47
Paras. 26 & 27
It is" known .'that "Vandyke Carter took up the" study of the parasites at a very
early stage in. the" history of our knowledge of them," and' that there are' pas-,
sages in his essay which justify us in thinking that he overlooked, apparently
purposely, the unpigmented amoebulae of the aestivo-autumnal varieties.
Nevertheless, in the "confirmed malarious subjects," to wtich he' seems-
specially to refer these" varieties should yield the large'and grossly pigment-
ed- crescents which Carter would certainly never have overlooked; while"
the other varieties are of course'always'pigmented. Hence, I think we may;
admit that he did observe' a secondary fever in confirmed malarious subjects
in which the parasites" were" not to be found. I invite attention to every
term of this remarkable passage, which is quite worthy of the- most distin-
guished of our Indian observers.
And fortunately, although I have been able to cull few observation's
pertinent to' this discussion from- literature based on the parasitic theorem,
I can cite some very striking passages from a work of an older school. The
work I refer to is perhaps the best exposition of the pathological anatomy
of paludism which we possess. Perhaps all the better for my present pur-
pose,- it proceeds not on the point d'appui of the parasites, but upon that of
their immediate derivative the black pigment, and on that of the yellow pig-
ment. The authors, practising in- a country, Algeria, where, as in India,
the chronic cases of malarial fever are almost as numerous and quite as
considerable- as the early attacks, give as minute attention to the former
as they do to the latter; and every statement of theirs is accepted as bearing
the highest authority. I refer to the classical work of Kelsch and Kiener
[36]
27. Kelsch and Keiner and Daniels on this Problem.—The authors
begin by the following definitions :—-
"Le poison palustre est un agent essentiellement destructeur des globules
sanguins."
They divide "the resulting disease practically into three persiods—the acute,
the' chronic, and the cachexial.
In studying the acute stage (intoxication paludenne aigue) they begin
with a description of the pathological anatomy and histology, and give a long
disquisition on the black and yellow pigments respectively. They then describe
the clinical symptoms .and deal particularly with the various forms and in-
cidents, the simple, bilious, gastric, and haemoglobinuric fevers, cerebral
complications, and so on.
"With regard to the second stage (intoxication paludeenne chronique) they
deal closely with the hypereuies phlegmasiques; show the gradual elimin-
ation of the black pigment and the permanence of the yellow; and describe
the fevers of this stage, particularly a fievre symptomatique.
In the third stage (cachexia hydroemique et gangrene,' and cachexia
paludeenne chronique)' they exhibit the gradual disappearance' of the black
pigment and the surcharge ferrugineuse of the organs; and conclude with a
picture of the final condition of the organs.
Theydo not finally accept the parasite as the agent destructeur because
at the time there was still discussion on the point-; but show themselves as
being favourable to the theorem.
The general picture; of the pathological anatomy ; presented by them is
one of the 'deposition of both pigments in the first stage ; and "of the gradual dis-
appearance of the black pigment and permanence of the irritating yellow pigment
in the later stages. The clinical manifestations of the first state are, then,
essentially those produced by the agent destructeur Itself; those of the later
stages are the results due to the yellow pigment, or perhaps, more correctly, to
the conditions of the organs produced by it.
In the second stage of the disease they devote a whole sub-heading to a
peculiar continued type of fever—the fievre symptomatique -which they consider
is not due directly to the pathogenetic agent, but rather to the condition of the
organs—the phlegmasies hepalique et splennque.
The applicability of this system to the questions now under discussion is
obvious.
The three stages of paludism described by the authors coincide with the
three stages of kala-azar as defined by me.