NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
56
Report on Kála-ázar.
certainly does do so in time in some cases. There is also a
tendency for persons who have recovered from the disease to
grow fatter than they were before their illness—a sign of the
great interference with metabolism. That more cases do not
recover is, I feel sure, due largely to the fact that, so few of
them remain under treatment long enough to allow of the
damage done by the fever to be repaired, so that when a
relapse comes, they are not in a position to meet it, and this
view will be further illustrated later in this section.
The high rate of mortality above given applies to cases in
which well-marked signs of chronic malaria have become devel
-oped, but there is good evidence to show that, when kála
-ázar is prevalent in a place, there are a greater number of
cases of apparently simple malarial fever, which are recovered
from, some of which must really be mild cases of kála-ázar.
Thus, on the tea garden, which has been mentioned as having
suffered so severely, many cases of apparently ordinary
malarial fever, which were more amenable to treatment than
typical kála-ázar cases, were met with during the early cold-
weather months, when other neighbouring gardens, which had
not been attacked by kála-ázar, had very few or no fever cases.
Some of these are nearly sure to relapse next rains and be
-come typical cases of kála-ázar, but others will probably be
protected by the slight attack against a more severe one.
ILLUSTRATIVE CASES OF KÁLA-ÁZAR.
The fulness of the previous clinical description of the
disease renders it unnecessary to record
the details of many cases, especially as Dr.
Giles gives in his report extracts of the
notes of thirty, which had been recorded by several of the Civil
Surgeons of the province, and two, which he himself diagnosed
as kála-ázar. A fairly accurate notion of the disease will, I
think, be best conveyed by brief notes of a typical group of
Illustrative cases of
kála-ázar.
Photo-etching.
Survey of India Offices,Calcutta, April 1897.
PLATE III
GROUP OF KALA AZAR CASES IN NOWGONG DISPENSARY.
Illustrative cases of Kálá-ázar.
57
cases, such as that depicted in the photograph opposite this
page, which included all the cases in the Nowgong dispensary
at the time it was taken, namely, early in August 1896. These
cases were followed up, as long as possible, usually till death put
an end to their miserable existence. It must be remembered
that the class of cases seen in a dispensary consists, for the
most part, of the more chronic type.
Case 1.—(First from the left in the group). Nankee, male,
aged 30, a native of Bhagalpur, Bengal, but has been in Assam
for the last seven years. He came to live in Nowgong in June
1895.
Family history.— He has no relatives in Assam, but one of his
companions died of kála-ázar. He began
History of illness. to suffer from fever in December last, at
first every day, and with a few days' remission now-and-then
it lasted up to the time of his admission on 28th April 1896.
He had some hæmorrhage from the nose last December ; has
never taken opium, and takes very little alcohol. Diet good.
(Notes taken on June 2nd, 1896).— He is thinner than he
u s e d t o b e ; c o n j u n c t i v a p a l e a n d s l i g h t l y
Present condition. yellow, but the vessels are still visible;
mucous membrane of the mouth pale; palate pigmented;
vision good; retinæ normal; sensation normal; no pains in
limbs; appetite not good; bowels irregular; has never
suffered from sickness. Temperature 104.8°F . at 8 a.m.
During May it had been normal, except in the last week, when
it varied between 101° and 102°. Pulse 128 a minute; artery
full, but very soft. Heart dulness normal ; apex beat feeble;
loud systolic murmur at the pulmonary cartilage, and a soft
one at the apex. Lungs normal. Liver dulness extends from
the fifth rib to the costal margin; its edge can be felt, and is
rather hard. Spleen extends to one finger's breadth below the
navel and to the middle line; over its upper anterior border is a
prominent rounded swelling, which is well seen in the photo
- g r a p h , a n d w h i c h I t h o u g h t m i g h t b e a n a b s c e s s i n t h e o r g a n .
No dropsy of abdomen; legs, or face. Urine :—sp. gr. 1,006 ;
1
58
Report on Kála-ázar.
colour dark straw; no albumen; a little phosphates; reaction
neutral. Thymol had been given, but no worms were found,
and, on examination under the microscope, no ova of anchylos-
toma, or of other worms, were seen, but some undigested
starch granules were detected. The plasmodia malaria
were found in his blood, taken when his temperature was high.
Examination on June 2nd showed hæmoglobin 30 per cent.,
red corpuscles 2,240,000 per cubic millimetre; white cor-
puscles 1,000 per cubic millimetre, or 1 to 2,240 red, and the
hæmoglobin value, or amount of hæmoglobin in each red cor-
puscle, as compared with the normal, which is taken as being
unity, was 67.
