42
Paras. 23 & 24
enlargement of the organs and scarcely any of the low fever, while the parasites
were found with the greatest facility.
Finally, any one who has examined rural fever in India will recognise
that the enormous splenic and hepatic tumours of kala-azar are very far from
being present only in Assam. I venture to think that cases with similar en-
largements are be found almost in every district in this country ; more so in some
localities, of course, than in others; but still almost, every where.
But it will now be asked, if the similarity of kala-azar to ordinary fever be
so great, how is a diagnosis ever effected at all? Laying aside for future consi-
deration the epidemiological test—that in kala-azar there is a history of relatives
of the patient having suffered from the disease, or that he has come from a kala-
azar stricken village—and considering the matter only from a patholqgical stand--
point, the answer is that in my experience a diagnosis of kala-azar depended
simply on the greater degree of enlargement of the organs and on what was-
probaby chiefly a consequence of this, the greater illness of the patient as
evinced by the greater severity of his. low fever, anæmia, emaciation, œdenia,
and so on. In cases 49, 50 and 53, for example, there was only a medium,
enlargement of the organs and the patients looked well and cheerful—they were
cases of ordinary fever; in cases 51 and 52 there was great enlargement of the
organs, but still the patients looked well and cheerful—they were cases of ordin-
ary fever : in cases 44—48, however, the enlargement of the organs was extreme,
the illness well marked,—the cases were kala-azar. In other words, the differ-
ential diagnosis appears to depend pathologically solely on a question of degree,
not of kind.
To sum up then—we arrived very early at the conclusion that the symptoms
of kala-azar are strikingly like those of pamdisrn in general. But the observa-
tions recorded in the preceding section go further. They exhibit cases of kala-
azar and kala-jwar existing side by side in the same localities with numerous
cases of paludism and indistinguishable from, them, at least by the tests applied,
except in regard to the degree of illness present. They establish the presence of
the parasites and melanin of paludism in a large percentage of early cases of
fever at Nowgong. They show that in many of these early cases in which the
parasites existed there was already the beginning of that notable enlargement of
the organs which, when further developed, is the characteristic of kala-azar.
They prove that the parasites or melanin existed in some early cases which were
actually diagnosed as kala-azar. They demonstrate the evolution of the cases
from the earliest days of what are quite unquestionably malarial fevers into
either cases of ordinary chronic malarial fever or of kala-azar, according only to
the degree of illness arrived at. And, finally, they record in many quite estab-
lished cases of kala-azar the presence of that substance, which, while it is not
peculiar to paludism, has long been known to be confined to it and a very small
group of diseases—the yellow pigment. In short, they convert what was a mere
symptornatological analogy into what may appear to be a pathological identity.
24. Objections against the Malarial Theory considered.—But the
difficulties in the way of accepting this view referred to in paragraph 22 still
remain to be discussed—no light task.
Two of them, however, the great fatality of kala-azar and its intractability
to quinine, may I think be disposed of easily enough.
In regard to the first we may enquire, (a) is ordinary malarial fever never
a very fatal disease ? and (b) are we quite sure that kala-azar is as fatal as sup-
posed ? The fact is that malarial fever, is under certain conditions, an extremely
fatal disease. We have only to instance the deadly fevers of the African coasts
and the Indian terais as examples. It is true that the ordinary malarial fevers
met with in most stations in India are far from being fatal. In the cases occur-
ring in my regiment at Secunclerabad, for example, several hundreds of which
were examined by me, I remember only one or two deaths to have occurred ;
even without quinine spontaneous recovery was common ; and enlargement of
the organs rarely took place. Everyone is familiar with fever of this type—it
is not serious. But occasionally in most places, and frequently in seme, we
observe attacks of a more severe nature, either causing death by pernicious
access or leading to the long train of secondary symptoms with which we are so
familiar. Where such cases abound we have the typical malarious locality, and