NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
15
During one of these periods the temperatures shown on the chart are not
higher than 99°—a temperature which, as a rule, may be regarded as normal—
but because the temperatures were taken only twice daily, and because through-
out the greater part of the period of examination they were consistently low, I
have regarded this slight rise as indicating a period of pyrexia.
The apyrexial intervals were as follows :—
November 11th to November 14th.
November 23rd to December 4th.
December 7th to December 14th.
December 18th to December 30th.
January 9th to
. . . . . . . . . . . . . . . . . . .
Freedom from symptoms was a prominent feature throughout the whole
period of examination, but this character was especially apparent during the
apyrexial intervals. Physical examination during such intervals revealed no
sign, excepting the splenic enlargement, by which a diagnosis could be made.
From a non-medical point of view the boy was quite well ; he complained of no
symptom and his enlarged spleen troubled him not at all.
During periods of fever the symptoms were more marked: he recognised
that he had fever and sometimes was incapacitated from work ; he complained
of loss of appetite and of occasional vomiting. The paroxysms frequently began
with a feeling of chilliness and shivering, but " cold," " hot," and " sweating "
stages were not definitely apparent.
On the whole, we must conclude that an illness which incapacitates a person
from work for only one or two days in a month is not a very serious one.
In order to make a diagnosis by clinical methods during the apyrexial
periods, we should have had to rely chiefly upon negative signs : the patient had
an enlarged spleen and was anæmic, but he complained of no symptom ; he was
not incapacitated from work ; he was not emaciated ; he had no fever : all these
point towards a diagnosis of malaria—the disease which by years of experience
the native of India has learnt to regard, if not with contempt, at any rate with
equanimity, " because it does not kill."*
During a relapse of fever (pyrexial period) our diagnosis by clinical methods
can be made on surer grounds ; we can take careful records of the temperature
and ascertain if the chart with results shows characters known to be associated
only with malarial fever. The application of this method is illustrated in
* The point of view from which the native of Assam regards malarial fever and kala azar respectively is
well illustrated in the account quoted by Surgeon-Major Giles, I.M.S., of an interview which Dr. Dobson
had with a native woman suffering from fever and enlargement of the spleen. When asked why she did
not apply for treatment at a hospital, she replied to the following effect : " If I have got malarial fever I
shall get well sooner or later anyhow, but if I have kala azar, nothing can cure me, so what is the good of
bothering me with medicine ? "—(A report on the diseases known in Assam as kala azar and beri- beri.
Assam Secretariat Press, 1890, page 14.)
16
the present case, but on inspecting the charts we see that in order to
derive information of value from it the temperature must be recorded
very frequently—at least every four hours and, preferably, every two hours.
It will be noticed that the chart of temperatures taken only twice daily
during the relapse of fever which began on the 31st of December does
not enable us to diagnose the disease ; like so many of the charts seen in
Indian hospitals, it shows merely a few days of " irregular" fever. But when we
turn to the two-hour chart of the same period, we see at once that the fever-curve
is not irregular at all, but is most definite : it is obvious that we have to do with a
case of malarial fever. Moreover, the chart enables us to state that we have to
do with a case in which at least two groups of Simple Tertian parasites are
present ; for corresponding rises of temperature presumably caused by one group
are to be noted at 6 P.M. on the 4th, 6th, and 8th, and by another at 12 P.M. on
the 5th and at 12 P.M. on the 7th. Possibly the rise to 102° at 6 P.M. on the
5th and to 101.4° at 6 P.M. on the 7th indicates the presence of a third group.
