panel and the rods driven into the grooves. This makes the
wire taut and the tension is equally distributed. All strands of
the mesh are fastened securely, which is not the case with gauze
fastened down by tacks. Over the rod a neat strip of moulding
can be fixed, which finishes off the panel and can be easily
removed. The great advantage of this method is that it is a
comparatively simple matter to take off the strip of moulding,
remove the rods, and substitute another piece of gauze. This
method is extensively used all through the United States.
Excellent arrangements for large private yachts and even
passenger steamers can be devised. I have seen nearly the
whole of the bridge deck enclosed with ordinary mosquito-
netting. The top was made of tarpaulin stretched on robes,
and the sides were made of gauze. At sunset the sides were
let down, and from fifteen to thirty people were able to dine and
sleep in comfort. The expense is not so great, and is amply
compensated for by the relief from mosquitos.^
1 Messrs John Holt & Co. have recently screened an entire ship for West
Africa. ā R. Ross.
By Dr OSWALDO GONgALVES CRUZ
Director of the Institute of Manguinhos
47. Prophylaxis of Malaria in Central and Southern
Brazil. ā Several anti-malarial campaigns have been carried on
under the technical direction of our Institute, all of which have
been crowned with the most complete success. They were
undertaken in the following chronological order : ā
(i) In the construction of the Itatinga Railway, Santos.
(2) In the work of damming the Rivers Xerem and
Mantiquira, for the water-supply of the city of
Rio de Janeiro.
(3) At the time of the extension works of the Brazilian
and Northern of Minas Railway,
(4) During the survey work for the Bahia and Espirito
Santo Railway.
(5) During the construction of the North West of Brazil
Railway.
(6) In the suburbs of the city of Rio de Janeiro in con-
nection with the prophylaxis of yellow fever.
The most important campaigns were conducted by Drs
Carlos Chagas, Arthur Neiva and Gomes de Faria, Members
of the Institute; and Dr Carlos Chagas (1906- 1907- 1908) had
already written on some of them, he being among us the first
to organise a scientific campaign against malaria.
The prophylactic formulae adopted by the Institute com-
prised the following : ā
(i) Prophylaxis by quinine exclusively, adopted when the
treatment had to be applied to a moving population
390
Sect. 47] QUININE 391
and one not remaining any length of time in a
particular zone (railway construction).
(2) Preventive administration of quinine, isolation of the
persons infected with gametes, in infirmaries fitted
with wire-gauze, and unrelaxing treatment of those
infected. This system was adopted when the
persons already infected had to reside for some
time in the infected zone with healthy persons, and
where the work was done more slowly.
(3) The same measures as above, together with systematic
sulphur disinfection of infected dwellings. Prophy-
laxis adopted when the staff remained for a longer
period in the infected zone, and where it was not
possible to carry out prophylaxis by means of
larvicide.
(4) Indirect prophylaxis by war on mosquitos.
Let us see more in detail how these prophylactic systems
were carried out among us.
The first prophylactic formula. ā This was put into execution
with success in the surveys for the South of Bahia Railway,
by Drs Mauricio de Abreu and F. Soledade, of the General
Board of Public Health. The process consisted in the daily
administration of 50 centigrammes of hydrochlorate of quinine.
It was compulsory, and the medicine was administered by the
doctors themselves, who saw that the patients swallowed the
capsule. In this case, as the persons never remained long in
the same place, the dose of quinine given was always prophy-
lactic, which is not the case when the persons remain for a long
time in the same infected places, as we shall see later. In the
special case, the results were most complete ; not one of the
persons subjected to the regime fell sick, whereas others who
accompanied the party, without belonging to it, and who would
not submit to the same prophylaxis, were attacked by malaria.
The second prophylactic formula. ā Here the process followed
out included : ā
392 MALARIA IN CENTRAL AND SOUTHERN BRAZIL [SECT.
(i) The preventive administration of quinine, in the dose
of 50 centigrammes every three days,
(2) The isolation of the persons infected with gametes, in
infirmaries protected by wire-gauze during the hours
the Anopheles sting, being subjected to strict treat-
ment until the gametes disappear.
(3) Early and radical treatment of persons infected for
the first time and not themselves infectious (this was
done without isolation), in order to prevent them
becoming infectious to mosquitos by the formation
of gametes.
Dr Neiva, who was entrusted with the carrying out of the
quinine prophylaxis on a large scale (among some 3,500 work-
men at Xerem), observed that among those treated with quinine
cases of first infection began to appear and increase rapidly.
