[BITList] Malaria and Kala-azar [Blackwater Fever]

[John Feltham]

G'day folks,

In the last two weeks of 5 years spent living on the Island of Bougainville, Papua New Guinea, I contracted Malaria. It did not appear until some weeks later when I first came to Townsville. The doctor didn't believe me when I told him that I was suffering from malaria. He changed his mind when I told him that I had recently returned from PNG!

A course of pills took the illness away and I have not had a recurrence.


ooroo


Read on...


This day designing God
Hath put into my hand
A wonderous thing. And God
He praised. At his command
I have found thy secret deeds
Oh million-murdering Death.
I know that this little thing
A million men will save
Oh death where is thy sting?
Thy victory oh grave?


To read this Life of the Day complete with a picture of the subject,
visit http://www.oxforddnb.com/view/lotw/2012-05-13


Ross, Sir  Ronald  (1857-1932), malariologist, was born on 13 May 1857 at the Himalayan hill station of Almora, North-Western Provinces, the eldest of ten children of General Sir Campbell Claye Grant Ross (1824-1892), then a captain in the 66th regiment of Gurkhas, and Matilda Charlotte (d. 1906), daughter of Edward Merrick Elderton, a London solicitor. The Ross family was Scottish, of clan Ross, but Ross's great-great-grandfather was a director of the East India Company, and his grandfather, father, and an uncle were soldiers in the Bengal army, so the Indian connections were long-standing. Nine of the ten Ross children survived into adulthood, three of Ross's brothers continuing the family military tradition, and two following him into medicine.

Early life

Ross remained in India until 1865, speaking English and Hindi interchangeably. He was sent for schooling to England, where he lived with a great-uncle, a retired doctor, in Ryde, Isle of Wight. His mother and three siblings came to Ryde two years later, and on his mother's return to India in 1869 Ross went to a boarding-school at Springhill, near Southampton. In his memoirs (1923), he remembered the school with affection, though not for the quality of the teaching. His early interests included drawing, music, literature, natural history, and outdoor pursuits. He would have preferred a career in the army, or to become an artist, but his father determined that he should become a doctor in the Indian Medical Service.

His father prevailing, Ross entered St Bartholomew's Hospital medical school in 1874. He was an average student, spending as much time enjoying London's cultural life as on his medical studies. Although he found a six-month stint as an unqualified assistant at the Shrewsbury Infirmary stimulating, he never considered clinical work especially rewarding. Three days' intense cramming was sufficient for him to pass the membership qualification of the Royal College of Surgeons, but he failed the licentiate examination of the Society of Apothecaries. The MRCS was adequate to become a ship's surgeon; he made four or five voyages, although the foibles of the passengers were more interesting to him than their sea-sickness and illnesses. He spent his spare time writing a verse drama and beginning a novel.

On his return to England, Ross passed the LSA and the qualifying examination for entry into the Indian Medical Service, but his ranking was not good enough to secure one of the more attractive postings in Bengal. Consequently, after the obligatory four months at the Army Medical College, Netley, he left in September 1881 for Madras. For the next seven years he led the peripatetic life of a bachelor medical officer, spending time in Madras, Vizianagram, Moulmein, Burma, and Fort Blair, in the Andaman Islands. His medical duties being light, he fished and played golf and tennis. More significantly, he spent his leisure teaching himself mathematics, and in a systematic study of European literature. He also began another novel and published his first work, a volume containing two verse dramas (1883).

Ross returned to England on furlough in 1888, where he took the diploma in public health of the royal colleges of physicians and surgeons and returned to his old medical college for a course in bacteriology with E. E. Klein. He later remarked that his ability to solve a complex mathematical equation on the diploma examination rescued him from an otherwise mediocre performance. While on furlough he also met, courted and, on 25 April 1889, married Rosa Bessie (18613-1931), daughter of Alfred Bradley Bloxam, a man of independent means. In mid-1889 she accompanied Ross back to India, where their first two children, Dorothy (1891-1947) and Sylvia (1893-1925), were born. Following active service in Burma, Ross was appointed to the staff surgeoncy at Bangalore. A novel, The Child of Ocean (1889), the publication of which was arranged while Ross was on furlough, and a Byronic poem, The Deformed Transformed (1890), continued his literary exertions.