Diagnosis by microscopical methods. —The record given on pages 13 and 14
shows the dates on which evidence of malaria was obtained and the dates on
which the result of the blood examination was negative. Despite the fact that
the patient had never been treated with quinine, the results of blood examination
were negative on 16 out of 33 occasions. It is to be noted also that often when a
positive result was recorded, so few parasites or pigmented leucocytes were found
that it is reasonable to conclude that if careful and long examination had not
been made they might have been missed. Other observers have recorded the
fact that in advanced cases of malaria, such as the one under discussion, parasites
are extremely scanty, and often (as judged by the examination of one or two
slides) absent. It is important to remember that this may be the case even when
the temperature is high and the chart typical. Although, on the 5th and 6th of
January, slides were examined every four hours, parasites were rarely found. On
comparing the results of blood examinations with the temperature chart, we note
that evidence of malaria was obtained only during pyrexial periods—never during
the apyrexial intervals. From the results obtained in this instance it would seem
that examinations of the blood do not aid us in a case like this at the time when
aid is most needed ( i.e., during apyrexial periods), and that at all times a positive
result is of far greater importance than a negative one. The latter is the rule
during apyrexial periods, and even during periods of fever a negative result is of
significance only if it is obtained at repeated very careful examinations made on
several successive days.
On the whole, we must admit that for the purposes of diagnosis in
this case the microscopical method was inferior to the clinical.
And here I may be permitted to digress for a moment to point an obvious
17
lesson arising from this conclusion. It is well known that some medical officers
in India and in other countries are of opinion that unless provided with micro-
scopes they cannot be expected to diagnose malarial fevers accurately. To such
as hold this opinion I would commend a study of the facts of this case. The
value of microscopical methods in diagnosis, no less than that of bacteriological
ones, depends entirely upon the skill and experience of the observer, and the
prevailing notion that if one possesses a microscope and a few of the
ready-made "bacteriological tests" one can dispense almost, if not entirely,
with clinical methods, cannot be condemned too strongly. It cannot be
denied that, so far as the diseases of India are concerned, the use—perhaps
I should say more correctly the misuse—of microscopical and so-called
bacteriological methods has hindered rather than hastened the discrimination of
the various forms of fever present in this country. No better example of this
truth is needed than is afforded by the history of kala azar—a disease long
recognised by clinicians of experience to be distinct, but repeatedly pronounced
by microscopists and bacteriologists to be one or other of the diseases already
known. The consideration of an example such as this suggests to us that in
future we should pay greater attention to those accurate, yet easily carried out,
clinical methods of investigation which sometimes we are apt to regard as of
minor importance.
2nd Case.—BAGHAN; aged 10 years. This boy was examined for the first
time on the 10th of April 1902. His parents volunteered the information that he
had suffered from fever "off and on" for about five months. He was fat and
cheerful and did not appear ill; but careful examination showed that he was very
anæmic and that his spleen was enlarged three inches below the costal margin.
His temperature on the evening of the 10th of April was 101º F., and in a film of
finger blood obtained on this day a considerable number of crescents and a few
pigmented leucocytes were found. On the 1st of May his spleen was still three
inches below the ribs; only one crescent was found in a film of blood. During
June his blood was examined on two occasions, but neither parasites nor pigment
were found. At the end of this month his spleen was only one inch below the
ribs. On the 28th of July his spleen was still one inch below the ribs, but neither
parasites nor pigment were found in a slide of finger blood. He was not
examined again until the 1st of November, when his mother said he had been
suffering from fever for about three days. The spleen was enlarged two inches
below the costal margin; no enlargement of the liver was detected. A system-
atic record of the temperature, which is reproduced here ( charts III and IV),
was begun from this date. The first attack of fever shown on chart IV ended on
the 8th of November; similar attacks occurred at irregular intervals for several
months.
D
With the aid of my Hospital Assistant I was able to obtain a two-hour
chart (chart III) of the attack which commenced about the 1st of January.
The results of blood examinations and the variations in the size of the spleen
were as follows :—
1-11-02
.
. A few Malignant Tertian rings. Spleen 2 inches below the
ribs.
4-11-02
.
. Two Malignant Tertian rings and four crescents after a short
examination.
7-11-02
.
. Many rings, crescents and pigmented leucocytes.
11-11-02
.
. One crescent, no rings, one pigmented leucocyte after a fairly
13-11-02
.
. One crescent only ; no rings.
15-11-02
.
.
A few crescents ; no rings. Spleen 2 inches below the ribs.
