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the hindrance hic quinine places in the way of the urowth of the
particulari grave, it prolonge hemolyti icterus and protundanaemia, hic compelle us to endra patient home to France.we did not recordi single pernicious attach and have hadio a sinuledeat to deplore, a fact hic stili further defines the prophylacticadministratio of the salis derive seo quinquina, rom the merepoint of vie is humanity in spite of the enormous cost of the rugat the present time. his drus properly administered therelare, almost certaini prevenis deat an osten alter the course of the disease fortite better that is sufficient reason hyest shouldie persistently used in ample doses to the ureat benefit of our soldiers and the maintenanceo ou strensi in ovilyin Spheres of operation B a sortis trony, the oni dissiculty hic preventive quinin administratio creates is for thos who have the dui os applyinscit. Quinin salis, a me haveaiready stated influence malaria manifestation to suo an extent that diasnosis is hereb rendere faulty Let medica me thereiare beadvise of these facis, let them constanti maintain watchlalnes and notaesitate to have recourse reely to the laborator which, in very many cases, ill alone enabi them to stri the mas off malaria. whichiresenta itself to them unde Such deceptive aSpectS. But the reade mill say, uretnit is no possibi tomahe aiiood test formi patient admitte into the hospita establishments of an
the militar doctor, hocis always at the Same timem hygieniSt mctybe ted o suspect the existence of malaria by a weli conductestenquiry. The conditions hic lead to the occurrence of malaria may be Sum med umin a very simple equation reservol os virus inophetes malaria. In the regio traversed or occupied are there or have there been malaria sufferer. It is certain that this resion is favourable tolli development of the anopheles and is ponds and stagnant,aters stili exist there, although malaria may seem to have disappeared, itS reappearance must be feared it the known arrivalis ne reservoirso virus. At that momentis dro of lood ahen and spread on astide an forwarde to the neares laboratory, is it ho S a positiVeresul in a single patient havin come fro France an no havingles the region is susscient to estabiisti the certaint that malaria Sabout o develo in endemi or epidemi form and then that the
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66 O THE DOGMA OF PREVENTIVE QUIN INE
SYStematic earchesor malaria must e perfue methodicali in the hospital Wards bearin in mind the anomalles created by preventive quinine. On ur arriva in Beyrout in the mont of a las it was a matter of public notoriet that there asino malaria in the to n. In the ourse of previous ears the doctor ho had precededius hadoni observexa very limited number of malaria infections. eiur-selves in the ourse of the las Summer, ere ablerio observe onlya single case which had been actuali contracte in the to n. ut
the perusal of the inevitable Baedehe had lavsh us that the regiono the rive of Beyrout to the eas of the town was an unhealthyresion and that a litile further on, a stream, the Nahr-El-Mot Rivero Death owed his appellation to the nhealthines of iis banks. Throus conversations it the locat doctors, mos of them former
successivel occupied therio naad ahen care noto cam in his rive region and had sive preference to the red sand of Saint-Elieto the outh. These facts ted oneri apprehend a recrudescence of malaria in a region here forms of the anopheles ere habitualedand where the would without fati, resume their nefarious action uponthe favourable arrival of the reservolrs of virus contributed by the hostis emigranis Armenians and Greeks fleein Do Turhis re-prisais, ho ere installe there in indescribable ulments amidsordid lith and surrounded by stagnant,aters. Falling this it might also have been eare that our Colonia natives Annamites, Malsaches an Senegales frequentin the hops of the arm has in the vicinit of the rati a station ea the rive mistit, in themSelves. constitute smali reservolrs of virus and allow of the revivalis malaria, hecause during the war malaria a seen to appea in France in regions hic had ill the been laee o the arriva o Coloniatsharpshooters. 4rs caseis malaria observexi a soldie cominuiso the home Country and who ad neve les the regio of theriVer, pene ou eyes and made us alive to the necessit of hema-tologica testis ali patient cominifrom the nava base of the armyand iis vicinity, nava iretes operators, militar nurses, clerkS nd workmen of the administration, soldier of the arm aviatio park,
suspected region Thus, in spite of the preventive quinine, there mere
discovered these 1 patienis,hich the clini alon was able toriden tisy, and the more imposin froumof 38 soldiers illi dissulsed malaria, an impressive totai,hicli to-da rightly sive great concern to
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ON THE DOGMA OF PREVENTIVE QUIN INE 67
