there. Their valuable observations are contained in a series
of reports [1899-1903].
Also following our first expedition to Sierra Leone, the
Liverpool School of Tropical Medicine sent out a stream of
expeditions, all of which gave useful information about local
malaria, or started practical measures.
At the end of 1900 a very important event occurred —
W. Read, J. Carrol, J. W. Lazear and A. Agramonte proved
in Havana that yellow fever is carried by Stegotnyia calopus
{fasciata) just as malaria is carried by Anophelines. They
proved this by direct experiment on men ; but did not succeed
in finding the yellow fever organism either in man or in the
mosquito. Early in 1901 General Leonard Wood instructed
the Chief Sanitary Officer of Havana, then Major M. C. Gorgas,
to commence operations against these insects. In a few
months the disease was banished from Havana.
It was very disappointing at this time that so little had
yet been done in British possessions to combat malaria by
any of the measures rendered possible by the previous dis-
coveries. There was a brilliant exception. On my visit to
Sierra Leone I had met Dr H. Strachan, the Principal
Medical Officer of Lagos, and he took up the matter with
great interest. Fortunately the Governor of Lagos, Sir William
MacGregor, himself a medical man (like General Leonard
Wood), immediately saw the value of the new ideas, and began
to push malaria prevention in Southern Nigeria in a most
admirable way by all methods — drainage, quinine, wire-gauze
and public instruction. But elsewhere local bodies had ignored
the subject almost entirely. Even in Sierra Leone, where the
way had been pointed out exactly, and where the disease was
40 HISTORY [Sect.
the principal enemy of the colony, little had been done. The
Acting Governor, now Sir Matthew Nathan, who had been very
sympathetic during our visit in 1899, had left for the Gold
Coast ; and, beyond appointing a single person for a few
months to check the mosquitos, the municipality of Freetown
had dropped the matter. Calcutta, where also I had suggested
an anti-mosquito campaign in 1899, had done the same. Every-
where, my proposal to reduce mosquitos in towns was treated
only with ridicule.
Early in 1901, therefore, I determined to try and give
an object lesson in the work recommended by me. A
rich gentleman of Glasgow kindly offered me ;^2,0C)0 to
defray expenses ; and others helped me in various ways.
On the 2nd July I arrived with Dr M. Logan Taylor, at
Freetown, and, with the support and approval of the Governor,
Sir Charles King Harman, commenced the work at once.
Since 1899 I had gradually become convinced that anti-
mosquito campaigns had better be conducted, not only against
Anophelines, but against all kinds of mosquitos at once ; and
this opinion was strongly reinforced by the yellow fever dis-
covery just made, and also by the fact that certain Culicines
carry filaria. In fact, since then I have always maintained
the opinion which may be put as follows : // is one of the first
sanitary duties of all municipalities and town councils in warm
climates to keep down as much as possible the numbers of
mosquitos within the area placed under them. We therefore
engaged the services of twenty men, to whom the Governor
added twelve ; and with these we removed piles of mosquito-
breeding rubbish from the back yards of houses, and drained,
emptied, filled up or oiled numbers of Anopheline pools. I
returned to my duties in Liverpool on the i6th August; but
M. Logan Taylor continued the work. In September C. W.
Daniels of the London School of Tropical Medicine arrived
in Sierra Leone, and reported favourably on the work ; and
in January 1902 I visited it again for a week to watch progress.
7] VARIOUS CAMPAIGNS 41
There is no doubt that a great reduction in the number of
mosquitos was effected by our measures ; but, of course, our
work was meant only for a temporary object lesson, and we
stated clearly that the improvement would last only if our
measures were continued by the local authorities. Later in
1902, however, Logan Taylor reported that these authorities
did not appear very anxious to continue them ; and we
consequently closed the work when our money was expended
— having done, we thought, as much as private persons
could do.^
After my third visit to Freetown, Prince August d'Arenberg,
President of the Suez Canal Company, asked me to advise
regarding the prevention of malaria at Ismailia on the Canal.
