NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
Report on Kála-ázar.
with in the disease is so typical of that which is seen in cases
of malarial cachexia all over the world, that there are very few
points to which special attention need be directed. The
changes in the liver and spleen are characteristic of the disease.
The granular and fatty degeneration of the heart, together
with its atrophied condition, are of considerable importance in
determining the great fatality of the inflammatory complications
of the lungs, as the right ventricle becomes acutely dilated
when any extra work is thrown on it, as was seen in the two
post-mortems after death from pneumonia given in illustrative
cases in Section III. There was no change in the suprarenal
capsules such as could account for the darkening of the skin
so frequently met with in the disease. It is due partly to
the natural pigment of the skin being more apparent owing
to the anæmic condition of the patient, but more still to a
deposit of fresh pigment in the integument, which is derived
from the hæmoglobin of the broken-down red corpuscles, for
it may be very noticeable in chronic cases in which the anæmia
is slight.
The atrophy and pigmentation of the mucous membrane of
the small intestine are changes which are of great significance
in relation to the high mortality of the disease, as they are the
result of an inflammation of the mucous membrane, which shows
itself clinically in the diarrhœa which so often begins during an
acute attack of the fever, and goes on, after the temperature
has fallen, in a most obstinate manner. Not unfrequently, as was
very well illustrated, in some cases of which the notes and tem
- p e r a t u r e c h a r t s w e r e k i n d l y r e c o r d e d f o r m e b y D r . D o d d s P r i c e ,
a rapidly fatal form of diarrhœa sets in directly the temperature
falls after a severe and prolonged attack of remittent fever. In
these cases it must be set up by an enteritis, which occurs
coincidently with the high temperature, and it is well known
that this is a symptom of almost absolutely fatal significance.
It is in marked contrast, as already pointed out in Section
III, to the constipation, which is the general rule in anchy
- l o s t o m i a s i s . T h e s e i n t e s t i n a l c h a n g e s a r e t h e c a u s e o f t h e
112
Pathology and nature of kála-ázar.
113
loss of digestive powers, which so greatly retards recovery
of strength and weight after the fever has become less,
or has ceased, and to them must be attributed much of the
fatality of the disease.
Portions of the livers of five cases were sent to Cal-
cutta for analysis of the amount of iron in
them, which was kindly carried out for me
by Dr. Waddell, Chemical Examiner to
Government, at the Medical College. The object was
to determine if there was an excess of iron such as is
present in chronic malaria, or a diminished quantity, as was
found in some cases of anchylostomiasis by the late Dr. Bevan
Rake. Unfortunately the specimens which were obtained
at the time they were required, were a singularly unfavour-
able series for the purpose, as the case of anchylostomiasis
was complicated by malaria, while three out of the four
kála-ázar cases were complicated by anchylostoma in con-
siderable numbers, considering that two of them were
children.
An examination of the amount of iron found in the liver
by different observers in health, vary so much that it must
depend greatly on the exact method adopted in the analysis.
Thus, while William Hunter gives eight analyses of the liver
in pernicious anæmia by different observers to average .713
per cent., and that in 14 cases of other disease to average
.203, Ralph Stockman found an average of .185 in
two cases of pernicious anæmia, .07 in five normal livers,
a n d . 0 3 i n f o u r c a s e s o f a n c h y l o s t o m i a s i s . M y f i g u r e s
are lower still, in spite of the fact that an excess of iron was
found in some of these livers by microscopical examination,
and onl y aver age . 023. I t i s t hen obvi ous t hat t he met hods
of analysis were not sufficiently similar to allow of accurate
comparisons between the figures obtained by different ob-
servers, and those of any series will only be comparable with
one another.
2
Analyses of the iron
in the liver after death.
114 Report on Kála-ázar.
The figures given in the following table will therefore be
of only relative value:
—
Disease.
Age.
Anchylostoma
found, p. m.
+ percentage of
iron in liver.
Total iron in liver.
(I)
Kála-ázar ...
25
21
'0316
'50 gramme.
(2)
Ditto
. . .
7
50
'0237
'162 ,,
(3)
Ditto ...
