NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
34
Scientific Memoirs by
with very active amœboid movement as shown in fig. C. 1 and 2. Fig. 2 shows
an appearance which was frequently observed, as if a small portion of the proto-
plasm of the parasite became broken off, and again re-united with the main mass.
Careful observation led me to the opinion that no true separation occurred, but
that this appearance was due to the formation of a knob-shaped end to a
delicate pseudopod, extruded from the parasite and again absorbed.
(4) At 44 hours :—
Growth of the parasite had still further advanced ; it filled about ¾ths of
the red cell. Amœboid movement was very slow and slight in amount, and
the bodies tended to assume a circular shape. The pigment had also lost its
active movement, it assumed a peripheral arrangement ( fig. D. 1) or spread
through the protoplasm in slowly flowing lines, frequently with a figure of 8 con-
figuration (fig. D. 2). Fig. D. 4 shows a free spherical organism with
actively moving pigment, which, as before mentioned, may be found at any
stage.
(5) At 62 hours :
—
The parasites now filled almost the entire cell, there was no movement in the
protoplasm ; the pigment was irregularly distributed ( fig. E . 2), or peripheral
in its arrangement, or grouped in delicate lines like dark streamers running
through the cytoplasm.
It will be noted that during the whole course of the development of the
parasite the red cell had undergone no increase in size, it retained its normal
contour, and showed, in its unaffected portion, no diminution of hæmoglobin.
(6) At 68 to 76 hours : that is during an hour or two before the fresh
paroxysm and during its continuance :
—
The parasites were now found to fill the entire cell, of which a faint
remnant could, however, in most cases be made out (figs. F. 2, 4 and 5 ).
The pigment was found to be undergoing a change in position. In a few it
still remained scattered uniformly through the protoplasm ( fig. F. 6), but in
the great majority it had entirely, or nearly entirely, collected towards
the centre of the cell, in a rounded irregular mass with a few small radial
streamers projecting towards the periphery ( fig. F. 1). In others (fig. F. 2)
radiating towards the pigment thus collected in the centre, darkish lines were
seen in the protoplasm dividing it into a series of small segments. These
divisions were most marked at the periphery, where they first seem to develop,
and the peripheral ends of the segments became early rounded off. In others
(fig. F. 3) a similar condition was observed, but with the addition of small highly
refractile rounded spots towards the base of each partially formed segment.
Again in others ( fig. F. 4) segmentation was found to be complete. The
segments, which generally numbered 8, were rounded and wide towards their
bases and tapered to a somewhat obtusely rounded point at their central
Medical Officers of the Army of India.
35
extremity, the accumulated pigment lying between their ends. At the centre of
the thickest part of each was a small, light, highly refractile spot, easily seen
even in unstained specimens by careful illumination and focussing. This is the
" forme en rosace " of Golgi . In some, the point of collection of the pigment and
centre of radiation of the segmental spores was not in the centre of the parasite,
but towards its periphery, in which case the general appearance resembled
that of a fan ( Fig. F. 3 and 5 ). Non-sporing spherical forms with the pigment
in motion, were still to be found at this, as at all other stages of the fever.
At 2 to 4 hours after the height of the paroxysm some sporing forms were
still seen, with, in addition, a number of small clear bodies in or on the red blood
cells, which differed from those shown fn. Fig. A. only, in being smaller, in
having no pigment in their interior and in possessing very slow amœboid
movement.
In cases of simple quartan fever the changes above described may be easily
observed, by any one accustomed to the use of high powers with the micro-
scope, through any number of generations, as long as the patient's fever conti-
nues and he gets no quinine. I have purposely described the forms simply as
they were observed, without in any way theorising regarding the connection
of one set of appearances with another, but a glance at the drawings in the series
from A to F is sufficient to warrant the assumption that they represent stages
in the development of one body, and that development has reached its height
at the stage of sporulation.
The effect of Quinine on the malarial parasite.
This may be very well studied in the case of quartan fever, and is shown in
the figures G, to F. The drawings in Fig. G. were made twelve hours after
the febrile paroxysm which attended the sporulation shown in Fig. F. No quinine
had been given up to the time, and the forms shown will be seen to correspond in
every way with those drawn in Fig. A.
