MALARIAL ANALOGIES. By Surgeon J. R.
ROBERTS, m.b., f.e.c.s., Eng., Indian Medical Service.
Modern investigation lias shewn the quality of specificity to belong to almost every disease ; it has certainly expounded this principle in the case of the febrile disorders; and although in each and every instance it may not yet have succeeded in a complete enquiry of the specific virus of the individual fevers, yet the fundamental
truth has been tapped, and the law or principle of specificity been laid down. In the case of malaria not only do clinical phenomena, and the investigation of the means by which it is introduced into the system, bear out this conclusion, but also does the work 011 its microbic origin, in spite of its present controversial state, as to whether this is bacillus or lirematozoon. Like any other specific fever, malarial disease has its means of introduction or general causes, its stage of incubation, its period of manifestation followed by that of elimination ; but it differs from all others, except rheumatism, in the residual element it manifests. Speaking in the strict sense on an analogy, malaria may be considered the rheumatism of the tropics, and rheumatism the malaria of cold climates; moreover, the similarity of the general causes of both diseases, and the rheumatism phenomena shewing themselves as sequela} of malaria betray a certain resemblance of the one to the other; yet to imagine that their specific causes are one and the same, would be a grave error to fall into. However thoroughly the clinical phenomena of this disease have been recorded, yet discussion has always followed the broaching of the subject of its general causes; some give predominence to water as tlio vehicle, others to personal surroundings and chills, and others again, with a certain oriental fatalism, say we cannot avoid it, it is in the air; but " a little quinine may be taken." So, with these vague and uncertain notions before them, one sees men starting out oil a campaign of prevention with such war cries as " boil your drinking water," or ei wear flannel next the skin," or " always sleep under " " mosquito curtains, because I did it in so and so, didn't get fever." Moreover, the same spirit that causes individuals to shout their own peculiar cry has led them to look at the subject As refrom too narrow-minded a point of view. " " of rumble-tumble the professional flecting in India of residents ideas, the conceptions among the causes of and means of avoiding fever are peculiar, if not striking. A great deal of harm is done by approaching the subject with too narrow views, and 011 these alone adopting our means of prevention, quoting individual experiences, all in one breath?this sentence between conversational commas, alone shewing how much real good impression the experience has left, for an experience without investigation is worth nil. As a preamble, we may take it as a fact that there exists a certain power of resistance in individuals to malaria; that this power varies among different persons, and moreover that it is apt to differ in any certain one 011 separate occasions. That it is dependent on his general health is true in a wide sense ; but, surely, we can sjiecialize it a little more, and say it is dependent 011 the state of his digestive organs; the saying, therefore, that a man with a good a
THE INDIAN MEDICAL GAZETTE.
88
alimentary
canal (another more colloquial and is generally used) is worth his in India, is founded on sound observation for more diseases than one. A consideration of the general causes of malarial fever, that is the means by which the virus is conveyed to the system, may be made much as
expressive word weight in gold
follows
:
(1) The soil; (2) the air ; (3) the water-supply ; (4) the food; (5) dwellings and their surroundings ; (6) chills and clothing ; and these may be considered as more direct data for prevention than climate, season, temperature, rainfall, the physical characteristics of the country and the amount of vegetation, although all these aid and abet in the breeding and fostering of malaria.
