THE VAL DE OF KOCH'S TREATMENT OF MALARIA.

Transcription

1 263 THE VAL DE OF KOCH'S TREATMENT OF MALARIA. By CAPTAIN N. E. HARDING. Royal Army Medical Oorps. WHEN it is considered that every year in India alone, according to the high authority of Ross,! "several millions die directly or indirectly of malaria," and that even the conservative estimate of Rogers 2 does not reduce the number below a million, it might well have been expected that a method of treatment proposed by the illustrious Koch,3 and prominently brought to the notice of the medical profession in that country by Franklin,4 would have met with prompt and thorough trial and full discussion. The smaller text-books, however, make no mention of the treatment, but when we examine the larger works we find Thayer 5 saying: " Koch, in order to avoid relapses, advises the administration of 15 grains of quinine about every seven days for two days in succession, this treatment being continued for two months," apparently a confusion between Koch's earlier plan of giving a gramme of quinine every fifth day for a month-a plan abandoned because he occasionally got relapses with it-and his method of prophylaxis, and in addition Thayer offers no opinion as to its value, merely saying that continuous is better than intermittent treatment. Manson 67 also makes no reference to Koch's treatment, but advocates the administration of a 15-grain dose every tenth and eleventh day after an attack for six months, and observes parenthetically that a cure is not always thereby secured. Scheube 8 again says nothing about it, though he points out the superiority of the gramme dose employed by the German physicians to the smaller and more frequent doses used by the English; and Rogers 9 is equally silent. I Lancet, September 28th, "Examination into 1,000 Deaths due to 'Fever' in the District of Dinajpur in 1903." 3 Zeitschrift filr Hygiene, xliii., pp , reviewed in Deutsche medizinische Wochen8chrift, xxix., No. 28 j "Literatur Eeilage," p Annual Report of the Sanitary Commissioner with the Government of India, Allbutt and Rolleston's "System of Medicine," London, "Tropical Diseases," London, "Lane Lectures," London, "Diseases of Warm Countries," translated from the German, London, "Fevers in the Tropics," London, 1908.

2 264 The Value of Koch's Treatment of Malaria The Sanitary Commissioner with the Government of India 1 in 1904 says: "In most stations where successful results were reported to have been obtained by quinine administration" the system embraced not only prophylactic doses, " but also the continuous treatment for from six weeks to three months of every patient who had been admitted into hospital for malarial fever during the year, and there is no doubt that this latter measure is of prime importance in the prevention of relapses." After also pointing out how at Kamptee forty-two men contributed no fewer than 100 admissions for this disease, one man being readmitted no fewer than five times, he goes on: "It is obvious that many of these readmissions on account of relapses can be avoided by the institution of a thorough system of quinine treatment and prophylactic administration "; and in the following year he again lays stress on the need for "thorough treatment of malarial patients and cases of latent infection with quinine." Fernando 2 also speaks of a modification of Koch's quinine prophylaxis, which, though only continued for a month after an attack, caused a remarkable diminution in the number of cases of fever on the plantation on which it was tried, and Ross (op. cit.) lays down as part of the "ideal procedure for towns in the Tropics the treatment of old cases of malaria with quinine." At the risk of being thought egotistical it may be as well to tell how I became acquainted with the method, and to give a detailed account of what I actually do, before proceeding to summarise the cases treated, my excuse being its apparent novelty. Almost as soon as I arrived in Burma at the end of 1903 I was struck by the obvious inaccuracy with which nearly every case of pyrexia was diagnosed "ague," and the equally obvious failure of the methods of treatment in vogue to cure genuine cases, methods which gave a man quinine in doses of varying size and equally varying frequency, either by the mouth, rectum, subcutaneous tissue, or muscles, till his symptoms disappeared, and then discharged him from hospital to be detained or readmitted if his symptoms were urgent enough, or otherwise to have his occasional " touch of fever" in his barrack-room, and be a permanent source of infection to his comrades, methods strongly reminiscent of the happily extinct way of treating another chronic infective fever- 1 Annual Report of the Sanitary Oommi88ioner with the Government of India for 1903, 1904, 1905, and British Medical Journal, September 28th, 1903.

