NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
Clinical description of Kála-ázar.
45
as frequently in kála-ázar, as it is in healthy persons in
Nowgong; while if the size be taken into account, as, of course,
it should be, in order to obtain a correct comparison, then it
may be said that this organ is markedly enlarged in kála-ázar
15 times as often as it is in the ordinary inhabitants of Nowgong,
for the tea garden coolies who were examined lived in lines
near jungle, and with a beel close by, so that the site was
quite typical of Assam, and a large proportion of them had
suffered from malarial fever at one time or other in the course
of the last two years. The great majority of the men in jail
were Assamese.
This symptom will be only briefly discussed here, as it
will be more fully treated of in the next
section. It was present, as shown by
pallor of the conjunctiva or buccal mucous membrane, in 93
per cent, of the cases, being slight in 31 per cent. and marked
in 62 per cent. Moreover, in the cases in which the con-
junctiva was of a good colour, the hæmoglobinometer
showed distinct evidence of anæmia being actually pre-
sent, and it is worthy of note that the hæmoglobin may
in some cases be reduced by one-half without anæmia
being visible in the mucous membranes, and the use of the
instrument has proved that anæmia is really an absolutely
constant symptom of the disease. As already mentioned,
however, the conjunctiva is not always of a yellow colour, but
in very nearly one-third of the cases in which this point was
noted, it was white, and in the other two-thirds yellow. It was
more frequently yellow in those cases which showed marked
enlargement of the liver. In those cases who had not suffered
from fever for a long time, the blood improved markedly, and
this often occurred while the patient was still very weak and
thin. Such cases were very liable to be carried off by diarrhœa,
pneumonia, etc. It may also be noted here that the anæmia
was in proportion to the fever, and if fever was slight or absent
for a few weeks, an immediate improvement in the blood took
place, and, as soon as fever recurred, the blood ran down again,
Anæmia.
Report on Kála-ázar.
proving that the anæmia is directly due to the fever, and to
that alone. Moreover, if the temperature only rose to 100°F.,
or so, even if it was fairly persistent, the blood maintained
its state without gaining or losing in any degrees; but if the
temperature rose to 103° or 104°F., it rapidly became worse—
a point of practical importance. I have seen the hæmoglobin
run down, in a final fatal attack of fever, to 12 and even to
8 per cent. of Gower's standard; but such extreme anæmia is
rare in kála-ázar, although common enough in anchylos
-tomiasis.
This symptom appears either as a slight œdema of
the feet, which is of little significance,
or as well marked swelling of the
lower extremities, which may in rare cases involve the
abdominal cavity, and even the pleura and pericardium. The
slight form was present in 12.5 per cent. of the cases, and
had been present at some previous time in 19.5 per
cent. more, or altogether in about one-third, while the more
severe form was met with in 12.5 per cent., in one-third
of which it was present in the abdominal cavity. Œdema
of the face is very rare, and only occurs in the very last
stage in that class of cases in which œdema of the serous
cavities is a marked feature. This is in marked contrast
to the œdema of anchylostomiasis, which Lutz describes as
being most frequently seen in the eyelids and cheeks, and as
appearing early and giving to the patient a characteristic
look. The dropsy of kála-ázar, which always begins in the
feet, is of cardiac origin, while cirrhosis of the liver, perihep
- a t i t i s a n d p e r i p l e n i t i s , a n d p o s s i b l y , b u t I t h i n k r a r e l y ,
pressure of the enlarged abdominal organs on the inferior
vena cava may assist in its causation. In anchylostomiasis it is
due to the poverty of the blood, more especially to its low
specific gravity, as will be shown later on. A very consider
- a b l e p r o p o r t i o n o f
k á l a - á z a r
c a s e s , o v e r o n e - h a l f , g o t h r o u g h
their whole course to a fatal termination without any œdema
whatever, while it always occurs in fatal cases of anchylos-
46
Dropsy.
Clinical description of Kála-ázar.
47
tomiasis, except, perhaps, in some of the very rare so-called
acute cases.