the supreme command of therarm and the civit hystene services of of the greater Lebanon. Subjeci herelare to the no ledse by practitioners of the dim- culties placed in the way of the trachin out os malaria by the prophylactic administration os quinine Salis, the principie of the preventiveus o quinin remain unShaken Could it notio everte a least extended to the doses tot siveά It is ellanown that the disap-pearance of the blood parasite in the organism canini he obtainedsomelimes it 1 to iram o quinine per day by repeate series of realmenis. In orde to take the right course an be absolutelysure of preventin malaria, these fame quantities of medicine must besive resulari during the whole time the danser of malaria lasis. It wil readit be understood that s active a course of hemicat prophylaxy, hic is anserous to the astri mucosa an to the delicate nervous terminations of the labyrint of the ear, ould onlybe possibi in the course of militar operations of shor duration in particulari infested zone. e formur pari, houldiso hesitate in practising this heroic prophylaxyina particularlyunhealthycountryin the course of a militar operation no exceeding one to two months. But in the colonies and in particular in Syria, here quinin must besive ali the summer, that is, rom the besinning of Iune to the endos November, ni a more modest object an e pursved that fpreventin the pernicious attach, modi*in the evolutionis malaria
and diminishins, is possibie, the number of person affecte thereby. Since the egi nning of the XVIII h centurnali observers who have
fought against malaria have almed alio ther result, and we can dono belle than modet ou coursein that pursued by them fore us. rapid review of the means sed and the succes recorded by these forerunners oui then, o necessity lea us to-da to a doctrine
applicabie to all. In bries in the course of the last two centuries, the prophylax of malaria has been applied on three method ali of hic number succeSSeS. Some practitioners, sue a Collis in Malacca Bizardet in Senegat Metar an Cornebois in Alseria, uenne a Majunga, SatnNMacarmin Dahomey. Blanchi in Italy Salanove in therioudan, had recourse to ea dati doses of 04,20 centiframs. Some, Suchas America doctor during the war of Secession Lane at Ouarsia,
l. his stud was closed on the date of the 31s October 1923 other malaria
Sufferer comin homili regio of the rive are stili arrivin inmur ard HS the Summer his ea encroachesin the month of November. Further patients have also been identifie in the wards, an in the course of health inspections o the Spol.
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68 O THE DOGMA OF PREVENTIVE QUIN INE
it is more Appearance than realit - not to corresponesto unit ofvie s. The fac is howeve that thous practitioner are almost holly won ove to the invioliabilit of the doctrine of preventive treaimenti quinine and the reali of the resulis tot expected fromit, the were unable to appi a uniform method in ali the regions here the practised it. The had to take into account the intensit of the malaria infection and the gravit of the clinical forms encount-ered Thus G. Alvam record that the mali dati doses in the Italia Arm fave hi belle resulis than massive eekl doses. Robert och on his part thinks that incentifram every three days
excepi in cases here infectio is orae eared . inalty Laveran. considering that quinin would form an obstacte notininto infectioni person De Dom malaria, ut also arrest an initia infectio and prevent relapses in atready infecte subjecis, sive preferen e tomedium intermittent doses Thus a single linei conduci in ali cases and in ali countries cannoti adopted. oes this mean howeve that the prophylaxis of malaria cannoti translated into a mali numbero formulae we hin this is perfecti possibie. I the regionis
operations istut stistiti infested is benis tertia an quartan re observed. hicli are ut infrequently the generator os pernicious attachs an is the sta in the countrycis to last for man months,
Choice may be made belween the methodis mali dati doses Aloaminand the intermittent medium dos method Roch and Laveran . Is the country occupied is badi infested and malignant tertian and pernicious nitacks are observed i it is tot traversed in asse χays. recours may be had to heau dati doses of 75 centifram incentandiuroo an evenis tora ram a me hould advocate. f the duration of tayeXCeedit monili Laoerans method of the intermittent medium dos musti applied. Is e destre to apply the foresoinu datario Syria and the Lebanon in the light of the observations made inivr hospital wards whicli in
formis o the originis the cases by means os interrogation, and on
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their ravit by the clinica evolution, erahould illinsly, as in the Na . and after the manne of ABaro, sive incentifram os quinine hydrochloride datly to the troops quartered in the regionis the riverwher no doub the malignant tertia rases, ut here reventive quinine has hitherio arde offiernicious attacks we hould o theother an sive 80 centifram every two or three dctys, after themanner o Michon and Laveran to the troops of Alexandria El-Hamma and Rayach. rom here the mos Seriou case reachedisinit pronounce hemolyti icterus and marked splenomesali anae- min. . . And we ma no sum mihi stud a follows: l. The dogma os preventive quinin remains intansibie. 2. It applicatio musti suided by the intensit of the infestation. the durationis exposure to contagion the clinica form observed. the character of the parasit identifled. 3. his application must choose belween three methods smali dailydoses intermittent medium doses, heau dati doses, exceptional, applicabie to militar operations os very hor duration in a very