8
8 0
'0233
'195 ,,
(4)
Ditto ...
27
103
'0134
'123 „
(5)
Anchylosto -
miasis plus
malaria.
20
161
'0242
'203 „
From this table it will be seen that No. (I), which was the
only uncomplicated case of kála-ázar in an adult of the
series, had a much higher percentage of iron than any of the
others, while the total amount in the liver in this case was
more than double that of any of the rest. In the other three
kála-ázar cases, the percentage of iron decreased in propor-
tion to the increase in the number of anchylostoma present,
just as might have been expected.
In the last case, although the patient died of anchylos-
tomiasis, it was complicated by chronic malaria, as was
shown by the spleen being large and very hard, and conse-
quently the amount of iron is comparatively high, although not
nearly so high as in the uncomplicated case of
kála-ázar.
It must also be borne in mind that owing to the intense
and comparatively rapid course of
k
á
la-
ázar,
it could not
b e e x p e c t e d t h a t a s m u c h i r o n p i g m e n t w o u l d h a v e t i m e t o
collect in the liver in these cases, as in ordinary chronic
malaria, which so often last for years.
It is evident then that in uncomplicated
k
á
la-
ázar,
there
is an excess of iron in the liver after death, as has also been
proved to be the case by means of cutting sections of the
organ, as shown at page 115, but that there is not
sufficient difference between the results obtained in
kála-ázar
Pathology and nature of kála-ázar.
1 1 5
complicated by anchylostomiasis, and in anchylostomiasis
complicated by malaria, as to be of any practical use in
differentiating the two conditions.
It is also worthy of note that the hæmoglobin value
was not much reduced in some of the cases of kála-ázar in
which the iron analysis was comparatively low, which sup
- p o r t s t h e c o n c l u s i o n t h a t t h e r e s e r v e i r o n i n t h e l i v e r m u s t
be considerably diminished before the hæmoglobin value falls
materially, a point of considerable interest.
A series of agar agar tubes were inoculated with the blood
obtained by pricking the fingers of kála-
ázar patients with due precautions. Some
were also inoculated with blood withdrawn directly from the
spleen of a case in which abscess of that organ was suspected,
but not found. Negative results were obtained, in which
respect my observations are in accordance with those of Dr.
Giles, so it may safely be concluded that there are no organ
-isms in the blood of kála-ázar patients, which will grow on
agar agar.
Although the plasmodium malaria is not, strictly speaking,
a bacterium, its presence in kála-ázar may be conveniently
considered under this heading. A great deal of time has
been expended in an examination of blood of kálá-ázar cases
for these organisms, as the probable malarial nature of the
disease being soon evident, it was hoped, and even expected,
that the plasmodia in this virulent form of fever would differ
from those met with in ordinary cases of malarial fever in
Assam, in such a degree as to allow of the differentiation of
the two types of fever from one another. In the later
stages of the disease, when anæmia has become a distinct
feature, great changes in the sizes and shapes of the cor
-puscles, together with neucleated ones and heamatocytes, etc.,
take place to such a degree as to render a minute study of
any malarial organisms that may be present doubly difficult.
In order to overcome this difficulty, a series of early cases of
fever on affected tea gardens were examined, which could not be
Q 2
Bacteriology.
Report on Kála-ázar.
definitely diagnosed as kála-ázar, but some of which occurred
in families or houses in which true cases of the disease were
present, and so were likely to develope into the typical condi-
tion. After an interval of six or eight weeks, they were all
seen again, and the notes and sketches of the organisms
which were found in the blood in those cases which had devel-
oped into typical kála-ázar, were compared with those which
had turned out to be apparently ordinary malarial fever. No
differences, however, were found in the two classes, except
that in the kála-ázar cases the organisms seemed to be less
frequently pigmented, but the difference was not sufficiently
constant and striking to allow of their being differentiated by
it. The forms found include most of those figured by Italian
authors as typical of quotidian fever, only I never came
across any cresent forms, which at first surprised me, as they
are usually found in relapsing kinds of malarial fever, such as
kála-ázar is; but, on the other hand, cases in which they have
been met with by Italian authors, are always of a very acute
nature, often ending with coma or other complications, in which
respect they differ greatly from the type in kála-ázar, in which
such acute symptoms are never seen. My former work on
the malarial organisms ( Indian Medical Gazette, February
1896), moreover, together with that of other observers, seems
to show that the cresent bodies are only met with in certain
less common types of fever in India, and not in the great
majority of them. In addition to the series above noted, the
organisms were also found in nearly all the more advanced
typical cases during the presence of fever, in all stages of the
disease up to the day before death, and in numbers roughly
proportionate to the height of the fever.