He was able to verify these positively by excluding the cases
of reappearance noted after the beginning of the campaign.
Satisfied that the dose of quinine was not sufficient to guarantee
the prophylaxis, he proceeded to administer it at intervals of
two days ; after some time, fresh cases of first infection began to
appear, and these were only really stopped when he commenced
to administer the quinine in a daily dose of 50 centigrammes.
It is interesting to note that among the persons thus treated
with quinine an outburst of malaria occurred when they dis-
continued the use of quinine, even though the practice had
been continued after leaving the infectious malarial zone ; and
to prevent such attacks it became necessary to continue the
use of quinine for a long time, and repeat treatment at intervals.
Stranger still, persons who, after leaving the malarial zone,
went to reside in places which were certainly not infected,
where they continued the use of the quinine (50 centigrammes
daily) for a month, as soon as they abandoned this preventive
were attacked by malaria. Such persons had remained for
fourteen months in the infected zone without ever suffering
any attack of fever. When under the action of quinine they
47] DESTRUCTION OF ADULTS 393
had no fever, but harboured plasmodia in the system. Dr
Neiva, in view of his observations, admits that during the
quinine prophylaxis the plasmodia become gradually accustomed
to the quinine and immune against t/it's pot'son, giving rise to a
family able to resist the quinine, and similar to the families of
trypanosoma which defy atoxyl. Subsequent to this interest-
ing observation of Dr Neiva's (made in October 1907) several
other authors have referred to analogous facts.^
The occurrence of the new infections could not be attributed
to the inefficient administration of the quinine. This was com-
pulsory, and was administered by trustworthy persons, the
infections being found to exist in persons who undoubtedly
had taken the prescribed doses.
The second item of the prophylactic formula under con-
sideration is intended to destroy the gametes in circulation,
which prevents the infection of the mosquitos, which, as we
know, can only occur when there are gametes in the periphery.
This result was obtained by the daily and continuous adminis-
tration of 50 centigrammes of quinine. It was proved by
the microscope that after a time it was no longer possible to
recognise the existence of gametes, whether of the benign or
of the malignant (tropical) tertian. When the parthenogenesis
of the gametes occurred, following on excessive work or heavy
rains, i gramme of quinine was given daily, as a rule by
intramuscular injection. It should be noted that no scabs
appeared after the injections.
The above shows the necessity of carrying on the anti-
malarial campaigns by persons capable of making the utmost
use of the assistance furnished in such cases by the microscope.
T/ie third prophylactic formula. ā Dr Carlos Chagas, in his
studies on the epidemiology of malaria, and on the biology
of the Anopheles responsible for the transmission of the trouble
within the zones, found that there were dwellings constituting
regular hot-beds of malaria, and that such houses were invaded
^ Incubation retarded by quinine is well known. ā R. Ross.
Sect. 47] DESTRUCTION OF LARVAE 395
at night by the Anopheles, which stayed there till dawn, some
withdrawing to the woods, whence they returned the following
night, others remaining concealed in the dark damp places of
the huts.
These infected mosquitos caused the permanently infected
condition of these dwellings. The opinion that malaria is a
disease commonly infectious in houses finds a perfectly feasible
basis in arguments relating to the biology of the Anopheles,
and in numerous facts arising from careful observation. In
view of this Dr Chagas resolved to make systematic cleansing
by sulphur vapours in such dwellings, and thus succeeded in
sterilising these centres of infection.
These measures were always accompanied by quinine
prophylaxis. But as an experiment Dr Chagas ascertained
that the treatment of dwellings by sulphur was sufficient to
prevent the infection of the persons who passed the night in
such deadly centres of malaria, and who were not subjected
to the action of quinine.
The fourth prophylactic formula. ā This consists of indirect
war against malaria by the destruction of the larvae of the
Anopheles. This prophylactic system was tested at Rio de
Janeiro, when the prophylaxis of yellow fever was carried out
in the metropolis of Brazil. One part of the war on mosquitos
was begun by drying up all temporary deposits of water, the
destruction of the larvae in natural deposits by means of
the cultivation of larvae - devouring fish {Girardinus caudi-
maculatus), by the protection of indoor water - cisterns from
mosquitos, the petrolising of large sheets of water, the destruc-
tion of the Bromelias epiphytes, etc.
