48] OTHER PARTS 403
cases, and weak hematine gave us good results in staining
the zygotes. Sometimes no infection of the insect took place,
or the zygotes failed to reach maturity. We felt that such
variations were probably due to the diet of the mosquito, and
a note by Sehoo of Holland confirmed this ; for he pointed
out the importance of avoiding acid fruit in the food of insects
under infection experiments, and when we fed them on melons
the growth of the zygotes was uninterrupted.
The role then of Anopheles in Spain admits of no doubt •
and the mosquito has never been found wanting in malarial
districts in the fever season when searched for by competent
observers.
These investigations were confirmed elsewhere in Spain
by Huertas and Mendoza in the province of Caceres, and by
Pittaluga in Catalonia (Barcelona), Valencia, Madrid, and the
Balearic Isles, where he found A. maculipennis, A. psendopictus,
A. superpictus and A. bifurcatus.
In 1903 Pittaluga collected the investigations up to date
on malaria in Spain, and from the papers of different writers
in that volume some idea was obtained of the extent of malaria
in modern Spain. His map gives a good idea of its distribution.
Though exact data are difficult to obtain, it is quite apparent
that the disease still reigns with great severity in the Peninsula.
In 1900 there were 4,703 deaths from malaria in Spain in a
population of 18,300,000, which is a malarial mortality of 0*25
per milk. In relation to the general mortality of 536,716 (29-3
per mille), this represents 1/114 of the general mortality, or
9 per 1,000 of the cases of death. In 1898 and 1899, when
the troops came back from Cuba, the malarial mortality rose
immediately, and probably gave in each of these years a
mortality of not less than 8,000 per annum. The following
figures from a railway company give a further idea of the
ravages of malaria in Spain to-day. In 1902 12,746 employees
were treated medically or surgically, and of these 1,904 were
malaria patients. Five deaths were directly attributable to fever
404 MALARIA IN SPAIN [Sect.
and the company lost 14,275 days' work in consequence of the
disease.
On certain divisions of the line this company keeps a double
personnel to alternate every fifteen days, and the employees
themselves call one notoriously unhealthy area " Little Cuba,"
where their doctors admit that the mortality is equal to that
of tropical countries.
After these researches some stimulus was given to prophy-
laxis, but, so far, in Spain it has only been undertaken by a
few companies and private individuals. In a country where
typhus last year raged in her capital, and the isolation hospital
is unknown in her provinces, sanitation is only in its infancy^
In the city of Badajoz in 1899, in one street 500 people were
attacked by malaria, and the supply of quinine ran short in
the town. Yet no municipality has yet organised a scheme
of prophylaxis.
Through the kindness of Dr Varela we are enabled to
submit the following figures from the Madrid, Zaragoza, and
Alicante Railway, where protection of the railway servants'
houses by wire-gauze, and the administration of quinine, are
the methods employed, and have given a gradual but steady
diminution in the cases of fever : —
1901-1902 no protection 631 cases
1903-1904 with protection 306 „
1905 „ „ 190 „
In Rio Tinto, supported by a company which recognises
the importance of the health of their staff, we initiated measures
of prophylaxis, on a small scale, which have been continued
under the direction of Dr Russell Ross, the chief medical officer,
with eminently satisfactory results. The English staff of this
compan)', with their wives and families, number about 170
persons. They live in a group of thirty houses, in close
proximity to the ravines where Anopheles pools are found.
A few years ago in the malarial season each house had its
fever patient, and the place was notoriously unhealthy. The
48] RIO TINTO 405
pools are now filled up or drained away ; and, where it is
impossible to remove the water completely, narrow channels
are made by which a rapid flow is maintained, and stagnation
prevented. Simple open drains have been laid in the bed of
some water-courses. The use of nets is recommended, and
some families have their houses protected by wire-gauze. The
effect on the number of mosquitos has been marked, for now
they are hardly ever seen. Hen-roosts and places harbouring
domestic animals are smoked out once a week by a mixture
producing sulphurous acid gas. The diminution in the cases
of malaria may be seen by reference to the following table
which we owe to the kindness of Dr Ross : —
Cases of acute
malaria
25
2
O
o
I
The attack on the Anopheles pools has recently been
extended to the ravines round the workmen's villages, where
gangs of men under supervision drain away and fill in the pools.