Ross's first medical paper did not appear until 1893; ironically, it argued against the notion that malaria was caused by the haematozoon which had been seen in the blood smears of malaria victims by the French army doctor Charles Laveran in 1880. The paper at least highlighted Ross's growing interest in malaria, however, and when he and his family returned to London on furlough in 1894, he sought out Patrick Manson, the leading British expert on tropical diseases. Manson demonstrated Laveran's parasite to Ross, introduced him to the recent malaria literature, and took him on several occasions to see patients with the disease in London hospitals. He also shared with Ross his belief that the mosquito was somehow implicated in the life cycle and spread of the parasite. Ross wrote an essay on the disease which, though never published, won the Parkes gold medal of the Netley medical college. He returned to India in March 1895 determined to prove the mosquito hypothesis, which he then called Manson's 'Great Induction'. During his furlough he had devised a portable microscope, made by a London instrument maker and subsequently used by Manson in his teaching.

Malaria and mosquitoes

Between 1895 and February 1899, when Ross left India, he and Manson produced one of the great correspondences of scientific history. Ross averaged a letter every fortnight, Manson about half as many. Ross's letters record his increasing skill at hatching mosquito larvae, dissecting the insects at various stages of their development, and identifying the several parasites which infect them. Manson had speculated that the malaria parasite developed in the mosquito's larva, and that human beings contracted the disease through drinking contaminated water, or breathing infected air. Ross tested the hypothesis with ambiguous results; he also soon realized that when some species of mosquitoes bit patients with the malaria parasite in their blood, nothing subsequently occurred in the mosquito.

Ross's researches were frustrated not simply by the complexity of the problem but by the demands of his routine work in the medical service. He was sidetracked for several months by sanitary work in Bangalore, where a cholera epidemic had broken out, and by subsequent postings to stations where malaria was not common. For his part Manson did his best to secure research leave for Ross, reported the latter's work in his 1896 Goulstonian lectures to the Royal College of Physicians, and facilitated the publication of Ross's papers in the British Medical Journal. A brief period of research leave being granted in the spring of 1897, Ross spent it at a highly malarious area, Sigur Ghat, near the hill station of Ootacamund. He caught malaria, which he attributed to drinking some tea which had been inadequately boiled. He successfully treated himself with quinine, but that episode, and a subsequent severe attack of cholera in Secunderabad in June 1897, turned his thoughts increasingly towards taking his pension from the service, and devoting himself entirely to literature. By then, his third child, and first son, Ronald Campbell (1895-1914), had been born, and some of his letters to Manson were devoted primarily to his precarious finances and the bureaucracy of the service.

Then, in August 1897, Ross started working with a new kind of mosquito, brown and 'dapple-winged'. He hatched some larvae, let the insects bite a patient suffering from malaria, and began periodically to dissect the mosquitoes. On the fourth day, 20 August 1897, and on his penultimate insect, he discovered some black pigmented cells in the wall of the mosquito's stomach. In the final insect, dissected the next day, the cells had grown. He composed ten lines of what became his most famous poem ('This day designing God/Hath put into my hand/A wonderous thing'), wrote to his wife that he had 'seen something very promising indeed', and on 22 August gave Manson a cautious, but full, account of his discovery. Ross ever afterwards celebrated 20 August as 'Mosquito Day'.

He had now got the malaria parasite from human blood into the mosquito, but a transfer in September to Kherwara, where there was no malaria, hampered his work. Manson was eventually able to get him assigned to six months' special duty in Calcutta to continue his malaria studies. He began in February 1898, eventually overcoming the scarcity of human malaria patients by working on birds, which are susceptible to a parasite closely resembling the Plasmodium that causes human malaria. He further traced this parasite from the mosquito's stomach to its salivary glands, which provided valuable support for the hypothesis that transmission occurs through the bite of the mosquito. By early July he had become adept at infecting hatched mosquitoes by causing them to bite infected birds, and completing the cycle by giving healthy birds malaria via the bites of infected mosquitoes. This constituted the formal proof that he had sought on the mechanism of malaria transmission. Manson described this work at the British Medical Association meeting in Edinburgh in late July and arranged for Ross's researches to be reported in the BMJ and The Lancet. He also used its practical implications for malaria control as a lever to encourage Joseph Chamberlain, colonial secretary, to secure a government grant to help establish the London School of Tropical Medicine (1899). The Royal Society established a malaria committee, which promptly dispatched Charles Daniels to India to confirm Ross's observations and continue his work. By the time Daniels arrived in Calcutta in December 1898 Ross had returned from three months' fruitless work in Assam, investigating kala-azar, a disease often confused with malaria but later shown by other investigators to be caused by another parasite.

