an analysis of the clinical picture in kala-azar · an analysis of the clinical picture in...
TRANSCRIPT
AN ANALYSIS OF THE CLINICAL
PICTURE IN KALA-AZAR.
PART I.
By L. E. NAPIER, m.r.c.s., i,.r.c.p. (Lond.),
Special Research Worker on kala-asar,
Calcutta School of Tropical Medicine and Hygiene.
During the year from March 1921 to March
1922, five hundred and eighty-one patients attend- ed my out-patient clinic at the Calcutta School of Tropical Medicine or were admitted under my charge in either the Medical College Hospital, or in the Carmichael Hospital for Tropical Diseases, Calcutta.
The cases were diagnosed either kala-azar or non-kala-azar. If the case was diagnosed as kala- azar, he or she was either (a) admitted in hos-
pital; (b) told to attend for treatment as an out- patient in the out-patient department; or (V) ad- vised as to the treatment necessary. If they were diagnosed as non-kala-azar, they were referred to the Medical College Hospital Dispensary or else- where, or, in the cases where a definite diagnosis was made, they were given a prescription and advised to attend elsewhere, if further treatment
Nov., 1922.] ANALYSIS OF CLINICAL PICTURE INKALA-AZAR: NAPIER. 407
was necessary. The diagnosis of these cases was made as follows :?
Diagnosed as kala-azar by spleen puncture . . . . 300 *
Diagnosed as non-kala-azar by spleen puncture . . 140
Diagnosed by means other than spleen puncture as kala-azar . . 62
Diagnosed by means other than spleen puncture as non-kala-azar 79
It is only the cases of the first two groups that are here analysed. On nineteen cases a second spleen puncture was
performed, and on five cases a third. Of these
cases, two proved positive at the second spleen puncture, and one at the third. One must not deduce from this that had the other 124 cases had a second spleen puncture 10 per cent, of them would have shown the presence of Leishman- Donovan bodies, as the nineteen cases were select- ed ones. It would probably be safe to assume that not more than three or four of the cases in which parasites were not found on spleen punc- ture were cases of kala-azar. This small number will give rise to a negligible error.
Geographical distribution.?The patients were
questioned as to where they lived, or had been living a few months prior to and at the time of their first attack of fever. In very few of the cases was there any room for doubt as to the place at which they had contracted the disease. Most of the mofussil patients had only left their native village to get treatment, and most of the Calcutta patients were permanent residents of the town.
Table I gives the geographical distribution of the cases.
Table: I.
Calcutta
Adjoining Districts.
Districts to North.
Districts to East.
District. Kala-azar I ^on-kala- azar.
Calcutta City ... 102 14
24-Perganas _
...
Howrah District...
Hooghli District... Jessore ...
Burdwan Nadia Murshidabad Malda ...
Rangpur Rajshai ...
Dinajpur Jalpaiguri
Khulna ...
Pabna ...
Faridpore Dacca Noakhali
16 4
22 9 19 10 1
"l 3
District.
Districts to South-West.
Bihar
Midnapur Bankura Birbhum
Purnia ...
Sonthal Perganas Bhagalpur Patna ...
Dharbunga Gaya Muzaffarpur Chapra ...
Shahabad Balasore Cuttack ... Puri
Assam ...
Tippera ... United Provinces Goa
Place of origin of fever not
recorded or doubtful.
Total
Orissa
Elsewhere ..
Kala-azar.
30U
Non-kala- azar.
140
The districts from which the cases came may be divided into seven areas (excluding a few cases which came from outside Bengal, Bihar and Orissa), namely, (1) Calcutta City; (2) dis- tricts adjoining Calcutta; (3) districts to the north of Calcutta, which are ifor the most part on the banks of the Ganges; (4) districts to the
east, which lie in the river delta; (5) districts to the south-west; (6) Bihar and (7) Orissa.
