NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
5
one. The edges of the film should, if possible, be straight as this facilitates
considerably the rapid examination of a large number of leucocytes. Such
a filsm stained deeply by Romanowsky's method can be satisfactorily searched
in a little over an hour. After some practice I was able to find the parasite
with a Leitz 1-6th objective even before the stained film was dry.
I t may be asked, ' i s i t necessar y t o exami ne a f i l m at some par t i cul ar hour
during the day or night ?' In order to settle this point I have on two separate
occasions examined films taken every hour from a patient suffering from
Kala Azar in whose peripheral blood I had found the parasites. The record
of these observations will be found on the chart appended which also shows
the temperature taken hourly. It will be seen on examining this chart that , the
number of the parasites in the peripheral blood bears no relation to the temper-
ature, and that there is no particular hour when parasites are especially abundant.
The observations are of interest in showing that the number of parasites in the
peripheral blood is not dependent on any definite periodicity in their discharge
into the circulation, but varies from hour to hour throughout the day with each
specimen taken.
One of the first cases of Kala Azar I studied was, a boy of 14 (Case 1),
in Major Donovan's ward, suffering from uncontrollable diarrhœa; his spleen
was one inch and his liver one inch and-a-half below the costal margin, and on
palpating his abdomen great pain was complained of all over the large
intestine. Two blood films were examined, one contained 34 parasites in
the leucocytes and the other 60 ; in the latter they were nearly all in the
polymorphonuclear leucocytes which were distinctly increased in numbers.
I have since examined eight similar cases in each of which diarrhœa was
the most marked symptom. One of these cases was particularly interesting,
for the patient, a boy of 17 (Case 10), had been ill for only four months. The
disease began with fever, which was followed by diarrhœa that persisted
till death ; the spleen could not be felt below the costal margin although
the liver extended four inches below the normal limit, and on palpation of the
abdomen great pain was complained of in the region of the large intestine, even
down to the first part of the rectum. The motions, varying in number between
ten and sixteen, were of a greenish yellow colour and contained flakes of necrosed
tissüe, some mucus and undigested food, and often small quantities of blood.
The temperature never rose above 102° F. during the twenty-four hours. In
a film of finger blood made seven days before death I found 75 parasites,
most of which were in polymorphonuclear leucocytes, though a few were in
the mononuclear cells. Fig. 1 on the plate shows a large mononuclear leucocyte
containing seven parasites, and Fig. 2, a polymorphonuclear leucocyte containing
Jour parasites ; both these cells were found in thesame film. The para sites
6
have the same appearance as those seen in films of splenic blood. The two
following blood counts were made from this case on March 19th :—
Count I.—
Total leucocytes counted
.
.
.
.
.
.
. 5 0 0
Polymorphonuclear leucocytes
.
. .
. . .
75.6 per cent.
Large mononuclear leucocytes including transitional and inter-
mediate cells
.
.
. 11.4 ,,
Small mononuclear leucocytes.
.
.
.
6.8
, ,
Myelocytes
.
.
.
.
.
. 2. 6
,,
Eosinophyl cells
.
.
.
.
.
.
3.6
, ,
I found one parasite in an eosinophyl cell, two in a large mononuclear cell
and sixty in the polymorphonuclear leucocytes, many of which contained as many
as three parasites.
Count II.—
Total leucocytes counted
.
.
500
Polymorphonuclear leucocytes
•
.
.
. .
78.4 per cent.
Large mononuclear leucocytes including transitional and
intermediate cells
. . . . . .
9.6
,,
Small mononuclear leucocytes
. . . .
9.8
, ,
Myelocytes .
.
.
.
.
1.4
,,
Eosinophyl cells
. . . . .
.8
, ,
In this film there were 98 parasites in polymorphonuclear leucocytes and
12 in the large mononuclear leucocytes.
