Digitized by the Internet Archive in 2010 with funding from University of Toronto http://www.archive.org/details/annalsoftropical05live ANNALS OF TROPICAL MEDICINE AND PARASITOLOGY @ (THE UNIVERSITY OF LIVERPOOL ANNALS ee OF TROPICAL MEDICINE AND PARASITOLOGY ISSUED BY THE LIVERPOOL SCHOOL OF [TROPICAL MEDICINE VOLUME V (April 20, 1911, to February 26, 1912) With twenty-five plates, thirty-six figures in text, fifty-seven charts, and three maps LIVERPOOL : AT THE UNIVERSITY PRESS, 57 ASHTON STREET. 2TAUN A. ava avipraaM 1 A108 pntly Wie, YOOLOT len aA ¥ 4G, Misa | en Le Aa Al Sheri TADIMOR Pe LOOK 2. | 460 - 7 | bt | AS5 re “ae vy su thiov iStoi- Oe yuundet of 2107 os lhgAy ; a : i . x= ye ontilg vo) etal % CONTENTS No. I McCarrison, Roser. Further Experimental Researches on the Etiology of Endemic Goitre. Plates I, UU. Carter, Captain R. Markuam. Non-ulcerating Oriental Sore: the Cultural Characteristics of the Parasite as compared with a New similar Parasite in Erthesina fullo (Thumb), a Penta- tomid Bug. Plates III, IV Critien, A. Infantile Leishmaniasis (Marda tal Biccia) in Malta. THomson, Davip. I.—A Research into the Production, Life and Death of Crescents in Malignant Tertian Malaria, in Treated and Untreated Cases, by an Enumerative Method 1].—The Leucocytes in Malarial Fever: a Method of Diagnosing Malaria long after it is apparently cured Boyce, Sir Rupert. Note upon Yellow Fever in the Black Race and its bearing upon the Question of the Endemicity of Yellow Fever in West Africa. ‘Two diagrams FantuaM, H. B. On the Amoebae Parasitic in the Human Intestine, with Remarks on the Life- Cycle of Entamoeba coli in Cultures NewstTeAp, Roser. Some Further Observations on the ‘Tsetse-fly, described in these Annals as Glossina grossa, etc. Korke, Visunu T. On the Correlation between Trypanosomes, Leucocytes, Coagulation ‘Time, Haemoglobin and Specific Gravity of Blood PAGE ™N >) J/ 103 127 CONTENTS No. 2 In Memoriam—Professor Sir Rubert Boyce, F.R.S.. With portrait Gassi, Prorrssor UMBERTO. Note on Tropical Diseases in Southern Italy Newsteab, R. The Papataci Flies (Phlebotomus) of the Maltese Islands. Plates V-VII McCarrison, Roserr. The Experimental Transmission of Goitre from Man to Animals. Plates VIlI-xX Navss, Ratpo W.; and Yorke, WARRINGTON. Reducing Action of Trypanosomes on Haemoglobin SrePHENs, J. W. W. The Anti-Malarial Operations at Ismailia. ‘Two Maps Newsteap, R.; and Carter, Henry F. On some New Species of African Mosquitos (Culicidae). Plate XI ... Topp, Joun L.; and Worsacy, S. B. The Diagnosis and Distribution of Human ‘Trypanosomiasis in the Colony and Protectorate of the Gambia. One Map Yorke, WarrincTon ; and Nauss, Rateu W. The Mechanism of the Production of Suppression of Urine in Blackwater Fever. Plates XII-XIII Simpson, G. C. E.; and Ebr, E. S. On the Relation of the Organic Phosphorus Content of Various Diets to Diseases of Nutrition, particularly Beri-Beri PAGE 139 187 199 215 233 245 287 a =. = aA CONTENTS No; 3 Ross, Proressor Sir Ronatp ; and Storr, WaAtrrER. Tables of Statistical Error ... Sripetin, Dr. Haratp. Notes on some Blood Parasites in Reptiles. Plates XIV-XV ... Ross, Sir Ronatp ; and Epir, E. S. Some experiments on Larvicides GranaM, W. M. An Investigation of the Effects produced upon the Excretion of Urinary Pig- ments by Salts of Quinine. Plate XVI Yorke, WARRINGTON. The Passage of Haemoglobin through the Kidneys. Plate XVII Ross, Sir Ronatp ; and Tuomson, Davin. Pseudo-Relapses in Cases of Malarial Fever during Continuous Quinine Treatment Yorke, Warrincton ; and Bracktock, B. The Trypanosomes found in ‘Two Horses Naturally Infected in the Gambia. Plate XVIII Wisz, K. S. An Examination of the City of Georgetown, British Guiana, for the Breeding Places of Mosquitos Srannus, Hucu S.; and Yorke, WARRINGTON. A Case of Human Trypanosomiasis in Nyasaland with a Note on the Pathogenic Agent. Plate XIX McCarrison, Roserr. A Second Series of Experiments dealing with the Transmission of Goitre from Man to Animals. Plates XX-XXII ... Tuomson, Davin. A New Blood-Counting Pipette, for estimating the numbers of Leucocytes and Blood Parasites per cubic millimetre Fantuam, H. B. Some Researches on the Life-Cycle of Spirochaetes Srepuens, J. W. W. “Desmogonius desmogonius, a New Species and Genus of Monostome Flukes. Plate XXITI 409 443 453 471 479 497 CONTENTS No. 4 PAGE Serpetin, Dr. HARraLp Notes on some Blood-Parasites in Man and Mammals. Plate XXIV Lath, S02 Patron, Captain W. S.; and Crace, Captain F, W. The Genus Pristirhynchomyia, Brunetti, 1910. Plate XXV ... Ri. oe BOD Patron, Captain W. S.; and Cracc, Caprain F. W. The Life History of Philaematomyia insignis, Austen ere = al i ee Bracktock, B. The Measurements of a Thousand Examples of Trypanosoma vivax weet gee Tomson, JoHn Gorpon. Enumerative Studies on T. brucei in Rats and Guinea-Pigs, and a Comparison with T. rhodesiense and T. gambiense se ed i, ei ug yg. Biacxtock, B. A Note on the Measurements of Trypanosoma vivax in Rabbits and White Rats 537 Ross, Srr Ronatp ; and Tuomson, Davin. A Case of Malarial Fever, showing a True Parasitic Relapse, during Vigorous 2!) Lote and Continuous Quinine Treatment. INDEX PAGE Inpex or Auruors.. ill GENERAL INDEX.. - SA ili INDEX OF GENERA, “SPECIES A AND VARIETIES NEW TO ) ScteNCE Rcbhag Amae ts vil INDEX OF AUTHORS PAGE | PAGE Blacklock, B.. Whe ab 20s haz | Ross Gir. ; and Rdiey Br'o:.+ 20.4, tse 305 Blacklock, B. ; and Yorke, Wee gag |) sRoss, oir Sand Stott WW. .. c2..60.2 847 - | SE Su) 3 ie 103 Ross, Sir R. ; and Thomson, D. ...409, 539 omer, HH; F.; Newstead) Rics.....: 233 Seidelin, Harald ...... ee 501 Gutter, R. Mareen TRY ake 15 | sunpson,G, C. BE. ; and Edie, E She ieosabe Vie Cragg, F. W.; and Patton, WS + 509, 515 | Stannus, H.S.; and Yorke, W. ...... 443 Crtien, As >... pr IY Stephens, J. W. W.. HT. BIS AT Edie, E. S. ; San Ross Sir RR ees) 465 | Stott esand Ross, Re oe 347 Edie, E. ae and Simpson, GC. E....°313. | Thomson, David. 37, 83, 471 Bamemimots. B. 7.4.0... MLDS AYO) «| Thomson, be and Ross, ‘Sit R.. ..409, 539 ERI Cette... 135 (| (homson, J. Glen. 531 Graham, W. M................0..0-. 39f | Todd, J. L.; and Wolbach, S. B.... 245 PM VIGNE Do... 5 sc se eee ese=- 127 Wise, K. S. NAG McCarrison, Robert....... -¥,. 187, 453 Wolbach, S. ‘B.: “and Todd, Je alts . 245 Nauss, R. W. ; and Yorke, we ...199, 287 Yorke, W. arrington see .«+ 401 Newstead, Robert.. EA. 125. B20) | Yorke, W.; and Blacklock, ‘B.. 1» 413 Newstead, R.; and ‘Carter, H. jae 233 Yorke, W.; and Nauss, R. W.. 199, 287 Patton, W. S.: and Cragg, F. W ., 509, 515 Yorke, W.; and Stannus, H. Steaeee 443 GENERAL INDEX PAGE PAGE Amoebae parasitic in the human Blacklock, B., and Yorke, W., Try- intestine ..... III panosomes of naturally infected Amoeboid parasites i in blood- d-plasma HOESCS e PAD ic dessee at ev een sen sn ce 4E3 of Lizard . . 380 Blackwater Fever er, ., Kidney in ...402 ¢t seq. Anophelines, Ave Larval ' measures at y ae Leucocytes in...... 93 Tomaiiarlei.: 44: 1220 <3 Urine, Mechanism Pe Breeding places ahs at of Production of ASMAaLiaeUAY. ...i5.45. OA suppression of, Argus persicus, Spirochaetes in ......... 485 MOTE cc ctsaes we ZO Auto- gales in human trypano- Blood-counting Pipette.. or . 471 somiasis ....... 260 Blood, in Trypanosome infections, 127, 200 Bacillus bulgaricus ii in the treatment of ,, Reducing action of Trypano- BOLLS, 4.50.00 UA semiwdys: te somes on haemoglobin ...... 200 Barbados, Yellow Fever itt.........:..... 106 Boyce, Sir R. In Memoriam ......... 133 Beri- Beri, Phosphorus, Organic, con- Boyce, Sir R. Yellow fever in the tent of diet and .....:... 313 cit pO A de Oe Bee 6°, a Rice, polished and un- Cancrum oris in Infantile Leish- polished in.. 314 et seq. RAMNGNG AA). Dead ond Whe vers be ube edb ebin LD Blacklock, B., Measurements of T. Cater,.H. F., “and Newstead, R. vivax . Se se GABP RST New African Mosquitos............... 233 PAGE Carter, R. M. Non-ulcerating oriental sore; cultural character- istics Of parasite ...-...+ece seer Cellia arnoldi. .........c0 ener pseudosquamosa, N. SP. ys Squamosa, Var. arnoldt ....++0 +--+: Cragg, F. W., and Patton, W. S. The Genus Pristirhbynchomyia ...++++++ Cragg, F. W., and Patton, W.S. Life history of Philaematomyia insignis... Critien, A. Infantile Leishmaniasis in Malta 2i......creces de -meeeee Dengue Fever in Italy .....----+1-00 Desmogonius desmogonius, N. 8-5 N. SP. ...2e000s ae 2 ee Dysentery, Amoebae Of .....-.+-:++- 299+ Edie, E. S., and Ross, Sir R. Experi- ments on larvicides ....--e ee eeres Edie, E. S., and Simpson, Gac. & Organic phosphorus content of diet and BerisBerh... fof eae ree ven ee Entamoeba sp. (Noc) ee ae: se plea AR hceas ss S25 ., Life-cycle of, in cul- FUEES fbb fapen ste eanees = sf ., Leucin, Skatol and Tyrosin in Culture media of oe OMENS 2 eo <0 vee - E13, TE; histolytica.........--113, 119, ” Widslia Too ct abe, 11D, - nipponica . “TRS, 200; 7 phagocytoides «..-.- 114, 116, 5 tetragend..........--114, 116, tropicalis _.112, 116, undulans Enumerative Methods aeons Blood-count- ing Pipette os Studies of crescents in malignant tertian gna baraa casiaup eet -f¢be $s Studies on T. brucei ... Erthesina fullo...ccsvecececiserennre Parasites from intestinal sract bli .. 4... aame--9's Fantham, H. B. On the Amoebae parasitic in the human intestine... Fantham, H. B. Life-cycle of Spiro- CHACCES |. a clin cel neo kaleiss = one eo ne hae eens Filaria imperatoris 2.0.00 c00 ce verses ” ” 29 9 479 ihe PAGE Gabbi, U. Tropical diseases in Southern Italy. ......-0:ceeeseereeeeeres 135 Gambia, Horses naturally infected with Trypanosomes in ee Georgetown, Mosquito breeding places in os aoe Gland palpation and puncture in human trypanosomiasis. ......-.257 ¢t ¢q. Glossina grossa, Synonym of Gl. nigro- ee cs morsitans, 1. rhodesiense probably transmitted by... 449 , NigrofUsca, Ni. SP. --eeeeeeeeres 125 .. palpalis, var. Wellmamt .....- 125 Goitre, Earthworms in the spread of... 187 ,, Endemic, Experimental _re- searches on Etiology 1 z a treatment of......... 12 ,, Experimental, Carbonates_ of Lime, Mag- nesium, and Sodium, in... 458 et Seq. - a4 transmission from man to animals, 187, 453 Graham, W.M. Salts of quinine and the excretion of urinary pigments... Haemoglobin, Reducing action of Trypanosomes on ore Haemoglobinuria, Experimental eae 404 sgt 39 bP Suppression of urine “’ Haemogregarina imperatoris, TSP. +--+ Ismailia, Anopheline breeding places 221 ,, Anti-malarial operations at 215 Italy, Southern, Tropical diseases ofee Kala-azar, Infantile .....- .. eae o 5 so aM [tally .. ee 136 Kidneys, Blackwater Fever, suppres- sion of urine in......402 ef 5ég. “4 Haemoglobin, passage of, 2 through «an « a» oeehela en ‘ Piroplasma canis ..++ 403, 406 Korke, V. T. Correlation between trypanosomes, leucocytes, coagula- tion time, haemoglobin and specific gravity of blood «1.0... seers Lactic ferments in the treatment of BOUETE seo cece ce neer eee eeteereen see metas 12 127 PAGE Larvicides. . bovis tp aed eer nee abee Seng Leishmania “infantum in infantile Leishmaniasis .......... ..44, 136 Leishmaniasis, Infantile, ocras Ors td). 2.. 39 a Fe clinical pic- Pures 775-4 38 t. y in ltaly?.<3)t 136 x 43 int’ Malktavys: 1°37 Leucocyte counts in blackwater fever 93 Pa 4 mialatiay 11. ee 65, 83 $3 5 oriental sore ... 20 Leucocytes ingest malarial parasites, 72, 85 Leucocytic extracts in Malaria ...... 86 McCarrison, R. Experimental re- searches on the Etiology of Endemic SSOMUTE. ...5..-+.. I McCarrison, BR. Experimental tt trans- mission of Goitre... ect yey Le Malaria, Diagnosis by leucocytes ...... 83 a Ismailia, anti-malarial opera- tions at Aa xcen LG ,, Latent, diagnosis of Ul es 89 = Leucocyte counts in ......... 65 Been EGUCOCYTES ID. os.csch soc. ores 83 fe) Leucocytic extracts in ...... 86 » Pilocarpine injections in...... 87 re Quinine and excretion of urinary pigments 391 > “ Quinine Prophylaxis...... 228, 398 »» Quinine Prophylaxis and cure 73 . Quinine treatment, pseudo- relapses during 409 ;. Quinine treatment, true par- asitic relapse during ...... 539 “ Relapses, pseudo, during quinine treatment ......... 409 . Relapses, true parasitic, dur- ing quinine treatment 539 ee Wrtan i 5.¥ . 507 Malarial parasites, ingested by leuco- 5 a eS Oy - » Methylene Blue, the effect of, on Crescents..st..67 Production, life and ” 9 death of crescents 57 ™ s,s Quinine, effect of, on crescent pro- duction....,...i00 7 & Malta, Infantile Leishmaniasis in...... 37 PAGE Mediterranean Fever in Italy......... 