NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
68
Report on Kála-ázar.
Progress of the case.
Thymol was given, and nine anchylostoma were passed.
He had a short attack of remittent fever
just after his admission, that is, in the
middle of June, and another with high fever, accompanied by
looseness of the bowels, a month later. During the first half
of August, he again had high and nearly constant fever run
-ning up to 100º and 105°F. Up to this time he had been
taking an arsenic mixture, with quinine in two to four-grain
doses, with an occasional ten-grain dose. He was now put
on larger doses, namely, to to 15 grains, two or three times a
day, and subsequently he only had slight fever up to 100° or
101°F., with intervals of a week or two free from fever. He a
improved a good deal during this time, and left the hospital
on October 10th, much better, but still getting fever every
now-and-then. He cannot be considered cured, but if he
escapes lung complications, he will probably recover his health
during the cold weather.
The two girls to the right of the central child in the
group, are of great interest from the point of view of
treatment by bone marrow tabloids, for, if the result obtained
in one of them is confirmed by subsequent experience, this
will be of the greatest value in saving chronic cases, who have
to a great extent lost their fever, but remain in a wasted
condition in spite of nourishing diet until they succumb to
lung and bowel complications.
Case 9.—(Third adult from the right in the group).
Maharsani, female, aged 15, admitted July 28th.
Family history.
Her father, mother, and two brothers died of kála-ázar,
and she has only one brother and two
sisters living.
History of illness.
•
She has had fever on and off for one
year.
Present condition.
She is weak and very emaciated; no dropsy; the spleen
extends to one finger's breadth below
the navel, and nearly to the middle line,
and the liver to four fingers below the ribs, and its edge is
Illustrative cases of Kála-ázar.
69
hard. Conjunctiva pale and slightly yellow. There is a
pulmonary systolic murmur to be heard over the third right
costal cartilage, but no venous hum in the neck. Bowels
regular.
Blood examination.
On August 13th, hæmoglobin 37 per cent., red corpuscles
3,010,000, white 2,000, or 1 to 1,505 red,
sp. gr. 10.52; hæmoglobin value .6
1. Santonin was given, and some round worms only were passed.
The progress of the
case.
From the beginning of August to the 11th of September,
there was almost daily intermittent fever
rising to 100° or 102°F. From this date
she had a remission of three weeks, during which bone
marrow tabloids, one twice a day, were given. Her weight
was 68½ lbs. at the beginning of this treatment, and the
same after three weeks, so that no change had resulted. A
relapse of the fever now occurred, and the tabloids were left
off. She had been taking arsenic and small doses of quinine
when not taking the tabloids. As I was away on tour at this
time, I was not able to record the effect on the blood of the treat
- m e n t . E a r l y i n O c t o b e r , s h e h a d a s h o r t a t t a c k o f r e m i t t e n t
fever, and quinine was now given in 10-grain does three times
a day, and in two weeks she was free of fever, but was now
very emaciated and reduced to 60 lbs. in weight. She was
now given tabloids again for a short time, and began to improve,
and remaining free of fever, became fat and well nourished, In
February 1897, however, she got an attack of pneumonia and
died rather suddenly with cyanosis. Here again, but for the
lung complication, I feel sure she would have recovered,
and that she would have owed this to the larger doses
of quinine, and I think, also in some degree, to the bone
marrow treatment, although its results were not so striking
in this case as in the next one.
Post-mortem.
Body very well nourished, with a good layer of sub
-
cutaneous fat. The heart weighed 7 oz.,
and the right side of it was distended
with blood. The base of the right lung was in a state
70
Report on Kála- ázar.
of red hepatisation, and was loosely adherent to the
pleura. The base of the left lung was congested. The
s pl een wei ghed 1 l b. 6 oz. , and was r at her har d on s ect i on.
The liver weighed 6 lbs. 2 oz., and was of a yellow colour,
showing marked fatty changes. The mucous membrane of
the stomach was thick and corrugated, but the small intes
- t i n e w a s n o r m a l , a n d c o n t a i n e d o n l y t w o r o u n d w o r m s , a n d
no anchylostoma. The bone marrow was of a light-red
colour, lighter than I have usually found it in cases dying in
the stage of cachexia.