I arrived there in September 1902 with Sir VV. Macgregor,
who did me the honour to accompany me. The town was
swarming with both Culicines and Anophelines ; and efforts
to control the malaria by liberal quinine distribution had not
succeeded. I advised a continuance of this measure with
general mosquito-reduction. In this case "intelligent and
persistent efforts " were made ; and within a year the insects
of both groups were almost entirely banished, and the ad-
missions for malaria reduced from about 2,000 a year to 214.
Since then, endemic malaria has entirely disappeared. Dr A.
Pressat says that he originally reduced the disease by means
of a mosquito brigade of only four men qui a tout fait [1904].
Scarcely less brilliant was the campaign at Klang and
Fort Swettenham in the Federated Malay States, commenced
in 1 90 1, and carried out chiefly by Dr Malcolm Watson. At
Hong Kong also, a campaign was commenced at the same
time, and carried out chiefly by Dr J. C. Thomson with very
good results. Several anti-mosquito campaigns have been con-
ducted in the United States; and in 1906- 1907 my brother,
E. H. Ross, acting under the orders of Sir Horace Pinching,
1 A year later it was pretended that our efforts had failed, and the only thanks
which we ever received for our pains was a subterranean effort to injure us.
42 HISTORY [Sect.
completely cleared Port Said of Culicines. Other campaigns
have been those of Dr A. Balfour at Khartoum, of many
officers in Candia, some West Indian Islands, the East Indies,
and Durban. In 1906 I went to Greece to advise regarding
malaria at Lake Kopais ; and in 1907 to Mauritius (with
Major C. E. P. Fowler) to advise the Government on malaria
prevention there. As regards magnitude, however, the great
American campaign, under Colonel Gorgas, against both malaria
and yellow fever, at Panama ; that of Oswaldo Cruz at Rio
Janeiro ; and that, so well guided by Drs Ed. and Et. Sergent
in Algeria, have long held public attention. Descriptions will
be found under the appropriate sections in this book.
In spite of these brilliant examples, however, little was
attempted against malaria for many years in the vast bulk of
tropical countries. It is true that questions in Parliament
and elsewhere often led to assertions that much was being
done ; but those who really know what might have been done,
and who were in a position to obtain the information from men
on the spot, remained far from satisfied. On 23rd April 1906
the Earl of Elgin, Secretary of State for the British Colonies,
issued a circular at the instance of Colonel Seely, M.P., to all
Governors of Crown Colonies asking for specific details on this
point. In September of the same year I read a paper at the
14th International Congress of Hygiene at Berlin [1907] in
which I described what had been done in some tropical localities,
and also criticised the lack of efforts in others. Still, however,
little effect was produced, and I came to the conclusion that in
many malarious places the authorities had no real desire to carry
out anti-malaria measures, or else were entirely ignorant of
how to do so. For example, though they always urged lack
of funds as an excuse, they often omitted to do things which
would cost almost nothing, such as to undertake the measure-
ment of malaria, to issue careful reports, or to form the nucleus
of an organisation.
At the end of February I visited the Medical Congress at
8] REMARKS 43
Bombay in order to ascertain what work was being done in
India, but met only with disappointment. A few months
later, therefore, I gave a lecture at the Royal Institution of
Great Britain, in which I ventured to complain very strongly
regarding this state of affairs [1909]. Fortunately this has
been followed by a considerable improvement. An anti-malaria
league was started in South Africa, and the Indian Govern-
ment held a conference on malaria at Simla, which practically
endorsed all our teaching. Moreover, other movements for the
generalisation of anti-malaria measures are now on foot, and
will, I hope, produce better results.
8. Remarks. — Such in brief is the august history of malaria
— and some day it will be considered as being no unimportant
part of the world's history. To the thoughtful student of human
affairs it contains many points of interest.
We should note in the first place that several methods of
prevention were well known long before the mosquito-theorem
was established. Probably the ancients, and certainly the
Italians, since the time of Lancisi (171 7), were so well acquainted
with the good effect of drainage that this principle was accepted
as a dogma in all the medical schools. The excellent results
of quinine, both for cure and prevention, have also been well
known, at least since the time of Maillot in Algeria (1834) — so
well known in fact that the Government of India has sold the
drug for many years at the public post-offices for a small price.