Table II shows the percentage of kala-azar cases and the percentage of non-kala-azar cases which come from each of these seven areas and also the percentage of cases that were kala-azar from each area.
Table II.
<D C a o
. P.,2 8 o N rC e?
. ? c4 O
csw o
w
c3 ft,? ~S O
* .1 Ifc o
Calcutta ...
Adjoining Districts ..
Districts to North
,, to East ? to S.-West ..
Bihar Orissa
102 34 0% 56 19-6% 77 25 6% 28 9*3% 4 1-3%
19 6-3% 7 2-3^
14 10-5% 20 15-0% 65 49-0% 16 12 0% 9 7-0% 6 4-5% 2 1-5%
- ? .
-4-? tj) ^ m c3
09 -S J o u ?? J ? (! (J
"J.a.n n
88-0% 73-7% 54-2% 63-6% 30-8% 76-0% 77-7%
The most striking^ contrast is between areas 1
and 5, that is between Calcutta and the districts in Bengal which lie to the west and south-west of the city, the former provides 34 per cent, of the kala-azar cases and only 10.5 per cent, of the non-kala-azar, whereas the latter provides only 1.3 per cent, of the kala-azar cases, but as much as 7 per cent, of the non-kala-azar. That is to
say, that for every case of non-kala-azar that came from area 5, one-and-a-half case came from area 1, and for every case of kala-azar that came from area
"
5," twenty-six cases came from area "
1."
* The roundness of this figure might suggest that the cases were selected. The cases were taken con- secutively. It was found that up to the end of March 300 definitely diagnosed cases had been collected, and as this represented about one year's clinical work, I decided to analyse the cases that had been collected up to this date.
408 tHE INDIAN MEDICAL GAZETTE. [Nov., 1922.
To put it another way, of Calcutta cases of "
spleen fever
"
88 per cent, are cases of kala-azar, where- as of cases from the districts included in group 5, only 30 per cent, are cases of kala-azar. The same contrast, though not quite so marked, will be seen between Calcutta and the districts to the north ; here the figures are larger and therefore more reliable.
It is obvious from the figures that either kala- azar is very much more prevalent in Calcutta than elsewhere in Bengal, or
"
spleen fever" from other causes is much less common.
Sex, caste and age distribution.?1 have divided the ages into five groups, namely, (1) infants up to the age of three years; (2) children from three to ten years old; (3) ages from ten to
twenty years : (4) ages from twenty to thirty years; and lastly, (5) thirty years and older.
Anglo-Indians are grouped as Europeans. Tables III and IV give the age, caste and sex distribution for kala-azar and non-kala-azar cases, respective- ly, Figure 1 shows graphically the age distri- bution for kala-azar and for non-kala-azar.
Table III. Kala-azar cases.
<uO U O
bfl >> fcflcvi to >?
< < < <i
Males. Hindus ... 17 63 44 32 156 Mahomedans .... 4 22 17 13 56 Indian Christians .. 2 5 5 2 14 Europeans .... 4 8 7 7 26 Chinese ..
.. .. .. 2
Africans
foTAL .. .. .. .. ?? .. 255
Females. Hindus ?? 2 . . 10 3 1 jg Mahomedans .. 1 S ?? 1 7 Indian Christians .. 2 . ? 2 ] 5 Europeans .. .. 4 7 4 .. J5
Total .. 2 34 120 86 58 Grand Total .. .. ,. ..
?? .. 300
Table IV.
Non-kala-asar eases.
Males.
Hindus
Mahomcdans
Indian Christians
Europeans
Jews
Totai. ? ?
Females.
Hindus
Mahomedans
Indian Christians
Europeans
Total ..