These two counts show distinctly an increase in the polymorphonuclear
cells which is probably due to the ulceration of the large intestine, and it is
of interest that under these conditions the majority of the parasites are
in the polymorphonuclear cells. Two days before the death of the patient
I found. 128 parasites in a blood count of 500 leucocytes, this being the
largest number of parasites I have yet found in a film of peripheral blood.
At the autopsy, the hepatic flexure of the large intestine was found
firmly bound down to the lower surface of the liver; the large intestine was.
ulcerated throughout, and in the liver there were two abscesses the size of
oranges and several small ones containing glutinous pus.
All these observations show that, if careful search is made, the Leishman-
Donovan bodies can be found in the leucocytes in the peripheral circulation,
and further, that the parasites occur in large numbers in those cases in which
the large intestine is markedly ulcerated.
Rogers 6 has recently shown that the development in his acid medium of
the parasites embedded in the polymorphonuclear leucocytes is in every respect
typical, but somewhat slower than that seen in the free forms ; therefore,.
since the parasites occur in the peripheral circulation and that they are
7
capable of further development while in the leucocytes, it is not difficult to
understand that infection may be acquired by some blood-sucking insect.
We may now consider if there is any other evidence in support of the
view that some blood-sucking insect acts as the carrier of the parasite.
Rogers,1 2
t r a c i n g t h e s p r e a d o f t h e d i s e a s e f r o m v i l l a g e t o v i l l a g e
in Assam, found that when a person suffering from Kala Azar went to reside
in an uninfected village the next case occurred in the house in which this
person had lodged, He12 also records instances of Europeans contracting Kala
Azar by coming in contact with natives who subsequently died of the disease ;
in two instances there was no other case for miles around.
In Madras many of the Kala Azar patients give very clear histories of
having lived with or near persons who have either died of, or are still suffering
from the disease, and I have often noted that the first case in a house termin-
ated with very severe diarrhœa.
Dr. Bentley 1 3
r e c o r d s i n " N o t e s o n K a l a A z a r i n A s s a m " t h a th
e
h a s f r e
quently noticed when the epidemic was at its height that cases showing dysen-
teric symptoms, especially when bed-ridden, were followed by fresh cases
in the same household or among the attendants ; and that when the intestinal
form of the disease is in abeyance the epidemic assumes a milder type.
That cases of Kala Azar with extensive ulceration of the bowel are a source
of danger to others living in close contact with them is in accordance with my
observations on the blood of such cases. A blood-sucking insect feeding on
these cases could easily take in leucocytes containing the parasites, and if the
insect was a suitable host and there was nothing to prevent the development
of the parasites, infection later of a healthy individual could follow.
Two instances of a multiplicity of cases occurring in one house have
recently come to my notice, and I am indebted to Dr. Vigayaraghavelu for the
notes of the first series of cases, which are given below :—
Case No. 1, R.
.
. Son of No. 2
.
. Age 20 years
.
Disease began February
1902, patient still living.
Case No. 2, A.
.
. Father of No. I
.
. Age 42 years
.
. Disease began May 1902,
died January 1904.
Case No, 3, S.
.
. Son of No. 5 .
.
. Age 9 years
. Disease began June 1903,
died March 1905.
Case No. 4, K.
.
. Daughter of No. 5 .
. Age 15 years
.
. Disease began December
1903, patient still living.,
Case No. 5, R.
.
. Father of Nos. 3 and 4,
brother-in-law of No. 2.
Age 39 years
.
. Disease began April 1904,
patient still living.
Case No. 6, P.
.
. Daughter of No. 2
. Age 13 years
.
. Disease began September
1904, patient still living.
Case No. 7, N.
.
. Nephew of No, 5 .
. Age . 11 years
. Disease began October
1905, patient still living.
8
I visited the house occupied by this family, and saw those who are still
suffering from the disease. They all had enlarged spleens, were getting fever-
regularly, and had œdema of the lower extremities. Case No. 4, a girl of 15,
was very much reduced owing to diarrhœa which was evidently getting worse,
The house in which the family lived had a central courtyard in to which all
the rooms opened. Some of the family were accustomed to sleep in the
verandah along the courtyard, and the others in the rooms. On searching for-
blood-sucking insects I found only bugs, which were in large numbers in
crevices in the doors and roof.
