# Tropical Diseases/Chapter 8

CHAPTER VIII
MALARIA: TREATMENT
Quinine.—— Many drugs have been employed in the treatment of malarial disease, and many drugs have some influence on it; all sink into insignificance in comparison with quinine. In serious cases, to use any drug to the exclusion of quinine is culpable trifling. Therefore, so soon as a diagnosis of malaria has been arrived at, unless there be some very manifest contraindication, the first duty of the practitioner is to set about giving quinine. There are many ways of exhibiting the drug; however given, care must be taken that it is so administered that there can be no mistake about its being absorbed. If the patient for any reason, such as inability to swallow or persistent vomiting, cannot take quinine by the mouth, and the existing condition be grave, it may be injected by the rectum; but if the circumstances of the case are such that neither of these channels for administration is available, and a rapid action of the drug is imperative, it must be injected at once intramuscularly, or into a vein.
When and in what dose to give quinine in ordinary cases.—— During a paroxysm of ordinary intermittent fever it is better, before giving quinine, to wait until the rigor and hot stages are over and the patient is beginning to perspire. A fever fit, once begun, cannot be cut short by quinine, and to give quinine during the early stages aggravates the headache and general distress; but so soon as the skin is moist and the temperature begins to fall, the earlier the drug is commenced the better. Ten gr., preferably in solution, should be administered at the commencement of sweating, and thereafter 5 gr. every six or eight hours for the next week. This is an almost certain cure. The quinine may not always ​prevent the next succeeding fit, but it nearly always diminishes its severity. In ninety-nine cases out of a hundred the second following attack does not develop.
When giving quinine it is well to administer an aperient and to keep the patient in bed; in ordinary cases neither aperient nor rest in bed is absolutely necessary. In cachectics, however, and in all obstinate cases, both are valuable adjuvants.
My practice in the treatment of ordinary malarial fevers is to give quinine for a week in the doses mentioned. At the same time, with a view to prevent recurrence of fever, I direct the patient, particularly if I have found the crescent form of the parasite in the blood—— for such cases are especially prone to relapse—— on one day a week (to give precision to my directions I generally mention Sunday) to take a mild saline, sulphate of soda or Carlsbad salts, in the morning, and three 5-gr. doses of quinine during the day, or 15 gr. in one dose. After the first week, iron and arsenic in pill, tabloid, or solution are prescribed for a fortnight, and, after an interval of a week, for another fortnight. The weekly aperient and quinine had better be kept up for six weeks or two months or longer. In other cases I recommend, after the preliminary week, 5 gr. of quinine daily; this dose to be kept up for three months, and repeated for a month every spring and fall for two years.
Dose of quinine: toxic effects.—— There is great difference of opinion and practice about the dose of quinine. Some give 30 gr. at a dose, some give 3 gr. The former, in my opinion, is too large a dose for ordinary cases, the latter too small. It must never be lost sight of that occasionally quinine in large doses produces alarming effects; not singing in the ears and visual disturbances merely, but actual deafness and even amblyopia, both of which may prove very persistent and occasionally permanent. It may also produce profound cardiac depression and gastric disturbance, and even death from syncope. Urticaria is another, and not very uncommon, effect ​of even small doses of quinine; some cannot take it on this account, and prefer to endure the disease rather than suffer the intolerable irritation induced by the remedy. I believe that nothing is gained by excessive doses; in ordinary circumstances, 30 gr. spread over two or three days is usually ample to check an intermittent.
In the endemic area of hæmoglobinuric fever, and even in the case of individuals who have long left that endemic area, large doses of quinine do sometimes undoubtedly determine an explosion of that highly dangerous disease, especially so, but not exclusively so, in the cachectic. This important fact must not be lost sight of, and when there is any good reason to apprehend such a calamity, quinine should be given at first in ½-gr. or 1-gr. doses, gradually increased to 5 gr. or more three or four times a day.