Grand Totai.
to ̂
< fcJDCM
<
31
10
CJ o
<
35
7
1
49 44
V v
<
25
10
91
27
1
16
39 18
140
In order to gauge the value of the figures for the caste and sex distribution, I obtained the
figures for the admissions into the medical wards of the Medical College Hospital and of the attend- ance of the medical cases at the out-door dispen- sary of this hospital for one month. Tables V and VI compare, respectively, the sex and caste distribution for kala-azar cases, non-kala-azar cases and general attendance at the Medical Col- lege Hospital. The incidence in the two sexes does not show
any striking difference. There is a very distinct
predominance of the disease amongst Christians. The only other noticeable fact, and this was in all probability an accidental one, is that all of the
Table V.
Of cases of each sex, Kala-azar cases. Non-kala-azar cases. the percentage that
were kala-azar.
Males ... 255 or 85% 122 or 87-15% 67'6 % Females ... ... 45 or 15 % 18 or 12-85 % 71*4 %
General medical at- tendance at the Medical College
Hospital.
789% 21 1 %
Table VI.
Hindus
Kala-azar cases.
174 or 58 % Mahomedans ... ... 63 or 21 % Indian Christians 19 or 6'3%) Europeans ... ... 41 or 13 7% V 20*3% Africans ... ... ... lor 0*3% J
Of cases of each General medical
xr , , sex, the percentage attendance at Non-kala-azar cases.
that were kala- Medical College azar. Hospital.
107 or 76-4% 61 -9 % 62-2% 27 or 19-3% 70-0% 19*3% 2 or 14% l ...
3 or 2-1% j. 3-6% 92 3% 11*6%
Chinese ... ... ... 2 or 0'7% j 2'2% Jews ... ... ... j 4*8%
AN ANALYSIS OF THE CLINICAL PICTURE IN KALA-AZAR.
By L. E. NAPIER, M.R.C.S., L.R.C.P. (Lond.)
Special Research Worker on Kala-azar, Calcutta School of Tropical Medicine and Hygiene.
Figure I.
diagram showing the age grouping in fcalaazar and non-kala-azar cases.
FROM IO TO 20 YEARS
PROM 3 TO IO YEARS
UP TO 3 YEARS
FROM 20-30 YEARS
OVER 30 YEARS
Ot'/, q-7 7. u-3 V. 5?L 40% 35% 287 % 31*% 19-3% 27 97,
Kala-azar Shaded areas. Non-kala-azar = Blank areas.
-t- ?ot
-- 2 5%
-- 157;
5 /.
Figure I.
diagram showing the age grouping in liala-azar and non-kala-azar cases.
Kala-azar = Shaded areas. Non-kala-azar = Blank areas.
Nov, 1922.] ANALYSIS OF CLINICAL PICTURE'IN KALA-AZAR: NAPIER. 409
seven Mahomedan women who came for treat-
ment were diagnosed kala-azar.
A comparison of the age distribution is made
in Table VII.
Table VII.
Comparison of age groups.
Infants Ages 3 to 10 years Ages 10 to 20 years Ages 20 to 30 years Ages over 30 years
Kala-azar cases.
2 or 07% 34 or 11'3% 120 or 40 % 86 or 28'7% 58 or 19"3%
Non-kala azar cases.
1 or 0'7% 7 or 5 %
49 or 35 % 44 or 3l"4% 39 or 27*9%
Of each age group the per- centage of
cases that weie kala-azar.
66 % 83 % 71 % 60*7% 5 9'9%
It will be noted that the age groups from 3 to
10 years and from 10 to 20 years provided more
than half the cases of kala-azar and that the
former of these groups gives the greatest relative incidence.
*\ atm c of onset. The patients or their friends were questioned as to the kind of onset. It was
not always possible to get any definite story from the patient. Table VIII gives the various modes
of onset that occur in both conditions.
Taeus VIII.
Type of onset.
Kala-azar. Non-kala- azak.
Double daily rise of temperature.
Single daily rise of
temperature. Fever on alternate
days. High continuous fever Low ,, ,,
High remittent and intermittent fever.
An attaok diagnosed as
" typhoid."