q. Quinin hydrochloride is the salt whicli musti preferredi insto it greater solubilitTand iis lower attachininpowersin the organism. 5. Preventive quinin must notis expecte to brin about thedisappearance of malaria, hicli Dis not always able to do, but thereis the certaint that it ill reduce the number of person affected, wili favourabi modis it clinica evolution and will with certainty, ward off the pernicious attBck. 6. ut doctors ili oncessor all. be put o thei suard against the possibi maskin os a malaria attac by the chemicat prophylactic
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70 SOME LINES OF CONDUCTI MALARIA THERAPYSOME LINES OF CONDUC IN MALARIA THERAPY
i compliance it the invitationis the publisher, there are et out
The nature o malaria may of coursei assumed tote known to the reader. Nevertheles the fac may be speciali recalle that inmctn cases for instanc in parasite carriers, ali traces of laver maybe abSent, and again, in active malaria, durin the laveris attach, the hiverin Stase a faticio appear especiali in the pernicious form R. och s tropica formi, further in ne mutarer hom malaria perniciosa pleni enlarsement may be absent, and above ali in the perniciou formasain, malaria parasites may be absent rom the peripheralilood a me hepinnis of the attach. As is known the lalter sporulate preferably in the capillar regionsos internat organs so that Sometimes a positive result in the peripheralblood canini be found severa hour later. It hould therefore alway be ad the uterio repea the blood examination acie hour after a negative result, hen malaria is SuSpected the more oras, especiali in region infecte wit perniciosa the alter may appea in the mos varied clinica forms of any other prologoon or bacteria infectious disease, an consequently. ithout lood est is stili osten no recognised frequently mixed infections it the above mentioned diseases also occuri TheeXtreme importance of the blood est is perfecti evident rom his Anyoneno able himself to diagnos the parasit should at least sensa michdro preparation ' an a thi uniform lood film, Ac on a preparation iide, to the eares biood testin office. The Haemato-
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SOME LINES OF CONDUC IN MALARIA THERAPYIi
logical Institutes also Send ut correspondin instructions). For thethic dro preparations it is sussicient to ab ut a ro Ofilood of the siet os a large lenti to the siet of a hallaenny allo citrio drycompletet in the air, then to dimit twice in cooled boiled water putit on iis edse to drain and for ardui, after complete dryins. Genera rules of quinin treaiment I the diagnosis is determine mitti certaint microscopicali sorviit suffcient reliabilit clinicatly energetic therapy must stari atonce. The more energeti an rapi the lalter the greater the prospectis thorous cure and prevention of the formationis sexuat formsand consequent disseminatio of the malaria. Ouinin is and remain the speclinaseainst malaria howeve muchlalteri attempis may have been made to decryciis value. The vie I have advocated for ears that quinin acts o the parasite notdirectly but indirectly has been stili further strensthenedi recenti vestigations of Muhlens and nrschbaum. A quinin acis it mos certaint o the younse, SeXua formsand ut litile, o somelimes nolint all, o the exuat forms, it is important that quinine e applied chiefly hen in sporulation the divisiona form separate, .e some 2 to 3 hour before the everattach expected. The quinine preparations for genera practice re, bove ali. quinin hydrochloride, Sulphate, quin idine or recenti a mixture fali quinin aikaloid finias India the so-calle Cinchona febrifuse. in Germany Neopanchinal Dr Schmitet, Brestauin the averas datlydose for each preparation is 1 to 2 rams. Accordins to the statemento Messrs Zimmer Oxo. . las of quin Sulph. COSt 87 kS., quin . hydrochlor. 100 ks. quinidine 70 ks. . ut the ver effective hydroquinine 220 ks. Ouinin sulphate or quintainoeshouldie taken far more extensivelythan hitherio hecause the therapeuti effect is almos equa to thatos quinine hydrochloride while that os quinidine is even undoubtedlySuperior in cases hicli resis quinine. domo recommend administration in liquid form a most perSonSHcquire in rectSin aversion to the bitter drus in spite of the additiono correctives It is est o take it in the formit tableis, readilySolubie in ater o in elatine capsules o cacheis. I found it eryphasant, particulari for hilare an other discula persons toras minister it in one tablespoonfulos marmelade inhic entiret Surmurarithe bitte medicine and dispenses inith the expensive quin in Cho late tablata. o the stili more expensio an les bitte substituteS,
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72 SOME LINES OF CONDUC IN MALARIA THERAPY