The assumption is therefore allowable
that the parasites had entered on a new cycle of development, and, if uninterfered
with by treatment, would have gone on through their regular stages as before.
On this day, however, immediately after the observation was made, the adminis-
tration of quinine was commenced and during the next 24 hours 6o grains were
given. On the following day, i.e., at 36 hours after the paroxysm, the appear-
ances shown at Fig. H. were observed. Normally the forms would have re-
sembled those drawn in Fig. C. , but marked changes were to be observed. The
parasites were in very active amœboid movement ( Fig. H. 1—4 ), The figures
a and b in each case were outlined by the camera lucida as rapidly as possible
after each other. The movement had a writhing character quite distinct from
the ordinary leisurely amœboid movement of a healthy parasite. Pseudopodia
were rapidly shot out from the main mass, then broke off, separated, and
F 2
36
Scientific Memoirs by
formed small rounded bodies which moved rapidly through the hæmocyte.
Each detached part contained, as a rule, one or more particles of melanin.
These portions frequently again united with each other, and again separated with
great rapidity, presenting a most curious and beautiful microscopic object. In
addition large and small spherical bodies were seen, with no amœboid movement,
but with actively moving pigment.
Quinine having been continued, the parasites, next day, presented the
appearance shown in Fig. 1. Their growth had apparently stopped, the separate
pieces noticed the day before had united, the parasite had shrunken and had
entirely lost the power of amœboid movement and all movement of the pigment
had ceased. The protoplasm, instead of being clear and highly refractile, pre-
sented a dull, necrotic appearance, and the pigment granules were gathered
together in coarse heaps of a sooty black, instead of the normal warm sepia
colour.
On the following day no paroxysm of fever occurred, and the only varieties
of parasite which could now be found were the free spherical forms ( Fig. F.)
which persisted for two days longer, after which, they also disappeared.
Having now carefully traced the life history of a parasite through eight
days, during the first four uninterfered with by drugs, and during the second
four under the influence of 20 grains of quinine sulphate given three times a day,
we find :—
(1) That the parasitic forms observed correspond in every way with
those described as charateristic of quartan fever in Europe, by
Golgi and others.
(2) That the majority of the parasites, at first free in the form of
spores, then probably epicorpuscular for some hours, become
intracorpuscular, increase in size, become rounded and quiescent,
and after a period of development of 72 hours, divide into a number
of nucleated spores.
(3) That others, after developing into spherical bodies of various sizes,
remain in that form, do not develop spores, leave the red blood
cells, and produce the bodies shown at A. 2d, G4, H6, A3, D4,
F6, H5, and F . These persist without alteration during several
generations, and resist the action of quinine. They sometimes
develop flagella when on the stage of the microscope, and
appear to be in many ways homologous to the crescents developed
in the quotidian forms of fever.
(4) That the paroxysm of fever is undoubtedly coincident with, and is
probably caused by, the sporulation of the fertile parasites.
No explanation has as yet been given of the differentiation of two apparently
similar young parasites into (1) a spore-forming fertile body, and (2) a body, which
Medical Officers of the Army of India.
37
does not form spores, which appears to remain sterile as long as it persists in the
peripheral blood, which lives through many generations and which has the
power of forming flagella when lying on a slide after removal from the body.
The larger forms of these may be seen at all periods of the fever, while the
smaller ( A 2d, G.4 H. 6 ) were seen by me only in blood examined on the first
and second day. The method of production of one of these bodies from a
small amœboid parasite (A2 ), has been described, and it appears to be at
least possible that the sterile forms may all be produced by parasites which
have prematurely separated from their cell hosts.
Tertian Fever.