Irregular fever Enlargement of spleen only.
Eruptions followed
by irregular fever. Dysentery followed by irregular fever.
Total
Type of onset not
noted.
33
126
10
63
125
492
1-6
3-9 1-9 3-5
1-6
24-6 0-4
0-4
0 4
a. a) n >> ci a ** ? cl
4-0 ! 865
39*5 ! 72-0
5
19
3 ; 2-4 57-0
3 2-4 77 0 3 2 4 62-5 2 i 1*6 81-8
256 44
57 1
124 16
lOO'O
45-9 52*5 0-8
0-8
It will be noticed that the history of a daily double rise of fever only occurs in 12.5 per cent, of cases, but that when this history is given the case is almost always kala-azar, that is to say, the symptom is important as a point on making a
positive diagnosis, but not in making a negative one. Typhoid-like and high remittent and inter- mittent fever are other types which have diagnos- tic significance.
Family and house history of kala-azar.?An attempt was made to get a family or house his-
tory of the disease in each case, but unless this
history was fairly definite, it was ignored. Table
IX gives the result of this enquiry.
Tabix IX.
Family and house history of kala-azar.
Two or more members of family had
kala-azar.
Husband had kala-azar
Father ,, ,
Mother ,, ,,
Sister ,, ,,
iirother ,, ,,
Other relatives in same house had
kala-azar.
School fellow had kala-azar
Total (occupants of same house)
Near neighbours had kala-azar
Total percentage giving local or family history
Kala-azai cases.
1
4
2
4
7
10
40
15
18-3%
Non-kala- azar cases.
10%
83*3% of the cases giving a house history of the disease were cases of kala-azar.
A family or local history of the disease was not obtained in a very large number of cases, but it was obtained nearly twice as frequently in the case of kala-azar patients as in the case of non- kala-azar patients. History of rigors.?Table X gives the figures
for this symptom.
Tabus X.
Rigors.
Patients giving a his- tory of rigors at some period of disease.
No history of having had rigors.
Information not avail- able.
Total
Kala-azar cases.
151
111
38
300
57-6%
42-4%
Non-kala- azar cases.
mu v to d
? CJ! rt V ,, U o J>
57-67.
42-4%
69%
69%
It will be seen that the presence or absence of this symptom is a matter of no diagnostic importance.
The effect of quinine on the fever.?Informa- tion on this point was not always obtainable. The figures are given in Table XI.
410 THE INDIAN MEDICAL GAZETTE. [Nov., 1922.
Effect of quinine.
Patients on whom quinine had r.o
effect.
Temporary effect only.
Definite effect ..
No quinine was
taken in
No information was available in
Total
Table Xr.
Kala-azar CASES.
Ill 71-1%
14-7%
22 14*1% J 36
108
29%
Non-kala- AZAR CASES.
49
12
18
18
79
*5 ?-*
*
u
O G
69'4? 62%
1S'2%"| 65-7%
J 38% 22
300 .. 140
55% 60%
Although quinine had a temporary effect as
often amongst kala-azar cases as amongst non- kala-azar cases, it had a
" definite "
effect more
frequently amongst non-kala-azar cases. Length of duration of illness.?Table XII gives
the length of duration of illness at the time of examination.
p I Length of duration of disease
P* 1 at the time of examination.
C.
D.
Less than 1 month
,, 2 months 3 ?
B. Less than 4 months ? 5
6 ?
Less than 7 months 8 9
Less than 10 months .. II ?
12 ?
about 1 year ,, 13, 14 or 15 months
I
About years 21 months 2 years
I4 :: 4 5
More than 5 years
Total
Table XII.
Kala-azak.
dumber.
3 9
20
29 21 28
31 10 19
11 8 4
50 3
16 2
12 2 9 3
Total.
32
78
63
76
50
299
Per cent.
10-7
26'1
21-1
25*4
13 1 13 5' 10
167 11
Non-kala-azar.
