Chapter 10

It was only in 1879 that Klebs and myself, after having been thoroughly freed, by a long series of preparatory studies, from the unfortunate paludal idea, undertook together some investigations in malarious districts of the most varied character, marshy and not marshy. We employed the system of fractional cultivation, making experiments on animals with the final products thus obtained. We felt ourselves justified in recognizing the malarial ferment in the _schizomycete bacillus_. The numerous researches made subsequently by us, and by many other observers, in the soil and in the air of several malarious localities, as well as in the blood and in the organs of men and animals specifically infected, have put it henceforth almost beyond doubt that we really have to do with a schizomycete. Very recently, MM. Marchiafava and Celli have succeeded in demonstrating that the germs of this schizomycete attack directly the red blood-globules, and destroy them, causing them to undergo a series of very characteristic changes which admit of easy verification, and which render certain the existence of a malarial infection.

Several observations made recently in Rome tend to demonstrate that the schizomycete of malaria does not always assume the complete bacillary form described by Klebs and myself; but this morphological question possesses no further interest for the hygienist. For him the essential thing is to know that he has to deal with a living ferment which can flourish in soils of very varied composition, and without the presence of which neither marshes nor stagnant pools of water are capable of producing malaria.

We must not think, however, that all earth containing this ferment is capable of poisoning the superjacent atmosphere. Popular experience, certain modern scientific investigation, and the facts which one can often verify when the soil, which was malarious in ancient times and which has since ceased to be so, is turned up to a great depth, all agree in proving that the ground remains inoffensive as long as it is not placed in certain conditions indispensable for the multiplication of this specific ferment. Up to this point the organism lives, so to speak, in an inert state, and may remain so during centuries without losing any of its deleterious power. There is nothing in this fact that ought to surprise us, since we know that the life and the power of evolution belonging to the seeds of plants of a much higher order than these vegetable organisms constituting ferments, may remain latent for centuries, and may then revive at once when these grains are placed in the conditions suitable for their germination.

Among the conditions favorable to the multiplication of the malarial ferment contained in the soil, and to its dispersion through the superjacent atmosphere, there are three which are absolutely essential, and the concurrence of which is indispensable for the production of bad air (malaria). First, a temperature which does not fall below 20°C. (67.5°F.); next, a very moderate degree of permanent humidity of the soil; and finally, the direct action of the oxygen of the air upon the strata of earth which contain the ferment. If a single one of these three conditions be wanting, the development of malaria becomes impossible. This is a point of prime importance in the natural history of malaria, and it gives us the key to most of the methods of sanitary improvement attempted by man.

Let us see first what can be done in this direction without the labor of man. For nature herself makes localities salubrious by _suspending_ for a greater or less time the production of malaria. It is thus that winter brings about in every country a freedom from malaria which is _purely thermic_, for it is due simply and entirely to a sinking of the temperature below the required minimum. Indeed, if the temperature in winter rises above this minimum, there are often sudden outbreaks of malaria. Sometimes, during very warm and dry summers, the heat extracts all the humidity from the malarious soil, and thus procures for us a freedom from the disease which is _purely hydraulic_. This may continue for a long time (as happened in the Roman Campagna during the years 1881 and 1882), but may also be completely destroyed by a single shower. Nature also sometimes renders a district healthy in a manner _purely atmospheric_, by covering a malarious soil with earth which does not contain the malarial ferment, or with a matting formed of earth and the roots of grasses growing closely together in a natural meadow.

In the attempts of purification by suspending the malarial action, which have been devised by man, the same thing has been done; that is to say, it has been sought, to eliminate at least one of the three conditions essential to the development of the specific ferment contained in the infected soil. Naturally, they have not thought of bringing about a thermic purification, such as nature produces in winter, because of the impossibility of moderating the action of the sun; but they have tried from all time to procure hydraulic or atmospheric purifications, and sometimes to combine these together in a very happy way.