That malaria resides in the soil may be taken axiom. Moreover, this soil must be well heated, rich in decomposing organic matter (a source of internal heat)?vegetable matter presumably, and must be damp. This is the primary nidus, and from this it is disseminated. Why throw the blame on certain geological formations ? There is malaria alike in the alluvium of the Gangetic plain, in the tertiary rocks of Assam and the Lushai Hills, and there is malaria enough and to spare in the gneiss valleys of the Trans-Indus district of Grilgit, even up to 7,000 feet; but it does not reside in the soil of the ghastly bare hill-sides of this rainless country, or the dry alluvium of its deep valleys, in which you can dig and delve to your heart's content without stirring up malarial effluvium ; but irrigate it, cultivate it, and let it stand in this condition throughout the fierce summer heat, and you raise a goodly crop of malaria in the autumn ; then drink the water from off these fields, and you become a victim at once. Why blame the disintegrated granite of Hongkong; they irrigate and cultivate there as well, llice can be raised in Hongkong, Burma, Bengal, and Afghanistan, why not malaria. Here is -prima facie an anomaly on the great alluvial plains of Riverinain New South Wales, where the heat of summer rises to 112? or over in the shade, and the winter resembles that of the Lower Punjab, yet men and the lower animals there shew no signs of malaria; presumably, the soil is not sufficiently rained on : 10 inches per annum is not enough to create the necessary damp; you can drink at the stagnant water-holes with impunity. One is curious to know what will be the effect of the irrigation schemes being carried out in There is plenty of malaria in that country. with its higher rainfall. Queensland The air is accepted as a vehicle for the dissemination of malaria ; it is said that the specific miasm rises into it from marshes, etc., becoming visible like a mist; of what, hcematozoa or bacilli? Prevailing winds scatter and carry it to other regions?a statement made without asking anything of the conditions of life in that as an
[Feb.
1891.
said other region, or the season or the soil in that unfortunate part, or the rainfall during the prevailing wind. Moreover, it may be carried over a range of hills and manifest itself among the people in the valley beyond ; but what about the people on the hill top over which it has passed, remember the very tip-top, and what about the conditions in the valley beyond. The ingenuity of this fiction is only equalled by the statement that it can be carried out miles to sea and attack those in ships. Can one for one moment believe that the recent epidemic of malarial fever in the British fleet off the east coast of Africa was due to this cause without enquiring into other questions, as food and water-supply. It is against our common sense, i.e., the light of modern investigation, and against all the analogies of other diseases, whose specific causes have been definitely investigated ; that air is powerless to oxidize and destroy malaria ; if it were so, one and all of a body, men inhaling such an atmosphere or prevailing wind would succumb to the poison ; but, experience proves that the attacked is small or medium in percentage amount. Again, a belt of water is said to purify the air of this miasm; it is a pity we hadn't more of these belts of water possessing such wonderful properties ; the most of our rivers and stretches of water wont act in this way ; so it would be best to enquire into the conditions of life of the people on both side of this wonderful malaria barrier before buying it up as a profitable speculation for health's sake. I presume, too, that the inhabitants of one side do not pay visits to the opposite bank, that they remain so If one were to sleep with one's free of fever. head over a hot-bed of malaria?but be sure it is a hot-bed?one is most certainly exposed to the virus, in the analagous way that a man sitting in a limited space beside another, wallowing in decomposing typhoid or cholera ejecta is exposed to the risk of infection, and in both cases the air is the vehicle. If you admit the power of fresh air to destroy the virus of the latter when you open the windows to admit it, why say malaria resists such a destroyer, even although the clearing of jungle to give air free access is a As a matter measure much to be recommended. of fact, malaria is very susceptible to oxidation ; for example, drain a soil, that is, introduce air in the place of the sub-soil water and malaria
disappears.
water is the most frequent which malaria is introduced iuto the system is a firmly established truth, and moreover boiling the tainted water is a means of destroying it. It is surface water of course that is especially dangerous, and not that of deep uncontaminated wells or springs. Reference is made to rivers passing through malarial tracts of country carrying the virus far and wide?a statement made without taking into consideration
That
means
drinking
by
Fed. 1891.]
