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·ANTI-MALARIA WORK
IN MACEDONIA
AMONG BRITISH TROOPS
BY
G WILLOUGHBY
MD LOND. (
30 CM AND S BLEM) DPH CAN
11 10 RAMC TF
MICAL O O O HAL * EASTO *
AND
LOUIS CASSIDY
MI B. CH. E. FRCSI Cart R.AMC.
HA LEWIS & CO LTD
316 GOWER STREET LONDON WC.
1918

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·PREFACE
At the close of the second malaria season during which
British troops have occupied part of Macedonia we
thought it might be interesting to describe some of
the aspects of the anti malaria work carried on in and
near one large section of the front
The continued prevalence of so much malaria in
spite of the persistent efforts of the RAMC and
others is a matter for regret This regret is however
mitigated by the knowledge that the work 'resulted in
an improvement in 1917 as compared with 1916
The account in the following pages is not intended
as a scientific work but is simply a record of personal
practical experience which may possibly we hope be
of use to others called upon to do antı malaria duties
in this difficult country
To make the account more complete foi those with
httle previous knowledge of malaria we have added
a brief description of the mosquito and its connection
with the disease
V GW
Vovember 1917
LC

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·CONTENTS PAGE CWAT ER PREFACE 19 24 კი 33 1 GENERAL MATURE OF MALARIA-ITS COVA ECTION WITH MIOSQUITOES-LIFE HISTORY OF HOS QUITOES 11 PREVALENCE OF MALARIA-RECURRENT ATTACKS III TRE NATURE OF THE COUNTRY WATER-VEGETA TIO-CLIMATE-INJIABITANTS IV ANTI MALARIAL BIEASURES ADMINISTRATION LABOUR V REMOVAL OF MEN FROM BIALARIOUS AREAS 11 THE DESTRUCTION OF MOSQUITOES PRAIRIE FIRES FUMIGATION-RUBLEVATION OF MOS QUITOLS VII THE DESTRUCTION OF EGGS LARVA AND PUPA CHANYELLING - WEDS DRAINING - MOS QUITO TRAPS-OILING PATROLLING-POISOWS -NATURAL ENEMIES OF LARVÆ VIII PROTECTION OF MEY FROM BITES NETS-VEILS -GLOVES CLOTHING – DUG OUTS AFTER SUNSET RAVINES AFTER SUNSET 1x GCININE PROPHYLAXIS * CONCLUSIONS 3r 40 51 59 64 vit

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·LIST OF ILLUSTRATIONS HO PAZ ILLUSTRATIONS CONPARING ANOPRELINES AND CULI CINES (Magnified 18 PLATES TLA U 15 1 (A AND A) VIEWS OF TUE THO LALES DESCRIBED IN THE TEXT TE (AANO B) EXAMPLES OB TUSE USARSSTY BORDERS OF THE LAKES ANOPULLINE LARY E ABUNDANI 112 (A) RUSHES AT INE LARZ MARGIN (8) A STREAM DID WITH BIANY WEEDY SUALLOW POOLS A FAVOURITE BREEDING-GROUND XV (A) A WIDE STREAS BED WITH MANY POOLS ANO PRELES IY LARGC QUANTITIES (8) TNE SAME STRCAU DOD LATER. TRE NARROW CHANNEL 11AS DRAIVED TUE SITALLOWS AND TUIRE WERE NO LARVE V (A) A SWALL STREAS IN A RAVIV BEFORE TREAT BONE KANY LARA PRESENT (8) THE SAME STREAS CUANNILLED AND CLEARED OF WEED NO LARVE vt () A WILL CJJAA VELLED STREAU BED WITH Ove TOOL LEFT NEGLECTED AND FOLLOY LARVX TEGUGU OPEN TO THE SUN AND WEEDLESS (3) A SIMILAR REGLECTED POOL UNDER A BUSU ALSO FULL OF LARVÆ 43 43 44 ·K 46 46 LIST OF ILLUSTRATIONS YLATE TANG TAGI vu (A) PROCESS OF CLEARING A STREAM NEAR A CAMP OF MOSQUITOES AND LARTA THE UNDER GROWTR PARTLY CLEARED AWAY 45 (B) CHANNELLING THE STREAN BY NATIVE TURK LABOUR VIII (A) SIPHONING A LARGE POND IN A CUP LIKE DE PRESSION AMONG THE HILLS (B) A HAUNT OF HIBERNATING MOSQUITOES IN A VILLAGE DESERTED EYCEPT BY STORKS AND INSECTS ** (A) A DUG OUT IN A RAVINE A FAVOURITE ANOPHELINE HAUNT 47 (B) A VILLAGE FOUNTAIN WITH MANY LARVA IN THE WASTE WATER 47 * (A) A WELL CHANNELLED RAVINE STRZAS WITH STONES TO PROTECT THC BANKS NO LARVE (B) A RAVINE OF ROCKS THE SLOWLY FLOWING STREAM CONTAINED LARVÆ X (A) THE USUAL BISOUAC FOR TWO MEN TTL MOS QUITO NET 52 (B) A MOSQUITO PROOF HUT 3 ZII PROTECTION VFIL GLOVES AND SHORIS TURNED DOWN OVER THE BARE KNEE XIII BELL TENT WITH A NEGLECTED HOLE IN THE NOSQUITO NET 50 50 - 55 68 ·- IN ANTI-MALARIA WORK MACEDONIA CHAPTER I MALARIA AND THE MOSQUITO MALANIA is due to a microscopic organism whose lifehistory is only complete when it has existed in the human being and in a mosquito While apparently any human being is a useful medium for this organism it is selective as regards its definitive host the mosquito and only thrives in certain species of these insects At least three varieties of the organisin cause malaria Plasmodium titat causes benign tertian P malarıæ causes quartan and P falciparını causes malignant tertian malaria The mosquito hosts of the plasmodia are anophelines There are various varieties of anophelines some of which act as hosts and some do not The chief malaria transmitting species in one country may not be so in inother country In Macedonia the chief anophelines we have found have beca A maculipennis and A siperpictus 11 ·I 2 ANTI MALARIA WORK IN MACEDONIA A pseudopictus and A bifurcatus and possibly others also occur The aim of this work being to describe practical prevention of malaria we do not propose to discuss the important question as to how far any particular species is concerned with any particular form of illness This matter is being investigated by scientists From the association of certain forms of malaria with the seasons and places of finding certain species of anophelines particularly prevalent it is likely that A superpictus and A pseudopictus are responsible especially for malaria of a malignant type but practa cally there need be no local selective process in the work of destroying mosquitoes even if all those engaged in the work had the requisite 4nowledge The complete extirpation of one variety of mosquito in any locality will involve that of the others also since their habits and mode of development are to this extent sufficiently alike in any event all mosquitoes are nuisances they may be carriers of other diseases besides malaria and should therefore be destroyed The course or cycle of infection is briefly as follows An anopheline mosquito infected with the plas modium in biting transmits the organisms from her salivary glands to the blood-circulation of the human victim After the lapse of about twelve days these organisms have so multiplied and have so acted in connection with the red blood cells that the symptoms of malaria appear ·SLALARIA AND THE MOSQUITO The individual thus bitten becomes later on a carrier of organisms unless be has had very thorough treatment a chronic case being more dangerous in this respect than an acute case When this infected person is again bitten by a mosquito requiring blood for the development of her eggs she at the same time sucks in with the blood a number of the organisms These are sometimes altered in that they have taken on a sexual character and in the stomach of the mosquito exercise their sexual functions The resulting progeny eventually find their way from the stomach to the salvary glands of the insect and are in readiness for injection into another human victim and the cycle is complete The course of events in the mosquito itself lasts from ten to tweise days and a temperature of at least about 60 F is said to be requisite for the process Only the female mosquito bites man she must have blood for the development of her maternal acuvities She can take over a cubic millimetre of blood at a tune and we are informed that this quantity of blood from a fasourable human subject may contain thousands of organisms The male insect is apparently a vegetarian and harmless except for the breeding of more females The cycle of infection briefly described above which is often complicated by repeated buting is the only mode of spread of malaria scientificalis demonstrated at present and gives the clue to the necessary basis for presentase action ·ANTI MALARIA IYORS IN MACEDOVIA It indicates that in addition to the plasmodium itself vluch cannot be dealt with apart from the mosquito or the blood of the human victim there are three principal essentials for a case of malaria These are the infected person from whom the mosquito orginally obtains the plasmodium the mosquito o the particular species by which this can be transmitted and thirdly the victim In Macedonia infected persons abound among the natives and now also among our own mea The transiruttibg species of mosquito also abound our troops are the victims In our account of preventive methods we therefore discuss the destruction of the mosquito in all stages of its life-lustory and the protection of the troops the potential victims As regards the infected individual who starts the cycle much can also be done to render lus infected state a lesser danger to the community In the case of the infected natives especially children isolation and removal from the neighbourhood of our men s practicable and has been carried out to a great extent at the front In the case our owa infected men who cannot be removed from the destact the points to be aimed at are their cure by very thorough qurtune treatment and their thorough protection from further mosquito bites so that the infection cannot be passed on to others Apother method of defence that requires attention is that of rendering the infected bite harmless to the victim by the use of prophylactic drugs especially ·UT MALARIA AND THE MOSQUITO 35 quinige Though important this is obviously but a subsidiary resource to be employed when other methods are not sufficiuatly practicable to be efficient A working knokledge of the course of development ol the mosquito its life and habits is necessary before the various means of preventioa can be put into satisfactory operation The common species of mosquitoes in lacedonia are anophelines various varieties of which can transmit the malaria plasmodium and culiciaes sluch are apparently harmless as regards malaria The life-history of the anophelinc is briefly this The adult insect lays her eggs on the surface of water after about two to three days the eggs batch into larvæ much in their turn become pupæ in from about seven to ten days The insect emerges from the pupal stage after another two to three days The time of the complete cycle is therefore from about eler en to sixteen days It is important to bear these times lo mund in planning destructure processes The lar al stage is very important in ants malaria work for it is that in which destruction can be most cally carried out Larix are easily seen being from about one quarter to half an inch in length they constantly come to the surface of the water but can remain belaw for some time so that search should 10t be abandoned too quickly Sometimes when they are not at once seen a gentle movement of the "eed or other contents of the water will cause them to show themselves N ·16 ANTI MALARIA WORL IN MACEDOVIA The commonest anopheline larva in our area was a small very dark one with 7 light neck the larva of A superpictus Weedy streams were a favourite haunt of this variety The larger lighter larva of A macılı pennis was also common especially early in the summer Occasionally other species were found The A pseudopictus found in the marshy borders of a lahe was apparently associated with the severe type of malaria in the vicinity The principal breeding time is from mid June to the end of September but larvæ have been found even in the winter months Mid September seems to be the culminating point of the breeding most cases of malaria in our district in any one week in 1917 were notified in the beginning of October The anopheline larva is said to prefer shady clear and stagnant water with weeds in it This is so especially as regards weeds but we have found these larvæ in any and every variety of water in Macedonia The anopheline mosquito bites as a rule in the twilight and at night we have however seen them biting in the daytime in darkened places such as dug outs They remain in dark places and in undergrowth during the day Anophelines have been found in large numbers in the day shelters 19 in the quite dark dug outs they may be scen on the walls and ceilings They are found among clothes and bedding between the layers of double tents and also in shelters such as helmets Heavy rain drives them into buildings in large quantities as well ·VALARIA IND THE MOSQUITO 37 The anopheline bite is less unitating than that ok culex Vosquitoes strongly object to wind and are found cluefly to leenard of the breeding places They travel much farther than the half mule which has been sometimes mentioned as their limit of fight A temperature of 60 r is said to be necessary for the changes in the plasmodium inside the mosquito though winter cases seem to show there may be exceptions The anopheline mosquito hibernates during the winter months in dug outs and dark parts of buildings It is said that she can retaja during this time her infecting organisins ready for action in the following spring, and summer In Afacedonia how ever there is abundant material for fresh infection of anophelines all the year round The follosing are some practical points in distin Guiskin, the anopheline or malaria mosquito from the culicine (a) TUE INSECT The anopheline alights on and rests on a surface with its body at an angle to at the common forms in Vaccdona kane spotted wings tic female s palp is about as long as ber proboscis The culicine s body is nearly parallel to the surface on which it alights sts wings are clear and the palps quite short (6) THE LARY --The anopheline when at the surface lies parallel to it on the water its head is small compared with the thorax and it frojects po siphon

