NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
23
(5) For the purposes of diagnosis during an apyrexial period we must rely
chiefly upon negative signs and symptoms : the patient does not complain of
being ill ; he is not incapacitated from doing his work ; as a rule, he is not
emaciated ; he has no fever ; repeated blood examinations may yield entirely
negative results.
(6) During a relapse of fever (pyrexial period) the temperature chart is
definite and characteristic, and we are able to make a diagnosis by inspecting
such a chart. Blood examinations are an important aid if positive results are
obtained, but we cannot place reliance upon them if negative.
Nearly all these characters of " malarial cachexia " are very different from
those described in text-books as being present in this condition, and it therefore
behoves us to ascertain if they are applicable to a number of examples. This
we may now proceed to do.
The following case is similar to many seen in military hospitals for native
troops :—
AMIR KHAN, sepoy ; aged 25 ; seen in 1901 in the regimental hospital at
Alipore near Calcutta. The patient had been admitted into hospital on the 28th
of April suffering from fever and enlargement of the spleen. On his medical
history sheet two previous admissions for " ague " were recorded. His tem-
perature chart from the 28th of April, as recorded by the hospital authorities, is
reproduced here (chart VIII). I saw the patient for the first time on July the 2nd,
that is, when he had been in hospital a little more than two months. His spleen
was enlarged nearly to the level of the umbilicus, and his liver could be felt two
fingers' breadths below the ribs. He was very anæmic, and the conjunctivæ were
very yellow, but he was not markedly emaciated. It was said that quinine had
been administered to him " off and on " since his admission, but it is doubtful
whether the drug really had been well tried. As the patient was not improving,
the medical officer had decided to send him upon sick leave.
On inspecting the temperature chart, we see that it closely resembles those
of cases already described : it is divided into periods of pyrexia and periods of
apyrexia. The first attack shown on the chart lasted from the 28th of April
until the 10th of May and evidently was a severe one ; it was followed by an
apyrexial interval of seven days' duration. The second attack lasted from the
18th until the 31st of May ; it was followed by an apyrexial interval lasting only
four days. The third attack was a mild one lasting five days ; it was followed by
an apyrexial interval lasting nineteen days ;—and so on. Examinations of the
peripheral blood made on the 2nd and 3rd of July did not reveal the presence of
malarial parasites or pigmented leucocytes, and with the medical officer's
permission quinine treatment was discontinued.
Blood examinations were made again on the 10th, 12th, and 17th of July,
24
but no malarial parasites were found. On the 18th, however, a few Malignant
Tertian ring forms were found in a slide of finger blood and many ring forms and
one crescent in a slide of splenic blood. On the evening of this day arrangements
were made to have the temperature taken every two hours, and the chart
reproduced here (chart VII) is the result. On the 20th a good many crescents
and a few ring forms were found in a slide of finger blood; on the 21st many
crescents but only one ring form ; on the 22nd no ring forms after long search.
Crescents were found in considerable numbers until the 27th, when the examina-
tions were discontinued.
This case differs in no important respect from the case of Malignant Tertian
fever previously described, and although at the time when I saw him the patient
was in the condition usually diagnosed in India as "malarial cachexia with enlarge-
ment of the spleen," an accurate diagnosis could have been made during any of
the fever periods by inspecting a carefully recorded temperature chart. Also
the signs and symptoms present were very similar to those which characterised
the case of Baghan. The illness was not sufficiently severe to necessitate
confinement to bed, and if the patient had been a civilian, I do not doubt that,
during the periods when he was free from fever, he would have carried on his usual
occupation.
The following are some more cases of "malarial cachexia" illustrating the
signs and symptoms observed when patients suffering from this condition are
admitted into hospital during pyrexial periods :—
ABDUL G AFUR ; aged 16 years ; seen at Gauhati in Assam. At the time when
I saw him he had been in hospital for about a week ; but before his admission
he had been treated as an out-patient for some days. The case is of especial
interest in that it was shown to me as being, in the medical officer's opinion, a case
of kala azar. At the time of my first examination the patient complained
chiefly of dysentery, but stated that he had suffered from fever "off and on" for
about two years. Possibly as a result of the dysentery he was very weak, but he
was not emaciated, and not more anæmic than are many apparently healthy
coolies in Assam.* The spleen was enlarged nearly to the level of the umbilicus.
