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were respectively liper cent. I 2 per cent. - very fe . In Metcovic inundation territory the splenic-index referre to hereaster as S. I.)was 80 per cent in l922 in children 68 per cent in 1923 in childrenan adulis, and 50 per cent in children in l92q. Plate XVI . Durinuour visit there,a a great deal of malaria in Some resions of the barrenKarsi a Vrana e found in the school childre an S. I. per
and 1.5 per cent. o ou visit the S. I. in children was nil. In Serbia Macedonia the service of the stations ha been besunto recenti to allo is observin any changes Ont a Duschano at near hoplj was the S. I. in children in 1922, 35 per centi, andis no Q per cent. A figure agreein With the lalter,as hown at Prietren Higher figures,ere hown howeve in the inundation territor round Strusa q3 per cent. and the districtis Stim q2 per centi . In Greek Macedonia after the importation o 300 000 refusees in l915 a recrudescence of malaria occurred whic attained iis maximum in 1916 and whic vias repeate in l923 after the influx had besunasai in 1922. Nothin is now of malaria statistic amon thenative population, an I have atready mentioned the uncertaint in this respect. The death-rate rom malaria in contrast,it almos allother places hicli, visited was hiςh 70 per thousandis ali inhabitants of the ammat Toemba nea Salonika 50 t 70 per thousandi the district o Lanuada. 8 per thousan in anitet an 6 per thousan in Salonika The S. I. amon the refusee wa 57 per cent. at aniteta and amons thos in the Struma Vallew20 per cent. children . In Buuaria the notification os malaria is obligator on head offamilies, priest an teacher and is then checked by the before mentioned Feldscher . In addition to this in l922, a spleen examinctiionfor purposes of information too place and it mill surpris no one that the w di notisree with ach other so that a good deal of malaria a reporte fro districis illicio splenic-index an vice verSB.we urselves found in the Maritet valle an S. I. of 254,32 per cent.
in l922 it was I per cent in and nea Bursa 52 per cent sal in children . The mortalit in consequence of malaria is sive fores 92ll 923 as . to . per thousand senera death ratera to 30 per
thousandi. In Mumani statistica enquir is stilicio hesin There are onlyknown om figures resardin the number of malaria patienis in hoS
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I Russia there exist sincera 887 particular resardin the numbero malaria cases stranset enous no covering the mortality Dom
an are collecte and what value the possess,e were not old, even after speciali askin forcit. Certaint in ome of the places. perhaps in most the ubiquitous Feldscher , is responsibi for them. Therelare these figures remo considerextrusi orth - no evenaster the introductio os compulsor notification in 192 l. ut it is considere that the may be serviceable is multiplied by a factorvaryin Do 2 tori, notuakin into consideratio that the data justas in Bulsaria. may be to hish. In these circumstances it does notcome within my intention to discus here the various conclusions madeo the basis of these figures for instance, the influence of cro fallureo malaria . The data of the malaria stations in themselves are correct, ut cannot be sed statisticatly because the represent the examinationo an unknown portio of the sufferer of a populationi unknown siete Furthermore, the number of sufferers ho repor themselves depend o the stock of quinine at the station. I the lalter is large more patient appear Therefore Di bymo means certain for inStance, in l92q. that in the Ukrain there a more malaria than in 1923. hecause there a much more quinin avallabie.
The examinatio of the population is mostly limited to the inhabitant of childrens homes and factor orkers in thelowns. The formermostly emanat from quite a different part of the country in Κharho v forinstance Tartar childre from the Volgain As thes froups after beins examine mere thoroughi treate mitti quinine ascis indeed rightithe Aremo serviceable or an later comparison excepi in orde tosho the emcienc of the reaiment. Eo the purpos of determinins the extent of the malaria mons the population there ore, only thoSe investigations os certain delachments ,ho carrie out spleen and
blood est amons a large par of the inhabitant of certain villases in themon territor an in the Steppes to the East of the Volsa areos value In the last named territor Novo Uzenskhthere mere found 65 per cent of malaria sufferet in the autumni 1922 and 42 per cent. in Mawl923 in t o different seasons there remo comparabie). In
the course of time such investigations may furnisti serviceable resulis. Durins ou stan e seldom ound ver extensive malaria. Considering the population prope alone, e found in the Ukraine an S. I. of 30 per cent. and also in themon territory excepi in ne villase
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6 per centi . in the Volsa territor lueto 36 per cent. Once 66 per centi . In Italy in spite of the compulsor notificationis malaria litile valueris attached to thes Statistics, except to thos of the Red Crossin the Pontine Marshes and the Commune o Rome in the Auro
Romano I mahe nomention here of the arm and the employees of the State aitways. because these form a non natura an a chansinspopulation. Nor for the Same eason the populationis Flumicino.
