The neighbourhood of marshes, or of a district which has been at some recent time under water; the banks of extensive lakes, and the shores of rivers and seas where the water flows sluggishly, and in some places stagnates; shallow rivers; extensive level tracts of forest land, where moisture is always present; and the surface of the land constantly covered with excavation from the ground,—these are the terrestrial physical conditions, in which marsh and littoral fevers are almost universally to be found, although it must be admitted that there are some marshy districts in which the disease does not show itself.
In these latter localities the effects of the miasmatic poison, show themselves in cholera or typhus. No precise knowledge of the nature and source of this subtle poison which, in default of a better name we call malaria, has yet been acquired; indeed it has yet to be proved that malaria has a distinct existence. Science has as yet been unable to discover the presence of any poisonous principle in the air of ague on other regions.
Ague may exist without any alteration of structure being set up; but in the milder forms of this fever a greater number of organs and tissues are morbidly altered than perhaps in any other form of disease. The parts so affected are the liver, spleen, lungs, heart, brain, and the serous and mucous membranes of the body generally. Within certain limits, the specific action of the malarial poison may be said to be in the inverse ratio of the intensity of the fever which attends its action. The affections of the liver and spleen also vary greatly according to the locality in which the patient is attacked; for instance, whilst in some parts of India the spleen is the organ principally involved, in other districts of the same continent it is the liver. In England, under proper medical treatment, the patient usually recovers without any manifest derangement either of structure or impairment of function of any organ or tissue. The liver may, however, become affected if the patient suffering from the disease has been neglected for any length of time.
Notwithstanding the opinions of Finke and Professor Colin, there appears to be considerable ground for the supposition that ague may be caused by drinking marsh and surface water. In an interesting paper on the ‘Indian Annals’ for 1856, Mr Bettington, of the Madras Civil Service, says:—“It is notorious that the water produces fever and affections of the spleen.” In confirmation of this assertion, he brings forward what seems to be some remarkably strong evidence. He cites cases of villages placed under the same conditions as to marsh-air in some of which fevers were prevalent, whilst in others they were absent; and he found on inquiry that whilst the latter villages were supplied with pure water, the inhabitants of the former had to drink marsh or mullah water, full of vegetable débris. In one village there were two sources of supply—a spring and a tank, the first fed by surface, and the other by marsh water. Those only who partook of the tank water were attacked by fever. Again, in Tulliwaree the fever was so universal that scarcely any inhabitant escaped it. In this village Mr Bettington caused a well to be dug, and the result was that the fever disappeared. Similar cases have occurred in this country. Twenty years ago Mr Blower, of Bedford, directed the attention of medical men to a case that occurred in a village, in which ague had nearly disappeared when a well was dug; and to another instance which occurred in the village of Houghton. In this parish almost the only family which escaped ague was that of a farmer; the members of this family partook of well water; whilst those who did not escape the disease drank ditch water.
In the ‘Indian Annals’ for 1867 is a paper by Dr Moore, confirming the opinion that ague may be produced by the causes already stated, and M. Commaille (‘Rec. de Mêm. de Med. Mil.,’ Nov., 1868) states that in Marseilles, paroxysmal fevers, formerly unknown, have made their appearance, since the water supply to that city has been drawn from the Marseilles Canal.
In his report for 1870 Dr Townsend, the Sanitary Commissioner for the central provinces of India, states that the natives of India hold an opinion that the use of river and tank water during rainy seasons (when the water always contains an increased quantity of vegetable matter) will almost always cause ague. Boudin (‘Traité de Géographie et de Statistiques Médicale,’ 1857, t. i, p. 142), records an extraordinary case. Eight hundred soldiers, in good health, embarked in three vessels to pass from Bona, in Algiers, to Marseilles, in the year 1834. They all arrived at Marseilles the same day. In two vessels there were 680 men, without a single sick one amongst them. In the third vessel, the Argo, there had been 120 soldiers; 13 died during the short passage, and of the 107 survivors no less than 98 were disembarked suffering from all forms of paludal fevers. We may presume that the diagnosis was correct, since Boudin himself examined the men. When the vessels started the crew of the Argo had not a single sick man aboard. The crew and soldiers of all the boats were exposed to the same atmospheric conditions. The influence of air must, therefore, be excluded. There is no mention of food, but it has never been suggested that food has ever been concerned in the production of malarious fever. It was a very different matter, however, with the water supply. In two of the vessels the water was good, whilst the Argo had been supplied with marsh water, which was offensive to the smell, as well as unpalatable. This latter was supplied to the soldiers, whilst the crew drank uncontaminated water. Amongst those who deny that marsh water is the cause of ague must be quoted Professor Colin. The professor, who is regarded as an authority on intermittent fever, in his work De l’Ingestion des Eaux Marécageuse comme cause de la Dysenterie et des Fièvres intermittentes,’ instances numerous cases in Algiers and Italy in which impure marsh water gives rise to indigestion, diarrhœa, and dysentery, but in no case to intermittent fever; and he states that in all his observations he has never met with an instance of ague having such an origin. Without contesting the case of the Argo, he views it with considerable suspicion, and doubts whether Boudin is correct in his details. Finke also states that, in Hungary and Holland, marsh-water is daily drank without causing any ill-effects. The inhalation of the fumes of oxide of zinc appears to produce in workers of this metal a variety of ague termed by Shackrah “brass ague,” and by Dr Greenhow, “brass-founder’s ague.” The symptoms of the malady are tightness and oppression of the chest; with indefinite nervous sensations, followed by shivering, an indistinct hot stage, and profuse perspiration. These attacks, however, are not periodical.
It is open to doubt whether the malarious poison exists in the form of a gas, for the observations of microscopists go to show the extreme minuteness of the germs of disease, which are probably not more than 1⁄70000th of an inch in size, and it is regarded as probable that the real cause of ague is the entry into the circulation of some low forms of spores of fungi, or of some minute animalcules. Ague is always to be met with in places where fungi grow, and is always associated with what Pettenkofer calls “the ground air”—that is, the air contained in the interstices of the soil, no inconsiderable volume of which is drawn into every house which has a fire on the floor which rests on the earth. That animalcules (?) may exist in the blood is evidenced by the discovery of Dr Lewis, who found hair-like worms in the circulation; and whilst considering this point, we must bear in mind that the
remedial agents employed to check ague, quinine, arsenic, &c., are drugs capable of destroying animal life, and it is not impossible that they may exercise a beneficial effect in destroying the spores or animalcules to which the disease may be due.
The best means to be employed to combat malarial fevers in any district are thorough and efficient drainage (and it must be remembered that drainage purifies both the ground-air and the ground water) and a supply of wholesome water free from decomposing vegetable matter.
That the adoption of the above means cannot fail to succeed is incontestably proved by the fact, that during the last 200 years, ague in England has diminished to a wonderful extent, in short, as good drainage and a pure water supply have prevailed, there has been a proportionate diminution of paludal poisoning.