His temperature had been taken twice daily since his admission, and the chart
showed evening rises of temperature to between 100° and 101°. He was being
treated with a mixture containing quinine. At my request the medical officer
ordered this treatment to be discontinued and the temperature to be taken every
four hours throughout the day and night. The examination of a slide of finger
blood taken on the 22nd of May—the date when I saw the patient first—was
negative. For two or three days the temperature chart was somewhat irregular,
* On account of the prevalence of ankylostomiasis the value of anæmia as a diagnostic sign in Assam
is very small.
25
but from the 25th to the 30th it showed the typical characters of Quartan fever.
On the 27th, Quartan parasites in considerable number were found in a slide of
finger blood and, on the same day, in slides of splenic blood many Quartan
parasites and blocks of malarial pigment were found, but no "Leishman" or other
parasites were seen. Adequate doses of quinine were administered to the patient
on the 30th and subsequent days, and the fever quickly disappeared.
RAJIA ; aged 40 ; an in-patient of the dispensary at Soneput near Delhi.
The patient stated that he had suffered for more than a year from occasional
attacks of fever similar to the one for which he was admitted. His spleen was
enlarged two inches beyond the level of the umbilicus ; no enlargement of the
liver was detected. He was not emaciated nor weak, and complained only of
fever. His temperature was taken every four hours, and the chart exhibited
typical Tertian periodicity. In a slide of finger blood a few Simple Tertian
parasites were found, and two similar parasites were seen in a slide of splenic
blood. No other parasites were found. Quinine was administered to the patient,
and in a few days the fever disappeared, when, being of opinion that he was
cured, he requested to be discharged from hospital. His spleen was still
enlarged beyond the level of the umbilicus.
TULSA ; aged 25 ; seen in the Civil Hospital at Delhi. The patient had
been admitted for fever, and quinine had been administered to him from the date
of his admission. I saw him on the fifth day after admission, by which time his
fever had ceased. The lower edge of the spleen reached to a point midway
between the umbilicus and pubes, and the liver was enlarged two inches below
the costal margin. A temperature chart had not been kept systematically, but
I was informed that his temperature was 102° at the time of his admission and
that it had risen to between 100° and 101° each evening on the three first days.
From the date when I saw him it did not rise above normal during the
remainder of his stay in hospital. He remained some time for the treatment
of a chronic ulcer on the leg, but when this was healed he left. His spleen and
liver were in much the same condition as at the time of his admission. I
found no malarial parasites nor pigment and no "Leishman" parasites.
These two cases illustrate the freedom from severe symptoms which, as
I have already pointed out, is characteristic of native patients suffering from
true "malarial cachexia," as well as the shortness of the periods during which
fever is present, the amenability of the fever to quinine treatment, and, above
all, the lack of heed which the patients pay to the fact that their spleens are
enlarged, regarding themselves as quite well and able to carry on their usual
occupations as soon as the attack of fever has passed.
Finally, I shall give some instances of cases of "malarial cachexia" examined
during apyretic intervals. In hospital practice among natives of India such
E
26
cases unaccompanied by fever are seen commonly only in patients who seek
treatment on account of other affections such as ulcers or dysentery, for, as a
rule, the native of India who suffers from chronic malaria does not attend hospital
unless he has an attack of fever; but when one carries out an investigation
upon the inhabitants of a village, it is usual to find numerous cases.
P—A— : seen in 1901 in the surgical ward of the General Hospital
in Calcutta. The patient had been admitted to have an operation performed.
It was found that his spleen was enlarged beyond the level of the umbilicus, and
on being questioned he said he had had occasional attacks of fever during the
previous two years. He reported that generally the attacks lasted only a few
days and did not trouble him much. He had noticed that his spleen was enlarged,
but did not consider it of importance, and said he had not come to hospital for
the treatment of fever, but for a surgical affection. For some time after his
admission his temperature remained normal and no parasites nor pigment
were found by repeated examination of his blood. On the 22nd of July he
developed a typical attack of ague; he had a severe rigor and his temperature
rose to 105°F. Quinine was not administered. On the 23rd and 24th his
temperature did not rise above normal, but on the 25th he had another typical
paroxysm, his temperature rising to 103°. Quinine was then given and he
suffered from no more attacks during his stay in hospital. On the 24th, 25th and
26th his blood was examined and a fair number of Quartan parasites were found on
each day. On the 27th only two parasites were found after long search, and on
the 28th no parasites nor pigment were seen. When the patient left the hospital,
his spleen was about the same size as at the time of his admission.