The hydraulic systems are very numerous, for the problem which is presented, namely, that of depriving the ground of its humidity during the hot season, necessitates different solutions according to the nature and the bearing of the soil. Sometimes this is done by digging open or closing ditches intended to draw away large bodies of water. At other limes a system of drainage is established, by means of which the water is drawn out of the earth and its level is depressed, so that the upper malarious strata, exposed to the direct action of the air, are deprived of moisture during the hot season. This system of drainage is not a modern invention; the Italian monks understood it as well as, and even better than, we do. In deep and loose soils they used sometimes, just as we do now, porous clay pipes; but when the subsoil was formed of compact and nearly impermeable matters, they employed a system of drainage, the extent and grandeur of which astonishes us. It is that of drainage by cavities, applied by the Etruscans, Latins, and Volsci to all the Roman hills formed of volcanic tufa, the tradition of which I have found still preserved in some countries of the Abruzzi.

We may sometimes establish a double drainage, from below and from above; that is to say, to drain the subsoil, and at the same time increase the evaporation of water from the surface of the ground. It is well known that clearing off the forests of malarious countries has often proved an excellent means of making lands salubrious which were before too damp; for, by removing every obstacle to the direct action of the sun's rays upon the ground, we cause an increase of evaporation from its surface, and may thus be enabled to exhaust the superficial strata completely of their water during the hot season. In very moist lands, which lend themselves readily to deep drainage, the combination of the latter with a clearing of the surface has, in almost every quarter of the globe, rendered possible a very widespread and sometimes a quite lasting freedom from malaria. But, although a nearly universal experience proclaims this fact, there is a school which, following in the footsteps of Lancisi, maintains the contrary opinion, that it is necessary to preserve the forests in malarious districts, and even to increase their extent, since the trees filter the infected atmosphere and arrest the malaria in their foliage. This strange theory was formulated by Lancisi in 1714, on the occasion of the proposed clearing of a forest belonging to the Caetani family, and lying between the Pontine Marshes and the district of Cistema. Lancisi was completely imbued with the paludal notion, and consequently believed that the very severe malaria of Cistema was brought by the winds from the coast marshes, instead of being produced in the soil surrounding the district, which was then covered by this forest. He believed then that the forest acted as a protective rampart, and he prevented its being cut down. But toward the middle of the present century the Caetani had the woods cleared off from the entire belt of land surrounding Cistema. Twenty years later I was able to show that Cistema had gained greatly in salubrity. I published my observation in 1879, and, naturally, was taken to task rather sharply in the name of the sacred tradition. Happily these recriminations led our Minister of Agriculture to have the question studied by a special commission. This commission, after a conscientious examination extending over three years of all the malarious localities in the province of Rome, has just published its report,[1] the conclusions of which are entirely in accord with the facts of universal experience. They were not able to verify a single fact in support of Lancisi's theory, while they found many of the same nature as that of Cistema, and which have resulted in overturning the theory entirely.

[Footnote 1: Della influenza dei boshi sulla malaria dominante nella regiona marittima della provincia di Roma. Annali di Agricoltura, No. 77, 1884. Roma: Eredi Botta.]

It has also been thought possible to practice drainage from above by means of plantations of certain trees which would draw considerable moisture from the earth, a method which might really be serviceable in some malarious districts. But in accordance with the idea that malaria is a product of paludal decomposition, the trees selected have almost always been the _eucalyptus_. It has been maintained that trees of so rapid a growth ought to drain the soil very actively, and also that the aroma of their foliage ought to destroy the miasmatic emanations. I have hitherto been unable to verify a single instance of the destruction of malaria by eucalyptus plantations, but I do not consider myself justified in denying the facts which have been stated by others. There is nothing to oppose the admission that these plantations, when properly made, may sometimes have been of great utility. I maintain frankly, however, that they have not always been so, and that it is necessary to guard against the exaggerations into which some have allowed themselves to fall in recent times. Such exaggerations might have been avoided if, instead of talking about these plantations on the basis of a theoretical assumption, the results only had been studied in places where the eucalyptus abounds. It would then have been known that even in the southern hemisphere, the original home of the eucalyptus, there are eucalyptus forests which are very malarious. This fact has been demonstrated by Mr. Liversige, professor in the University of Sydney, Australia. Among us also, although everybody was convinced by the statements of the press that the locality of the Tre Fontaine, near Rome, had been freed from malaria by means of the eucalyptus, people were disagreeably surprised by an outbreak of very grave fever occurring throughout the whole of this colony in 1882, a year in which all the rest of the Roman Campagna enjoyed an exceptional salubrity. If, alongside of these hygienic uncertainties, we place the agricultural uncertainties, we must conclude that it is necessary to contend strongly against this fanatical prejudice in favor of the eucalyptus tree. These plants are, in fact, very capricious in their growth. In full vegetation during the winter in our climate, they are often killed instantly by a sharp winter frost, by damp cold, by the frosts of spring, or by other causes which the botanists have not yet been able to determine. At other times, if the winters are very mild, these plants grow too rapidly in height, and then are broken short off by moderately strong winds. It should further be mentioned that these plantations are sometimes very expensive. In fact, if the earth contains too much water, it must be drained under penalty of seeing the roots of the eucalyptus rot. Then again, if the subsoil is compact, it is necessary to dig deep trenches in order to give room to the long roots of these trees, and often indeed these trenches must also be drained, as is done for olive trees. The conclusion evidently is that it is better to confine ourselves to hydraulic methods of promoting the health fulness of a locality, the immediate effects of which are less uncertain. And then, when the local conditions are such as to make it desirable to try the effects of plants possessed of strongly absorbing powers, it is better to choose them from among the flora of our own hemisphere. This is more sure, and will cost less.