Ross after India

Ross initiated Daniels into his methods and findings, and, with his family, returned to England in February 1899. After retiring from the Indian Medical Service he was appointed lecturer in the Liverpool School of Tropical Medicine, newly established by Liverpool philanthropists, especially Sir Alfred Jones. His last child, Charles Claye Ross (1901-1966), was born in Liverpool. Ross's Indian experience had convinced him that Anopheles mosquitoes, identified as the carrier of the malarial Plasmodia, were relatively fragile and easily controlled. He set out his ideas in several short works, including Instructions for the Prevention of Malarial Fever (1899) and Mosquito Brigades and how to Organise them (1902), and, under the auspices of the Liverpool school, went on malaria expeditions to Sierra Leone (1899, 1901) and Lagos (1901). These proved frustrating to Ross, as his recommendations about mosquito control were not carried out after he and his teams returned to England. An attempt to apply Ross's measures at the military cantonment at Mian Mir, near Lahore, between 1902 and 1910 largely failed, and alienated Ross from the talented group of malariologists in India. After his retirement from the Indian Medical Service he visited India only twice. He also advised on malaria control measures in Ismailiyyah, Egypt (1902), Greece (1906), Mauritius (1907), and Cyprus (1912). He went to the United States in 1904 to lecture, during which time he also observed malaria and yellow fever control measures in Panama. He made contact with the Russian Malaria Commission during a trip to Russia in 1912.

The discovery that the Anopheles mosquito was an essential link in the transmission of malaria between human beings catalysed international interest in the possibility of preventing the disease. Several different strategies were elaborated, including widespread use of prophylactic quinine, segregation of Europeans from the principal human reservoirs (identified as native children), extensive drainage of swamps and marshes, and the systematic policing of common urban breeding sites, such as wells, cisterns, and puddles. While these approaches were not mutually exclusive, Ross always strongly favoured vector control as the most cost-efficient means to prevent the disease, and he developed a sophisticated mathematical model of malaria epidemiology to show that it was not necessary to eradicate all Anophelines in a particular area to effect a significant reduction in malaria incidence. Ross's model was rooted in the mathematics of probability (what he called a theory of happenings), and although it was later recognized as a basis of mathematical epidemiology it was poorly appreciated in Ross's lifetime and made relatively little impact. He first announced his mathematical ideas to an unsuspecting audience in St Louis, Missouri ('who did not understand a word I said'; Ross, 491), and elaborated them in his The Prevention of Malaria (1910).

In this volume Ross edited chapters by different experts on malaria control in many malarious countries, but the bulk of the monograph contained Ross's own reconstruction of the contributions made by various individuals to the discovery of the transmission of malaria by Anopheles mosquitoes. He placed himself centre stage, and virtually all his later writings on malaria were obsessively concerned with his priority. The principal object of his opprobrium was the Italian parasitologist Giovanni Battista Grassi. Grassi and several of his co-workers were actively investigating malaria in 1897 and 1898, and it was they who demonstrated the malaria cycle in human beings, shortly after Ross's definitive work on bird malaria. Their rivalry, always intense, became vicious after Ross was solely awarded the Nobel prize for medicine or physiology in 1902, and Grassi dedicated to Manson a slim volume aggressively stating his own claims to scientific spoils in the matter. Although the dedication had been done without Manson's knowledge or permission, and Ross forced Manson to issue a public disclaimer, the episode resulted in a marked cooling of the relationship between Ross and his former mentor. It is probably significant that Ross published his memoirs in the year after Manson's death, and one of his last publications, Memories of Sir Patrick Manson (1930), belittled the contributions which Manson ('nothing but a medical man') had made to founding tropical medicine as a scientific discipline. He considered Grassi as little more than a scientific pirate.