The results obtained were very favourable, as may be seen
by an examination of Table No. i, which we give below. In
Table No. 2 is given the complete result of the anti-yellow
fever campaign. The malaria figures do not show the same
decrease as those for yellow fever, because in the table for
malaria the cases existing in the urban hospitals, where
396 MALARIA IN CENTRAL AND SOUTHERN BRAZIL [Sect.
patients were received from rural zones not influenced by the
prophylactic campaign, appear.
TABLE II.
TABLE OF MORTALITY BY YELLOW FEVER IN RIO DE JANEIRO FROM
1872 TO 1909.
1872
1873
1874
1875
1876
1877
1878
1879
1891
1892
1893
1894
1895
1896
1897
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
16
23
122
3
156
102
138
50
3
8
79
15
201
6
30
510
57
51
1,006
4
371
27
524
28
22
99
42
13
32
133
2
3
6
SI
168
319
ID
420
227
496
67
13
9c
208
28
351
18
39
719
103
357
1,290
57
1. 351
41
731
33
90
170
64
41
64
142
7
13
9
953
168
385
1,405
74
331
226
471
46
23
335
253
58
483
89
29
281
297
301
1,019
35
130
169
273
26
27
598
210
51
304
37
128
539
142
187
169
1,026
960
1,404
410
108
135
1.978
695
86
141
1,002
445
37
20
255
287
204
91
78
61
69
64
16S
178
151
99
7
8
23
59
6
8
6
14
I
165
244
395
40
60
81
"5
25
12
300
68
65
74
18
116
97
109
600
147
172
305
104
136
17
36
37
154
24
10
64
3
83
69
104
147
12
23
54
58
14
8
III
15
57
23
61
38
421
35
141
114
77
37
6
78
25
28
17
131
10
4
61
I
4
3
37
41
4
18
43
18
13
I
69
12
44
9
I
50
27
22
190
14
73
14
51
20
3
65
II
9
14
79
9
4
26
18
16
383
I
37
7
166
102
3.659
829
1,292
3.476
282
1,176
974
1.625
257
863
445
1-449
137
747
2,156
719
4.456
4.312
825
4.852
818
2,929
159
1,078
731
344
299
984
584
48
289
42
39
4
Table No. 3 shows the results obtained in the campaign
undertaken at the time of the damming of the Rivers Xerem
and Mantiquira for the water-supply of the city of Rio de
Janeiro. The region through which canalisation work had to
47] BRAZILIAN ANOPHELINES 397
be extended was so devastated by malaria that 95^ of the
men employed in the work were attacked, the mortality being
so heavy that the Government was obliged to abandon the
first attempt. Work could not be resumed until the special
prophylactic service for malaria had been organised, with the
result that in a few months the works were completed and
the city of Rio de Janeiro provided with an abundant supply of
drinking water.
In the malarial zones of Brazil the following species of
Anopheles are found : ā Cydolepteron mediopunctatuin (Theob,
Lutz), Cydolepteron interniedimn (Chagas), Cellia argirotarsis
(Theob), Cellia albiniana (Wied), and Arribalzagaia pseudoma-
culipes (Chagas).
These are undoubtedly the transmitters of malaria, as was
experimentally shown by the characteristic forms of evolution
of the Plasmodium in them.
The following species are suspected of transmitting the
malaria, so far as can be judged by epidemiological studies: ā
Myzomyia lutzi (Theob), Cellia braziliensis (Chagas), Myzorhyn-
chella lutzi (Cruz), Myzorhynchella parva (Chagas).
As to the habits of the Anopheles, Dr Chagas noticed that
as a rule they suck only at certain hours, at nightfall, when
they come in swarms, or in the early hours of the morning.
They disappear entirely during the day and night, at which
time, therefore, there is no danger of men being infected by the
contaminating mosquitos, or of the mosquitos being infected
by sick persons with gametes. An exception to this rule is
the Cellia braziliensis (Chagas), which attacks for preference
during the day and in the sun, which fact shows the necessity
of studying the Anopheles fauna of the region in which it is
proposed to start an anti-malarial campaign.
Further details as to the Brazilian Anopheles and their
relations with malaria may be found in the works of Dr A.
Neiva, lately published (1909).
In dealing with the organisation of the systematic prophy-
398 MALARIA IN CENTRAL AND SOUTHERN BRAZIL [Sect. 47
laxis against malaria a knowledge of the existence of the
Myzoniyia lutzii (Theob.) in the region is deserving of special
attention.