I was unable to find a case of Kala Azar in the adjoining houses, and
was informed by the occupants that they had not heard of one. I have every
reason to believe the statements of these people who were intelligent and
knew the disease quite well.
The second instance of a number of cases occurring in one house is also,
of interest. Most of the cases had been in hospital and were diagnosed either
by splenic puncture or by examination of the peripheral blood. The family
lived in a, small detached house which consisted of two rooms with a verandah
on each side. The first case in this house (Mr. T.) had been for some time
in hospital where the disease had been diagnosed as Kala Azar after splenic
puncture. His friends removed him during the last stages of the disease, when
he was bed-ridden and suffering from acute diarrhœa, and he died at home on
August 2, 1905, about a week after he left the hospital. His mother-in-law-
(Mrs. C.) died on August 24, 1905, in hospital, where her case was not diag-
nosed as Kala Azar, but as anæmia and diarrhea. The next case (William
C.) was diagnosed after examination of splenic blood in hospital, as one of Kala..
Azar. He died at home on October 29, 1905, Nelson C., who was ill
during his brother's lifetime and had also been in hospital several times, when
the parasite was found in the splenic blood, died on December 8, 1905.
Mrs. W., whose illness began in October, died in hospital on December 14,
1905, four days after admission. Many parasites were found in films of
splenic blood. In March 1906, Mrs. T. came to hospital suffering from fever
and an enlarged spleen, in which parasites were present in large numbers.
Mabel W. came to hospital with a history of irregular fever and diarrhœa which
had persisted for nine days. Her spleen was only slightly enlarged, but I found
a parasite in a film from her finger blood. The house occupied by this family
was in a very insanitary condition and bugs were plentiful in the furniture and
also on the walls.
These two instances show very clearly that the infection tends to spread,
through a household.
In Madras among the blood-sucking insects which might be concerned in
the transmission of the disease are the louse, mosquito, house flea, bed bug, and
9
the human tick (Ornithodoros savignyi), recently found in Madras. No experi-
ments were carried out with the flea, as I was unable to find it in any number
in the houses.
Pediculus capitis. —Finding that pediculus capitis was common on the
heads of patients, I began my experiments with this insect,
Experiment I, Case 1.—On December 2, 1905, I found 34 parasites in
a film made from the finger blood of this boy. On the same day about 50
1 ce were placed on his head. The next day eight lice were dissected, their
mid-gut contents were carefully examined and in one slide a single free
parasite was found which showed no change either of development or
degeneration.
On December 4th the boy died, and the remaining lice were removed
and placed on the head of a second patient (Case 2), in whose peripheral
blood parasites were found. On the same day ten lice were dissected, and in
two slides four parasites were found which were unaltered, and, if anything,
showed commencing degeneration, evidenced by their somewhat ill-defined
outlines. The remaining lice were dissected on December 5th, 6th, and 7th, but
I failed to find any parasites in the films. Altogether 47 lice were dissected.
Experiment II, Case 2.—On December 8th, ten parasites were found in
a blood film taken from the finger of this patient, and shortly after this 32 fresh
lice were placed on his head. On December l0th, 11th, and 12th, these
lice were dissected and examined, but I was unable to find a single parasite.
After dissecting 102 lice, no further experiments were undertaken with them,
as I could find no evidence of development of the parasites in their mid-guts.
Pediculus corporis.—Experiment I, Case 3. —About 15 of these lice were
placed on the patient on December 12th, on which day 10 parasites were found
in a blood film. On the 14th, 15th, and 16th, the lice were dissected and
examined, but I was unable to find any parasites. No further experiments were
carried out with these lice.
