NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
5
No.
Age.
Condition of spleen.
Result of examination of slides of
finger blood.
1
4 years I hand's breadth below costal
margin.
Positive. Simple Tertian parasites.
2
4 "
3 fingers' breadth below costal
margin.
Negative.
3
3 "
Palpable
.
.
.
.
. Positive. Quartan parasites.
4
4 "
I hand's breadth below costal
margin.
Negative.
5
4 "
Ditto .
.
.
.
.
. Positive. Malignant Tertian rings.
6
3 "
Ditto .
.
.
.
.
. Positive. Quartan parasites.
7
3 " 3 fingers' breadth below costal
margin.
Ditto.
Ditto.
8
3 " I hand's breadth below costal
margin.
Positive. Simple Tertian parasites .
9
2 "
Ditto .
.
. . . .
Positive. Quartan parasites.
10
4 " No enlargement detected
.
. Ditto.
Ditto.
1 1
4 "
Palpable
. . . . .
Ditto.
Ditto,
12
3 "
3 fingers' breadth below costal
margin.
Positive. Crescents.
13
4 "
No enlargement detected
.
. Negative.
14
2 "
Palpable
.
.
.
.
. Positive. Crescents and Quartan parasites.
1 5
10 months To umbilicus
.
.
.
. Positive. Quartan parasites.
1 6
1 1/2 years Palpable
.
.
.
.
. Positive. Malignant Tertian rings and
crescents.
17
5 months 1 finger's breadth below costal
margin.
Positive. Malignant Tertian rings.
1 8
2 years 2 fingers' breadth below costal
margin.
Positive. Quartan parasites.
19 15 months Ditto .
.
.
.
.
. Positive. Malignant Tertian rings.
20
2 years
Ditto .
.
.
.
.
. Positive. Quartan parasites.
21 15 months No enlargement detected
.
. Positive. Simple Tertian parasites.
22
5 "
1 finger's breadth below costal
margin.
Positive. Simple Tertian parasites.
23
5 "
Not enlarged
.
.
.
. Negative.
24
9 " 2 fingers' breadth below costal
margin.
Positive. Simple Tertian parasites.
25
2 years
Ditto .
.
.
.
.
. Negative.
Among the children of this village the spleen-rate per cent. was there-
fore 84 and the malarial endemic index was 80. It is interesting to note
also that Malignant Tertian parasites were present in 4 of the 20 positive
findings. If kala azar has any connection whatever with malaria, this is the
kind of village in which it should be especially prevalent.
6
We may now compare the results of the investigations in Ulloobari and Old
Salonah villages thus :—
Place.
Prevalence of
kala azar.
Spleen-rate per
cent. of children.
Malarial
endemic index.
Species of malarial
parasites present.
Ulloobari .
.
. 17 per cent. of the in-
habitants examined
were suffering from
this disease.
32.5
12.5
Quartan and Simple
Tertian parasites.
Old Salonah ••
Nil
84
8 0
Quartan,
Simple
Tertian and Malig-
nant Tertian para-
sites.
In case any doubt as to the correctness of my argument still remains, I shall
now compare the relative prevalence of kala azar and of malarial fever in two
villages which, being inhabited by the same class of people and being situated
only a short distance apart, are under similar conditions.
For this purpose
I shall select the villages of Old Salonah and New Salonah, both situated on the
Salonah tea estate near Nowgong. The results of my investigation in Old
Salonah village have already been given. New Salonah village contained, at the
time of my visit, about 450 inhabitants, and careful inspections showed that there
were 12 advanced cases of kala azar among these people. The disease was
endemic in the village and new cases frequently occurred.
The prevalence of malaria is shown by the results of my examination of
children as follows :—
No.
I
Age.
3 years
Condition of spleen.
.
Enlarged.
.
Result of examination of slides of
finger blood.
Positive. Quartan parasites.
2
6 "
Not enlarged
..
,
.
. Negative.
3
4 "
Enlarged .
.
.
. . Positive. Quartan and Simple Tertian
parasites.
4
3 ,,
Ditto
.
.
.
.
. Positive. Quartan parasites.
5
2
Ditto
.
.
.
.
.
Negative.
6
3 "
Ditto
. . . . . Positive. Simple Tertian parasites.
7
8 "
Not enlarged. .
.
Negative.
8
5 ",
Ditto
. . . . . Ditto.
9
2 „
Enlarged .
.
.
.
. Positive. Simple Tertian parasites.