135 Mercuric chloride as larvicide ......... 388 Methylene blue, the effect of, on malarialierescentgieayites..<....0c. 67 Mtkrofilaria. See Filaria. Mosquitos, African, new species of ... 233 4 Breeding places in ee town . 435 = Larvicides 385 Molluscs, Lamellibranch, Spirochaete of.. ..488 et seq. Nauss, R. W. 3 “age vee W. Action of trypanosomes on haemoglobin... 199 Nauss, R. W., and Yorke, W. Sup- pression of urine in Blackwater fever 287 Neocellia christyi, n. sp.. TERS SSS Newstead, R. Papataci Pie of Maltese PAS 55 MERE < cwnvaned an) BOO Newstead, R. The Tsetse-fly described as Glossina grossa, etc.... 125 Newstead, R., and Carter, H. F. New African Mosquitos NE waSe 2293 Nyasaland, ‘Trypanosomiasis, “human, cases of, in 443 Oriental Sore, Italy 137 # 5, non-ulcerating, eae characteristics of parasite Of Wa. e (ES Ornithodorus moubata, eet, in 485 Papataci Fever in Italy ......... 137 sau 2 Plves of Maltese Islands 139 Paraplasma subflavigenum, n. sp. ....+. 504 Patton, W.S., and Cragg, F.W. ‘The Genus Pristirhynchomyia ........+++ 509 Patton, W.S., and Cragg, F. W. Life history of Philaematomyta insignis... 515 Petroleum’ as larvicide %. 2 hii... 22 385 Philaematomyia gurnet, 0. sp. 513 7 insignis, Life history OES .o 53 A ead G15 ij HARARE 2 octal oo! GIZ Phlebotomus, Bionomics of ...140 et seq. a Morphology of Genus 153 ¢t seq. a Prophylactic Measures 148 et seq. Phlebotomus minutus , 169 3 nigerrimus, N. Sp. 168 99 papatasit 174 99 pernictosus, n. sp. 172 Pilocarpine injections in Malaria...... 87 PAGE Piroplasma canis, Kidney in 403, 406 Plasmodium sp., monkey naturally in- fected with .......00 falciparum, Biology of sexual form of........... 57 Polyneuritis, Experimental, in animals 314 et seq. yeast, Pro- 595 tective and cura- tive effect ai. 0... 321 et Seq. Potassium cyanide as larvicide ......... 388 Pristirbynchomyia, Genus .. sige ¥5OO Pyretophorus distinctus, n. sp: gba ene a4: 4 - var. inelano: costa, N. var.... 236 Quinine, Effect of, on crescent ll duction bazashe “39 (60 », Malaria, pseudo- relapses in, during treatment with ... 409 Malarial Prophylaxis, 73, 228, 398 , Urinary Pigments, Effect produced upon excretion of, by . 391 Reedomyia simulans, n. sp. ....- . 240 Reptiles, Blood parasites of ............ 371 Ross, Sir R., and Edie, E.$. Experi- ments on larvicides —.........:1-00++ 385 Ross, Sir R., and Stott, W. ‘Tables of Statistical EPEOT a anh ss 347 Ross, Sir R., and Thontson,. D. Pseudo-Relapses in malaria during quinine treatment . sees 409 Ross, Sir R., and ‘Thomson, D. True parasitic relapse in Malarial Fever during quinine treatment... 539 Sanitas-Okol as larvicide ............... 386 Schaumann, H. Beri-Beri ...313 et seq. Seidelin, H. Blood parasites in man and. masnmals 25 gcd sith scree hOl Seidelin, H. Blood parasites in reptiles .. a7 Simpson, G. C. E., and Edie, E. S. Organic phosphorus content of diet asd Beri-Ben . 35... inate cee Gl F Sleeping Sickness. See ‘Trypano- somiasis, Human. Spirochaeta anodontae, Spores of ...... 489 a balbianit, Spores of ...... 489 PAGE Spirochaeta duttoni, Lite-cycle of, 480 et seq. st marchouxt, Life-cycle of 480 et Seq. 5 recurrentis, Life-cycle of... 480 et seq. 3 solenis, N. Sp.......480, 488, 493 Spirochaetes, Life-cycle of . 479 Stannus, H. §., and Yorke, W. Case of human Wide in Nyasa- land . - 443 Statistical Error, ‘Table of. a 347 Stephens, J. W. Anti-malarial operations at eee 215 Stephens, J.W.W. New species and genus of monostome flukes. . uns 407 Stott, W., and Ross, Sir R. "Fables of Statistical Ertor :.)aeee ee Strychnine as larvicide ............:.000 Suez-Canal, Anti-malarial operations at Ismailia . ...0...). .2c).sunes eee ae Thomson, D. _ Blood-counting PIPCtte os n0.ssecssnnnese abies seeeeenn Thomson, D. Leucocytes in malarial fever; method of diagnosing MA ALIA sss. so.s vo.cien sie Coe Thomson, D. ‘The production, life, and death of crescents in malignant tertian malaria........ shod sas eae Thomson, D., Aer Ross,, Sir ie Pseudo-Relapses in malaria during quinine treatment . lads on ea Thomson, D., and ‘Ross, Sin True parasitic relapse in Malarial Fever during quinine treat- MCN Lc evcecvcccececcceccccccssccccers Thomson, J.G. Enumerative studies ODT. BRUCE iciiad kisi de plde see eee Thyroid gland, Goitre ...............4 2b Seq. Experimental 189 ¢ét seq. 454 et Seq. Todd, J. L., and Wolbach, S. B. Trypanosomiasis i in the Gambia . Trematodes, Desmogonius desmogonns, 1.2.) D.Sple pees - 497 T. brucei, Enumerative studies on . . 531 I. dimorphoty todresljeas0 Yorke, W. Passage of haemoglobin through the Kidneys 4o1 Yorke, W., and Blacklock, B. Try- panosomes of naturally infected UNS CME a tanec soa es. vrianmesas AEG Yorke, W., and Nauss, R. W. Action of trypanosomes on haemoglobin... 199 Yorke, W., and Nauss, R. W. Sup- pression of urine in Blackwater fever 287 Yorke, W., and Stannus, H.S. Case of human trypanosomiasis in Nyasa- PO rece pharina circ Buws jo ocseeec ties ee MAG DererualVAtIaTIA IM “Ss ic csveccrewese ss §OY INDEX OF GENERA, SPECIES AND VARIETIES NEW TO SCIENCE PAGE Cellia pseudosquamosa —..iceeeceeeeeenees 236 RE IIL. « os.5.10'0.0i vies ois Mee sssviewee'ss vs AQF a desmogonius te. Saeed 4s 407, NGS TALTOPUSCE x0. vies ceo s,odeesones 125 Haemogregarina he Ne a shh ara Sy 374 MEME COTESEYT — . . cdsna yas ssceaumysss 238 Paraplasma subflavigenum ....ccceceus. 504. Philaematomyia gurnet ........000000 +. 513 PAGE Phlebotomus nigerrimus 0 ..0.0c.0c00 0+. 168 5 . . fe POTAUIOSES. soci vcorsisvess LZ Pyretophorus distinctus .....scscwees 234 melano- costa, 230 Spirochaeta solenis cites bi 493 Reedomyia stmulans ...ccse ee .. 240 5 5 var. 4 rs fbots . aTtL rts 4 = mn novuled ; , Y tshit ; ; j owed Me ' + = (nid 15D aiuitdt * : <* ‘ < ao! eB veecdl wth sent seatint * : ‘ ie ii — é a ‘4 r "4 , a vs eo . d ; 45 es ’ ~~, 3 wy ; | ‘ ‘ os { ‘| < 2 y * ‘ . aa ae 1 of ‘ ed = oe hi - j : 3 ar. ats ’ - : UA) ; ; 2 e } i is > ° ie ¢ a idee t ¢ ‘ f -F f ‘i ina , Pt, F pe f = - - eo * e > * : af mae? i Jb) 0 f Pa t i > bi tyinieets 3 —. : a ; ol apht - Py Saal a a. 1 ot slay e Apion hss = 4 Aerie Sue Lifton vel Fe ished AO LOUD Y a e . re + fs iekel beaters soithie 4 . $4) Lo tee tee SE caine iF iT atthe. Saal on Laks MY : Ei od pas Ptail 4 te “ i \ - . ae = : 62? ater | = rinht ex ibul / 130 f° 2S : sie 7 “Aa ; Vv a i ars ‘ &F a? he oe rl- Eke ee a : 5% } ’ ¢ oka = 24ers “Sana me, 4 , pir, ea ’ ; . P ; y © cL BA Dea i) a . ad on @ SY 22 2 4 a & te ~ Ay CH } f A - Hy ‘ e. ex he 7 “ ' — gates depot Oe te 1 uF ty Marsa foe ° ) 4 Lie y = . 4 Be es “ ae , 8 = ) \ oe iy 7 = thors Sg . ZB ¢e a 33 VI.—A group of organisms drawn from a culture of parasites from Erthesina fullo after seventy-two hours. Note the parasites are seen in all stages of development, large blue coccoidal masses are seen attached to two rosy zooglea masses. The morphological details of the bluish monadine form are chiefly crithidial in type. The rosy bodies similate those found in non-ulcerating Oriental sore. The parasites are seen living symbiotically with bacteria. 34 PLATE IV. Series of drawings of living specimens of the gut parasite from Erthesina fullo in blood cultures. I-XII and No. XIX drawn with 1/12 objective No. 2 eye-piece, XIII-XVIII and No. XX drawn with 1/12 objective and No. 4 eye-piece. I.—Oval body showing nucleus, nucleolus and vacuole. II and III.—Monadine parasites (4) with small oval or boat-shaped bodies, (a) apposed at the root of the flagellum. IV and V.—Flagellated large oval parasites. VI.—Monadine flagellate (0), and small oval body (a). Note granular posterior and anterior ends of the former. VII and VIII.—Flagellate parasite with the posterior ends globose and filled with granules. IX and X.—A monadine flagellate dividing by fission from the anterior end of the parasite. XI.—Monadine flagellate with globose granular centre. XII.—Edge of an air bubble in a cover-glass preparation showing the arrangement of an aggregate of monadine flagellates, with their flagellae towards the centre of the lower surface of the bubble. XIII.—A pair of parasites, the one (6) a monadine flagellate, the other (a) a cyst-like body unflagellated apposed at the level of the nucleus of the monadine parasite. The monadine parasite (4) presents a ground-glass-like nucleus about its centre. The posterior end of the parasite presents two dark dots. The anterior portion of the parasite presents fine granules and a small, clear, dark-edged oval area surrounded by a fine vacole. Occasionally the root of the flagellum can be traced ending in the neighbourhood of the vacuolar area. The oval parasite (2) presents a fine capsule. To one side lies a large dark dot surrounded by a ring of fine dots. These adjoin a reniform ground-glass-like area, seemingly like a faint vacuole. This latter is sepirated from the capsule of the parasite by a line of equidistant dots of equal size. PLATE 39 XIV, XV, XVI and XVII.—Similar pairs of parasites, the oval parasite flagellated or not. XVIII.—Cyst-like bodies packed with small golden granules, which seemed to boil within the capsule. XIX.—Four monadine flagellates with acicular posterior extremities, each parasite attached by a fine elastic cord to a spot in a mass of zooglea material. XX.—A parasite showing the posterior end of the parasite contains clear fine granules. A and B show two positions of the parasite leaving the zooglea clear mass with the flagellated anterior extremity forwards. 6.—The fine elastic posterior ‘ anchor cord.’ ct leu “ait yt t eu. Pit 0 218g wwhilrari HH re A hans IVR WK VIA hor 13 fy sei) yuk ahesisg ledasd voblod Usaw die dieehie esibod ailieg = Tivae = ofyeqes wit aatiiw Tied of boateme donty iD : ie Tate ht gir mots Naxgak wiiDROOm m0 TGS ; Hisoley and fa tDevlontte aeaTg dome ,2ettensixe = ‘Tart ye) £571 7OR Lo aan & tage f ot > eee CATED 142hIsq DOG » Ot igriaies au arf3 git wode slizemnq A= < amigaty sai tok ‘ sslanoy. at gnvraul otiewisg. alt To-anertizoq, awd wodz A bas. $ 7 ; - Jiinstiee) fanetGe bots!ioush oft dine eeem.. ss0!> ébiewior hicn Aonote ' Sohtateog dHesio snd Sd a7 INFANTILE LEISHMANIASIS (MARDA TAL BICCIA) IN MALTA BY A; GRITTEN,-M. Ds; DiPAe, D.T.M: (LIiv.) (Received for publication 23 January, IgII) There exists in these Islands a morbid condition characterised by great enlargement of the spleen and profound anaemia. It is met with almost exclusively in very young children, and is nearly always fatal. Although, with the exception of splenic leukaemia, all the anaemias with chronic swelling of the spleen are clinically little differentiated, there always has been a feeling among local practitioners that they were dealing with a special pathological entity, which being in its clinical manifestations very much like some of the better known disorders of the blood and haematopoietic organs, they could not very well, in the absence of some special element of diagnosis, dissociate from the latter. Etiologically its connection with syphilis, tubercle, rickets, or amyloid degeneration is not apparent; as to malaria, it is not endemic in these Islands. The disease is variously certified at death as leucocythaemia, splenic leukaemia, splenic anaemia, pseudo-leukaemia, splenitis, splenopathy; but in the Maltese language it is referred to by the professional and the layman alike under one name, ‘ Marda tal biccia.’ The disease begins very insidiously with spells of fever of a slow type, at a period of the child’s life when slight ailments are very frequent and not made much of. If the initial pyrexia tends to establish itself without any obvious explanation such as dentition or gastro-intestinal troubles, Mediterranean fever is apt to be suspected, especially as on percussion the spleen is already found somewhat enlarged. More often, the initial attacks of fever do not attract attention until there arrives a time when the child, having lost its 38 usual brightness and desire for food, becomes pale and begins to lose flesh. By this time the spleen can be felt as a distinct tumour in the left hypochondrium, and the little patient is shown to a doctor. From this stage the malady has a protracted course of from six to eighteen or twenty months. The following is a short clinical picture of the disease when fully developed :—The skin is waxy white or sallow, according as the subject is fair or dark; the lips and mucous membranes are blanched ; the eyes are full of sadness and look abnormally large in the emaciated little face; all the muscles are flabby and more or less atrophic, the distended abdomen contrasting with the wasted thorax, its fulness more pronounced on the left. The outlines of the splenic tumour may sometimes be easily made out by inspection. On examination the spleen is found generally to extend down to the level of the umbilicus, firm but not hard, freely movable, only slightly tender on pressure or not at all, its margins rounded but well defined, its notches well pronounced. In growing downwards as a rule it keeps to the left of the navel, reaching very often down to the iliac crest; but in some cases it fills the pelvis, and, crossing the linea alba, occupies the right inferior quadrant, where in an extreme case I have found it in close apposition to the anterior border of the enlarged liver. The occurrence of the caput medusae is very common. The liver is also enlarged, but to a less degree, not more than one or two fingers’ breadth below the costal margin. In the cases observed the presence of fluid in the abdominal cavity could not be detected. The lymphatic glands accessible to examination are not sensibly enlarged, but when the wasting is very pronounced they can easily be felt and seen. Transitory oedema of the feet, hands and eyelids is common. The appetite is very indifferent, but sometimes there is a great craving for food; it is rarely perverted: in some cases the patients pick and chew bits of plaster or little stones. Gastro-intestinal troubles are the rule, manifested by intercurrent attacks of very fetid diarrhoea. A symptom met with sooner or later consists of a solitary or repeated attack of dysenteriform diarrhoea with tenesmi, slimy motions containing blood and mucus or mucus only. The frequent passage of loose stools is not infrequently accompanied by temporary shrinking of the spleen. In one case this was observed to such a 39 degree and the improvement of the other symptoms was so marked and continued that the mother firmly believed the abdominal tumour—the spleen—had been passed with the motions. Curiously enough the case ended in complete recovery; the patient, a boy of six, when seen by me was in perfect health. Evidently, he also had had cancrum oris, as the upper middle incisors were missing and the gums were badly scarred. Intercurrent attacks of bronchitis are by no means rare. Epistaxis is a common occurrence, so is bleeding of the gums, and the appearance of one or more crops of purpura all over the trunk and face. In one case a few vibices were observed. A frequent terminal complication is cancrum oris. The mortification may assume formidable proportions in a few days, or it may evolve less acutely, death supervening in a month or six weeks. It sets in very stealthily, almost without pain, the increased flow of saliva at first being ascribed to irritation of the mouth due to dental evolution. The process in the cases observed started from the gums in connection with the upper incisors, lower or upper premolars. The gangrene is often very extensive and exceedingly repulsive to the eye and nose, and the deformity is generally such that no plastic operation could ever remedy. The blood in advanced cases is quite watery; it separates quickly into clot and plasma. Prognosis is very bad. Nearly all practitioners, however, quote from experience one or two instances of the disease ending in recovery ; but some maintain that all recoveries are cases of mistaken diagnosis. It is wonderful how some patients can go on living; on the other hand death occurs when least expected. Bronchial complications are very frequent towards the end. The disease, as outlined, was found to have reached a more or less advanced stage in the twenty-one cases, to which the following notes refer : — 1. Girl, 4 years, seen in May, 1gog. Ill since October, 1908, after whooping cough. Intercurrent waves of fever of a remittent type, profuse perspiration, no appetite, anaemia, muscular atrophy, transitory oedema of both legs, spleen reaches down to iliac crest, liver also enlarged, purpura, dysenteric diarrhoea with great loss of blood, bleeding from gums, noma, fall of upper incisors. Peripheral blood examined : two Leishman-Donovan bodies in a large mononuclear, well-marked large mononuclear increase. Died about one month after. No post mortem or puncture of spleen after death allowed. 2. Girl, 44 years, seen in July, 1909. Very scanty notes taken at the time. Died in January, 1910, after an illness of about fourteen months. Two weeks before death a swelling of the left cheek and a very foul condition of the mouth foreboded 40 the very common final complication, noma. The disease had started with spells of fever with very high temperature of a remittent type, then anaemia, great pallor of the integuments, enlargement of the spleen, intermittent attacks of diarrhoea, oedema of the extremities followed. Liver moderately enlarged, lymphatic glands not affected. No other cases in the same family. No dogs kept. Smears and sections from spleen post mortem: smears were literally studded with Leishman- Donovan bodies, but the parasites were not so abundant in the sections. 3. Girl, 34 years, seen in October, 1909. Had measles in April, 1908. About four months ago had fever for twenty days, no high temperatures, no regular type. She gradually became anaemic and lost flesh. Now her skin is of an earthy pallor, marked muscular atrophy, no oedema, no haemorrhages, the appetite very poor, is at times abnormal, has diarrhoea every now and then, no blood with stools. Spleen is enlarged down to two fingers’ breadth below the navel. Anterior border of liver is two fingers’ breadth below costal border on mammillary line Glands not enlarged. No noma. Died about three months after. 4. Boy, 25 months, seen in October, 1909. Ill since six months. Mother did not notice any fever at first; two months after he had a spell of dysenteric diarrhoea with loss of blood. Now he is very pale and has lost flesh, very fretful, glands not enlarged, no oedema, fever of an irregular type. Spleen reaches down to three fingers’ breadth below navel, no marked increase of liver. Mother stated that she had had the same disease when a child. Case has not been seen again. 5. Boy, 6 years, born in Malta of English parents, seen in October, 1909. Ill since one year. Spleen began to increase in size about five months ago. Extreme anaemia and wasting, spleen enormous, spells of fever every now and then, appetite good, no purpura, no bleeding from gums, no blood with stools, one or two vibices on the back. Later on had several purpuric eruptions, bleeding from gums, profuse diarrhoea. The doctor attending noticed an almost complete retraction of the spleen a few days before the end and the diarrhoea ceased, but there was no amelioration of the other symptoms. The child died of exhaustion in April, 1gto. 6. Girl, 3 years, seen in November, 1909. Ill since one year. Moderate anaemia, no marked wasting, no oedema, has a temperature every now and then, appetite good. Spleen reaches to just below navel. Has had purpura and dysenteric attacks but no bronchial phenomena. Glands not enlarged. Blood smears from ear: no parasites. Child lost sight of. Doctor attending stated to have observed a great improvement following a course of injections of methyl arsenate of iron. 7. Girl, 6 years, seen in December, 1909. III since one year, after sustaining a fractured clavicle. Earthy colour, extremely anaemic; very extensive gangrene of gums, both lips, nose and cheeks. Great emaciation. Spleen, but for the enlarged liver which reaches to about four fingers’ breadth below costal margin, occupies the whole abdomen; has dysenteric diarrhoea; appetite fairly good. Died four days after. No examination of the blood or spleen puncture allowed. A sister died from the same disease when two years old: had noma followed by same . extensive gangrene. An elder brother, who is stated also to have had the disease when six years old, is now quite well. An aunt and a cousin on the mother’s side are supposed to have died of the same complaint. 8. Boy, 3 years, seen in January, 1910. II] since eighteen months, spells of fever with profuse perspiration, intercurrent attacks of diarrhoea and bronchitis, purpura, epistaxis, bleeding from gums, extreme pallor and emaciation. Face has a very old and sad look. The spleen free, firm, notchy, easily movable, not painful, reaches down to the inguinal fold ; liver has grown to four fingers’ breadth below the costal margin. Died suddenly in February. Two dogs had been in the house for a long time. A fragment of spleen obtained post mortem: Leishman-Donovan bodies in smears and sections. 41 g. Girl, 5 years, seen in January, 1910. Ill since November, 1909. Had whooping cough a year ago. The disease began with spells of fever and anaemia, then swelling of the spleen; this organ now reaches to inguinal fold; liver is little enlarged. She is very pale and very sad, has diarrhoea, no blood with stools, no epistaxis, no bleeding from gums, no purpura, feet are oedematous. A cousin on mother’s side died from the same complaint when eighteen months old. Seen again in April, no change; administration of 77. semegae suggested. Seen again in October : very marked improvement, the spleen has receded to one finger’s breadth below the costal margin, the child has recovered her gaiety, has a healthy colour and good appetite. One dog in house. 10. Boy, 34 years, seen in January, 1910. Ill since seven months, after a fright, as stated. Spells of fever, loss of appetite, great pallor and emaciation, oedema of feet, hands and eyelids, great sadness, dysenteric diarrhoea and bronchial catarrh. The splenic tumour fills the left inferior and part of the right inferior quadrant ; the liver reaches down to a finger’s breadth below costal margin. Seen again in February, the spleen maintains the same curved configuration but does not reach quite down to the ilium, the liver is also smaller, the diarrhoea persists, general condition worse. Peripheral blood examined, no parasites. Died in November, 1g10. A brother died of the same disease in June, 1907, when two years old, after an illness of fourteen months. No dogs. 11. Boy, 3 years. He is one of six, of which the eldest is 14 years old and the youngest 15 months. No other children have had the disease. III since fifteen months. It was only after three months of irregular fever that the enlarged spleen began to attract attention. Iron preparations were prescribed. After three months’ treatment the splenic tumour was so reduced in size that the mother believed him cured. He then contracted whooping-cough and the spleen started growing again. About the time this patient sickened two other children living near were suffering from splenic anaemia, both developed cancrum oris and died. A dog was owned by these people. I saw the child in March, 1o10, three days before death: great pallor and emaciation, oedema of feet and eyelids, spleen reaches down to one finger’s breadth from iliac crest, liver moderately enlarged, diarrhoea, a black stool occasionally (melaena?). Cancrum oris started opposite right upper premolars, now mortification of right cheek, exposure of buccal cavity; no epistaxis, no purpura. Post mortem: Cancrum oris, extensive destruction of right cheek and gums, ioss of teeth. Lungs: right, caseous lobular pneumonia; left, emphysema. Heart: all cavities dilated. Liver: enlarged, consistency increased. Spleen : weight 8} ounces, about three times normal size, rounded margins, many notches, very firm, capsule thickened and adherent; the cut surface greyish towards the middle, brownish-red at periphery, malpighian corpuscles prominent. Mesenteric glands enlarged, not caseous, the other glands normal in size and appearance, bone marrow body of femur reddish and swollen. Smears and sections of spleen and liver show a fair number of Leishman Donovan bodies. Smears from mesenteric glands, a few parasites present. Smears from bone marrow, owing to defective fixation, could not be stained successfully. 