For children under one year, ½ to 1 gr. for a dose suffices; for older children the dose must be increased proportionately to age and strength. Children tolerate the drug well, so that in serious cases—— pernicious comatose or other cerebral forms—— the drug should be vigorously pushed.
If a supposed ague resist the doses of quinine mentioned, the diagnosis should be revised.
Quinine in pregnancy.—— Care should be exercised in giving quinine to pregnant females, for undoubtedly it sometimes causes miscarriage. The fact of pregnancy, however, must not debar the use of the drug altogether; only, in such circumstances, it should be given in the minimum dose likely to be effectual, say 3 gr. repeated every eight hours for two days. A pregnant woman will run more risk of miscarriage and of detriment to her health from repeated ague fits than from a reasonable dose of quinine.
Quinine in the puerperal state.—— It is a wise precaution in malarious countries to give a few 5-gr. doses of quinine during labour or soon after. The puerperal state seems to have the effect, as any other shock or physiological strain might, of waking up the slumbering malaria parasite. A dose or two of quinine in these circumstances does no harm, ​and may, by choking off a threatening fever, avert suffering and anxiety, not to mention danger.
Form, in which to administer quinine.—— Quinine is best given in solution, and probably the hydrochloride, as containing a larger proportion of the alkaloid than the sulphate, is the best salt. Some, under the impression that hydrobromic acid prevents the singing in the ears attending the free use of the drug, prefer this to dilute sulphuric acid as a solvent for the ordinary sulphate. When the tongue is fairly clean and digestion not .altogether in abeyance, the quinine may be given in freshly prepared pill, in tabloid form, in cachet, or enclosed in cigarette paper; but in serious cases, particularly where the tongue is foul and digestion enfeebled, pills and tabloids are not to be trusted to. In these circumstances they are apt to pass through the bowels and to appear in the bedpan unaltered. In grave cases this occurrence must not be risked.
Euquinine or euchinine, the ethyl carbonate of quinine, quinine tannate, and aristoquinine—— a diquinine carbonic ester—— have the advantage of being almost tasteless, an important property in the case of fever in children or fanciful patients.
Milk as a menstruum for quinine.—— If the taste of the ordinary salts of quinine be very much objected to, and if euquinine is not available, a good plan is to give quinine in powder in a tablespoonful of milk after the patient has previously lubricated the mouth with a morsel of bread and butter. Given in this way the bitter taste of the drug is not perceived.
Injection of quinine.—— In any type of fever, if vomiting is persistent, if the brain is affected, or if the patient is insensible and cannot or will not swallow, recourse must be had to rectal, or intramuscular, or intravenous injection of quinine. In all cases in which life is in imminent danger, and in which the earliest possible action of the drug is of importance, it must be so administered. The intramuscular method is sometimes a painful one, and may be attended with some risk of abscess; in the circumstances, such possibilities count for little. ​The most suitable readily procurable salt for injection is the hydrochloride, or, better, the bihydrochloride, which is soluble in less than its own weight of water. The hydrobromide is equally soluble. If neither of these salts can be procured the sulphate may be used, solution being effected by adding half its weight of tartaric acid.* Seven to 15 gr. dissolved in 30 to 60 min. of sterilized water would be a full dose; in grave cases this dose should be given three times in the twenty-four hours
In giving an intramuscular injection the needle should be driven well home, deep into the muscles of the gluteal or scapular region, the skin being previously carefully cleansed. The solution must be freshly prepared and boiled, and the syringe and needle thoroughly sterilized. A syringe having a well-fitting glass piston and a plugging needle is the best instrument for giving these injections. In the malignant fevers of Rome as much as a drachm of quinine, divided into three or four doses, is sometimes administered intramuscularly in the course of twenty-four hours with the best results.† ​The best place for an a intramuscular quinine injection is the gluteus maximus muscle at a point somewhere from 2 to 3 in. below the crest of the ilium. After the injection is made the part should be gently massaged so as to diffuse the solution, and the little wound sealed with collodion. Quinine ought never to be injected into the neighbourhood of large nerves or blood-vessels, and never into the subcutaneous connective tissue, as in the case of morphia and other alkaloids. I have long been in the habit of using intramuscular injections of quinine, both in hospital and in private practice, and, so far, without mishap. My belief is that abscess, indurations, and similar accidents are for the most part attributable to imperfect methods and carelessness.