·18 ANTI MALARIA WORK IN MACEDONIA
The culicine larva lies under the water at an angle
of about 45° with the surface through which the
siphon projects the head is large and the lateral hairs
plain
(c) THE PUPA --The siphon tubes of the anopheline
are broad and situate at the middle of the head end
of the pupa in the culicine they are longer not so
broad and situate at the back of the head
(d) THE EGGS -In anophelines the eggs are in sets
of about 100 in irregular patterns in cultcines the
eggs are about 250 in number set vertically in rafts
of about one-fifth of an inch in longest diameter
Rapid differentiation is only practically easy in the
larva and insect stages but there is for most antı
malaria workers among the troops no need to dis
criminate, but to kill any and every mosquito possible
in any stage of its cxistence

·ANOPAFLINES
CULICIHES
Y
8
3
Let to
6 WTARSYG
YO ALI
CEL CU
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·CHAPTER II PREVALENCE OR XIALARIA to As the object of this work is to give an account of anti malaria work in a fasge past of the area in Macedonia occupied by our troops at would be more com plete if it included statistics showing the extent to which the disease has prevailed On the other hand under present circumstances obviously no figures can be given which might indicate numbers of troops We are confined therefore mentioning certass of the broad facts within our exponence It is common knowledge that the troops of all nations operating in Macedonia suffer consider ably from malaria Statistics on the subject will no doubt be ataslable at the end of the war The smallness relatnely of the casualty lists tant appear in the Press in connection with the Salonha Force has apparently sometimes given the uninformed the mistaken idea that the troops on this front have had an easy time In proportion they have had a considerablc share of fighting but the casualtz figures are duarſed by those of sickness due to maları3 There are few men who would not gladly exchange out of malarious Vacedona Tront line troops have 19 ·20 no ANTI VALARIA WORK IN MACEDONIA not only fighting to do but are continuously exposed at night and sometimes by day also, to the bites of thousands of small enemies which cannot be adequatels dealt with because their breedin, grounds are in man s land between the opposing forces or because of other difficulties indicated later on The malaria following the bites disables men for a time as Surely as a wound (without the compensating gold stripe on the sleeve) recurrences are common and a long and tedious convalescence often en ues In this way a large proportion of the troops have to carry on knowing that in the unavoidable ab ence of complete precautions thou, h the bullet may miss its billet the mosquito will probably not do so Belund the front line anophelines are still $0 omni prosent that notwithstanding unceasing antı malarial work the troops are everywhere exposed nightly to the chances of infection though much less so than at the front (except in certain areas) A few districts of the occupied portion of the country are almost free from infected mosquitoes but in most parts they abound and in none is there absolute immunity The circumstances in 1917 were more difficult to contend with than in 1976 in this important respect that owing to the cases of the previous y car infected carriers Here to be found in almost all units In spite of this there has been an appreciable decrease of malaria among troops in the area to which this book refers and probably elsewhere also In September a very satisfactory percentage of men was ·FREYALENCE OF MALARIA 15 sared for actue service as compared with September 1976 When the great increase of material for infect ing mosquitoes is considered together with the fact that the same partly untreatable malarious districts had to be still occupied it all be understood that 1 great increase of malana might have been expected cather than a decrease had not the continuous antı malarial work hard a good measure of success The curse of neekly notifications of the cases of malarna remoned to the base hospitals was at its lon est in the beginning of Janurry and at its hughest in the second week of October Allowing a fortnight for the development of the disease and a week s delay in notification and blood examinations this points to a maxmur biting season at mid September Recurrences due to other causes than fresh infection by biting probably do not affect the accuracy of this as a general proposition It is not possible to distinguish for statistical pur poses bettyeen recurrences due to chills heat fatigue or other similar causes and recurrences due to regened infection by biting When the curve was at its lowest in January in the region with which we are deaing about a man in 7 000 wechly was evacuated to the base with malaria at its height carly in October the proporti n was I 191 30 or less In addition there were or any cases not seserc enough for csacuation beyond the area Vany of the cases were repealed recurrences to the same individual

·CHAPTLR III
NATURE OF THE COUNTRY
The natural characteristics of the part of Macedonia
Occupied by British troops conduce to malaria The
country is mostly mountainous with many separate
hills of varying he ht in each range The rabines
and valleys are therefore very numerous and contain
in the aggregate an abundance of water At the foot
of the hills there are large plains through which the
water has to find its way to lakes and to the sea
The
number of ravines in both hills and plains is quite
a feature of the district They intersect in all direc
tions the many semi isolated hills which rise to heights
varying from about five to sisteen hundred fret above
the pluins In the parts immediately beyond those
occupied by our troops the hills and ranges are occa
sionally very much higher
In the ravines the watercourses are narrow with
frequent rocky pools The water is overhung with
vegetation Though the current may be strong there
are weeds and many quiet off shoots in which larva
are found
In the plains the large volume of water in winter
24