12. Girl, 4 years, seen in March, 1910. Has had fever and diarrhoea since three months, moderate emaciation, skin and mucous membranes anaemic, loss of appetite, the child is listless and sad. Diarrhoea every now and then, with tenesmi and passage of mucus, but no blood. Splenic tumour rather narrow, it does not reach below navel, easily movable, not painful; liver cannot be felt on palpation, lymphatic glands normal in size. Seen again in December. Abdomen greatly distended as the splenic tumour has grown down to the iliac crest and, to the right, under the linea alba, the liver is two and a half fingers’ breadth below the costal margin, cervical glands are larger than normal, eyelids are oedematous, respiration is much hindered, hollow cough, fever, no haemorrhages. December 3rd, 1910.—Peripheral blood examined: no parasites. Relative leucocytic values : Large mononuclear, 36:2; small mononuclear, 29°4; transitional, 7°0; polynuclear, 26-2; eosinophile, 1°2. 42 13. Girl, 3 years. One of a large family, but no other member ever had the disease. A child next door died of splenic anaemia in 1902. Patient has been ill since December, 1909. In January, 1g10, had a slight attack of diarrhoea with tenesmi; after three or four weeks of fever, attended with profuse perspiration, mother noticed the splenic tumour just below costal margin. Seen by me in March : no marked emaciation, moderate anaemia, no oedema, no purpura, appetite fair, no great depression. Splenic tumour reaches down to three fingers’ breadth below costal margin, liver is just palpable, no diarrhoea. Splenic puncture with an ordinary hypodermic needle, usual antiseptic precautions: Leishman-Donovan bodies present in a fairly large number. Treatment with senega preparations suggested. Marked improvement during the next two months; the case, however, ended fatally in September. 14. Boy, 21 months. Ill since August, 1g09. Two cousins on mother’s side of about the same age died from same disease after a year’s illness. In August, 1909, after a fright, the boy started having a temperature at irregular intervals, with perspiration; several attacks of dysenteric diarrhoea, slight epistaxis and crops of purpura followed. Seen in March, 1910: great pallor of skin and mucous membranes, loss of flesh, profuse salivation, initial mortification of gums at the base of left premolars and slight bleeding, oedema of feet and eyelids. Spleen enlarged down to iliac crest, moderately hard, freely movable, not painful, very marked notches, liver just palpable. Died in April. 15. Boy, 19 months, seen in March, 1910. No history of splenic anaemia in the family—a large one. Ill since 44 months; spells of fever with perspiration. No diarrhoea, no bronchial catarrh, no epistaxis. Appetite good but perverted, is always picking and chewing stones. On examination : moderate anaemia, no great loss of flesh, gums normal, splenic tumour reaches down to iliac crest and to the right, 14 inches beyond linea alba, liver can be felt two fingers’ breadth below costal border. Splenic puncture : Leishman-Donovan bodies present in all smears in moderate numbers. Treatment: tinctura senegae in large doses. Seen again in April: extreme pallor, slight bleeding from gums, purpura. Died the same month. 16. Boy, 18 months, seen in April, 1910. There is a history of short spells of fever before mother noticed that spleen was enlarged, five months ago. Since then has had diarrhoea off and on, slight bleeding from gums, a few spots of purpura, no oedema. Now skin and mucous membranes anaemic, loss of flesh, appetite fairly good, spleen reaches down to iliac crest and laterally almost to umbilicus, caput medusae, liver one finger’s breadth below costal margin, lymphatic glands not enlarged. Splenic puncture: no parasites met with. Died in August. 17. Boy, 2 years. Weakly child from birth. Seen in April. About two months before had enteritis with tenesmi, passage of mucus but no blood, no haemorrhages. Cancrum oris started three weeks before I saw him, when a small slough formed in the gums over the upper incisors. Mother never noticed any enlargement of spleen. Now great pallor and emaciation, diarrhoea, prolapsus ani, mortification of upper lips, nose, cheeks and lower eyelids. Spleen and liver can hardly be felt on palpation, but abdomen is very distended. Died 2oth April, 1910. Post mortem, partial : spleen exceeds costal border by about two fingers’ breadth. Spleen smears swarming with Leishman-Donovan bodies. About a year ago they had a small dog in the house. Eldest sister died five years ago; two other boys and a baby, of whom the former are older than patient, all alive. Eldest sister was ill for one year, and presented the following symptoms: progressive anaemia and emaciation, fever, attacks of diarrhoea with passage of mucus and prolapsus ani, but no enlargement of spleen was noticed by mother. Then gums in connection with lower left molars underwent a process of mortification which extended to cheek, sloughing through. At that time they also kept a dog different from one mentioned above, 43 18. Girl, 25 years. Seen in May, 1g1o. III since five months: Anaemia, emaciation, loss of appetite, diarrhoea with passage of mucus and tenesmi. Now great dejection, bronchitis, no oedema, splenic tumour reaches to about four fingers’ breadth below costal margin, liver enlarged but to a less extent, lymphatic glands normal. Died August, 1910. 19. Boy, 15 months. Not seen during life. Post mortem, twenty-four hours after death, 2nd June, 1910 : extreme anaemia, mucous membranes bleached, no great emaciation, spots of purpura, oedema of lower limbs, liver very large especially left lobe, splenic tumour reaches toabout two fingers’ breadth from iliac crest, and is pushed to the left by the enlarged liver, cancrum oris with loss of upper incisors, mortification of gums, upper lip, left cheek, and nose up to lower eyelids on both sides, lymphatic glands normal. Spleen: 5 inches by 3 inches, weight 6 ounces, perisplenitis, patches of infarction, free edges rounded, deep notches, firm but not hard. Liver: 7 inches by 4} inches, weight 144 ounces, uniform yellowish white colour, on section very anaemic, dry, mottled appearance. Abdominal cavity contains a small amount of clear yellowish fluid. Mesenteric glands colourless, normal size. Lungs very anaemic, otherwise normal. Heart flaccid and anaemic, pericardium contains a moderate quantity of clear transparent fluid. Smears and sections from spleen, liver and kidneys contain Leishman-Donovan bodies, numerous in the spleen, very few in the kidneys. 20. Girl, 2 years. II] since April, 1910. At first fever of slow type lasting two weeks. In September the child, who had acquired a sickly hue and lost flesh, started again having a temperature, and by the middle of November the spleen was so enlarged as to be easily palpable. Had no diarrhoea, appetite maintained, no petechiae, no epistaxis, slight bleeding from gums, no oedema. She is the fifth child in a family of six, all in good health; but a cousin on the mother’s side died of the disease. No dogs kept. Seen on the 25th of November: very pale and emaciated, no oedema, no purpura, has a hollow cough. Spleen comes down to the level of navel, liver is not palpable. Abscess the size of a large walnut just behind angle of right mandible, gums normal, diarrhoea with tenesmi and passage of blood-tinged mucus. Spleen puncture : Leishman-Donovan bodies in large amount, mostly free, some in large mononuclears, others in groups of 8 to 11. 21. Girl, 25 years. Il] since three months (?). Seen in December, 1910. Great anaemia and emaciation, rise of temperature at irregular intervals, diarrhoea with tenesmi but no blood, cancrum oris starting over first left upper premolar, cheeks swollen hard and tender, has had no haemorrhages, no oedema, accessible lymphatic glands normal, appetite maintained. Spleen freely movable and painless, occupies upper and lower left quadrant, the liver reaches down two and a half fingers’ breadth below costal margin. P. is the youngest of five, of which two died when quite small, eldest two are living and in good health. A dog kept up to ten months ago. Splenic punctures : Leishman-Donovan bodies present in fairly large numbers. For the observation of these cases I am indebted to the kindness of medical colleagues practising in different parts of the Island, especially Dr. Cannataci, Dr. Wirth, and the staff of the Central Hospital. The symptomatology, the age of the patients, the almost constantly fatal termination, all point to a common morbid condition. It is likewise justifiable to infer that the majority of deaths catalogued under the different names referred to before, more especially if belonging to a certain age period, are instances of one and the same disease. 44 The question now arises whether all the deaths due to this disease are caused by Leishmania infection. Up to the time of writing* Leishmania infantum has been found in nine out of ten cases by examination of the spleen and other organs, and in one out of three cases in which films of peripheral blood were stained. These facts do not as yet justify generalisation, the more so as no case of infantile leishmaniasis should be counted as such unless the clinical diagnosis be supported by the demonstration of the specific protozoa; but they go very far to show that the bulk of deaths under five certified as due to leucocythaemia, splenic leukaemia, pseudo-leukaemia and splenitis are cases of anaemia infantum a letshmania (G. Pianese, 1905), or infantile kala-azar (C. Nicolle, 1908). The conditions I have found associated with the disease will now be reviewed. The disease is not notifiable, hence all considerations regarding its incidence are based on the deaths imputable to it. Having regard to its fatality, the deaths must fall very little short of the number of attacks. Locality. During the ten years, 1899-1908, 686 deaths under five were registered in Malta and 58 in Gozo. In order to form an idea of the prevalence of the disease in the various localities the population under five for Malta and Gozo and for the different populated centres in Malta, as estimated in the last census, 1901, have been divided into the number of deaths for the said decennium and the results multiplied by 100. The figures obtained may be taken to represent a sort of endemic index expressing with some degree of approximation the intensity of the disease in the different * The following are some notes kindly given me by Captain W. L. Baker, R.A.M.C., of a case under his care :— Male child, aged 1g months. First seen end of June, 1910. Spleen then enlarged to umbilicus. Blood Count ... R.C. 4,000,000 per c.cm. W.C. 4,400 os Hgb. Index 25 per cent. Spleen became more enlarged and child developed diarrhoea with passage of blood, small haemorrhages also occurred in skin of limbs and trunk. Anaemia increased, and in the middle of August the count was :— R.C. 2,050,000 per c.cm. W.C. 3,000 5 Hgb. Index 20 per cent. Before death, which occurred early in September, spleen retracted two fingers’ breadth above umbilicus. Leishmania sp. found post-mortem in spleen in enormous numbers, and in lesser numbers in liver. places. 45 Populations under five, deaths and indices have been tabulated as follows :— TABLE I Persons under 5. Deaths, Locality Census 1901 1899-1908 Endemic index | FB 3 aa eae es aet OE 8! se Malta ... 19,684 686 34 Gozo . 2,256 58 2°5 Malta— Valletta 25295 40 1-7 Floriana 559 4 o'7 Senglea 914 fe) be) Cospicua 1,475 43 2.9 Vittoriosa ... 693 14 2:0 Calcara 128 17 132 Zabbas : 720 24 a-3 Tarxien and Paola 576 40 6:9 Zeitun and Marsascirocco 908 55 6:0 Asciak 217 20 9:2 Luca 335 13 38 Gudia 117 6 51 Chircop 82 9 I0'9 Micabiba 158 12 7°5 Safi ... 53 4 7°5 Zurrico 452 38 8-4 Crendi : ne 192 17 8:8 Misida and Pieta ... 539 21 378 Sliema and St. Julians 1,415 39 2-7 Hamrun 1,394 40 27 Birchircara ... 1,057 49 46 Curmi 1,193 22 18 Zebbug 624 20 372 Siggieui... 395 32 8-1 Balzan Lia and Attard 464 16 3°4 Naxaro 414 6 I°4 Gargur 170 I O'5 Musta Fe 6 635 29 4°5 Imgiar and St. Paul’s Bay 117 5 4:2 Melleha_... 