ROBERTS ON MALARIAL ANALOGIES.
whether the districts on the river banks lower down are capable of breeding malaria or not, and
the process of oxidation that flowing rivers. Why the Hooghly
disregarding
goes
on
in all
itself supplies good enough
or can
water to
Calcutta,
it be supposed that the rough filtering through sand deprives it of its poison, remembering that the sand is obtained from the river-bed close by, and subjected to drying and oxidation before use, though not with that purpose of purifying it in view it is admitted. Surely one must give full credit to rivers oxidizing malaria as well as other matters, and remember also that the former finds itself in an element foreign to its existence, and capable of destroying it. Perhaps that wonderful barrier acts in this way, and further enquiry would prove that the people on one bank drink surface water, and those on the other, the river water. Take the rapidly flowing Grilgit river into which there flows from the tracts of irrigated and malaria sodden land on either side numerous little streams of poisoned Water from the fields, and yet you may drink of the river with impunity at any season of the year. Another fact proving water to be a vehicle for malaria is that when the fields above Gilgit are irrigated, and the water allowed to run off into the channel supplying that place with water, this is followed by an increase of fever, consequent on the contaminations, this being marked in autumn. It would be well to make enquiries with regard to food being a vehicle for malaria. I have no exact scientific facts, but only general ones to put forward. The Lushai column of last season served in a highly malarious densely jungle-covered terai country. Bags of rations were from the force of circumstances often wetted by rain were piled up in heaps and in places in didirect contact with a highly malarious soil. This, as can be supposed, resulted iu their becoming heated and fermented. Surely their contents were nothing more than decomposing vegetable matter, and on that account a fitting nidus for As it was a question between eating malaria. this or starving, the terrible prevalence of fever among the men to whom it was served out has some connection, although it may be urged that in the preparation of food it is exposed to a high temperature, yet how much does the interior of a thick roughly made chupatty get? In vapour bath climates such as Eastern Bengal is not the question of storing grain in damp godowns, an important question in connection withmalaria. In camps along the road made by this column from Demagri eastward, several European officers suffered from a severe type of remittent fever, iu spite of their precautions with regard to water, clothing, and living in hutsr aised above the ground ; but the condition of their cooks' huts was certainly remarkable. The earthen floors were sodden with slops and garbage such
89
native cooks alone know how to accumulate ; the places were swarming with flies, and in this steaming, fermenting, foul atmosphere lay officers' food?biscuits, bread, tins of beef, &c. In addition to this lying in corners were the foulest of damp dish cloths used to wipe the plates Can one and spoons and what-not besides. doubt the consequences, or wonder at the servants who slept there being so fever-stricken, or hesitate to pronounce this a hot-bed of disease, including malaria. Moreover, this is not a peculiarity, but a good index tu the condition of kitchens throughout India; if such a state of things is admitted to be a fertile source of bowelcomplaints, why not by analogy a source of malaria ? the conditions certainly seem favourable. No one doubts the wisdom of applying the principles of hygiene to dwellings and their surroundings fov the prevention of disease, including malarial fever. It is necessary to follow the exshewn ample by natives in certain climates in building houses raised several feet above the ground ; in other words, admitting plenty of air and oxidation in and about dwellings; the damper the climate, the better the precaution ; but to say that it ought to be applied to all malarial climates is unnecessary ; would one advise it in the dry Punjab, or such climates where it is proved health can be maintained without it. The question of clothing and chills is an important one. The advice to wear flannel next the skin is important to follow, but to believe it to be a panacea for the prevention of fever is going too far. Siuce Europeans must cover up their bodies, their clothing in hot climates is apt to become sodden with perspiration, especially if cotton garments are worn, and on cooling to cause a sudden stoppage of the functions of the skin?a dangerous process and analogous to shaving and varnishing a dog to shew how quickly its death will be produced by preventing this function. Would you attribute the greater proportion of malarial fever among natives than among Europeans to the fact of their wearing Their method of avoiding cotton garments ? is chills by wearing next to nothing perspiration when at work. A chill, whether produced by cold perspiration or exposure to the night's lowering of temperature without sufficient covering to the body is fertile enough in producing an attack of fever; but it is not the means of introducing it into the system : it will awaken latent or residual malaria, or lower the power of resistance to more or less coincidental doses of the poison. A chill in causing congestions of internal organs and producing disturbances of function is another question, and has nothing to do You would not say that a with specific fevers. chill was the direct cause of typhoid, or scarlet fever, of small-pox or of measles. Wh}r throw the whole blame of malarial fever on a chill ? and be careful to eliminate preliminary rigors as
40
THE INDIAN MEDICAL GAZETTE.