Intramuscular injections of bihydrochloride of quinine, 7 to 10 gr. in 10 to 20 minims of water daily for a week, is the best way of checking obstinately relapsing malarial attacks.*
Precautions.—— It may be well to mention—— not with the idea of deterring the practitioner from using the drug in this way, but to impress upon him the necessity for sterilizing the patient's skin at the place selected for injection, and for care in keeping instruments and solutions aseptic—— that not only abscess, sloughing, and chronic painful indurations have sometimes followed the hypodermic injection of quinine, but also tetanus. In these latter unfortunate cases it was not, of course, the quinine that directly caused the tetanus; it was the tetanus bacillus, and this tetanus bacillus was introduced either on a dirty needle or in a fouled solution. Further, as Semple has pointed out and emphasized, the tetanus bacillus may be present in the body without giving rise to symptoms, provided the vitality of the tissues is not seriously impaired by injury or irritant. Unlike morphia, or emetine, quinine is a powerful irritant, and, when ​injected, may suffice to render the implicated area a suitable culture ground for the bacillus and the elaboration in lethal quantities of tetanus toxin.
Tetanus is an exceedingly common disease in some tropical countries. In Western Africa, for example, a large proportion of wounds, no matter how trifling as wounds they may be, if they are fouled by earth or dirt result in tetanus. The French in Senegambia have found this to their cost. A gentleman "who had travelled much in Congoland told me that certain tribes poison their arrows by simply dipping the tips in a particular kind of mud. A wound from these arrows is nearly sure to cause tetanus. In many tropical countries, so general and so extensive is the distribution of the tetanus bacillus that trismus neonatorum is a principal cause of the excessive infant mortality. Every precaution must therefore be taken to ensure that the little instrument which is so potent in saving life may not by carelessness be turned into an instrument of death. The systematic use of tetanus antitoxin in quinine injection treatment has been advocated; but, it seems to me, this is hardly practicable under ordinary tropical conditions.
It is scarcely necessary to add that the intramuscular injection of quinine must not be practised without good reason, or as the routine treatment of ordinary malarial attacks.
Quinine by enema.—— Quinine may also be given by enema. It is readily absorbed if the bowel be not too irritable. The dose should be a large one. Thirty gr. given in this way and repeated in an hour or two in malarial comatose fever has sometimes a rapid effect. It is the most effective method of exhibiting the drug in such attacks in children. Five gr. in warm solution, repeated hourly, retention being ensured by the attendant keeping the patient's buttocks together, is strongly recommended by Daniels.
Intravenous injection of quinine.—— In cases of pernicious comatose remittent, in which it is of importance to obtain a rapid and powerful action of the drug, Bacelli recommends the intravenous injection ​of the following solution: Hydrochloride of quinine 1 grm., sodium chloride 75 eg., distilled water 10 grm. This solution he has employed in these desperate cases with much success, injecting directly into a vein 5 to 7 grm. at a time. He states that whereas with hypodermic injection the mortality in such cases amounted to 17 per cent., with intravenous injection it was reduced to 6 per cent. Wright recommends for intravenous injection doses of 15 gr. in 250 to 300 c.c. of normal saline, to be repeated once or twice if necessary. The intravenous injection of quinine is now regarded by many British practitioners of tropical experience as the most appropriate and efficient treatment in all pernicious comatose and hyperpyrexial attacks. Bass, speaking from large experience, remarks that it is never necessary to give more than 30 gr. in twenty-four hours and never more than 10 gr. at one time. Large doses are dangerous.