1-12-02
.
. A few Malignant Tertian rings ; a few crescents. Spleen 3 inches
below the ribs.
3-12-02
.
. No rings ; two crescents.
15-12-02
.
. Scanty rings and crescents.
19-12-02
.
. One crescent ; no rings after long search.
30-12-02
.
. Two rings ; no crescents.
2-1-03
.
. A fair number of Malignant Tertian rings ; no crescents.
3-1-03
.
. Scanty rings only.
4-1-03
.
. No parasites nor pigment after long search.
5-1-03
.
Ditto
ditto.
6-1-03
. 12 P.M. A few Malignant Tertian rings.
7-1-03
.
. 12 noon. Very scanty rings.
4 P.M. Very scanty rings.
8 P.M. Only two rings found.
12 P.M. Three rings ; one crescent.
8-1-03
. .
4 A.M. One pigmented ring only found.
12 noon. A fair number of rings.
8 P.M. Two rings only.
9-1-03
.
. 6 A.M. A fair number of rings.
11-1-03
.
. One ring only found. Spleen 3 inches below the ribs.
20-1-03
.
. One ring ; one crescent.
23-1-03
. No parasites nor pigment after long search.
25-1-03
.
.
Ditto
ditto.
26-1-03
.
.
Ditto
ditto.
3-2-03
.
. One ring after long search.
11-2-03
.
. One crescent ; no rings.
21-2-03
.
. One crescent.
8 - 3 - 0 3
.
. One ring after long search. Spleen 2 inches below the ribs.
Signs and symptoms ; diagnosis by clinical methods. —At the time when the
systematic examinations in November were begun, it was known that this child
had suffered from an entirely untreated infection with Malignant Tertian malarial
parasites for seven months, and from the mother's account it was probable that
the infection had lasted considerably longer than this. if we admit that the
19
results of long-continued untreated malarial fever as described in text-books are
applicable to the native of India, the case was one in which serious symptoms
and well-marked pathological changes should have been present. But this
was not so. On inspecting the temperature chart, we note that long-continued
irregular fever was absent ; like that of the previous case, the chart is divided
definitely into periods of apyrexia and periods of pyrexia. Freedom from
symptoms was a prominent feature during apyrexial periods, and the child
played with other children of the village as though perfectly well ; he was not
emaciated, and, practically speaking, the presence of an enlarged spleen was the
only sign which suggested a diagnosis of malaria. During periods of fever,
however, the child was obviously ill and suffered much from vomiting and
diarrhœa. But the illness lasted only a short time ; it ceased with the disappear-
ance of the fever, and within a few hours the child was as bright and cheerful as
if in the best of health.
As regards the problem of diagnosis by clinical methods during apyrexial
periods, I have nothing to add to the remarks already made on this portion of my
subject in the previous case. During a relapse of fever we can apply the same
method as was carried out in that case ; its application is shown in the two-hour
chart reproduced. It will be noted that, although the ordinary morning and
evening temperature chart of the attack which began about the 1st of January
does not reveal characters by which a diagnosis of the disease can be made, the
true fever-curve, as exhibited on the two-hour chart, is quite as characteristic, in
its own way, as that met with in Simple Tertian infections. As often happens in
Malignant Tertian infections, there are daily paroxysms of fever. In the paroxysm
on the 4th the temperature has risen to 100.8º at 4 P.M.: it then drops to 99° at
6 P.M., but rises again to a point higher than the first rise, viz., to 101.4°,
at 10 P.M. This is the typical Malignant Tertian fever-curve described by
Marchiafava and Bignami—initial rise, pseudocrisis, precritical elevation, and true
crisis. We note that on subsequent days the chart shows precisely similar
characters, and I am sure it will readily be admitted that these characters are such
as are not met with in any other disease than malaria.