In most of the more chronic cases of kála-ázar, the veins
on the surface of the abdominal wall become enlarged, so as
to stand out very prominently, and many of these cases also
have slight œdema of the feet or legs. This enlargement
of abdominal veins is only met with in cases where the spleen
and liver are much enlarged, and is due to the obstruction
of the portal circulation. They disappear completely in
cases of recovery, even when they have previously been well
marked.
The changes in the circulatory system are mainly dependent
on the changes produced in the heart
itself, so these will be first described. I
was mucn struck ny the small size of the heart post-mortem,
especially in the more chronic cases, but subsequently came to
the conclusion that this was, to a great extent, accounted for by
the general wasting of the whole body, although not entirely so.
Clinically, the heart is often smaller than normal, as shown by
the apex beat being usually in the fourth space, and just in
- s i d e a n d b e l o w t h e l e f t n i p p l e . T h e d i m i n u t i o n o f c a r d i a c
dulness was also common, it being very frequently limited by
the left edge of the sternum, the fourth rib, and only extend
- i n g o u t w a r d s t o a f i n g e r ' s b r e a d t h i n s i d e t h e n i p p l e l i n e . T h e
apex beat was usually invisible, and very often could not be
detected by palpation in spite of the thinness of the chest-
wall, If felt, it was usually feeble, and with a tendency to
diffuseness, which made it difficult to accurately localise it.
The heart sounds were usually seeble at the apex and over
the aortic cartilage, but the pulmonary second sound was
sometimes noted to be louder, but probably this was only
of a relative nature, except in a few cases where there
were signs of mitral regurgitation. Murmurs were of surpris
- i n g r a r e n e s s , c o n s i d e r i n g t h e m a r k e d n a t u r e o f t h e a n æ m i a ,
as they were only occasionally met with, most frequently
being heard over the pulmonary cartilage.
Circulatory system.
Venous murmurs over the neck were not uncommonly
present.
Enlargement of the heart was only met with in very chronic
cases, and in those in which mitral regurgitation was present.
The tendency to diminution of the size and power of the
heart, is no doubt due in great part to the deteriorating effect
of the prolonged fever, which produces granular degeneration
of the heart muscle (which I found in a marked degree
in the case of a man who died within a few hours of having
a temperature of 105.4°F.) followed by fatty degeneration.
The anæmia also aids in producing the fatty changes.
The dropsy of the lower extremities is a result of the cardiac
weakness. The pulse remains to be described, and it will be
noted that it is in accordance with what might be expected
from the above-described cardiac changes. Thus, the artery
is usually small in the latter stages, and the tension is nearly
always low, the high tension pulse of anæmia being quite the
exception, although it is met with in some cases where the
power of the heart is fairly well maintained, while, presumably
from the diminution of the quantity of the blood in the body,
the arteries are small, having contracted down on the blood
contained in them as it were. When there is fever, of
course, the pulse is increased in frequency, and in the last
stages, especially when dropsy has set in, it is permanently
accelerated. It is usually quite regular both in force and
frequency, unless marked fatty changes have taken place in
the heart.
The changes in the heart are of considerable diagnostic
and prognostic importance, especially in differentiating the
disease from anchylostomiasis, for in this latter affection the
heart is very commonly enlarged from dilatation, and often also
subsequent hypertrophy, and well-marked and visible palpita
-tion, is a well-known feature. Moreover, hæmic murmurs are
of very frequent occurrence, accompanied by venous murmurs
in the veins of the neck in anæmia of coolies, doubtless due
to the alterations in the specific gravity of the blood
Report on Kala-dzar.
Report on Kála-
48
Clinical description of Kála-ázar.
49
in this disease, while in the anæmia of kála-ázar, as will
be shown in detail in Section IV, the most important elements
of the blood are reduced in much more equal proportion than
they are in anchylostomiasis.
Nervous system.
The changes in the nervous system are very slight, as might
be expected in a slow-wasting disease of
this nature, for this system has been proved
to be the last to lose weight in starvation. Sensation does not
appear to be ever affected in the way it is in the true form
of beri-beri, which is met with in the Straits Settlements (but
has never been found in Assam, so that the use of this name
for anæmic conditions is incorrect), nor is the knee-jerk lost,
although it may be somewhat difficult to elicit it in the
latter stages of the disease.