This case, in which the diagnosis of "malarial cachexia" was certainly
justifiable, illustrates nearly all the characters of this condition previously
summarized : the presence of a greatly enlarged spleen unaccompanied by fever
or any other important symptom; the fact that during the apyrexial period the
patient felt quite well; the negative results of blood examinations during this
period; the definite character of the temperature chart during the relapse of
fever; the positive results of blood examinations during this period; the fact
that the illness caused by the relapse was very temporary, the patient leaving
hospital before his spleen was appreciably reduced in size.
MOLAR; aged 40; an in-patient of the dispensary at Soneput. He gave a
history of having had attacks of fever at irregular intervals for 1½ years, but stated
that the last attack had ended some months ago, and that he sought admission
into hospital not on account of fever, but for the treatment of a chronic ulcer on his
leg. His spleen was enlarged one inch beyond the level of the umbilicus.
His temperature did not rise above normal during his stay in hospital. No
malarial parasites nor pigment and no "Leishman" or, other parasites were found.
27
When the ulcer was healed, the patient left the hospital, his spleen being
enlarged to the same extent as at the time of his admission.
In a previous memoir dealing with Oriental or Delhi Sore * I gave brief notes
of 28 cases in many of which the condition was similar to that of this patient—
a condition which I believe to be similar also to that of Hira, Baghan and Man
Singh during the intervals between their relapses of fever. I propose now to add
a further series of similar cases examined in Assam.
No.
Place.
Name and
age.
Condition of spleen. Other particulars of the case.
Result of examination
of blood.
1 N ongpoh
(about half-
way be-
tween Gau-
hati and
Shillong).
Gokhal ; 30
years.
To umbilicus
Has had attacks of fever
at irregular intervals for
several years. The last
attack, of 11 days' dura-
tion, occurred a month
ago. He is a police
constable and is not
incapacitated
from
carrying out his duties
efficiently.
Finger
blood.
No
malaria parasites ; no
pigment ; no other
parasites.
Spleen
blood.
No
malaria parasites ; no
pigment ; no other
parasites.
2
"
Munshi ; 24
years.
One inch beyond
the umbilicus.
Has had attacks of fever
" off and on " for 6
months. He states that
he gets an attack about
every 15—20 days, but
that between the attacks
he is able to do his work.
At the time of examina-
tion his temperature was
101º ; he said that he
had been suffering from
fever for four days. He
had taken no quinine.
Finger blood. Many
SimpleTertian malaria
parasites ; no other
parasites.
Spleen blood. A few
Simple Tertian ring
forms ; a fair number
of pigmented leuco-
cytes ; no other para-
sites.
3
"
Bera; 15
years.
To umbilicus
Said to have had fever
" off and on" for 3
months : at first it was
of continued type ; after
two weeks it ceased and
he was free from fever
for 3 weeks ; it then
came on every other day
for a month. At the
time of examination he
was free from fever.
Finger
blood.
No
malaria parasites ; no
pigment ; no other
parasites.
Spleen
blood.
No
malaria parasites ; no
pigment ; no other
parasites.
* Scientific Memoirs by Officers of the Medical and Sanitary Departments of the Government of India,
New Series. No. 13.
E 2
28
No.
Place.
Name and
age.
Condition of spleen. Other particulars of the case.
Results of examination
o f b l o o d .
4
Moriaputty
( Golaghat
district).
Hait Ali ; 9
years.
Beyond the um-
bilicus.
Has
suffered
from
occasional attacks of
fever for a year ; has
been free from fcver for
nearly 2 months.
Finger
blood.
No
malaria parasites; no
pigment ; no other
parasites.
Spleen
blood.
No
malaria parasites ; no
pigment ; no other
parasites.
5
,,
Haru Aya ;
16 years.
Four inches be-
low the costal
margin.
Liver palpable.
She stated that she had
an attack of continued
fever, which lasted 20
days, 6 months ago.
Afterwards she was well
for 2 months. Since
then she has had fever
occasionally. No fever
at time of examination.
Finger
blood.
No
malaria parasites ; no
pigment ; no other
parasites.
