Quinine prophylaxis in Italy
Distribution of Malaria in Italy
As our knowledge of malaria in the Malay States became more clearly focused, it was apparent that its distribution was very different from what had been found in other countries, in Italy, for example. The existence of malaria in large tracts of that country had led to its study, and the subject was one of much more than purely scientific interest. Its profound economic importance pressed persistently for solution. In all countries the alluvial plains are the richest agricultural land; they are Nature’s great factories. But in Italy in the summer and autumn, when the factory was capable of working at its highest speed, the wheels were still; the land was deserted. Malaria had made the plains almost uninhabitable; and perhaps in no other country in the world had the disease been so carefully studied. And so notable had been the contributions to the knowledge of malaria made by the Italians, that the general ideas of the disease found in the textbooks of other countries have been largely cast in the mould of Italian experience.
The Italians had established quite beyond dispute that the hills were healthy even when the plains only a few feet below were intensely malarious. And it was from the knowledge of this fact that the authors of books on tropical sanitation advised people to build their dwelling houses on high, dry situations, “avoiding a clay soil if possible.” – “As high ground as possible, is a golden rule for a camp.” – “Against the vertical uprising of malaria, elevation, however small, affords some protection.” In Italy, too, the association of malaria with swamps was no mere school-man’s theory. It was something so real to thousands that it had woven itself into the texture of their daily lives. Year by year, as the summer months came round, thousands left the plains each evening and slept in the hills, to return in the morning to their daily task. To spend a night in the plains was only to court the disease; and the lesson had been taught too often by bitter experience to be unknown even to the most ignorant. The distribution of the disease was indeed so peculiar, that men much less acute than the leaders of medicine in Italy could not fail to mark it.
When we search for the explanation of the freedom from malaria of the Italian hills, we at once find it in the habits of the local Anopheles. In Italy the only mosquitoes that carry malaria live in swamps, pools, and very sluggish drains overgrown with vegetation. From the drains they disappear when these are freed from vegetation, or when the current reaches a certain velocity. In Italy, unlike the Malay States, no Anopheles are to be found in the hill streams; and so in Italy, no malaria is to be found in the hills. While, then, it is a golden rule for Italians to avoid the plains and live in the hills, the rule does not apply to Malaya; nor, as we shall see, to many parts of Asia, where the distribution of malaria is different from what it is in Italy, since the Anopheline fauna have different habits.
Physical Conditions Favouring Malaria
Italy consists of the high lands of the Apennines, and a stretch of flat land from the hills to the sea. In the flat lands or plains there is little “fall,” and the waters find the sea with difficulty. Dashing down the hills laden with detritus, the rivers soon reach the plain. Now no longer able to carry their burden, where the current slackens they throw it down, and sometimes the bed of the river is above the level of the land through which it flows, and over which it would flood but for the confining banks made by man.
The sea, too, seems to have joined in the conspiracy to swamp the land. Practically tideless, the sea for ever holds up the rivers as they seek to empty themselves, and it dams them back in stagnation for miles. Were the sea but to recede three or four feet even for a few hours in the twenty-four, it would stir the rivers to life. It is the stagnation that brings malaria and death. And not content with this sullen grip of the river’s life, from time to time in the paroxysm of its storms the sea throws barriers of sand along the shore, and across the river, as if trying to shut it up completely. Sometimes the river bursts through these bonds; more often, winding along the coast behind the sand dunes, after a long detour it reaches the sea. But in its course it has become a swamp rather than a well-defined river. This is the cause of many marshes along the coast of Italy, not the least well-known of which are the Pontine Marshes.
The physical conditions favour the creation of these marshes along the coast; and malaria was so prevalent in the Italian littoral that the Tuscan school formulated the theory that malaria was due to a mixture of fresh and salt water. A map of the marshes of Italy was indeed a map of its malaria; and not only were the Italians aware of the direct connection between swamps and malaria, but they were aware—they had proved it hundreds of times—that the thorough drainage of swamps had freed portions of the land from the pestilence. Rome itself was an example of the beneficent result of drainage. Yet with the physical conditions just described, it will be seen that drainage generally along the coast presented the greatest difficulty, and we can readily understand why the Italians often abandoned the attempt. The project would have appealed probably more to those great engineers, the Dutch.