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·PLATF !
T
22
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·NATURE OF THE COUNTRY 25 and in sudden storms has won very deep and is places very wide stream beds These stream beds are only partially filled with water in the hot malaria months There are then large pools and patches of stagnant water generally full of weeds The stream atself has often no very definite channel but spreads over its ssde bed forsing weedy shallows which with the isolated ponds offer an irresistible attraction to the mosquito for breedin, purposes Streams in a sandy bei often end abru, tly and reappcar louet down the channel having run for varying distances under the surface, Depressions in the bed are filled with water and form breeding places The lakes in the district have in places large sur roundng patches of marshy ground or ergrown with ruishes and weed and containing here and there şools of open water These marshes are so full of dense vegetation and are so water logged that the mosquito has an ideal place in which to thrive both in its insect and larta stages of etistence One of these marshes is mant square kilometres in area and 3 mmch used road runs for come miles along its border Vilitary i ugencies required that in the summer of 1917 cumps should be atuated near this particular marsh The men temporarily fouing in these camps and those using the road at night were particularly cxposed to mosquito bites In the case of another large lake the border marsh 15 smaller but adjoins a portion of the front line occupied by Batski troops ·26 ANTI VALARIA WORK IN MACEDONIA There are other smaller areas of marshy ground which are not such difficult problems in anti malarial work These are sometimes caused by a spring ring on level ground or by a stream ending bundly on 23 level without a natural outlet Ponds and pools abound especially in ravines and beds of streams In the latter the bottoms of the pools are often below the level of the remnant of water in the stream Such incidents as removal of sand for road maling or hoof marks of horses and mules in the rker beds cause pools to form which quickly become breeding places In the ravines of the hilly country rocky dams cause the formation of sheltered pools ia shich there may be a slight current which is not strong enough to prevent the hatching out of mosquitoes Springs are plentiful Every village has at least one public fountain led by a spring Similar fountains are also found here and there at a distance from villages The Turks were very good at providing water supplies in a fair number of fountains the flou is constant all the year round and the unkempt waste forms semi stagnant water logged areas wluch are soon adopted for breeding purposes in the summer by the mosquito Wells are less common but therc are many of them and these also may become infested with larva The almost unit ersal presence of all forms of natural accumulations of water in the district has its import ant uses but from an anti malarial point of view

·PL ITE
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THB LKZ
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WR Y POR RR
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·NATURE OF THE COUNTRY 11fessitates much constant labour To this was to be added the secessity for constant attention to the abundant collections of accidental water 191 such places zs old tins horse-troughs tubs and imigation chaands Any form of water comes handy to the ubiquitous mosquto if the water is jelt without atten tion for a sufficient number of days EGCTATION The universally abundant vegetation along the banks of the streams and lakes is useful to the mosquito as a resting place by day Trees in most of our area are not common The abundant long grass and rushes form very convenient shelters for insects of all kiads in the hilly districts a small oak scrub bracken and dense brakes of undergrouth are found sa and near the ravincs When a stream has to be channelled especially in the plains the Overlapping undergrowth has first 10 be cut away At times this 125 necessary before he could even sco the water which requcd attention So grcat 135 the amount of lang grass and other Weeds in 1917 eren apart from the neighbourhood of Water that wholesale had to be organised on an extensnc scale The wholesale destruction of villages in the arious Ballan wars has done away with much of the artı tically cultivated cgetation and fasourcd the growth of woods Tegetation in the water itself flourishes Rushes and water-grasses are common A particularly ubi gutous and rapidly growing green water weed repraine fires ·28 ANTI MALARIA WORL IN MACEDONIA sembling a loose piece of cotton wool in consistency and lying entirely in the water enables larvæ to enjoy a comfortable existence eten in a fairly fast flowing stream The larvæ of A superpictus particularly lourished in such positions If a stream bed that has been canalised is not cleared of this weed in par ticular at regular interval, the value of canalisation is to a very great extent lost CLINATE The great heat of the Macedonian Summer favours mosquto life In July August and September the average temperature is well up in the nineties in the shade The nights remain sarn and the heat is a humd one A shade temperature of 106 8° F was recorded about 2 pm which is usually the hottest period on one day in August There were others of over 100°F from time to time Rain during these three months was rare The rain of large thunder storms is useful in destroying mosquitoes and their larvæ but resulting water requires attention and channelling requires repair THE INHABITANTS -- In addition to the ideal natural conditions for its existence the mosquito has another advantage as a salaria transmitter in the state of the inhabitants These who are very mixed and include Bulgars Greeks and Turks must be practically all malaria carriers The number and extent of the village cemeteries bear eloquent testimony to the ravages caused by this disease The survivors, especi ally the children verv often show their saturation with malaria in their facey Another marked feature ·NITURE OF THE COUNTRY 29 about the children is the protrusion of the abdomen due to their enlarged spleens The lack of energy displayed by the laccdonan Grech though probably Very much the result of living in such a hot chervating climate and of having many generations of malarious ancestors is largely due to the cffect of his own par ticular attacks of malaria When a female anopheles batea any of these people she can hardly fail to miss absorbing some of the plasmodium organisms wuch she will inject into her next victims who may be Bntish soldsers Fortunately there are not many natives near the front Villages abound but many of them are tcnantless having been destroyed in the rarious wars The grass di crgrown ruins afford many hiding places for hibcuating mosquitoes and for those drven in by rain and by artificial fires It will bc scen from the above that owing to the natural characteristics of the country and of its inhabitants the mosquito has an easy task in transmitting malaria while the anti malanal worker bas a correspondingly heavy one

·CHAPTER IV
ANTI MALARIAL MEASURES ADMINISTR4TIOV
THE Organisation that had been adopted in the area
to which we were attached was very complete
The Deputy Director of Medical Services at the head
of this organisation had a system of workers which
could only fail in efficiency by individval neglect this
if it happened could be soon detected The Assistant
Directors of Medical Services were responsible in their
respective divisions
Divisional areas were divided into districts with
the officer commanding a Field Ambulance responsible
in each These officers appointed malaria medical
officers from ther units to superintend antı malarial
work in the areas from which they collected and
evacuated sick and wounded
Beyond these were the regimental medical officers
who were responsible for their units and their battalion
areas as regards malaria and superintended the antı
malaria squads of their units when such existed
Outside the above direct chain but connected with
it were the sanitary vections attached to the corps
and divisions which co-operated in the work
30

·ANTI DIALARIAL MEASURES ADMINISTRATION 31 Beyond the divisional areas the OC corps head quarters sanitary section during the summer of 1977 acted as a special antı malarial ofhcer for the corps area and was responsible for the drainage canalisa tion and other treatment of all forms of water in his district The A DMS (sanitary) and some experts general or temporarily attached also made frequent surveys and were atatlable for consultatie purposes Reports were sent in weekly by the various officers as to the nature and progress of the antı malamal measures taken Tue reports were accompanied by maps Monthly reports were also sent in by some of the antı malarial Officers. The question of labour lor anti malanal work was a Serious one Where possible the regimental units had to supply the necessary men for dealing with water within a reasonable distance (generally half a mile) of their respectu e caraps It has been assumed that half a mile is about the limit of fught of a mos. quito but wind and other circumstances affect this limitation and there are very many exceptions. It is not a safe rule on which to depend Various military requirements interfere from time to time with the use of soldiers for ordinary anti malars, work but it is an important duty and may be much more valuable than some of the other drills or duties. Only the executive commanding officers can fare the responsibility of deciding as to the best method of using the men w fighting areas any of 3

·3
ANTI MALARIA WORK IN MACEDONIA
them base given very sympathetic help It would be
far preferable to have a permanent skilled antı malaria
squad of workers These could be formed indepen
dently and attached for the special work
Behind the lines civil labour under skilled direction
is an excellent method of carrying out the work The
natives can work all day whereas the soldier new to
the climate and handicapped by other duties can
only work within limited hours The natives more
over are accustomed to draining and ditching They
have to be adequately superintended to work well
The value of natives in anti malarial work has not
been nearly enough appreciated Applications to
military authorities for native labour were received
with much demur With much pressure a squad of
twelve natives was allotted in July in one area where
such work as channelling was badly needed These
tweke Turks did much good work and for one or two
weeks through persistent requests and refusals to be
put off the use of a large number of short time local
prisoners was obtained
At the time when only twelse natives were allotted
in an urgent period of the malaría season over twelve
hundred were employed in repairing roads in the
same limit of district Prevention of malaria just
then should not have been rated at one-hundredth the
value of the repair of roads