Subsequent course
of the case.
His temperature continued to vary between normal and
105°F. in a very irregular way until June
27th, when it became normal for a week.
On July 1st, he was noticed to be more anæmic, and
his feet were swollen. At this date his hæmoglobin was
found to be only 22 per cent., and his red corpuscles
numbered 1,700,000, showing a considerable decrease since
the last examination. During the next fortnight, there was
very little fever, the temperature having only twice ran up to
101°F., and on the 20th of July, the hæmoglobin was 32 per
cent., and the red corpuscles 2,770,000—a decided increase in
correspondence with the decrease of the fever. He again
relapsed, the temperature frequently running up to 103°F., and
he got steadily worse, and his feet became swollen. The
swelling over the spleen increased in size, and became very
painful, so on August the I2th, I passed the middle of an aspi-
rating syringe into the prominence, but did not obtain any
pus. The blood was used to inoculate some agar agar tubes
kindly supplied me by Professor D. D. Cunningham, but with
negative results. He died of fever on the 9th of September.
Treatment.
In this and the following cases, except where otherwise
stated, the treatment was carried on by the
civil hospital authorities, as I desired to
study the disease and to see the effects of the ordinary treat-
Illustrative cases of Kála-ázar.
59
ment in which I seldom interfered in the earlier stages of my
investigation, although I wish to acknowledge that I am much
indebted to the Civil Medical Officer of Nowgong, Mr.
McNaught, for kindly allowing me a perfectly free hand in
trying any treatment I might desire. Unfortunately, my fre-
quent and prolonged absence on tour prevented me from
doing much in this line. In this case quinine in small doses,
usually combined with arsenic, was the chief medicine given.
Body much wasted. Feet and legs œdematous. Pericar-
dium contained 31/2 oz. of clear fluid.
Heart weighed 6 oz. 3 drm. Heart muscle
somewhat pale, and showed signs of fatty degeneration.
Cavities and valves normal. Left pleural cavity con-
tained 3 oz. of fluid, and the right 1 oz. Both lungs were
emphysematous at the edges, and congested and œde-
matous at the bases. The abdominal cavity contained 64 oz.
of fluid. Stomach normal; duodenum normal, and without any
anchylostoma; small intestine contained 8 anchylostoma, but
its mucous membrane was normal in appearance, and present-
ed no signs of cicatrices or of pigmentation. Mesenteric
glands normal; large intestine showed a patch of congestion
of the mucous membrane; liver weighed 3 lbs. 111/2 oz,; its
capsule was adherent to the neighbouring organs and to the
parietal peritoneum; on section it showed red and white mottled
patches, mostly near the surface, and it was easily broken down
on pressure. Spleen weighed 3 lbs. 6 oz.; on its anterior bor-
der was a rounded swelling, which, on section, was found to be
similar to the rest of the organ, which was of a dark-red colour,
and broke down easily on pressure; no mark of the puncture
was seen, but a little above where this must have passed was
a thick band of adhesion binding the organ to the parietal
peritoneum. Kidneys normal; weights 4 oz. and 31/2 oz.,
respectively; suprarenal capsules normal; brain normal; pia-
mater under medulla oblongata pigmented. Bone marrow of
the shaft of the femur was of a dusky-red colour, and softer
I 2
Post-mortem exami-
nation.
60
Report on Kála-ázar.
than normal. Sections of the liver, spleen and kidneys showed
well marked pigmentation under the microscope.
This is a typical case of the disease, and illustrates very
well the dependence of the anæmia on the
fever, and the absence of more than a very
few anchylostoma from an early period of the illness. The
fluid in the abdomen was evidently of an inflammatory nature,
and the simulation of abscess of the spleen caused by an
irregular swelling of the organ accompanied by pain due to
perisplenitis is noteworthy. The demonstration of the malarial
organism during life, and of pigmentation of the liver, etc.,
after death, completes the proof of the malarial nature of the
disease from start to finish.
Case 2.—(Fourth from the left in the group). Nandi Keot,
female, aged 22, Assamese, lives in Nowgong.
She has lost 11 near relatives in the last three years from
kála-ázar, including six brothers, and
has only five now living, one of whom
has the disease.
She first got fever in November 1894; it began with
shivering, and came on daily for twelve
days. She came to the hospital, and
stopped one month. She has had fever on and off since that
time: some three or four attacks in all. She was free of fever
for a month up to shortly before her re-admission on July
2 1st, 1896, with a relapse.