The improvement in the health of the people has been
most marked. In former years departments with 2,0(X) men
at times had hundreds incapacitated by fever, and difficulty
was sometimes found in maintaining the service. Now, though
some cases still occur, fever never rages to the extent it
did formerly. Villages which were recognised as hot-beds of
malaria, and consequently avoided by the workmen, have been
rendered comparatively healthy again. The cost of these
measures in Rio Tinto and its environs is less than £\Q0
per annum ; but costs are lessened by assistance given by the
various departments of the mine. Ten years ago there was
a yearly despatch of 1,225 oz. of quinine; it is now reduced
to 900 oz., though there is an increase of 50% in the number
of workmen.
Cases of illness
1896 .
no prophylaxis
89
1906-07
61
1907-08
1908-09
prophylaxis
64
78
1909-Ioj
80
By Professor ANGELO CELLI
Director of the Institute of Hygiene, University of Rome
49. The CampaigTi against Malaria in Italy.^— In my report
to the International Congress, held at Brussels,^ I described how
a Society for the study of malaria in Italy had arisen, and
stated that it had initiated its work for the purposes of know-
ing better and vigorously combating this grave scourge of our
country.
I have much pleasure now in noting summarily the results
obtained from 1903 till to-day.
Since Ross's discovery was confirmed and consolidated by
the work of some of our members, and later by many other
workers, we have continued to work in the scientific and
practical fields.
In the scientific field we have made researches on the etiology,
physio-pathology, epidemiology and prophylaxis of malaria.
In the practical field we have introduced new and improved
prophylactic measures into medical use, legislation and the
habits of the people.
In order to keep within the narrow limits assigned to me, I
can note only the following facts : —
^ Owing to pressure of work, Professor Celli has asked me to take for his contribution
to this book his article in the Journal of Tropical Medicine for 1st April 1908 (trans-
lated by Dr John J. Eyre), with special additions. The editor of the Journal has
kindly permitted this. — R. Ross.
2 Septime Section. " Hygiene Coloniale, Deuxieme Question : Prophylaxie de la
Malaria," vol. viii. , Bruxelles, 1903, and Giornale della R. Soc. ital. d'/giene, Milan,
1903.
406
Sect. 49]
QUININE AND MORTALITY TABLE
407
FIG. I. — MORTALITY FROM MALARIA AND THE CONSUMPTION OF QUININE
IN ITALY.
I Annual number of deaths from malaria from 1887 (upper part).
^ Kilograms of quinine imported by private measures from 1 89 1 onwards.
^ Kilograms of State quinine sold yearly from 1902 (lower part).
4o8 THE CAMPAIGN AGAINST MALARIA IN ITALY [Sect.
I.— The Principles of Epidemiology
By our researches it has been demonstrated and confirmed
in different ways that : —
(i) Man is the only source at present known of malarial
infection.
(2) Not only infants, but also children and adults, are the
bearers of the infective germs.
(3) The recurrences, sometimes obstinate, in spite of every
kind of treatment, are the most marked characteristic of every
form of malarial fever. They maintain the contagion between
the healthy and the diseased from one epidemic year to the
next, and are one of the main causes which regulate the local
and annual variations of the malarial epidemics.
(4) As the indication of an epidemy, it is necessary to take
into consideration : —
(a) The infantile malarial morbidity and the relative splenic
enlargement: this splenic index, as it is named by
Christophers and Stephens, may be easily ascer-
tained, but is neither exact nor exclusive ; moreover,
it does not suffice, when alone, to indicate the
intensity of an epidemic,
(^) The morbidity in the whole population or in some
classes of it (country people, miners, soldiers, railway
employees).
(c) The recurrent cases which are more or less obstinate.
(d) The numerical relation between the aestivo-autumnal and
the mild tertian fever cases.
(e) The more or less severe clinical features and complica-
tions (haemoglobinuria).
(/) The manifestation of domestic epidemics or of sporadic
cases.