8 372 2 O'5 Rabato and Dingli 1,007 36 3°5 Reference to Table 1 will show that the disease prevails in Malta more than in Gozo, and that the rural population, on the whole, is more heavily affected than the urban, the east of the Island more than the west, with an intermediate zone exhibiting intermediate intensity. Endemicity is lowest in Gargur, Melleha, Floriana and Senglea; Naxaro, Valletta and Curmi come next; whilst Calcara represents the highest. Zeitun, Tarxien, Asciak, Gudia, Safi, Micabiba, Chircop, Crendi and Zurrico, a group of villages to the 46 east of a line passing along the greater axis of the Island, and at no great distance one from the other, appear to suffer heavily, their indices varying from 6 to 10°9. One fact stands out: the low endemicity in the towns and the comparatively moderate endemicity in the suburban areas. To what extent this difference is attributable to certain conditions found to be more closely connected with our rural populations it would be rash to say at present. But the disease is such that less personal and domestic cleanliness, worse housing conditions, more frequent excremental pollution of soil and water, closer and more indiscriminate contact with domestic animals may very well help to spread. Analysis of deaths, besides showing the prevalence of the disease to vary in the different populated centres, furnishes data for stating that the influence of locality is still more selective. Endemicity, in fact, is often found to be restricted to, or more intense in, some neighbourhoods or streets in preference to others. To a certain extent this may be accidental. But given the very protracted course of the disease, when the deaths do not happen to be separated by a lapse of several years, inference is justifiable that the specific virus has been conveyed from one house to the other by some common carrier. Allowing for changes of residence, which are not frequent in the villages, bringing together persons that were infected in different, and parting those that were infected in, the same streets, I believe the following graphs to be of interest. The broad lines represent roadways between blocks of buildings, the dots stand for houses from which deaths were registered, the figures in italics indicate the number of the houses, the others the year in which death occurred. Age and sex. The total deaths under 5 for the period 1899-1908 were made up of 392 males and 352 females. Of 41 deaths at ages over 5, 16 were between 5 and Io years of age. wn 1904 47 1902 * ® 26 6 19OI 1908 16 © 1907 4 1899 1899 J J T5 I9O0I 48 9 1907 98 RO Se ees 8 8 8 ssf) 23 15 1904 1906 1903 49 10 1905 . : e be r16 3 190 e 3 1903 903 I9OI II =e e 1907 code 1906 % - ; co) . G @ 6 ‘ i ae 1904 1905 904 2 1907 1907 Be 17 A ® 14 15 CHURCH ) . 9 IZ 1900 1900 50 In the succeeding table deaths have been grouped according to sex and age. (Table 2.) Deaths under I appear to be equally distributed; but there is a distinct predominance of males over females at age group I to 2, which is responsible for nearly all the excess observed in the total males over females. Again, age-groups I to 2 contribute almost half the total deaths, 328, while the age-groups immediately preceding and following these account between them for 252 deaths. Owing to the protracted course of the disease, deaths recorded at ages below six months cannot be counted as caused by the disease unless it be assumed that this may prove fatal in a comparatively short time. As yet no such instances have been met with by me. Ponos, however, a disease endemic in the Greek islands of Spetsae and Hydra identical with ‘marda tal biccia,’ both as to its symptomatology and age of persons attacked, may prove fatal in one or two months. Social circumstances are not specially restrictive of the disease, as cases do occur in families of well-to-do people, where the usual conditions associated with poverty are absent; its prevalence, however, appears to be more extensive among the children of the lower classes. Children born of English or Italian parents are not immune. Recurrence of the disease in the same family and amongst velatives. Investigation has shown instances of brothers and sisters or first cousins dying of the disease to be not infrequent. Besides the cases that have come under my observation, I have been able to trace several others. These do not represent all that could be collected; but inquiry over a period reaching sometimes ten or twelve years back is for obvious reasons not easy, the more so when one has to overcome a not unnatural reticence founded on the belief that a sort of taint attaches to the disease. The view maintained by some practitioners that ‘marda tal biccia’ is a_ hereditary complaint is based on its aptitude to recur in two or more members of the same family. This standpoint is untenable both as regards direct transmission or transmission of proclivity if the following facts be duly considered, viz.: the special age incidence, the almost inexorably fatal termination of the disease, the healthiness of parents whose children are attacked, and of the ops 1b sivak § TAO gS $e $z 989 +1 sivak + oS 6z 1% sievak £ bhi sivak Z ZI reak 1 sdnory ay oo of °8 qeok I JepuqQ gol oS gS syquour g ayy Surunp payijzeo Ajiepluns syqep Jo Joquinu osye ‘go61-66g1 potsod ‘sratuayds ‘vrwarynajopnasd ‘eruaeur stuayds ‘ermaeynay oruazds ‘erwoeryyAd09na] Woy syVap Jo JOqUINU ayy LIE Jo puLysy ay) Joy SuLMoYS—vz aIa¥ L fz rz ZI syjuou £ xaS soyeula J soe] saTeure J sore | jens aoe Aqyesor] "OZOH JO purysy ay3 10g potsad oures ay} JO¥ saxas yIoq ur sdnosZ ase pesvaas ur puv § sapun Ayyedouards 52 brothers and sisters of the children attacked who very often are members of a large family. Instances of recurrence in the same family and amongst cousins are here appended, showing sex, age at death, year and month in which they died. (Table 3.) In Groups 1 to 12 and 18 the patient died before his or her sister or brother were born, in some cases several months intervening between the two events. The disease, therefore, cannot have been transmitted by direct contact. As it happens, belief in the communicability of ‘marda tal biccia’ is so rooted in the mind of the people that all articles of clothing and bedding used by the little patients are destroyed. Transmission by fomites is thus hindered to a considerable extent. Hence the existence of an intermediate parasite host becomes extremely probable. The sphere of action of an animal host would extend to members of different families in so far as their connections are more intimate and frequent. Generally speaking this is true of persons related by marriage and of their children. Instances of the disease among first cousins can thus be accounted for. 1 The specific cause of ‘marda tal biccia’ is a protozoon of the genus Lezshmania. The parasites are morphologically identical with Leishmania donovani. Described first by G. Pianese, in 1905, in the splenic tissue from some cases of infantile splenic anaemia, they were observed in three cases of infantile splenomegaly in Tunis by C. Nicolle and E. Cassuto, in 1908, of which the former succeeded in cultivating the parasite and named it Lezshmania infantum. Since then many similar observations have been made by Gabbi, Basile, Jemma, and Feletti in Southern Italy and Sicily; Sluka in Vienna; the writer in Malta* ; Alvarez in Lisbon. Infantile leishmaniasis is found to have a daily widening endemicity. In common with other observers, the writer has found the Leishman bodies in the spleen, liver, kidneys and mesenteric glands, and once in films of peripheral blood. As the morphology and staining reactions of the parasite are well known, any mention here would be superfluous. Splenic puncture zuztva vitam was performed in * Kala Azar Infantile 4 Malte. Note préliminaire. Archives de 1’Institut Pasteur de Tunis. II. 1g10. 53 TaBLE 3—BRoTHERS AND SISTERS Io. Il. 13. 14. 15. 17. 18. 19. 20. Sex, and age at death oP Ps-2. male fo: M.P., 6/12, female . R.C., 1 8/12, female A.C., 1 1/12, male - E.P., 1 9/12, female F.P., 10/12, female eye sIVi-. 3) anale N.M., 1 4/12, male 2 C-C.,,3, female A.C., 2, male . C.V., 14, female A.V., 1 3/12, female a .CG. 1, sale N.G., 1, female . A.P., 24, male C.P., 14, male . A.X., 1 8/12, male E.X., 14, male N.A., 24, male N.A., 2 4/12, male M.C., 3, female R.C., 2 1/12, female Eez.1Ds, 25;male S.D., 1, female G.A., 2 3/12, male C.A., 1 2/12, male R.A., 13, female P.C., 2 2/12, male S.C., 4, female M.C., 9/12, female P.M., 34, male C.M., 24, female ... . A.M., 3, male C.M., 1 10/12, male M.F., 14, female . G.F., 1, male A.C., 1 7/12, female R.C., 1 4/12, female C.B., 1 8/12, female G.B., 3, female S.S., 3, male E.S., 2, female Year and month of death ...| Died March, 1904 ... », November, 1904 »» May, 1904 35 July, 1905 »» September, 1903 »» January, 1907 » March, 1903 ... March, 1906 ... » April, 1903 5, August, 1907... » August, gor... », November, 1907 », October, 1902 » February, 1905 March, 1902 ... >> April, 1904 55 January, 1903 3» December, 1908 3, December, 1899 »» May, 1904 5» June, 1900 3, November, 1902 », October, 1906 » May, 1908 5, June, 1g00 ” July, IgoI » October, 1903 »» May, 1904 », November, 1907 >» April, 1908 “- October, 1902 »» April, 1904 » July, 1907 », December, 1907 55 October, 1gor »» February, 1go2 » March, 1904 ... jypeearch, 1908)... 5, September, 1899 5) June, 1902 5, November, 1904 »» May, 1905 A] ean Residence at time of death Same house Different houses Same house Same street, different number Same house 21. n N 54 TaBLe 3—continued.—First Cousins Sex and age at death S.B., 1 8/12, male S.B., 5, male . C.M., 14, female ... G.M.M., 2, male .. 2? Year and month of death .| Died February, 1908 September, 1908 January, 1902 July, 1907 «if } aly Residence at time of death Different houses 23. C.F., 1 10/12, female 3» October, 1908 ” (Cousin to Na. 4) 24. A.C., 64, male », May, 1903 ...| | Same street, N.C., 1.7/12, male » February, 1903 ...|) different number A.C., 1 4/12, male 3, December, 1903 ...| Different street 25. A.G., 3, male : » February, 1908 .| Different houses (Cousin to No. 5) 26. C.V.,10/12, female »» May, 1905 “F (Cousin to No. 6) five cases* : no untoward results were observed. The examination of the contents of blisters raised by vessication resorted to in two clinically typical cases of the disease proved negative. In several cases material for examination was available twenty-four hours or more after death, but the appearance of the Leishman bodies was still characteristic, only they were a little smaller than those obtained during life and their cytoplasm stained badly or not at all. The best specimens are obtained by splenic puncture zutra vitam. The free parasites in the same film vary somewhat in size and shape, elongated and round forms are met with side by side; some have typical chromatin masses, in others the blepharoplast is punctiform, others, again, show the nucleus only. Forms are also met with containing two large chromatin masses, or nuclei, with or without a blepharoplast. The writer found 7 out of 53 stray dogs examined post mortem in April and May, 1910, infected with Lezshmania, sp.; 11 dogs seen Some dogs were heavily infected, others less so, the parasites being always more numerous in the spleen than The bone marrow was not examined. Almost all the in September were free. in the liver. * In March, 1911, another. case—a boy, 2 years—was diagnosed by splenic puncture. 55 infected dogs were small mongrels, some were mangy and extremely emaciated, one had chronic sores on the ischia and suppuration of the conjunctivae. A few ticks, of which some were gravid females off an infected dog, were dissected and examined with negative result. Only in a few instances dogs have been found associated with human leishmaniasis, on the whole less frequently than expected. Until it be known how the virus is eliminated from the body of a naturally infected dog, and whether it may be withdrawn from its blood by blood-sucking insects, the results of my enquiries in this direction cannot minimise the importance of this animal as a probable factor in the transmission of the disease. If the excreta of an infected dog are able to carry infection or represent the means by which the parasite is dispersed about in order to undergo some as yet unknown developmental cycle, the presence of a diseased dog in a given street or neighbourhood is sufficient to explain the endemicity of ‘marda tal biccia’ in such street or neighbourhood. In the light of this hypothesis the special incidence of the disease at certain ages below five, and its preference for the children of the lower classes are easy to explain. By far the largest number of deaths occur between the 12th and 24th month of life, the next heaviest mortality is registered at ages between 24 and 30 months, the next again between the 6th and 12th months. It is not inconsistent with the variable duration of the disease for infection to occur when the child, having manifested more or less precociously a certain desire or ability to use its limbs, is put down to crawl. As long as the child is unable to do so the chances of infection appear to be very small. The families of the poorer classes, as a rule, live in the ground-floor, in the front room by preference, where they get more light and air; more often than not they have no other accommodation. The children crawl about through the doorway to the street. This ground they hold in common with the dog, that trots from door to door at its leisure. If the dog is a reservoir of the virus, its habits and the habits of children are so fitted that infection by ingestion or through skin abrasions is bound to occur. The scope of this paper is to put on record that ‘ marda tal biccia’ and anaemia infantum a leishmania, or infantile kala azar, are 56 one and the same disease, and to contribute to the study of some of the conditions associated with it. As a specific parasitic complaint ‘marda tal biccia’ becomes ipso facto preventable. The ease with which dogs contract experimental leishmaniosis, and the presence of infected dogs wherever infantile leishmaniosis has been shown to exist, make it extremely probable that the dog is a very important factor in the propagation and continued existence of the disease. The exact way of transmission is occupying the attention of several observers. Whether the dog be the only channel of infection, with or without the mediation of insects, or whether the disease be also contracted by one human being from another without the intervention of a lower animal, it is hoped that the epidemiology of the disease may be soon cleared up so that prophylactic measures may be applied on sound scientific lines. 