This case well shows from what a very bad condition
these cases may sometimes greatly im-
prove if the fever only ceases, and yet
eventually succumb to complications.
Case 10.—(The girl on the right of the central child).
Alagae, female, aged 17, admitted May 14th.
Father, mother, one sister, and two young brothers died in
one house of k á l a - á z a r
o n e s i s t e r o n l y
living.
She has been ill for one year, and was in hospital in March
and April 1896. Illness began with fever
of an irregular type, which has continued
with longer or shorter remissions ever since. She has never
had any œdema of the feet or face, but her menses have
stopped since she had fever.
She is very thin, especially in the arms and face, and
her face is very dark. Her conjunctivæ
and buccal mucous membrane are pale,
and the former also yellow. Vision good, but the arteries
of the retina are very small, but no hæmorrhages could
be seen. Heart and lungs normal. Spleen extends to
the level of the anterior superior spine of the ilium, and
is rather tender, and the liver extends from the level of
the fifth rib to two fingers' breadth below the costal
margin, and is rather hard. Urine light straw colour, sp. gr.
1,010;no albumen or phosphates. No ova of any intestinal
Remarks.
Family history.
History of illness.
Condition on re-ad
-mission.
1
Illustrative cases of Kála-ázar.
71
worms could be found in the fæces, but particles of undigested
starch were seen.
Hemoglobin 28 per cent., red corpuscles 2,180,000, white
2,33o, or 1 to 948 red; hæmoglobin value
Blood examination. 64.
On May 17th, her temperature rose to 1o4.6,° but from
this date she was free from fever until the
Progress of the case. beginning of July, and the condition of her
blood steadily improved, the percentage of hæmoglobin rising
to 33 on June 9th, and 36 on July 1 st, and the size of the spleen
and liver had also become somewhat reduced. During the
whole of the first week in July, she had high fever of an irre
- g u l a r l y i n t e r m i t t e n t t y p e , r u n n i n g u p t o 1 0 4° a n d 1 0 5°F . , a n d
accompanied by slight looseness of the bowels, after which only
slight fever was present, but on July 17th, her hæmoglobin
was found to have become reduced to 26 per cent. From this
time on, she only had an occasional rise of temperature to 100°o
r 102°F. On July 2oth, her blood was as follows: Hæmo-
globin 27 per cent., red corpuscles 2,370,000, white 2,500, or
1 t o 1 , 2 6 o r e d ; h æ m o g l o b i n v a l u e . 5 7 . O n J u l y 1 8 t h , s h e w a s
put on two bone marrow tabloids every day, and this was con-
tinued with only three days' intermission until October 22nd,
except that during three weeks of the time she only took one
tabloid a day. The photo in which she is shown was taken
soon after this treatment was commenced, and she was then
extremely weak and emaciated, so much so that I looked on
the treatment rather in the nature of a forlorn hope, especially
as she had already been in hospital for over two months with
-out any benefit, but rather the reverse. Three weeks later on
my return from a tour, I was surprised to find her much better.
She was distinctly less emaciated, and, on examining her blood
on August 11th, it was as follows: Hæmoglobin 31 per cent.,
red corpuscles 2,330,000, white 3,75o, or 1 to 620 red,
s p . g r . 1 . 0 4 8 ; h æmo g l o b i n v a l u e . 6 7 . No w I h a v e s e e n q u i t e
as great an improvement in the blood in as short a time from
treatment with arsenic, etc., and, although I had given the
Report on Kála-ázar.
bone marrow in the hope of producing a more rapid improve-
ment in the blood than by other means, it was the general
improvement in the state of the patient that was its most
marked effect, together with an increased appetite and power
of digesting and absorbing food. On September 7th she
was fat compared to what she had been, while her spleen
now only reached to just below the navel, and her liver
could not be felt. The blood on this date was hæmoglobin
38 per cent., red corpuscles 2,900,000, white 5,500, or
1 to 527 red; hæmoglobin value .66. On September 14th, she
weighed 77½ lbs., but a month later she had improved up to
90lbs. She continued to gain weight after the tabloids were
left off, but somewhat more slowly, and was discharged cured
on November 11th, and is now quite well, and has married.