3 N. E. Harding 265 syphilis. In the course of my search for something better I picked up Franklin's review (op. cit.), since when all my cases have been treated according to the following plan with only very slight modifications in detail: On admission, unless there is any obvious reason to the contrary, all cases suspected to be malarial are given 5 grains of calomel, to be followed six or eight hours later by a small dose of white mixture. At the same time a bloodfilm is taken and if necessary examined at once or ordinarily within the next six hours. Should a parasite be found, I immediately order the medical warrant officer in charge of the case to give the patient 15 grains of sulphate of quinine, dissolved with a slight excess of sulphuric acid in 1 ounce of water, by the mouth irrespective of the temperature, but with the proviso that if vomited it is to be repeated until retained (as far as I can recollect it has never been necessary to do this more than twice). Should there be any doubt as to the nature of the parasites or the number of broods present, a second film is taken at the same time, before the quinine has had time to be absorbed, while should the film fail to show the parasite and yet be at all suggestive of malaria, as from the presence of pigment granules, large mononuclear increase, or swollen and mauve-coloured erythrocytes, another film is taken, but the rule" no parasite, no quinine," is strictly observed. The following morning the same dose of quinine is given, again irrespective of the temperature, and a film is generally taken to see whether the parasite has vanished; if not, a film is taken every morning till it has. The dose is repeated on five further consecutive mornings, and the patient is then fit for discharge as a rule. If only small rings are found, films are taken after a lapse of a week from the first discovery of the parasite until crescents are found, and if not found after a week's daily search the case is recorded as "parasite found, but not differentiated," as in my opinion it is impossible to be absolutely certain as to the nature of a small ring. On discharge the patient is given a paper telling him on what days he is to attend for further doses, and a duplicate of this is kept by the nursing sister, assistant surgeon, or hospital assistant whose duty it is to give them, and who reports any failure to attend to me, each dose being shown by ticking off the date, so that when treatment is completed a record exists of the actual number and date of those taken. When handing him the paper I personally warn the patient that in the interests of his comrades no less than of himself he should come on the appointed days, explaining the reason for this, and in general he gives but little trouble in this respect, while

4 266 The Value of Koch's '1'1'eatment of Malaria if he fails to come I send him a message or note to the effect that if he does not come I shall have to send for him officially, a hint which is invariably quite sufficient. He is not struck off any duty to allow him to do this, the only concession being that he can come at any hour of the day most convenient to himself. The dates for further doses are calculated by taking the tenth and two subsequent days from the first dose, and every tenth day after them for three months; for instance, a man in whom the parasite was found on May 1st would receive doses on May 1st, 2nd, 3rd, 4th, 5th, 6th, 7th, 11th, 12th, 13th, 21st, 22nd, 23rd, and 31st, June 1st, 2nd, 10th, 11th, 12th, 20th, 21st, 22nd, and 30th, July 1st, 2nd, 10th, 11th, 12th, 20th, 21st, 22nd, 30th, and 31st, i.e., not fewer than thirty doses. In cases of malignant tertian I take films from time to time during treatment so as to see when crescents have disappeared, and on completion of it I always see the patient myself, and again some months later, to find out how he has been, and to take films from him. At first, in the attempt to be wiser than my master, and acting on the supposed lesser resistance to quinine of the benign than the malignant tertian parasite, I only treated cases of the former for six weeks, with the result to be seen below. I have kept notes of all cases that have been in my care for more than a few days, but owing to changes of station, failures to keep up treatment, and various other causes, find I have only twenty-five which can be traced for at least six months after completion of treatment, and a brief abstract of each of these is given below. (a) CASES DIAGNOSED ON CLINICAL GROUNDS ALONE, i.e., BEFORE A MICROSCOPE WAS AVAILABLE. (1) Originally contracted at Bhamo in July, 1903; thereafter had a rigor about once a fortnight, but was only detained and never admitted. Given sixteen doses between May 25th and July 26th, Seen again on August 9th, 1905, when he stated he had been entirely free from fever since beginning treatment. (2) Originally contracted at Bhamo in August, Had occasional rigors, but was not admitted till September 29th, 1904, when he was treated with quinine and discharged on October 10th, only to be readmitted three days later, and given 20 grains of sulphate of quinine daily, despite which he seems to have had a rigor on the 15th. On the 22nd the following note appears in the ward prescription book: " Stop quinine except on days you

