NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
34
Report on Kála-ázar.
advanced cases of malarial cachexia. Two very different clini
-cal types, however, occur, which may best be distinguished by
wasting of the body, accompanied by great enlargement of the
spleen and liver, although to a variable degree in different
cases in one type, and in the other by the same symptoms
complicated by dropsy of the legs and abdomen, and in the
very last stage, only in rare cases, of the face also, which
imparts a very different aspect from that met with in the first
class. The latter may easily be mistaken for anchylostomiasis,
and, indeed, can sometimes only be diagnosed from it by an ex
-amination of the blood. The dropsical type is much more rare
than the other, and its pathology will be explained presently.
Taking then the common type, a case will show great wasting
of the whole muscular system, best seen in the thinness of the
arms and face, and the prominence of the ribs, and even of
the sternum (breast-bone), which contrasted with the enlarged
abdomen in which the outline of the enormous spleen and
liver may sometimes be dimly discerned, forms a striking
clinical picture which is well illustrated in the photographs
opposite pages 33 and 57. If to these prominent features be
added anæmia of a more or less marked character, usually,
but not necessarily, accompanied by a yellowness of the
conjunctiva, and more or less marked weakness and fever, and
in a minority of the cases by slight œdema of the feet, the
picture will be fairly complete. The skin presents a leaden
hue, which is said to be characteristic of the disease, but which
is difficult to appreciate if the patient is seen but once,
although those, who see people whom they have known well
in health gradually waste away from the disease, are unani
- m o u s i n l o o k i n g o n i t a s a c o n s t a n t f e a t u r e o f t h e a f f e c t i o n .
I can, however, confirm the fact from my own experience, as
I was much struck on my return to Nowgong after two
months' absence on tour, by the darkening of the face in sever
- a l c a s e s i n t h e N o w g o n g d i s p e n s a r y , w h i c h h a d t a k e n p l a c e
during my absence. Its pathology will be discussed in
Section V.
Clinical description of Kála-ázar.
The average duration from the first admission for fever
to the date of death, taken from 193
cases on a Nowgong tea garden, was
7.4 months. The cases at the beginning of the epidemic,
however, averaged only 4.5 months, and during the last year
they averaged 10 months, the intermediate two years being 5.5
and 7 months, respectively, showing a progressive increase in
the duration of the disease each year, proving that the disease
was most virulent at the beginning of the outbreak, and dimi
- n i s h e d i n i n t e n s i t y e a c h y e a r . M o r e o v e r , r e c o v e r i e s w e r e m o r e
common during the last year, pointing to the same conclusion.
A very few cases died within two months of their first admis
- s i o n t o h o s p i t a l , b u t t h e y h a d p r o b a b l y s u f f e r e d f r o m f e v e r
for some considerable time before admission, as I have never
seen any case which I have been able to follow through the
greater part of the illness, that has been fatal in less than
three months; while, on the other hand, they may extend, with
remissions of some months' duration, over three years. From
two months to three years may be taken as the extreme
limits, while the usual duration is from four to nine months.
This point has also been worked out from the tea garden
cases, which show that, although they be-
gin in all months of the year, yet there is an
increase in the number commencing in April, they are highest
during May, June, and July, decline again in September, and
reach the minimum during December, January, and February.
This seasonal incidence agrees very closely with that of ordin-
ary malarial fevers in the Nowgong district, except that
it is a more extended one, and is of considerable importance,
as will be shown in a later section. The death-rate, on the
other hand, showed two maxima, one in April and the other in
October and November, and this again agrees with the monthly
death-rate from kála-ázar and ordinary fevers combined during
the epidemic years in this district, as is shown in the chart
given in Section VI, for it is certain that the illiterate
agents who register the deaths, do not accurately distinguish.
35
The duration of the
disease.
The seasonal incidence.
F2
Report on Kála-ázar.
between those from the two kinds of fever, Cases then begin
chiefly during the rainy season, for in each of the years during
which this tea garden outbreak has lasted, namely, from 1893
to 1896, there was a considerable amount of rain in the months
of April and May, while the main death-rate occurs at the end
of the rains, and at the beginning of those of the ensuing year,
which is accounted for by the fact that most of those cases,
whose fever begins during the rains, die at the end of them, or
at the onset of the cold weather, while those which survive that
period, usually lose their fever for a time during the cold
months, but relapse and die as soon as the rains begin
in the next year.
