Popular Science Monthly/Volume 24/December 1883/Malaria and the Progress of Medicine
THE attempt to estimate the successes of medicine on the grand scale is met at the outset by a source of fallacy which can not well be eliminated. Medicine has certainly a share, and it may be a very large share, in the general lengthening of life, in the decrease of pain and suffering, and in the increase of working-power; but other influences, besides the thought and endeavor of the medical profession, have helped to bring about those results. A brief consideration of malarial fever (including simple ague and the more deadly tropical forms), of the causes that have made it less common at home, and more amenable to treatment everywhere, and of the views entertained about it, will serve to show how various are the forces that make for improved well-being, and how checkered the medical record has been. No single cause of premature death, of life-long misery, and of loss of working-power, has ever equaled malaria. There is some reason to think that it was from personal experience of the ague, and the hepatic derangements consequent on it, that Descartes got his profound conviction of ill-health being the greatest of all hindrances to the wisdom and capability of the individual. There can, at least, be hardly any question that malaria is, and always has been, the largest single element in the miseries of mankind. Fortunately, malarial fever has almost disappeared from Great Britain, and it has hardly existed in some of our colonies, particularly the Australasian; it has decreased considerably in many parts of Northern Europe and the United States. Again, there is a drug, cinchona-bark, with its products, which has a great power over the course of the fever. The cultivation of the cinchona-tree is now a great industry both in the Eastern and Western Hemispheres, and whatever quinine or other products of the bark can do for malarious sickness will be, at no distant time, a benefit that may be shared by all but the very poorest and the races least accessible to civilization. Lastly, the symptoms, course, and complications of the intermittent and remittent fevers which malaria causes are known with all the precision that can be wished. What share, then, has medicine had in dealing with this destroyer of human happiness in the past, and what is the attitude of medicine toward malaria at present?
The almost total extinction of malaria at home and its decrease abroad have been brought about in the ordinary course of draining and cultivating the soil, and by a wise attention to the planting or conservation of trees. There is a characteristic passage at the end of Kingsley's novel "Hereward," in which he commemorates his hero as the first of the new English "who, by the inspiration of God, began to drain the fens." The draining of the fens and all such achievements throughout the world have brought better health with them, but neither the doctors nor even the sanitarians have been the primary moving forces. Again, the medicinal uses of cinchona-bark were known first to the indigenous inhabitants of the Peruvian Andes, where the trees are native and where the ague is common; and it was the Jesuits who introduced it widely into Europe (1630) and the East. The story of the reception of this remedy by the medical profession has its unpleasant side. The arch-stupidities of the Paris faculty, who still live for the amusement of the world in Molière's comedies, opposed it with their united weight. Court physicians in other European capitals than Paris assailed it with abuse, and no one wrote more nonsense about it than Gideon Harvey, the physician of Charles II. The new remedy, apart from its merits, fell in with the views of the Paracelsists, and disagreed with the views of the Galenists, and was recommended or condemned accordingly. Even the great Stahl, nearly a century after cinchona was first brought to Spain, would have none of it, and, in his servitude to his theories, he even went so far as to make use of Gideon Harvey's ignorant tirade against the drug by reprinting it in German. As late as 1729, an excellent physician of Breslau, Kanold, whose writings on epidemics are still valuable for their comprehensive grasp, declared in his last illness (a "pernicious quartan") that he would sooner die than make use of a remedy which went so direct against his principles! The world, of course, gave little heed to these inane disputations; the value of cinchona was beyond the power of the faculty either to discover or to obscure. But, on behalf of the faculty, it remains to add that cinchona found powerful advocates within it from the first; and it will not surprise any one to be told that these were generally the men whom medical history, on other grounds as well, has extolled or at any rate saved from oblivion. Such were Sydenham and Morton in London, Albertini in Bologna, Peyer in Schaffhausen, and Werlhof in Hanover. The therapeutic position of cinchona was firmly established by Torti's treatise on the treatment of periodical fevers, published at Modena in 1709.
The next step in the relief of malarious sickness on the grand scale was the extraction of the alkaloid quinine from the cinchona-bark. The powdered bark was not only very unpalatable, but it was cumbrous to carry and dispense, and, although the principle of the remedy remained the same, it has proved of infinitely greater service in the form of quinine, and in the form of the cheap alkaloidal mixture known in Bengal as "quinetum." The first extraction of an alkaloid was in the case of morphia, from opium, in 1805; the discoverer was an apothecary of Hameln, who was rewarded rather better than the celebrated piper of that town, for the French Academy of Sciences voted him two thousand francs. Quinine was discovered in 1820 by the French chemists Pelletier and Caventou. The sciences and arts of botany and practical forestry, of chemistry and practical pharmacy, are now all concerned in the production of this most invaluable of remedies. The commerce of the world has taken cinchona in hand, and there are now plantations of the trees not unworthy to be named beside those of coffee and tea. The value of the crude bark imported into England alone in 1882 was nearly two millions sterling. The original and native cinchona region on the damp eastern slopes of the Andes in Peru is still a source of wealth, and a still greater source of wealth are the new plantations on the Andes in Bolivia. The Indian Government has successfully cultivated the bark on a large scale in the Nilghiri Hills in Madras, and more recently at Darjiling in the Himalayas; while a crowd of private planters have followed in the same enterprise in Coorg, Travancore, and Ceylon. The Dutch Government, who were the pioneers of cinchona cultivation, have found the climate and soil of Java well adapted for the species and varieties of trees most rich in quinine. Jamaica is the latest field to which this new and ever-increasing industry has extended.