X umber.
8 6 1
3 3
26 1
Total.
13
18
33
60
139
9-2
13-0
15 | 10-7
23-7
43*2
Per cent.
Of the cases of each g'oup those that are kala-az u\
71-1%
81*25%
80*7%
687%
45-45%
6S-26%
I have divided the cases into five groups, namely :?
(a) Cases that had been ill for less than three months.
(b) Cases that had been ill for three months, but less than six months.
(r) Cases that had been ill for six months, but less than nine months.
(d) Cases that had been ill for nine months but not more than fifteen months.
(c) Cases that had been ill for eighteen months or more.
; The reason'"'for not' keeping strictly to the
periods of three months was that the period "
about one year "
probably indicated periods varying from ten to fifteen months, if not a wider range. It seemed fair to bunch all these periods together in one group instead of making an arti- ficial division. As most of the symptoms and physical signs of the disease are dependent to some extent on the length of duration of the disease, I have divided the cases into these five groups for the purpose of this analysis.
Figure II compares graphically the length of duration of illness before applying for treatment of kala-azar and non-kala-azar cases.
It will be seen that a history of duration longer than eighteen months is very distinctly against the diagnosis of kala-azar.
Date of onset of the disease.?Figure III is a curve showing the date of onset of disease in
263 cases of kala-azar. In seven cases the infor- mation was not available and in thirty cases the history was longer than two years. These cases were not included as it was assumed that their
history would not be sufficiently accurate to be of any value.
AN ANALYSIS OF THE CLINICAL PICTURE IN KALA-AZAR.
By L. E. NAPIER, m.r.c.s., l.r.c.p. (Loncl.)
Special Research Worker on Kala-azar, Calcutta School of Tropical Medicine and Hygiene.
LESS THAN THREE
MONTHS.
Figure II.
Length of duration of disease prior to commencement of treatment.
LESS THAN SIX MONTHS.
LESS THAN NINE MONTHS.
Kala-azar = Shaded areas. Non-kala-azar = Blank areas.
UP TO 15
MONTHS. ABOUT 18 months
OB LONGER
Figure II.
Length of duration of disease prior to commencement of treatment.
Kala-azar = Shaded areas.
Non-kala-azar = Blank areas.
Nov., 1922.] ANALYSIS OF CLINICAL PICTURE IN KALA-AZAR: NAPIER. 411
The curve shows a very distinct rise during the winter months.
Appetite.?Table XIII shows the number of
patients in each group with a good appetite. The
total number of observations is given so that it is
an. easy matter to calculate the number with a
bad or indifferent appetite.
Table XIII.
Group. Total observa-
tions.
K.A. I Non-K. A
A I 25 B j 69 C i 53 D 68 E
Total.
47
262 121
No. with fiood appetite.
K.A
17 40 27 38 23
145
Non-K. A.
4 6 6 15 28
59
Percentage with good appetite.
K.A. iNon-K.A.
68-0% 57 9% 50-9% 55 8% 48-9%
55 3%
36 3% 42 8% 54-5% 5(1-0% EO-9%
487%
Table XV.
Group. | Epistaxis only.
Non-K. A.
A
B
C
D
E
Per cent. of Total
Per cent, of each condition with K. A.
K. A.
6
9
6
12
10
43
15-6%
14
18
KV9%
Bleeding from the
gums only.
K. A.
62
22-5%
Non-K. A.
3
2
3
9
16
33
25-6%
70 5% 65-3%
Both condi- tions.
K. A.
1
9
10
14
16
50
Non-K. A-
No history of either.
Total.
K. A. I Non-K. A. 1\. A. Non-K. A.
3
6
6
10
25
18-1% 19-4%
66 6%
16
41
26
22
16
121
43-8%
7 30 11
10 74 16
4 ?6 13
13 69 30
19 1 47 59
53 276 129
41*1%
69-5%
The history of a good appetite is equally com- mon in kala-azar and in non-kala-azar in the later
period of the disease, but in the early stages it will be seen that a good appetite is a symptom dis-
tinctly in favour of the diagnosis of kala-azar.