category, as tliey are part and parcel of the disease. The analogies between malarial fever and other specific fevers in their clinical phenomena are There is the period of incuvery marked. bation, that of manifestation, and that of decline and elimination. The phenomena of the latter basis stage are the most important, as forming a for rational treatment. The channels by which specific poisons are expelled from the body are the kidneys, skin, bowels, and, I believe, the symptom of salivation, sometimes though rarely seen in malarial fever and others, is correctly interpreted as a phenomenon of elimination. There are the analogies of scarlet fever virus being thrown off by the skin and kidneys, of small-pox by the skin, of typhus by the skin, of rheumatism by the skin, of yellow feven by the alimentary canal, and presumably enteric by the same channel. By analogy we ought to expect the same in malarial fever; the evidence here is perfectly clear, especially in the severer types. There are the kidneys at work during the cold stage, the skin during the perspiring, and the more complete the latter, and the sooner we are able to produce diaphoresis, the greater the relief; nor who can doubt that the vomiting of bilious remittent, or that of the severer terai intermittent, is a similar process of elimination. The vomiting of uraemic poisoning is thus interpreted. There is evidence of the bowels ulso taking part, for a copious liquid motion is often passed without an aperient having been administered ; care being taken that it is not confounded with some rare effect of quinine or antipyretics. Then, again, in remittent natural diarrhoea is quite a
from that
usual phenomenon.
[Feb.
1891.
In drawing 011 analogy between malarial specific fevers, a striking peculiarity of the
and former is seen in its residual element. What lias been said of syphilis?" syphilis once, syphilis always,"?is equally true of malaria, also of rheumatism,?rheumatism once, rheumatism always. Even as external causes bring sleeping rheumatism into play, so do they latent malaria, and this is where chills come in, and what more potent ? so do disturbances of the digestive organs, fatigue and exposure to sun. In the case of the latter, malaria, in addition to disturbed organic functions, seems to leave behind it in the heat
regulating
tendency to deranged action, inability of the cachetic to stand exposure to sun without impunity ; in other words, a slight stimulus disturbs its even shewing
Our rational treatment is therefore based on these quite independently of the acknowledged specific action of quinine?the blankets to produce perspiration, the beneficial action of a diaphoretic mixture, or better than this antifebrin or phenacetin, acting so well because of the perspiration they produce; also the aperient that lias become the rule of thumb, even when there is no evidence of a disturbance of the alimentary canal, especially in mild intermittent. Ot antipyretics too much is expected; a dose per paroxysm is enough given in the hot stage ; if it ? fails, no good is done by " piling it on." It will act some time sooner or later if continued, and especially if salicylate of soda is added to the It is the diaphoresis of salicylate that dose. causes its specific actions in rheumatic fever, the acid perspirations of this disease evidencing the elimination of the poison. In India the types of malarial fever vary exceedingly, but for general purposes, that of damp terais and Eastern Bengal may be taken as the fundamental type and the others as varieties. Specific diseases are all markedly modified by locality, or in different epidemics so is malarial fever.
work.
centre
itself
by
a
the
There is not a trace of a fact to shew that "auto-genesis" plays any part in the febrile disorders, therefore why should there be in malaria; why should a chill call up a fatal remittent. This doctrine of a disease being autogenetic must be discarded, the more so because it is fatal to the proceedings of a wholesome prophylaxis. With regard to latent rheumatism who can mention all the subtle causes that awaken its twinges, so with malaria, who can lay down the law of cause and effect ; but it is well not to confound the specific agent of the primary inoculation and its result, with the cause of the secondary awakening of the dormant disease. These I believe to be the more striking analogies of malarial fever.