The retina was examined in a good many cases in the
latter stages, and showed some changes of interest which
account for the diminution of vision, which is not unfrequently
met with, and which usually takes the form of night blindness,
or inability to see after sunset, when the light is fading, and is
accompanied by diminution of the field of vision. The change
most commonly seen was a remarkable diminution of the
size of the retinal arteries, while the veins remain of nearly full
size. This was usually most marked in those cases in which
the pulse was also noted to be small and of low tension.
The disk was also pale, and probably the retina shared this
change; but owing to the great variation in the shade in
different natives, this cannot definitely be stated to be the
case. Haemorrhages were very rarely, if ever, present, although
carefully looked for, especially in view of the fact to be presently
mentioned, that haemorrhage from the nose was frequently
noted to have occurred. Their absence seems to be partly
due to the contraction of the retinal arteries, and partly that
these vessels were found to be unaffected by the fatty degener-
ation, even in a case in which the cerebral arteries were so
affected. The anæmia of kála-ázar is moreover rarely so
great, as that seen in so-called pernicious anæmia. The
50
Report on Kála-ázar.
impairment of vision is evidently due to loss of sensibility
of the retina from diminution of its blood-supply.
There are no primary changes in the respiratory system,
with the exception of the increase of the
frequency of respiration during fever. Con-
gestion, especially of the bases of the lungs, and more
rarely actual pneumonia, usually of the lobar type, or pleurisy,
are not an unfrequent complication in the last stages, espe-
cially during the cold-weather months, and they often play
an important part in bringing about a fatal termination of
the case. Acute œdema of the lungs may rapidly cause
death in cases which are already suffering from abdominal
or pleural effusion.
The pallor and pigmentation of the mucous membrane
of the mouth, have already been described.
The appetite is reduced in two-thirds of the
cases, but there is sometimes a very remarkable desire for animal
food, which will even lead those who have never partaken of it
before, owing to caste reasons, actually to ask for it. This
appears to be due to the loss of the power of digesting vegetable
foods, as is shown by the fact that when looking for anchylostom
ova, I have frequently seen starch granules, which have passed
through the whole intestinal tract untouched. Sickness is very
rare, being only noted once, but nausea after food is more
common. Diarrhœa is very common, and was noted as having
been present at some period or other in three-fourths of the
cases. It is most commonly met with in the latter stages, when
the patient is very emaciated, and is due to either inflamma-
tion of the small intestine accompanying high fever or to the
resulting atrophy of its mucous membrane which allows of the
food passing through the intestinal canal undigested, and so
causing irritation of the bowel. It is a very bad sign if persist-
ent, such cases showing no recuperative power, even if the
fever ceases, and die of asthenia or a relapse of the fever.
They seem to have lost all power of assimilating vegetable
food, and the only chance for them is a diet of milk and animal
Respiratory system.
Digestive system.
Clinical description of Kála-ázar.
51
food, and above all, treatment by bone marrow tabloids, as will
be described further on. Constipation is uncommon, and was
only met with, to a slight degree, in 5 per cent. of the cases.
This is a very different state of affairs to that found in
anchylostomiasis, in which Dr. Sandwith noted constipation
of an obstinate nature in 6o per cent., and diarrhœa in only
28 per cent., in some of which it was due to Bilharzia ulcera
-tion in the rectum. Cancrum oris not unfrequently appears
in the later stages of the disease, and is almost invariably
fatal, although I have seen one case recover from it with
much resulting deformity.
As soon as cachexia and anæmia become marked
symptoms, sexual power and desire is lost,
and menstruation ceases. The urine
varies according as fever is present or not. In the former
case, it is scanty and high coloured, and with a fairly high
specific gravity, while in the absence of fever in advanced
cases, it is normal, or of rather a high colour (in which
respect it differs from that of anchylostomiasis, which is
light coloured), neutral or faintly acid, and of a low specific
gravity, usually from 1,006 to 1,012. A trace of albumen is
met with in a small proportion of the cases, and in a few it is
present in larger quantities, usually in the dropsical class.
