Part 36

The story of the discovery of the malarial parasite is worth recounting. These organisms inhabit the red blood corpuscles and were first seen by Alphonse Laveran (1845-) in 1880 in Algiers. His observations were extended by French and Italian observers, who showed that the sudden rise in temperature in Malaria coincides with a process of division of the parasite. Later the suggestion that the parasite might be conveyed to man by the mosquito was made by Patrick Manson (1844-1922). The matter was clinched in 1898 by Ronald Ross (1857-), who showed that the malarial parasite necessarily passes through a stage in the stomach of the mosquito. The process was first traced by Ross in a malarial parasite that is peculiar to certain birds, and was subsequently demonstrated for the allied species of parasite that produces human Malaria.

We have here an illustration of the value of comparative pathological studies. Since the demonstration of the life-cycles of the malarial parasites of man (Fig. 123), the chief attention of hygienists interested in

Malaria has been directed to the mosquito (Fig. 124). Controlling the breeding of the mosquito has proved the best method of reducing the incidence of the disease. Engineering and sanitary works in some places previously infested with Malaria have had the effect of almost entirely eliminating disease. The classical instance is the Panama zone, where, as is well known, the two mosquito-born diseases, Yellow Fever and Malaria, have disappeared. There are now many areas in the Tropics, previously infested, in which the disease is almost unknown. There are many devices for dealing with the mosquito larvae.

By advances such as have been made in the knowledge of Yellow Fever and Malaria, those areas of the Tropics which are under proper sanitary control have become far safer habitats. There is good hope of an early and rapid extension of the process, ultimately rendering new areas of the Tropics suitable for permanent habitation by the white races and healthier and happier places for the colored.

The life-histories of the parasites of the malarial diseases of man have been completely traced. The parasites run through a double cycle, one in man and the other in the mosquito. In our diagram the cycles of only one species are represented; there are however two other special malarial parasites in man.

On either side the head of the mosquito involved is diagrammatically shown, just below the ‘cycle in man’.

In man the parasites conveyed by the bite of the mosquito (32) or formed by a division of a parasite already in the blood (7) make their way into the red blood corpuscles (1 and 2), develop there (3 and 4). Some of them ultimately divide to go through the same cycle (5, 6, 7 and back to 1, 2). The process of division corresponds to the period of fever. Others develop into crescent-shaped bodies (8, 9 and 10), which can be differentiated into two slightly different forms corresponding to two sexes (9 male, 10 female). These, if sucked up by a biting mosquito of the right species, pass into the animal’s stomach where they develop further (11, 12, 13 male; 14, 15, 16 female) and end by dividing into forms which conjugate (17). The resultant of this conjugation or union of the two sexes (17) develops into a lanceolate form (18, 19, 20) which passes into the cells of the mosquito’s stomach (21, 22) and finally penetrates these cells (23). The parasite then secretes a cell-wall and forms a ‘cyst’ (24), which enlarges (25). The enlargement continues while the nucleus breaks up (26, 27, 28). In the cyst, which is still growing, a large number of needle-like forms develop, each of which contains a fragment of the nucleus (29). Finally the cyst bursts (30), the needle-like forms are cast forth into the body of the mosquito, and ultimately lodge in her salivary glands (31). When the mosquito bites another man, she injects some of her saliva into him through her proboscis. Thus she infects his blood with some of the needle-shaped parasites that lurk in her salivary gland (32). So the cycle is re-enacted again and again. We may note that to prevent this process of repeated reinfection it is only necessary to break either cycle at one point. Thus destruction of mosquitoes or of their breeding-places will suffice, or, again, protection of human hosts from bites of mosquitoes will be sufficient. Either process, if persisted in, will lead to the extinction of the parasite in the region under supervision. In England both methods have been in operation and the disease is almost extinct there so long as any of the malarial mosquitoes remain in one district. However, the disease can always be reintroduced by the introduction of subjects of malaria from without.

(From C. M. Wenyon’s Protozoology, Vol. II, by kind permission of Messrs. Baillière, Tindall and Cox. Slightly reduced in size.)]

FIG. 126. CHART OF CASES OF MALARIA reported in Italy in recent years, showing the seasonal variation of the disease. The date of the year is written, in each case, below a vertical line corresponding to midsummer. It will be seen that the maximum incidence is always in the months July to September, and the minimum incidence is always in the months January to March. This incidence corresponds to the known facts of the life-history of the mosquito and of the evolution of the malarial parasite within the body of the mosquito. ]

§ 15. The Changed View of Insanity.