ROBERTS, m.b., f.e.c.s., Eng., Indian Medical Service.
Modern investigation lias shewn the quality of specificity to belong to almost every disease ; it has certainly expounded this principle in the case of the febrile disorders; and although in each and every instance it may not yet have succeeded in a complete enquiry of the specific virus of the individual fevers, yet the fundamental
truth has been tapped, and the law or principle of specificity been laid down. In the case of malaria not only do clinical phenomena, and the investigation of the means by which it is introduced into the system, bear out this conclusion, but also does the work 011 its microbic origin, in spite of its present controversial state, as to whether this is bacillus or lirematozoon. Like any other specific fever, malarial disease has its means of introduction or general causes, its stage of incubation, its period of manifestation followed by that of elimination ; but it differs from all others, except rheumatism, in the residual element it manifests. Speaking in the strict sense on an analogy, malaria may be considered the rheumatism of the tropics, and rheumatism the malaria of cold climates; moreover, the similarity of the general causes of both diseases, and the rheumatism phenomena shewing themselves as sequela} of malaria betray a certain resemblance of the one to the other; yet to imagine that their specific causes are one and the same, would be a grave error to fall into. However thoroughly the clinical phenomena of this disease have been recorded, yet discussion has always followed the broaching of the subject of its general causes; some give predominence to water as tlio vehicle, others to personal surroundings and chills, and others again, with a certain oriental fatalism, say we cannot avoid it, it is in the air; but " a little quinine may be taken." So, with these vague and uncertain notions before them, one sees men starting out oil a campaign of prevention with such war cries as " boil your drinking water," or ei wear flannel next the skin," or " always sleep under " " mosquito curtains, because I did it in so and so, didn't get fever." Moreover, the same spirit that causes individuals to shout their own peculiar cry has led them to look at the subject As refrom too narrow-minded a point of view. " " of rumble-tumble the professional flecting in India of residents ideas, the conceptions among the causes of and means of avoiding fever are peculiar, if not striking. A great deal of harm is done by approaching the subject with too narrow views, and 011 these alone adopting our means of prevention, quoting individual experiences, all in one breath?this sentence between conversational commas, alone shewing how much real good impression the experience has left, for an experience without investigation is worth nil. As a preamble, we may take it as a fact that there exists a certain power of resistance in individuals to malaria; that this power varies among different persons, and moreover that it is apt to differ in any certain one 011 separate occasions. That it is dependent on his general health is true in a wide sense ; but, surely, we can sjiecialize it a little more, and say it is dependent 011 the state of his digestive organs; the saying, therefore, that a man with a good a
THE INDIAN MEDICAL GAZETTE.
88
alimentary
canal (another more colloquial and is generally used) is worth his in India, is founded on sound observation for more diseases than one. A consideration of the general causes of malarial fever, that is the means by which the virus is conveyed to the system, may be made much as
expressive word weight in gold
follows
:
(1) The soil; (2) the air ; (3) the water-supply ; (4) the food; (5) dwellings and their surroundings ; (6) chills and clothing ; and these may be considered as more direct data for prevention than climate, season, temperature, rainfall, the physical characteristics of the country and the amount of vegetation, although all these aid and abet in the breeding and fostering of malaria.