Her arms and face are rather thin; no dropsy; conjunctiva
very pale and yellow; palate shows well
marked pigmentation. Vision good;
retinal arteries rather small, and retinæ pale, but no hæmor
- r h a g e s i n t h e m . T e m p e r a t u r e 1 0 2 . 4°F . ; p u l s e o f l o w t e n s i o n .
Heart normal, and no hæmic murmur in the neck. Appetite
fair when she has no fever; bowels rather constipated; liver
not enlarged. Spleen extends to the level of the navel and
to the middle line, not very hard. Lungs normal.
Remarks.
Examined on: Family
history.
History of illness.
Condition on re-admis
-sion.
Illustrative cases of Kála-ázar.
Hæmoglobin 24 per cent., red corpuscles 2,390,000, and
white corpuscles 1,500 per cubic milli
-metre, or 1 white to 1,593 red;
globin value .50.
The fever continued to be of an irregularly intermittent
type, and at one time was tertian in its
character for eight days, until the 25th
of August, when there was a remission for a fortnight, which
was accompanied by a temporary improvement in the con
- d i t i o n o f t h e b l o o d , b u t t h i s w a s f o l l o w e d b y a n o t h e r r e l a p s e ,
which passed into a remittent form of fever, ending fatally on
September 18th. On August 7th, the liver was found to
extend to three fingers' breadth below the ribs, and on Sep
- t e m b e r 5 t h , t h e p a t i e n t w a s f o u n d t o w e i g h o n l y 7 0 l b s .
During the last month she suffered on and off from diar
- r h œ a , s o m e t i m e s o f a d y s e n t e r i c n a t u r e , w h i c h , a s I h a v e
noticed in some other cases, was worst when the fever stopped
for a few days.
She was given arsenic and iron tonics and quinine
usually in five-grain doses twice a day,
and latterly various drugs were tried for
the diarrhœa with very little success.
Body emaciated. Heart weighed 6 oz.; structure normal.
Lungs congested at the bases. Stomach
contained three round worms, otherwise
normal. Small intestine contained one anchylostomum in the
jejunum. The cæcum Contained numerous trichocephali, and
there were 18 round worms in the colon. Liver weighed 4
lbs. 2 oz., was firm, and on section was of red colour mottled
with yellow. Spleen weighed 3 lbs.; on section was hard.
Bone marrow of shaft of femur darkish-red in colour.
Here, again, the dependence of the disease on the fever
is very evident, but probably the first
attack noted in November 1894 was
one of ordinary malarial fever, and the fatal disease began
later. While in hospital, with the exception of a fortnight's
Blood examination.
Progress of the case.
Treatment.
Post-mortem.
Remarks.
Report on Kála-ázar.
remission, the fever was constant, and the small doses of qui
- n i n e w h i c h w e r e g i v e n h a d v e r y l i t t l e , i f a n y , e f f e c t o n i t . T h e
attack of diarrhœa doubtless hastened her death.
Case.3 —(The small child in the middle of the photo
-graph). Sonalie Kachari, female, aged 5.
Father, mother, and a brother died of kála-ázar; and as
she has no relatives to look after her, she
came into hospital.
She has been suffering from fever with enlargement of
the spleen for six months.
Is much emaciated; appetite fair; bowels inclined to be
loose; spleen reaches three fingers'
breadth below the ribs and nearly to the
middle line.
Hæmoglobin 24 per cent., red corpuscles 2,060,000, and
white 2,250, per cubic millimetre, or 1 to
916 red; hæmoglobin value .58.
She continued to get fever of an irregularly remittent type,
usually rising in the evening to between
100º and 102° F., but occasionally running
up to nearly 104°F., which continued up to the time of her
death on September 20th.
Treatment given was a mixture of arsenic, nux vomica,
and quassia, and during a part of the time
quinine in two-grain doses twice a day.
Body much emaciated, and the feet œdematous. Pericar-
dium contained 6 drms. of clear fluid;
heart and lungs normal. Peritoneum con
-tained 6 oz. of clear fluid. Stomach normal. Small intes
-tine contained 15 anchylostoma and 20 round worms. (Santo
-nin had been given on admission, but not thymol, owing to her
bad condition.) In the large intestines, there were several
ulcerations. Liver weighed 12½ oz. The spleen weighed
4 oz., and was hard and dark red. There was some fluid in
the ventricles of the brain, and the bone marrow was dark red.
62
Family history.
History of illness.
Present condition.
Blood examination.
