses to make use of it. Remembering
that this method arises out of the fact that natives in malarious
districts are the chief source of danger, and that anopheles mosqui-
toes seldom fly more than half a mile, care should be taken -when
camping out never to pitch one's tent within half a mile of a native
village. Travellers in Africa, as a rule, disregard this precaution
entirely, with the result that they suffer a great deal from malaria.
In India also a night spent in the dâk bungalow of most villages
very frequently results in a bad attack of malaria, unless the strict-
est precautions have been taken to guard against mosquito bites.
If, for some reason or other, an individual is not able to carry out
the directions given above, he must fall back upon, the plan of
attempting to ward off malarial fevers by taking prophylactic doses
of quinine, according to the method already described. The
uncomfortable effects produced by the large, but necessary, dose of
quinine twice every 9 or 10 days renders this method a very trying
one, which no one would resort to unless it were quite impossible for
him to employ the simpler and more effective method of protecting
himself from being bitten by mosquitoes.
The prevention of relapses of former attacks.—Relapses only
occur in cases in which a former infection with malaria parasites
has not been completely cured.
They have no connection whatever with mosquitoes and may be
brought on by almost any exciting cause such as a chill, overfatigue,
exposure to the sun, etc. The best way to avoid these relapses is
( 41 )
to go through a thorough course of quinine treatment similar to
that which will be described later under the heading of the "disin-
fection of infected individuals." It is almost useless to take a dose
or two of quinine occasionally, in an irregular manner.
FIGurE 2.
A. B. Barracks of the men. C. Hospital and Prison. D. Syce lines. In-
fection of children 35 per cent. E. Syce lines. Infection of children 56 per cent.
F. Hospital Followers. Infection of children 60 per cent. G. Regimental
bazaar. Infection of children 40 per cent. H. H. II. Irrigation watercourse.
Breeding place of anopheles mosquitoes.
2. Prophylaxis for a particular body of individuals.—We
may next consider the case of a number of individuals, such as a
regiment or company of soldiers living together in one or more
barracks, surrounded on all sides by native bazaars and by breeding
places of anopheles mosquitoes. I refer, for example, to such a
condition as is illustrated above (Figure 2), a condition which is
commonly met with in Indian cantonments.
A. and B. are the barracks of the men. C. is the hospital and
( 42 )
military prison. D. and E. are syce lines containing perhaps 200
children, from 40 to 60 per cent. of whom have malaria parasites in
their blood. P. is the hospital followers' quarters, containing per-
haps 40 or 50 children, 60 per cent. of whom have malaria parasites in
their blood. G. is the regimental bazaar containing numerous child-
ren, the majority of whom are infected with malaria parasites. All
these children form a constant and abundant source from which the
numerous anopheles mosquitoes which breed in the irrigation water-
course (H.) and in many other watercourses near, become infected.
It will be readily seen that under these conditions the men in
the barracks must suffer severely from malaria. They are in fact
in the midst of an area of infected anopheles mosquitoes and it is
difficult to understand how, under the circumstances, any of them
can escape getting malarial fever.
If we consider in such a case only the soldiers themselves in our
system of prophylaxis, it is evident that we shall probably attain
most success in prophylaxis by an extension of the principles already
indicated for the individual.
Our first aim would be to thoroughly cure all men who had
previously suffered from malaria and who would therefore be liable
to relapses. This would be done by the method described on
page 45 for the disinfection of infected individuals. At the same
time we should set about protecting the soldiers from being bitten
by mosquitoes, by covering all doors and windows of the barracks
with mosquito-proof netting, and as a further safeguard by giving
each man a mosquito curtain. In most Indian stations this plan
of protecting the men against mosquito bites would be impracti-
cable; owing to the fact that the intense heat during the summer
nights would render it quite impossible for men to sleep under
mosquito curtains in mosquito-proof barrack rooms. In such sta-
tions therefore the best plan would be to adopt; in a modified form;
the method of segregation already described; that is to remove the
native lines and the bazaar to a greater distance from the barracks,
so that the men may be if possible half a mile from any source of
infection.
If neither of these methods could be carried out we should
have to fall back upon prophylactic doses of quinine.
( 43 )
3. Prophylaxis for communities.— Either the method of protect- .
ing all the men from mosquito bites, or that of segregation, would
doubtless protect the particular body of individuals referred to
from getting malarial fevers. No system of prophylaxis however,
can be considered satisfactory which aims only at the protection of
a few, however important these few may be, while it leaves the great
mass of the inhabitants of a place in the same condition. The object
of a good malarial prophylaxis should be to render everyone less liable
to contract malaria, to transform, in fact, a malarious place into a
healthy one. Measures which aim at anything short of this are of
more scientific interest as proving that protection from the bite of
infected mosquitoes ensures protection from malaria, than of real
practical value.
How then can we set about turning a malarious place into a
healthy one ?
We know that if we can exterminate all malaria-carrying
rcosquitoes from the place we shall entirely get rid of malaria there,
and this is therefore the method which must be attempted.
The suppression of anopheles mosquitoes.—Anopheles and
other kinds of mosquitoes are, as we have already seen,
much more easily dealt with in their larval condition in water
than in their adult state. The main object of all efforts directed to
the suppression of mosquitoes is therefore to get rid of all places
where they can breed. This is comprised in the words " effective
drainage." From the earliest times it has been recognised that
malaria may be diminished and in some places banished altogether by
drainage and drying of the soil. It is almost certainly by these
means that large tracts of country in England, Holland, France and
many other places which formerly were very malarious have been
rendered healthy and productive. It is also for this reason that large
towns such as Rome in Italy, Calcutta, Bombay and Madras in India,
are far less malarious than the outlying villages which surround
them, though in the latter cities a great deal in the way of effective
drainage still remains to be done. In our large towns in India, in
proportion as we effectively prevent the formation of stagnant pools
of water, and in proportion as we carry out measures for drying the
soil and lowering the level of the subsoil water, so will the number
( 44 )
of malaria-bearing mosquitoes and in consequence the prevalence of
malarial fevers, diminish.