Spleen
blood.
No
malaria parasites ; no
pigment ; no other
parasites.
6
,,
Dalnoor ; 28
years.
To umbilicus. The patient stated that he
had had attacks of fever
for about 6 months : in
the first attack, which
lasted about 2 months,
the fever came on every
other day. He noticed
that his spleen was en-
larging. He was doing
his work and had no
fever at the time of
examination.
Finger blood.
No
malaria parasites ; no
pigment ; no other
parasites.
Spleen
blood.
No
malaria parasites ; no
pigment ; no other
parasites.
7
"
Gopin ; 18
years.
To umbilicus . A history of occasional
attacks of fever for a
year. Lately it has come
on almost every day.
The patient is well-
nourished
and
not
markedly anæmic.
Finger blood.
No
malaria parasites ; no
pigment ; no other
parasites.
Spleen blood. One large
Simple Tertian
parasite in a stippled
cell (Romanowsky's
stain) found. No
other parasites.
8
"
Lakshman
Singh ; 25
years.
Beyond the um-
bilicus.
Liver one inch below the
costal margin.
It is stated that the
patient has had fever
" off and on" for a year.
The fever conies on at
intervals and often he is
free from it for a month
or more.
Finger blood.
No
malaria parasites ; no
pigment ; no other
parasites.
Spleen blood.
No
malaria parasites ; no
pigment ;
no other
parasites.
9
"
Thor p o r;
30 years.
One hand ' s
breadth below
the costal
margin.
A history of fever nearly
every day for two
months. The patient is
very anemic. He is
attending hospital and
is taking a " spleen
mixture" which contains
small doses of quinine.
Finger blood.
No
malaria parasites ; no
pigment ; no other
parasites.
Spleen blood.
No
malaria parasites ; no
pigment ; no other
parasites.
29
No.
Place.
Name and
age.
Condition of spleen. Other particulars of the case.
Result of examination
of blood.
1 0
Moiraputt y
(Golagha t
district )—
contd.
Lepton ; 20
years.
To umbilicus . A history of occasional
attacks of intermittent
fever for 1½ y e a r s . H e
has no fever now and is
doing work.
Finger blood. No
malaria parasites ; no
pigment ; no other
parasites.
Spleen blood.
No
malaria parasites ; no
pigment ; no other
parasites.
1 1
"
Jumratti ;
25 years.
One hand's
breadth below
the costal
margin.
A history of attacks of
fever for 2 months.
Temperature at the time
of examination 101º.
Finger blood. Numer-
ous Malignant Tertian
ring parasites ; no
other parasites.
Spleen blood.
Many
Malignant Tertian
ring parasites ; no
other parasites.
12
Kacharih at
(Golagh a t
district).
Amir Chand ;
18 years.
To umbilicus . The patient stated that
he had had fever " now
and then " for a year.
He is doing work.
Finger
blood.
No
malaria parasites ; no
pigment ; no other
parasites.
Spleen blood.
No
malaria parasites ; no
pigment ; no other
parasites.
13
"
Methai ; 15
years.
1½
hands'
breadths below
costal margin.
A history of occasional
attacks of fever for 6
months. No fever at
the time of examination.
Finger blood.
No
malaria parasites ; no
pigment ; no
other
parasites.
Spleen blood. No malaria
parasites ; no pigment ;
no other parasites.
1 4
"
Tor Singh ;
35 years.
Nearly to pubes Liver 3 inches below the
ribs.
A history of occasional
attacks of fever for 3
years. The patient had
slight œdema of the legs
at the time of examina-
tion, but was free from
fever and was carrying
on his occupation of
cultivator.
Finger blood.
No
malaria parasites ; no
pigment ; no
other
parasites.
Spleen blood. No malaria
parasites ; no pigment ;
no other parasites.
15
"
Pya Ram ;
14 years.
Beyond the urn-
bilious.
A history of occasional
attacks of intermittent
fever for 9 months. The
patient was anæmic and
weak at the time of
examination, but had no
fever.
Finger blood.
No
malaria parasites ; no
pigment ; no
other
parasites.
Spleen blood. No malaria
parasites ; no pigment ;
no other parasites.
30
No.
Place.
Name and
age.
Condition of spleen. Other particulars of the case.
Result of examination
of blood.
1 6
Kacharih at
(Golagh at
district)
—concld.