These darker aspects of Ross's personality intruded in the satisfaction he might have felt about the honours and fame which came to him: his fellowship of the Royal Society (with Manson as his chief proposer) in 1901, the Nobel prize, and decorations by Belgian and British Governments (CB, 1902; KCB, 1911), culminating in his KCMG in 1918. Nor were his relationships with the Liverpool school ever easy. He had expected to be made dean of the new school, a position which went instead to Rupert Boyce; the school's precarious finances meant that his lectureship was not put on a permanent footing for several years, and he received an honorary chair only in 1912. Despite his contempt for 'mere clinicians', he was hurt when no beds were made available to him in the Liverpool hospitals. Various initiatives that he attempted in Liverpool, such as a malaria bureau, faltered through inadequate financial support. His research on topics other than malaria, including the influence of cold temperatures on parasite development, were not notably productive. He never was able to develop a lucrative consulting practice and complained regularly that his earnings were not commensurate with his contributions to knowledge and human health.

On the other hand Ross could be energetic in his support of others whom he thought to have been badly treated. He actively campaigned on behalf of the Russian born Jew Waldemar Haffkine when the Indian government dismissed him following a disaster with contaminated plague vaccine. Although Haffkine had developed the vaccine an enquiry subsequently showed that he was not responsible for the contaminated batch. Ross also spearheaded an unsuccessful petition to parliament which sought to secure public funds to reward scientific and medical researchers. He used the pages of Science Progress, a journal he edited from 1912 until his death, to further the cause of science and scientists. He followed the career of Sir William MacGregor with interest and affection, because of MacGregor's liberal ideas about the role of colonial governments in the area of health and disease prevention. Ross's own analyses of the economic and social costs of disease were cogent and humane, but they were generally unheeded by penny-pinching administrations.

Although Ross was quite prepared to settle in Liverpool ('the second city of Empire') on his retirement from the Indian Medical Service, London always attracted him as a more suitable arena for his talents. He flirted with an appointment at the Lister Institute in 1902, but remained there only a few months. He returned permanently to London in 1912, accepting an appointment as consultant physician to King's College Hospital, although he continued to lecture in Liverpool until 1916, by which time his war duties had made it difficult for him to honour his commitments. He was an adequate lecturer but unenthusiastic teacher. During the First World War Ross was made a consultant in malaria to the War Office; he travelled to Egypt, Macedonia, Italy, and elsewhere during the war, surviving the torpedoing of the French military transport in which he was sailing in 1917. In addition to his malaria work he also advised on prevention and treatment of dysentery in Egypt. After the war he became a consultant with the Ministry of Pensions.

Much of Ross's energy during the latter years of his life was taken up with fighting old battles. These included the priority dispute with Grassi and an attempt to secure his place in the history of mathematics. As early as 1901 he had sent the manuscript of a volume entitled Algebra of Space to P. G. Tait. Tait died shortly afterwards and Ross's attempt to get the manuscript back was unsuccessful. Although he published a revised version of the monograph in 1901, he subsequently believed that others had purloined his ideas. He privately issued pamphlets in 1929, 1930, and 1931, restating his claims to mathematical brilliance.

Ross also continued his literary work, republishing some of his earlier novels and poems, writing poetry almost until the end, and serving as president of the Poetry Society, from which he resigned after a dispute. He enjoyed the friendship of several literary figures, including Osbert Sitwell and John Masefield, and had the satisfaction of winning the James Tait Black memorial prize in 1923 for his memoirs. He also dabbled in musical composition. Like many individuals obsessed with their place in history he kept a large personal archive, which he advertised for sale in 1928. About this time he also subsidized the publication of a hagiographic biography of himself by Rudolph Megroz, to which Sitwell contributed a preface.

