60
Para. 32
In my experience of true parasitic fever amongst the natives of India—that
is, of fevers during which the fever-producing forms of the parasites are found
in the blood—the amplitude of the curve is almost always large, and consists of
about eight or nine degrees—say from 96° F. to 104° or 105°F. Even when this
fever assumes a remittent character, the temperature still occasionally drops
suddenly to a point some distance below normal, to be often followed by as
sudden a rise to a high point preceded by a rigor or a chill. Of course, in a
typical intermittent fever this occurs with the classical periodicity.
Again, in true parasitic fever the pyrexia does not continue indefinitely.
After lasting a week or so, during which the fever-forms of the parasites are
found in the blood, it ceases and is followed by an indefinite period of apyrexia,
during which the morning temperatures are particularly low, though there are
frequently small oscillations in the evening to just above 99° or so. At this stage
no fever-forms are found as a rule. Another attack follows in a short time ; and
the early history of a case of paludism is made up of such periods alternating
with each other.
Thirdly, in parasitic fever, quinine has a marked effect.
In natives of India, among whom malarial remittent fevers are not very
common, an early morning temperature above 98°P. generally suggests that the
fever is not due to the parasites.
Now, in the low fever described in paragraph 6 and figured in Appendix C,
we have very different characteristics. The amplitude is not large, and lies
between about 99° and 102° only ; the morning temperatures are not often
below 98° ; and every day, for weeks and months, we have an almost exact
repetition of what occurred on the previous clay ; while quinine—at least in a
few large doses—appears to have no effect whatever.
There are, of course, some variations. In several charts, for instance, the
morning temperatures were often decidedly low ; but the other characteristics—
the small amplitude, the diurnal regularity, the intractability to quinine—
remained.
Now, regarding the cause of this fever—its general characters as well as the
apparent absence of parasites, differentiates it sharply from the parasitic fevers.
On the other hand, the curve is exactly that of low fever clue to moderate local
irritations, inflammations or congestions.
What local irritations or congestions were present in the Nowgong cases to
account for fevers of this type ? Kelsch and Kiener have already supplied an
immediate answer—the condition of the liver and spleen, perhaps of other
organs.
Looking at such cases as they stand, putting aside all thoughts of any
parasitic invasion which may have existed at an earlier period, and fixing the
attention only on the enormous and often tender eulargement of the organs, we
may ask, have we any right or justification for assuming that such grave local
lesions should not be associated with a low fever of the kind described ?
Certainly not ; any experienced physician will say that such fever is just what we
would expect to find in association with such lesions, however these lesions may
have been produced. It is almost impossible to conceive such lesions to exist
without considerable febrile reaction ; and if we were asked to define the prob-
able character of this febrile reaction we should, in reply, draw a chart pre-
cisely similar to those obtaining with the kala-azar cases—a small amplitude, a
somewhat raised morning temperature, a long and regular continuance, and
resistance to quinine.
In short, Kelsch and Kiener describe and explain the fever in a word—in
the name they adopt for it—la fièvre symptomatique.
It may be said that this is no explanation ; that we require to explain why
an enlargement of the organs produces fever. I fear I cannot attempt an
answer. A secondary bacterial infection may be suggested. Por my present
purpose it is sufficient to point to the existence of this fever and to its apparent
association with enlargement of the organs. Whatever it may be exactly due
to, the fact of its occurrence remains a very important one in respect to
treatment ; and I therefore invite a closer attention to it than appears generally
to have been given it.
We do not even know the precise cause of the enlargement of the organs
paludism.
Kelsch and Kiener would attribute it to the yellow pigment or to