5 N. E. Ha1'ding 267 expect fever." On the 29th he had another rigor, and his temperature rose the two following days. On November 1st the note appears: U Quinine 25 grains in solution at 7 a.m. alternate days" ; on the 5th: "Quinine 25 grains on day of fever only"; and on the Gth: "Quinine 25 grains every second day." On the 12th his temperature rose again, and on the 14th he had a definite rigor. On the 16th he was given" 20 grains quinine every second day," and on the 20th and 22nd his temperature rose again. About the 26th he came under my care, and from that day onwards was given 15 grains a day and was free from fever till discharged to duty on December 5th. Seen again by me on February 10th, 1905, when he stated he had been free from fever since discharge. He had lost the sallow cachetic look and been doing full work. March 5th. completed treatment, patient having been quite well from beginning it. Unfortunately the paper showing the actual number of doses taken was lost. March 18th, film showed no evidence of malaria. December 26th, 1905, quite free from fever up to date. (b) PARASITE FOUND BUT NOT DIFFERENTIATED. (3) Infected at Fort Syriam, Rangoon, in June, 1906, and first had a rigor on July 3rd. July 4th, admitted; film showed rings, about 3 fl in diameter, fairly common. July 6th, rings about the same size, common in morning, but doubtful if any present in afternoon. July 7th and 8th, no parasite seen. July 15th, discharged. Had in all thirty-three doses. In October he was in hospital for five days with simple continued fever, but no parasite was found and no quinine was given, so it was probably nonmalarial. October 1st. 1907, quite well and free from fever since last note; film appeared normal. (4) Infected at Rangoon itself; first had a rigor on August 4th, August 6th, admitted; film showed small rings to be fairly common both morning and evening. August 7th, 8th, 12th and 13th no parasite seen. August 13th, discharged. September 18th, completed treatment, having had eighteen doses in all. March 17th, 1908, quite well and free from fever from beginning treatment to date; film normal. (c) BENIGN TERTIAN. (5) Apparently contracted in Rangoon in November, 1905, when he was admitted for dengue and treated with quinine. After discharge be had several attacks of what was undoubtedly ague from