Warburg's tincture.—— A very effective medium for giving quinine, and one of high repute in many places, is Warburg's tincture. This contains, besides quinine, a number of drugs, many of them doubtless inert, although some of them certainly possess valuable therapeutic properties. Experience has shown that the combination is really a good one, and that Warburg's tincture sometimes succeeds where quinine alone fails, or acts too slowly. It generally proves a powerful sudorific. The dose is ½ oz., and is repeated after two or three hours. The action appears to be somewhat similar to that of the antipyretics now in vogue—— antipyrin, phenacetin, etc.—— drugs which, when given in combination with quinine in the routine treatment of malarial fevers, although they have no curative properties, sometimes contribute very markedly to the relief of headache and febrile distress. They must be used with great caution in adynamic cases. At the present time these drugs are much abused in many malarial countries.
Mode of action of quinine.—— In what way quinine acts has not yet been satisfactorily explained. ​Some, reasoning from the toxic influence this drug exerts on many kinds of free amoebæ, say that it acts in malaria in the same way that is, as a direct poison to the parasite. They support this view by pointing to the degenerative changes, as evidenced by imperfect staining reaction, exhibited by such parasites as persist in the blood after administration of quinine has been commenced. Others maintain that it acts in stimulating the phagocytes, the natural enemies of the parasite. Some experimentalists allege, on the other hand, that it paralyses the white corpuscles. That quinine does not kill all blood protozoa is certain, for it has no effect on the hæmoprotozoa of birds and reptiles, or on the trypanosomes. Certain it is that in man, with the exception of the crescent body, it usually quickly causes the parasite to disappear from the general circulation. It is said by some to be most effective against the free spores and the very young intracorpuscular forms, but inoperative against the more mature parasites; hence they advocate giving it early in the parasitic cycle. Others, on the contrary, maintain that it is operative only on the large intracorpuscular forms, and therefore advocate its use at a late stage of the cycle.
Strange to say, quinine, especially in small doses, seems sometimes to wake up latent malaria and to bring about an ague fit. The same may be said of a course of mineral waters, of hydropathic treatment, and of sea-bathing.
Treatment of bilious remittent.—— In bilious remittent and other severe forms of malarial fever one must not, as in a simple intermittent, wait for the remission before giving quinine. To wait for remission or sweating used to be the practice; it was said that to give quinine at any other time was wrong, and that something terrible would happen if the superstition were ignored. In all grave, fevers a full dose, 10 or 20 gr., should be administered at once. The parasite cannot be attacked too soon. It is desirable to have the bowels freely opened; quinine is said to act better then. It is a mistake, however, to delay the administration of ​the specific pending the action of the aperient. If an aperient be indicated, it should be given along with the quinine. Five or 10 gr. of calomel is the best. Thereafter the quinine, in 5- or 10-gr. doses, should be repeated every three or six hours until fever has subsided. If there be much bilious vomiting, an emetic of ipecacuanha or repeated draughts of hot water will clear the stomach and perhaps, after a time, enable it to retain the quinine. The drug is sometimes more readily retained if given in chloroform water or in effervescing form. Mustard poultices to the epigastrium, small hypodermic injections of morphia, ice pills, sips of very hot water, effervescing mixtures, champagne, 1- or 2- drop doses of tincture of iodine, are each of them, on occasion, aids in stopping vomiting. If these measures fail, and if the vomiting is so frequent and so severe that the dose is immediately rejected, and if there is no diarrhœa, it is advisable to clear out the rectum with an injection of warm water and, when the action of this has concluded, to throw up an enema of 30 gr. of quinine in 3 to 10 oz. of water with a few drops of acid to aid solution; at the same time, 5 or 10 gr. of calomel may be given by the mouth. This failing, or in preference to this, recourse must be had at once to intramuscular injections. So soon as the stomach has quieted down, quinine may be given again by the mouth.