(£■) The total or absolute mortality related to the whole
population (relative mortality), or the one related to
49] GENERAL PRINCIPLES 409
the number of the infected individuals (pernicious-
ness or lethality from malaria),
(/z) Demographic indications, especially the excess of deaths
over births and the following depopulation and
desolation which are but too sad a characteristic
of malarious lands.
When we take into account all these indications, we may
every year not only exactly establish the course of epidemics
in our districts, but also precisely compare our observations
with the international ones.
An historical description of epidemics in these last years, by
making use of the above - mentioned indications, would be
possible only for small, well - circumscribed and thoroughly
studied areas.
Therefore we must generally content ourselves with the
mortality index, and, so far as possible, with the morbidity
index too.
(5) The severe tertian, the mild tertian, and the quartan
have each a special type of epidemy ; that is to say, the first is
aestivo-autumnal proper, the second is the only one which
presents itself in the spring, the third is principally autumnal.
(6) The Anopheles are never wanting where the fevers exist,
but their quantity is not always in direct proportion to the
intensity of the epidemy ; in fact, it is frequently in inverse
proportion. On the other hand, there may be plasmodia and
Anopheles without malaria developing itself, even when malarial
patients arrive there from other places, or some autochthonous
or sporadic case of fever manifests itself there. Plasmodia and
Anopheles may therefore persist, and, notwithstanding this, the
malaria may become attenuated and disappear.
(7) The number of Anopheles infected is always small, even
in the places and months most affected by the fevers. The
hereditary transmission of the infection from mosquito to
mosquito has not been demonstrated up to now.
(8) Various annual epidemic types exist, namely : —
4IO THE CAMPAIGN AGAINST MALARIA IN ITALY [Sect.
{a) The South of Italy type, with great predominance of
the aestivo-autumnal parasites, with virulence gener-
ally exalted.
{b) The North of Italy type, with more or less predominance
of the parasites of the mild tertian and the initiation
of this in the spring.
(c) The North of Europe type, with the absolute pre-
dominance of the mild tertian and the precocious
development of the epidemy in the spring.
In Hungary, Greece and Russia epidemic types like those
observed in Italy are met with,
(9) The mortality from malaria in the whole of Italy from
1887 onwards {cf. fig. i, upper part) has been subject to regular
periodic oscillations, with a maximum every five or six years.
This periodic course is most marked in the most malarious
regions — namely, from Latium downwards, and in the islands
{cf. fig. 2), while in the rest of Central and North Italy the
progressive descent without notable variations is manifest.
The morbidity also from malaria in the Rome hospitals is
subject to periodic oscillations which in the last fifteen years
have reached their maximum every five years.
No relation has been as yet established between the meteoro-
logical conditions and the annual and periodic epidemic oscilla-
tions, which would seem to be due more to general biological
properties inherent in the specific parasites themselves than to
climatic reasons.
(10) In the study of the malarial epidemics, besides infected
men and Anopheles, it is necessary to take into consideration
also other predisposing or immunising causes of biological or
organic {x), physical or local {y), economic or social {s) origin.
Although they are unknown in their intimate mechanism of
action, nevertheless they have undoubted influence both on man
and on Anopheles, and hence they may stimulate or impede the
development of a malarial epidemy. Therefore, for the primary,
very simple equation: Malarial man-\- Anopheles = epidemy of
49] TABLE OF RESULTS 4"
malaria, we must substitute this other : Malarial man â– 'r Anopheles
+ x,y, 5 = epidemy of malaria.^
(ii) The above-mentioned facts show that the problems of
NUMBER
OF DEATHS
887
BST
89
90
91
92
93
94
95
96
97
98
99
900
01 02 03
04
05
06
07
08
itooo
500
lOOOO
500
9000
500
8000
500
7000
500
6000
500
5000
500
4000
500
3000
500
2000
500
lOOO
500
O
•
t
1
•
A
—
—
—
A
iL
1
i
•
^
r
V
J\
^
=y>
•
T.
^
j
V
S
y
\.
•
^i
-\
\l
4
\
V
u,
1
\
•
'
\'<
— ^
\
\
\^
\
/\
\
\
«
|a
"^
v>
A
i
1
\
'^
\
f t
\ \
^V*
V
y
\
\
N
•
V
\^
-.-
../
•
\
s...