Referring to the prevention of malaria by the destruction of mosquitoes, Celli writes:8
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 or the neglected state of the complementary drains and the discharging canals helped to maintain the anophelism.
Experience with quinine
It was mainly, then, on account of the difficulty of draining many parts of Italy that Celli so strongly advocated the use of quinine, and the drug was widely distributed by the State, with the result that the number of deaths from malaria in Italy has been greatly reduced; but in many respects their experience with the drug has been identical with that in the Malay States. Celli, indeed, writes of it:9
We have proved over and over again that some fevers are pertinacious in recurring in spite of the abundant and protracted use of quinine, either alone or in association with the so-called re-constituents (iron and arsenic). … 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 exterminate malaria from an extensive locality is much more difficult than one would imagine. In any case it must be a 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.
Commenting on this in 1909, I wrote:10
To me it seems only the vision of a dream that any organization will ever induce a whole tropical population to take quinine in doses required by the Italians. And when it is further considered that the population, even when taking quinine, would still be infectious, the policy of spending money on quinine for an indigenous population where drainage is physically possible appears to me indefensible, either on medical or financial grounds.
Report to the Superior Council of Health
As the discovery of the best method of eradicating malaria was the most important medical question in Italy, a strong and representative Commission investigated the whole subject, and presented a report to the Superior Council of Health in 1910. A summary of this report appeared in the August number of the Monthly Bulletin of the Paris International Public Health Office, and has been translated 11 by Major N. P. O’Gorman Lalor of the Indian Medical Service. The Commission found that “great progress” had been made in treating the sick. “The treatment of malaria has everywhere advanced by leaps and bounds. The laws in force against malaria have created an excellent social prophylaxis by placing quinine at the disposal of all, and have thus made it possible for the sick to be treated from the outset of the disease.” They also found that “it is absolutely certain that malaria has undergone notable diminution in places where the windows of dwelling houses have been provided with wire gauze mesh to prevent the entry of mosquitoes. Nevertheless the experience of former years shows the grave difficulties which the application of this measure has encountered.”
The Commission consider that it is better to petrolise pools and marshes than trust to larva-destroying fish, with which experiments had been made. But while advocating the use of quinine for the sick, the Commission condemn the wholesale issue of quinine to healthy individuals on account of (1)the wastage which the system has occasioned, and (2)the impossibility of ascertaining to what extent this prophylactic quinine is consumed. In the report they say:
In brief we see that in Italy prophylaxis has been applied in few places, and in a very limited fashion. The administration of quinine to healthy individuals has been rather nominal than real, and if the past is to furnish an index to the future, we can say that the possibility of extending to every quarter of the kingdom the prophylactic work practised in experimental areas under the control of committees, associations, etc., is a possibility too remote from realization to be relied upon.
With this conclusion I think all who have any knowledge of the use of quinine as a prophylactic will agree. Finally the Commission point out, that only where “intensive cultivation has overspread the land” has malaria disappeared. They insist that it is not enough to cut large canals; these are necessary, of course, for without them the land cannot be cultivated at all; but of no less importance are the smaller drains and the digging over of the ground, which creates that porous soil into which rain sinks instead of forming pools on the surface of the land.
Hydraulic reclamation constitutes an advance towards a state of more perfect hygiene, but it does not suffice, since it deals with large canals, not with the smaller and more useful ones, made by the spade of the peasant. The real work of reclamation lies in the intensive culture of tracts previously drained by the aid of hydraulic reclamation. State quinine has availed to reduce sickness and mortality from malaria, but the disease has not disappeared except in places where intensive cultivation has overspread the land. In these latter circumstances malaria is found to disappear even where the related mosquitoes have continued to infest the locality. It is necessary, then, to insist particularly upon the smaller works of reclamation so often neglected in favour of more grandiose projects which entail enormous expense and which are of less use from a health standpoint. Especially is it necessary to prevent the formation of artificial collections of water.
In other words, the better the land is drained by large and small canals, the more porous the soil becomes, and the fewer the pools in which the mosquito can breed. So the final conclusion of the Italian Commission is that the best way to eradicate malaria is to cultivate the soil—and the more thorough the cultivation the more rapidly will malaria disappear. So that after years of work along the lines of quinine prophylaxis, the Italian Commission now inclines to the conclusions we had arrived at on the other side of the world.