Even the benefit of using a mosquito-net during sleep was,
I remember, looked upon as an elementary doctrine when I first
went to India in 1881. The mosquito-theorem has merely
verified and precised these old ideas.
It was therefore I think possible, long before 1899, to reduce
the disease anywhere on a large scale. Efforts in this direction
would have been invaluable in numbers of settlements in
Africa and in the East and West Indies ; but were, I believe,
seldom if ever made. Certainly many intelligent medical men
44 HISTORY [Sect.
advocated them ; but there is a wide interval between the
suggestion of public health measures and their execution.
Where they were commenced they were soon abandoned ; no
continuous public policy against the disease seems ever to have
been adopted ; settlements were left for years at the mercy of
marshes known to be poisonous ; and the methodical distribu-
tion of quinine remained undreamed of. I have little doubt
that if more intelligence had been shown in these respects
many of these settlements would have already grown into
prosperous states.
Laveran's discovery of 1880 was one not only of theoretical,
but of practical, importance. It enabled medical men to dis-
tinguish with certainty cases of malarial fever from other diseases,
and, after making the diagnosis, to treat the patient methodically.
But many years elapsed before it began to be used for these
purposes. The parasites were not seen in India, for example,
until 1887 (by Vandyke Carter). I did not hear of the dis-
covery until 1888, and did not see the parasites until 1894.
Scarcely half a dozen men were studying them in India at that
time. The use of the microscope scarcely became general
anywhere in the tropics until after 1900; and quite recently
medical men have told me of hospitals which were not even
provided with these indispensable instruments. Numbers of
others had never read the fundamental literature ; and up to
the present day many colonies possess no sufficient organisa-
tion for circulating recent medical papers. Yet in most tropical
countries there were large public medical services which ought
to have been properly provided for in these respects.
It is surprising, when we remember that malaria often
causes a third of the sickness in a place, to note that Laveran's
discovery was not immediately followed by public investigations
on the subject, especially as to the route of infection.^ The
work was done almost entirely by private persons. Even when
^ In 1898 the Government of India appointed me to undertake researches on
malaria— this being, I believe, the first case of the kind.
8] INACTION 45
information was thus obtained, it was left for years untaught in
the medical schools, or neglected in practice. But worse than
this, little has been done even to encourage the private workers.
Indeed I know of several cases where such workers have
received for their pains nothing but the ridicule of less laborious
colleagues, and the persecution of jealous superiors.^
There was no reason why the prevention of malaria accord-
ing to the new methods should not have been commenced after
1899 in every civilised malarious country. Such countries
possess responsible governments and expensive sanitary and
medical services — in fact all the machinery required for the
work. But the efforts actually made have been due almost
entirely to isolated enthusiasts, while in many places nothing
approaching a genuine campaign has even yet been attempted.
In others, again, some efforts have been reported, but their
perfunctory nature is only too apparent to those who are
acquainted with the subject. Yet the work has been done, and
well done, in many places. Why then has it not been done
in all?
The facts are undeniable. In numerous localities the disease
causes not only an immense amount of sickness, but a great
loss of efficiency amongst officials, soldiers, workmen and the
general public, and a corresponding waste of public money and
reduction of prosperity. It can be combatted only by well-
organised government action ; and governments admit their
responsibility in such matters. Yet governments have taken
little part in the investigation of malaria, and have even
neglected to utilise for practical purposes the investigations of
others. Nor is the case of malaria the only one of the kind.
Filiriasis is very prevalent in many localities, where it produces
numerous unpleasant diseases ; yet P. Manson's discovery of
1877, that the parasite is carried by mosquitos, has scarcely
ever been utilised up to the present (except perhaps in the case
^ The treatment of my brothers in Egypt is well known. In British administration
we do not expect gratitude for scientific work ; but is there anything more childish
than to punish such labours by gratuitous persecution ?
46 HISTORY [Sect.
of G. C. Low's work at Barbados). Another example (and I
could quote many) is that of the entry of plague into India in
1896 — an event which has destroyed millions of lives and
wasted millions of money. Precisely similar complaints are
frequently heard regarding diseases of animals and of crops, and
regarding mining, manufactures and commerce.