Aristochin Euchinin . Psychological factor then appea to renderabsorption more rapid and complete in children. Preferably the quinine houldi sive about 1 ora hour after a meat, a then the increased secretionis astric uice allow of speedierabsorptionis the quinine. O the basis of more recent investigationsit oes no appear necessar an longe to administer quinin asformerly with dilute HCl. In Domitin an ali derangements of intestina actiost ansaboveat in ali nem cases of perniciosa, quinin Shouldae sive in therapeuti doses intramuscular*, to ensure absorption in the formis quinine rethan 0 5 ora ram, in the upper externa par of thesluteus maximus. The content of the ampullae must ho ever, afterbeins dra n minio a large Record Syringe be diluted with a least times the volume of sterile solution Osi 85N NaCl. Ιf the contenis of the ampullae, ascis unfortunately done in imos ali cases, re in jecte undiluted, ainsul quinine deposit mill unquestionabi formaster severa injections. Ample massas is destrabie. In cases of anser o life particulari With comatos malaria, quinine rethanei 5 ora gram fi 85 NaC solution houldie administere intravenously, ut the injectio must e made erystoli in orde to avoid collapse and neve more thani 5 gramini a time Chitaren, in hom the malaria osten ahes a very cypicalcourse without a typical shiverins attach shouldi siveni 0 gramos quinine forisac 1 tb of eight. Spectat. In ordinar non-resistant tertia anci quartan the rule is generallymis adhere to as far a possibi that quin in is uiuen in doses of oram 2 to 3 houribebore the attach is expected hecause the quinine leve of the blood is then at iis hishest at the moment of the attach, after his dati a the fame timera ramo quinine unti defervescen ei disappearance of the sexuat formS. In ambulator an mas treaiment an above ali in ne cases, Iurgenti recommen sivin liram immediatel aster diagnosis, nomalter in hat state os development the parasite are, an So ndatly unti thei disappearance. There is no stas of the Sexuat parasites hicli remain uninstuencedi quinine Persons of Strons constitutio ma even, Withou hesitation, he sive a secondiram os quinine at the en of the attach. 2. In perniciosa, during the Gys of severas arula 2 grams o uinine dat* eitherutices oram ores times 9-5 unti debemescenoe or disAppearance of the asexuat forms. In ne cases I, in principie administer,
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SOME LINES OF CONDUCT IN MALARIA THERAPY 73
durins the strat 3or Mys either liram of the above quantity in oneoperation or in t o injection of 0 5 Ach aY. In recurrent pernicious malaria in hic pro und and resula intermission occur thetota dati quantity of the quinin Should ii possibie be sive durins
the intermission that S. At a time in hicli pigmente signet rinsparasites are visibi in the peripheralilood, a then the Youniforms resultins hom division cani sol at. It is a fac that amons alliations during the world war, perniciosa was osten combated with far o litti energy.
laxis I decide in favour of m methodis undivide doses.
In case of ris of lachwater laver an in person SenSitive Oquinine Nocht' method neverthelescis tot recommended. attach hie importance bove ali to the energetic reaimentis pernicious malaria ith iram dati doses of quinine. Further potnis restardin penera therapy of malaria resistanceto quinine Durins and after the world war cases were again obSer-
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7 SOME LINES OF CONDUCTI MALARIA THERAPY
ve in hic quinine apparenti falle completely. I have dividedihi quinine resistanc into 3 groupS: a. Occasionecti preferentia locationis me parasites in the capiLlar region os internat mans determine in a number of certain
c. Occasionedi absence of AII immunit factors, in respectoo hic matterra refer o my work New Problem os malaria investigation . Berliner Min chr. l920. No. 28-29. This also containsa reference to the earlier ork of Baiae and Rodeniatad. B ever case mentisneci unde a L in principie combine quininetrea ent,im me systematic applicationis uinckes hol atriaths.
ho bath, in order by hyperaemia of the uter hin, o dra theblood rom the interna orsans. In this mani may be hoped that theparasites,ill be brought into the peripherat circulation and made more accessibi to the actionis quinine. finalty rem into the habitis using these ho air bath in ac casei relapse. At the fame time quantit of hol ea wit lemon uicei Ladois against in remainins ' provocator memori particularly the injectionis adrenalin. To . quinine e combined, as Iready mentioned inith Neo-SALDarsari. The alter, AS is nown produces an intense paracilicidaleffect in tertian even ithout quinine Moeriheles even inim ordinar tertian, I, ct a matter of principie combine quin in mim eo salvarsan in the manne above mentioned. To c. Startins ut rom the clinical experience that every reductionos the internatio ers reduces the curabienes of malaria by quinine, endeavou by the ulmos attention to nutrition unde certain Cir cumstances even artificiat nutrition and com ordito restore the senerat
an cache es mos stronset recommend the injectioni infusion of attuneci χBOd. For technique se m monographin. Ostreat importancessor the cur is also an underanstediunctioninuo me lioer for absorption and splittins up of the quininei Therefore provision hould e made for absolute resularit o digestion by
O increaSe of the genera symptoms, when the laver attach and the quinin actio coincide, the troubles and an aversion to quinine may be reduce by caresul doses of morphia.