Simple hydraulic methods of purification, even the most perfect, do not, however, produce permanent hygienic effects, since the moisture necessary for the multiplication of the malaria in the soil is so slight that these effects may be compromised by anything whatever that is capable of restoring a moderate degree of humidity to the ground during the hot season. It has often been thought that a suspension of malarial production would be better assured by suppressing at the same time the humidity of the soil and the direct action of the oxygen of the air upon the superficial strata of earth which contain the ferment. This has been successfully accomplished by the system of overlaying (_comblées_). This consists in covering the infected soil by thick layers of uninfected earth, carried there either by the muddy waters of rivers or by the hand of man. At the same time the steady drainage of the surface and underground water is provided for. Last year I advised our Minister of War to undertake in another form a hydraulico-atmospheric purification of the district of the Janiculum surrounding the Salviati Palace on the Via della Longara, by draining the soil carefully and covering with a layer of very close turf all the parts of the surface which could not be macadamized. It would seem as if this system had been rather successful, since there has not been this year a single case of fever in the _personnel_ of the new military college, established in the Salviati Palace; while in the Corsimi Palace, which is situated on the same side of the Via della Longara, but which looks out upon that part of the Janiculum which is still uncovered, there have been some fatal cases of fever.

Furthermore, we have had in Rome, during the past few years, some very evident proofs of the efficacy of atmospheric methods of purification. I will confine myself to the relation here only of the most striking instance, one which has been furnished us in the building up of new quarters of the city. There was much discussion at first as to whether the improvements should be undertaken in the parts where they now are or in the valley of the Tiber, for the uncovered lands of the Esquiline and of the Quirinal were malarious, and, as nearly everybody then thought that the malaria of Rome was carried into the city from the coast marshes, it was supposed that this state of things was irremediable. We opposed to this view the fact of the salubrity of the Viminal, which is situated between the Esquiline and the Quirinal, and which ought to be as unhealthy as the two other hills were the malaria of the latter imported into the city instead of being indigenous. Believing it to be indigenous, we hoped that by shielding the surface of these hills from the direct action of the air (by building houses and paving the streets), the malaria would cease to be produced there. That is precisely what has happened, for the new quarters are very healthy. But the malaria is only held in abeyance, and is not definitely overcome; for if an extensive excavation is made in these hills, and the contact of the air with the malarious soil is thus re-established, during a hot and damp season, the production of malaria commences anew. A complete atmospheric purification is nevertheless the most stable of all the methods of obtaining a suspension of malarial production, but unfortunately its realization is very limited, for it is restricted to inhabited localities and to sodded surfaces.

The ideal method of insuring freedom from malaria should be to obtain a permanent immunity, that is, to be able to modify the composition of the infected soil in such a way as to make it sterile as regards malaria, without taking from it the power of furnishing products useful for the social economy. But all the elements indispensable for obtaining such a result fail us utterly just here. We do not yet know what ought to be, in general terms, the composition of a soil incapable of producing malaria, yet retaining those properties which are suitable for vegetation. When we shall have arrived at this first stage, there will still be a long road to travel; and the most difficult part will be to discover a practical means of imparting this salutary composition to all the numerous varieties of malarious soils.