1 0 o
4
Ditto
. . . . . Ditto.
Ditto.
1 1
1 year
Ditto
. . . . . Negative.
12
1 „
Not enlarged.
. . . Ditto.
13
1 ",
Enlarged .
.
.
,
. Positive. Simple Tertian parasites.
14
2 years
Ditto
. Ditto.
Ditto.
15
3 "
Not enlarged
. . . . Negative.
16
1 year
Ditto.
.
.
•
•
Ditto.
17
8 months
.
.
Enlarged .
.. Positive. Simple Tertian parasites.
18
3 years
Ditto Ditto.
Ditto.
19
8 months Ditto.
.
. . Positive. Pigmented leucocytes.
20
2 years No enlargement detected
.
. Positive. Simple Tertian parasites.
21
3 ,,
Enlarged.
. Positive. Quartan parasites.
22
2 , ,
Ditto
. Ditto.
Ditto.
23
1 year
Ditto. Positive. Simple Tertian parasites.
7
Among the children of this village the spleen-rate per cent. was therefore
69 and the malarial endemic index was 65.
The prevalence of kala azar and of malarial fever in the two villages referred
to may now be compared as follows :—
Place.
Prevalence of
kala azar.
Spleen-rate
per cent.
Malarial
endemic index.
Species of malarial
parasites found.
Old Salonah
.
.
Nil
84
80
Ouartan, Simple Ter-
tian and Malignant
Tertian.
New Salonah
.
. 12 cases among 450
inhabitants = 2.6 per
c e n t .
69
65
Ouartan and Simple
Tertian.
New Salonah is very malarious, and if the investigation had been carried out
only in this village, it might have been supposed that the prevalence of kala azar
was due to this fact; but when it is found that in the much more malarious
village of Old Salonah kala azar does not exist, such a supposition is at once
shown to be untenable.
The evidence detailed above may now be summarized :
(1) In Gauhati, Ulloobari, Tezpur, and Kohbari, kala azar is prevalent, but
malarial fever is rare or absent.
(2) Old Salonah is an intensely malarious place, but kala azar does not occur
there.
(3) Ulloobari is a slightly malarious place, Old Salonah an intensely
malarious one : 17 per cent. of the residents in Ulloobari were suffering from. kala
azar, but the disease was not present in Old Salonah.
(4) Old and New Salonah are under similar conditions : both are very
malarious ; but this, where kala azar exists, is less so than that, where kala azar
does not occur.
In my opinion, this evidence is sufficient to warrant the conclusions that
kala azar is not a form of malarial fever and that its presence depends upon
conditions other than those necessary for the presence, of this disease ; but
there is yet one more argument, to which brief reference may be made, inasmuch
as, whilst not being essential for our proof, it serves to emphasize the justness
of our conclusions.
On reading the reports of previous investigators of kala azar, one's attention
is arrested, amidst a number of conflicting statements and views, by the agree-
ment which exists regarding the opinion that natives who have lived all their lives
on the same tea-garden are quite as liable to the disease as are new-comers. There
is no reason to doubt the correctness of this opinion, but it is difficult to understand
how any one can hold it and yet believe that kala azar is a form of malarial
8
fever. In a previous memoir * I have shown that in very malarious places the
native of India acquires an immunity to malarial fever : for example, among
the syces and their families who had lived all their lives in Mian Mir the immunity
of the adults was very marked : while 63 per cent. of children between 0 and 10
years of age had enlarged spleens due to malaria, among people between 11 and
25 years of age the percentage with enlarged spleens was only 23, and among
people between 26 and 40 years of age it was only 8. The percentage
of people with malarial parasites in their blood diminished at advancing age-
periods in a similar manner. Now, the people of all ages were equally exposed
t o m a l a r i a l i n f e c t i o n , a n d i t i s b e y o n d d i s p u t e t h a t t h e a b s e n c e o f e n l a r g e d s p l e e n s .
and of parasites among the adults was due to their having acquired, by repeated
attacks in early life, an immunity to malarial infection.
This rule, that natives who have resided during a number of years in a
malarious place acquire an immunity to malarial fever, has been found to hold
good in several places in India besides Mian Mir, and the following tables will
show that it holds good also in malarious places in Assam :—
P l a c e .
Age-period of people
e x a m i n e d .
Number of people
examined.
p e r c e n t a g e o f people
w i t h
e n l a r g e d s p l e e n s .
Old Salonah (Nowgong district) . Between 0 and 5 years.
