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Appendix A
palpation—the patient himself complaining of pain in them. This attack of fever remains
indefinitely for various periods. In many cases there is then another apyrexial period, followed
again by a similar attack. This history is repeated on several occasions. The spleen and liver
have now become much enlarged and easily visible through the emaciated parietes of the
abdomen. At the same time, with the first and second attacks, anæmia may be present in some
instances, but is never very marked. As the attacks recur, anæmia may become more marked;
hut in most cases never reaches any high degree, the tongue generally remaining red. Anæmia
is by no means a leading characteristic of the disease. By this time emaciation has become
marked, while the superficial veins of the epigastric region are enlarged. The patient now
suffers from a low form of fever which remains for weeks and even months. In many cases
there is epistaxis, which is sometimes controlled only with difficulty. This condition remains
for mouths. Dropsy of the face and in some cases moderate ascites are present; in rare in-
stances there is puffiness of the eyelids and face. There is undoubted darkening of the skin in
many cases from my own observation; and this is also stated to be the ease by the relatives.
According to my observations, this symptom is visible only in the more advanced cases.
Jaundice may occur with the earlier attacks, but is not common. At any time during the
illness, but more especially after two or three attacks of fever, there may be intercurrent
affections, such as bronchitis, pneumonia, diarrhœa and dysentery; but these do not always
occur. Sometimes, during the chronic stage, there is a sudden attack of high fever, not neces-
sarily, T think, due to pneumonia, which not infrequently terminates the case.
"Further on, in the chronic stage, the low fever disappears, and often there is a decrease
in the size of the organs; but the emaciation and darkening of the skin remain. The patient
is able to go about, and complains of nothing but debility and perverted appetite; especially a
desire for animal food, which is so marked that good class Hindus will take forbidden flesh.
The emaciation progresses until the man is sometimes a walking skeleton, the temperature
often being subnormal. If an attack of diarrhœa or dysentery does not terminate the case,
the patient generally dies of asthenia.
"I think that death may occur even during the first attack of fever or at any later stage,
but oftener after several attacks, and still more frequently in the advanced stages. The
general duration of the disease is from six to nine months; though I have known cases to last
years.
"Recovery may take place at any stage except perhaps the last ones; but very few re-
coveries occur."
In answer to questions :—
"I think that enlargement of the liver is present in every case. It is a marked feature
of the disease. The spleen is enlarged in every case; sometimes it is simply enormous.
I have never seen suppuration in these organs in cases of kala-azar. If recovery ensues, the
enlargement of the spleen and liver may disappear entirely. I have never known "black-
water" occur in kala-azar, but I have known three cases amongst Europeans in the tea-
estates. I know several cases of kala-azar which have been treated with quinine from the
earliest stages and which have not recovered. A dozen cases at least in this district alone.
The doses were 10, 12, 16 grains daily, generally in the morning. Some of the cases took
over an ounce of quinine altogether and died finally. The popular belief is generally that
quinine is not only useless but harmful."
Q. How soon after the actual beginning of the case, do you remember, was this treat-
ment commenced?
A. Within a few days; after the usual preparatory treatment by purgatives, ipecacuanha
and antipyretics.
Q. Is there any change in the local conditions which may account for the epidemic ?
Do Europeans suffer as much as natives ?
A. No change whatever. Europeans suffer less frequently; but I have seen some
attacked.
Q. Before kala-azar commenced here, were chronic malaria and malarial cachexia not
to be seen ?
A. There were cases — but few. When I came here it did not strike me that the popula-
tion was by any means a malaria-stricken one.
Q. How do you distinguish between kala-azar and malarial fever in their earlier stages.
A. It is most difficult to make this distinction during the first attack. But when a second
and other attacks occur with marked enlargement of the spleen, and especially of the liver also
in a family in a locality known to be affected with the disease, the presumption that it is
kala-azar gains ground, especially when anti-malarial treatment fails to prevent the recurrence
of fever.
Q. How do you distinguish between kala-azar and malaria in their more chronic stages?
A. It is most difficult to do so, apart from the history of the case showing that it occurred
in a kala-azar-stricken house or locality.
Q. Generally speaking, what differences are there between kala-azar and malarial fever?
A. (1) Kala-azar is more fatal. (2) It is more intractable to treatment and is not cured
by quinine. (3) It is certainly communicable from the sick to the healthy; it runs in families
and is epidemic — which, so far as 1 know, cannot be said of malarial fevers.
Q. Do you think kala-azar is ankylostomiasis?
A. No, absolutely and entirely different.