Scientifically, then, in the present state of our knowledge we are unable to affirm anything on this point. Practically, we are not much further advanced. It is very probable that the combination of hydraulic purification with a forced cultivation of the soil has sometimes determined changes in its composition by which it has been rendered sterile as regards malaria. If that has happened, it has happened by chance, and we are unable to reproduce the result at will; for we have not all the data which might enable us to understand how it has come about. Most of the purifications obtained in ancient times, by means of forced cultivation, continued during centuries, have not been definite at all, but the production of malaria has been simply suspended. Hardly was the regular cultivation of the fields interrupted than the production of malaria recommenced. Among the numerous examples that I might cite in this connection, I will limit myself to that of the Roman Campagna. This seemed to have been made permanently healthy under the Antonii, but after the fall of the empire it began again to produce malaria, as if the forced cultivation through so many centuries had never been.

One might, strictly speaking, be content with such a result, and boldly undertake forced cultivation of all malarious districts, without stopping to ascertain whether the freedom from malaria so obtained would be definite, or whether the production of the poison were only suspended. Unfortunately, one is never sure of arriving at such a result, and no one can say, _à priori_, whether the forced cultivation of a given malarious tract will render it healthful. It must always be remembered that the first effect of forced cultivation, which requires an overturning of the soil by means of the plow, the spade, and the pick, is an unfortunate one, from a hygienic point of view, whenever we have to deal with a malarious country. Experience has shown, especially in Italy and America, that this overturning of the soil almost invariably increases the local production of malaria. And this can be readily understood, since the plowing and the digging in a soil containing the specific ferment increase the extent of surface of the ground in immediate contact with the atmosphere. This first mischievous effect is often gradually weakened by the continued cultivation, and may end by disappearing. At other times, on the contrary, it persists obstinately, and one is often forced in desperation to the resolve to level the ground again and to varnish it, so to speak, with a thick sowing of grass, if he wishes to suspend or weaken the malarial production.

However, when the local conditions will permit, it is well to try whether, by means of forced cultivation of the soil, it may not be possible to increase the efficacy of the hydraulic method of procuring immunity from malaria, or of the hydraulico-atmospheric method of "overlaying." The moment that it is known that this cultivation has frequently been advantageous, there comes forward a crowd of social reasons which induce us to attempt it, even though we be persuaded that we are about to engage in a game of chance. But to dare to attempt it is not all that is necessary; we need also the possibility of so doing, and just here we find ourselves in a vicious circle from which it is not easy to emerge. Forced cultivation cannot be accomplished without the presence of agriculturists in the region during the entire year; and the agriculturists cannot remain in the region during the fever season, for they run thereby too great a risk. For the solution of this question there is but one means: _try to increase the power of resistance of the human organism to the attacks of the malaria_. It is to a search after the means of accomplishing this result that I have devoted myself during the past few years.

There is nothing to hope for, as regards malaria, in acclimation. _Individual acclimation_ is, and always has been, impossible. The malarial infection is not one of those a first attack of which confers immunity from other attacks. It is, on the contrary, a progressive infection, the duration of which is indeterminate, and which is of such a nature that a single attack may suffice to ruin the constitution for life. Collective or _racial acclimation_ certainly existed in the past, at a time when specific remedies for pernicious malaria were unknown; and even later, when the employment of these remedies was very limited. The acclimation was due to a natural selection made by the malaria upon successive generations, from which it took away, almost without opposition, all those who possessed but a feeble individual power of resistance to the specific poison, while it spared those who possessed this power of resistance in an extraordinary degree. The first were, according to the Grecian myth, _the human victims destined to appease the monster or demon who opposed the violation of the territory over which he had up to that time exercised an absolute sovereignty_. The second became the founders of the race, and through them, from generation to generation, the collective power of resistance to the malaria was progressively increased. In our own days a like selection may take place among barbarous races, as it does among the cattle and the horses in a malarious region, but it has become an impossibility among civilized nations. By means of the specific remedies which we possess, the use of which is now so general, the lives of a large number of individuals whose resisting powers are very feeble are preserved; and these individuals beget others whose power of resistance to the action of the specific poison is still more feeble. This results after a number of generations in the physical degradation of that part of the human race which inhabits malarious countries.