This is by far the worst case in which I have seen
recovery take place, and the rapidity
with which marked improvement in nu-
trition occurred was in striking contrast to anything I have
witnessed in other cases, for, as I have before remarked, a
characteristic feature of the disease is the way in which the
patients remain in an emaciated state long after the fever has
left them, and the frequency with which such cases fall a
victim to lung and bowel complications. Unfortunately I
could not continue my trials of this treatment owing to all
the tabloids I could get in India having been exhausted; but
Dr. Dodds Price and Dr. Lavertine are now using it in the
treatment of kála-ázar cases, and are so far well satisfied
with its effects, and we may hope to hear shortly if my results
are confirmed or not. The only explanation that I can
think of to account for the improvement of nutrition from
the use of bone marrow tabloids, is one which assumes that
the yellow marrow in the shafts of long bones has the func
- t i o n o f s e c r e t i n g s o m e s u b s t a n c e , w h i c h a f f e c t s t h e d i g e s t i v e
powers and nutrition in a somewhat similar way to the action
of the internal secretions of the thyroid or suprarenal capsules,
and that the changes found in the bone marrow in
72
Remarks.
RECORD OF TEMPERATURE.
Name—Kamar Lalong. Age-22—years. Disease—"Kála-ázar." Date of admission—16th April 1896, Result—Died. Date of death—14th July 1896.
Illustrative cases of
kála-ázar. kála-ázar cause a loss of this secretion, the place of which is,
however, supplied by the bone marrow tabloids. The relation
of the deterioration and improvement in the blood to the
presence or absence of fever, is again well illustrated in this
case, while the family history is characteristic.
The following case, with the accompanying temperature
chart, illustrates very well the extreme irregularity of the
type of fever in kála-ázar:
Case II .—Kamar Lalong, Kachari, aged 22, was a cul
-tivator who lived 14 miles from Nowgong.
He has lost his father, mother, and brother of the disease,
and has no near relatives living. He
came into jail on October 8th, 1895, but
had suffered from fever before that time. While in jail he was
in hospital for one week at the end of January with fever, and
on April 16th, was re-admitted for the same disease, and has
had fever on and off since that time up to the 25th of May,
when I examined him, and he continued to suffer from fever up
to the day of his death on July i4th, as shown in the chart.
This attack, while he was in jail, was most likely a relapse of
the fever from which he had suffered before admission, but
it must be mentioned that there were two other cases of
kála-ázar in the jail hospital at the same time that he was
there.
His condition on May 25th was as follows:—He is some
- w h a t w a s t e d i n a p p e a r a n c e a n d d a r k i n c o l o u r . H e s a y s h e
is darker than he used to be. Heart dulness is diminished;
arteries small and pulse feeble. No dropsy. Spleen extends
to just above the navel, but the liver dulness is normal.
Appetite fair, and bowels regular.
Hæmoglobin 43 per cent., red corpuscles 2,700,000. Ma-
larial organisms were found in his blood
this day. An ovum of the anchylosto-
mum was found in his fæces after a long search, but on giving
thymol, only two of the worms were passed. He had never
had thymol before.
73
Family history.
Blood examination.
L
Report on Kála-ázar
Quinine and arsenic in small doses, with occasional single
doses of from ten to twenty grains of
quinine, or of five grains of antifebrin,
were given, but the fever continued; his hæmoglobin ran down
to 26 per cent., and his white corpuscles to 1 to 1,750 red;
the liver became enlarged until it reached to two fingers'
breadth below the ribs; the malarial organisms were again
found in his blood on June 8th, and also when his temperature
was high on the day before his death, which was due solely to
the fever, and post-mortem pigmentation of the liver, spleen,
and kidneys was detected under the microscope, so that it is
clear that the case was one of malarial fever from first to last.