In isolated villages we should aim at carrying out the same
principles—the draining away of large areas of water, the filling in
of all small tanks and pools, and the removal of stagnant water
wherever it may be.
In many parts of India irrigation by means of canals is the
chief cause of the prevalence of malaria. We have already seen
that the chief malaria carrying species of anopheles mosquitoes
breed almost entirely in the running water of irrigation water-
courses, and apart from this the effect of bringing in large supplies
of water to a district which already is improperly drained, is to
farther increase the water-logging of the soil and the formation of
numerous pools where mosquitoes can breed.
The same result is produced by bringing in a drinking water
supply to a town from outside without first providing for the
efficient drainage of all superfluous water.
There is little doubt that, at any rate in cantonments, where
the chief need for irrigation is in the making of flower gardens,
irrigation by means of wells should be substituted for the present
method by canals. For these purposes well-irrigation is quite
effective, and has the great advantage of lowering the level of the
subsoil water and drying the soil.
Any superfluous water which cannot be drained away, may be
made an impossible breeding place for anopheles mosquitoes by
covering it with a layer of kerosene oil, which not only kills all
larvæ, but also any adult mosquitoes that may come to lay their
eggs on the water.
If irrigation canals, streams, etc., cannot be done away with
in any place, they may, to a certain extent, be rendered inhospi-
table breeding places by keeping their edges very smooth and clean
and free from weed and grass.
The extirpation of malarial fevers,
Quite distinct from the foregoing measures for the prevention
of malarial fevers,—though the ultimate aim, of both is the same,—
is the proposal of Dr. Robert Koch to exterminate all malaria
( 45 )
parasites, by the systematic treatment of all infected individuals
with quinine. Dr. Koch compares the campaign against malaria
to that which is carried out against cholera. Just as in cholera it
is necessary to search out all the sick, the convalescent, and. the
healthy who harbour the cholera vibrio and to isolate and disinfect
them, so in a campaign against malaria it is necessary to search
out and disinfect all people who harbour the malaria parasite. The
method is carried out in the following way. The blood of all the
inhabitants of the district which it is desired to free from malaria,
is systematically examined, and all those in whom infection with
malaria is found are treated by the following plan for " the disinfec-
tion of the infected." A dose of 15 grains of quinine is adminis-
tered on each of two or three successive days and repeated at inter-
vals of eight clays throughout a period of three months. If during
the course of the treatment the individual gets a relapse of fever, or
if, even without a relapse, malaria parasites are found in his blood, he
receives five consecutive days' treatment with quinine given in the
following doses :—On each of the first and second days 30 grains of
quinine (15 grains in the morning and 15 grains in the evening)
and on each of the third, fourth and fifth days 15 grains. The
after treatment is then continued in the same way as before, viz.,
15 grains on two or three successive days every eight days for three
months.
By this method Dr. Koch and his assistants have obtained
successful results in a number of malarious districts under differ-
ent conditions.
In carefully selected malarious places in India, and especially in
cantonments, where all the inhabitants are under supervision, it is a
measure which is likely to prove of the greatest service in spite of
its apparent impracticability. Looking back at the illustration on
page 41 (Fig. 2), the syce lines, the hospital followers' quarters,
and the bazaar are practically the only centres of malaria from
which all the anopheles mosquitoes in the lines become infected.
If we were to treat all the infected natives in these groups of huts
with quinine, we should not only greatly benefit the people them-
selves but we should also do away with the main sources of
infection of anopheles mosquitoes. This would not be by any
( 46 )
means an impossible task, and as a matter of fact the experiment
has already been tried in a modified form in the cantonment from
which our illustration is taken.
All the children living in one of the syce lines (over 100 in num-
ber) and all the children in the hospital followers' lines (35 in
number) were treated systematically with quinine from August to
November 1902. Each child received from five to ten grains of
quinine according to age daily for the first ten days and afterwards
ten grains twice a week on consecutive days.
As a result of this treatment no parasites were found in any
of the children of the syce lines, and in only 16 per cent. of the
hospital followers' children, during the fever season of 1902,
although during the previous year a very large number were
infected. The spleen rate of the children was also markedly reduced,
and the best result of all was found in the fact that scarcely a
single case of fever occurred throughout the year among the
adults (the syces and hospital followers) although they them-
selves received no quinine. During the year 1901, although
the adult syces and hospital followers received a prophylactic dose
of quinine, they suffered so severely from malarial fever that more
than half their number were frequently incapacitated from work.
This is a very good proof that the children are really the chief
source from which anopheles mosquitoes become infected, and that
if we can get rid of the parasites in them we shall do much towards
reducing the prevalence of malaria and the liability to infection in
any place.
We have now briefly considered the different measures which
have been recommended for the prevention of malarial fevers as
well as Dr. Koch's plan of attempting to eradicate all malaria para-
sites, and it only remains to say that it is impossible to lay down
hard and fast rules for a campaign against malaria that will be
applicable to every place. Before measures in a district are under-
taken, it is essential that the conditions under which malaria prevails
there should be thoroughly known, and the practicability of each
measure thoroughly weighed before the campaign is begun. If this
were always done, much money would be saved and much dis-
appointment prevented.