choseni Grassi as a subjectis study. In the Pontine Marshes the percentas of malaria sufferer fellisomo per cent in l909 per centi in l9lq. the ros in l916 tot per cent. . in 19l Masal to 13 per centi an feliciora per cent in l921. In the Afro Romano these figures ere 3 per cent in 1900, 20 per cent in 190 and 902. 1 per cent in l903 per cent in 1909.6 per cent in l9lq. li per cent in l9l and per cent in 192 l. Ascis mellanown great importanc is attached in Italy to the mortality figures due t malaria. The dropped Domi. per thousandunt 887 o 0.06 per thousand in l923. it a ris to . per thousandi 19l8. Besore 900 his decline alternate with recrudescen es continuali decreasinsin Aster that time the decline runs regularly,
except for the war disturbance. . Character of the malaria. Quite senerali it was aid that helare the wa there a muchles tropica malaria than after it This as asserte particulari in Greece. here the refugees ere sal to have imported it. In ther quarters this again was contradicted and my impression is that nothinuis reatly known concerninscit. All three forms of parasites occur in the countries visited by us Thetertia is osti found in May oni in some places in Serbia it was thought that two tertia climaxe were observed, ne in May-Iune, due to relapses the ther in Augusti later due t primar CBSeS. The tropica is found in August-October, the quarta in autumn In Saratowit was thought that the tertian climax in May was duoeto prim-ar cases A this talis illii a time hen there are ut se anopheles these cases just as,ithis are attributed to infections in theprevious eaSon or in the winter Simila observations ere made
The relation belween the number of carriers of the different hinds of parasites,ill thereiare no doubi vary accordininas the investigation is mctde in Syring or autumn Thus in Novo-Uetens in Maw85 per
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centi of the carriers ere found with tertian lyper cent. ith tropical in the autum these figures ere 15 per cent. and 87 per centi, Almost the reverse As sufficient attention is no always palesto his, the figures are not entiret comparabie with achither for the differ
In Dalmatia there as for the entire ea 38 per cent tropiccti, q3 per cent tertian and 26 per cent qUHrtctn.
In Serbian Macedonia there a found 37 to 5 per cent tropical, but in Boenia the tertian predominated 8 per cent. , while the tropical in addition was solenisn that it was thought to be a race differinsfrom the Macedonian In Buluaria there a somewhat les tropicat 2 per cent in stili tes in the cinmine 6 loci per cent in but furthersouth in the Rostoli resion again much more 2 to 2 per cent in also on the outhern Volsa 5 per cent in In the environs of Mosco and ijni Novsorod the tropica figure a least 2 tori per centii. The mortalit hom malaria WAS. senerali Specthlias, low, even in the so severet visited Volsa territor 0. to . per centi. . percent at the moStὶ An Xception is constituted only by the refusees in Greeh Macedonia the refusees in the amma Toemba nea Salon- ik and the districtis Lansada mortalit figuresin page 37ὶ.Blackwater eve occurre in ome paris of Dalmatia, Serbia and Gree Macedonia. I ma refrain rom a summin up Dother phe-
ascertaine parasitologicalty horti after birth. In Shradin Dalmatia in the ourse of 2 ears, q0 of these cases ere observed theparasites ere found to 5 day after birth. At Persianovka Donterritory in cases the parasites mere found Thour after hirth: at Zarizyn Volsa in cases immediatel asteriirili in mother and ehild an in the blood of the umbilica cord.