·CHAPTER V
RCHOVAL OF MEV FROY VALARIOUS AREAS
HISTORY has shown that there have been times when
military and other operations have had to be aban
doned owing to the ravages of malana Recent
history in Panam3 and elsew here has shown that the
Inowledge of the connection between malaria and the
mosquito fas ended thas helpless posttion where the
necessary money and labour are forthcoming
In Macedonia the malaria problem is complicated by
the fact that some of the worst mosquito haunts and
brecding places lie within the fighting zone and this
limits the possible extent of anti malarial measures
Outside the fighting zone the destruction of mosquitoes
and other means of lessening malaria are matters of
time labour and expense
In the Struma district in 1916 the itapossibility of
adopting suficient measures made it advisable to
adopt another line of front Elseu here the multary
advantages outweigh the disadiantages through illness
particularly as the latter is proportionately decreasing
oking to the measures taken
Although it is gecessary for the troops to remain in
33

·34 ANTI MALARIA WORK IN MACEDONIA this malarious country and fight on a malarious front, much illness can be prevented by care in choosing camp sites for the many troops not actually in tbe front line We think that more could be done in this direction In choosing sites away from the front line it is advan tageous to keep a proper sense of proportion between the importance of malaria prevention and that of military convenience as apart from military necessity In any case expert medical advice should always be obtained in the antı malaria interest even if for military reasons it must be eventually disregarded A via media may be arrived at in some such cases which may reduce the number of cases of malaria 1 without detriment to miltary interests The neighbourhood of water for example is always important for camp sites especially for those unuts with much anınal transport The trouble and incon vetuence however of carrying water for some distance from a malarious stream to a camp would in many instances be well repaid by a lessening of the number of cases of malaria As regards efficiency of the unit the repayment through health may be very great, as regards expense the laying in of a pump and pipes or the carrying of water for a distance by mule labour is obviously far cheaper than the unending cost of sick men and their attendants, and of the resulting reinforcements necessary We have in mind an animal transport unit where

·REMOS AL OF ME FROY MALARIOUS ANEAS 35
the sickness through camping near a Iller bed must
have far outreiched the advantages from proumts
of trater Practically all the officers and men had
malaria at some ume with frequent recurrences
Camps should be well up & hull Mosquitoes dislike
wind. If there is a prevailing wind a site on the
Windward side of the water should be chosen and as
far from it as possible The half mile limit sometimes
advised is a useful working figure but to be varied
according to circumstances especially in the direction
of an increase ol distance,
Wheneser possible men should be away from the
neighbourhood of water in Macedonsa after sunset
In most camp areas some portions are more free from
mosquitoes than are other parts In the long summer
evenings we have seen men bathing in and sitting too
near to the water after sunset The beauty of some
of the ravine streams and the coolness of the water
are tenuptations to running risks by remaining by
them after sunset

·34 ANTI MALARIA WORK IN MACEDONIA this malarious country and fight on a malarious front, much illness can be prevented by care in choosing camp sites for the many troops not actually in the front line We think that more could be done in this direction In choosing sites away from the front line it is advan tageous to keep a proper sense of proportion between the importance of malaria prevention and that of military convenience, as apart from muitary necessity In any case expert medical advice should always be obtained in the anti malana interest even if for military reasons it must be eventually disregarded A va media may be arrived at in some such cases wluch may reduce the number of cases of malaria) without detriment to military iriterests The neaghbourhood of water for example is always important for camp sites especially for those units with much animal transport The trouble and incon venience however of carrying water for some distance from a malarious stream to a camp would in many instances be well repaid by a lessening of the number of cases of malaria As regards efficiency of the unt the repayment through health may be very great, as regards expense, the laying in of a pump and pipes or the carrying of water for a distance by moule labour is obviously far cheaper than the unending cost of sich men and thetr attendants and of and of the resulting reinforcements necessary We have in mind an anumal transport unit where

·REMOVAL OP ME FROM MALARIOUS AREAS 35
the sickness through camping near a mer bed must
have far outweighed the advantages from proximity
of water Practically all the officers and men had
malaria at some time with frequent recurrences
Camps should be sell up a full Mosquitoes dislike
wind. II there is a prevathng wind a ste on the
unduard side of the water should be chosen and as
lar from it as possible The half mile limit sometimes
advised is a useful working figure but to be varied
according to circumstances especially in the direction
of an increase of distance.
Whenever possible men should be away from the
neighbourhood of water in Macedoma alter sunset
In most carp areas some portions are more free from
mosquitoes than are other parts in the long summer
evenings we have seen men bathing in and sitting too
near to the water after sunset the beauty of some
of the ravne streams and the coolness of the water
are temptations to running risks by remaining by
them after sunset.
HT
1

·CHAPIER VI
DESTRUCTION OF THE ADULT INSECT
Wuu E the mosquito is most easily destroyed in large
quantities in its larval stage much malaria may be
prevented by the systematic destruction of the adult
insect itself As the female anopheline lass about
100 eggs at a time the destruction of a female adult
particularly is as valuable as that of many larvæ
The haunts of the insect by day are especially under
growth such as weeds and long grass and places
sheltered from the light
Clearing undergros th by cutting and burning
especially along stream beds is generally po ible and
very much has been done in this direction Prairie
fires have been very extensive and useful In some
places near the front clearing and burning cannot
be carried out Undergrowth is often a protection
from observation The men of a unit that had a
sharp bout of malaria had about a fortnight previously
been engaged in putting up wire in dense grass
Our troops do not occupy many buildings at the
front but a favourite day haunt of the mosquito is
the universal dug out used by the men for sun
36

·DESTRUCTION OF THE ADULT INSECT 37 protection or for shelter from shes bursts There are necessarly many of these places of all sizes and shapes which possess the attnbutes of shelter coolness and absence of light in various degrees Very dark dug outs in the ravines harbour many mosquitoes Praire fites and heavy rain tend to drive the mosquitoes into such places Destruction of mosquitoes in buildings and slug outs can be carried out by furugation with sulphur ta the proportion of r pound to 500 cubic fect of space Burning of cresol is also useful Spraying with z per cent solution of fortalın or other insecticide is effective for thus purpose the foot sprayer is better in practice than the knapsach sprayer Syringing is not so useful Anophelines will bite in the dug outs during the dagtime We have seen one biting the wrist of an officer at midday thougl there is enough daylight in the dug out for ordinary purposes for ordibasy pusposes Anophelines bide in accumulations of such artilles as clothes and bedding and between the layers of double tents A Greek churchs used for services cepused regular disinfection for mosquitoes shortly beforc each day a occupation In the dus out thic catrance of what is illus trated by one sweep of a small net zong the wall echt mosqutoes see taught The place 175 thoroughly fumigated and nose see then found It then thirts 5 hours mosquitoes were as prctilent there as before A slagle fumigation only deals uith the insects present the process does not prevent

·CHAPTER VI
DESTRUCTIOV OF THE ADULT INSECT
WHILE the mosquito is most easily destroyed in large
quantities in its larval stage much malaria may be
prevented by the systematic destruction of the adult
insect itself As the female anopheline lays about
100 eggs at a time the destruction of a female adult
particularly is as valuable as that of many larva
The haunts of the insect by day are especially under
growth such as weeds and long grass and places
sheltered from the light
Clearing undergrowth by cutting and burning
especially along stream beds is generally posible and
very much has been done in this direction
Prairie
fires have been very extensive and useful In some
places near the front clearing and burning cannot
be carried out Undergrowth is often a protection
from observation The men of a unit that had a
sharp bout of malaria had about a fortnight previously
been engaged in putting up wire in dense grass
Our troops do not occupy many buildings at the
front but a favourite day haunt of the mosquito is
the universal dug out used by the men for sun
36

