48
Para. 27
The disappearance of the melanin (and, therefore, by implication, of the
parasites) and the permanence of the yellow pigment, compares itself with my
observations on kala-azar.
The fièvre symptomatique coincides with the low constant fever found by
me (and others) in the second stage of the disease.
I should like to quote some whole pages, including exemplary cases, from
Kelsch and Kiener's work ; there is much that is closely applicable to the
present subject. A few leading passages must, however, suffice. With regard
to deposition of the pigments they say (p. 634, translated.)
" The formation of the one and of the other pigment continues throughout
the course of the malarial infection. But, in the same degree as the affection
becomes older, two modifications tend to appear ; 011 the one hand, the formation
of the melanæmic pigment becomes inconstant and more and more exceptional
without one being able to explain the causes of the cessation of a phenomenon
considered specific. Have the parasites ceased to multiply ? Have they only
ceased to produce pigment ?—We can only ask these questions."
"On the other hand, the formation of the ferruginous pigment not only
does not cease but seems to be augmented, and acquires, in certain cases, an
intensity comparable to that which one observes in certain incurable and pro-
gressive anæmias. This process, entirely in obedience to the general laws which
we have sought to establish in Book IV, presents, because of its chronicity and
of the consequent alterations in the structure and tolerance of the organs, some
particulars, which must now be put in evidence "—which the authors proceed
to do.
In the above passage the deposition of the black pigment is recorded as going
on, though constantly becoming less, throughout the course of an infection ; and
no limits to the process as regards time are mentioned. The following extract
establishes a rough shorter limit (p. 413):—
"We cannot easily assign a limit to the duration of the process of résorp-
tion (of melanin). It seems to us little probable that the work requires years
—as Arnstein thinks ; because it frequently happens that among patients who
have succumbed to malarial cachexia, only a few months after the beginning
of the infection, we find no vestige of melanosis."
In support of this the authors give autopsies in which the black pigment
was not observed—see particularly the conclusion of Ob. II, page 622—occur-
ring in the cachexial period.
I translate the whole paragraph referring to the symptomatic fever (p. 565).
"Concerning symptomatic fever in chronic malnr\ill\.—Amongst a great
number of our patients suffering from the chronic infection, we have noticed
certain febrile processes for which we have been led to recognise another cause
than the pyrogenetic action of malaria.
There exists a pyrexial condition more or less marked which is prolonged
sometimes many days and even many weeks after the serial attacks. It consists
sometimes of slight evening exacerbations, without initial chills, and showing
little elevation of temperature ; more often of a continued febrile movement
from 38° to 38.5°C. (100.4° to 102.2°F.) and giving a feebly-broken chart,"
This fever shows itself more specially after violent attacks accompanied by
icterus or hæmoglobinuria. While it lasts, the liver and spleen are always
tumefied and are the seat of a dull and continued pain. It is not accompanied
by a marked destruction of red corpuscles, and the examination of the blood,
practised from the point of view of the black pigment, is generally negative.
The sulphate of quinine is without action ; and only alteratives affecting the
hypochondriac organs are sometimes efficacious.
The ensemble of these characters differentiate this febrile condition from that
of malarial fever properly speaking. We think that there is reason to connect
them with the hepatic and splenic congestions caused by the latter. Chronic
hepatitis, such as we observe outside malarious localities, is ordinarily accom-
panied by a febrile movement more or less marked, above all in its initial periods.
A fortiori, we may expect a like effect in the parenchymotous malarial inflam-
mations which implicate all the abdominal viscera and of which the evolution
is more rapid than that of ordinary hepatic cirrhosis."
Three charts with which these remarks of the authors are illustrated, are
given in Appendix C, Nos. 13, 14, 15.