Insanity is as old as History. The Bible, Homer, and the Hippocratic Collection, for instance, recount numerous examples of the disease. Until the nineteenth century there was practically no scientific knowledge of the conditions classed as insanity. Nevertheless, hospitals for the insane were instituted at an early date. A well-known instance is Bethlem Hospital or Bedlam in London, which was developed as an insane asylum in the fourteenth century.

The new era in the treatment of insanity begins with the abolition of the old system of restraint. This was primarily due to two noble-minded men, one a Frenchman and the other an Englishman. Philippe Pinel (1745-1826), physician at the Bicêtre and afterwards at the Salpêtrière at Paris, at great personal risk both to his life and liberty, insisted on freeing from their chains the unfortunate lunatics under his charge. His Medico-philosophical Treatise on Mental Alienation (1791) was devoted to championing the humaner treatment of the insane. His contemporary, the Quaker philanthropist William Tuke (1732-1822), succeeded in 1792 in establishing at York a small retreat for the insane, where the antiquated, unnecessary and cruel restraints were abolished (Fig. 127).

While Pinel was beginning the humaner treatment of insanity in France, considerable interest was aroused in the subject in Germany. There, however, the medical profession was still under the influence of the mystical Stahl (pp. 132-3), who regarded all forms of insanity as perversions of the moral tendencies of the soul, produced by sin!

In France Pinel was succeeded in 1810 by Jean Étienne Dominique Esquirol (1772-1840). The influence of Esquirol was as radical for the scientific study of the subject as had been that of Pinel for the humane treatment of the sufferers. Esquirol threw himself into the task of founding properly conducted asylums, and he produced in 1838 his monumental work On Mental Diseases considered in their Medical, Hygienic, and Legal relations. It is the first important, rational, scientific treatise on the subject. Esquirol abandoned the barren type of speculation that had characterized previous works on the subject and devoted himself to the systematic collection of data. He was able to sketch out some of the main forms of insanity, including that now known as ‘General Paralysis of the Insane’. This disease was finally differentiated by one of his pupils. Another pupil of Esquirol was the first to succeed in the training of idiots. The main school of French alienists is descended from Esquirol. In the early forties his work resulted in the foundation of journals and societies devoted to the study of Insanity in France, England, the United States, and Germany.

England was behind France in her treatment of the Insane. Not until 1828 were there proper laws governing their certification. In 1844 the great and good Lord Shaftesbury (1801-85), the seventh Earl, brought in his Bill establishing the Board of Lunacy Commissioners with the duty of inspecting all lunatic asylums. It was a subject to which that great philanthropist gave much thought. The same period saw also an awakening in the United States, where Miss Dorothea Lynde Dix (1802-87) carried on a very successful campaign for the better treatment of the insane and the establishment of proper houses for their reception. Her labors resulted in the foundation of many asylums on a reformed model in the United States and Canada. In 1845 the provision of asylums out of the local rates was made compulsory on the local Justices in England.

The late sixties and early seventies saw in every country a further change for the better in the treatment of the Insane. The causes of this improvement were two. On the one hand, Insanity came generally to be recognized as a group of diseases which, like other diseases, have usually a traceable physical basis. On the other hand, the great improvement of the system of nursing under the inspiration of Florence Nightingale (pp. 298-300) began to reach the asylums. In 1877 there was a Parliamentary investigation into the care of the Insane in England and Wales, and in 1890 the duties of asylum administration were transferred from the Justices to the County Councils. This has resulted in an immense improvement in the accommodation and treatment of the insane poor in England. At the same time the order of a magistrate became necessary for the consignment of a private patient to an asylum. In 1913 provision was made for the mentally defective, who do not come within the Lunacy Act. Lastly, with the establishment of a Ministry of Health in 1917, the general control of the Insane has passed to that body.

Many types of insanity have been traced to an organic cause in the Nervous System itself. The Morbid Anatomy, both coarse and microscopic, of some of these diseases has become recognized. Chief among them is the well-known condition known as ‘General Paralysis of the Insane’. During the intensive study of the factors in the causation of Insanity it has become clear that in some groups, as in General Paralysis, which is always preceded by Syphilis, a ‘toxic cause’ is at work. Other types of toxic insanity are due to the actual intake of a poisonous substance. This is sufficiently evident in cases which are associated with Alcoholism. There is also evidence that in a considerable number of cases toxic conditions result from perversion of metabolic processes, or, again, are associated with ‘deficiency’ states (pp. 302-8). This is a very hopeful finding, since by removing the toxic cause, or by remedying the deficiency, relief may be possible.

Much less hopeful is the outlook with those forms of insanity, especially common in the adolescent, which are of the nature of a perversion of development. Such is the large group known as ‘Dementia praecox’. These cases almost invariably originate from a mentally unsatisfactory stock. This is less so with the Epileptic insane, though a considerable proportion of epileptics may be classed with those who are born mentally defective and are liable to give rise to a bad stock. Whatever view may be taken of the question of the artificial limitation of human fertility, it is almost impossible to imagine that the free breeding of these classes of defectives, epileptics and their congeners, will continue unchecked in any civilized community.