Treatment of hyperpyrexia.—— Hyperpyrexia must be promptly met by prolonged immersion in the cold bath, rectal injections of iced water, ice-bags to the head, etc. At the same time quinine must be injected intramuscularly, or into the rectum or into a vein, in full doses, and repeated every three hours until 30 or 40 gr. or more have been given. Prompt action in these cases is of the first importance, and may save life. If temperature be kept down for three or four hours the quinine gets time to act on the parasites crowding the intracranial vessels; but if temperature be allowed to mount and to remain high the patient is destroyed before the specific has a chance. The cold bath, therefore, is absolutely ​necessary. In such circumstances, antipyrin and similar antipyretics are worse than useless. Good rules are to prepare to give the cold bath, or cold pack, if the axillary temperature reach 106° F., and to remove from the bath when rectal temperature has fallen to 102° F. Although the temperature has been reduced by this means, thermometrical observations must be continued at short intervals, say every two hours; directly it begins to rise again, say to 102-103 F., the patient should be replaced in the bath: this must be repeated as often as necessary. Patients who have suffered from a hyperpyrexial attack should be invalided home.
Treatment of algide and dysenteric attacks.—— Algide and dysenteric attacks demand quinine combined with a little opium. If dysenteric symptoms persist, emetine, or ipecacuanha, or the aperient sulphates in full doses, and opium, according to the nature of the dysentery, must also be given.
Other drugs in malaria.—— During the continuation of a fever I have never seen much, if any, good from arsenic. The place of arsenic is not as a substitute for quinine during fever, but as a blood restorer after fever. I have heard of cases of obstinate ague cured by ½-drachm doses of liquor arsenicalis; I have never myself ventured on these heroic doses. Recent experiments show that although salvarsan and neo-salvarsan have some effect on the quartan and tertian parasites, they have little if any on the subtertian. A strong infusion of "the hairs that grow between the grain and the outer leaves of the mealie cob " (dose, 3 tablespoonfuls) has recently been recommended as a cure for malaria; I have no experience of it. I have never seen benefit, in any way approaching that derived from quinine, from methylene blue, carbolic acid, iodine, anarcotine, analgen, phenocol, parthenium, ailanthus, chiretta, eucalyptus, or any of the many drugs which from time to time have, on very limited experience, been recommended in malaria. In those cases, however, in which from some idiosyncrasy the patient is unable to take F ​quinine, it may be necessary to have recourse to some of these drugs. Methylene blue in doses of 2 to 3 gr., and pushed until the urine becomes deeply tinged or signs of kidney irritation appear, enjoys a certain reputation in America and in Germany. Anarcotine was at one time, during a quinine famine, extensively and successfully employed in India; the dose is from 1 to 3 gr. Phenocol hydrochloride, in 10-gr. doses, administered five, three, and two hours before the expected paroxysm, has been used with advantage in Italy, and is said to have succeeded in some instances in which quinine had failed. Tannin has been recommended in obstinate cases where quinine had failed or could not be taken. A grain of capsicum with 5 gr. of quinine is said to succeed sometimes where quinine alone fails. I have given this pill, but cannot determine how much the capsicum contributed to the cure. I cannot say I have ever seen an ordinary uncomplicated ague absolutely resist quinine properly given. I have seen cases of obstinately recurring ague apparently permanently cured by a few intramuscular injections of quinine, although the same drug, given in the ordinary way, had proved a comparative failure. There can be little doubt, however, that in rare cases it does fail, and that it is more efficient against the benign tertian and the quartan than against the malignant parasites. It does not always prevent relapse, even in the non-malignant infections.