Diagnosis by microscopical methods. —The great majority of blood
examinations yielded positive results, and it is probable that during almost any
period a diagnosis could have been made by this method if very careful long
examinations had been undertaken. An inspection of the record of blood findings
shows that the greater frequency of positive results in this case than in the case
of Hira was probably due to the presence of crescents, which persisted in the
peripheral blood throughout the apyrexial periods ; for we note that as regards
asexual forms negative results were fairly frequent, and that as regards these
forms a negative result was the rule during apyrexial periods. Towards the end of
D 2
20
December, parasites were evidently becoming far less numerous, and they were
found only with difficulty. Their scantiness during the relapse which lasted from
about the 1st to the 12th of January is especially noteworthy, and if the patient
had attended hospital for the first time during this period it is possible that a
diagnosis could have been made more easily by the clinical method indicated
above than by blood examinations : at any rate, the finding of parasites at a single
examination of the blood would have been a very fortunate circumstance.
3rd Case.—MAN SINGH ; aged 12 years. As in the two cases already
described, malarial parasites were found in the blood of this boy in April 1902.
At this time his spleen was enlarged to the level of the umbilicus. The infection
was with Simple Tertian forms. During the summer his spleen decreased
considerably in size, and on November 1st, when systematic examinations were
begun, it was only three fingers' breadths below the costal margin. About this
time he must have contracted an infection with Malignant Tertian parasites,
for on the 1st of November, when he was brought to me with a temperature of
102.6°. I found two Malignant Tertian ring forms, but no Simple Tertian para-
sites. Until the beginning of December the infection appeared, from the results
of blood examinations, to be an unmixed one, but on the 5th of this month
Simple Tertian parasites were again found, and from this date the case
must be considered as a mixed infection with Simple and Malignant Tertian
parasites.
The results of blood examinations and the variations in the size of the spleen
were as follows :—
1-11-02
.
. Two Malignant Tertian ring forms found. Spleen 3 fingers'
breadths below the costal margin.
4-11.02
.
. One crescent ; numerous pigmented leucocytes ; no rings.
7 - 1 1 - 0 2
.
. Numerous young crescents ; many pigmented leucocytes ; no rings.
9-11 -02
.
. Numerous crescents ; one pigmented leucocyte.
11-11-02
.
. A good many Malignant Tertian rings ; many crescents.
1 2 - 1 1 - 0 2
.
. Many rings, pigmented leucocytes and crescents.
1 5 - 1 1 - 0 2
.
. Many rings, crescents and pigmented leucocytes. In a fresh pre-
paration flagellated bodies were seen.
1 7 - 1 1 - 0 2
.
. Many crescents and pigmented leucocytes ; only one ring after
prolonged search.
2 0 - 1 1 - 0 2
.
. Many crescents ; a few rings. Spleen 3½ inches below costal
margin.
23-11-02
.
. Many crescents ; no rings seen. Spleen 3½ inches below costal
margin.
29-11-02
.
. A few crescents ; two rings after long search.
1-12-02
.
. Two crescents ; no rings.
3 - 1 2 - 0 2
.
. One ring ; one crescent.
5-12-02
.
. A few rings ; a fair number of crescents ; one young Simple
Tertian parasite. Spleen 3 inches below the costal margin.
21
15-12-02
.
. A few medium-sized Simple Tertian parasites ; a good many
crescents.
19-12-02
.
. A few young Simple Tertian parasites ; a few crescents.
23-12-02
.
. Crescents only found.
Spleen 2 inches below the costal
margin.
26-12-02
.
. Crescents ; pigmented leucocytes ; a few very young rings (? S. T.)
28-12-02
.
. Crescents ; pigmented leucocytes ; rings and large Simple Tertian
parasites.
30-12-02
.
. Crescents ; a few young rings ; a good many medium-sized
Simple Tertian parasites.
2-1-03
.
. Many young Simple and Malignant Tertian rings ; a few large
Simple Tertian parasites ; crescents.
4-1-03
.
.
A good many large Simple Tertian parasites ; a few Malignant
Tertian rings ; a good many crescents.
6-1-03
.
. 12 noon. Temp. 103°. Many crescents ; several pigmented
leucocytes : no rings seen.