The student will do well to ask himself the cause of this
phenomenon — which is of fundamental importance in connection
with our subject. We recognise, of course, that the world is by
no means perfect ; but for this very reason we should endeavour
to extricate the causes of its imperfections. The following
points may be suggested for consideration, or correction, by
the reader.
The principal cause of the faults referred to seems to me to
lie in a curious tone of thought which is now very prevalent,
especially in this country ; according to which all matters of
practical utility to mankind are looked upon as being rather
base preoccupations for the more perfect type of human being.
The study of nature, the extirpation of disease, the management
of cities, invention, the development of agriculture, manufactures
and commerce, and the organisation of prosperity are inferior
things. We are to seek a higher level in personal manners,
literary criticism, eloquence, sport, party politics, sectarian
dogma, and so on. It is the modern equivalent of Indian
fakirism, by which, lost in various lofty speculations, we are
tauerht to remain content in the midst of starvation and disease.
This spirit, fostered in us from childhood, leads to false
ideas of government. The scientific side of administration is
apt to be forgotten in the noise of endless and despicable
party strife ; progress ceases while we discuss abstract notions
about law, liberty, representation, nationalism and so forth ;
the machine refuses to work while the mechanics are quarrelling
over the lubrication. The result is precisely what may be
imagined — cities built without sense or forethought, filthy slums,
hovels filled with disease, gulfs of destitution ; and the voices of
8] IRRATIONALISM 47
those who would better this state of affairs by scientific methods
are lost among the yells of the opposing factions.
Though in the tropics we are still spared many of the evils
of party government, the same spirit of inutilitarianism often
remains. Money which would suffice for the assainment of
whole towns is wasted rather on the construction of extrava-
gant town halls and post-offices. The cost of a new hospital
would often suffice to prevent more cases of sickness than are
treated in it ; and that of invaliding to prevent the disease
which causes it. The British Government spends ;^ 15,000,000
a year on the education of children ; but gives, I believe,
literally nothing for the scientific investigation of scarlet
fever, measles, whooping - cough, chicken - pox and mumps,
which work such mischief among these same children — a
fact which by itself proves the illogical nature of the educa-
tion given. Similarly in the tropics I have seen a large
class of coloured children, almost all of whom were suffer-
ing at the time from fever or enlargement of the spleen,
being taught the dates of accession of the Plantagent kings !
We all know how often sanitation receives only the crumbs
which remain at the bottom of the public pocket after all
the other departments have been well fed — the final triumph
of fakirism.
But we must not blame the general public alone. We are
familiar with the manner in which individual medical men
give their services, not only to medical science, but for the
gratuitous treatment of the poor ; yet nevertheless the medical
profession as a body possesses little influence or power in
public affairs. It is a body without a head. It does not
take a high enough stand with the public regarding scientific
and sanitary matters. The duty of the profession does not
lie merely in teaching and in the cure of the sick, but in
everything that appertains to the health of the people. Yet
it is apt to be dominated, not by this lofty ambition, but by
other ideals ; and it therefore seldom bestirs itself regarding
48 HISTORY [Sect. 8
its higher duties. Can we wonder then that governments also
are apt to neglect the same duties ?
Several high officials have told me that medical men do
not often become good administrators. This is probably due
to the fact that governments seldom take enough care in the
selection of their administrative medical officers. I have seen
many able men in such posts, but others who were not fitted
for them. The head of a large sanitary or medical depart-
ment should possess a full knowledge of the recent scientific
and practical advances in his subject. Too often we find
officials who have been promoted merely on account of
seniority, or in consequence of self-service ; men who express
contempt of these recent advances because they know nothing
about them ; who have no ideas, and who make no efforts.
Such men, when taxed with defects in their department,
always complain that the Government does not grant enough
funds. But they are the responsible heads of those departments ;
and if their advice is neglected they should resign their post.
