74
Para. 41
blood from the spleen contained no pigment. Cases 61 and 62 were typical of
this condition ; and so was case 75, until the final weak invasion, which
occurred just before death, set in.
Now quinine in large doses is invaluable during the parasitic stage ; but
in such doses it is often distressing to the patient, and may even be hurtful at
a time when the patient requires good alimentation to support him through
the illness. Why then give it when no longer required ?
This leads to my next recommendation :—Before attempting to treat a
chronic case of paludism it is necessary to assure oneself as to how far the
parasites are still present.
Regarding the incidence of kala-azar on the organs and the low fever, I
think that malarial fever in all parts of the tropics frequently shows similar
phenomena. We must, therefore, not imagine that a case of chronic paludism
always consists of nothing else but an invasion by the parasites of the red
corpuscle. There is reason to believe that long after these have vanished, the
secondary effects which they leave behind them may still destroy the patient.
Practically speaking—that is, speaking from the point of view of treatment—
most of the cases of kala-azar at Nowgong were no longer cases of malarial
fever ; they were cases of enlargement of the liver and spleen with a concomi-
tant low fever, and required treatment as such. The treatment which, I think,
would commend itself to most practitioners would be that by alkaline laxatives,
weak quinine and arsenic, and, above all, the best possible dieting.
I recommend, therefore, that in the older cases of malarial fever the
closest possible attention be paid to the secondary effects of the parasitie
invasion.
These recommendations may, I think, be accepted as being founded on
assured facts ; my next one, however depends more on hypothesis, namely the
hypothesis of continued pervasion of the blood by the parasites, advanced in
paragraph 29.
Usually, except in such patients as we can keep continually under treat-
ment, quinine is given or taken only during the periods of fever. The patient
then closes himself freely ; the parasites are destroyed to a certain extent ;
partial recovery ensues, and the drug is no longer employed. But presently,
no longer being checked by the quinine the parasites multiply again and
another attack of fever ensues—to be treated in a similar manner. Such
treatment appears to me to be quite insufficient ; correct treatment would aim
not at reducing the parasites temporarily, but at exterminating them altogether.
The question whether the parasites during the apyrexial periods undergo
encapsulation or continue to propagate themselves as usual in small numbers,
is important as regards treatment, because in the former case quinine may be
useless during such periods, and in the latter case small doses, persisted in for
a long time, should suffice to conclude the infection. I believe in the latter
alternative for many reasons ; and therefore recommend as follows :—Quinine
should be given continuously for weeks or even months after an attack of
(parasitic) fever. Small doses (up to 10 grains daily, according to the patient's
amenability to the drug) generally suffice, if given with great regularity ; especi-
ally if given in the morning, just before breakfast. I can speak with experience
of this method, which I have frequently used. On the other hand, I generally
find that it is those patients who take quinine only when they " are getting
fever " who suffer most from secondary effects.
The examination of the blood for the parasites of malaria, though quite
easy to those who have mastered the technique, is not so easy or rapid a process
as the examination of dejecta for the ova of intestinal parasites. Moreover,
while always useful, it is not absolutely necessary when the typical fever
suffices to establish the nature of the disease. Hence I hesitate to recommend
its adoption as a routine. But in doubtful cases, and in old cases of paludism,
where it is necessary for the purpose of treatment to ascertain how far the
symptoms are secondary and how far they are still being caused by the presence
of parasites, correct practice demands a search being made for the organisms.
Further than this, in some doubtful cases where no parasites can be detected in
the peripheral blood, or where there are severe secondary symptoms which may
be due partly to a small remnant of the parasitic invasion, exploration of the
spleen for parasites or recent melanin is advisable. Hence I recommend