->
,^
\
\
\
"\
N
k
..^
N.
•»•
r»»«
'•••
"-
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'•♦.
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'••.
'•..
^
•••
...
...
"N
*s
>
—
_
â– "l-
• *••
>■•
FIG -^ —MORTALITY FROM MALARIA IN THE REGIONS OF ITALY BEFORE
AND AFTER THE STATE QUININE.
Latium and South Italy.
- - - Sicily and Sardinia. , t i \
Central Italy (excluding Latium and North Italy).
the epidemiology and prophylaxis of malaria cannot be con-
sidered from a narrow point of view.
II._The Measures for Combating Malarial Epidemics
Our first attempts were directed to the destructmi of the
mosquitos by physical and chemical means. The laboratory
1 Compare section 28. — R. Ross.
412 THE CAMPAIGN AGAINST MALARIA IN ITALY [Sect.
experiments were encouraging. Later attempts, with great
perseverance, were carried out by Galli-Valerio and by J.
Rochaz de Jong, by biological means (animals and plants which
kill mosquitos or impede their development). On carrying this
into practice on a large scale one meets with many difficulties
owing to which, at least among us, with so many extensive
marshes and so much intensive culture, one cannot succeed,
save in exceptional cases and by long and assiduous work, in
destroying malaria by means of the destruction of mosquitos.
Nevertheless, to the old and reliable methods of the campaign
against malaria, namely, draining and agrarian sanitation^ our
efforts were directed.
The hygienic effects of the sanitation by drainage already
carried out were studied. The result was that on large
extensions of land the best drainage sanitation very frequently
failed to drain off all the water or to give it sufficient velocity to
impede the aquatic life of Anopheles. Frequently, also, the
deficiency of the neglected state of the complementary drains
and of the discharging canals helped to maintain the anophelism.
Consequently, very often the drainage improvement is not
synonymous with sanitation, to which one will arrive in time,
when the agrarian sanitation supervenes, which, therefore, must
be the necessary complement of the drainage improvement.
Both, however, as we shall see, can, and should, be facilitated
and shortened — with incalculable saving in health and time
— by means of the medical, mixed, or at least the quinine
prophylaxis.
In its turn the agrarian sanitation helps to improve the
conditions of life of the worker by better housing, alimentation,
work and clothing. These coefficients, together with improved
medical assistance and the consumption of quinine, have led
after a long time, and now lead more quickly, to the sanitation
of a territory, even where paludism, with the relative anophelism,
still exists, and even can usefully exists inasmuch as it helps to
render, by the utilisation of the waters, the agriculture more
prosperous.
49] MEASURES COMPARED 413
Keeping away infected mosquitos from the person and frotn
the house is another mode of protecting oneself from malaria,
which is directly derived from the new theory.
However, if man on whom this scourge weighs should wish
to free himself from it only by the mode which is directly
derived from the theory of the Anopheles, that is, by the destruc-
tion, or at least by the keeping away of these insects, who
knows how long he would have to wait ?
We refer to the difficulties met with by us in our campaign
in endeavouring to destroy the mosquitos.
A quicker and, within certain limits, a more easy method is
to prevent them biting one by keeping them away. But only the
minor part of the population, namely, the richer and, therefore, the
least attacked, can enjoy this benefit.
In fact, in order to prevent the bites of mosquitos one
requires, above diW, proper clothing, which frequently is wanting,
and owing to the great heat cannot be supported ; thus, also,
the gloves and masks for protecting the uncovered parts of the
body are very inconvenient, and prevent one working.
Odours, ointments, and washes containing culicidal sub-
stances, which, according to our researches and those of others,
are many, have a very restricted action in closed spaces, and
little or no action in the open air.
On the other hand, he who can live in some kind of habita-
tion, with all the openings protected with wire - netting to
prevent the entrance of mosquitos, can thus, as a rule, preserve
himself from malaria.
This method, which was first adopted by us in 1899, by our
advice is coming more and more into use in the houses along
the railways, as shown from the subjoined table.
This mechanical prophylaxis has been adopted in the
Custom-house officers' barracks.
It, however, is not equally practicable for soldiers.