This mosquito, which appears to be responsible for the
transmission of malaria in the regions where there are no
swamps, lives in the waters found in the Bromelias epiphytas
(Lutz, 1902), and is so small that it can pass through the wire-
gauze of 1*5 mm. mesh, usually employed for protection of
houses. For this further reason it is advisable to study the
Anopheles fauna of the region before proceeding to instal
mechanical prophylaxis of malaria.
Finally, it should be mentioned that the quinine prophy-
laxis has been carried out without the slightest inconvenience
to the persons subjected thereto^ there being a large number of
people who have used daily 50 centigrammes of hydrochlorate of
quinine for the last two years and ten months without showing
the slightest bad effect from the employment of this medicine.
Further, the phenomena of noises in the ears, etc., are not
observed when the quinine is administered at meal times. No
cases of hoemoglobinuria have been observed following on the
administration of the quinine, and the few cases (8) of this morbid
nature observed disappeared with the quinine treatment.
BIBLIOGRAPHY
1902. Dr Ad. Lutz.ā " Forest Mosquitos and Forest Malaria." Central-
Blatt ficr Bakt. etc., ist pt. orig. vol. xxxiii. p. 282.
1906-7. Dr Carlos Chagas. ā " Prophylaxis of Malaria." Brazil-medico,
year xx. pp. 315-337 and 419 ; year xxi. p. 151.
1908. Dr Carlos Chagas.ā A paper on " Malarial Prophylaxis." Zeit-
schrift fiir Hygiene und Insect krank. vol. Ix. p. 321.
1908. " Prophylaxis of Malaria." Paper read at the 6th Brazilian Congress
of Medicine and Surgery. In Revista Medica de Sao Paulo.,
No. 19, year xi. p. 391.
1909. Dr Arthur Neiva.ā" Contribution to the Study of Diptera."
Observations on the biology and organism of Brazilian Anopheles,
and their relations with malaria. Proceedings of the Oswaldo
Cruz Institute, vol. i. p. 69.
Table 3.
di^JiL-lWlli:ii..i.-^:^ -
\To face page 398.
By IAN MACDONALD, M.D, Edin, M.D., Paris
Huelva, Spain
48. Malaria in Spain. ā Among the countries of Europe,
Spain has always suffered severely from malaria, and the
records of history show that it swept over her with the virulence
of plague. In September 1283, when Philip the Bold of France
besieged and took Gerona, his army was almost destroyed by
pernicious fever, and he himself succumbed to an attack at
Perpignan. In this epidemic, according to Dormese, great
importance was attached to " some flies which caused death
by their bites," Of its ravages in the Peninsula no better
picture has been given us than that of Johnson in 1771, "the
attack of Carthagena is yet remembered, where the Spaniards
from the ramparts saw their invaders destroyed by hostility of
the elements ; poisoned by the air and crippled by the dews ;
where every hour swept away battalions ; and in the three
days that passed between the descent and the embarkation
half an army perished." From historical data, it is clear that
the greater number of Spanish authors up to the eighteenth
and first half of the nineteenth century in many cases con-
founded malaria with the whole group of infectious diseases.
In these times one Spanish clinician, Ludovic Mercado,
physician to Philip II and Philip III, stands apart from the
rest, for in 1608 he differentiated pernicious intermittent fevers
of tertian type in the midst of the pathological chaos around
him. In 1783 Masdevall described the lamentable effects of
malaria in Lerida and the devastation it caused among the
French troops massed in Cdceres. He pointed out the relation
399
400 MALARIA IN SPAIN [Sect.
between fever and the pools left by rivers and after rains, and
remarked that the greater number of cases were always found
amongst those who worked in the sun and who slept at
night in the open air. He completes those accurate observa-
tions by recommending the use of Peruvian bark for the cure
of the disease.
In the first years of the nineteenth century (1800- 1805)
several papers appeared on the value of quinine in epidemics
of yellow fever, and Nelson in one of his last letters to Lady
Hamilton, writes of " the dreadful effects of yellow fever at
Gibraltar, and in many other parts of Spain."
Though Stegomyia fasciata, the carrier of yellow fever,
exists in the cities of Southern Spain, from a study of the
symptoms, and course of this fever and the therapeutics
employed by these authors, it is clear that they were dealing
with severe types of summer autumn fever with hepatic
symptoms.
In 1888, discussions began in Spain as to the validity of
Laveran's great discovery, and till 1896 the best paper on
the parasite was that of Thin and Marshall, who accurately
described the types of fever met with in Southern Spain.
