16
Para. 13
to flukes of the organs, especially distomum sinense, which is known to pro-
duce in Japan a widely prevalent disease with enlargement of the liver and
spleen, jaundice, anasarca and a final cachexia ; or to some entirely new para-
site, animal or vegetable. In such cases the fever would he of a secondary,
possibly associated septic, nature—in which case we may even conjecture it,
from our knowledge of septic fevers, to simulate quotidian intermittents.
Again, it may he quite possible that kala-azar is really akin to one of the
primary anæmias—say Addison's Disease, Hodgkins' Disease or leucocythæmia.
In these maladies we have anæmia, emaciation, often enlargement of the spleen
or liver, and very frequently a persistent fever, closely similar to that observed
in the second stage of kala-azar, and sometimes astonishingly like a malarial
quotidian (the chronic recurrent fever of Ebstein). In Addison's Disease,
moreover, there is a peculiar bronzing of the skin, which, translated to the native
of India, may constitute the blackening popularly connected with kala-azar.
It is true that those maladies are not known to be infectious, but a possibility
of this remains open in the absence of more definite knowledge.
Lastly, as Dr. Manson has lately suggested to me, and as I have often
thought in respect to some cases of paludism, we may, in such instances as occur
in kala-azar, have an auxiliary bacterial invasion of the liver and spleen follow-
ing a primary protozoal infection by the parasites of malaria.
Indeed, laying aside the apparent malarial pathogenesis of the disease,
numerous suggestions may be made as to its nature ; and it is obvious that a
hasty conclusion based on its general similarity to paludism is not justifiable.
I may now add that suspicions in this respect were violently excited in me by
a discovery—to be related presently—which I made early in my pathological
examination of cases of kala-azar ; so that, on many grounds, it appeared
absolutely necessary to undertake a careful examination of the question.
At the same time it was understood that if the disease proved to be malarial
after all, further research as to its pathogenesis would not be required.
13. Literature bearing on the Malarial Nature of Kala-Azar.—In
order to demonstrate the malarial nature of a given case of sickness, it is neces-
sary not only to show the existence of occasional attacks of the typical fever, or
the occasional presence of the typical parasites, or the typical enlargement of the
organs, or even the typical pigmentation, but to establish that the ensemble of the
symptoms accords with that of paludism. For instance, in a malarious country
like Assam we may expect frequent attacks of fever in patients suffering
from all sorts of diseases ; we may expect even to find the enlargement and
pigmentation of the organs in many. This is not enough. We require entire
accordance, not only an occasional coincidence, of the symptoms.
Secondly, to establish an exhaustive diagnosis of paludism. we must
depend not alone on the macroscopic symptoms, but on a demonstration
regarding the minute pathological anatomy, especially of the pathogenetic
parasites, of their immediate product the black pigment, and of the remoter
derivate of their toxic influence, the yellow pigment.
Whether this has been entirely done in existing literature on kala-azar
is capable of discussion. So far as the symptomatology goes we have evidently
a very clear accordance between kala-azar and paludism ; but with regard to
the minute pathology, it has been felt — see especially [14, p. 199] — that ex-
isting records are not complete.
Giles, proceeding on the ankylostomiasis theory, does not, naturally, ex-
amine the pathology closely from the malarial point of view. In the annual
Sanitary Reports there is little reference to the histology ; and the rest of the
kala-azar literature depends for its facts in this respect on the report of Rogers.
This report, then, practically constitutes · the whole of the existing kala-azar
literature relating to the pathological anatomy and histology. Captain Harold
Brown's report [16] on kala-dukh, however, furnishes some valuable informa-
tion which may apply to kala-azar.
It is necessary to examine the observations of the seofficers somewhat closely,
as they differ materially from mine.
With regard to kala-dukh, Brown states that out of 50 cases of the
disease examined by him he found the " hæmatomonas malariæ " in 45.
With regard to kala-azar, Rogers' observations are as follows. In his
report [4, p. 116] he says, " the organisms were found in nearly all the more