Unfortunately, owing to the first cost and that of repair, it
414 THE CAMPAIGN AGAINST MALARIA IN ITALY [Sect.
is an expensive prophylaxis ; besides, it presupposes a special
hygienic education in those who inhabit the protected houses,
and that they should retire there during the most dangerous
hours of the day, things which are very far removed from the
mode of life to which our peasants are accustomed.
TABLE I
Mechanical Prophylaxis along the Adriatic Railways
Percentage attacked
Percentage of
WITH FEVER.
CONTROLS attacked.
Year.
Persons
protected.
Recurrent.
Primary.
Min.
Max.
1899
24
20
20
96
_
1900
27
5-5
7-5
n
92
I901
5,165
3-3
20-2
20
96
1902
5,851
lOI
2"
12
81
1903
8,230
22-5
4-6
10
32
1904
12,378
87
2-0
10
27
Fortunately, much easier and quicker results can be obtained,
when one wishes it, by the proper administration of quinine.
It is very well known that quinine is a truly sovereign
remedy, both for disinfecting the blood of malarial patients and
for provoking an artificial medicamental immunity. But this
very powerful weapon with a double edge has not been well
managed by others; whereas in our hands it has constantly
increased in value, not only for the curative treatment, but also
for the preventive treatment of malaria.
There is no doubt that this remedy acts in inverse pro-
portion to the degree of development of the malarial parasites
in the blood-stream ; that is to say, it acts best against the
sporozoites directly they are inoculated, and least against the
forms destined to maintain the recurrent fevers, and little or
not at all against the sexual forms destined to propagate the
species. We have thus proved over and over again that some
49] PREVENTION BY TREATMENT 415
fevers are pertinacious in recurring in spite of the abundant
and protracted use of quinine, either alone or associated with
the so-called reconstituents (iron and arsenic). In fact, these
latter drugs, under whatever form and in whatsoever way
administered, have no value as direct anti-malarial remedies.
It follows from this that even the best treatments in the pre-
epidemic period do not succeed in preventing, as Koch thought
they would, the development of malaria in the following summer.
Therefore, by the quinine treatment alone to extirpate malaria
from an extensive locality is much more difficult than one
would a priori imagine. In any case, it must be the work of
long duration, that is to say, treating in every period of the
year, day by day, energetically and assiduously, every case of
malarial fever.
Quinine, however, is the best remedy for the radical treatment
of malaria, even latent and recurrent. The essential thing is to
continue the treatment for a long time with great patience and
perseverance ; and the secret of success is to administer the
quinine in the most agreeable and therefore also the most tolerable
form. Besides, it is better, when possible, to call in the aid of
other means pre-eminently beneficial, such as alimentation,
habitation, clothing and moderate work.
Since, therefore, the latent and recurrent infections cannot
be prevented, much less eradicated, // is necessary to do every-
thing to prevent completely the malarial infection itself.
The quickest and best results regarding the preventive treat-
ment are obtained by quinine administered for this purpose.
To establish firmly the scientific and practical basis of this
preventive treatment of malaria has been, since 1900, one of the
principal tasks we have undertaken.
Thus, by degrees, with the assistance and control of able
collaborators, we have come to the following conclusions : —
{a) That quinine, provided it be administered daily, is in
average and even therapeutic doses better tolerated, and for a
longer time than a priori one could have believed ; that is to
4i6 THE CAMPAIGN AGAINST MALARIA IN ITALY [Sect.
say, after the first two or three days it no longer produces the
least singing in the ears, and is not only completely innocuous,
but also acts as an aid to nutrition and as a tonic to the
digestive apparatus and muscles, thereby increasing the appetite
and the power of work.
(b) Quinine taken daily is always present in the blood, and
thus prevents instead of producing the phenomena of quininism.
Further, there is not, perhaps, another example of a remedy so
perfect, nor one which so rapidly establishes itself, and can be
prolonged for a long time (up to five or six months), and yet
can be interrupted when desirable without any disturbance, and
without, although the organism is habituated to the small and
average doses, diminishing the curative efficacy of the large
doses when they are necessary.
{c) But if quinine be given at intervals longer than three
days the phenomena of quininism present themselves every
time ; in consequence the method of intermittent administration,