7 P.M. Temp. 102 . 4°. Many crescents ;
numerous heavily
pigmented leucocytes ; one segmenting Malignant Tertian
parasite ; no rings seen.
10-45 P.M. Temp. 103°. Crescents and pigmented leucocytes ;
two rings after long search.
7-1-03
.
. 2-30 A.M.
Temp. 1.3 . 2°.
Many crescents and pigmented
leucocytes ; two rings.
8-30 A.M.
Many crescents and pigmented leucocytes ; no rings
found.
4 P.M.
8 P.M.
12 P.M.
Ditto
Ditto
Ditto
ditto.
ditto.
ditto.
9-1-03
.
. Crescents only found. Spleen 3½ inches below costal margin.
12-1-03
.
.
Ditto
ditto.
19-1-03
.
. Crescents still present in fair numbers ; no other parasites found.
28-1-03
.
. A few medium sized Simple Tertian parasites ; crescents still
present.
8-2-03
.
. One Malignant Tertian ring form ; two Simple Tertian parasites
in stippled cells.
16-2-03
.
. One ring only found after long search.
24-2-03
.
. Crescents present in fair numbers. Spleen 3 inches below costal
margin.
Signs and symptoms ; diagnosis by clinical methods.—Although the
infection with Malignant Tertian parasites found in November was probably a new
one, it was known that the patient had suffered from an untreated infection with
Simple Tertian parasites since the previous April, and throughout the summer his
spleen had been enlarged nearly to the umbilicus ; so that a diagnosis of " malarial
cachexia " was justifiable. Despite the severe infection there is nothing of note
to record regarding the symptoms. As in the other cases, the illness consisted of
a series of attacks of fever, during which the boy was obviously ill, separated by
intervals of apyrexia, during which he recovered. On the whole, he appeared noss
22
worse at the termination of the systematic examinations in February 1903 than he
was at their commencement in November 1902. On the contrary, there was
evidence that the attacks of fever were being felt with much less severity, and that
he was rapidly acquiring an immunity against malarial infection. As regards
diagnosis by clinical methods, I need refer only to the diagnosis during pyrexial
periods. In spite of the fact that the infection was a mixed one, chart V shows
that during most of the relapses even the taking of temperatures only twice daily
would have sufficed to enable a diagnosis of malaria to be made ; but while on
inspecting such a chart we should have had no doubt that the case was one of
malaria, we should have been much puzzled to state what type of parasite was
present. Seeing that throughout the period of examination no other parasites
than Simple and Malignant Tertian were present, it is remarkable that the chart so
frequently showed a Quartan type of fever. This is seen during more than one
period between December 8th and January 14th, but nowhere so plainly as
between January 7th and January 14th. This portion of the chart is typical of a
double Quartan infection. Had the two-hour chart ( chart VI) been carried beyond
the 8th of January, this curious coincidence might have been explained more
easily.
Diagnosis by microscopical methods. —The record of blood examinations
shows that probably at any time a diagnosis by this method could have been made
easily : at the same time we must remember that the infection with Malignant
Tertian parasites was probably a recent one, and that, had there remained only the
old-standing Simple Tertian infection, the difficulties might have been somewhat
similar to those present in the case of Hira.
So far as a study of these three cases enables us to form an opinion, we may
sum up the signs, symptoms, and method of diagnosis of " malarial cachexia,"
as it occurs among natives of India, somewhat as follows :—
(1) Enlargement of the spleen and anæmia are the most evident physical
signs.
(2) As a rule serious symptoms are absent.
(3) The illness is not a continuous one ; periods of fever and illness alter-
nate with periods of apyrexia and recovery. The patient becomes anæmic and
his spleen becomes enlarged, but he does not go from bad to worse ; on the
contrary, there is evidence to show that each relapse of fever is felt with less
severity than the one which preceded it, and that finally he acquires a relative
immunity to malarial infection.
(4) The temperature chart shows definite pyrexial and apyrexial periods ;
long-continued " irregular " fever is not present, and there is no indication of
the presence of fever resembling the fièvre symptomatique described by Kelsch
and Kiener.