All of this reinforces the fact that Ross's London years were unfocused. His self-image was always primarily as a scientific researcher, but he never secured a stable research base for himself in London. He briefly worked in the Marcus Beck Laboratory associated with the Royal Society of Medicine, but this was interrupted by the war and was never adequately financed. Ross resigned from the society in 1917. Already by then there had been moves to establish a Ross Institute; in 1923 a public appeal was launched which raised about £50,000. The prince of Wales, later Edward VIII, opened the institute in Putney in 1926, but the endowment was never sufficiently large to support the institute's independent existence. When the London School of Hygiene and Tropical Medicine was expanded in the late 1920s the Ross Institute moved to the school's site in Bloomsbury and was formally incorporated into the school in 1934.

By the time the Ross Institute was established Ross himself was a tired old man, concerned mostly with his past and his reputation. He prided himself on having had malaria only once, but his health began to fail in the 1920s, and he was confined to a wheelchair during his last years following a stroke in 1927. Ross's wife predeceased him in 1931; he died at the Ross Institute and Hospital for Tropical Diseases, Putney, on 16 September 1932 and was buried beside his wife in Putney Vale cemetery.

Ronald Ross was an easier man to admire than to love. He was highly intelligent and multi-talented, but far too prone to vanity. He did not suffer fools gladly and was quick to assume that anyone who did not agree with him was a fool. At the same time he was sometimes capable of self-parody, and his memoirs record several instances of jokes at his own expense. He worried constantly about his finances and said repeatedly that his scientific researches had been inadequately rewarded by an ungrateful humanity. At the same time his contributions to both the aetiology and epidemiology of malaria were fundamental, and his analysis of the health problems of tropical countries was broadly based and consonant with the approaches of later times. Unusual in his time he looked upon the cost of sanitary reform as an investment, not a current expenditure. In a later period, when shared Nobel prizes became the norm, Ross would have shared his prize with one or two others who helped elucidate what he called the 'great malaria problem'. As it was, he was the first Briton to be awarded one, against formidable competition, and on merit.

W. F. Bynum 

Sources  E. R. Nye and M. E. Gibson, Ronald Ross, malariologist and polymath (1997) + R. Ross, Memoirs, with a full account of the great malaria problem and its solution (1923) + W. F. Bynum and C. Overy, eds., The beast in the mosquito: the correspondence of Ronald Ross and Patrick Manson (1998) + E. Chernin, 'Sir Ronald Ross, malaria, and the rewards of research', Medical History, 32 (1988), 119-41 + H. H. Scott, A history of tropical medicine, 2 vols. (1942) + G. Harrison, Mosquitoes, malaria and man (1978) + M. E. Gibson, 'Ronald Ross and India', Indian Journal of Malariology, 34 (1997), 56-70 + W. F. Bynum, 'An experiment that failed: malaria control at Mian Mir', Parassitologia, 38 (1994), 107-20 + H. J. Power, Tropical medicine in the twentieth century: a history of the Liverpool school, 1898-1990 (1999) + CGPLA Eng. & Wales (1933) + BMJ, ob. 7
Archives Bodl. Oxf., corresp. + London School of Hygiene and Tropical Medicine, corresp. and papers + NRA, corresp. and papers + Royal College of Physicians and Surgeons, Glasgow, corresp. and papers + Wellcome L., corresp. relating to foundation of Royal Society of Tropical Medicine and Hygiene + Wellcome L., papers | London School of Hygiene and Tropical Medicine, corresp. with Sir Patrick Manson + Royal College of Physicians and Surgeons, Glasgow, corresp. with John Masefield + U. Reading L., letters to R. L. Megroz + Wellcome L., corresp. with Sir L. Rogers
Likenesses  photograph, 1898, London School of Hygiene and Tropical Medicine · photograph, 1908, repro. in Ross, Memoirs, 500 · photograph, c.1916, London School of Hygiene and Tropical Medicine · W. Stoneman, two photographs, 1917-28, NPG [see illus.] · F. Bowcher, bronze plaque, 1929, NPG · F. Bowcher, silver plaque, 1930, London School of Hygiene and Tropical Medicine · photographs, Ross Institute of Tropical Hygiene, London
Wealth at death  £7403 4s. 0d.: probate, 16 March 1933, CGPLA Eng. & Wales




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