Culex fatigans. —This is one of the commonest mosquitoes in Madras City,
being very abundant in George Town where it breeds in wells and gutters. A
large number of the larvæ of this species were kept in the laboratory, and the
adult mosquitoes were used for the experiments. On selecting a suitable
case, a mosquito net was fixed on the bed, the mosquitoes being placed inside
the net at night and collected in the morning.
Experiment 1, Case 4. —A large number of these mosquitoes were placed
in the net on the evening of December 15th, and next morning ten fully gorged
female mosquitoes were recovered. A blood film examined on December 15th
contained seven parasites.
On December 18th, the seven remaining mosquitoes were dissected and c
10
in the mid-gut of the sixth in the series a flagellate was seen in the fresh
condition, but on smearing out the film it was lost. At first I was inclined
to think that this flagellate represented a fully developed Leishman-Donovan
body, as I was not then aware of the common presence of flagellates in
mosquitoes bred out from larvæ in the laboratory. I was, however, soon after
informed by Christophers that he had found similar flagellates in the mid-guts of
the males of this species, and that on examining the gastro-intestinal tract of the
larvæ he found the early stages of development of the parasites. I have since
been able to examine these flagellates, which are long slender spindles tapering
posteriorly possessing a long wavy flagellum. They are probably a species of
Herpetomonas.
Similar, if not identical, parasites were found by Major Ross 14 in 1898
at Ootacamund, and he has recently called attention to these observations on
the presence of the parasites in the larva, pupa, and imago of Culex fatigans.
Novy, MacNeal and Torrey 15 in a short paper on mosquito trypanosomes,
say they have found flagellates in 15 per cent. of caught mosquitoes
subsequently fed on clean animals, rats, guinea-pigs and pigeons. These
parasites appear to be of several distinct species, the most common being Her
-petomonas (probably Herpetomonas subulata) and Crithidia fasiculata. These
observers have been able to cultivate the parasites on solidified blood agar, and
found that the cultural forms conformed in every respect with the parasites found
in the mosquitoes. I have since found similar parasites (Herpetomonas) in the
mid-guts of Culex pipiens.
One hundred and fifty-seven female mosquitoes ( Culex fatigans) which
were fed on the patient were dissected between December 18, 1905, and
January 17, 1906, but I was unable to find any Leishman-Donovan bodies
in their mid-guts. Blood films were taken daily from the patient, and with three
exceptions, parasites were always found. Two of the mosquitoes contained
normal flagellates ( Herpetomonas).
In most of the dissections of these mosquitoes, after examining the fresh
preparations, the films were smeared out and stained by Romanowsky's method.
Besides the flagellates mentioned above, many of the films contained bacteria
and a few spirilla. As nothing to suggest the development of the Leishman-
Donovan bodies was seen, I decided to abandon any further experiments with
this mosquito.
Ornithodoros savignyi. — Captain Christophers1 6
h a s r e c e n t l y d r a w n a t t e n t i o n
to the presence in the Madras Presidency of this tick which was first brought
to his notice by Dr. Oliver who found it in the gravelly floors of the third-class
passenger sheds at Tirapaty. Specimens have been obtained also from Kala-
hasti, Tirapati West, Yerfed, Gekakur, Vendod, Tanjore, Conjeeveram, and
lately, in Madras itself. In Madras they are found in the sand under the trees
in the People's Park and on the outskirts of the town, but I have not been able
to find any evidence of the presence of the tick in the houses in George Town.
I have myself searched on the floors of some of the houses and also along the
streets, but without success. Boys suffering from Kala Azar have, however,
told me that they were bitten by ticks when playing under the trees on the out
-skirts of the town.
Experiment 1; Case 5 . —On January 16, 1906, ten parasites being found
in a blood film, four adult female ticks were placed on the patient's abdomen
where they soon began to suck blood and when fully gorged dropped off. On
the 27th, seven parasites were found in a blood film, and the ticks were
again fed.