That malaria resides in the soil may be taken axiom. Moreover, this soil must be well heated, rich in decomposing organic matter (a source of internal heat)?vegetable matter presumably, and must be damp. This is the primary nidus, and from this it is disseminated. Why throw the blame on certain geological formations ? There is malaria alike in the alluvium of the Gangetic plain, in the tertiary rocks of Assam and the Lushai Hills, and there is malaria enough and to spare in the gneiss valleys of the Trans-Indus district of Grilgit, even up to 7,000 feet; but it does not reside in the soil of the ghastly bare hill-sides of this rainless country, or the dry alluvium of its deep valleys, in which you can dig and delve to your heart's content without stirring up malarial effluvium ; but irrigate it, cultivate it, and let it stand in this condition throughout the fierce summer heat, and you raise a goodly crop of malaria in the autumn ; then drink the water from off these fields, and you become a victim at once. Why blame the disintegrated granite of Hongkong; they irrigate and cultivate there as well, llice can be raised in Hongkong, Burma, Bengal, and Afghanistan, why not malaria. Here is -prima facie an anomaly on the great alluvial plains of Riverinain New South Wales, where the heat of summer rises to 112? or over in the shade, and the winter resembles that of the Lower Punjab, yet men and the lower animals there shew no signs of malaria; presumably, the soil is not sufficiently rained on : 10 inches per annum is not enough to create the necessary damp; you can drink at the stagnant water-holes with impunity. One is curious to know what will be the effect of the irrigation schemes being carried out in There is plenty of malaria in that country. with its higher rainfall. Queensland The air is accepted as a vehicle for the dissemination of malaria ; it is said that the specific miasm rises into it from marshes, etc., becoming visible like a mist; of what, hcematozoa or bacilli? Prevailing winds scatter and carry it to other regions?a statement made without asking anything of the conditions of life in that as an
[Feb.
1891.
said other region, or the season or the soil in that unfortunate part, or the rainfall during the prevailing wind. Moreover, it may be carried over a range of hills and manifest itself among the people in the valley beyond ; but what about the people on the hill top over which it has passed, remember the very tip-top, and what about the conditions in the valley beyond. The ingenuity of this fiction is only equalled by the statement that it can be carried out miles to sea and attack those in ships. Can one for one moment believe that the recent epidemic of malarial fever in the British fleet off the east coast of Africa was due to this cause without enquiring into other questions, as food and water-supply. It is against our common sense, i.e., the light of modern investigation, and against all the analogies of other diseases, whose specific causes have been definitely investigated ; that air is powerless to oxidize and destroy malaria ; if it were so, one and all of a body, men inhaling such an atmosphere or prevailing wind would succumb to the poison ; but, experience proves that the attacked is small or medium in percentage amount. Again, a belt of water is said to purify the air of this miasm; it is a pity we hadn't more of these belts of water possessing such wonderful properties ; the most of our rivers and stretches of water wont act in this way ; so it would be best to enquire into the conditions of life of the people on both side of this wonderful malaria barrier before buying it up as a profitable speculation for health's sake. I presume, too, that the inhabitants of one side do not pay visits to the opposite bank, that they remain so If one were to sleep with one's free of fever. head over a hot-bed of malaria?but be sure it is a hot-bed?one is most certainly exposed to the virus, in the analagous way that a man sitting in a limited space beside another, wallowing in decomposing typhoid or cholera ejecta is exposed to the risk of infection, and in both cases the air is the vehicle. If you admit the power of fresh air to destroy the virus of the latter when you open the windows to admit it, why say malaria resists such a destroyer, even although the clearing of jungle to give air free access is a As a matter measure much to be recommended. of fact, malaria is very susceptible to oxidation ; for example, drain a soil, that is, introduce air in the place of the sub-soil water and malaria
disappears.
water is the most frequent which malaria is introduced iuto the system is a firmly established truth, and moreover boiling the tainted water is a means of destroying it. It is surface water of course that is especially dangerous, and not that of deep uncontaminated wells or springs. Reference is made to rivers passing through malarial tracts of country carrying the virus far and wide?a statement made without taking into consideration
That
means
drinking
by
Fed. 1891.]