The age of the patients is of importance, as it may be
compared with that of anchylostoma
cases as noted by other observers. The
disease attacks people of all ages, from children one year
ol d t o qui t e ol d peopl e. My cases vary from a baby of one
year, who was still being suckled, and whose mother and
father had the disease, to a man of 67. There is, however,
a very marked tendency for it to attack children. Thus, of
the cases of which I have notes, 25.6 per cent. were under
10, 24.4 per cent. were between 10 and 20, 34.15 per cent.
were between 20 and 30, 10.97 per cent. were between 30 and
4 0 , wh i l e 4 . 8 7 p e r c e n t . we r e 4 0 o r o v e r . E x a c t l y h a l f t h e n we r e
under 20 years old, while the average age of the whole was
only 14.84 per cent. The ages of 402 cases of anchylostomiasis,
as given by Dr. Sandwith of Cairo, are as follows: under
10, 0.25 per cent., between 10 and 20, 13.94 per cent.,
between 20 and 30, 42.28 per cent., between 30 and 40, 34
per cent., 40 or over, 10.67 per cent. Thus, only 12.25 per
cent. were under 20 years old, as compared with 50 per cent.
of kalá-ázar cases. With regard to the sex, the tea garden
cases show that both sexes suffer equally, and, moreover, the
occupation of the coolies does not affect their liability to the
disease, for those who work in the tea-house suffered just as
much as those who did hoeing and other outdoor work.
36
Age and sex.
Clinical description of Kála-ázar
37
Predisposing and op
- p o s i n g c a u s e s .
Although all classes suffer from the disease when once
it has been introduced amongst them,
yet the poor, I think, suffer in a dispro
-portionate degree, and have less chance
of recovery, owing to their living in more crowded dwell
-ings, and to deficiency of nourishing diet, especiailly of a
nitrogenous nature. On the other hand, I have known a Babu
in very good Government employ, who lost 39 relatives of
the disease. Again, Europeans who were thought by Dr.
Giles to escape the disease, have, since his report appeared,
been proved to be liable to it. I have reliable informa
-tion of seven certain cases, about most of which I have
obtained details from the Medical Officers who attended them,
while in the Nowgong district alone, there have been five
cases with one recovery, and two of the deaths occurred in
one household. I find, too, that in the tea garden cases, a
good many had suffered from such depressing affections,
as dysentery and diarrhœa, etc., shortly before they were
first attacked by kála-ázar, while two cases had previously
had anchylostomiasis, for which they had been successfully
treated a few months before they got kála-ázar, but were still
anæmic.
On the other hand, there is evidence to show that opium-
eaters suffer less from the disease than those who do not take
it. Thus, although it appears from the evidence given before
the Opium Commission that a considerable percentage of the
natives of Assam habitually consume this stimulant, yet out
of 51 adults, who suffered from kála-ázar, only one was an
opium-eater before he was attacked by the disease, and he
recovered from it, while two others took to it after they got ill,
and one of these recovered, and the other died of lung compli
- c a t i o n s , s o m e w e e k s a f t e r h e h a d l o s t a l l f e v e r . A g a i n , i t w a s
given in evidence before the Opium Commission that a village
of opium-eaters in the Kamrup district escaped the epidemic,
although others around them were depopulated by kála-ázar.
This opinion was also confirmed by my enquiries in some of
38
Report on Kála-ázar.
the villages of the Nowgong district, and it was found in
one outlying part of this district that the villagers had become
so convinced of both the prophylactic and curative action
of opium, that its consumption had greatly increased among
them, as will be shown in further detail in Section VII.