Treatment of splenic tumour and malarial cachexia.—— The enlarged spleen of malarial cachexia is best treated by counter-irritation (linimentum iodi, or ung. hydrarg. biniodid.) and saline aperients, combined with quinine, arsenic, and iron. The subjects of hepatic enlargement and abdominal congestion arising from malarial disease of long standing generally derive much benefit from a course of Harrogate, of Kissingen, of Carlsbad, or of other aperient mineral water. When these waters cannot be obtained, a morning aperient saline, kept up for two or three weeks, is an efficient substitute. Aperient courses should, as a rule, be com​bined with moderate doses of quinine, and be followed by courses of iron and arsenic. Cachectics should leave the malarial centre where they are being poisoned, and spend at least one year in Europe. They must be careful to clothe warmly, especially on first entering colder latitudes; to keep lightly employed both in body and mind; to avoid over-fatigue, constipation, exposure to a very hot sun, high winds, rain; to live temperately, and generally to follow the dictates of common sense. Residence in a dry, cool, sunny climate, or a sea -voyage, is an admirable restorative in malarial cachexia.
Malarial cachectics must exercise great caution about exposing themselves to the fresh sea-breezes on the return voyage to Europe. Neglect of this is nearly sure to be punished with an attack of fever, sometimes of fatal blackwater fever. Many such fatalities occur yearly in cachectics from West Africa during the voyage to Europe. Return to Europe in the winter season should, if possible, be avoided, the colder months being spent in the Canaries, Egypt, or the Riviera. If quinine is being taken when the patient leaves for Europe, its use, in the accustomed dose, should be systematically continued during the voyage and for several months, at least three, after arrival. I find that malarial cachectics are often allowed to start on the voyage to Europe inadequately instructed on these important points.
Food and drink in malaria.—— The food in malarial fevers ought to be light and principally fluid. Effervescing mixture often helps to clean the tongue and settle the stomach. Lemon decoction (made by boiling for half an hour a sliced lemon, including skin and seeds, in a pint and a half of water, straining, diluting, and sweetening) is much
PROPHYLAXIS
The basis of malaria prophylaxis is the fact that particular species of mosquitoes are indispensable for the propagation of the parasites. Practical measures, therefore, have for their object the extermination of these insects, or, failing this, the prevention of their bites. War need not be waged against all mosquitoes; our present knowledge seems to indicate that only the Anophelinæ have to be considered. As the members of this sub-family are easily recognized (p. 146), and as they are somewhat fastidious in their habits, their extermination in limited areas is by no means a hopeless task.
Drainage, cultivation, and flooding.—— Experience has shown that much can be done to free a locality of malaria. Drainage and cultivation where the land will repay the expenditure, permanent and complete flooding where it will not and where such flooding is possible, proper paving and draining of unhealthy towns, and the filling-in of stagnant, swampy pools these are the more important things to be striven for in attempting the permanent sanitation of malarious districts. In England, in Holland, in France, in Algeria, in America, and in many other places, enormous tracts of country which formerly were useless and pestilential have been rendere-9d healthy and productive by such means.
