41
Para. 23
If anything serves to establish this similarity and continuity of the cases,
it is the gradual evolution of that symptom which is, perhaps, their leading and
characteristic feature -I mean the enlargment of the organs. Take the earliest
cases-of less duration than a month ; we perceive at once the beginnings of
this enlargement, and even a notable increase, after a few days' fever (cases 2, 6,
8, 10, etc.). In case 8 for example, after only six days' illness, the spleen extended
to an inch and a half below the ribs, and the liver to half an inch; while in one case
(28), who declared he had been ill for only one month, the liver was two inches
below the costal arch and the spleen extended to the umbilicus. To leave no
'doubt as to its very rapid enlargement of the organs at Nowgong, we have cases
2 and 27, in which a marked increase was noted within a fortnight (paragraph
18) during which the patients were observed. Considering next the cases of
two, three and more months, we find an ever progressive enlargement in the
main, sometimes of one organ sometimes of the other, often of both ; until, finally,
we observe the huge tumors of cases 51 and 52 (fever, one year) or of cases 46,
54, 61, 75 (kala-azar), for example. Last of all we have the final diminution
of recovery or cachexia (cases 64, 73 74). This symptom is in fact as it were a
thread on which all the cases are uniformly strung together. It is the
dominant note of nearly all of them, and its gradual development may be
watched in them from the beginning to the end.
Considering the fever -it is of course evident that complete charts could
not often be obtained in out-patients, but such thermometry as could be prac-
ticed together with enquiries of the patients, served to elucidate the nature of
the curves. In the early cases we have a high fever broken up by periods of
complete intermission -in fact, generally of a subnormal temperature, espe-
cially in the morning ; in the later cases there is a regular chart, a daily
fluctuation between proximate limits persisting indefinitely and generally
showing a raised morning temperature. And there is evidence of this latter
kind of fever, not only in the kala-azar cases, but in case 35 for example, and
also in similar cases seen in other parts of India (paragraphs 19 and 20).
All this, however, is practically a mere repetition based on my own observa-
tions of the symptomatology of kala-azar given in paragraph 6 and deduced
largely from the statements of medical officers transcribed in Appendix A : and
we may now turn to the more minute pathology of the cases. Here, again, we
observe the same uniformity in all of them, whether they be called ordinary
fever or kala-azar. At first, in the early cases, the parasites are found with
great facility; later as the disease advances into several months, they are dis-
covered less and less readily, though when not observed in the peripheral blood,
they or their immediate product, melanin, can generally be detected in the
spleen or liver ; finally, when the enlargement of the organs has become very
marked and the low fever is established, we fail to find either the parasites
or the melanin at all in most of the cases. And precisely the same law holds
both in the cases diagnosed as kala-azar and those supposed to be ordinary fever.
In the early cases we have commencing enlargement of the organs, a
broken temperature curve and the presence of parasites.
In more advanced cases we have a more advanced tumefaction of the
organs, with increased difficulty in finding the parasites, but, generally, with
the presence of melanin in those organs.
Still further, we get the established enlargement of the spleen and liver, the
constant low fever, together with an absence of both parasites and melanin.
Here, however, we frequently find the yellow pigment.
Lastly, we have the period of recovery or cachexia.
The observations made at Naxalbari, and described in paragraph 19, tend
in same direction. Not only were the cases of ordinary malarial fever indis-
tinguishable from those brought to me as instances of kala-jwar, but all alike
were almost exactly similar to the cases examined at Nowgong. There was
the same enlargement of the organs ; the presence of similar parasites in the
early cases ; the absence of those parasites and the existence of the low fever at
the advanced stages of the disease-
In other parts of India (paragraph 20) I have often noted the absence of
parasites and the presence of low fever in old cases of paludism, especially with
much enlargement of the organs. In my regiment at Secunderabad, however,
when the soldiers were treated early with quinine, I observed very little
G