Phosphates are also often present, and mucous in small
quantities. The comparatively high colour of the urine in
kála- ázar is doubtless derived from the hæmoglobin of the
red blood corpuscles, which are constantly being broken down.
This symptom must not be omitted, as apart from any
dropsy, it is very commonly met with.
It may be so marked as to lead to the
admission of the patient under the heading of rheumatism,
and is due to the porosis of the bones brought about by
the changes in the bone marrow, which will be described it
Section V. It is more common in the lower extremities, and
may be most severe in either the shafts or the ends of the
long bones.
H 2
Genito-urinary sys
-tem.
Pain in the extrem
-ities.
Report on Kála-ázar.
As the disease progresses, the appearance of the patient
becomes more and more typical, and,
although individual cases cannot be dis-
tinguished from ordinary chronic malaria, yet when several
members of a family or small village are affected by the
disease, the clinical picture is quite characteristic of
k á l a - á z a r .
T h e f e v e r r e l a p s e s a g a i n a n d a g a i n , t h e s p l e e n a n d
liver become more and more enlarged, until the abdomen
stands out in marked contrast to the emaciated face, chest-
walls, and extremities, in which the outline of every bone
is easily seen beneath the integument, which loosely covers
it, while the leaden hue of the skin contrasts with the pallor
of the mucous membranes, the feet often become swollen
with œdema, and the patient drags on a wretched existence
until a fresh attack of the fever, or less commonly diarrhœa,
congestion or inflammation of the lungs, or cancrum oris
brings him a merciful release from his miseries.
It is evident that the last stages of kála-ázar may closely
resemble those of anchylostomiasis, and especially if the
patient is seen during a prolonged remission of the fever,
which so often occurs in the cold-weather months, and if
in addition any enlargement of the spleen and liver is
regarded as an accidental feature, and the history of previous
fever is taken to mean only that the patient "had been
feeling ill for a long time," then it will not only be easy, but
quite natural, to look on the case as one of anchylostomiasis.
If, then, the ova of this parasite be found in the fæces,
and it is not recognised that they are present in from 70 to
80 per cent. of the ordinary inhabitants of Assam (and it must
be borne in mind that this fact was not known at the time
of Dr. Giles' investigation), then the diagnosis will very
naturally be considered a certain one. The fallacies in
-volved in this argument will be evident from what has
already been written, for apart from the fact that fever and
enlarged spleen are constant symptoms of true kála-ázar, it is
now obvious that in order to constitute anchylostoma a
52
Progress and ter
-
mination.
Clinical description of Kála-ázar.
53
factor in the causation of kála-ázar, it will be necessary to
show that they are present in all, or at least a great majority
of, the cases in considerably larger numbers than they
are in ordinary healthy people of the infected districts. Let
us see if this is the case or not.
In deciding whether anchylostoma play any part in the
causation of kála-ázar, it is necessary to
determine in what numbers they are
present in both healthy people and in
cases of the disease. Dr. Dobson's work has proved that
they are present, for the most part in small numbers, in over
80 per cent. of all imported coolies, and in nearly 70 per
cent. of persons resident in Assam. I have examined 50
men in the Nowgong jail in precisely the same way that
Dr. Dobson examined his cases, and found the worms present
in numbers varying from 1 to 293 in 66 per cent., but in
only two cases were over 100 found. The average number
met with in those men who were infected by this parasite,
was 18.8. Again the average number met with in 7 medico-
legal post-mortems was 32.
Thus it will be seen that, although they are very frequently
present in healthy people, they are usually found in quite
small numbers, which, in view of the opinion of all who have
had much experience of anchylostomiasis, that 500 of these
worms must be present for from six months to one year in
order to cause anæmia in a healthy person, may be expected
to be absolutely harmless in healthy well-fed people. That,
as a matter of fact, they do not cause any injury to the blood
when present in these small numbers, will be proved in the
next section. On the other hand, in 4 cases of anchylos
- t o m i a s i s e x a m i n e d
p o s t - m o r t e m ,
I found the worms to average
200.
Let us now see in what numbers they are present in
cases of kála-ázar. In 1891, Dr. Dobson found them present
in 75 out of 99 cases of this disease, but the numbers
present were not given. In his report in 1892, however, he
The frequency and
number of anchylostoma
present in kála-ázar
cases.