One more case will be given, which came under my treat
-ment in the earliest possible stage, and which illustrates in a
nutshell the pathology of the disease and the proper line of
treatment
:
Case 12.—Kondor, male, aged 11, but looking only 8 or 9,
was brought to me by his father, a Babu holding a high position
in the Education Department, who said that he had lost 39
relatives of kála-ázar within the last six years, including five
this year. This son had only suffered from fever for the last
four days, and showed none of the signs of malarial cachexia.
His spleen was normal, and his liver was just felt below the
edge of the ribs, and was tender; temperature 103°F., pulse
118, and respirations 30 a minute. Lungs normal. His blood
was examined, and he was found to have 61 per cent. of
hæmoglobin, and 4,030,000 red corpuscles, and 23,000 white
corpuscles per cubic millimetre, or 1 white to 174 red.
Hæmoglobin value 76. From this it is evident that his blood
was just about the standard, which I have found in healthy
natives of Assam in the rainy season, while the great excess
of white corpuscles is evidence of very active leucocytosis,
such as is always met with in early acute cases of malarial
fever, but never in the chronic stage of kála-ázar. It is
evident then that his father's statement, that he had only
suffered from fever for a few days, was confirmed by the state
74
Progress of the case.
Illustrative cases of kála-ásar.
75
of the blood. The malarial organisms were also found in
a specimen taken on this date.
I ordered quinine to be given in five-grain doses three times
a day, and I saw the boy again on July
15th. Meanwhile a thermometer had been
obtained, and his temperature recorded by his father every
few hours. On working out a chart from this, it appeared
that the fever was of an extremely irregular remittent type,
such as is so very common in the earlier stages of kála-ázar.
Moreover, the temperature had only once risen to 103°F., and on
this day the father said that he had omitted the quinine for
the first time. It was then evident that the drug had served
to keep the temperature lower than it was when it was
not being taken, yet had not sufficed to stop the fever. It was,
therefore, increased to 20 grains in the day—a consider
-able dose for so small a boy—and three days later the fever
stopped. I saw the boy for the third time on July 25th, and
he had now been free from fever for a week after having
suffered from it for just over two weeks. To all appearances,
he was perfectly well, and his father regarded him as being so.
He had no enlargement of the spleen or liver, nor did he show
the smallest trace of anæmia in his mucous membranes. To
look at the boy, one would suppose he was none the worse for
the fortnight's fever from which he had suffered, yet on re
-examining his blood on this date, it was found that his hæmo
-globin had become reduced to 46 per cent.—a loss of just one
quarter in three weeks. It was then obvious that if this boy
left off all treatment, and in the course of a few weeks got a
relapse of the fever before his blood had again reached the
normal, he would rapidly lose another quarter of his hæmo
-globin, would develope an enlarged spleen and liver and
anæmia, and would become a typical case of kála-ázar. On
the other hand, I argued, if only the fever could be kept off
until his blood had been fully repaired, a second attack treated
in the same way should leave him no worse than he was after
the first. I therefore got him to take a mixture containing
L2
Progress of the case.
small doses of quinine, combined with arsenic, nux vomica, and
quassia, and he continued this for six weeks, by which time I
found his hæmoglobin had improved up to 59 per cent. He
had no fever in the meantime, and he has been under my
observation now and then up to the end of February 1897,
and was then still quite well.
Now it is unfortunately impossible to prove that this was
really an early case of kála-ázar, but
from the strong family history, the irre-
gularly remittent character of the fever, its resistance to
ordinary doses of quinine, and the rapidity with which the
blood was destroyed by it, I feel morally certain that it was
so, and that the boy was saved from a lingering and almost
certainly fatal illness by the prompt, vigorous and continuous
line of treatment adopted.
THE TREATMENT OF KÁLA-ÁZAR.
It has already been mentioned that I have had very little
opportunity for systematic treatment of kála-ázar cases,
especially after I had obtained definite proof of its mala
- r i a l n a t u r e , s o t h a t m u c h o f w h a t f o l l o w s i s r a t h e r o f t h e
nature of suggestions for treatment than dogmatic rules re
-garding it. It is also evident from the fact that the disease
is entirely malarial in its nature, that no new cure for it could
be expected to be discovered, but the recognition of this fact,
and more still of its extreme intensity and resistance to ordi
-nary doses of anti-malarious remedies, is of the first importance
in deciding on the therapeutical measures, which are likely to
afford the best results. Some information of interest and
practical importance has, however, been obtained from the
experience of those who have recently treated many cases
throughout their long illnesses on some of the tea gardens of
Nowgong, and from my own more limited observations.