In 1730 Dr Thomas Fuller {Exanthematologia, Charles
Rivington, London — quoted by W. S. Thayer) wrote: "Can
any man, can all the Men in the World, tho' assisted by
Anatomy, Chymistry, and the best Glasses, pretend positively
and certainly to tell us, what particles, how sized, figured,
situated, mixed, moved, and how many of them, are requisite
to produce a quartan ague, and how they specifically differ
from those of a tertian . . . ? " We are now able to tell all
these things. They have been written in hundreds of books^
and are familiar to thousands of students. Those who belittle
the powers of science are not always, perhaps, the wisest of
men.
The history of malaria contains a great lesson for humanity
that we should be more scientific in our habits of thought,
and more practical in our habits of government. The neglect
of this lesson has already cost many countries an immense
loss in life and in prosperity.
CHAPTER II
SUMMARY OF FACTS REGARDING MALARIA
{Suitable for Public Instruction)
9. The Parasites and the Fever. — Malaria, or Malarial
Fever, is also known by the names Paludism, Marsh Fever,
Jungle Fever, Ague and Periodic Fever. It is often called
by local names such as Country Fever, West African Fever,
Burma Fever ; and varieties of it are called Intermittent Fever
Remittent Fever, Pernicious Fever and Blackwater Fever,
Malarial fever occurs more or less in all warm climates,
especially in the summer, after rains, and near marshy ground ;
and causes a quarter or more of the total sickness in the tropics.
It is caused by enormous numbers of the minute parasites
of the blood called Plasmodia.
These parasites are introduced into the blood through
the proboscis of certain species of the mosquitos called
Anophelines.
On being introduced, each parasite enters one of the red
corpuscles of the blood, in which it lives and grows.
On reaching maturity each parasite produces a number of
spores which escape from the containing corpuscle, and enter
fresh corpuscles ; and this method of propagation may be
continued indefinitely for years.
Thus, though only a few hundreds or thousands of the
parasites may have been originally introduced through the
mosquito's proboscis, their number rapidly increases until as
many as some millions of millions of them may exist in the
blood.
At first, while the number of parasites is still small, the
49 D
^'
50 SUMMARY OF FACTS REGARDING MALARIA [Sect.
infected person may remain apparently well. When, however,
the number is large enough, he begins to suffer from fever.
The parasites tend to produce their spores all at the same
time ; and it is at the moment when these spores escape that
the patient's fever begins.
The fever is probably caused by a little poison which
escapes from each parasite with the spores.
After from six to forty hours or more this poison is
eliminated from the patient's system ; and his fever then tends
to leave him.
In the meantime, however, another generation of parasites
may be approaching maturity, and may cause another attack
of fever like the first ; and so on, indefinitely for weeks or
months. In this manner the attacks of fever follow each other
at regular intervals.
But it often happens that before one attack has entirely
ceased another one commences ; so that the attacks overlap
each other, and the fever is continued.
After a time, even without treatment, the number of parasites
may decrease, until not enough of them are left to produce
fever ; when the patient improves temporarily.
It generally happens, however, sooner or later, that the
number of parasites increases again ; when the patient again
suffers from another series of attacks.
Such relapses are frequently encouraged by fatigue, heat,
chill, wetting, dissipation and attacks of other illness.
They may occur at intervals for a long time after the patient
was first infected, and after he has moved to localities where
there is no malaria.
It is probable that as long as one parasite remains alive in
the patient's blood he may remain subject to such relapses.
Besides fever, the parasites often produce anaemia and
enlargement of the spleen, especially in patients who have
suffered from many relapses.
Death is sometimes caused by sudden and grave symptoms.
lo] THE PARASITES AND THE FEVER 51
Chief among these are the symptoms known as Blackwater
Fever, or Haemoglobinuria, which generally occurs in old and
neglected infections.
Death is also often caused during the course of a malarial
infection by other diseases, such as pneumonia or dysentery,
acting upon a constitution already enfeebled by the parasites.
If the patient survives, the parasites tend to die out of
themselves, without treatment, after a long period of illness —
leaving him more or less " immune."
The parasites are at leasFof three kinds, which can easily
be distinguished in blood placed under the microscope. These
are (i) the parasite which produces its spores every three days