54
Report on Kála-ázar.
records that he found anchylostoma in 11 out of 15 cases,
the average number being 10.4.
Dr. Campbell also found them to be present in 75 per cent.
of 88 cases; but among this number he included 15 cases of
pure anchylostomiasis, and he does not give the numbers
in which they were found. Coming to my own researches,
I examined for the ova of the worms in as many cases as
possible, and to some, who were in a fair state of health,
I gave thymol, and counted the worms which were passed.
In searching for the ova, a small piece of fæces was spread
out under a cover slip, with a drop of carbolic lotion, and the
whole of the specimen carefully and systematically examined
under the microscope. I found this a much surer way of
finding the ova than that described by Dr. Giles, and by this
means I was able to detect the ova in three successive cases,
in which, after giving thymol, only 2, 14, and 8 worms,
respectively, were found, so that it is evident that if only from
ten to twenty were present, they would thus be detected.
In this way it was found that there were either no ova detected
or less than 20 anchylostoma were passed after thymol in
8 3 . 3 3 p e r c e n t . o f t h e k á l a - á z a r
c a s e s , w h i l e i n 1 6 . 6 6 p e r
cent. 50 or more were present; but in only 10 per cent. did the
blood changes show that these had affected its composition.
Again, in 25 post-mortems on kála-ázar cases, an average
of 21.48 worms were found, including three mixed cases, in
which the disease was complicated by 50, 80, and 103 worms,
respectively. Thus it appears that in the great majority of
kála-ázar cases, anchylostoma are not present in sufficiently
large numbers to affect the patient in the least degree. In
view, however, of the argument, that when the worms are
only found in such small numbers during life or after death,
they may have been present in much larger numbers at
some previous stage of the disease, which is true in excep
- t i o n a l c a s e s , i t i s d i f f i c u l t t o a b s o l u t e l y e x c l u d e t h e i r a c t i o n
in this way. A means of doing so has, however, been found
in the blood changes, as will be shown in the next section.
Clinical description of Kála-âzar.
55
T h e d e a t h - r a t e . This only remains to be discussed, and it may at once be
said that it is so high that some have
even doubted if it is ever recovered
from. The most reliable evidence has been obtained from the
study of the tea garden outbreak, in which the mortality was 96
per cent. This contrasts very markedly with the death-rate
from anchylostomiasis, which, in the 402 cases of Dr. Sand
- w i t h , w a s 8 p e r c e n t . , w h i l e L u t z l o s t 5 o u t o f 1 5 0 , 3 o f w h i c h
died from other complications, and he quotes two Italian
observers as treating 787 successive cases without a death.
Moreover, Dr. Dodds Price tells me he now very rarely
loses a coolie from anchylostomiasis. Again the great ma
- j o r i t y o f t h e t e a g a r d e n
k á l a - á z a r
c a s e s w e r e t r e a t e d w i t h
thymol in an early stage of the disease, not because they
were thought to be cases of anchylostomiasis, for they were
looked on by Dr. Price as a bad type of malarial fever, unlike
anything formerly met with in the district, but because in
view of Dr. Giles' report it was thought well to exclude pos
- s i b l e c o m p l i c a t i o n b y a n c h y l o s t o m i a s i s . T h i s s e r i e s o f c a s e s
may, therefore, be taken alone as furnishing conclusive proof
that, whatever kála-ázar may have been in the Gauhati
district in 1889, the increased mortality on this tea estate
was not due to anchylostomiasis. This mortality agrees
closely with that in villages in the Nowgong and Mangaldai
districts, where it is nearly always over 90 per cent., but I have
met with a somewhat larger proportion of recoveries among
patients treated in the Nowgong dispensary; but, on the
other hand, it must be admitted that I worked at a time when
the epidemic was subsiding, at which time, as already pointed
out, the disease is less intense, and will accordingly be less
fatal.
In cases of recovery, the first change is a prolonged
cessation of fever accompanied by a marked diminution of
the anæmia, and subsequently an improvement in nutrition,
and a reduction in the size of the spleen, which, however,
usually takes a many months to reach its normal size, but it