This form of malarial fever is common in Lahore. Many cases occur,
chiefly in the spring and late, autumn months. The following, from which the
accompanying drawings were made, may be taken as typical :—
(1) Kishan Chand, a male Hindu, æt. 12, resident of Lahore, was first seen
on the 12th May 1895. A history was given of fever, which had attacked the
patient at intervals since September 1894, and which had maintained the tertian
type throughout. His parents were intelligent people and the history was
reliable. The attacks of fever had always succumbed to the administration of
quinine, but the drug had not been persevered with on any occasion after the
pyrexia had disappeared, with the result that relapses occurred. The last attack
had continued for ten days, during which time no quinine had been given.
The blood was examined at 7 A.M., when large intracorpuscular parasites
were seen lying in swollen, very pale red blood cells. Fever came on at 10 A.M.,
the onset being accompanied by an attack of sickness and vomiting, and a
maximum temperature of 103° was recorded. After the next paroxysm, which
happened on the 14th, quinine was administered in doses of 15 grains three
times a day ; the fever did not return on the 16th and his friends, thinking that
he had recovered, stopped treatment too soon. On the 8th June the fever
returned and was again of pure tertian type ; the paroxysms again reaching
their height from 10 to 12 o'clock every forenoon. Treatment by quinine once
more apparently restored the child to health, The patient's father was instructed
to continue the administration of the drug for at least three weeks, and presum-
ably did so with satisfactory results, as nothing more was heard from him.
Considerable interest is attached to this case from the fact that the fever
had recurred so often. It is very unlikely that the infection was a fresh one on
each occasion, and there is little doubt that, if the administration of quinine had
been continued for at least a fortnight following the cessation of the fever after
any of the attacks, recurrence would not have taken place.
(2) Lal Khan, a Pathan from Ghazni,
æ t 4 5 , w a s a d m i t t e d o n t h e 6 t h
December 1895. He had come to the Punjab with horses in the late autumn
38
Scientific Memoirs by
and gave a history of perfect health, with no previous attack of fever. Six days
before admission he had high fever about midday, and gave a history of the
fever having recurred every second day till the date of admission. On the after-
noon of the 6th he had fever which reached a temperature of 105°. Next
morning the temperature was normal.
The spleen was found to be enlarged 1½ inches below the costal arch in the
left mammary line ; physical examination did not reveal abnormality in any
other organ, but the tongue was furred and the bowels constipated. The general
condition was extremely good. The temperature remained normal on the 7th,
on the 8th it rose to 102.4 at 6 P.M. (probably higher in the early afternoon)
and on the 10th it reached 106° just before midday. Quinine sulphate was then
administered for the first time, in doses of 15 grains three times a day. On the
12th the temperature commenced to rise in the morning, and reached its
maximum, 100.8, at 5 P.M, The first effect of the quinine was therefore to
modify the paroxysm, producing a prolonged febrile period with delay in the
occurrence of the maximum. On the 14th the temperature remained sub-nor-
mal, and the patient, who now protested that he was perfectly well, refused to
remain in hospital and went on down country with his horses.
This case was evidently a typical one of a fresh attack of tertian fever in
a previously healthy man of strong constitution.
FORMS OF PARASITE.—Fresh blood, drawn in the usual way about
12 hours after the height of the febrile paroxysm was found to contain :
—
1st.—Numerous intracorpuscular parasites, which filled about ¼th of the
hæmocyte, and which contained a quantity of pigment of a bright sepia colour,
in small rounded granules. The pigment was in lively movement, the parasites
themselves were actively amceboid, as shown in Figs. L. 2a, 2b, 2c, which
were outlined at intervals of one minute. The position of the parasite in the red
cell was also seen to change. The red cells themselves were a little enlarged
and slightly paler than normal.
2nd.—Free globular parasites, about the size of a red blood cell ( M. 5 and
6 ) . T h e p i g m e n t i n t h e s e h a d v e r y a c t i v e m o t i o n a n d t e n d e d t o a r r a n g e i t s e l f a t
two opposite poles and round the periphery, with fine lines of moving granules
crossing the intervening space. Some of these spherical bodies were occa-
sionally seen to produce flagella ( M. 6), which had at first an extremely lively
lashing, movement, but soon became quiescent.