How does quinine control, modify, or cut short an attack of ague? This is a question with which the commerce of the world can not grapple, but only the medical profession; and the truth requires it to be said, that the medical profession knows little of the modus operandi of quinine in ague. Sydenham, two hundred years ago, laid down the two great rules for the administration of bark: to give it after the first paroxysm and in the subsequent intervals, and to continue its use as a precaution against the recurrence of the fever. Little remained to be added to these practical indications; they were empirical, indeed and they are empirical still. The profession is not even sure whether quinine acts by breaking the recurrent habit of ague (as an anti-periodic), or otherwise. There are also the most conflicting statements as to whether the taking of quinine will ward off the attack of ague in passing through a malarious locality; there are a good many reasons for believing that quinine has no preventive or anticipatory action against the first onset of a remittent or intermittent fever, but the professional advice will probably be that quinine taken as a preventive can at least do no harm.
But it is when we leave the sphere of empirical experience, and enter the physiological and pathological workshops of the profession, that we realize most acutely how great is the disproportion, in this matter of malaria, between the opportunities of medicine and its achievements. Take, for example, the following sufficiently eclectic statement on the physiological actions of quinine:
Quinia, C20H24N2O2, one of the alkaloids of cinchona, in small doses accelerates the heart's action in the warm-blooded animal; in moderate doses it slows it; and in large doses it may arrest it, and cause convulsions and death. Research shows that its action is essentially upon the central nervous system. It destroys all microscopic animal organisms, apparently killing vibrios, bacteria, and amœbæ; but it seems to be without action on humble organisms belonging to the vegetable kingdom. It arrests the movements of all kinds of protoplasm, including those of the colorless corpuscles of the blood. It arrests fermentive processes which depend on the presence of animal or vegetable organisms, but it does not interfere with the action of digestive fluids.—(Quain's "Dictionary of Medicine," p. 35.)
There is here something far everybody; and, if we now go to the pathological workshop, we shall discover the beautiful adaptation of these varied actions of quinine to the various opinions that are entertained of the malarious fevers over which the drug has so powerful an influence. Is malarial fever a fermentive process, depending on the presence of animal or vegetable organisms? then quinine arrests such processes. Is malarial fever caused by a profound disturbance of the nervous mechanism which regulates the animal heat? then the action of quinine is "essentially upon the central nervous system." Nothing could be more accommodating, and nothing more unsatisfactory.
The theoretical notions about malaria form an instructive page of medical history. Until about 1823 it was always thought to be associated with marshes and swamps, but in that year Dr. William Fergusson brought to England numerous proofs that it occurred abundantly in elevated and rocky regions. Such evidences have gone on accumulating, and it is now well known that malaria has no necessary connection with the marsh. But the profession is still profoundly impressed with the belief that malaria is an actual or material poisonous substance. To Homer it was the arrows of Apollo in anger, to the mediæval folk-lore it was the mischief of elves and sprites; and, if scientific medicine does not now permit us to personify the malaria, it teaches us at least to materialize it. Although the fevers which malaria produces are quite unlike the fevers that are contagious or communicable, the present scientific guides of the profession are resolved to find a material virus or poison as the cause of them. The malarial poison was sought for, in the early days of chemistry, among the various gases of the marsh, but the chemical search proved fruitless. "When the microscope came in, the miasm was diligently looked for in the soil of malarious localities and in the vapors overhanging them. From 1849 to the present year, some twenty different vegetable organisms or their spores, of very various degrees of complexity, have been described each in its turn as the malarious miasm and as the specific cause of remittent and intermittent fevers; and the quest for a material substance assumed to be the cause of malarial fever is regarded with much favor in the best scientific circles. Meanwhile a body of opinion, which takes due account of all the manifold associated circumstances of malaria throughout the world, has been forming, and yearly growing in volume, that there is no malarious miasm at all; that "malaria," indeed, is a profound disorganization of the nervous mechanism that presides over the temperature of the body; and that this upsetting of the heat-regulating center is likely to happen when the body has been exposed during the day to extreme solar heat and to fatigue, and exposed at sundown and in the night to the tropical or sub-tropical chill, which will be severe in proportion to the rapid cooling of the ground and the amount of vapor condensed in the lowest stratum of the air. There is no more beautiful mechanism in nature than that which keeps man's internal heat always about 98° day and night, summer and winter, in the Arctic regions or in the tropics; but even that most wonderful of all self-adapting pieces of mechanism, if it be taxed too much, as by extremes of day and night temperature, will get out of gear; and a fever, still retaining something of the diurnal periodicity, will be the result. No one can read the powerful criticism of Surgeon-Major Oldham, of the Indian Medical Service, without discovering this rational explanation of malaria to have the best of the facts and the best of the logic on its side.
The decision of this point of theory one way or another has the most momentous issues, not so much for the treatment of malarious fever as for its prevention. It is, in short, a question, on the one hand, of common prudence in warm countries, more often moist than arid, and more often level than mountainous, against exposure of the body to the direct action of the sun's rays and to the nightly chill that follows; or, on the other hand, of a fatalist doctrine of vegetable spores or organisms of the lowest grade making ceaseless war upon mankind. The world has a way of finding out the truth by its experiences on the large scale. It settled the inane theoretical objections to the value of cinchona-bark, and it will probably form its own opinion on the relative merits of the vegetable-spore theory of malaria and the theory of exposure and climatic vicissitudes. It will be a regrettable circumstance if in this matter the profession has to follow public opinion instead of leading it.