85
Appendix A
seen death occur in the earlier stages; it generally takes place after a year and a half or
two years. It is then generally due to asthenia and anæmia. I have never seen pneumonia
in connection with the disease. Diarrbœa is apt to set in towards the end o£ the case. I
have never noticed a decrease in the liver and spleen towards the end of the cases. The fever
is less violent towards the termination; but I don't think it ever wholly disappears. Anæmia
begins to become marked about the third or fourth month. I think it is a continuously
progressive anæmia. It becomes extremely marked. (Edema sets in at a late stage — of the
feet and about the face. Ascites occurs, but I don't think is very marked; it is certainly
not always present. I think there is always darkening of the skin, though in the case of
natives it is hard to tell with certainty. I do not think it is due to actual pigmentation.
Emaciation is very marked, especially in the later stages. The final picture presented is that
of emaciation; anæmia; sunken eyes and drawn face; protuberant abdomen due to enlarged
spleen, and giving the appearance of an ovarian tumour ; abdominal veins enlarged; often
dropsical feet; and fever, which, however, may disappear toward the end. I have not noticed
epistaxis.
"In my experience quinine does no good, even given in doses of 20 grains every morning.
I cannot speak certainly of its effect from the commencement of the disease; but in some cases
in which it was certainly used from the beginning, it did not check the illness."
Q. Are you quite sure that fever and enlargement o£ the spleen are constant features of
the disease?
A. Yes.
Q. How do you distinguish between kala-azar and malarial fever ?
A. By the place where the patient has come from; by the fact that he goes from bad to
worse in spite of treatment; and that he eats well. These points may not be distinctive, but
my diagnosis is based on a consideration of them.
Q. Judging from the mere picture presented by the two diseases, can you distinguish
between them?
A. No, I cannot.
Q. Do you think kala-azar is malarial fever ?
A. It is certainly very like it. I have always thought it is malaria; but its mode of
spreading is so contrary to one's accepted ideas regarding malaria, that I hesitate to come to
any conclusion on the subject.
Q. Do you think the disease is ankylostomiasis ?
A. No; it is something quite different; ankylostomes may or may not be present, but they
no more cause the disease than do round-worms which also very frequently occur in the cases.
Q. Have you any further remarks to make?
A. It strikes me that the disease is very like what I have read of surra in horses. The
disease seems to me to spread at the rate of about two miles a year amongst a settled popula-
tion. I can't say at what time of the year infections most generally take place. I rarely
find rigors in Assam fever generally. I give quinine generally in pills or tabloids.
6. Statement of Dr. C. W. Daniels, Colonial Medical Service, Malaria Commission,
taken on the 18th January 1899, at Calcutta.
Q. Where have you studied malaria ?
A. British Guiana.
Q. About how many cases of malarial fever or enlarged spleen have you examined during
life for the parasites of malaria ?
A. Roughly about a hundred and fifty.
Q. What varieties of parasites did you find in Georgetown ?
A. Æstivo-autumnal only.
Q. Did crescents abound in the cases ?
A. No; they were rare even in cases kept long under observation and frequently
examined.
Q. Do you find parasites as easily in capes of chronic enlarged spleen with pyrexia as in
cases where there is no chronic enlargement of the spleen ?
A. No; it is very exceptional to find parasites in cases of enlarged spleens with fever or
without.
Q. Do you observe in cases of enlarged speen any pyrexia which is not accompanied by the
presence of the parasites in the peripheral blood ?
A. Frequently.
Q. In cases which have died during or shortly after this kind of fever, have you ever
found an absence or only a small amount of melanin in the spleen at the autopsy ?
A. Frequently with none ; sometimes with little.
Q. What is the nature of the curve of this fever?
A. Very irregular; sometimes transient; sometimes continued; not commonly high;
often what would be called a low type of fever.
Q. Is this fever markedly affected by quinine?
A. No; I have given up using it except as a tonic.
Q. Have you observed any tenderness of the spleen during this fever?
A. Often discomfort in the splenic region; but usually not exactly tenderness.
Q. Do you think that the severity of this fever bears any relation to the amount of the
splenic enlargement ?
A. I have observed no relation.