6 268 The Value of Koch's Treatment of Malaria a clinical standpoint, though he was not readmitted till February, 1906, when he was diagnosed simple continued fever and treated with quinine. After discharge he again had attacks of fever, and was admitted in March with debility. After this he did not recollect having had an attack till June 15th, when he was admitted with a temperature of 104 F. A film taken on June 17th showed half to three-quarter grown benign tertian parasites to be fairly common; another on the 18th suggested that there were perhaps two broods present. June 19th, no parasite seen; discharged on June 23rd. He had in all fifteen doses of quinine up to July 20th, and remained well all this time, but about three weeks later had a rigor. It is not certain whether he had attacks after this, but after his transfer to Port Blair at the end of the year he remained well and free from fever. (6) Infected in Rangoon; admitted in April, 1906, for dengue, which was probably an error of diagnosis, as he had attacks of fever after discharge, and was again admitted in May for simple continued fever. June 23rd, readmitted; a film showed half-grown benign tertian parasites to be present, but few in number. Another film taken the same evening showed no parasites, as did films taken on the 24th and 25th. He was discharged on June 28th, and had in all sixteen doses up to August 5th. On September 16th, 1907, was quite well and free from fever. (7) Infected at Fort Syriam, Rangoon; first rigor June 26th, June 28th, admitted, when a film showed no parasites, and one taken that evening gave negative results. June 30th, film again negative., July 1st, film showed benign tertian parasites to be fairly common, and two or possibly three broods present, the largest nearly full grown and the smallest about 3 to 4 JL in diameter. Another film taken that afternoon showed only a few half-grown benign tertian parasites. On July 4th he had what was at first thought to be a relapse, but proved to be an attack of dengue (see temperature chart 1., showing failure of quinine to affect this). Films taken then and on the 5th, 6th, and 14th failed to show any parasites. July 18th, discharged. On August 22nd he had received in all fifteen doses, in addition to an unknown quantity which he took on his own initiative at the beginning of the month. On September 9th, 1907, he stated that he had suffered from occasional attacks of fever from shortly after last note till April, when he was admitted for a few days. After this he had more attacks, but did not report sick. (8) Infected at Fort Syriam, Rangoon, and had a rigor daily

7 N. E. Harding 269 from June 27th, 1906, onwards. Detained July 3rd, when a film showed benign tertian parasites to be present in two broods, one almost full grown and the other small. That afternoon he had a rigor, but a film taken then failed to show a parasite. July 4th, admitted, but film negative; discharged on the 11th. July 14th, quite well and film negative. August 16th, had eighteen doses to date and been quite well. September 11th, 1907, stated he was quite well till March, since when he had occasional attacks. A film showed apparently normal blood. It would appear that the attacks of which he spoke were most probably non-malarial or less probably due to a reinfection, as he had again been stationed at Fort Syriam. JU NE I JULY OATE ' 30, S 7 e I. DAY or S ' IS I F' I \ V If \ U IV " lv f I\, 102 \ I A j\ i 98 L ~I:' CHART 1. (9) Infected in Rangoon, July 14th, 1906; detained, when a film showed the benign tertian parasite to be present in two broods, the commonest very small and the other about half grown. Another film taken that afternoon showed benign tertian parasites to be scanty and only one brood present. July 15th, admitted; film again showed two broods, the commonest about half grown; July 22nd, discharged. August 16th, had in all sixteen doses to date and been quite well. October 1st, 1907, quite well since last note, film normal. (10) Apparently infected in the jungle, where he had been shooting up till July 4th, Had a rigor on the 17th, admitted on 19th. July 20th, film at 11 a.m. showed benign tertian parasites but doubtful whether in two broods. Another film at 5 p.m. failed to show any. July 21st, film at 9 a.m. showed benign tertian parasites in two broods, one small and the other almost V

8 270 The Value of Koch's Treatment of Malaria full grown. July 22nd, film negative; 23rd, ditto; discharged on 27th. August 11th, had in all thirteen doses up to date, quite well all the time. September 3rd, quite well till this date, when he had a rigor. Film in morning showed a number of benign tertian parasites about three-quarters grown and also apparently some very young ones; another film at 5.30 p.m. was negative. September 4th, admitted; film negative. September 5th, film showed a solitary benign tertian parasite; discharged on the 11th. October 11th, had twelve doses to date; case passed out of my hands. September 17th, 1907, has had several attacks of fever, both in and out of hospital, since last note, and is now yellow and debilitated. (11) Apparently infected either in the guardroom or cells at Rangoon, probably the former. August 11th, 1906, had loss of appetite and headache, but did not think he had any fever till 15th, when he was admitted, but a film was negative. August 17th, films both morning and evening showed what were possibly parasites. August 18th, morning film showed a solitary half-grown benign tertian parasite, and one,at 5 p.m. showed several about the same size. August 19th, film negative, discharged on the 26th. September 19th, had in all fifteen doses up to date and been quite well all the time. September 11th, 1907, quite well smce last note; film normal. (12) Probably infected in Rangoon. September 4, 1906, first had a rigor. Admitted on 7th, when a film showed about halfgrown benign tertian parasites to be fairly common; another film taken in the evening gave similar results. September 8th, film showed benign tertian parasite in two broods, one about half grown and the other just on the verge of sporulation. September 16th, discharged; had a rigor on the 17th (see chart n.), and admitted on the 18th. Films on the 18th and 19th gave negative results despite prolonged and careful search. September 25th, discharged and diagnosed simple continued fever, though probably a relapse. October 20th, had in all eighteen doses to date. September 8th, 1907, stated he "had not had a day's sickness" since last note. (13) Bhisti, R.A.C.D.; admitted January 14th, 1907, film negative. January 15th and 16th, benign tertian parasite present, but not common. February 28th, completed treatment, having had in all eighteen doses to date and having been quite well the whole time. July 30th, quite well up to date when fever came on again and a film showed some doubtful small rings and a. half-grown benign tertian parasite. July 31st, half-grown benign

