40
Paras. 22 & 23
IV-The Pathological Difficulties Discussed.
22. Position of the Argument.-We are now in a better position to
discuss the pathogenesis of kala-azar.
It has already been possible in going along to attenuate the issues on this
point. In paragraph 11 it was shown that the symptomatology alone, as
previously arrived at, sufficed to exclude the ankylostomum duodenale as the
pathogenetic agent. On the other hand, the striking similarity of the disease to
paludism was pointed out in the next paragraph ; but on closer examination
(paragraphs 12, 13, 14) I determined that it would not be safe to trust this
similarity alone as sufficient to warrant a conclusion as to the nature of the
disease. Indeed, it was shown that there were many possible, and some very
forcible, arguments against the malarial theory.
The position of the discussion at that point may be summed up as follows:-
For the malarial theory-
(a) The symptoms of kala-azar are almost, if not quite,  identical with
those of malarial fever.
(b) The disease occurs in malarious regions.
(c) Most of the cases contain yellow pigment.
Against the malarial theory-
(a) The high death-rate of kala-azar.
(b) The intractability to quinine.
(c)  The existence of a low constant fever, not amenable to quinine, and
not like malarial fever, in the second stage of the disease.
(d)  The  apparent absence  of the parasites and melanin of  paludism
from many established cases of the disease.
(e)  The communicability of kala-azar from  the  sick  to the healthy ;
and its epidemicity.
It was finally determined, then, that these questions could not be properly
discussed without having recourse to farther observations ; and the best method
of research was judged to be the comparison of a number of cases of fever,
including cases of kala-azar at Nowgong. These observations are given in
paragraph 17, and are summed up in paragraph 18. We may now ask, what
deductions, if any, can be drawn from them ?
23. Deductions from the Observations at Nowgong.-On referring
to paragraph 18 it will be seen that out of 75 cases examined at Nowgong, 26
were definitely diagnosed at the Civil Hospital to be cases of kala-azar, 6 were
supposed there to be probably so, while most of the remainder were thought
to be ordinary fever. The first question is, what difference was observed
between the cases of kala-azar and those of ordinary fever ?
Of course, owing to most of the cases being out-patients, many of them
were not examined very thoroughly, but at the same time many were exa-
mined thoroughly-at least thoroughly enough for the purpose of this report ;
while nearly all of them exhibited a striking uniformity of symptoms. In
short, it appears to me permissible to extract a definite answer to the question
from these observations. And the only answer can be that, if there was any
difference at all between the cases of kala-azar and of ordinary fever, it was
only a difference of degree. The cases diagnosed as kala-azar were, perhaps,
more severely ill than those considered to be ordinary fever cases-that was all ;
no difference whatsoever in kind could be detected.
I think that this must be admitted from a perusal of the cases ; it was
certainly very apparent from the actual inspection of the patient.
In other words, to judge from my observations, all the cases examined at
Nowgong (excepting perhaps cases 4 and 42 ) were examples of one and the
same disease. On reading the cases from those of the shortest to those of the
longest duration and excluding some of the least typical ones, we are almost
tempted to imagine that they constitute records of the same case taken from
its beginning to its end. We have in the earliest cases the sudden onset of fever,
generally with rigors, and the early appearance of enlargement of the organs ;
next an established enlargement of the organs with a low constant fever in the
worst cases ; and lastly a cachexia.