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Appendix A
Q. Are you quite certain of the identity of kala-azar as described above ?
A. I am quite certain of it — from my own experiences in the Garo Hills and in this
district, and from reports of others in other districts. The people themselves are perfectly
familiar with the disease. I am quite sure that it is, primarily a fever with enlargement of the
spleen and liver ; and the people themselves give exactly the same account.
Q. Do you know Assamese well ?
A. Yes; I have passed the lower and higher standards.
Q. Do you know Garo?
A. I have passed the examination in that also.
Q. Have you any remarks to add ?
A. Along with the symptoms of kala-azar described above, a few of the cases present
symptoms of excessive anæmia and marked dropsy, which, in my opinion, are due to the
combination of ankyloetomiasis with kala-azar. These symptoms are, I find, in proportion to
the number of worms and to the length of time the patient has been suffering from them.
In autopsies of kala-azar I generally find a few ankylostomes (20 or 30), but rarely as many
as three or four hundred. In some cases they are quite absent. I have sometimes found the
worms in small numbers in healthy medico-legal cases. Anæmia with dropsy had been very
prevalent formerly in tea-estates, though it has not been recognised as ankylostomiasis until
comparatively lately. 1 am sure that owing to this recognition and the appropriate treat-
ment there is now a most marked diminution of these cases.
Menstruation is checked in the advanced cases of kala-azar. It is the popular belief
that males are more affected than females, and that there are more widows than widowers
in the villages.
Before the appearance of the epidemic, ankylostomiasis was very prevalent in the tea-
estates. It was not prevalent in the villages.
3. Statement of Dr. J. C. Lavertine.—Taken in the presence of Dr. Price on the 23rd
October 1898:—
"I have been seeing kala-azar since March 1891 in the Nowgong District. I am
absolutely certain about the identity of the disease. I am certain that it is a disease which is
communicable from the sick to the healthy. The communicability varies directly as the
degree of proximity; and the infection clings about houses.
"The disease begins always with fever, which may be remittent or intermittent, and is
rarely preceded by rigors; but mere chills occur sometimes, especially in the intermittent
forms. The fever is generally severe at first; it may vary between the limits of 95°F
and 106°F.
"It may last from three weeks to three months. There is then an apyrexial period; fol-
lowed by another go of fever which may last a variable period. There may be a second and third
similar attack.
"Both spleen and liver begin to enlarge generally three or four weeks after the beginning
of the illness, and are tender on pressure. The tumefaction of the spleen generally reaches a
large size, sometimes an extreme one. The liver also is invariably enlarged, and I think
that most frequently the enlargement is on the upper surface. When the enlargement of the
the organs has reached a certain degree, I observe that the temperature, as a rule, remains
above normal night and day.
"At this stage icterus may or may not (as a rule, not) be present. Epistaxis is fairly
common. Dropsy of the feet, ascites, puffíness of the face, are rare at this stage. Emaciation
commences at the first stage and progresses continuously, becoming finally very marked,
Anæmia at first is not very marked; but it becomes so as the illness progresses. There is an
access of anæmia with each attack of fever, with improvement in the intervals. I think
that blackening of the skin commences from the very first. I have personally known cases
in which it has quite undoubtedly occurred. It cannot be explained by mere dirt of the skin.
The lustre of the skin is gradually lost, and the epidermis acquires the appearance of a grate
which has been black-leaded but not polished.
"There may be a third stage during which the enlargement of the spleen and liver con-
tinue, but in which the temperature becomes subnormal. The tendency to Symptoms of
diarrhoea and dysentery, always existent from the beginning of the disease, is greater at this
stage. There is now extreme weakness and emaciation; also extreme anæmia, more so, I
should say, even than in ankylostomiasis; though the tongue may remain fairly red to the
end. I no not think the kala-azar cases develop pneumonia; but that the converse sometimes
occurs.
"Death may happen at any stage. During the earlier stages it may occur with great
suddenness either from diarrhœa, or some unascertained cause, or from severe fever. In the
third stage, death is asthenic, and due generally to very malignant cancrum oris which origi-
nates during the period when the temperature is subnormal and the tumefaction of the spleen
and liver continues."
Q. How do you distinguish between kala-azar and malarial fever in their earlier stages?
A. I think it is impossible.
Q. And in the later stages ?
A. By the extreme degree of enlargement of the organs and of the anæmia, emaciation
and darkening of the skin; and, I think, by the comparative absence of oedema. Also by the
fatality, the resistance to quinine, the frequency of cancrum oris, and the communicability of
the disease.
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