Phenomen os immunityV against malaria ouldaeis particular interest in the infeste regions. ecause ali of them have seasonalmataria hichus considered acies sultable for creatins a conditionos immunitYV than continuous malaria, ascis ometimes Mund in the
In Serbian Macedonia here, here and there, an Settier Hrefound Dom region infeste litile orto at ali mith malaria, the impression a that he have to suffer more hom malaria than theorisinat population, at an rate durins the firs three ears of course
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observe in Greeh Macedonia Yanitza where amon Childre of the orisina population, e found n enlctrsement of the spleen and amons hos of the refusees, a pleni index of 5 per cent But therelasees ere perhap more expoSed to infectio than the old inhabitanis. In Azan finalty an examinationis Children and adulis teld-ed the folio in resultS:
Spleen index Parasite index Children l Lyears. 9 per cent. 52-q per cent.
hic certaini potnis in the directioni an immunit arisin in the
Non of these data are howeve sufficient to decide the potnt. 5. The use of quinin in the styhi astainst malaria. amo opinio that sine the war, the valueis quinine has been estimate hisher than previously because there a a dearthis it. have atready reporte this in connection illi Russia. ut almost every here the lac o quinine a sive us a being one of the
cause of the sudde recrudescence of malaria. To much was formeri expected rom quinine: entire disinfectiono the lood an consequent toppage of the malaria. hemit was found that it could not do this many thousiit it sood nous for individuat work but notior work on a large scale No also, frequently encountere the opinio that the trussi against malaria is onlyeffective hemit is a Strussi against the mosquito quinin trectimentis ni patchwork. his is reali stili the officiat opinion every here, an even o wholly unknown incitaly. The bove mentioned valuation o quinin is indeed ni a haliaconscious ne In practicelio ever, the actualiush mosti comes to quinin trectiment.
This is quite consciousi applied in Mumania, here ali anti-larvalwor is abandoned As early as 906-l9l in a series of villases. it a maximum o 125.000 inhabitanis, resula quinine prophylaXyand reaiment was applied to a part of the population the rest servinsfor controii. it continuous contro of the diasnosis by blood est. Good result were obtained though nature helpedio erfully, a iSshown by the reductioni malaria in the entire country. The attempti no madeo set id of the ourcei infectioni disinfectin ali sufferer of the revious earina dati dos of 2 gram os quinine
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is held thatio ne infections occur . Is necessary this is continued by liram os quinine twice a wee ori. per day. Distribution in defaesto doctors, is effected by sanitar asenis Feldschers i. The stoc o quinin in Roumania is q.000 s. The populationknows iis value on market days the farmers pay l0 ei about twopencei forcit. In 1922. 532 kilosis quinin mere consumed in l923. 25l5kς and in the firs half ear of 192q. 153 ks. In Bulparia there is a quinine monopoly Exceptio pauperS quinineis ni avallabie to ali re os charse in hos districis hic are declare to e insected it malaria. The State no distributes annuali 6000 kss of quinine of the value o 20 million leus about 5.12. - peras.). Prophylax is limite to the most severet smittenresions Among the population after reaimen is mostly inefficient. Distribution is effecte throus the Feldschers . In the district of Philippopel toruac malaria sufferer there mas not more than 3.5 gramSos quinine per ectr. In Serbia the mos important,ork of the epidemic doctor is the distributionis quinines see organisationi. whether the reductionis the malaria in Marina and Trouir in 1923 is tot explained by quininetreaiment, or by the anti-larva measures like is carried out there, cannot of coursei ascertained Else here,ork had been besumtoo recently to allow of judsin resulis. where easibi the fight by meanso medicines as assisted by improvement in feedin of the popula tion distributionis flour the German brea controi is malariai. Gree Macedonia a distinguished by very large quinine doses. In the Harmakio camp. for instance, there a sive a a curntiVeassent datly for 24,3 d s. 2 rams of quinine in urethane intrasluteal, continuinxit per os In alamaria there a sive a a Prophylactic, fram o quinine 5 aYs per eeh. In spite of those large doses which may eve so priora to iramsin, cases of malaria re complained of hic are quite refractory, evenister intermittent trectiment continue for eeks O in to the senera decline os malaria in l92 the resulis tot attribute to quinine reaiment in particulctr, could notis observed.Iuduin hom the unusuali his mortalityisom malaria in the Cam o Toemba the effect seem at times tohave been exceedinsi stistit. In the malaria areas the entire popula tion receives per day 0. iuram os quinine hom Manto October whichmahes 90 gram per head The suppinis forario laeday at a time. Distribution is effecte throus loca commissions on hic the Schoolmaster priest, and other notable sit. As resard Italy I need oni potnt to the generalty known mortal-