Progress of the case.
Treatment.
Post-mortem.
I l l u s t r a t i v e c a s e s o f K á l a - á z a r .
This child was in an almost hopeless condition on admis-
sion, and it is extraordinary that she lived
as long as she did. Fever of a persistent
type was again the marked feature of the case and the cause of
death. Thymol would only have removed the small number
of worms present in this case, at the cost of setting up a
rapidly fatal diarrhœa.
The three patients on the right of the photograph form a
characteristic family group, the man and the woman being
the father and mother, respectively, of the baby, who is the
youngest case of the disease that I have met with, being
only one year old, and was still at the breast, although other
food was given to him. They are also of interest, as showing
how patients, who appear to be doing fairly well, often get
fatal lung affections at the onset of the cold weather. Brief
notes only need be given of them.
Case 4. —(The man on the right of the group). Patua,
male, aged 42, Kachari, admitted to hospital 4th August.
His brother and one daughter have died of
kála-ázar ; no near relative now living is
free from the disease.
Two years ago he had fever for five months, but has had
very little for the last year; he still gets
it every now-and-then, but has none
at present. He is slightly anæmic only, and is fairly well
nourished. He has no dropsy, but had suffered from both it
and epistaxis formerly, and is now in every way much
better than he has been. Heart normal. Spleen extends to
one finger above the navel, and three to the right of the
middle line. Liver reaches to one finger's breadth above
the navel, and is hard. Bowels irregular and inclined to be
loose. He took opium for one month after he got ill in the
hope of its stopping the fever, but without any result. Hæmo-
globin 38 per cent., and red corpuscles 2,820,000, white cor-
puscles 4,000, or 1 to 705 red, sp. gr. of the blood 1.057;
hemoglobin value .67. Thymol was given, and several round
63
Remarks.
Family history.
History of illness.
64
Report on Kála-ázar.
worms were passed, but no anchylostoma could be found after
washing the stool, etc. He remained free from fever, and
seemed on the high road to recovery, until on the 1st of
October, he got an attack of pneumonia, and died in three
days.
Body stout; no œdema. Heart normal, but right side
distended with blood. The upper half of
the left lung was consolidated, and sank in
water; the pleura over it was adherent to the chest wall.
Stomach and duodenum normal; jejunum and ilium were
pigmented, no worms of any sort present. Liver weighed 6 lbs.
15 oz., and the spleen 2 lbs. 13 oz.; both organs harder than
normal. Bone marrow of shaft of femur was of a yellowish-
red colour.
This man I regarded as nearly recovered when he came to
hospital; and if he had escaped the lung
complications of the early cold weather,
would have probably got quite well, so that his case illustrates
the necessity of caution in saying that a given case is cured,
and it is, for this reason, that the tea garden series are
of such value in proving the very high death-rate of the disease,
for they were under continuous observation for years.
Case 5.—Kundari, female, aged 23, wife of Case 4.
(Second from the right in the photo.) Admitted to hospital
on August 4th, 1896.
Same as Case 4.
She began to get fever nine months ago, which continued
for three months; but after one month her
spleen was enlarged. After this she had
a remission for a time, but it came on again in the rainy
season, and has continued on and off ever since. Bowels
somewhat loose. She is anæmic; her spleen extends to the
level of the anterior superior spine of the ilium, and two fingers'
breadth to the right of the middle line, and the liver from the
level of the fifth rib to four fingers below the costal margin,
Post-mortem.
Remarks.
Family history.
History of illness.
I l l u s t r a t i v e c a s e s o f K á l a - á z a r .
both organs being hard. There is no dropsy, and she has
never had any; she suffers from pain in the legs, mostly along
the shafts of the tibia and femur. No enlargement of the
surface veins of the abdomen.
Hæmoglobin 25 per cent., red corpuscles 1,750,000, white
2, 000, or 1 t o 875 r ed, sp. gr . 1. 051;
hæmoglobin value °71.
During the whole of August and the first half of September,
she had only slight fever running up to
between 100° and 101°F., and was treated
with tonics and quinine in from 3 to 6-grain doses. During
the last part of September and the first week of October, she
had high remittent fever running up to over 104°F., and accom-
panied by diarrhœa, which weakened her very much, and
shortly after she developed pneumonia, which went on to
gangrene of the lung, and terminated fatally on October 18th.
During the latter period quinine in 10-grain doses was given,
while various remedies were tried to control the diarrhœa
with very little effect. The external application of creasote
seems to have had most effect in reducing the fever in this
case.