This is the most essential and constant feature of the
disease. True cases of kálá-ázar in-
Fever,
variably begin with fever, which may be
of an irregularly remittent or of an intermittent type. The
former is most common in the first attacks, and is also
met with not unfrequently in the final fatal relapse. In
the majority of cases, which I have been able to follow
up for some months, both types occur at different stages
of the illness, as is well shown in the temperature chart
opposite page 73, while in a few cases only occasional attacks
of a remittent: nature are seen, and in a fair proportion
only intermittent fever occurs, and in these the fever is of
a much more constant nature than in the former instance,
and sometimes lasts for two or three months at a stretch,
but then usually the temperature does not rise above io1°o
r 102°F. In the remittent attacks, it may reach 105° or
more, and I have seen a temperature as high as this the
day before death. I have seen the temperature fall two
degrees below normal, but have not met with the persistent
low temperatures described by Dr. Giles, except in cases of
pure anchylostomiasis. In the great majority of the cases
which succumb during the rains, death takes place during a
final paroxism of fever, which is often more severe than has
occurred for some time previously. I have notes of three
cases in which the first attack of fever was said to have been
of a tertian character, in one of which the patient was positive
that it persisted for two months. Dr. Campbell also mentions
that the fever may be tertian in kála-ázar, and this is a point
of considerable importance, for it is obvious that if one case
may begin as a tertian, and another as a quotidian, while a third
starts as a remittent fever, then the fever has no characteristic
i f
Clinical description of Kála-ázar.
and constant type such as would constitute it a special
form, malarial or otherwise, such as the summer-autumn type
of malarial fever, described by Marchiafava and Bignami, and
this accounts for the impossibility of distinguishing it from
ordinary malarial fevers. The temperature was taken four
times a day in a series of cases; but this only served to
reveal the extreme variability and irregularity of the course
of the fever. As regards the constancy of the occurrence cf
fever in true kála-ázar, not only was a clear history obtained
in every case, but an analysis of the tea garden cases shows
that each was admitted on the average 3.5 separate times
for fever, in addition to other admissions under such headings
as anæmia, rheumatism, diarrhœa or dysentery, and dropsy,
during many of which they doubtless also suffered from fever.
About three-quarters of the admissions were for less than one
week, while the intervals between the admissions vary from a
few days to two months or more, the commonest interval
being from two to four weeks. Many of the cases were
admitted for debility, anæmia, diarrhœa, or even dropsy, within
a very short time of their first admission for fever, showing
that they had suffered from the latter in a mild form for some
time before coming to hospital, as, indeed, the history of the
cases shows to be very commonly the case. In fact, I should
say that about half of the cases begin in this way, while the
rest begin with a sharp attack of remittent fever. The fact
that the earliest cases which I could find showed in almost
every instance marked changes in the blood, such as could
only be produced by fever of some duration, also strongly
supports this opinion. One other very marked characteristic
of the fever in this disease remains to be mentioned, and that
is, that after two or three attacks the patients seem to lose all
reaction to the fever. Thus it is a well-known fact that
patients, who have a temperature of 103°F. or over, will some
-times deny that they have any fever at all, and will, moreover,
eat a very fair meal without any apparent discomfort. I have
even seen a coolie on a tea garden get most indignant at
39
40
Report on Kála-ázar.
being kept in hospital, and say he had no fever, although his
temperature had been between 102° and 104°F. for several days.
In such cases, the white corpuscles will be markedly reduced,
e v e n t o o n l y 1 t o 2 , 0 0 0 r e d , s o t h a t l e u c o c y t o s i s c a n n o t o c c u r
to any extent, and this is very likely the explanation of the loss
of reaction to the fever. This point also explains the short
stay of the majority of the patients in the tea garden hospital,
especially as most of the cases occur during the busy season,
when the coolies can make a great deal of extra money, and
are correspondingly loath to stop in hospital. It is also a fact
that these cases will work up to within a few days of their
death, for, as long as they are free from fever, they will work
unless prevented from doing so, although they can do but
little, and then they will get a relapse of the fever, which will
carry them off in a very few days. Thus, I find that about
half the tea garden cases died within a week of their last admis
-sion to hospital. This loss of reaction to the fever results in
the patients working when they have got fever upon them; and
as they are also for the most part anæmic as well, they are
thus deprived of the rest which is absolutely essential to their
having any chance of recovery—a fact that, together with their
not applying for treatment, or, if they do come to hospital, their
discontinuance of it after a very few days, partly accounts for
the fatality of the disease. It is also of great importance in
connection with Dr. Giles' statement that, "on a more and
more close interrogation, however" (which, by the way,
generally results, in the case of a native, in getting him to say
whatever the questioner has in his mind), "it generally came
out that there had been comparatively little fever, and that
what the patient really meant was merely that he had been
feeling ill for a long time," for it is obvious that patients suffer
-ing from kála-ázar will under-estimate, rather than over-esti
-mate, the amount of fever from which they have suffered.