57 I—A RESEARCH INTO THE PRODUC- TION, LIFE AND DEATH OF.CRESCENTS PN MARIGNANYT “TERTIAN’MALCARTA, IN TREATED AND UNTREATED CASES, BY, AN~ ENUMERATIVE METHOD BY DAVID THOMSON, M.B., CH.B. (EDIN.), D.P.H. (CAMB.) (Received for publication 23 February, 1911) PREFATORY NOTE. This research has been carried on in the Tropical Ward of the Royal Southern Hospital, Liverpool, under the direction of Major Ronald Ross, C.B., F.R.S., and is a continuation of the research described in a former paper (Ross and Thomson [1910]). The funds were supplied by the Advisory Committee of the Colonial Office. The work has been facilitated by a new instrument, which enables one to estimate the number of parasites, leucocytes, etc., in a given volume of blood by a method based on Ross’s ‘ Thick Film Process’ [1903]. A following paper will describe this instrument and the method of its use. INTRODUCTION Knowledge regarding ‘Crescents,’ or the sexual forms of the malignant tertian malarial parasite (Plasmodium falciparum), is of considerable importance owing to the fact that mosquitos are infected by them, and thereby transmit the disease from man to man. As is well known, there are three distinct stages in the life history of the malarial parasite, namely (1) the stage of asexual parasites (fever forms); (2) the stage of sexual parasites or gametes ; and (3) the stage of the parasite in mosquitos. All these stages are essential for the spread of malaria, so that by dealing successfully with any one stage the disease can no longer be propagated, and must therefore dwindle and die. 58 It is, however, the second stage (sexual stage) of the parasite that I wish to consider. Less is known concerning it than of the first and second periods. No one can demonstrate how the sexual forms are produced, nor how long they live; and no effective method of killing them has been found. Research regarding this obscure stage is therefore necessary, and of great importance. When we know how to destroy the sexual malarial parasites, or how to prevent their production, we will have another powerful weapon whereby we can exterminate the disease. In this article I shall call the sexual parasites ‘crescents,’ as I have dealt only with cases of P. falciparum. The accompanying table has been compiled from the cases studied by the enumerative method used in this research. Some of the results have already been mentioned in the previous paper referred to above. THE PRODUCTION OF CRESCENTS From the figures given regarding the forty-two cases of P. falciparum studied, it is clearly noticeable that the production of crescents is extremely irregular. Certain paroxysms of fever result in a numerous brood of crescents even up to 7,000 per c.mm. of the patient’s blood. Other paroxysms produce very few or none at all. Thirty-one, or 74 per cent. of the cases, showed crescents at some time during the period of examination. Eleven, or 20 per cent., showed no crescents at any time while under observation. A. HOw ARE CRESCENTS PRODUCED AND WHERE ARE THEY DEVELOPED? All malarial experts seem agreed that the crescents are developed from the ordinary asexual spores or merozoits of the parasite. Mannaberg [1894] stated his belief that they were produced from the conjugation of two asexual parasites within a red corpuscle. If this is so, then the more numerous these asexual forms are, the greater is the likelihood of two or more finding their way into a red cell, that is according to the theory of probability. In Case 13 where there were 300,000 asexual parasites per c.mm. of blood, many of the red cells contained more than one parasite. In Case 18 asexual parasites were few and difficult to find (1,860 per c.mm.), and no doubly infected corpuscles could be detected; yet 59 in the former case no crescents were produced, whereas in the latter, 286 crescents per c.mm. of blood appeared. Again, as shown in Table A, the cases with very numerous asexual parasites produced on the average fewer crescents than cases with much less numerous asexual parasites. These facts would appear to bring strong evidence against Mannaberg’s hypothesis. The following quotation is from Stephens and Christophers [1908] :—‘ The sexual cycle, it has been thought, commences in the blood when the conditions are unfavourable for the continuance of the asexual cycle, and, in fact, has been taken as a sign that the patient has already developed immunity against the fever-producing young parasites (spores). Thus it is well known that in malignant tertian the sexual forms, gametes or crescents, first appear a week to ten days after the first febrile attack. If this view be true, then it follows that the gametes develop from forms already present in the system, viz., the asexual forms, and possibly the divergence into sexual forms takes place from the youngest form of the parasite, i.e., the spore. But it is possible that the divergence takes place at a stage previous to the youngest form of the parasite, i.e., at a stage immediately preceding the entry of the sporozoits into the blood, so that we have from the first indifferent and sexual forms present, involving indeed the existence of three kinds of sporozoits. Sexual development has been supposed to proceed mainly in the internal organs, e.g., the bone marrow, but it is being gradually recognised that young forms of gametes are also found in the circulation.’ This research would appear to support the idea that the crescents are developed from the asexual spores when a certain amount of immunity has developed, but it seems to me that they do not come from special asexual spores, but that they arise merely owing to a transformation of an ordinary asexual spore into a sexual parasite. I will give evidence to show that the development of immunity is necessary for their production, and I fail to see why, if they do develop from special spores they cannot be produced at any time independently of immunity. There seems to be little doubt also that they develop chiefly in the internal organs, and when completely developed they appear suddenly in the peripheral blood ; for, although small undersized crescents are sometimes seen, yet their occurrence in the peripheral blood is rare. I have never seen 60 in the peripheral blood anything which could be considered as an intermediate stage between an asexual spore and a true crescent. B. WHEN ARE CRESCENTS PRODUCED? The accumulated evidence of the crescent cases studied seems to show that a period of ten days elapses between the appearance in the peripheral blood of the asexual spores, and the crescents which are produced from these spores. As a general rule the crescents appear in the peripheral blood on the fifth day after the attack of fever, and increase in number for four or five more days, so that they are most numerous on about the tenth day after the height of the fever. Those crescents appearing on the fifth day after the paroxysm correspond to asexual parasites existing in the blood five days previous to this paroxysm. Asexual parasites can exist in the blood in numbers as great as 2,000 and rarely 10,000 per c.mm. without producing any temperature reaction. They gradually increase in number by sporulation till they are numerous enough to cause a paroxysm of fever. The numbers may then fall spontaneously or by quinine treatment so that only one single paroxysm results. It is by the study of such single paroxysms that the time required for the appearance in the peripheral blood of the corresponding crescents can be best determined. In such cases the graphs representing the numbers of asexual parasites and crescents show a striking similarity, the points on the crescent graph occurring on the tenth day after the corresponding points on the graph of the asexual parasites. It is very difficult to demonstrate this with mathe- matical accuracy, and very frequent examinations of the blood require to be made. The chart of Case 20 shows the correspondence fairly well. A careful study of all the charts leads one to the conclusion that the corresponding points on the crescent curve occur about ten days after those of the asexual curve. This conclusion is strengthened by the chart of Case 38. In this case the numbers of leucocytes, crescents and asexual parasites were estimated several times daily for twenty-three days. This case is extremely interesting, as the patient had nine successive daily paroxysms of fever. Four paroxysms on the four days before admission, and five paroxysms on the next five days. Corresponding to these nine fever paroxysms or sporulations we 61 have nine outbursts of crescents into the peripheral circulation, each occurring on the tenth day after the corresponding fever paroxysm. The asexual parasites were rapidly destroyed by quinine after the ninth paroxysm of fever, and a corresponding diminution in the production of crescents is evident ten days later. It is stated in the above quotation from Stephens and Christophers that many have observed the appearance of crescents on the eighth to the tenth day after the first paroxysm of fever, but this delay is attributed to the development of immunity, whereas it is due to the fact that crescents take that time to develop from the asexual spores before they appear in the peripheral circulation. The following diagrammatic charts A and B represent the correspondence between asexual parasites and the crescents developed therefrom, where only one blood count is made per day. DIAGRAM A. (Single fever paroxysm.) PREWEN PALLET TTT | 22| oe 3 ra Wits <9 dine 36 2S 1 3 = hy See CUTE ee ie PV Pe ee C. WHY ARE CRESCENTS PRODUCED IN SOME CASES AND NOT IN OTHERS ? Crescents would seem to be developed from the asexual spores, due to a development of immunity towards the latter. When the asexual spores find that their environment is becoming unsuitable, they undergo a transformation into a sexual generation and thereby save themselves from destruction. In this new state they remain passive, waiting for their transference into a more suitable host. Schaudinn and other observers have stated that Te mera ture. <7 Ca. am. of Nawbers A Temperature. Bloed. 