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it statistics the favourable utcome of hic is attribute in thehrs place to the quinine la S. Perhapso some the Statistic atready mentioned, rom the Auro Romano and the Pontine Marshes are os more value. The formershowin heavy decline in the number of malaria cases, hile the alter indicate litile permanent improvement. In the former, quinine reat
ment as applied and the countr draine an lalteri powerfulmeasures have been ahen against larvae but the improvement dates Dom longaefore this alter measurei. In the Pontine Marshes quininetrealmen is almos the ninthing the population reali lives in themountains an comes down Do September o Iune to look after livestoch burn Charcoal and to a mali extent, o do agricultural and sarde work Theyclive in huis,hichire far inferior to the dwellings of our Iavanese although the are osten quite et os Domin moneypoint of vie . These manderer also come and look o wor in the Agro but there is also a fixe population. hicli of these factorsresulis in the successiein s muchi reater in the Afro than in the Pontine Marshesci do no venture to decide.The human factor too
The State supplies annuali 60.000as o quinine. I have atreadyspoken page , about the quinin consumptionis the Italia Red
we a perhaps mos clearly in Russis the influence of quinine, or at an rate hear of it. I do not mea the demonstration hichthis counir provide a to ho an almost pure tertia epidemiclooks henio quinin is vallabies pase 28ὶ but ather the positive resulis secured there in childrens homes and labourer froups O insto the peculiar System prevallin contro groups ere frequently tot iun and wouldie even more numerous is me had been ableto se a litile more of the auricultura population Thus, Mund the spleni index of the children in childrens homes and labourerS colonies in Various places tot 2.5 per centi forither children30 to 6 per cent. The forme were realed with quinine, both HS curatiVe an prophylacti trealmen and were presumahly also bellersed clothed and housed. The mos important utcome in the deparimentis quinine recti ment of malaria is no doubi secure in the eat areas of the GoVern ments of Mosco and Nishesorod. hicli Dalready mentione onpas 28. The methodis quinin administration in Russia hows here and there a curious eature Thus in the Ukratne it is done by the Rou-baShkine method, viz. sub-culaneous injections of 0.ytora gram of
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quinine hydrochloride per danimali cases for the after trectiment also, and in combination with antipyrine and iodine or with methylene blue. This is done here hecaus it is thought that les relapse thu occur, a thin which. for that matter, is contradicted by the experien e in Rostosf. at eas a resard the long date relapsesin but in Saraisin. here injections re also constanti made, his is done in orde tomanas with a les quantit o quinine. Asainst the habit. known in Russia like ise of sivin quinine fori long time successively in orderto fight relapses objectio was alsed in Rostoff. The aster treaiment consist in a dos of l. 5iram os quinine 2 aYs ut os ver 8. Isthos 2 days are increased to 6 it makes no dissereno as resard thelikelthood os relaPSe. As resard the quantit of avallabie quinin salis, his amounted
belleve that there are require 240,000as per ear, i,e. 20 gramSPer Atient per ear, his number ein estimate in 1925 at 12 million). A par of the quinin is supplied gratis, another portio isbou0hti loca organisations for resale in the Ukraine for instance,
6. Measures astainst Dryae anci fulliroin anopheles. Although it is no ne observation we are nevertheles each timestruc by the fac that there is frequently solitile connectio belweenthe observabie densit of the anopheles population and the amounto malaria in a place even when the species is always in question as a the CAS in our ourney, namely exclusively with A. maculipenniS, apar hom A. elatus in addition to therars mentioned a Metcovic
index. his fac canis explained in various ways: Grassi say that this antis agreement is S great and that amons the se anophetes in aleavily infested territory infectedines are so seldom encountered that he must suppos that the are ablerio conve the malaria direct that is ithout sexua development of the parasite). For, Pari, Iassume that in principi a relativel smal number Panophetes arerequired frequently ardes than there reatly are in orde to maintain the leve o malaria any here and that once this has been reached.