In carrying out extensive public works care should be exercised to provide good subsoil drainage in connection with irrigation, to provide efficient drainage to carry off superfluous water before introducing a larger water supply into a town previously inadequately watered, and to avoid interfering with the natural drainage of a district in constructing railways and so forth. To do anything that may raise the level of the subsoil water in potentially malarial districts is most dangerous. Equally so is the neglect to fill up or provide for the drainage of excavations, such as the " borrow-pits " in railway construction, or similar holes in which rain-water may accumulate and create breeding pools for mosquitoes. ​Location of dwelling - houses.—— The inhabitants of malarious districts ought to live in villages or towns with well-paved streets and courts, going out to cultivate their fields during the day, but returning to sleep in the town before nightfall. Houses should be placed, if possible, on high and dry situations, a clay soil being avoided. All forest under-growth should be cleared away. It is unwise in countries such as Africa, where nearly all Europeans suffer from chronic malarial poisoning, to place dwelling-houses in exposed situations, or where high winds are apt to produce chills and consequent fever relapses. For the same reason, in elevated situations houses should be well sheltered by trees planted at some distance from the premises, or by higher ground. In the neighbourhood of houses the felting of natural grass should, if possible, be preserved, or, if it be disturbed, replaced immediately, or the exposed soil covered with rammed clay or cement. It is unwise to have flower-beds or vegetable gardens near bedroom windows, or to allow water from bath-rooms or cook-houses to flow over the ground in the vicinity of the house, or to keep water unchanged in tubs or water-butts for mosquitoes to breed in. Pools and puddles of stagnant water should be filled up and turfed. Water-butts and cisterns should be screened, and sagging roof-gutters rectified; discarded tins, jars, pots, bottles, and all rubbish capable of holding water in which mosquitoes could breed should be got rid of, and plants or trees in which collections of water occur should be cut down. Ponds should be stocked with fish, as fish tend to keep down mosquitoes by preying on their larvæ. The neighbourhood of swamps is to be avoided. A few ounces of petroleum thrown on the surface of a pond will prevent mosquitoes from depositing their eggs on the water, and will asphyxiate their larvæ; the petroleum requires to be renewed from time to time—— say once a week. Coal tar may be used in the same way. There are many simple precautions of this sort which will occur to every prudent man, and which, in malarious countries, he should take care to have carried out. ​Danger from vicinity of natives.—— Seeing that in malarious localities a large proportion of the native children harbour the malaria parasite, and that a large proportion of the anophelines in the neighbourhood of native houses are infected, it is manifest that to visit native quarters when mosquitoes are feeding, especially in the evening or during the night, is fraught with danger. For the same reason the European should build his house or pitch his camp well away ——a quarter of a mile at least—— from native quarters, and beyond the flight of infected anophelines; and, for the same reason, native children should not be allowed to frequent European establishments.
The cultivation of trees and plants—— Much was expected at one time from the cultivation of eucalypti of different species particularly Eucalyptus globulus—— as a means of suppressing malaria. Specific virtues were attributed to its balsamic exhalations. These hopes have not been fulfilled in every case; but, undoubtedly, the effect of this rapid lygrowing tree in drying the soil is of use in some localities. The same may be said of the cultivation of the sunflower, chrysanthemum, kiri tree, and other plants. Possibly these plants influence insect life in other ways.
Native experience to be consulted.—— It is unwise to build where the natives say the neighbourhood is unhealthy; natives generally know such places. Neither, if it can be avoided, should a stay be made where the natives are anæmic and have enlarged spleens sure indications of an unhealthy district.
Other precautions.—— Bedrooms should be situated in an upper storey, and dwelling-rooms be well raised on piles or arches above the ground. Common sense tells us that campaigns and journeys in malarious districts should be conducted and concluded during the healthy season, if there be one. Mosquito nets must invariably be used; many travellers attest their value, so plainly indicated by recent discoveries. The body should be covered up during sleep, and every precaution (as fires, etc.) that ​circumstances permit should be employed to keep mosquitoes away.
The subjects of malarial infection are dangerous to their companions; they should, therefore, be avoided or, if this is impracticable, compelled to sleep under efficient mosquito nets. Mosquitoes must e rigorously excluded from hospitals. It will prove a truly economical procedure to supply natives liberally with quinine; this should go hand in hand with other steps that may be taken to render a place salubrious.
Mosquito - protected houses.—— It has been proved experimentally and practically that complete protection from mosquito bite, and therefore from malaria, can be secured by having the dwelling-house protected by gauze fittings, with a mesh not larger than twelve strands to the inch, in the doors, windows, chimneys, and ventilators. When possible, such easures should be adopted and intelligently applied. I believe some such arrangement will, in the near future, be a feature in the domestic architecture of malarial countries.