ROBERTS ON MALARIAL ANALOGIES.
whether the districts on the river banks lower down are capable of breeding malaria or not, and
the process of oxidation that flowing rivers. Why the Hooghly
disregarding
goes
on
in all
itself supplies good enough
or can
water to
Calcutta,
it be supposed that the rough filtering through sand deprives it of its poison, remembering that the sand is obtained from the river-bed close by, and subjected to drying and oxidation before use, though not with that purpose of purifying it in view it is admitted. Surely one must give full credit to rivers oxidizing malaria as well as other matters, and remember also that the former finds itself in an element foreign to its existence, and capable of destroying it. Perhaps that wonderful barrier acts in this way, and further enquiry would prove that the people on one bank drink surface water, and those on the other, the river water. Take the rapidly flowing Grilgit river into which there flows from the tracts of irrigated and malaria sodden land on either side numerous little streams of poisoned Water from the fields, and yet you may drink of the river with impunity at any season of the year. Another fact proving water to be a vehicle for malaria is that when the fields above Gilgit are irrigated, and the water allowed to run off into the channel supplying that place with water, this is followed by an increase of fever, consequent on the contaminations, this being marked in autumn. It would be well to make enquiries with regard to food being a vehicle for malaria. I have no exact scientific facts, but only general ones to put forward. The Lushai column of last season served in a highly malarious densely jungle-covered terai country. Bags of rations were from the force of circumstances often wetted by rain were piled up in heaps and in places in didirect contact with a highly malarious soil. This, as can be supposed, resulted iu their becoming heated and fermented. Surely their contents were nothing more than decomposing vegetable matter, and on that account a fitting nidus for As it was a question between eating malaria. this or starving, the terrible prevalence of fever among the men to whom it was served out has some connection, although it may be urged that in the preparation of food it is exposed to a high temperature, yet how much does the interior of a thick roughly made chupatty get? In vapour bath climates such as Eastern Bengal is not the question of storing grain in damp godowns, an important question in connection withmalaria. In camps along the road made by this column from Demagri eastward, several European officers suffered from a severe type of remittent fever, iu spite of their precautions with regard to water, clothing, and living in hutsr aised above the ground ; but the condition of their cooks' huts was certainly remarkable. The earthen floors were sodden with slops and garbage such
89
native cooks alone know how to accumulate ; the places were swarming with flies, and in this steaming, fermenting, foul atmosphere lay officers' food?biscuits, bread, tins of beef, &c. In addition to this lying in corners were the foulest of damp dish cloths used to wipe the plates Can one and spoons and what-not besides. doubt the consequences, or wonder at the servants who slept there being so fever-stricken, or hesitate to pronounce this a hot-bed of disease, including malaria. Moreover, this is not a peculiarity, but a good index tu the condition of kitchens throughout India; if such a state of things is admitted to be a fertile source of bowelcomplaints, why not by analogy a source of malaria ? the conditions certainly seem favourable. No one doubts the wisdom of applying the principles of hygiene to dwellings and their surroundings fov the prevention of disease, including malarial fever. It is necessary to follow the exshewn ample by natives in certain climates in building houses raised several feet above the ground ; in other words, admitting plenty of air and oxidation in and about dwellings; the damper the climate, the better the precaution ; but to say that it ought to be applied to all malarial climates is unnecessary ; would one advise it in the dry Punjab, or such climates where it is proved health can be maintained without it. The question of clothing and chills is an important one. The advice to wear flannel next the skin is important to follow, but to believe it to be a panacea for the prevention of fever is going too far. Siuce Europeans must cover up their bodies, their clothing in hot climates is apt to become sodden with perspiration, especially if cotton garments are worn, and on cooling to cause a sudden stoppage of the functions of the skin?a dangerous process and analogous to shaving and varnishing a dog to shew how quickly its death will be produced by preventing this function. Would you attribute the greater proportion of malarial fever among natives than among Europeans to the fact of their wearing Their method of avoiding cotton garments ? is chills by wearing next to nothing perspiration when at work. A chill, whether produced by cold perspiration or exposure to the night's lowering of temperature without sufficient covering to the body is fertile enough in producing an attack of fever; but it is not the means of introducing it into the system : it will awaken latent or residual malaria, or lower the power of resistance to more or less coincidental doses of the poison. A chill in causing congestions of internal organs and producing disturbances of function is another question, and has nothing to do You would not say that a with specific fevers. chill was the direct cause of typhoid, or scarlet fever, of small-pox or of measles. Wh}r throw the whole blame of malarial fever on a chill ? and be careful to eliminate preliminary rigors as
40
THE INDIAN MEDICAL GAZETTE.