9 271 tertian parasites common. August 31st, discharged from the Service, so cannot be traced. I do not think there can be much doubt that this was a case of reinfection, as for five months after completion of treatment he remained free from fever. (14) Lance-naik, R.A.C.D.; admitted March 3, 1907, when a film showed benign tertian parasites to be present, but few in number. March 4th and 5th, benign tertian parasite again found. March 8th, discharged. April 30th, had in all twenty-one doses up to date, and been quite well. June 2nd, fever came on again. June 5th, fever came on again. June 5th, admitted; morning film negative, evening showed a couple of three-quarter grown benign tertian parasites. June 6th, benign tertian parasite found morning S(P 1906 DATE IpAYofDlS ! F'." I Z 101 1\ " \ ~ '/\ j ] ~ " \ I 99 i 1 I'. 9. i 1 [\ CHART n. and evening. August 27th, completed treatment, having had in all thirty doses to date. March 23rd, 1908, quite well and free from fever since June 8th. It is doubtful whether the second attack was a relapse or a reinfection. (15) Ward-servant, A.H.C.; stated he had fever for nearly a month daily before March 1st, 1907, when he was detained. A film showed benign tertian parasites in two broods, one young and one nearly full grown, also a benign tertian parasite just prior to sporulation. Another film six hours later showed only one brood of benign tertian. March 2nd, admitted; film showed parasites to be bigger than nineteen hours earlier but not so common. April 30th, had in all twenty-one doses up to date. March 6th, 1908, quite well up to date. (16) First had fever on June 10th, 1907; detained on the 13th,

10 272 'l'he Value of Koch' 8 Treatment of Malaria when a film showed half-grown benign tertian parasites to be fairly common. June 14th, morning film showed a couple of benign tertian parasites just prior to sporulation, and evening film half-grown benign tertian fairly common. June 15th, admitted; discharged on the 19th. July 26th, had in all eighteen doses up to date. March 23rd, 1908, been quite well, film normal. (17) Ward-sweeper, A.H.C., first felt sick on August 1st, August 4th, reported sick, when a film showed benign tertian parasite. August 5th, film showed small rings and also halfgrown benign tertian parasite. August 6th, half-grown benign tertian parasite again found. September 27th, had in all twentyone doses up to date and been quite well, film normal. March 23rd, 1908, has been quite well since last note, film apparently normal. (d) MALIGNANT TERTIAN. (18) First attack November 5th, 1904, when he was admitted to hospital for eight days, the entry on his medical history sheet being: "Ague, climatic, mild; quinine; recovered." After discharge had perhaps half a dozen" touches of the ague," but did not report sick. March 25th, 1908, crescents found. March 27th, carefully examined and seemed to be healthy, neither liver nor spleen being enlarged; crescents again found; treatment begun, man not being admitted. March 28th, crescents again found_ April 2nd, crescents again found, though perhaps not so common; given a second dose that evening which gave him tinnitus, a thing he had not had before. April 3rd, crescents as plentiful as ever_ April 5th, crescents again found, though perhaps fewer in number. About this date I went away on leave and so could not examine his blood. June 26th, completed treatment, having had in all thirty doses and having been quite well all that time. July 24th, no evidence of malaria, even on very careful and prolonged examination of a film. September 29th, no parasite seen; quite well up to January 22nd, (19) Admitted October 19, 1905, but film negative. October 22nd, 23rd and 26th, films again negative; discharged on the 27th. November 6th, detained; film showed one or two possible parasites. November 7th, apparently well, so given medicine and duty. November 12th, crescents found but no other form of the parasite present. November 14th, crescents again found and very plentiful; given dose of quinine, which produced very marked headache and tinnitus lasting about six hours. November 15th, given 11 grains

