Use in Psychiatry.—Following the observation of W. Jauregg in Vienna in 1917, that certain chronic conditions showed im provement after malarial attacks, the therapeutic use of malaria in psychiatry has been extensively applied in many countries. Many cases of general paralysis have benefited, some sufficiently to be able to return to family and social life. Time must be given to determine the permanency or otherwise of the ameliora tion. Its use in other cases of cerebrospinal syphilis and also in such mental diseases as dementia praecox, confusional insanity and encephalitis lethargica is under consideration. The parasite used is P. vivax and it appears more satisfactory to inoculate the patient by an experimentally infected mosquito than by infection with blood from a case of malaria. Thereby all risks of other infection are avoided, a wise precaution, especially in an endemic region where other species of the parasite occur. Infected cases are allowed to have six to ten febrile attacks of malaria and are then given quinine which in these experimental cases readily cures the attacks.
Until the war spread to the Eastern fronts British armies suffered little from tropical diseases. In the summer of 1916 an epidemic of malaria occurred among the troops on the Salonika front, and continued until the end of the war.
Following the outbreak of malaria at Salonika, Sir Alfred Keogh, the director-general, Army Medical Services, early in 1917 appointed a special malaria hospital in each command in the United Kingdom, for the express purpose of finding a permanent cure if possible, and of treating the thousands of men who were being returned home sick with malaria from the Eastern fronts, Sir Ronald Ross being also appointed consultant in malaria at the War Office. The fact that moderate doses of quinine will control actual attacks within a few days was fully verified, with very few exceptions. Almost every form of treatment that had ever been suggested—enormous doses of quinine reaching 10o grains per diem, smaller doses continued for three weeks or more, additional medication with arsenic and other drugs, continuous doses lasting for a month, and various kinds of interrupted dosage—all proved uncertain. Thirty gains of quinine, continued every day for three weeks, proved a failure. Intramuscular injections and even in travenous injections did no better. Men who were presumed to be cured relapsed again after returning to duty; a large proportion of those infected with malaria became almost useless for further service. Numerous nostrums advocated for malaria proved value less, the only exceptions being one or two arsenical preparations, which, however, were no better than ordinary quinine.
In all these attempts, treatment had seldom been continued for more than one month and rarely or never for more than two months—owing, of course, to military exigencies. It was decided to deal with the large numbers of discharged soldiers by a longer period of treatment. In 1918 two whole divisions, full of malaria, had been brought from Salonika to France and were there sub jected to a longer course of treatment preparatory to their being sent again into the firing-line. The regiments arrived in an ex tremely bad condition, were all placed in camps in the Dieppe region, and the men were given 15 grains of quinine in solution once daily for a fortnight, followed by ten grains of quinine in solution daily for two and one-half months more. The course, designed and carried out by Col. J. Dalrymple, had marvellous results, almost the whole of the two divisions being found fit for the front at the end of three months. About the same time large malaria concentration-camps were established in England, where cases were given similar treatment, but for shorter periods ; and it was found generally that (I) doses of less than ten grains daily did not suffice to prevent relapses even while they were being taken; (2) doses of ten grains daily did so suffice, except in about 6% of the cases, most of whom, however, relapsed during the first days of the treatment ; (3) 15 grains a day reduced the relapses still further, but only to about 4% or 5%.
The long-continued treatment of malaria was now proved to be satisfactory, and was extended to pensioners also. In one London clinic alone nearly 30,00o pensioners have been treated in this way. The results have been admirable, and probably few who have taken the treatment properly have returned. But the ten grains of quinine must be taken religiously every day, and it is well to associate this with or follow it by a course of arsenic. Quinidine replaced the quinine in a small number of these cases. Empirically, three months appear to be enough, but in obstinate cases four months might be better. Even long courses of treat ment will not necessarily cure people who are subject to rein fection during treatment; and it is even possible that they are not so effective during the first six months or the first year of in fection as they are later. The results described above were ob tained among returned cases in Britain.
The prevention of malaria on the battle-front was always diffi cult and sometime impossible. Mosquito-reduction in the face of enemy fire is impracticable; quinine prophylaxis was under such conditions disappointing; and the armies were obliged to fall back upon mosquito-nets and mosquito-proof tents and bivouac shelters, carefully designed by the British War Office. Better results were obtained at the bases of operations, especially in Palestine; and a very successful campaign of mosquito-reduction was carried out by Col. J. C. Robertson at Taranto in southern Italy.