On the 29th, one of the ticks was dissected and its gut contents being
smeared out on several slides were stained by Romanowsky's method and
carefully examined, but with negative results. On the 31st, the second tick.
was dissected and this time, in addition to examining the gut, the ovaries
were also smeared out and stained, but in none of the films could I find any
parasites. The two remaining ticks were allowed to ovulate in order later to
examine the larva and nymphs.
Seven more ticks were fed on another patient (Case 6) and examined
between February 5th and 17th, but nothing was found in the dissections. In
each case films of blood, examined shortly before feeding the ticks, contained
parasites. Larva and nymphs were examined later with negative results.
No more experiments were carried out with this tick as there were no
evidence of the development of the Leishman-Donovan body in their guts.
Anopheles stephensi. —This is the only species of anopheles that has been,
so far as I am aware, found in George Town. I have had occasion to examine
many larvae from the wells in this part of Madras, and they have always
been those of Anopheles stephensi.
Captain James,17 I.M.S., reports having, found the larvæ of this species
in Madras City in unused wells, and I have often satisfied myself that the larva
can live in wells in constant use. I noted that larvæ could be found in one
particular well although it was used constantly by the occupants of four adjacent
houses. This observation is of considerable interest as showing that the larvae of
this mosquito can live in spite of adverse conditions.
A large number of the larvæ of this mosquito were collected early in March
1906, and when the mosquitoes had hatched out they were kept in bottles,
the mouths of which were covered with netting. These bottles were taken
to the ward at night and placed under the flexed knee of .the patient, a method
of feeding these mosquitoes which I have found satisfactory.
C 2
Experiment I, Case 7.—On March 11th a film of blood from this patient
contained 14 parasites, and six adult mosquitoes were fed on the same night.
They were again fed on March 12th, when I found four parasites in a blood film.
On the 15th the remaining five mosquitoes were dissected and examined, and in
four of the films there were many flagellates, which on staining appeared to
be a species of Crithidia. They were short organisms measuring about 4.8µ,
with their anterior ends truncated or concave.
Thirty-four female mosquitoes were fed on two patients (Cases 8 and 9)
between March 12th and 28th, and on dissection they were found to contain
no Leishman-Donovan bodies, though 23 of the mosquitoes contained normal
flagellates ( Crithidia). On examining the gastro-intestinal tracts of the larvæ
of this mosquito these normal flagellates were found in varying stages of develop-
ment.
Leishman-Donovan bodies were found in large numbers, in films of the
finger blood of one of these patients, on one occasion as many as 75 being
found. No more experiments were carried out with Anopheles stephensi.
Stegomyia sugens. —This mosquito is common all over Madras, being
specially prevalent in the wells in George Town.
Experiment I, Case 10.—Ten female mosquitoes were fed on this patient
during the day on March 15th, a blood film taken shortly before feeding con-
tained 78 parasites. On March 17th and 19th the mosquitoes were again fed,
blood films taken on these dates contained respectively 32 and 21 parasites. A
few bugs were also fed on the patient on the 19th, but they were eaten by
ants which had got into the pill boxes. The mosquitoes were dissected on
March 22nd, but I was unable to find any parasites. After having been fed,
several times, 21 female mosquitoes were dissected between March 20th and
26th, but no parasites were found in the smears. On each of these days
blood films taken before the mosquitoes were fed contained many parasites.
On account of all these failures no other species of mosquito was experi-
mented with.
Bugs.—At first, some difficulty was encountered in keeping and feeding
these insects. They were confined in pill boxes, the lids of which were
perforated to allow for ventilation, a few pieces of crumpled filter paper being
placed at the bottom of the boxes. When required for feeding, the boxes were
opened and inverted on the arm or leg of a patient. Owing to the facts that it
was often difficult, especially at night, to recover all the bugs, and that ants
could readily enlarge the holes in the lid, I adopted another plan for keeping
them. Small glass specimen tubes, such as are used for storing mosquitoes,
were found to answer the purpose. A few pieces of filter paper were put into the
tubes and the bugs on being dropped in hid themselves in a short time in the