Thus there is no definite type of fever in the disease, while
its duration, and that of the intervals between the attacks
differ very widely, the only constant characteristic being
Clinical description of Kála-ázar.
41
the inveterate tendency to recur again and again until a
fatal issue results, and the rapidity with which the liver and
spleen become greatly enlarged, and the extremities and body
waste.
The spleen is always enlarged in some stage or other of
cases of kála-ázar, but it is not so much
the frequency of its occurrence as the
constancy with which it attains to a very considerable size,
that is the most remarkable feature of the disease. Thus, in
a series of 70 cases, it was found to be enlarged in all, while
in 94.5 per cent. of them it reached at least three fingers'
breadth below the margin of the ribs, while in 56.5 per cent.
it reached to or below the navel, and in 27.7 per cent. it
extended as far as the level of the anterior superior spine of
the ilium. In the more chronic cases it was hard, but in other
cases it was soft, and sometimes varied in size from week to
week in a remarkable manner. In cases of recovery it not
unfrequently disappears entirely beneath the ribs after some
months, even when it has been very large during the illness.
The liver was enlarged in 93 per cent. of the cases, including
a few in which it extended upwards only, as revealed by a
higher level of its dulness than normal. Here again, the
size which it often attained to, was remarkable, and has,
indeed, been thought by some to be a characteristic feature
of the disease in which it differs from ordinary malarial
fevers; but, as a matter of fact, as will be shown directly,
it is not more enlarged in kála-ázar in proportion to the
enlargement of the spleen, than it is in the ordinary malarial
fevers of Assam. It extended to two fingers' breadth be-
low the ribs in 64 per cent., and to four fingers below
in 24 per cent. The edge could usually be easily felt, and
in the more chronic cases it was quite hard. Pain over the
liver and spleen is of frequent occurrence, and may be very
severe, being due to peri-splenitis and peri-hepatitis. Dr.
Giles was of the opinion that the spleen was not more often
enlarged in kála-ázar than it was in the "reputedly healthy G
Enlargement of the
liver and spleen.
42
Report on Kála-ázar.
population," but he produces no evidence in favour of this
view beyond quoting Dr. Dobson, as having found 21 out of
42 children in a Goalpara village to have enlarged spleens,
and this in a district which was at the time affected by kála
- á z a r ,
a n d t h a t h e h a d f o u n d a b o u t t h e s a m e p r o p o r t i o n i n
the Chaygaon district (also affected by the disease), but he
could not give the figures, as he had lost his notes on the
subject. On the other hand, he does not state in what pro
- p o r t i o n h e f o u n d t h e s p l e e n e n l a r g e d i nk
á l a - á z a r ,
a l t h o u g h
he admits that it is so in "most of the cases;" but as he
included pure cases of anchylostomiasis among them, the
absence of the exact figures is of no account, for, as I shall
prove in the next section, this disease is quite distinct from
k á l a - á z a r .
In order to estimate the importance of the en
- l a r g e m e n t o f t h e s e o r g a n s , i t i s n e c e s s a r y t o k n o w i n w h a t
proportion of apparently healthy inhabitants of the district
they are enlarged, and to what size. To determine this
point, I examined 65 men in the Nowgong jail in the month
of June, with the result that 12 of them, or 18.46 per cent.,
had some enlargement of the spleen; but of these, in only one
was it three fingers or more below the edge of the ribs, and
this man died of kála-ázar very shortly afterwards. Again, I
examined 200 coolies in the lines of a tea garden, where there
were no cases of kála-ázar, except the Assamese wife of one
of the sirdars, who came from an infected village. The
size of the spleen and liver, as well as the presence of
anæmia, pigmentation of the mucous membrane of the
mouth, and the amount of fever from which each coolie
had suffered during the previous two years, were noted.