11 N. E. Harding 273 of qumme only, which also produced very marked symptoms. November 16th, crescents again found. November 24th, had a typical rigor; given 15 grains, which was vomited almost at once. November 28th, had a rigor last night, given 10 grains of euquinine, which produced no symptoms, but he had an abortive rigor, temperature rising to F. three and a half hours later; given 15 grains of euquinine the same evening. November 29th, no symptoms from euquinine, but is weak and dizzy on walking; dose repeated. November 30th, had marked deafness about an hour after dose lasting for ten hours or so; dose repeated, and about an hour later he had a feeling of tightness in the head. December 1st, dose repeated but caused such marked symptoms that he felt certain he could not take it except in bed. December 2nd, given 7 grains of ac. quin. hydrochlor. deep into buttock, which seemed to produce few or no symptoms. December 3rd, 4th, 5th, 6th, 7th and 8th, injection repeated; discharged on the 8th, after having been up and walking about for some days. Same injection given on December 12th, 13th, 14th, 22nd, 23rd, 24th, and January 1st, 2nd, 3rd, 11th, 12th, 13th and 21st, up to which date he was quite well and free from symptoms alike from the fever and the quinine. August 8th, 1906, had a letter from him written on manamvres in Sussex, in which he said he had not" had the slightest signs of fever or ague since arrival in England" at the end of February. I have included this case, though it might be argued that the cure was due to change of climate, on account of the very marked susceptibility to quinine. (20) Was in jungle on shooting-pass from July 4th to 18th, 1906, with four other men, all of whom developed fever. July 22nd, first felt sick with "cold shivers and pains up the back" ; admitted on the 24th. July 25th, film negative, but on 26th film showed a few undoubted small rings and also the rare malignant tertian form just prior to sporulation. Another film taken that evening showed very small rings to be abundant, but no other form. July 27th, morning film showed a few small rings, evening film negative, as were those taken on the 28th, 29th and 31st. August 1st, crescents common, but no other form present. August 4th, discharged. August 7th, crescents present, but not so common. August 17th, only one crescent seen on prolonged search. October 17th, had in all thirty doses and been quite well all the time. Was in hospital under another medical officer with simple continued fever from 20th to 26th, no parasite being found. March 19th, 1908, stated he had an odd day of fever since last