62 they have seen sexual gametes undergoing a change back into asexual spores by parthenogenesis. Although this has never been observed by workers in the Liverpool School of Tropical Medicine, yet in the light of the above theory it would seem quite possible that such a retransformation might take place, especially in cases where the acquired immunity had become less or disappeared. This phenomenon must, however, be very rare, as it would otherwise have been noticed more often. DIAGRAM B. (Showing tertian paroxysms with corresponding outbursts of crescents ten days later.) Pays [1 [2] 3/4 | slo [y|s |o [oly v2 [ra |e [rs]e [> [8-9 [20] [2e]2s] 2n]es] 26/27 [25 | ARIA TTI APM ar Te Cy Y Min The following evidence would seem to supply seven points in support of the statement that crescents are formed after the develop- ment of partial immunity. (1) The relationship between the number of asexual parasites and the number of crescents produced. Taking very acute cases, I find that out of eight paroxysms of fever caused by numbers of asexual parasites over 50,000 per c.mm. of blood, only three, or 37°5 per cent. resulted in crescent production. A total of 724,000 asexual parasites per c.mm. produced a total of 1,354 crescents per c.mm., giving a ratio of 535 asexual parasites to one crescent. Eleven subacute paroxysms had asexual parasites varying from 20,000 to 50,000 per c.mm. of blood; of these, seven, or 63°6 per cent., resulted in crescent formation. A total of 318,700 asexual 63 parasites per c.mm. produced a total of 3,952 crescents per c.mm. of blood, giving a ratio of 81 asexual parasites to one crescent. Twenty-six mild chronic cases had asexual parasites, varying from 1,100 to 20,000 per c.mm. of blood. Eighteen of these, or 69°25 per cent., resulted in crescent production. A total of 172,360 asexual parasites per c.mm. produced a total of 3,343 crescents per c.mm. of blood, giving a ratio of 52 asexual parasites to one crescent. The mild, chronic, and probably partially immune cases had therefore a crescent-producing power fully ten times greater than the very acute cases. (2) The duration of the disease in relation to the production of crescents. Sixteen paroxysms occurred during the first thirty days of the disease. Of these 43°7 per cent. produced crescents. The total average number of crescents was 1601 per c.mm. of blood. Twenty paroxysms occurred between the thirtieth and the sixtieth day of the disease. Of these 65 per cent. produced crescents, the total average number of crescents being 551 per c.mm. Sixteen paroxysms occurred after the sixtieth day of the disease. Twelve, or 75 per cent. of these produced crescents, and the total average number of crescents was 650 per c.mm. of blood. Thus it would appear that crescents are more likely to be produced in cases of long standing, where a certain amount of immunity has had time to develop. (3) Crescent production in cases which have had previous attacks of fever one or more years previously. Sixteen cases had had previous attacks of fever. Of these, 87 per cent. developed crescents during the period of observation. There were twenty-six cases which had no history of previous attacks; of these, only 46 per cent. produced crescents. It is reasonable to suppose that these cases, which had a history of previous attacks, were more immune than the primary cases. (4) The relationship between crescent production and the age of the patient. From the table it can be seen that 50 per cent. of the cases up to twenty years of age (average eighteen years) produced crescents, the average number being 130 per c.mm. of blood. 64 Cases between twenty and thirty years of age (average twenty- sIX years) gave an average of 526 crescents per c.mm., 74 per cent. of the paroxysms resulting in crescents. Cases between thirty and sixty-eight years of age (average forty- five years) gave an average of 1,018 crescents, 71 per cent. of the paroxysms producing crescents. There is apparently an increase in crescent-producing power in older patients. This might be attributed to a greater power in adults of developing immunity, as compared with the young growing patients. Many of the older patients, however, had been in the tropics for a long time, and had had previous attacks of fever. The young patients had not been long in malarial districts, and in most cases it was their first attack of malaria. The greater crescent-producing power in the older patients may therefore have been due to immunity developed from previous attacks. (5) The relationship between crescent production and the percentage of the patient’s haemoglobin. Nineteen paroxysms of fever, occurring chiefly in different cases where the haemoglobin during the next ten days was 75 per cent. and under, produced only an average of twenty-two crescents per c.mm. of blood. Of these paroxysms, 52 per cent. produced crescents. Twenty-seven paroxysms, where the haemoglobin during the next ten days was over 75 per cent., produced an average of 428 crescents per c.mm., and nineteen, or 70 per cent., of these paroxysms produced crescents. It would seem therefore that a low percentage of haemoglobin is not so favourable for crescent production as a fairly high percentage. This again might be explained by the supposition that immunity to the asexual parasites is more likely to be successfully developed in cases where the blood standard is fairly healthy. (6) Crescent production in relation to the size of the spleen. Twenty-six cases had palpable spleens. Of these, fifteen, or 75 per cent., produced crescents. In twenty-three cases the spleen could not be palpated. Twelve, or 52 per cent. of these produced crescents. ; 65 According to Ross [1910] the number of asexual parasites tends to vary inversely as the degree of splenomegaly, that is, the parasites tend to die out in persons with very large spleens. Again, N. F. Surveyor [1910] states that malignant malaria is more fatal in cases where the spleen is not enlarged, and less fatal in those with splenomegaly. These statements would seem to indicate that immunity to the disease increases pari passu with the size of the spleen; hence the increased crescent production where the spleen is enlarged. (7) Crescent production in relation to the number of leucocytes. The average number of leucocytes in the ten-day periods following paroxysms which produced no crescents was 7,284 per c.mm. of blood (56 per cent. mononuclears). After paroxysms producing up to 100 crescents per c.mm., the average number of leucocytes during the same period was 7,411 per c.mm. (52 per cent. mononuclears). While after paroxysms producing over 100 crescents per c.mm., the average number of leucocytes was 8,924 per c.mm. (53 per cent. total mononuclears). Again in thirteen cases, which produced no crescents at any time, the average number of leucocytes throughout was 8,646 per c.mm. (total mononuclears 55°9 per cent.), as compared with an average of 10,970 per c.mm. (total mononuclears 489 per cent.), in sixteen cases with numerous crescents throughout the period of examination. It would appear therefore, that greater numbers of crescents are produced in cases where the leucocytes are numerous. The leucocytes in malaria increase markedly in number, simultaneously with the quiescence of the disease. About one week after the last paroxysm of fever, the leucopenia (characteristic as a rule of the febrile period in malaria) disappears, and a leucocytosis takes its place, provided the fever does not return. Thus a high leucocyte count is characteristic of quiescent malaria and in post- . malarial conditions, and would appear to be coincident with periods of immunity. This increase in the number of peripheral blood leucocytes occurs after the fever abates, whether quinine has been given or not. Where quinine is given, it occurs earlier and remains permanent, because during the treatment no true relapse E 66 can occur. The leucocytes decrease in number previous to the onset of arelapse. The chart of Case 20 shows the fall in the number of leucocytes with the onset of a relapse, and later an increase in crescent production when the leucocyte count again becomes high. These facts would tend to show that a high leucocyte count and immunity are co-existent, the latter explaining the increase of crescents. (8) Crescent production in velation to the month of infection. We have not sufficient cases on record to make any reliable deductions. We can only state, that from West Africa, cases infected in all months of the year except June produced crescents, and again cases infected in every month, except May and July, showed no production of crescents. From this evidence there seems no reason to suspect that crescent production depends upon the month of infection. D. THE EFFECT OF QUININE ON CRESCENT PRODUCTION*. It would appear that quinine in doses of ten grains three times daily, given just before and during the paroxysm of fever, diminishes the subsequent formation of crescents. The cases showing the greatest numbers of crescents had little or no quinine for several days previous to the producing paroxysm, and little or no quinine during that paroxysm. Case 23 seems to show the good effects of quinine in this respect. In this case the first paroxysm of fever produced 852 crescents per c.mm. of blood, resulting from 50,000 asexual spores per c.mm. Twenty grains of quinine were given during this paroxysm, but none was given for several days before or after it. The next relapse where no quinine was given till the day after the paroxysm produced 468 crescents per c.mm., while the next paroxysm of this relapse produced 344 crescents per c.mm. from 54,000 fever forms per c.mm. During this last paroxysm and afterwards thirty grains of quinine was given daily. A subsequent relapse treated similarly with quinine gave a production of only four crescents per c.mm. from fever forms amounting to 16,000 per . c.mm. of blood. This case and others would seem to indicate that if quinine is given in doses of ten grains three times daily during * The various salts of quinine used were kindly supplied by Messrs. Burroughs, Wellcome & Co. 67 the fever paroxysm and afterwards, it helps much to prevent the formation of crescents. The destructive action of quinine in these doses on the asexual spores is so powerful and rapid that one is surprised at the subsequent appearance of even a few crescents. If quinine is withheld till one or two days after the fever paroxysm and then given in the above daily doses, the crescents may still appear in large numbers—vzde Cases 20, 22, etc. This shows that when once the crescents have commenced to develop, the quinine does not then prevent them from reaching maturity and appearing in the peripheral blood on the tenth day or thereabout. I would therefore conclude that quinine in large daily doses, given during and after the fever paroxysm, diminishes the crescent-producing power of that paroxysm, not by acting on the crescents themselves, but indirectly by destroying the asexual spores from which the crescents are produced. However, if quinine be given in smaller doses, say five grains daily, or ten to twenty grains irregularly, then instead of the crescent production becoming less, there is evidence to show that it may become even more prolific. Thus in Case 18, crescents became much more numerous after quinine was administered in daily doses of five grains. This case with such treatment showed a very high crescent-producing power, the ratio of asexual spores to crescents being as eight is to one approximately. It is quite reasonable to suppose that in such cases, quinine given in small doses destroys only some of the asexual spores, but enables the host to keep the disease under control, and to develop some resistance or immunity. In the consequence more crescents develop from the remaining parasites. Case 18 and others showed the presence of asexual parasites for many days during the administra- tion of quinine in doses of five grains daily. Quinine given continuously in daily doses of twenty to thirty grains, has never failed in our cases to reduce the crescents to numbers less than one per c.mm. of blood in a period not exceeding three weeks, vide chart of Case 49. This reduction of crescents by quinine has also been noted by Darling [1910]. E. THE EFFECT OF METHYLENE BLUE ON CRESCENTS. It would appear from the careful investigation of six cases treated alone with methylene blue, that this drug in doses of twelve grains daily, given by mouth (pill form), though not so potent in destroying 68 the asexual parasites, is yet more potent than quinine in preventing crescent formation. It would seem also to have some direct destructive effect on the crescents. It is good treatment, therefore, to give methylene blue along with quinine, especially where one cannot give large doses of the latter due to the idiosyncrasy of the patient. THE DURATION OF LIFE, AND THE DEATH OF CRESCENTS (a) There is evidence to show that the duration of life of a crescent cannot be more than twenty days. During the first ten days of this period they are developing somewhere, but