category, as tliey are part and parcel of the disease. The analogies between malarial fever and other specific fevers in their clinical phenomena are There is the period of incuvery marked. bation, that of manifestation, and that of decline and elimination. The phenomena of the latter basis stage are the most important, as forming a for rational treatment. The channels by which specific poisons are expelled from the body are the kidneys, skin, bowels, and, I believe, the symptom of salivation, sometimes though rarely seen in malarial fever and others, is correctly interpreted as a phenomenon of elimination. There are the analogies of scarlet fever virus being thrown off by the skin and kidneys, of small-pox by the skin, of typhus by the skin, of rheumatism by the skin, of yellow feven by the alimentary canal, and presumably enteric by the same channel. By analogy we ought to expect the same in malarial fever; the evidence here is perfectly clear, especially in the severer types. There are the kidneys at work during the cold stage, the skin during the perspiring, and the more complete the latter, and the sooner we are able to produce diaphoresis, the greater the relief; nor who can doubt that the vomiting of bilious remittent, or that of the severer terai intermittent, is a similar process of elimination. The vomiting of uraemic poisoning is thus interpreted. There is evidence of the bowels ulso taking part, for a copious liquid motion is often passed without an aperient having been administered ; care being taken that it is not confounded with some rare effect of quinine or antipyretics. Then, again, in remittent natural diarrhoea is quite a
from that
usual phenomenon.
[Feb.
1891.
In drawing 011 analogy between malarial specific fevers, a striking peculiarity of the
and former is seen in its residual element. What lias been said of syphilis?" syphilis once, syphilis always,"?is equally true of malaria, also of rheumatism,?rheumatism once, rheumatism always. Even as external causes bring sleeping rheumatism into play, so do they latent malaria, and this is where chills come in, and what more potent ? so do disturbances of the digestive organs, fatigue and exposure to sun. In the case of the latter, malaria, in addition to disturbed organic functions, seems to leave behind it in the heat
regulating
tendency to deranged action, inability of the cachetic to stand exposure to sun without impunity ; in other words, a slight stimulus disturbs its even shewing
Our rational treatment is therefore based on these quite independently of the acknowledged specific action of quinine?the blankets to produce perspiration, the beneficial action of a diaphoretic mixture, or better than this antifebrin or phenacetin, acting so well because of the perspiration they produce; also the aperient that lias become the rule of thumb, even when there is no evidence of a disturbance of the alimentary canal, especially in mild intermittent. Ot antipyretics too much is expected; a dose per paroxysm is enough given in the hot stage ; if it ? fails, no good is done by " piling it on." It will act some time sooner or later if continued, and especially if salicylate of soda is added to the It is the diaphoresis of salicylate that dose. causes its specific actions in rheumatic fever, the acid perspirations of this disease evidencing the elimination of the poison. In India the types of malarial fever vary exceedingly, but for general purposes, that of damp terais and Eastern Bengal may be taken as the fundamental type and the others as varieties. Specific diseases are all markedly modified by locality, or in different epidemics so is malarial fever.
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There is not a trace of a fact to shew that "auto-genesis" plays any part in the febrile disorders, therefore why should there be in malaria; why should a chill call up a fatal remittent. This doctrine of a disease being autogenetic must be discarded, the more so because it is fatal to the proceedings of a wholesome prophylaxis. With regard to latent rheumatism who can mention all the subtle causes that awaken its twinges, so with malaria, who can lay down the law of cause and effect ; but it is well not to confound the specific agent of the primary inoculation and its result, with the cause of the secondary awakening of the dormant disease. These I believe to be the more striking analogies of malarial fever.