·DESTRUCTION OF THE ADULT INSECT 37 protection or for shelter from shell bursts There are necessarily many of these places of all sizes and shapes wluch possess the attnbutes of shelter coolness and absence of light in various degrees Very dark dug outs' in the ravines harbour many mosquitoes Prairie fires and heavy rain tend to drive the mosquitoes into such places Destruction of mos. quitoes in buildings and dug-outs can be carried out by fumigation with sulphur in the proportion of I pound to 500 cubic feet of space Burning of cresol is also useful Spraymg with 1 per cent solution of formalın or other insecticide is eftective For this purpose the foot sprayer is better in practice than the Loapsack sprayer Syringing is not so useful Anophelines will bite in the dug outs during the daytime we have seen one biting the waist of an officer at midday though there was enough daylight in the dug out for ordinary purposes Anophelines hide in accumulations of such articles as clothes and bedding and between the layers of double tents A Greek church used for Services required regular dis infection for mosquitoes shortly before cach days Occupation In the dug out the entrance of which is illus trated by one suscep of a small net along the wall eight mosqutoes were caught The place was thoroughly fumigated and none trere then found Vathin thuty sie hours mosquitoes were as prevalent there as before A singlc fumigation only deals with the insects present The process does not prevent ·38 ANTI MALARIA WORK IN MACEDONIA others from adopting the shelter almost at once The effect of formalın is most lasting in this respect but ceases when it also ceases to be unpleasant to men. The openings into dug outs should be covered with mosquito-proof netting after fumigation spray ing or otherwise cleaning out the insects and to be effective this netting should be in constant use Thts applies especially to dug outs used regularly as day shelters Individual mosquitoes may be caught and killed at twilight in rooms or dug outs through their ten dency to fly to the windows or nets over the openings They can also be killed on wall surfaces during the day especially near sunset and sunrise Tents and bivouac nets should be examined night and morning for mosquitoes In cases of defective or insufficiently closed nets the mosquitoes found in the morning are often full of blood Fiy papers are of a very limited use Placed near window openings or by the lamp mosquitoes may be caught on them towards evening as well as very many of the sand files which also cause a troublesome fever The hibernating mosquito should be specially sought out and destroyed during the winter It will usually be found in the dark corners of uncelled roofs cellars outhouses etc The electric torch or other light should not be brought too close to the insect of the mosquito is to be Lilled with a fly flap Mosquitoes can also be drien

·39
DESTRUCTION OF THE ADULT INSECT
out into the cold When possible however destruc
tion is better than driving out the insects Each
building in a locality should be systematically
examined about every fourteen days starting from
early in November Double tents and dug outs
should also be dealt with by periodical taking down
and fumigation respectively
Articles such as blankets and clothing should be
shaken out from time to time We have known
biting to follow the opening of bundles of clothing
Although cases of malaria in the following spring are
often instances of relapses it is quite possible that
they may be fresh infections due to mosquitoes that
have hibernated

·CHAPTER VII
DESTRUCTIOV OF THE EGGS LARIÆ AND PUPÆ
These forms of the mosquito are more easily destroyed
in quantities than are the adult insects The problem
of their destruction resolves itself into one of dealing
with the open water of the district
The anopheline wishing to lay its cggs is said to
have preferences for certain conditions as regards the
water it selects clear still and shady waters have
been mentioned in this respect. We can confidently
state that for practical purposes no open water must
be regarded as above suspicion We have found
anopheline larvæ in all varieties of water--ın running
as well as in stagnant water in dirty as well as in
clear water and in water open to the sun as well as
that in shady pools We remember two shallos pools
in particular one in a sandy bed and one in a rocky
ravinc in which there was not a vestige of weed and
which were quite unshaded Each contained very
large numbers of anopheline larvæ whose shadows
were distinctly reflected on the sandy bottom of one
and the rocky bottom of the other
In the marshy districts surrounding the lakes the
40

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·DESTRUCTIOVOT THE EGGS LIRIÆ WDPUPE 41 extensive breeding grounds are very difficult to deal with. In these situations the marsh is seen at its worst There are two large lakes in the arca in which ve served one of them being about forty square kilometres in extent The marshy portion of the borders of this latter is in the front line and so cannot be adequately drained or otherwise treated A certain amount of ouing could however be carried out with advantage Thc marshy arca of the other lahes borders is about twelve square kilometres in extent A main road runs along it for some miles and it is necessary for there to be various camps in the viciasty in the marsh around this fake the water logged soul is full of rushes and other shorter vegetation Thic rushes are aght feet lugh s places and ther and the undergrowth are so densels pached together that Caporation is almost nu There are some patches of open water in this area Nothing short of a large aud costly schere could render this marsh free from the mnoswtoes which abound there If this district must sull be occupied by the army to suck an extent as it was in the summer of 1917 we think that the problem of improving the state of the lake border should foucier recere considerable attention The men of the units no had to fue near and work along the adjoining rond suffered cry considerabis from malan It is to be feared that the magnitude of the work the expense and the difficulty of getting labour are prohibitne es regards thus swamp but su tak ·42 ANTI MALARIA WORK IV MACEDONIA something of considerable effect might be done in the direction of reducing the amount of segetation and by oiling parts adjoining the shore where the larva are mostly found At least numbers of the pest might be destroyed and it is here that a mosquito was found apparently associated with a bad form of malaria in adjoining units In the open water of the lakes the larvæ have not such favourable circumstances for development since the movement of the water owing to wind is injurious to them Drowned mosquitoes can be seen to the leeward side of large water surfaces still entangled in their pupa cases RIVERS -Fortunately it is only in the case of the large lake marshes that destruction of larvæ presents what has hitherto been considered insuperable diffi culties Elsewhere though many the difficulties can be and have been to a great extent overcome. In the many valleys and deep ravines due to the hilly nature of most of the occupied area the flow of water is fairly fast except in the height of the dry season In the plains the flow in the streams formed from ravine water is more sluggish The stream beds of the latter especially being large enough to take the winter water are partly empty in summer and contain as a rule a small slowly flowing often intermittent stream with many adjacent pools All the streams have irregular overgrown edges with weedy semi stagnant offshoots in which larvæ flourish Channelling, and filling in of pools, are therefore the

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·DESTRUCTION OF THE EGGS LARVA AVUPUPE 43 principal works necessary in the beds of streams The water should be confined to a space in width only just large enough to contain it without overflowing As regards depth there must be bome in mind the ten dency for a channel to soon fill up with silting mud and sand The chanselling should as a rule be in the direction of the natural course of the stream otherwise over Lloys will occur when silting begins The banks of the channel should be made as strong as possible for anurdals are liable to break them down Stones are useful for strengthening these edges The channel Itself should be cleared of Heed in places where a stream has been flowing quite quickly we have found larvae and pupa among the weeds The species of fine green weed most commonly met with in these situations is castly cleared and if thrown out on to a dry surface the lary in it rapidly die. The channel banks must be sharply cut Any small bay or indentation in their sides encourages stagnation weed growth and breeding of farve A rocky bed is difficult to treat by channelling but the difficulties can be Oiercome if the general prin ciples of a swift stream with sharply cut edges and free from werds, are borne in mind The formed channel is better left open than covered with stones as is sometimes done except where a bridge is necessa) Defects and needs must not be Hidden from the periodical patrols la cach stream bed, ponds and pools are to be found ·YORK IV ALACCDO VIA with the stream sometimes cuey are generally full of weeds and are favourite breeding grounds Occasionally they can be drained dry by a channel into the main stream Oftener the bottom of these pools is at a lower level than the water in the stream Filling in to above the water level with earth or sand, is the best treatment for pools that cannot be quite emptied by drainage The material used should reach a height that will prevent a hoof mark from forming a little pool A permanently dry surface is also necessary from the fact that anopheline larve can exist in very wet sand or mud In the instances where draining and filling in are not possible oiling may be done Crude petroleum or other oil that will make a fairly stable surface filma will quickly destroy larve Half a pint of petroleum 'will make a film over about 100 square feet of surface It should be applied by a sprayer Tailing a sprayer a sach can be soaked in oil weighted by a stone and thrown into the centre of the pond The oil can also Le applied by slow dripping from a tin with a tiny aperture This method is useful for automatic reapplication in slowly moving water, or at the sind vard edge of a pond Theoretically, once a week should be enough for re-oilng but practically oiling is not a success unless it is done about three umes weekly The drawbacks to the use of oul include the items that wund clears the ou from vindivard to leeward that rushes and weeds interfere with the essential