The amœboid forms were seen in the blood during any time up to about
36 hours. They increased in size as the afebrile period progressed and became
more pigmented, and the red blood cells in which they lay were found to be
larger and paler each time of examination ( Fig. M. 1 to 4 ). After this time
the parasites were found to lose the power of amœboid movement, and to
become rounded, while the pigment retained its circulating and dancing motion.
Free spherical forms were still seen, as at all other periods of the fever, and
Medical Officers of the Army of India.
39
after having been removed from circulation for some time, an occasional flagel-
lated body was seen ( Fig. M. 5 and 6 ).
From 44 to 52 hours new forms were met with, in the act of sporing.
In the case of Lal Khan these were particularly abundant, several could be
seen in each slide made at the pyrexial period ; in most cases, however,
they have to be carefully searched for. In these the pigment was con-
centrated in the centre or towards one side, and the appearances were very
similar to those described in the quartan parasite (see Fig. N. 1 to 4) The chief
distinctive features are :—1st.—The sporing body is larger, and the spores are
much more abundant, averaging about 20. 2nd.—They are more irregular in
arrangement, and are more rounded. 3rd.—According to many observers, Golgi,
Marchiafava, Mannaberg, etc., they show, as a rule, no detail of structure in the
fresh state. This I have not found to be the case ; when fully developed the
nuclear or nucleolar highly refractile spot is distinctly marked.
The irregular form of sporing described by Golgi was never seen, and, in the
fresh state, the pigment was always seen to be collected into one mass. In
fixed and stained specimens it was frequently found to be irregularly scattered
through the sporing body ( Fig. 0. 10), but this may probably have been due to
mechanical disturbance while preparing the films. A detailed description of the
relation of the various forms to the course of the fever need not be given. In
all simple tertian cases an invariable connection was found to exist between the
appearance of sporing bodies and the febrile paroxysm, and between the smaller
forms and the early part of the apyrexial period, just as has been described in
the case of quartan fever.
Quinine apparently acts more slowly in tertian than in quartan fever. In
the latter, 20 grains three times a day during the first and second day prevents
the occurrence of sporulation on the third. In tertian fever, similar treatment
generally modifies the first pyrexial period, producing an abortive but prolonged
rise of temperature, while it appears to entirely prevent a second rise.
Similar changes to those already described, occur in the parasite under the
action of the drug, the intracorpuscular bodies become stunted and necrotic in
appearance during the first two days, a few form irregular spores, and on the
third day no abnormal element is to be found in the peripheric blood save a few
spheres and pigmented phagocytes.
Structure of the Parasite of Tertian Fever. — T h e t e r t i a n p a r a s i t e , o w i n g
to its large size, lends itself specially well to the study of the morphological
characters of the class. To bring out these characters it is necessary to care-
fully stain thin films of the blood which have been rapidly and accurately fixed.
Many stains have been recommended by various workers, the hæmatoxylin stain
of Mannaberg, used after fixing the films with his special picric acid solution
gives good results, but I have found none more satisfactory than staining
40
Scientific Memoirs by
with a dilute solution of Ehrlich's acid hæmatoxylin, carefully differentiating
with weak hydrochloric acid alcohol, and counter-staining with a weak alcoholic
solution of eosin during the process of dehydration. The films may be pre-
pared either by rapid dessication and exposure to heat, or (and I think better)
by the process recommended by Muir for the study of Leucocythæmic blood
(fournal of Pathology and Bact., Vol. I., p. 123 ). The preparations from which
all the drawings were made were prepared in this way. The film is obtained in
the usual manner by letting a small drop of blood spread itself out between two
cover glasses. These are drawn apart and immediately, before they become
dry, are floated film downwards on the surface of a saturated solution of mercuric
chloride. They are then washed for some minutes in equal parts of absolute
alcohol and ether, and are removed, through gradually weaker strengths of
alcohol, to distilled water previous to staining.
When treated in this way, the youngest stage of the parasite may be seen
to have two well marked layers ; an outer, deeply stained, and an inner much
more lightly stained. A small, circular, very deeply stained spot is seen to lie
in the outer layer. No other structure can be made out ; I have never seen
chromophil granules or fibres in the lightly stained central part ( Fig. 0. 1).