3 4
8 5
"
5 and 10 " .
.
40
65
"
10 and 15 "
. .
35
57
"
15 and 20 " .
.
76
39
20 years and over
.
164
15
Place.
Age of people examined.
Number examined.
Percentage of
people with
m a l a r i a l p a r a s i t e s o r
pigment in their
blood.
Old Salonah .
.
.
. Under 5 years
.
.
.
25
8 0
Over 25 years
.
.
.
25
0
* " Malaria in India": Scientific Memoirs. New Series, No. 2.
9
From these results we are justified in concluding that a native who is born
on the Salonah tea estate will acquire almost complete immunity to malarial
fever by the time adult age is reached, and it is obvious that if such a native,
after reaching the age of 25—30 years, begins to suffer severely from a disease
characterised by fever and enlargement of the spleen, it is in the highest degree
improbable that this disease is malaria.
C
10
II
P REVIOUS observers attempted to solve the problem set forth in the preceding
section by comparing the clinical signs and symptoms of cases diagnosed
as kala azar by medical men in Assam, with the clinical signs and symptoms
which they believed to be characteristic of malarial fever. But before any one is
entitled to use this method for the purpose stated, he must prove the truth of two
suppositions : one is that in Assam cases of kala azar are diagnosed accurately ;
the other that he has nothing more to learn regarding the signs and symptoms
of malarial fever as it occurs among natives of India. And even if the method
is not condemned by the difficulty of converting these two suppositions into
truths, it must be admitted that, for the purpose of fathoming the nature of a
disease presumably new to science, the comparison of its clinical signs and
symptoms with those of diseases already known, is a method of investigation
to be avoided ; for it is obvious that the signs and symptoms of two entirely
different diseases may be exceedingly similar. In employing the method
of investigation described in the preceding section, it was unnecessary to be
able to diagnose cases of the disease known to natives of Assam by the term
kala azar, nor was it necessary to know the signs and symptoms of malarial
fever as it occurs among natives of that country : it was necessary only to select
certain places in which the presence of a disease known as kala azar was
established, and certain other places in which a disease known by this name did
not occur, and to ascertain whether these places were, or were not, malarious.
From the results of the investigation carried out on these lines I was convinced
that, whatever the disease known as kala azar is, it is not a form of malarial fever.
Thus far we were able to proceed without studying individual cases. But in
order that we may be in a position to form an opinion as to what the disease is,
rather than what it is not, a study of individual cases is necessary ; and for this
purpose we must be able to diagnose them accurately. To this matter, therefore,
I propose to devote the present section.
If kala azar is not a form of malarial fever, it is evident that in India there
are two chief diseases (namely, malarial fever and kala azar) in which fever and
enlargement of the spleen are prominent signs. In the Punjab I could find only
one of these diseases (namely, malarial fever),* but the results to be detailed in
this section will show that in Assam both occur. The apparent difficulty of
distinguishing between them is to be explained, I believe, by the truth that
* See Scientific Memoirs by Officers of the Medical and Sanitary Departments of the Government of
India, New Series, No. 13.
11
previous observers, having confused cases of kala azar with cases of malarial
fever, recorded many signs and symptoms characteristic of that disease as being
present in this. So great, indeed, has been the confusion of the two diseases
that it is no exaggeration to say that the symptomatology of kala azar has yet
to be written, and some erroneous notions regarding the signs and symptoms of
malarial fever as it occurs among natives of India have yet to be corrected. I do
not propose to deal fully with so large a subject in this paper ; it is sufficient for
my present purpose to say that, inasmuch as previous observers often described
cases of malarial fever in the belief that they were describing cases of kola azar,
and cases of kala azar in the belief that they were describing cases of malarial
fever, we must admit that in investigating kala azar we have to deal with a
disease the symptomatology of which is not accurately known, and which,
therefore, at present can be recognized only by a process of exclusion. And,
fortunately, the only disease which presents any difficulty in this connection is
malarial fever : the accuracy with which we shall be able to diagnose cases of
kala azar will depend upon the accuracy with which we can diagnose, and
therefore exclude, cases of malarial fever.
I conjecture that the correct explanation of the cause of confusion
between kala azar and malarial fever lies not so much in the truth that the
method of investigation hitherto employed was a bad one, as in the supposition
that the notions hitherto held with regard to the signs and symptoms of malarial
fever as it occurs among natives of India were erroneous ; and therefore,
so far as my experience enables me to do so, it will be my chief object to give
an account of the signs, symptoms, and method of diagnosis of this disease :
for if I succeed in presenting a clear clinical picture of malarial fever as it occurs
among natives of India, it will be easy for others to note the many points in which
it differs from kala azar and to diagnose cases of this disease.