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·46 ANTI MALARIA WORK IN MACEDOVIA of a spring in a level piece of ground which is water logged up to the point where a natural outlet is found A channel should be cut from this outlet as far as possible into the Swamp in the hope of getting near the rising point of the spring The channel should be deep enough to drain the surface area in the immediate vicinity In the district there is a large swamp or rather pond fed by underground springs or mountain drainage and full of rushes and other growth This pond was a fertile source of mosquitoes It is situated high in the hills in a saucer like depression in the rock and could not be drained by a channel without much blasting of rock and was too large to be filled in It was moreover within long range of the enemy s guns A six inch iron pipe siphon was fixed and reduced the depth of water by four feet Thus the surface area of water was very considerably lessened Trenches with clean-cut edges will often collect the water of some swamps which can then be oiled or otherwise treated From all varieties of water rushes and weeds should be cleared and the undergrowth along the banks which harbours mosqutoes should be cut away and burnt- ACCIDENTAL WATER-In addition to the above forms of water accumulation there are various small but fruitful mosquito breeding places which are more dangerous than they seem to be at first sight Many of them are found close to human habitations tem porary or more or less permanent and consequently

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·DESTRUCTION OF THE EGGS LARYX AND PUPE 47 the mc quito is ncar its desired ource of buman blood There are very numerous natise water fountains throughout the occupied area. We have often found Anopheline lanz in the overflow waste water from these This waste water forms a marshy piece of ground which requres canalisation Tlie canal or channel should lead into a stream u possible other Misc it sliould be led into a large pond or pit that can bu carefully cxamined and treated from time to time We have found abundant anophelınc larvæ in a neglected tub or half barrel containing Water at a drink ing supply tap fixed on a pipe in a ravinc. The barrel was used to rinse Tessels and to catch waste and was never thoroughly emptied The men of the adjoining infantry unit regulurly visited this lountain for water many times daily and worse still in the evenings Malaria cases were occuring among them. Tinding lan in hoof marks along the edges of streams has been our constant experience These accidental holes hould be at once filled in Two neglected tubs in a vegetable garden were found to contain many lars. I in a district othenise comparaticly free from anophelines Vater was often put into tliese tubs but they were never com pictly emptied Aforinght after the removal of these tubs some otherwise unaccountable malaria in a neiglıbouring unit abated Any neglected tin or ressel with its opening up ward and capable of containing water for over a

·50
ANTI MALARIA VYORK IN MACEDOVIA
The cultivation of fish might be useful to some
extent but we have continually found numbers of
small fish and anopheline larvæ living apparently
amicably in the same pond
Natural enemies of mosquito larvæ probably exist
but do not make such an impression on their numbers
in Macedonian waters as would warrant any neglect
of other methods of destruction

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·CHAPTER VIII
PROTECTIOV Or THE MON TROV BITES
IT is obvious that dunng the course of a militar
campaign in such a malarious country the whole area
occupied by troops cannot be rendered frec from
mosqwtoes and their larva in the time and by the
means at disposal It is of the utmost importance
therefore that efficient measures should be adopted
and properly carried out for protecting men from being
Initten
First among these measures is the use of nets at
night time to keep out mosquitoes the mesh of the
netting fabric must be of at least twelve openings to
the inch and a finer mesli of eighteen openings is
ptu ferable
It is not necessary to describe in full dctail the
construction of the nets used especially as experienre
has led to frequent improvements The important
fact is that in 1917 some form of not quite eacrent it
properly used was unisersally provided
The bisous net has been the ordinary form.
Two men sleep unde cach net The illustration shows
the arrangement The net is cosered on the top by
s!

·52 ANTI SIALARIA WORK IN MACEDOVIA a movable bus ouac waterproof sheet and is sometimes under a sun shelter If it is kept in repair and the simple instructions with regard to its pitching and closing at mght are carried out, it is quite efficient for its purpose Its handy size and light weight are important where mobility is so essential and transport facilities are so limited A disadvantage of this bivouac net is its frailty Strengthening bands of material should be added to its large surfaces Another dras back is that the net is low There is thus insufficient space especially head room and consequently men use such expedients as that of raising the poles on stones Openings are in this way left for mosquitoes to pass through and the net may become a trap instead of a protection The best method of meeting the difficulty of head room is to hollow out the ground in the interior for about one foot in depth Improved bivouacs are being devised as a result of this years experience There will be more room and they will be more fool proof as regards the closing up arrangement Failure of efficiency with regard to the net is due to ignorance or neglect of the occupants who from fatigue caused by heat or stork or in some cases from laziness do not close the net properly at night The neglect of the Occupants in not repairing accidental holes also leads to inefficient protection On one occasion a surprise visit was made at night to a small unit and we found only three out of twenty

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·of bivouacs but this was negligible in that almost 1 weather this form of protection 19 preferable to that 33 PROTECTIOY OF THC VCV FROM BITES sur nets properly closed although cases of malaria were of daily occurrence in this unit A few minutes must be occupied in closing the net properly but they are essential and the trouble is well repad. The ni, ht nets of any form should be in place and closed from mosqutoes at sunset After fixtag it 15 well to make sure that so mosquitoes have accidentally been shut in Simple as the closing process is systematic drill should take place after the trial lastructioa has been given The nets should be examined as to proper closure after turning in time by someone responsible and able to insist on immediate closure Repairs should not be left to the men themselves as is usually the case but one or more men who can use the needle should be detailed for that special duty A net with a bole may become a mosquito trap Another forn of net issued to the troops this year was shaped so as to fit inside a bell tent There is more room in nets of this pattern but they possess no special advantages over the bivouac nets in efficiency against mosquitoes neglect to properly close the openings is common. lle have found the nets of a row of seven occupied te is all open at night and have also frequently found large holes in the nets li mosquitoes get in they are less easily caught than in many camps bell tents cannot be used in bad bivouacs in ·5+ ANTI MALARIA WORK IN MACEDONIA no rain fell in the district during July, August and September 1917 Special mosquito proof huts with wire netting of fine mesh have been used in certain parts during the latter part of this summer They proved very success ful and might be used with advantage on a more extended scale next year An illustration of one such hut is given There is much space in them and more protection from the elements Wire netting and fine fabric mesh have been much used in door and window frames for protecting huts and dug outs This protection is not very reliable and needs frequent attention Wood warps readily in the hot sun and the edges of dug out openings are often very irregular and crumbling The ordinary mosquito net used over a bed with the edges tucked in can only be used in favourable circumstances Au forms of net require nightly supervision and protection A mosquito can easily bite a bare skin surface which is pressed against the net An important point in connection with the proper use of nets in the fact that there are now so many malaria carriers amongst the troop It is essential to cfficiently shield these men from bites not merely to protect themselves from re-infection but also to avoid the transmission of infection from them to others Night nets should be used as long as mosquitoes are prevalent Fixed dates for their commencement ·為它 山

·PLATE VII
TLRXED 10W
R TECTI VABIL GOLE AV SHORT
VER P IARXA EL

·PROTECTION OF THE MCV FROM BITES and discontinuance are less important than the circum stances of the year Anophelices were still biting in november 1917 TACE NETS Tor mer sko hati to work at night it 19 very necessary that the uncovered portions of the body should be protected in some way Verls that fit on to the cap or helmet are provided. Thics have cach a stiff metal ring r.dxay to keep the material from settling on the cars and nose These sets must be properly put on "lchase seen men 15sing the veil sith the ring on the car and the cil thus touching the nose ears and chua when the and was tuched into the collar band Unprotected skon surface was thus at the mercy of the mosquito Certain cosh cannot be done ander sells especially at the front Gloves are also provided for sight work. The wrist of the glove is not as a rule long enough unless the man has hus sloses well pulled down. Expericncc has led to fool proof improvements in the detail of the sels and gloves if required for another malana 8C3Son Shorts are unisersally som sn summer leaving much of the ins and thi, h bate The shurts now provided base as cites10 sh is turned up in the dayim an I can bc tume down over the bare parts at night in the illustration the leg of th shorts is turned down 07 one idi Tsere 15 wc urderstand an order as to tuming them down at sunset I so thu order is too trafiently disregariet It seemed

