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Appendix B
APPENDIX B.
A case, supposed to be kala-azar, reported by Dr. Gibbons. Taken from the Indian
Medical Gazette, January 1890, page 22.
"Calcutta Medical Society meeting at the Medical College. Dr. J. B. Gibbons showed
a liver and spleen which had been removed from a fatal case of Assam fever, probably the
kala-azar, which has been for some years attracting attention in the Garo Hills.
"Sainburan, aged about 20 years, a native of Assam, was admitted into the first
Physician's ward on the 9th November, and died ou the 12th December 1889.
"He stated that he had been suffering from Assam fever for about a year. On admission
his condition was as follows :—Very emaciated and weak ; complexion sallow; conjunctivæ
yellow; liver extended about two and a half inches below the costal arch; spleen enlarged.
His temperature on the day of admission was 101.6°F; pulse weak.
"Fever continued until the 28th November, the temperature ranging from normal to
101°F., the evening temperature being generally aboutl01°F., while in the morning it was
lower, and some days normal. From the 25th to 28th he was free from fever.
"On 29th rise of temperature occurred and slight fever was present to the 3rd of Decem-
ber, when the temperature went up to 104°F., and from this date to his death the fever ranged
from 100°F. in the morning to 104°F. in the evening, and on one occasion reached 105F°.
"The bowels were constipated during the first fortnight after admission, requiring re-
peated doses of aperients to produce an evacuation. On the 7th December, mucus and blood
appeared in the stools, and from this date he passed several loose bilious stools containing a
small quantity of blood.
"He gradually became weaker and died at 9 A.M. on the 12th December 1889.
"Abstract of post-mortem notes.—The examination was made six hours after death. Body
very emaciated. No subcutaneous fat, no œdema, the peritoneal cavity contained about 16 oz.
of serous fluid.
"The liver was large, weight 3 lbs. 3 oz., mottled dark-green and yellow, much congested.
Microscopic examination shows great congestion of all the lobular capillaries, but most
marked in these belonging to the central veins. The hepatic cells are small, shrunken.
granular, and contain minute masses of brown pigment. In some lobules the hepatic cells
are completely destroyed, all that remains being an amorphous granular mass. The destruction
of the hepatic cells is the most striking feature, the fibrous frame-work is unaltered. The
spleen is large, weight one and a half pounds and soft and friable, of a brownish red colour.
Sections show extreme congestion but no pigmentation.
"The kidneys are slightly enlarged; the cortex is pale streaked with red; the medulla of
a dark-red colour; weight of each four and a half ounces. Microscopical examination;
extreme congestion, the renal epithelium is granular and disintegrating ; many of the tubules
contain masses of broken-down epithelium.
"The mucous membrane of the small intestine was bile-stained in the upper portion;
Payer's patches were healthy.
"The membrane of the whole of the large intestine was thickened and presented innumer-
able small shallow ulcers, some recent, some of long standing. No worms in the intestines.
"The muscle substance of the heart was pale and flabby.
"Remarks.—The course and symptoms in this case point to the probability of its being an
example of kala-azar. The patient was an Assamese, and only came to Calcutta a short time
before he was admitted into hospital. He suffered from enlargement of the liver, spleen and
anæmia, recurring attacks of fever and dysentery. These are the prominent symptoms of
all cases of kala-azar, vide Indian Medical Gazette, January 1889, pages 188-189. Of the post-
mortem appearances, the absence of pigment in the spleen is noticeable. In all cases of long
continued malarial poisoning in Lower Bengal, the spleen contains large quantities of pig-
ment.
"In the liver the destruction of hepatic cells is greater than I have found in any cases
of malaria in Bengal."
Note.—In my autopsies, the splenic and hepatic cells were found to be coarsely granular, but no destruction
of them was observed by Dr. Daniels or myself.—(R. Ross).