I shall begin my remarks upon malarial fever with the statement that I intend
to deal only with the subject of long-continued chronic infections such as would
be diagnosed correctly under the term "malarial cachexia." To this I shall con-
fine myself not only because the subject of recent malarial infections has been
frequently dealt with by others, but also because it has been thoroughly established
that the signs, symptoms, and temperature-curves observed in patients suffering
from a recently-acquired infection are so definite and characteristic that it would
be well nigh impossible for any one willing to investigate such cases carefully to
confuse them with cases of any other disease. I am aware, of course, that this view
is not held by all medical officers in India ; for, that many medical officers of long
experience have very rarely seen typical charts of Simple Tertian or Quartan
malarial fever, and that the opinion is widely prevalent that the signs and symptoms
of the malarial fevers of India are very indefinite, are matters of common.
C 2
12
knowledge. But however much we may regret that some medical officers still hold
such views—and the more so if, like a former investigator of kala azar, they do
not hesitate to express them in their writings*—it is not incumbent upon us, in the
light of the truth that at the present time such views are not held by any one who
has taken pains to study the matter carefully, to attempt to controvert them.
Without further prelude I shall therefore pass on to the subject of chronic
malarial fevers as they occur among natives of India.
In a former memoir I described very briefly some cases of infection with
Simple Tertian and Quartan malaria parasites. Although in several of these
patients the disease had lasted for many months and the condition present would
be correctly termed "malarial cachexia," the temperature charts were so
characteristic that, even in the absence of a blood examination, no other diagnosis
than that of malarial fever was possible : it was obvious that in many cases of
infection with Simple Tertian or Quartan parasites, even when the patients
presented all the signs and symptoms of advanced "malarial cachexia," the
characteristic periodicity of the fever enabled a correct diagnosis to be made with
ease. This was a new rule and one of some importance from the point of view
of diagnosis, for at that time the opinion was generally prevalent that the fever-
curve in advanced cases of malaria was very irregular, and that for this reason
the diagnosis of such cases was very difficult.
Since those were described I have had opportunities of examining cases
of chronic malaria during long periods, and it is chiefly upon the results of this
investigation that I shall base my remarks concerning the signs, symptoms, and
diagnosis of "malarial cachexia."
First I shall describe three cases of chronic malaria, one of which resulted
from an infection with Simple Tertian parasites, another from an infection with
Malignant Tertian parasites, and the third from a mixed infection with Simple and
Malignant Tertian parasites. After pointing out the chief signs and symptoms
and the mode of diagnosis by clinical and by microscopical methods in each,
I shall sum up such conclusions regarding "malarial cachexia" as appear to
be justifiable from their study : then, by giving notes of other cases, I shall
attempt to ascertain how far these conclusions are applicable to all cases of true
"malarial cachexia," in so far, that is, as such a term is applicable to the condi-
tion which arises in natives of India as a consequence of long-continued malarial
infection.†
* On pages 160 and 161 of the second edition of "A Handbook of Mosquitoes" by Lieutenant-Colonel
G. M. Giles, published in 1902, will be found the following statements : "little else than the æstivo
—autumnal fever is to be met with in India" and "never in India have I met with cases exhibiting the
absolutely classical malarial paroxysm ..............."
† Whether the condition is rightly designated by the term "cachexia" must be left to the reader to
decide.
13
1st Case.—HIRA ; aged 14 years ; seen in Mian Mir at the beginning of April
1902. He had come to Mian Mir in the previous year with his father, who was
a syce in one of the cavalry regiments. When first examined, he stated that he had
had a severe attack of fever in the previous October, and that he had suffered from
attacks at irregular intervals since that time. He said that during the attacks
the fever usually came on every night, but on some nights it was not so bad as
on others. He was suffering from an attack at the time when I saw him. His
spleen was enlarged nearly to the umbilicus and he was very anæmic, but the
fever did not incapacitate him from work. Many Simple Tertian parasites were
found in his blood on April 4th. By the middle of April his spleen was enlarged
one inch beyond the level of the umbilicus. During the summer months he
improved considerably, and the fever came on only in short relapses occurring
at long intervals. Several examinations of his blood in June did not reveal the
presence of parasites or pigment. On the 1st of November a few Simple Tertian
parasites were found in his blood, and systematic examinations and records of
temperature were commenced on the 4th. The temperature chart for nearly three
months from this date is reproduced here ( chart I).* With the help of my Hospital
Assistant, who undertook to remain in the patient's house for several nights
during the relapse of fever which began about the 31 st of December, I was able
to obtain a two-hour chart of the temperature during this period ( see chart II ).
