18
Para, 13
as much time as he could have wished to the microscopical part of the work,
owing to the pressing claims of the epidemiology of the disease ; the force of
which will be felt by those who have had similar duties to perform.
Apart from these brief references to the parasites and pigments in the
twelve cases, Rogers deals very curtly with this important part of the subject.
With regard to the pigments, he covers all his own observations by declaring
their coincidence with those of Kelsch and Kiener on paludism in general.
He does not give his own experiences in regard to the amount and distribu-
tion of the pigments, and, indeed, does not refer to the yellow pigment at all,
except indirectly in connection with some indeterminate estimations of iron
in the liver of five cases. His statement quoted above, to the effect that
"pigment " in the organs " was roughly in proportion to the chronicity of the
case," would, if he refers only to the black pigment, be just the opposite of
Kelsch and Kiener's observations (paragraph 27).
Similarly, he discusses the parasites only in two paragraphs of his report
[p. 115] and in one paragraph of his Reply to Criticisms [p. 249]. He
complains of a difficulty in studying the parasites in advanced cases of the
disease in consequence of the anæmia causing " great changes in the sizes and
shapes of the corpuscles." He gives no details as to the different forms of
parasites met with, " except that in the kala-azar cases the organisms seemed to
be less frequently pigmented "—without specifying what stage or form of the
parasites he refers to. He observes no special variety in kala-azar, but says
only that " the forms found include most of those figured by Italian authors as
typical of quotidian fever "—adding, however, that he " never came across any
crescent forms." He refers to having examined blood from the spleen during life,
but gives no noteworthy details.
For my own part I must confess to a great difficulty in understanding the
exact meaning of these statements. According to the Italian authors, quoti-
dian fever is produced by all forms of the parasites of malaria — by a single
generation of the quotidian parasite, by two parallel generations of the
tertian parasites, or by three parallel generations of the quartan parasite.
Hence there are no forms which can be said to be typical of quotidian fever—
at least according to the Italian authors ; and it is impossible to know which
forms Rogers refers to. According to the Italians, moreover (and almost every-
one else now-a-days), crescents are generally associated with the large group of
æstivo-autumnal parasites, which certainly very frequently cause quotidian
fever. The statement as to the deficiency of pigment in the organisms of
kala-azar is, in absence of any more detailed specification of those organisms, too
vague to be easily comprehensible ; and it is difficult to grasp how changes in
size and shapes of the corpuscles can make a study of the enclosed parasites
materially more difficult.
I have criticised Rogers' statements in these respects somewhat narrowly,
not only because they differ from my own observations, but because they refer
to a point of great importance in regard both to the nature of kala-azar and,
I think, to its treatment. To sum up, I believe it will be felt that his
observations in regard to the parasites and pigments are not given in sufficient
detail to establish entirely the malarial nature of kala-azar—certainly not
to justify the neglect of further investigations.
In this connection there is on record a remarkable case, said to be of kala-
azar, taken by Dr. J. B. Gibbons, and read before the Calcutta Medical Society
in 1889. The case was one of enlargement of liver and spleen, fever, emacia-
tion and some dysentery, the illness being of a year's duration. It is tran-
scribed fully in Appendix B. Gibbons calls the case Assam fever, probably
kala-azar, but, unfortunately, does not mention where precisely the disease was
contracted. It will be seen that the case reads exactly like my clinical picture
of kala-azar between the second and third stages, There is not only the
enlargement of the organs, but the constant low fever referred to by me. Death
seems to have occurred in consequence of intercurrent dysentery with high
fever. At the autopsy Gibbons states expressly twice that there was no pig-
mentation of the spleen ; but there were minute masses of brown pigment
in the hepatic cells. He draws the distinction between this case and instances
of malarial poisoning in Lower Bengal, where he says the spleen always contains
large quantities of pigment,