44
Paras. 25 & 26
Similar remarks may be made regarding the low constant fever, which
is certainly not malarial in type and which may be thought to be incompatible
with a malarial pathogenesis.
How explain the abnormity ? If kala-azar, be malarial fever a similar
state of things should be also found, at least in a certain percentage of cases,
in malarial fever generally. "What authority in literature have we for supposing
such to be the case ? And if we find the authority, how explain the fact ?
The problem, is defined in the following question. Is it possible that a
malarial infection, may reach a stage at which there is great enlargement
of the organs accompanied by a persistent low fever, but in which neither
parasites nor melanin are found even affer careful search?
Accepting as an absolute fact that the beginning of every case of palu-
dism coincides with an invasion of the blood by the pathogenetic parasites,
we may disintegrate this question into two simpler ones.
(a) Is it possible that the parasites and melanin may disappear after
some months of illness, either definitely or at least for long periods ?
(b) Is it possible that after they have disappeared, great enlargement
of the organs, together with a low fever, may remain ?
Let us first examine what existing literature on malaria has to say on the
subject.
26. Literature bearing on this Problem.—The literature of paludism
embraces three periods. First, the early symptomatology and epidemiology
culminating in the works of Torti and Pringle in the seventeenth and
eighteenth centuries ; secondly, the pathological anatomy based on the discovery
of the black pigment by Meckel and Virchow in 1847 and 1849, and culmina-
ting in the work of Kelsch and Kiener in 1889 ; thirdly, the discovery of the
parasites by Laveran in 1880 and the subsequent study of them by a host of
observers.
The literature of the last period is most voluminous and, on the whole, most
careful and exact ; but, unfortunately, it has one important deficiency—most of the
observations on which it is based were drawn from patients of the European race.
It is true that Laveran's own work was carried out in Algeria, and that other
studies have been made on patients of less civilised races ; but the fact remains
that most of the more elaborate monographs have been written in Europe and
America. Now, a European takes quinine as a rule, and does not often live
permanently in such malarious localities and in such squalid conditions as the
native of tropical climates.
Again, this absence of literature on indigenous tropical malaria suggests
that there may be varieties of the parasites differing from the known ones—not
necessarily morphologically, but in their effects on the human body—which have
not been studied at all.
The fact is that the deficiency is a very serious one as regards this discussion.
The cases on which my observations were made were nearly all natives of India
and lived in the most insanitary conditions, while they certainly very rarely
thought of taking quinine, or, if they did so, contented themselves with a dose
or two. In such, the first invasion of parasites is probably followed by numer-
ous reinforcements of them from without—the patient is infected over and over
again. No steps are taken to check their numbers and they occupy the host
indetinitely at their pleasure, until either death takes place or recovery ensues
as the result of some systemic re-action against them. The effect may well be
an enormous enlargement of the organs, and a final condition of cachexia. Such
cases are, of course, seen everywhere amongst malaria-stricken aboriginal popu-
lations. With Europeans we have a very different picture. The patient, quite
aware of the dangers of malaria, has either hurried away as fast as possible from
the malarious spot where he has contracted the disease, or has run to the first
medical man for treatment, or has freely cinchonised himself. The force of the
infection—probably a single one—is broken, if not subdued, by the medication.
In the case of infections occurring in the temperate climates of Europe and
America, it is probable that the virulence (or perhaps we should say, numerosity)
of the invasion is seldom so great as in hotter countries. The result is that,
in place of the frightful cachexias of the poor natives of tropical countries,
we find in the European as a rule only very broken and modified examples of