It may therefore be concluded that the malarial organism
is a constant accompaniment of the fever of kála-ázar, and
that the organisms found do not differ from those seen in the
ordinary malarial fevers of Assam and other parts of India, to
a sufficient degree to differentiate the type of the disease from
them, and this observation is in accordance with the absence
Nature of kála-ázar.
of any definite type of fever in the affection, and with its being
indistinguishable in individual cases from ordinary malarial
fever.
THE NATURE OF KÁLA-ÁZAR.
We are now in a position to discuss the true nature of
the pathological processes, which underlie
the disease, in the light of the facts set
forth in the last three sections. It will be conivenient to do so
under the headings given in Section II, as being possible
views of the nature of the affection, although the order
there given need not necessarily be adopted.
This is essentially the view taken by Dr. Giles, who
chylostomiasis?
writes
" All I wish to convey is that the increased mortality is due to
anchylostomiasis, and to no other cause.".
From an article in the Indian Medical Gazette of July last,
it appears that he is now more inclined to attribute a share in
the production of the disease to malaria, for he is quoted as
writing:
" The increased mortality is due to anchylostomiasis acting in
people already worn down by malaria . . . . Anchylostomiasis is, of
course, quite capable of acting alone, but it is only occasionally that it
gets the chance of showing what it can do without;its ally, malaria."
If by this Dr. Giles means that nearly every native suffers
from malarial fever at some period or other of his life, this is
quite true of Assam, and indeed of most parts of India; but if,
on the other hand, he means that nearly all the natives of
Assam show definite physical signs, such as enlargement of the
spleen, of the action of malarial disease, such as would pre
- d i s p o s e t h e m t o o t h e r d i s e a s e s , t h e n t h i s d o e s n o t a p p l y t o
the case of the Nowgong district, for, as I have shown in
Section III, only one-quarter of the ordinary inhabitants of this
district show any such signs, even during the height of the
fever season. Moreover, as late as 1892, in a letter to the
The nature of
á zar.
Is the disease an-
118
Report on Kála-ázar.
Chief Commissioner of Assam, in reply to the criticisms of
Mr. Melitus, the Secretary to the Chief Commissioner, Dr.
Giles writes:
"I will now take up the consideration of the objections advanced
by Mr. Melitus to the identity of kála-ázar and beri-beri."
(Anchylostomiasis), and again:
"What then is kála-ázar? Kála-ázar is anchylostomiasis."
This is certainly what he is generally understood to have
meant by all in Assam who have read his report, and the
quotations given in the first section of this report bear this out.
Unfortunately for Dr. Giles, it was not known at the time
of his investigation that over 80 per cent. of healthy natives
have the anchylostoma worms in them, for the most part in
quite small numbers, so that he regarded the mere presence
of these parasites, or even the finding of the ova in the fæces,
which I have shown, can be done when less than 20 of the
worms are present, as evidence of anchylostomiasis, that is, dis
- e a s e p r o d u c e d b y t h e s e p a r a s i t e s , a n d u n f o r t u n a t e l y h e d i d n o t
make any control examinations in healthy persons, or he would
have found out his mistake. But having found "a number of
anchylostomes" in one autopsy, and "enormous numbers
of the ova of the parasite" in the dejecta of five or six other
cases, he writes:
"Other post-mortems followed, and proved incontestibly that,
whatever kála-ázar might be elsewhere, the disease so called in
Gauhati was undoubtedly anchylostomiasis."