not in the peripheral blood. They then appear in the peripheral blood, some- times small in size. The majority of them must perish in the peripheral blood in a very few days. This must be so, for if they lived for say four days or longer, then the summit of the crescent curve would not be a sharp point as it always is, especially when the numbers are great. (6) The appearance of the graph, representing the life and death of crescents in the peripheral blood. ‘The crescent curve has a definite formation. Where the number of crescents is estimated only once daily, it assumes more or less the appearance shown in the diagram C. DIAGRAM C. (Crescent curve, numbers estimated once daily.) This is the usual type of crescent curve obtained after a single isolated paroxysm of fever, where the number of crescents is estimated once daily. When no quinine is given, a single isolated paroxysm is rare, and the crescent curve will as a rule be quite Crceseents ~ / Pree Cu. ree. of flood Nawmober o 69 different, as in Cases 1, 14, 16, 18, 23, 24, etc. In these cases the number of crescents remains high for some days, the graph resembling a kind of plateau containing several sharp peaks, as in diagram D. D1iAGRAM D. (Crescent curve with plateau formation.) : 6 ° ‘\ * \ The explanation of this plateau is quite simple, for if no quinine is given the asexual parasites remain alive, even though there is no fever to indicate their presence, and keep on producing new crescents. The source of crescents is not cut off, so that the supply is replenished by new broods of crescents, appearing every day, or on alternate days, or irregularly, according as the fever or asexual sporulation occurs every day, on alternate days, or irregularly. The sharp peaks on the plateau of the curve show that although the crescents are dying rapidly, yet their numbers are replenished by fresh broods coming into the circulation. As pointed out by Ross and Thomson [1910], these peaks on the crescent curve often show a tertian tendency. In ne case is there a plateau formed when quinine has been given in doses of thirty grains daily ten days previous to the height of the crescent curve. If a plateau has formed and quinine is then administered in large doses, its effect will not be manifested for about ten days, because although it very quickly reduces the source of supply, yet those crescents which commenced to develop during the previous ten days are not affected, but continue to appear in the peripheral blood replenishing the loss. Thus quinine, as is clearly seen in Case 23, takes about ten days to destroy the plateau formation. Hence, though quinine makes the crescents disappear from the peripheral blood more quickly than they would otherwise Number of Cresecents Act Gy wm. of Clood 70 do without its administration, yet this effect is not due to any direct destructive action on the crescents themselves. It is due indirectly to the destruction of the asexual spores from which the crescents are developed. The length of time that crescents will remain in the peripheral blood therefore depends upon the persistence of the asexual parasites. If immunity develops so strongly that the asexual parasites almost disappear, or if they are destroyed by quinine, then the crescents also will disappear in due course. In cases where immunity remains, but is only sufficient to keep the number of asexual parasites in check, crescents may continue almost indefinitely. Crescents have been observed to continue in the peripheral blood for eight weeks, Surveyor [1910]. Case 18, where the asexual source of supply was not destroyed by quinine till late, had crescents for forty-four days, and probably longer than this, as they were present when the case first came under our observation. Sufficient has been said to point out the fallacies regarding the duration of life of crescents. I must, however, once more refer to the chart of Case 38. Here the number of crescents per c.mm. of blood was estimated several times daily. The crescent graph obtained shows the great importance of making numerous observations, for had the numbers been estimated only once a day, the daily variation in the number of crescents would not have been noticed. Here we have a pure quotidian case of fever, resulting in quotidian outbursts of crescents into the peripheral circulation, each crescent outburst corresponding to a sporulation of the asexual parasites occurring ten days before. It is noticeable that the quinine in doses of thirty grains daily did not appreciably diminish the numbers of crescents till the tenth day after its administration. The number of crescents then diminished, rapidly at first and afterwards more slowly, for nine more days. This would seem to indicate that the quinine quickly destroyed the majority of the parasites of the asexual source, the remainder dying more slowly. The curve also clearly shows that the crescents die very quickly in the peripheral blood stream; a very marked fall occurs each day, but this fall is compensated for by a fresh brood each day. It is clear that but for this compensation the crescents would only remain in the peripheral blood for a very few days. Again it will be observed that although asexual parasites could no 71 longer be detected in the blood after the third day of quinine, yet crescents continued to be present till the eighteenth day of quinine treatment. Thus those crescents found after thirteen days of quinine administration had either a life of five days in the peripheral blood, or else they were new crescents produced from surviving asexual spores, so few in number that they could not be detected. When quinine has been given in the above doses for a few days asexual parasites can no longer be found, but the fact that relapses occur (even when there are no crescents), shows that they were still present. They may exist in numbers below the detectable limit, or (?) as resisting forms in the internal organs, and it is possible the crescents found more than thirteen days after the administration of quinine come from these. In other cases, where the number of crescents was estimated several times daily, the graph obtained was much more irregular than in Case 38. In these, daily irregular variations took place, vide chart of case 49. This is easily explained, for in many cases of malignant tertian, sporulation is extremely irregular. It is very seldom that one gets so well a defined quotidian sporulation as in Case 38. In cases of malignant tertian therefore with irregular temperature indicating irregular sporulation, one would expect the crescent graph, as estimated from several counts daily, to be irregular also. The majority of our cases have shown this irregularity. The following diagrammatic chart will indicate the idea more clearly. DIAGRAM E. (Represents a pure tertian fever or sporulation.) Pays |e [2 [3 [els fe [> [5s [of ef] nf | | a] sr [ae| = [eden ze date HH Nuwbers Av Crim. i eal . Nile VE ALAAA IT 72 This chart represents the true relationship between crescents and the asexual spores in a pure case of malignant tertian fever. A case with an irregular fever, indicating irregular sporulations, would give an irregular crescent graph. These points, however, still require to be worked out more thoroughly. There is, however, one very constant law regarding the crescent graph, viz., that the curve representing the diminution or death rate of the crescents is always a parabolic line (vide curve shown in Diagram C). This shape of curve arises from the fact that they die off by a constant fraction, say one-half to one-fifth of their daily number. One might give two explanations of this law regarding their death rate. (1) That it is a case of the survival of the fit, a certain proportion dying day by day according to their varying powers of resistance. (2) That it depends upon the law of probability regarding their contact with leucocytes, by which they are ingested. The mono- nuclear leucocytes, especially the large forms, undoubtedly ingest crescents, either when alive or after their death, for in cases where only numerous crescents are present in the blood, many pigmented mononuclear leucocytes are to be found. It is quite reasonable to suppose that there may be some truth in these two hypotheses, but I think the true explanation is to be found by studying the curve of the asexual forms from which the cresents arise. It is clearly seen from the charts of Cases 17, 38, and others, that the curve representing the death rate of the asexual parasites 1s also a parabolic line, as shown diagrammatically in Chart A. The curve is the same, whether they die off spontaneously or under the influence of quinine. Now, when the producers of crescents show this death rate curve, and if the crescents produced have approximately all the same duration of life, then necessarily the curve of their death rate which will occur ten days later will assume the same form. Hence the peculiar form of the crescent curve depends probably in every respect upon the form of the curve of the asexual parasites. The form of the asexual parasite curve most probably depends in its turn upon (1) The law of the survival of the fit; (2) The law of probability of leucocyte contact and ingestion. The large mononuclears undoubtedly ingest the asexual parasites, especially the spores. When the spores are 73 numerous many will be ingested, but as they become fewer the chance of contact and ingestion by these leucocytes will become less. CONCLUSIONS REGARDING PROPHYLAXIS From the above research one might give the following deductions regarding the prevention of malaria : — (a) It is a bad practice to give quinine in small doses of five grains daily, or irregularly, even though the doses be larger, for such treatment tends to increase the power of crescent formation. (6) All cases of malaria should be treated early and con- tinuously with doses of quinine of about twenty to thirty grains daily, as such treatment during and after the fever diminishes the subsequent formation of crescents. Continuous treatment with the above doses has never failed, as stated above, to reduce the number of crescents to less than one per c.mm. of blood in a period not exceeding three weeks. That is to say, it renders infective cases of malaria non-infective to mosquitos in a period not exceeding three weeks. SUMMARY 1. Crescents are produced from the ordinary asexual spores of P. falciparum, due to a development of immunity towards the latter. 2. They develop somewhere in the internal organs and then appear suddenly in the peripheral blood. 3. The period required for their development is about ten days. 4. Crescents do not generally live more than a few days in the peripheral blood. 5. Crescents may be present in the peripheral blood during periods as long as eight weeks, not because the individual crescents survive for that time, but because their numbers are constantly replenished from surviving asexual forms. 6. Fresh broods of crescents come into the circulating blood daily, or every other day, or irregularly, according as the asexual sporulations occurring ten days before were quotidian, tertian, or irregular. 74 7. Quinine has no direct destructive action on crescents, either during their development or afterwards, but it destroys the asexual source of supply. 8. Quinine reduces the crescents to numbers less than one per c.mm. of blood within three weeks, provided it be given in daily doses of twenty to thirty grains. g. Quinine in small doses tends to increase crescent pro- duction (?) by favouring the development of immunity to the asexual parasites. 10. Methylene blue in doses of twelve grains daily reduces the number of crescents, and would seem to have some _ direct destructive action upon them. LITERATURE DARLING (1910), /é¢d. Vol. IV, No. 2. MANNABERG (1894), ‘The Parasites of Malaria Fever,’ Marchiafava and Bignami, and Mannaberg, New Sydenham Society, 1894, p. 289. Ross (1903), ‘The Thick-Film Process for the Detection of Organisms in the Blood,’ Thompson Yates and Johnston Laboratories’ Reports, Vol. V, part I, 1903. Ross (1910) ‘Prevention of Malaria,’ p. 129. A. Celli, p. 406. Ross and THOMSON (1910), ‘Some Enumerative Studies on Malarial Fever,’ Annals Trop. Med. and Parasit., Vol. IV, p. 267. STEPHENS and CHRISTOPHERS (1908), ‘ The Practical Study of Malaria and other Blood Parasites,’ p. 52. 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