Quinine and arsenic as prophylactics.——A great deal has been written about the prophylactic use of arsenic and quinine in malaria. Opinions are very much divided on the subject. Most deny that arsenic possesses any prophylactic power whatever. Duncan, after an exhaustive study of the recorded evidence, and after extensive and carefully conducted experiments made by himself on large bodies of troops, concludes that arsenic has no prophylactic virtue whatever; but that quinine, in a daily dose of 3 to 5 gr., lessens the fever admissions by one-half. He therefore strongly advocates the systematic use of the latter drug in all campaigns involving a sojourn in malarious districts. In this he is backed by the opinion of many medical men of experience. Corre, although he admits the prophylactic power of quinine against ordinary malarial fever, says it has no influence in preventing pernicious fevers. Other authorities, on the contrary, state that those who take quinine systematically, though liable to mild fevers to some extent, enjoy immunity from pernicious ​attacks. On the whole, the evidence is distinctly in favour of the systematic employment of a dose of quinine as a prophylactic.
There is considerable difference of opinion and practice as to the dose and the time of administration of quinine. There are three principal methods: (a) 5 gr. every day after breakfast, (b) 10 gr. twice a week, (c) 15 gr. every tenth and eleventh day. Some prefer one method, others another; when one plan proves unsatisfactory another should be tried. If for any reason quinine is not tolerated, that individual is unsuitable for residence in malarial countries.
Other prophylactics—— Tea, coffee, and very small doses of alcohol are also decidedly of service; but they should be used in strict moderation, the last being taken only after the work of the day is over, and when there is no longer any necessity for going out in the sun. Crudeli speaks highly of lemon decoction (made as already described, p. 131) as a prophylactic; its use can do no harm, and it is a pleasant, slightly tonic, and slightly aperient beverage, well suited as a drink in hot climates. The decoction made from one lemon may be taken daily in divided doses.
Education,—— It is impossible to lay down directions for the prevention or suppression of malaria which would be applicable at all times and to all places, and under every circumstance. What might suit one set of conditions might not be appropriate under other conditions. But by one, or other, or all of the measures indicated above, much can be done to mitigate or avoid endemic malaria. Perhaps the most important initial measure in the struggle with the pestilence is the education of the inhabitants of malarial countries in the mosquito-malaria theory. Sanitary measures can rarely be carried out effectually without the co-operation of those whom they are intended to benefit; and this cannot be secured unless the rationale of their operation is understood. Therefore, those responsible for the public health in malarial districts should, by one means or another, indoctrinate the people in the mosquito-malaria theory. If he succeed in this, the sanitarian will have an easier and a more hopeful task.
* ↑ * The more serviceable salts of quinine, of which the bichloride of quinine and urea is one of the best, can now be procured in tabloid form specially prepared for intramuscular injection. These tabloids are much better than solutions, which cannot be kept for any length of time without risk of fouling.
* ↑ † SOLUBILITY AND EQUIVALENT VALUE or SALTS OF QUININE. Those marked by an asterisk are suitable for hypodermic injections. Name of salt. Percentage of the alkaloid in the salt. Solubility in cold water. Amount equivalent in value to one of quinine sulphate. Header text Sulphate 73.5 In 800 parts 1.00 Hydrochloride 81.8 " 40 " .90 *Bihydrochloride 72.0 " 1 " 1.02 Hydrobromide 76.6 " 45 " .96 *Bihydrobromide 60.0 " 7 " 1.23 Bisulphate 59.1 " 11 " 1.24 Phosphate 76.2 " 420 " .96 Valerianate 73.0 " 110 " 1.01 *Lactate 78.2 " 10 " .94 Salicylate 70.1 " 225 " 1.05 *Hydrochloro-sulphate 74.3 " 2 " .99 Arseniate 69.4 slightly soluble 1.06 Tannate 20.0 " " 3.67 *Bichl. of q. and urea
* ↑ * Quinine when lodged in a muscle is not invariably immediately absorbed. It may be precipitated and thereafter slowly absorbed, thus ensuring the continuous presence of the drug in the blood. To this and to the consequent continuity of action on the parasite has been attributed the undoubted efficacy of this method of administering quinine in obstinate cases of malarial infection.