The results, which are very instructive, were as follows:
The spleen was enlarged sufficiently to be felt in 25 per
cent., but in only 6 per cent. did it reach to three or
more fingers' breadth below the ribs, and in only 1 per, cent.
did it extend below the navel. What was more remarkable
was the fact that in 19 per cent. of the coolies the liver was
enlarged, and the enlargement was in proportion to that of
Clinical description of Kála-ázar.
43
the spleen. Thus, in the 150 cases in which the spleen was
not enlarged, only 3.33 per cent. had any enlargement of
the liver, while in the cases in which the spleen could be felt,
but did not extend as much as three fingers' breadth below
the ribs, 57.89 per cent. had some enlargement of the liver,
though in the majority of them it was not as much as one fin
- g e r ' s b r e a d t h b e l o w t h e r i b s ; b u t i n t h e c a s e s i n w h i c h t h e
spleen reached to three fingers or more below the ribs, in
91.65 per cent, the liver was enlarged, and in more than four
-fifths of these it extended one or more fingers' breadth be
-low the costal margin. This, it will be observed, is almost
exactly the same proportion as the liver is enlarged in kála
-ázar, so that it is evident that in this disease it is only en
-larged in proportion to the enlargement of the spleen, exactly
as it is in ordinary cases of malaria in Assam. Once more,
there is a very definite relation between the amount of fever
that the coolies had suffered from and the enlargement of
the spleen and liver, and also between these and the fre
-quency of anæmia amongst them. Thus, of the cases in
which the spleen was not enlarged, only 10 per cent. had
suffered from fever to any degree within the last two years,
and two-thirds of these had not suffered within the last year,
while 27.33 per cent. of them showed more or less anæmia,
but in two-thirds of these it was not marked. On the other
hand, of those who had slight enlargement of the organ (less
than three fingers' breadth below the ribs), 61.16 per cent.
had suffered from fever, and 55.33 were anæmic, and of those
who had marked enlargement of the organ, 75 per cent. were
anæmic, the majority of them being markedly so. It is also
worthy of note that in a good many of the anæmic cases
with enlargement of the spleen, the conjunctiva was white,
so that the conjunctiva need not necessarily be yellow
in cases of anæmia due purely to malarial fever; and the
main point which Dr. Giles relied on to differentiate
anchylostomiasis from the anæmia due to malaria, is based on
false premises, and the great majority of the cases which
G 2
Report on Kála-ázar.
he quotes from other writers, and states to be "clearly
cases of anchylostomiasis," are not necessarily so, while
the two cases which he details as having been seen by
himself, are not cases of kála-ázar at all, but simple
anchylostomiasis. Hence the necessity of this full description
of true kála-ázar. With regard to the pigmentation of the
buccal mucous membrane, it may be mentioned here that
I have been able to distinguish two kinds, one of which is
normal to many of the darker skin races of India, and is
most frequently seen in the indigenous inhabitants of Chota
Nagpur, namely, the Kols and Mundas, while the other
is, I believe, a pathological result of malarial fever, and hence
is of diagnostic value. The former presents itself as black
patches on the tip or sides of the tongue, and in extreme
instances on the floor of the mouth also, and as a diffuse
slate-coloured hue on the hard palate, only rarely extending
back to the soft palate. In fairer natives only a little light-
brown colour may be seen along the central line of the hard
palate, and this, as well as the darker colour, is of no clinical or
pathological significance. On the other hand, small dots of
a brown colour, usually of a lighter tint than the above de
-scribed, and often best marked on the soft palate, and not
seldom of a slightly raised character, are very commonly seen
in persons who have recently suffered from malarial fever,
especially if it has been of a severe or continued type. Thus
the former diffuse form was met with in from 50 per cent. to
66 per cent. of the different coolies classified according to the
enlargement or not of the spleen as above, but the dotted
form was seen in only 24 per cent. of those who had no enlarge
-ment of this organ, but was present in 76 per cent. of those who
had large spleens. The point is of some importance, as this
form of pigmentation is met with very commonly in kála-ázar,
and I am not aware that the distinction between the normal
and the pathological forms of pigmentation met with in the
mouth, has been pointed out before.
It is then evident that the spleen is enlarged four times
44