·PLATE VI?
TURNED pou
ROTECTIO , YEIL GLOVES A D SHORTS
OVER THE BARE Ft

·PROTECTIOV or TIC MEY TROJI BITES 53 and discontinuance arc less important than the circum stances of the scar Anophelides were still buting in Lorember 1917 FACE Nuts -Tor men who hase to work at night It is very necessary that the uncoleredt portions of the body should be protected in some way Vals that fit on to the cap or helmet are provide They have cach a shli metalning midway to hexp the matenal from setting on the cars and nose These nets must be properly put on Wehuse seen men using the scl with the ning on the cap and the cil thus touching the nose cars and chin when the and was tucked into the collar band Unprotected skin surface was thus at the mercy of the mosquilo Certain work canot be donc under reil especially at the front Gloves are also provided for might work The wrist of the glose is not as a sule long enough unless the man has leis sleeses sell pulled down Experience has led to lool proof improvements in the detal of the vals and gloves if required for another malara 8C2SOLL. Shorts are noucrsally horn in summer Icaring much of the Lncc and tługh bare The shorts now provided haycan extension which is turned up in the daytime and can be turneul doun oict the bare parts at night in the illustration the leg of the shorts is turned down on one side Tiere is no understand an order as to turmins them down at unset 11 tut order is too frequentis dish garded It seems to ·36 + ANTI MALARIA WORK IN MACEDOVIA be nobody s business to insist on this precaution being taken and the men seemed to object to the appearance of the turned down shorts In connection with face nets the following experience that is fortunately not common may be cited For certain purposes it was found necessary to form a camp near the bed of a stream of a bad type-se a sandy river bed about thirty yards wide with a sluggish stream about one yard wide spreading into pools Anopheline larvæ were very plentiful here and steps were at once talen to deal with the stream and pools We found that no face nets had been issued for the night guard This deficiency was immediately reported Four days later on visiting the camp we found that this report had just reached the commanding officer of the unit after passing through the hands of three departmental chiefs The CO was requested by the last of these to indent for the veus He did so and the veils arrived after about two to three weeks Eleven cases of maları2 occurred after the lapse of twelve days from arrival in this camp before the veils arrived Five of the affected men had been on might duty It ought to be in the power of the medical chief to send these nets at once when necessary The medical department has too little executive power in such matters REPELLEVTS-It will be understood that there are certain military duties to be performed at night which 14 ·PROTECTION OR THE Y TROSI DITES 57 preclude the use of any form of face act Some ingenuity has theretore been exercised to and a material that being appued to the skin surfaces fill repel mosquitoes Substances that has had at some time something said in their fas our in this respect by the troops using them in Macedonia include the following Crude paraffin Fariquit (official 3,sue) Strong essential oili zubbed up m a base such as tasclinc Tar preparations Vermell The erdicts of the man uing these preparations have varied considerably from quito successful to the mosquito $77 to prefer tho e Hith the pre paration on Our own personal expedienec is that there is a short fwerod during which these preparations repel mos quitoes and that this 15 thc period during which thic odont 15 strong Oil of ctronella lot oft biting 120cts for half an hout After that period the oiled skin erercised no repellent elect There is no doubt that on the riole repellents of the above Lind ate useful for aume and the first twa of them seem tou to have the best cffect Without depending on them shen the previously described preciutions are as 2ilable they must be considered asclul to those who from the nature of their duties have etposed shia surface at night Repeated

·$8
ANTI ZALARIA WORK IN MACEDONIA
appucations of the preparation must take placc
especially if there is much perspiration
From practical experience we have noted that men
are careless in the matter of malaria prevention
despite the numbers of sick they see around them
The men are too often in the ravines and neat water
courses in the evening By sunset all men should
have left water courses bathing pools and ritmes
cxcept those whose duty compels them to be there
We hare seen mer dathung in the streams after sunset
in August This w25 of course stopped when reported
Ignorance should be more combated There should
be systematic dnil in anti malarial measures The
French have sued instructive and anasıng posters
and picture postcards on the subject We hase
Interested many sen by showing them the larvæ and
explaining how the mosquito develops and how it
spreads disease This might be done systematically
In this connection re may refer to the fact that
two newly arrived medical officers told us that attend
ance at the lectures on malaria in their recent home
RANC training was optional !
Where dug outs are pred for shade during the
day more attention should be given to killing the
mosqutoes in them or to driving them out The
dug out of unprotected by a pet should be
abandoned of possible before twilight

·CHAPTER IT
QUINIVE PROPHYLAWS
117Le the efficacy of quinine in the treatment of
malara us so very mark cut its value as a prophylactic
is a subject on huch expert orion has been sarted
and contradictory from our expenescein Macedonsa
*c way say at once and extphatically that the prophy
lactic value of qunine in the doses given has been at
il cients so incomplete and questionable that song
of the other precautions can for a moment be neglected
in favour of such practice korcyer universally it may
be camad out
Pre tous experience of the riages of malaria
resulted in a practically unny crsal adoption of the
taking of qmnine as a prophylactic in our area during
the summer of 1917 Nowhstanding Dus malana
bas occurred in the case of a very large proportion of
the men In some specially mposed onus sery less
of thic mca escaped one or more attacks
Ven receiving at least 10 grans of the sulphate
solution 10 a week and often up to 10 guns d
for a long period lase beca taken all the
primary and recurrent lle may go so far
39

·60 ANTI VALARIA WORI IN MACEDONIA that in the summer of 1917 practically all the malaria patients had been taking quinine as a prophylactic in these doses. This confirms the results of experi mental investigations with small doses in other countries If it were possible or advisable to give curative doses of 30 grains daily as a prophylactic instead of the doses mentioned above the effect would have perhaps been more marked and of other precautions are impossible or nearly so men might be protected in this way It is likely that the doses that have been given have lessened the number and severity of the attacks and have enabled more men to remain on duty though we can give no figures to bear this out Thorough attention to the other antı malaria precautions would make the taking of prophylactic quinine unnecessary but this thoroughness is not always practicable oiving to military exigencies The broad facts are sufficient for practical purposes They indicate that while quinine prophylaxis should still be employed especially where other precautions are difficult reliance should be placed infinitely more on the various methods of protecting men from the bite of the mosquito We have found that there is occasionally a danger from an excessive faith in quinine In some instances this has led to a lessened acuvity in the more arduous directions of prophylaxis such as proper attention to adjacent water and to keeping birouac nets repaired and properly closed at night ·QUINIVE PROPHYLATIS 61 In the early days of the Macedonian campaign men often evaded their quinine by not being present at thic parade by being anay from the centre of the unit by ejecting the quinine from the mouth and by other method Direct refusals to take it were un common To make more certain of administration the mediane had to be given in solution and sometimes the device was necessary of making men swallow after taling at by requinng them to at once mention aloud their respective regimental numbers f'ersonal esperience of malaria and its effects and the desire to avoid them has reduced to an almost vanishing point any serious wash amongst the men to neglect their prophylactic dosage though they do not like it of the powder tablet and solution forms of ad ministration the last is the most certain The small amount of inconvenience is more than compensated for by the certainty of the man getting his dosc and that it will not pass unchanged through the intestine as might happen with a tablet It should be given after a meal und in the ciening A method of administration generally adopted in 1917 *as as follows Cicry maa had a dose of 10 grains of the sulphate of quinine in solution on Thursdays and Sundays old malaria patients an extra two doses of yo grans cich per week and men in very malanal areas at the front where other precautions can only bo partally if at all observed io grains per day The question has been sometimes aled is the ·60 AVTI VALARIA WORK IN MACEDOVIA that in the summer of 1917 practically all the malaria patients had been taking qunine as a prophylactic in these doses This confirms the results of experi mental investigations with small doses in other countries If it were possible or advisable to give curative doses of 30 grains daily as a prophylactic instead of the doses mentioned above the effect would have perhaps been more marked and if other precautions are impossible or nearly so men might be protected in this way It is lkely that the doses that have been given have lessened the number and severity of the attacks and have enabled more men to remain on duty, though we can give no figures to bear this out Thorough attention to the other anta malaria precautions would make the tahing of prophylactic quinine unnecessary but this thoroughness is not always practicable owing to military exigencies The broad facts are sufficient for practical purposes They indicate that while quinine prophylaxis should still be employed especially where other precautions are difficult reliance should be placed infinitely more on the various methods of protecting men from the bite of the mosquito We have found that there is occasionally a danger from an excessive farth in quinine In some instances this has led to a lessened activity in the more arduous directions of prophylaxis such as proper attention to adjacent water and to keeping bivouac nets repaired and properly closed at night ·QUININE PROPHYLATIS 61 In the early days of the Macedonian campaign men often evaded their quinine by not being present at the parade by being away from the centre of the unit by ejecting the qulaine from the mouth and by other methods Direct refusals to take it were un common To make more certain of adminustration the medicine had to be given in solution and sometimes the device was necessary of making men swallow after talın, it by requiring them to at once mention aloud their respective regunental numbers Personal experience of malaria and its effects and the desire to avoid them has reduced to an almost Vanishing point any erious wish amongst the men to neglect their prophy lactıc dosage though they do not like it of the powder tablet and solution forms of ad ministration the last is the most certain The small amount of inconienience is more than compensated for by the certainty of the man getting his dose and that it will not pass unchanged through the intestine as might happen with a tablet it should be given after a meal and in the evening A method of administration generally adopted in 1917 was as follows Lvery man had a dose of 10 grains of the sulphate of quinine in solution on Thursdays and Sundays old malaria patients an extra tuo doses of 10 grains each per week and men in very malarial areas at the front where other precautions can only be partially if at all observed 10 grains per day The question has been sometimes ashed Is the ·62 ANTI MALARIA WORK IN MACEDONIA efficiency of the men affected by prolonged dosing with quinine? The question is a difficult one and has received and is receiving attention by experts On the whole the answer to this question is apparently in the negative cases of cinchonism with the doses mentioned were very rare gastritis suffi ciently marked to be reported was not at all common We noticed a certain amount of deafness and occasion ally a slight slowing of mental effort The hard work of the front line troops in Macedonia has however gone on as usual in spite of the effects of malaria and the hot moist climate An intelligent and tactful medical officer of a unit could easily deal with any idiosyncrasy to quinine as it arose without interfering with routine administra tron An important feature of quinine prophylaxis is that in curative doses of 30 grains daily the drug might have a good effect in reducing the quantity of infective material by destroying the organtsm in the blood of carriers It has been proved that in small doses quinine has not much if any destructive effect on the sexual forms of the organism and these are the forms that enable the mosquito to carry on the cycle of infection Large doses cannot be given indiscriminately until more definite information is obtained as to the possible effects of so much quinine on the constitution of the healthy individual and on his capacity for work Investigations are going on which seem likely to ·QUINIVE PROPHYLAXIS 63 dissipate the doubt we have at present as to the advisability of giving such large doses to men in arduous work Apparently quinine prophylaxis does not interfere with the use of the drug as a curative agent when the subject has an attack of malaria Qunine prophylaxis as at present carried opt is from a practical point of view a form of malaria prevention that can only be considered an unsatisfactory refuge for those destitute of the other better formas It is well to bear in mind that while kept up to the extent indicated during the summer of 1927 the men taking the quinine had malaria in all forms to a very Serious degree 5