He does not give the number of the worms which he found
except, in two cases the full notes of which he records, one at
least of which was certainly a pure case of anchylostomiasis,
and not kála-ázar at all, "about a thousand anchvlostoma"
being found, while the spleen and liver were smaller than
normal. Dr. Giles' further statement, after visiting Upper
Assam to study anchylostomiasis, that
—
"nothing here struck me so strongly as the absolute identity of
the clinical pictures presented by these cases of acknowledged
anchylostomiasis with those I had just been seeing so much of under
the name of kála-ázar,"
Nature of kála-ázar.
119
can only be reconciled with the unanimous opinion of the
meeting of planters' doctors at Kokilamukh in October
1894, that—
"as the disease observed in the patients (kála-ázar cases) brought
before the meeting by Drs. Dodds Price and Lavertine, and from the
history of similar cases, appears to be entirely unknown in Upper
Assam above Nowgong, and differs in every particular from anchylos
-tomiasis, with which it has been confounded; and as the disease is
prevalent in certain districts, and is slowly, but most certainly,
advancing up the valley, an expert is necessary,"
on the supposition that, considering as he did that, enlarge
- m e n t o f t h e s p l e e n a n d l i v e r a n d f e v e r w e r e o n l y a c c i d e n t a l
complications, and not ordinary symptoms, of the disease, he
compared such cases of simple anchylostomiasis as he saw
in Gauhati with similar ones in Upper Assam. Dr. Giles'
opinion that fever was not a common or marked feature of
the disease, is accounted for by the fact that he was unfor
-tunate enough to happen to commence his clinical work in
Gauhati late in November, which is just the very time when
the fever is at a minimum, and remains so until the
commencement of the next rains, by which time Dr. Giles was
engaged on microscopical and other work in Shillong, so that
he only studied the disease at the season when most of the
cases, which have survived the previous rains, have lost their
fever, and fresh infections are at a minimum. Moreover, as
he admits in his preliminary report, the longest time that he
had any one case under observation was one month, while
the majority of them he could have seen but once or twice
in the villages which he visited. Now I have seen fever
remain absent from typical cases for more than a month, even
in the rainy season, and yet a fatal relapse occurs, while at the
time of writing (February) out of seven cases in the Now-
gong dispensary, just about the number that Dr. Giles
commenced work on in Gauhati, only one has regular fever,
and then only a temperature of 101° or 102°F., and this has
been the kind of thing ever since the end of November,
so much so that I have found great difficulty in getting
Report on Kála-ázar.
cases on which to try the effect of various modes of treat
- m e n t s i n c h e c k i n g t h e f e v e r . I n f a c t , i f I h a d b e g u n w o r k
at this time of the year, I should probably have fallen into
the same error that Dr. Giles did in this respect. Once
more, malarial complications are more frequently present in
the apparently healthy people of the Kamrup district than
in Nowgong, and anchylostomiasis is also more common in the
former, than I have found it to be in the latter district; and here
again I have had a great advantage over Dr. Giles. Indeed,
the facts just mentioned afford the true explanation of the
very different clinical results arrived at by Dr. Giles and my
-self, and it is only fair to point out the great advantages
which I have had over him, both in my happening to begin
my clinical studies in the fever season, and still more in having
the help of all the work that has been done by the Civil
Surgeons and private practitioners of Assam during the last
six years, and especially of the knowledge of the frequent
presence of the anchylostoma worms in healthy people of
both Assam and other parts of India.
To return to the question—Is kála-ázar anchylosto
- m i a s i s ? I n r e p l y , i t m a y b e s a i d t h a t I h a v e s h o w n t h e s e
parasites to be present in sufficient numbers to complicate
the disease, as proved by their effect on the type of the
anæmia in under 7 per cent. of kála-ázar cases, while
in 83 per cent. of a series of cases taken in as early a stage as
possible, and which had not previously been treated by
thymol, there were less than 20 of the worms present—a
number which I have proved to have no effect whatever on
the blood of healthy persons in the Nowgong jail, while Dr.