The general care and treatment of the insane has improved out of all knowledge during the last quarter of a century. It is probable that there is now no class of sick person who is more skilfully and considerately cared for.

From time to time an alarm is raised at the rapid increase in Insanity, and it is a fact that the proportion of certified insane has been, for some time, steadily rising. A considerable part of this rise is certainly due to the greater willingness of the insane themselves to enter an asylum, and of their friends to allow them to do so. Part of the rise in numbers of the insane is due to their increased length of life under improved treatment. It must be remembered that more than 90 per cent. of the insane in England and a similar percentage in other countries are paupers, who are not readily discharged as they have no means of support. Mild mental cases and the senile insane go now to the improved asylums. Before they would have been kept at home or sent to a rate-supported or a State infirmary. The general conclusion of those best qualified to judge is that Insanity, if increasing at all, is doing so only very slowly.

being the first institution in England where the insane were accorded humane and scientific treatment.]

§ 16. The New Movement in Psychology.

During the last half-century various new points of view have entered into our conception of Mind and its disorders. The evolutionary view of the origin of man, which was brought to wide notice by Charles Darwin, not only in his Origin of Species of 1859 but also in his Descent of Man of 1871 and his Expression of the Emotions of 1872, has given rise to new ideas as to the nature of many instincts and emotions. These views have been co-ordinated with our knowledge of lower types of man, both in his existing state and in his extinct and fossil forms. Much that we call Insanity has been found to be related to what is normal in other and less developed environments. The Mind, breaking free from its habitual restraints, ‘reverts to a lower type’. There is a constant though unconscious ‘conflict’ in the mind, which is variously resolved.

Whole schools of Psychology have arisen in the discussion of the nature and resolution of these conflicts. Sigmund Freud of Vienna (1856-) takes the leading place among those who have dealt with this subject. He holds these conflicts to be rooted in sex and has introduced the method of Psycho-analysis, which lays great stress on the subconscious or unconscious element in mental life. Largely under the direction of C. G. Jung of Zürich (1875-), preventive and curative measures, based on this view, have been introduced into medicine. It has been established that painful experiences, lurking in the unconscious mind, disturb the equilibrium of health. Such disturbance is often of the nature of a struggle to repress into the unconscious unpleasant memories which are tending to surge up into the conscious. The psycho-analyst seeks to release the repressed experience into the conscious. The recognition and consideration that follow a success in this attempt is often far less painful than the repression. Persistent unreasonable fears on the part of adults, but especially of children, are frequently thus dispersed.

The importance of suitable environment to children has always been recognized. But a new significance has been given to the mental impressions received in infancy by cumulative evidence of harmful results in the adult life of events in the early years of life that are seemingly forgotten. This recognition of the enduring character of mental impressions has led to a movement for the better instruction of mothers, and has thus been a factor in the remarkable development, in recent years, of work for infant welfare.

It is recognized, moreover, that certain instincts--such, for example, as the self-regarding instinct and the sex instinct--must have expression. Mere repression of such instincts is always harmful, but they are susceptible of a process of transformation, technically known as sublimation, to an almost indefinite extent. Thus the self-regarding impulse need by no means lead to the inconvenience and discomfort of others, but, rightly guided, may develop into a sense of personal responsibility for the welfare of others. So, too, sex instinct is but one aspect of that creative vital activity on which depends the continuance not merely of the human race but also of the culture that the race has built up. The sex instinct is thus habitually sublimed into other creative channels, and there are many altars, beside those of Venus, at which young men and women may kindle their essential fires.

§ 17. The Revolution in Nursing.

During the Middle Ages, and in Catholic countries after the Reformation, attendance on the sick in Hospitals and elsewhere was the task of religious sisterhoods. In Protestant countries the absence of these sisterhoods necessitated the employment of women specially for the purpose. The task was not an attractive one, nor did any social distinction attach to it. The profession of nurse became despised and was followed, for the most part, by a low and illiterate type of woman, though midwives were sometimes better educated and of a higher class (p. 180). The great philanthropists of the eighteenth century (pp. 171-72) could do little to improve the nursing profession. The conditions of employment formed the root of the evil. The vast improvement that has resulted in health and happiness to our whole population from the improvement in the character and training of nurses is probably seldom realized, even by medical men. Yet it may reasonably be doubted whether all modern medical and surgical advances put together--apart from Preventive Medicine and Infant Hygiene--have saved as many lives as the Reform of Nursing.