12 274 'l'he Value of Koch's 'l'reatment of Malaria note, but had never reported sick. Film showed nothing like a parasite. (21) Another of the shooting-party. First had fever on July 24th, 1908, but did not report sick until the 28th, when a film showed very small rings to be abundant. July 29th, admitted; morning film showed very small rings to be absolutely swarming, evening film the same, perhaps half a dozen being seen in a single field. July 30th, film showed only a few small rings; on the 31st, small rings still common. August 1st, what was probably a deformed crescent seen, but no other form. August 2nd, a solitary undoubted crescent found. August 4th and 7th, crescents scanty, but no other form present; on the 9th, discharged, and on 11th crescents scanty. October 21st, had in all twenty-eight doses to date. March 23rd, 1908, went home-time expired-but one of his chums stated he had been quite well since beginning treatment, and he certainly had no admission to hospital during the following six months. AUG 1906 DATE DAYofQIS IQ fo IT' \ IL 102 \ ~ 100 IV '\ \ V \ V IV "- CHART Ill. (22) Was in hospital with dengue in October, 1905, which was probably malaria as he got frequent attacks of fever after discharge, and for four days prior to admission had a rigor daily. August 13th, 1906, admitted. August 14th, film negative, but on 16th one or two minute" blue dots" seen, possibly young parasites. August 18th, morning film negative on prolonged careful search, but evening film showed an undoubted crescent. August 22nd, crescents seen, but no other form of the parasite. August 29th, no parasite seen; discharged, still some slight tinnitus and headache from qumme. September 1st to 13th, in hospital with tachycardia. and debility,

13 N. E. Harding 275 but had no rise of temperature. Quinine now caused no symptoms. October 29th, completed treatment, having had in all twenty-seven doses to date, and having been free from fever the whole time. March 19th, 1908, quite well and free from fever since last note, film quite normal. I have given the temperature chart Ill. as it is interesting. (23) Lance-naik, R.A.C.D.; admitted May 6th, 1907, and stated he had been having" fever" on and off for the past month. Morning film showed a possible but very doubtful parasite. evening film negative. May 8th, film again showed one or two possible but very doubtful small rings. May 14th, film showed a couple of crescents, but no other form of the parasite; on the 22nd, discharged. August 25th, had in all thirty-three doses to date and been quite well and free from fever since discharge. March 23rd, 1908, still quite well, film quite normal. Temperature chart IV. subjoined. MAY 1907 DATE 5 I DAYofDIS. lt~ " ~ F' r I. JI '" I IV / \ I I'-' V \ A ( I ;. /1 'B.v j' V~ 9' '-- CHART IV. (24) Lascar, R.A.C.D., June 14th, 1907, detained; stated he had suffered from fever daily for five days, film negative. June 16th, admitted; film negative, and remained so until the 23rd, when a couple of crescents were seen (see chart V.). Discharged on the 29th. September 24th, had in all thirty-two doses up to this date, and remained quite well and free from fever up to February 13th, (e) MIXED INFECTIONS. (25) On August 28th, 1907, detained; film showed a few crescents and some half-grown benign tertian parasites, in addition to a few I

14 276 'Phe Value of Koch's Treatment of Malaria small rings. Admitted on the 30th; film showed a few benign tertian parasites just prior to sporulation, but no other form of the parasite. On the 31st, film showed a few small rings, probably malignant tertian. Discharged on September 6th. Treatment completed on November 1st, having had in all twenty-six doses to date. He remained quite well up to March 23rd; film then normal. JUNE 1907 OATE 14 ' I 18 lo ZI l4 I' OAYorDIS. 5 6, r' ! 102 r 101 I A I' :V 100 / I 1\1 99 I \ 9S 97 J 1"'- CHART V. Remarks.-It will be noted that, as was the experience of Koch, treatment for a month or six weeks was not invariably sufficient to prevent relapse even in the case of the-supposedly-less resistant benign tertian parasite, whereas treatment for three months certainly was, as it can hardly be doubted that all the cases of malignant tertian were cured, with the possible exception of No. 20, and I think in all probability he was. Is it, then, too much to say that, having regard to the enormous importance of malaria, alike from the point of view of the sanitarian and the economist, this method of treatment of Koch's is the most marked therapeutic advance of recent years, one only to be compared with the discovery of diphtheria antitoxin, and that such a thing as a relapse from malarial fever should for the future be unknown? It must be added, however, that unless the diagnosis is made by the microscope failure and disappointment are bound to ensue, for to cases of liver abscess, enteric fever, septicremia, pneumonia, and syphilis, all of which I have known treated as malarial, not to mention the various undifferentiated Indian fevers, quinine is more likely to prove harmful than beneficial.