Dysentery and diarrhoea.?Table XIV gives the number and percentage of patients of each group that suffered from diarrhoea or dysentery at some period o:f the disease.
Table XIV.
? Total observa- GrouP- tions.
A
B
C
D
E
Total ..
K.A
27
75
62
71
49
?234
Non-li. A
11
16
14
3-2
6u
133
No. with
K.A
8
30
30
29
21
118
Non-K.A
6
11
28
48
Percentage with
K A.
?29 6%
40-0%
483%
40 8%
42*8%
415%
Non K. A.
91%
12-5%
42-8%
84*3%
46-6%
360%
For the first six months diarrhoea and dysen- tery are distinctive features of kala-azar. In the case of longer standing illness a history of dysen- tery or diarrhoea is nearly as frequent in non- kala-azar as in kala-azar cases. This suggests tW thpse svmotoms are not so common in the more chronic form of the disease.
Epistaxis and bleeding from the gums?These figures are given in Table XV.
These symptoms are extremely common in both conditions, but do not appear to show any pre- dominance in either.
Pseudo-Pigmentation.?Without asking a lead- ing question an endeavour was made to find out from the patient or his friends if he had got either darker or paler during his illness, The figures are given in Table XVI.
Figure III.
JULY. AUG. SEPT. OCT. NOV. DEC. JAN. 'r EB. MAR. APR. MAT. JUNE.
Figure III.
412 THE INDIAN MEDICAL GAZETTE. [Nov., 1922.
Group.
A
R
C
I)
E
Per cont. of Total
Per eenfc of each condition with K. A.
Table XVI.
Darker.
K. A.
5
33
26
35
21
12i>
51-7%
Non-K. A.
5
6
7
12
34
64
56 6%-
65 2%
Paler.
K. A.
8
13
12
8
18
59
25-4%
Non-K. A.
10
28
24-8%
67-8%
No change. Total.
K A.
9
16
11
13
i
53
22-8%
Non-K. K K. A. Non-K. A.
4 22 11
1 62 . 12
49 . 9
5 56 26
11 43 55
21 232 113
18-6%
716%
It would appear that a history of having become darker is not a point in 'favour of a diagnosis of kala-azar.
Lung symptoms.?The numbers and percentage of cases giving a historv of a cough are given in Table XVII.
Table: XVII.
Group.
A
B
C
D
E
Total
Total observa- tions.
K. A.
27
68
56
66
47
264
Non- K. A.
11
14
11
30
58
124
No. with
K. A.
14
31
29
36
20
130
Non- K. A,
6
11
24
55
Percentage with
K. A.
51-8%
45-5%
51-7%
54-5%
42-5%
49'2%
Non- K. A.
54-5%
57*1%
54-5%
36-6%
41-3%
44-3%
This symptom appears to occur with equal frequency in both kala-azar and non-kala-azar cases.
Loss of weight.?'Figures and percentages of the cases giving a history of loss of weight are shown in Table XVIII.
Table XVIII.
Group.
A
B
C
1)
E
Total
Total observa- tions.
K. A.
30
72
57
73
47
279
Non- K. A.
12
15
14
3 J
56
127
No. showing
K. A.
28
67
55
70
44
264 J
Noii-
K. A.
12
13
13
25
48
111
Percentage showing
K. A.
93 3 %
93-05%
96 4 %
95-8 %
93 6 %
94 6%
Non- K. A.
100'0%
86-6%
92-8%
83-3%
85*7%
87*4%
A very large percentage of cases of both groups give a history of loss of weight, but rather a
higher percentage of kala-azar than of non-kala- azar give this history, especially in the later stages of the disease.
(To be continued).