34
Paras. 17 & 18
most abundant in in the cells at the peripheries of the globules. No black pigment. No reac-
tion with acidified ferrocyanide (iron reaction). No fatty degeneration of the cells, which were
coarsely granular, No cirrhosis ; but surrounding some of the biliary ducts were numerous
cells of newly-formed fibrous tissue. Kidney ; in one of the sections, a little yellow pigment
was found. No iron reaction. The cells were coarsely granular."
NOTE.-It is evident that the final parasitic invasion was an extremely recent one ; the organs must have
been free from melanin a short time before death. It is, therefore, possible that the invasion was not connected
with the previous pathological condition. It is uncertain whether death were due to it, or to the great conges-
tion of the spleen-possibly to both. The brain should have been examined for parasites.
General Observations on the Autopsies.
In all the autopsies the structure of the liver and spleen was quite uniform-there were no
necrotic areas, neoplasms, or signs of parasites in the substance of the organs. The
capsules were always normal, though perhaps slightly thickened in cases 70 and 75; and
there were no adhesions. There was nothing in these organs to suggest any disease but
malaria ; such as, say, local inflammatory or parasitic diseases. The gall-bladder was always
distended with bile. I observed no changes in the suprarenal capsules. In short, except for
the absence or paucity of melanin, the picture presented was one which is generally given
as typical of paludism. Regarding the miuute appearances in the sections, Dr. Daniels
says, " In most of the cases there was no marked fatty degeneration of the bepatic or renal cells,
in this respect differing widely from the same organs in ankylostomiasis. There was no
amyloid degeneration. In the liver, in most cases, there was newly formed fibrous tissue
round some of the biliary duets, but nothing approaching schlerosis, except in case 69.
None of the kidneys were cirrhotic or showed any signs of nephritis. The spleen varied
more. In none of the cases were the malpighian bodies markedly increased or diminished,
but the amount of fibrous tissue in most was in excess. The main interest turns on the
pigmentary deposits. Melanin, as the direct product of the plasmodium, is, perhaps, of most
importance; it was present in five (out of the eight last cases), but in one (case 75) in such
a form as to indicate neither continued nor severe infection, The yellow pigment is evidence
and a measure of past hsemolysis, and is only indirectly produced by the malarial organism-
being frequently due to other agencies, amongst which I should include as an important one,
ankylostomiasis. In that disease, however, deposits in the spleen are very rare, while in this
series, when black was not found yellow was, and in the cases in which it was not detected
it may have been obscured by the melanin. The iron-bearing cells and granules are also
evidence of hmolysis and no direct proof of malaria. In ankylostomiasis they are occasion-
ally found, but, as a rule, alone in the liver and kidneys; or if, very exceptionally, in the
spleen, then in association with the other organs ; whilst in this series in each of the three
cases in which the iron reaction was met with, it was abundant in the spleen. The appear-
ances in case 74 are not in accord with those in the other cases (as regards yellow pig-
ment). In cellular struction of the organs, the cases without melanin did not differ from those
with it."
18. Summary of Cases at Nowgong.- It has been found impossible
to arrange these cases in a brief tabular form ; but the following summary of
the observations will be useful.
Out-patient cases up to one month's duration.
Out of 25 of these (cases 1-29, exclusive of cases 17, 20, 21, 22) malarial
Parasites were found in 19. They were not found in cases 4, 12, 15, 26, 27,
and 28. Case 4 had no enlargement of the organs and was probably not malarial
at all. In case 27 both black and yellow pigment were obtained from the
spleen. Cases 12, 15, 26 and 28 were not examined thoroughly enough to
permit me to say that the parasites were actually not present. It is probable
then that all these cases, except case 4, were truly malarial. There is a history of
rigors in 17 of the cases. It is obviously difficult to ascertain the fever curve
in out-patients, but such observations as were made suggested the ordinary
charts. Case 27 had high continued fever for some time, due to the pleuro-
pneunionia. Cases 1, 2, 8, 10, 18, 19, 23, and 27 were severe ones; of these,
cases 18, 19, 23 were suspected to be kala-azar, and case 27 was actually
thought to be so ; the first three had quartan infections, the next a tertian infec-
tion and the last showed only melanosis of the spleen. This organ was punctured
in cases 10, 13, l4, 23 and 27 and contained melanin in all. Yellow pigment
was found only in case 27.
The great enlargement of the organs is particularly noticeable, even at so
early a period. The spleen was enlarged in 16 cases and the liver in 9. A
rapid increase during the period of observation was noted in cases 2 (stivo-
auturnnal) and 27 (pigments) ; in case 2 the organs were normal when first
examined, but in a fortnight the spleen was 2 inches below the ribs, and the liver