72
Para. 41
complication. In several, however, such as Case 75, none could be detected ; while
in others they were obviously present only in small numbers and were producing
no discernible symptoms. I concur entirely with Rogers and others that when
present in large numbers they produce a condition of severe anæmia which does
not belong to kala-azar pure and simple, and which often suffices to show the
existence of this complication at a glance. The two diseases are quite different ;
the one being a fever, with an early history of a sudden febrile attack, leading to
great enlargement of the organs ; the other being a slowly progressive anæmia,
without enlargement of organs, but sometimes accompanied by slight fever
(Daniels—Appendix A).
Hence, it might be thought that the differential diagnosis should be easy—
at least, where the diseases exist in different persons. This, however, is not
always the case—if we rely upon microscopical symptoms alone. It is true
that malarial fever in its earliest stages of severe recurrent pyrexia and
in its second stage of enlargement of the organs (if this exist) can scarcely be
mistaken for ankylostomiasis. But in the later stages, where tumefaction
of the organs has not occurred to any great extent, or when it has subsided on
the establishment of cachexia (paragraph 6), and when the final anæmia
and oedema of malarial cachexia are very marked, the diseases may certainly
be easily confounded.
How much, then, must the difficulty of judging be enchanced when both the
diseases exist in the same person—that is, when ankylostomes are present in
the third stage of paludism ? In the earlier stages of the latter, when we find
the outbursts of typical malarial fever or the enlargement of the organs to be
constantly attended by more anæmia than is usually associated with such
symptoms, we are justified in suspecting the presence of ankylostomes at
once. If, for instance, we are confronted by a case of excessive anæmia and
dropsy, with marked tumefaction of either the liver or spleen or both and a
malarial history, we can scarcely hesitate in ascribing the condition to both
diseases. But later, when the epoch of the fever has passed, when malarial
cachexia is pronounced, when the organs have subsided to their normal sizes,
and only anæmia and dropsy remain as the final consequence of this cachexia—
symptoms equally of ankylostomiasis—how are we to discriminate? How
tell whether the condition is paludism simply, or paludism plus anky-
lostomiasis, or even the latter alone ? Yet it is just at this stage when we are
most urgently called upon to detect the complication if it exist, because it is just
the stage of a malarial infection when ankylostomes are calculated to have the
most fatal effect—when the system, already weakened by months of a severe
illness, requires all the strength it can summon, and can least afford to support
these debilitating entozoa.
Again, even in the earlier stages of paludism, when the ankylostomes,
though present, are so few that they cause no visible anæmia, are we justified
in ignoring their presence ? On what grounds may we do so ? Suppose the
paludism to be severe and to threaten a critical third stage, when the question
of recovery will depend on the final resources of the system, is it not necessary
that these resources should be husbanded to the utmost from the first ? The
ankylostomes may be too few to occasion anæmia at this early stage, but may
still make their presence felt heavily at a later one. If they produce no
anæmia, how are they to be detected ? In other words ; are we justified in wait-
ing for the entozoa to diagnose themselves, so to speak, by establishing an
anæmia which will probably kill the patient ?
This raises the general question of the proper diagnosis of ankylostomes.
Are we ever justified in allowing these parasites to diagnose themselves in this
manner ? To wait until they have disclosed themselves by inflicting a grave,
perhaps a fatal injury, when we have ready at hand the simplest and most
certain method of detecting their presence, would seem to be one of the most
inexcusable of doctrines and practices.
And this question does not apply only to Assam. It applies probably to
the greater part of India, as the literature of the subject shows clearly enough
[15, 17, 18, 19, 20, etc.]. The worms have a very wide distribution, and prob-
ably cause a monstrous mortality.
The pleasant and easy beliefs so sedulously repeated, that the worms are
harmless, or that they are harmful only in large numbers, such as five hundred