But the hypotheses of Laveran and Manson, at that date
passing from theory to fact in the researches of Major Ross,
received no support from these investigators ; for their con-
clusions are thus presented in a well-known text-book (1899):
" The observations of Thin and Marshall go to show that in
the province of Huelva at all events telluric conditions are
the permanent factor in infection, that the plasmodium is not
usually conveyed by water, and that there is no evidence of
the mosquito being an intermediary host." After the publica-
tion of Professor Ross's early papers, in the summer of 1899
we began to investigate malaria in the same province, over
an area of 60 miles, extending from the Rio Tinto mines in
the foot hills of the Sierra Morena to the coasts around the
town of Huelva. In the hills it would be difficult to find a
48] WORK AT HUELVA 401
more arid district, where water appeared to be completely
wanting-, for the vegetation within a three-mile radius had
been destroyed by the fumes of sulphur smoke. It lies 320
metres above the sea- level, and the soil is chiefly ironstone.
Hardly any rain falls from May to October (fever season),
with the exception of rare thunder-storms.
The aspect of the country is that of undulating hills covered
with low brush-wood beyond the smoke area. The valleys in
winter are often filled with roaring torrents. In summer these
streams dry up, leaving pools, varying in size from about 3 ft.
in diameter to the size of a plate or saucer. The district is
dotted over with small villages which are situated on the slopes
of the hills. The whole area was more or less malarious, but
certain villages were notoriously unhealthy, and it was a curious
fact that the lowest lying village was the healthiest, though
the moving of earth for mining operations went on at its very
doors. Yet half a mile off, where most of the British employees
lived, fever was frequent. In September 1899, we showed that,
so far from mosquitos being scarce owing to the presence of
sulphur smoke, they abounded in the district ; and in the
paludic villages Anopheles maculipennis was often the only
mosquito to be found in the houses. In the Province of
Huelva we differentiated the following varieties of mosquitos :
Anopheles maculipennis^ Anopheles superpictus Grassi, Myzotnyia
superpictus Blanchard, Stegomyia fasciata, Culex phytophagus,
Culexpipiens, Ctdex penicillaris {Grathamia penicillaris Rondani),
Culex spathipalpis {Theobaldia spathipalpis).
In south Spain A. maculipennis is the chief carrier of malaria.
A. superpictus is not often met with ; we have only found it
in three or four districts.
We have always found that the abundance oi Anopheles m
any district is in relation to the extent of malaria.
Since then, repeated observations in many places in the
South of Spain have always shown us the same conditions in
fever districts. Whether the town is in the hills or on the
2 C
402 MALARIA IN SPAIN [Sect.
plains, the dried - up water-course is always there, the pools
sometimes covered with algae. In the hills the water is often
running slowly. In the Sierra we have found Anopheles larvae
in rocky pools devoid of vegetation, but as a rule they contain
algae, at the edges of which the larvae swarm. The difficulty
of seeing the larvae of Anopheles compared with those of Culex
is of course well known ; and in some cases a careful examina-
tion is needed before concluding that there are none in the pool.
In the hills, if a muddy pool and a clear one existed side by
side, we constantly noted the preference of Anopheles for the
limpid water. As a general rule we have not found larvae in
artificial collections of water ā only very occasionally in old
barrels and iron tanks on a railway line. In mining districts
here, dams are often believed to be a source of malaria. We
have not yet found larvae in such collections of water, but
have often demonstrated them in the ravines within 50 metres
of the dam.
The adult insects in winter and spring hibernate here in
stables, hen-houses and pig-styes, where they can always be
found until the end of May or the beginning of June. After
that time they are also found in the houses. The course of the
epidemic season of the malaria in Spain confirms, as elsewhere,
the strict relation there is between the human infection of the
previous year (winter relapses, cahectics, children) and the
infection of the mosquito in June and July, the beginning of
the fever season. Our dissections showed that the percentage
of the infected mosquitos in June was only 7%, while towards
the end of July and in August it rose to 18%.
Of Anopheles captured in stables, etc., none were found
infected. We frequently found red larvae of Hydrachnides
fixed on the insects, and sections of some Anopheles which died
rapidly in captivity were examined by Laveran and were found
to contain a fungus in the wall of the stomach and in the
coloemic cavity, which possibly may be pathogenic for the insect.
For infection experiments, we fed A. viaculipemiis on fever