Opinions vary as to the nature of these differently staining portions. Mannaberg
believes the highly chromophil part to be a nucleolus, the clear portion to be
the true nucleus, and the peripheral portion to be the cytoplasm. Bignami and
Bastianelli have not been able to demonstrate any formation which they can
regard as a true nucleus, but believe the dark stained spot to represent a nucleus
in its functions.
The differentiation of the parasite into three distinct parts seems to disappear
very early in its life. From about 12 to 36 hours the body stains fairly uniformly
(Figs. 0. 2 to 7 ). It occasionally, but by no means always, presents areas defi-
cient in, or altogether devoid of, chromatin (Fig. 0. 5), while in other cases ill-
defined patches of deep staining may be seen ( Fig. 0. 6). I have not been
able to demonstrate the persistence for many hours of a more or less regular,
clear space (nuclear ? ), as described by Mannaberg, nor have I satisfied myself
in any case, that any remains of the chromophil granule ( nucleolus ?) can be
seen after about 12 hours. This may be due to imperfections of method, but
numerous and very careful endeavours were made to obtain the appearances
so fully described by Mannaberg, with negative results. It appears to be not
impossible that the clear spaces, referred to by him as nuclear, may be a
result of irregular contraction in the cytoplasm during fixation. I have also
failed in demonstrating any regular or constant division of the cytoplasm into a
pigmented ectoplasm and a non-pigmented endoplasm. The peripheral layers
are generally most richly pigmented but by no means always so, even in fresh
preparations. In short, from 12 hours to 36 or 40 hours, the parasite appears
Medical Officers of the Army of India.
41
to me to consist, simply, of an irregularly staining and sometimes vacuolated
mass of cytoplasm, which contains melanin granules, sometimes scattered irre-
gularly throughout its substance, sometimes confined chiefly to its peripheral
portion.
At about 40 hours, however, differentiation of structure again becomes ap-
parent. Small, deeply-stained, ill-defined spots commence to appear, scattered
irregularly through the cytoplasm (Fig. 0. 8). Their outline becomes more distinct
(Fig. 0. 9), the cytoplasm commences to collect round them ( Fig. 0. 10 ), and,
finally each becomes absolutely well defined and occupies a position in the centre
of a small ellipsoidal or irregularly pear-shaped body, each of which has a distinct,
sharp contour, and is completely separate from its neighbours. According to
Mannaberg the spores undergo a further change while still lying together, in
the formation of a lightly stained area lying near the chromophil granule. This
I have not seen, and I do not think that this differentiation occurs till after the
spore has lain some time free in the blood plasma, or has become attached to a
hæmocyte.
The facts which the writer has been able to demonstrate regarding the
structure of the tertian parasite are therefore as follows :-
(1) That the young parasite (from 1 to about 12 hours) consists of a
peripheral darkly stained layer, which contains a highly chromo-
phil granule or spot, probably nucleolar or nuclear in function ;
and an inner lightly staining portion.
(2) That at about 12 hours this differentiation disappears and that
the chromatin then becomes fairly regularly distributed through
the cytoplasm.
(3) That, about 40 hours, darkly staining bodies begin to separate
out, irregularly scattered throughout the mass of the parasite.
(4) That these acquire a sharply defined outline, that the remainder
of the cytoplasm collects round them, and that about 20 small
spores are thus formed by a process apparently of direct
division.
From these facts, therefore, I am inclined to believe that the dark chromo-
phil spot is, as held by Bignami and Bastianelli, of a nuclear nature.
In connection with this part of the subject, it may be permissible to remark,
that it is inconceivable how any one who has seen the sporing body properly
fixed and stained can possibly retain any doubt as to the vital nature of the
process. No form of degeneration in red or white blood cells could possibly
assume such definite structural characters. That the structure is definite and
constant, and that it presents exactly the same characters in India as it does in
Southern Europe, any one with a knowledge of the necessary technique and a
little experience in the preparation of blood specimens can easily satisfy himself.
Variation in method of fixing and staining may produce slight differences of G