Management of Malaria

This contemporary account of the prevention and management of Malaria during the Great War was taken from the 1916 Manual: "Memoranda on Some Medical Diseases in the Mediterranean War Area with some Sanitary Notes", 1916, Published under the Authority of His Majesty's Stationary Office, London.

A considerable number of cases of Malaria occurred at Cape Helles and at Suvla Bay, Gallipoli. Malaria was also endemic at Salonica.

During the Great War the only specific treatment was Quinine, given by mouth in various formularies, by intramuscular or even intravenous injection. Used as we are to giving injections routinely in the 21st Century, it is interesting to note how it was considered necessary to describe in such detail how intramuscular injections were given during the Great War.

Dr M. Geoffrey Miller, Editor

Prophylaxis--Personal.

The use of a mosquito net (18 meshes to the linear inch) where feasible. The use of mosquito repellants such as oil of cassia, oil of bergamot, etc.  The administration of quinine, say 6-grain doses of the sulphate, bisulphate or bil.iydrochloride daily with a double dose once a week.. If tablets or tabloids are employed they should be cracked before being swallowed. It would seem that doses under 6 grains are not always efficient. The 6 grain dose may be taken in an equal morning and evening dose or in a single evening dose.

In dealing out prophylactic quinine to soldiers it is highly important to see that it is duly swallowed. If quinine prophylaxis is adopted it must be carried out thoroughly and carefully, otherwise it is a mere waste of money, engenders a false security and leads to erroneous conclusions.

Prophylaxis--General.

For anti-mosquito measures see section on Insect Pests. Camps often abound in drainage channels and ditches, while, military positions are not uncommonly traversed by small streams. For such the use of an oil drip as shown in the figure is recommended. All grass and other vegetable growth must first be cleared away.

Oil drip made by inserting nail in bottom of can

Treatment.

This spells quinine, but the latter will often fail unless the liver is first of all put in good working order:  Hence a preliminary dose of calomel followed by a saline is advisable. In benign infections and when the patient has not to be hurried off it is better to wait till the sweating stage begins before giving the drug. Then administer 10 grains by the mouth and thereafter 5 grains three or four times daily for a week. The later doses may with advantage be given in effervescing form, the following formulae being excellent :--

(1)

R/ Quinin. sulphat. grs. 5

Acid..citric. ... grs. 10

Sacchar. lact. q. s.

Ft. pulv.

(2)

R/ Amnion. carb. grs. 3

Potas. bicarb. grs. 10

Syrupi simpliis or Syrupi aurantii ad i Dram

Aq., aurantii ad i oz.

Dissolve 1 in 2 and drink during effervescence.

This mixture is also valuable during convalescence or after an attack of malaria, quinine should be taken in gradually lessening doses for a period of three months. Otherwise in many cases the infection will persist even although the peripheral blood shows no sign of parasites.

A simpler but less efficient formula is:

R/ Quinin. sulph. 5 grains,

Dilute sulphuric acid 5 minims,

Syrup of oranges 1 drachm,

Distilled water ad i ounce.

In ordinary cases, where there is much gastric disturbance or where the drug appears to be failing to act when given by the mouth, recourse should be had to intramuscular injections. The syringe and needle must be most carefully sterilized by boiling and by rinsing thereafter with 1 in 20 carbolic acid, care being taken that not overmuch of the lotion is left behind. Paint a patch of skin in the gluteal region an inch or two below the middle of the iliac crest with tincture of iodine and inject the contents of one of the ampoules, vials or sterilettes in which sterilized quinine solutions suitable for injection are now issued, after wiping off quinine solution on the needle with a pledget of wool soaked in 1 in 20 carbolic. The full dose is 15 grains but it is perhaps better to inject half in one spot and half in the other. Be careful to avoid the line of the sciatic nerve. The deltoid is an alternative site.

If the solution has to be made on the spot, use filtered water. Dissolve 15 grams of the bi-hidrochloride or other suitable salt in 10 c.c. of this filtered water and bring the solution thrice to the boiling point to ensure sterility. If the solution is already made up in a bottle it can be poured into a spoon which has been lying in 1 in 20 carbolic, but before this is done the neck and mouth of the bottle should be swabbed with the carbolic solution. Then the quinine is drawn into the syringe from the spoon. With due precautions there is no danger of tetanus or septicity. The local discomfort is trifling and soon subsides and the effect is usually rapid and satisfactory.

In pernicious infections and comatose cases the intravenous route is undoubtedly that to be preferred. The dose should never exceed 10 grains of the hydrochloride or bi-hydrochloride, and the total quantity given in 24 hours should not exceed 30 grains. Five grains every four hours or 10 grains every eight hours may be injected. The strength of the solution should not be less than 1 in 300 and normal saline (0^.75 pet cent.) must be employed. A quantity of sodium bromide equal to that of the sodium chloride used may be added for treatment of cerebral cases.

The symptomatic treatment calls for no special notice here.

Surgeons should note that before carrying out any serious operation on a man who has, or may have, suffered from malaria his blood should, where possible, be examined for signs of infection, and if there is evidence of it and time admits a course of quinine given. Even when a blood examination cannot be made consider the advisability of administering quinine, for an operation often lights up a latent malaria and the disease may very seriously, and sometimes with fatal result, appear in a patient after operation.

In chronic cases exhibit iron and arsenic. A useful prescription for such cases showing splenomegaly

R/ Quinin. hydrochlorid ... gr. 5 to gr. 7

Acidi arseniosi ... ... ... gr. 1/36 to 1/4 grain.

Pulv. ipecac. co.... ... gr. 3 to gr. 4

Hydrarg subchorid ... gr. 1/10 to gr.4

Fiat. pulv in cachets.

Sig. One at 11 am. and another at bedtime.

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