43
Paras. 24 & 25
in such places a fatal issue results very frequently. It is, therefore, no argument
against the malaria nature of kala-azar to say it is a very fatal disease. I do not
suppose that the wave of kala-azar now spreading in Assam is more fatal than
the endemic fever found continually in many terais in India. We are more struck
by the former because it is a new invasion of a tract formerly comparatively
healthy ; whereas in the terais the fever has existed for years and has in fact
rendered them almost uninhabitable. But are we not justified in supposing
that, if we could move all the conditions which produce terai fever into the
heart of a crowded population—say that of Calcutta for example—a most deadly
pestilence would be produced ?
Again, the actual percentage of deaths and attacks in kala-azar must be
difficult to estimate, for the simple reason that the attacks cannot be identified
owing to their similarity to malarial fever. It is not fair to point to a case of
enormous tumefaction of the organs which will almost certainly have a fatal
termination, and then to adduce it as an example of the great fatality of the
disease. This would be to ignore the possible eventuality that many cases
recover before ever reaching such a stage. As Price says (Appendix A)
"when a case is cured we have our doubts whether it has been kala-azar."
At the same time we know that kala-azar is very fatal because of the great
mortality caused by it in given villages and hamlets ; although here, again,
doubts may be expressed in view of imperfections of registration. On the
whole, I think we may safely say that there is no reason for supposing that
kala-azar is a more fatal disease than paludism at its worst can be.
Similarly with regard to the inefficacy of quinine—we know as a fact
that may local fevers, especially those occurring in malarious districts, are
singularly resistant to the drug ; and before accepting as an absolute fact that it
is inefficacious in kala-azar we require to learn many details as to how and when
it was given. Quinine should be administered at the proper moment (before
the access, generally speaking), and should be given in large enough doses and
and be continued for a period long enough to ensure destruction of all the
parasites in the system. Again Price's remark in this connection just quoted
must be carefully remembered ; while, lastly, as I shall suggest in paragraph 41,
quinine may be given and may fail in a certain stage of malarial fever
without prejudicing the diagnosis. (Compare McNaught, Lavertine, Price and
Macnamara in the Appendix with the above remarks). One thing we do know
for certain, and that is that numerous cases of paludism all over the world die
in spite of a continual exhibition of the drug.
Why paludism should be more fatal and quinine less effectual in some
cases and localities than in others does not concern us here (see however para-
graph 31) ; but the fact remains, and I think that the objections to the mala-
rial theory just referred to have little weight.
Those which remain are far more serious. I propose to consider together the
presence of the low fever and the absence of parasites and melanin in established
cases of kala-azar ; and shall then proceed to examine the epidemiological difficulty.
25. The Special Pathological Problem of Kala-azar defined.—In
paragraphs 13 and 14 it was pointed out as a result of my first examinations of
kala-azar cases, that the really tangible objection to the malarial theory of the
disease lay in the absence of parasites and melanin in its later stages, even
at a time "when the fever and the general condition of the patients showed
that a morbific agency, whatever it is, was most certainly at work." A
possible explanation of this apparent anomaly was suggested, but it was noted
that the explanation involved a hypothesis which could not possibly be accepted
without further observations and without sufficient authority from literature.
The further observations were made. Their result is given in paragraph
23. It cannot be denied that they give very strong evidence indeed in favour
of the malarial theory. At the same time, however, they fortified equally the
evidence regarding the absence of parasites and melanin in old cases. Further
than this, several of the cases, such as cases 21, 35, or 52, tended to show a
similar phenomenon in patients who were thought to be suffering from ordinary
paludism ; while the same thing was suggested by not a few observations of
mine in other parts of India, notably the Darjeeling Terai and the Sigur Ghât.
Lastly, Gibbon's case of reputed kala-azar transcribed in Appendix B, may be
cited as a partial confirmation of my results.
G2