Thornhill, of Ceylon, admits that 50 or less anchylostoma
form a number "altogether too small to have any deleterious
effect." It is also worthy of note that Dr. Dobson found
less than 20 anchylostoma to be present in 82 per cent.
of 547 healthy coolies, which he examined in Dhubri, which
agrees with my results in kála-ázar cases. Again, I find
an average of fewer anchylostoma on the average in a series
120
Nature of kála-ázar. 121
of 25 post-mortems on kála-ázar cases, than I do in healthy
men who have died from accidental causes, and only about a
tenth of the number that I found to be the average of my cases
of pure anchylostomiasis. Once more, in the series of 200
cases of kála-ázar on a tea garden, 96 per cent. died, although
the factor of anchylostomiasis was excluded from them by
the use of thymol in an early stage of the disease. Finally,
and most conclusive of all, I find the blood changes as
illustrated by the type of anæmia present to be quite different
in the two diseases, and the clinical details in this report are
based on a series from which all cases of anchylostomiasis
were excluded by means of this check. These facts prove
incontestably that whatever kála-ázar may be, it is not anchy-
lostomiasis, and what is more, the latter disease is not even
an essential factor in the production of the disease, and only
complicates it in some six or seven per cent. of the cases, just
as it occasionally complicates every disease in Assam, and
especially on tea gardens, and also, I have no doubt,, in nearly
e v e r y p a r t o f I n d i a .
This is the view most widely held outside Assam? Those
who hold this view, including at the present
time apparently Dr. Giles himself, look upon
the anchylostomiasis as accounting for the
spread of the disease, while the malarial complication explains
the much greater mortality of kála-ázar over that of simple an-
chylostomiasis. The facts adduced in answer to the first ques-
tion, ate sufficient to negative the present one as well; but one
or two further points may profitably be discussed in this place.
Firstly, if anchylostomiasis is to account for the spread of the
disease, it must be a constant and marked feature, such as Dr.
Giles considered it to be, while the malarial complication might
be sometimes absent. The facts are quite the reverse. Again,
has anchylostomiasis ever been known to cause a fatal epidemic
which has spread from one district to another, dying out as it
goes along (for this will be shown to have been the case with
regard to kála-ázar in a later section), and lasting without
R
Is the disease a
combination of both
anchylostomiasis and
malaria?
122
Report on Kála-ázar.
sign of cessation of its spread over a series of twenty years,
as this epidemic has, and absolutely depopulating certain
tracts of country? If anchylostomiasis could do this, then the
St. Gotthardt tunnel outbreak should have caused such an
epidemic when the infected workers dispersed to their homes
on the completion of the work, for it is recorded that hundreds
and thousands of them suffered. Was this the case? Lutz
writes:
"As for the Gotthardt tunnel epidemic, it seems to have dis
- a p p e a r e d
i n l o c o
a f t e r t h e c o m p l e t i o n o f t h e w o r k . T h e i n f e c t e d
labourers were scattered elsewhere, and afforded opportunities of
observing the disease in still wider circles; yet these do not seem to
have given rise to any fresh epidemic outside Italy."
Again, both the observations of Dr. Dobson and myself
show that the resident natives of Assam less frequently har
- b o u r t h e a n c h y l o s t o m i a w o r m s t h a n d o t h e c o o l i e s i m p o r t e d
from Bengal and other parts of India. Why then should
Assam only suffer from kála-ázar? It cannot be due to any
climatic reasons, for there is no essential difference in this
respect between Assam and Lower Bengal.
Once more, if kála-ázar is due to a combination of these
two diseases, then it would follow that the severity of the
epidemic would be in proportion to the intensity of the two
factors in any given place or district. Let us see if this is
the case. Now it is generally recognised, and this was
also Dr. Giles' own experience, that there is plenty
of anchylostomiasis in Upper Assam, at least on the
tea gardens, while I find that the recent fever mortality
of the Sibsagar and Dibrugarh districts, which have not
yet been affected by the epidemic, has been higher during
the last four years than it was in the Nowgong district before
the appearance of kála-ázar there. Allowing then for the
slight improvement of registration during recent years, it
is evident that malarial fevers are at least nearly as prevalent
in these upper districts as in Nowgong, apart from kála-ázar,
while the fever-rate of Darrang was higher than that of