·CHAPTER X
CONCLUSIONS
It is evident from the foregoing pages that the anti
malaria work of 1917 in this area has been very exten
sive and it was successful in limiting malaria among
the troops
Military exigencies are such that it is inevitable that
there must be exposure to infection and consequent
malaria to some degree under the circumstances
all the breeding grounds cannot be thoroughly dealt
with nor can the men carry on all their night duties
under nets or be always using precautions
Wlule the above is true it is but natural that
experience has shown that even more thorough and
successful work can be carried out, if Macedonia has
to be occupied during another summer
In addition to points alluded to in the earlier pages
we venture to make the following comments and sug
gestions some of which are already receiving attention
to a limited extent
Education of officers and men of all branches of the
local army as to the causes and prevention of malaria,
might with much advantage be considerably extended

·65 CONCLUSIONS Co-operation in antı malaria mcasures is far more satisfactory when its basis is intellectual Ilustrated posters and postcards are in use in the French Array Practical demonstrations of larve and interesting Bccounts of the spread of the disease by the mosquito would lead we behere to more practical assistance from the units in exposed positions A still closer co-operation is advisable between executive officers and medical officers expert in malaria as to camp sites where these have not to be fixed by purely military exigences The prevention of cases of malaria may be a substantial gain in return for some inconvenience It is also possible that some twilight parades at right or morning might with advantage and without military detriment be aban doned or minimised. - A regular dnli in net closing and in the use of other antı malaria measures might be instituted That this 15 necessary is shown by the constancy with which torn and ineffectually closed nets are found The use of the gas mask has to be taught by drill and the proportion of men gassed in Macedonia to that of men invalided by malaria is absurdly insigruficant The medical department should be able to supply ribt away such iterns as nets and seals The requisite forms could be filled in afterward. The medical department in the army has too little executive power in such respects Vert recommendations lead to delay and much unnecessary waste of time and paper The saditat) men of units who have to look after

·CHAPTER
CONCLUSIONS
It is evident from the foregoing pages that the antı
malaria work of 1917 in this area has been very exten
sive and it was successful in liraiting malana among
the troops
Military exigencies are such that it is inevitable that
there must be exposure to infection and consequent
malaria to some degree under the circumstances
all the breeding grounds cannot be thoroughly dealt
with nor can the men carry on all their right duties
under nets or be always using precautions
While the above is true it is but natural that
experience has shown that even more thorough and
Successful work can be carried out of Macedonia has
to be occupied during another summer
In addition to points alluded to in the earler pages,
we venture to make the following comments and sug
gestions some of wbich are already receiving attention
to a limited extent
Education of officers and men of all branches of the
local army as to the causes and prevention of malarza,
might with much advantage be considerably extended.
64

·CONCLUSIONS 65 Co-operation in anti malaria measures is far more satisfactory when its basis is intellectual Illu trated posters and postcards are in use in the French Army Practical demonstrations of larve and interesting accounts of the spread of the disease by the mosquito would lead we believe to more practical assistance from the units in exposed positions A still closer co-operation is advisable between executive officers and medical officers expert in malaria as to camp sites where these have not to be fixed by purely military exigencies The prevention of cases of malaria may be a substantial gain in return for some inconvenience it is also possible that some twilight parades at night of moming might with advantage and without military detriment be aban doned or minimised. A regular drill in net closing and in the use of other ants malaria measures might be instituted That this is necessary is shown by the constancy with which torn and ineffectually closed nets are found The use of the gas mask has to be taught by drill and the proportion of men gassed in Macedonia to that of men invalided by malaria is absurdly insignificant The medical department should be able to supply right away such items as nets and tells the requisite forms could be filled in afterwards the medical department in the army has too little executive power in such respects Vere recommendations lead to delay and much unnecessary waste of time and paper The sanitary men of units who have to look after f 1 > ·66 ANTI MALARIA WORK IM DIACEDONIA patrol and other anti malaria work should be the best men available and not as is sometimes the case chance men perhaps unfit for other duties On the surface their incompetency may not be so noticeable as it would be in the case of other duties but in Mace donia particularly special ability and trustworthiness in these men is essential All these men should have been taught and should have been examined in the practical points as to malaria and its prevention Canalisation and similar work should be begun earlier in the year even in March or April This must depend to some extent on the rains which destroy such work but a lot can be done as the waters subside with out lying accumulations It should be borne in mind that though in 1917 the very extensive buting began early in June there were many primary malaria cases in the earlier months of the year After a warm spell larvæ will be found. If these early mosquitoes are destroyed obviously a useful work will have been accomplished The hibernating mosquito should receive special attention in the winter and spring months Early in November in two days a few intelligent men specially put on for the duty secured over 3 000 female anophelines in and near tko camps adjoining two villages In the camps themselves the average number caught in each tent between the double layers of canvas was five and in the darkened dug outs they were caught by scores They can be caught in such shelters especially after rain Dug outs daily attention require almost ·67 such items as faulty nets or neglected water courses CO\CLUSIONS Civi labour should be used to a greater extent where politically possible If and where such labour is not available then definite anti malaria contingents might be formed from labour battalions The antı malaria work is as essential in Macedonia as the repair of roads and the labour for it should be organised just as much as that for road making and other purposes In this way skilled workers would be eventually perma nently available It is hardly far to put this labour on to front line units Even if there is time or oppor tunity for it to be so carried on such labour is not regular or skilled Finally we consider that insufficient notice is too often taken of lapses of care on the part of individuals in protecting themselves and others from exposure to needless risks of mosquito bites. The discovery of should involve serious consequences to the offender as surely as any important military offence would do The photograph showing a bell shaped mosquito Det in a tent was not taken purposely to show the hole converting it into a trap only too common sight and its conspicuous position in this case shows how httle notice is taken of such neglect The instance has already been mentioned of a night visit to a camp where it was found that only six per cent of the men had taken the trouble to close their nets properly The only censure in the case of whach se heard was apportioned to the officer wborn It is unfortunately an

·68
ANTI MALARIA WORK IN MACEDONIA
made the discovery for not properly notifying his
visit before examining the nets of the unit.
There is no possible doubt that individual neglect
of the simple precautions at hand has accounted for
very many cases of malaria and such neglect should
not be treated so lightly as it is in many cases in such
a malanous country as Macedonia.
# Laris o Co LLL r Gower Strect, London, WGT

·5
$
PLATE VIII
1/65
HELL TET
TH A NEGLECTED HOLZ IN THE
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