Body much emaciated; no œdema present. Pericardium
contained 4 oz. of clear fluid; heart nor-
mal; upper lobe of left lung gangrenous;
lower lobe congested; right lung healthy; stomach normal;
small intestine contained 10 anchylostoma and 2 round worms;
its mucous membrane was thin, and in places congested, but
not pigmented; large intestine thickened and congested,
but without any ulceration; liver weighed 3½ lbs., and was
hard on section; spleen weighed 1 lb., dark red, hard on sec
- t i o n ; b o n e m a r r o w r e d d i s h - y e l l o w i n c o l o u r .
This woman, in spite of the great size of her liver and
spleen, did not appear to be by any
means a hopeless case when she came
into hospital, and did well for the first six weeks until the
fever relapsed; and in the course of a month's high fever and
65
Blood examination.
Progress of the case.
Post-mortem.
Remarks.
66
Report on kála-ázar.
diarrhœa, she rapidly became very emaciated, and died from
lung complications. The comparatively small weight of the
spleen and liver found on post-mortem, was due to a rapid
reduction in their size, which took place during the time she
suffered from diarrhœa, as I have also seen happen in other
cases.
Case 6.—Aghonu, aged 1 year, son of cases 4 and 5.
He began to get fever three months ago, and has had it on
and off ever since up to the time of his admission. Rather
thin, and anæmic. Spleen extends to the level of the navel
and to the middle line, and the liver nearly to the level of the
navel. Bowels loose; temperature 102.4°F. Santonin was
given, and seven round worms, but no anchylostoma, were
passed. The malarial organisms were found in his blood
when he had fever.
Progress of the case.
During most of August, low fever continued on and off; but
in September, except for one week, when
it was of a remittent type, it was absent;
and during October there was no fever, but a slightly subnor
- m a l t e m p e r a t u r e w a s r e c o r d e d , t h e c h i l d b e i n g m u c h b e t t e r .
This improvement followed the use of quinine in three-grain
doses three times a day, which is a large dose for an infant.
Late in October, when the child had much improved, he was
attacked by cholera, with a fatal result on October 29th. No
post-mortem was done.
This is the youngest case of the disease that I have met
with, although it is not at all uncommon in children under 10
years old. The use of relatively large doses of quinine was
very beneficial in this case, and, but for the cholera, might
have saved the child's life.
Case 7. —(Second man from the left in the group). Ba
- d a l , m a l e , a g e d 2 5 , l i v e s a t J a u m p u r , a n d h a s o n l y b e e n i n
Assam four months, three of which he spent in Gauhati and
one in Nowgong. He has no relations in Assam. He had
an attack of fever on the way up to Assam; and soon after
he reached Gauhati, he began to get fever every other day
,
Illustrative cases of Kála-ázar.
67
which went on for two months, by which time his spleen was
enlarged. He was admitted on May 29th, at which time he
was getting fever daily.
He is thin and wasted, and says he is darker than he used
to be; conjunctiva yellow, but not pale;
buccal mucous membrane also of a good
colour; no œdema; had epistaxis about two months ago;
has had pain over his spleen for the last five days; heart
sounds feeble. Spleen extends to level of the navel, and is
hard; liver edge can be felt one finger's breadth below the
right costal margin. Retina normal. No anchylostoma ova
could be found in his fæces. Over the base of the left lung
there was dulness, and crepitations could be heard. This was
the beginning of an attack of pneumonia, which began on
June 3rd, but he got over it, and from this time he lost his
fever, and during the three months he subsequently stayed
in hospital, he steadily improved, and his blood, which showed
5o per cent. of hæmoglobin and .57 per cent. of red corpus-
cles, also improved with his general condition, while both his
spleen and liver became reduced in size, and he left the
hospital fat, and well in the middle of September. I have
also seen another case, who lost all fever and steadily im-
proved in the same way, after getting over an attack of
pneumonia. The malarial organisms were found in his blood
during fever.
Case 8. —(Third from the left in the group). Khalai, male,
aged 22. His father, mother, and an uncle died of kála-ázar,
and he has no near relatives left alive. Has had fever for
five months, and is thin and anæmic, but has never had any
dropsy; bowels regular; spleen extends to the level of navel
and one finger beyond the middle line, and the liver can just
be felt below the ribs; heart sounds feeble; lungs normal; has
pain in the legs.
Condition on admission.
Hæmoglobin 40 per cent., red cor
-puscles 2,900,000, sp. gr. 1.045; hæmo
- globin value .69.
K 2
Blood examination.