The results of blood examinations and the variations in the size of the
spleen are given below. The blood examinations refer in all cases to slides of
peripheral blood :—
1-11-02
. . Spleen enlarged to umbilicus. A few large Simple Tertian
parasites found.
4 - 1 1 - 0 2
.
. No parasites, but many pigmented leucocytes.
7-11-02
.
. One Simple Tertian ring form found after long search.
9-11-02
.
. One ring form and several pigmented leucocytes.
11-11-02
.
. No parasites nor pigment after long search.
14-11-02
.
.
Ditto
ditto.
17-11-02
.
. Spleen to umbilicus. No parasites nor pigment after long search.
19-11-02
.
. One pigmented leucocyte found after long search.
2 2 - 1 1 - 0 2
.
. No parasites nor pigment after long search.
2 8 - 1 1 - 0 2
.
. The spleen is reduced in size ; its edge is nearly an inch to the
left of the umbilicus. No parasites nor pigment after long search.
1-12-02
.
. Edge of spleen one inch to the left of the umbilicus. No
parasites nor pigment after long search.
7-12-02
.
. One thick pigmented Simple Tertian ring.
9-12-02
.
. Spleen nearly to umbilicus. No parasites nor pigment after long
search.
1 1 . 1 2 - 0 2
.
. No parasites nor pigment after long search.
15-12-0
.
.
Ditto
ditto.
20-12-02
.
.
Ditto
ditto.
* The charts are bound together at the end of the paper.
14
28-12-02
.
. Spleen much reduced ; its edge is two inches to the left of the-
umbilicus. No parasites nor pigment after long search.
2-1-03
.
. Four Simple Tertian parasites—two being rings and two being.
large forms.
3-1-03
.
. One ring form and several pigmented leucocytes.
5-1-03
.
. Spleen to umbilicus. Slides taken every four hours.
8 A.M. Only one Simple Tertian ring form found after long search.
12 noon. Two pigmented leucocytes ; no parasites.
4 P.M. One nearly full-grown Simple Tertian parasite and one
pigmented leucocyte.
12 P.M. No parasites nor pigment after long search.
6-1-03
.
. 4 A.M. One pigmented leucocyte only.
12 noon. Two large Simple Tertian parasites.
4 P.m. One large Simple Tertian ring form ; several pigmented
leucocytes.
7 - 1 . 0 3
.
. 8 A.M. Two pigmented leucocytes ; no parasites.
6 P.M. One pigmented leucocyte ; no parasites.
8 - 1 - 0 3
.
. 10 A.M. Several pigmented leucocytes ; no parasites.
10-1-03
.
. Temp. 98°. No parasites nor pigment after long search.
The blood examinations were continued every other day until the 16th of January, but
parasites or pigment were not found again.
A careful examination made o n the 8th of January showed that the boy's
spleen was enlarged one inch beyond the umbilicus, his liver was just palpable
beneath the ribs, and his feet were slightly œdematous, He had remained in his
house for two days during the relapse of fever which occurred about this time, but
from the 10th of the month he began to recover his usual health very rapidly, and
in the month of March 1903, when he was last examined, beyond the fact that
his spleen was still enlarged nearly a hand's breadth below the ribs, there was
little or no evidence that he had ever suffered from malaria.
Signs and symptoms ; diagnosis by clinical methods.—At the beginning of
November 1902 this boy had suffered for at least a year from an entirely untreated
infection with Simple Tertian malaria parasites, and I think it will be admitted
readily that during the period of the systematic examinations made from
November 1902 until January 1903 he was in the condition usually diagnosed in
India as " malarial cachexia with enlargement of the spleen." On inspecting the
temperature chart we note that it is divided definitely into periods of pyrexia and
periods of apyrexia ; at no period does it present any sign of the " long-continued
irregular type of fever " usually described in text-books as being characteristic
of the condition termed " malarial cachexia."
The pyrexial periods were as follows :—
N ovember 1st (?) to November 10th.
November 15th to November 22nd.
December 5th to December 6th.
December 15th to December 17th.
December 31st to January
8th.