It will be not only convenient, but necessary, to divide the
disease up into early and late stages in discussing the
t r e a t me n t ; t h e l a t t e r i n c l u d i n g a l l c a s e s w h i c h h a v e d e v e l o p e d
76
Remarks.
Treatment of Kála-ázar.
77
such symptoms of malarial cachexia as greatly enlarged spleens
and livers, and together with emaciation, loss of digestive
power, and irregularity of the bowels; while the former includes
cases of early fever before they have reached this stage. It
may be at once objected that the early class of cases are not
distinguishable from ordinary malarial fever, and, individually
considered, this is quite true. It has been shown earlier in the
present section that, wherever ká la-ázar is prevalent, there
will be an excess of cases of apparently ordinary fever, some
of which will really be early cases of true kála-ázar. It is
just in this stage that efficient treatment may have a chance
of curing at least some of those which, if neglected, would
soon run on into the intractable chronic form. They may be
caught in the early stage in one of two ways, either by their
occurring in families in which well-marked cases of kála-ázar
have been, or are, present, or by all cases of fever in any place
which is affected by kála-ázar, which do not readily yield
to ordinary treatment, being looked on as suspicious and
treated in the more radical ways which are about to be
described.
The principles for the treatment in the early stages are
very simple, but require to be fully
carried out if success is to be obtained.
The last case given illustrates them very
well. They are (1) to get sufficient quinine into the system
to check the fever which is present; and (2) to prevent any
return of the fever, while the injury which has been done by it
to the blood is being repaired, the latter being hastened by all
available means. If this can be done before fever recurs, it is
obvious that the system will be in as good a position to meet
a relapse of the fever as it was at the first onset, and if a
relapse should occur, the same treatment must be carried out
again.
In carrying out the first of these indications, quinine will
be our sheet anchor. Now, it must be admitted that this drug
has fallen somewhat into disrepute in the treatment of
Treatment in the early
stages.
Report on Kála-ázar.
kála-ázar, but the reason is not far to seek. It has been re-
peatedly pointed out that this form of fever is of such unusual
intensity that it produces a degree of malarial cachexia in
about as many months as the malarial fever of the Sylhet
valley will take years to bring about, although the latter is
practically part of the huge swamp of Lower Bengal. It is
then at once obvious, that the doses of quinine that suffice for
the treatment of the ordinary malarial fevers of Assam, cannot
be expected to have any controlling influence on that of the
epidemic fever, which is now travelling up the Assam valley.
Yet I found that in several of the dispensaries of the Nowgong
district, quinine was being given in two and three-grain doses
twice or thrice a day, and that it was rarely that more than
enough for one or two days was given at a time. Now, although
there are a large number of dispensaries in this district, yet 11
in 3,257 square miles still leaves the great proportion of the
inhabitants of the district at least several miles from any of
them, and it is obviously impossible for people, sick of this
terrible disease, to walk or send several miles to a dispensary
every day, or even every other day, for medicine. Even if
they did, they would very soon find that such doses did them
little or no good, and would leave off attending. If it is also
remembered that a native has a great tendency to wait until
he has reached advanced stage of the disease before coming
to hospital, is it at all surprising that such doses of quinine
should have been found to have little apparent beneficial
effect in cases of an intense epidemic malarial fever like
kála-ázar?T h a t i t i s o f s o m e u s e , e v e n i n s m a l l d o s e s , i s
evident from the fact that it is universally employed in the
treatment of the disease, and from the observation that I have
found it lessen the height of the temperature, and also the
destruction of the blood corpuscles in some cases in which it
did not entirely stop the fever, while I have already given
instances in the foregoing illustrative cases of the action of
larger doses in controlling, or even stopping, the fever alto-
gether. I have seen several cases in which an increase of the