Basiruddin ;
30 years.
To umbilicus . Liver 2 inches below the
costal margin.
A history of occasional
attacks of fever for a
year. At the time of
examination he stated
that he had been almost
free from fever for 2
months.
Finger blood. No malaria
parasites ; no pigment ;
no other parasites.
Spleen blood. No malaria
parasites; no pigment ;
no other parasites.
17
"
Pharmude ;
13 years.
Nearly to the
umbilicus.
A history of attacks of
intermittent fever for 6
months.
Finger blood. Two Simple
Tertian malaria para-
sites found ; no other
parasites.
Spleen blood.
A few
pigmented leucocytes,
but no malaria
parasites seen; no
other parasites.
13
Nadikaner . Moha med
khan ; 23
years.
To umbilicus . It was said that the
patient had suffered
from fever " off and on "
for two years, but during
the last year only very
occasionally.
Finger blood. No malaria
parasites ; no pigment ;
no other parasites.
Spleen blood. No malaria
parasites ; no pigment ;
no other parasites.
19 Golaghat . Burgha on ;
22 years.
To umbilicus . The patient was seen in
the Golaghat hospital.
He had been admitted
for diarrhœa. He had
a sore, which was said to
be a " Naga Sore," on
his leg.
Finger blood.
One
pigmented large
mononuclear leucocyte ;
no parasites seen.
Spleen blood. A fair num-
ber of pigmented large
mononuclear leucocytes ;
no parasites found.
2
"
Lal Maho-
med ; 25
years.
Nearly to the
umbilicus.
Admitted into hospital
for the treatment of a
" Naga Sore." Has no
fever.
Finger blood. No malaria
parasites ; no pigment ;
no other parasites.
Spleen blood. No malaria
parasites ; no pigment ;
no other parasites.
I have now placed before the reader a considerable number of cases, all,
I believe, due to malaria and all having a certain group of signs and symptoms
in common. This group—of which the three most important features are
(1) enlargement of the spleen, (2) a temperature-curve which shows definite
pyrexial and apyrexial periods and during the pyrexial periods shows characters
met with only in cases of malarial fever, and (3) absence of serious symptoms
throughout the period during which the condition lasts, but especially so during
apyrexial intervals—recurs again and again in successive cases of chronic
malaria amongst natives of India ; and, therefore, upon it we are justified in
building up an imaginary picture, or type, of the condition (" malarial.
31
cachexia ") which results to the native of India as a consequence of long-
continued untreated infection with malaria parasites. The three characteristic
or typical features of the condition have just been given, and it will be seen
that they are very different from those which characterise the " malarial
cachexia " of the text-books. But it must be remembered that I am dealing
only with the results of malarial infection in natives of India, whilst what
we may call the text-book view of " malarial cachexia" was derived largely, if
not entirely, from a study of cases which occurred among Europeans. More-
over, even the writers of text-books are not infallible, and, having regard to
recent important additions to our knowledge, it is plainly their duty to ascertain
whether their views upon " malarial cachexia "—even when the term is applied
only to the condition as seen in Europeans—are or are not correct.
If my readers are prepared to agree with what I have written thus far, they
will agree also that upon the subject of the diagnosis of kala azar but little
need be said. For purposes of comparison I reproduce here the temperature
charts of some cases of this disease : it will be seen how very different they are
from the charts of cases of " malarial cachexia." In my experience charts with
characters similar to those in the cases of Bongi, Sindhoo, and Toolsa (charts IX,
X, XI) are most frequently observed in patients suffering only from kala azar ;
but charts like those of Mohisa Mal and Sunkopaha (XIII and XVI) are also
very common ; they recall to one's mind irresistibly Kelsch and Kiener's charts
illustrating the malarial fièvre symptomatique described by them. In his report
on kala azar Major Ross also drew attention to this similarity and used it as
evidence in favour of the view, which he then held, that kala azar is a form of
post-malarial cachexia ; but we have seen that in true " malarial cachexia" among
natives of India, fever of this nature does not occur, and it is not improbable that
the patients in whom Kelsch and Kiener observed it were suffering not from malaria,
but from some other disease, perhaps, indeed, from kala azar. Whoever under-
takes the difficult task of writing the symptomatology of kala azar will need, when
drawing inferences regarding the character of the fever in this disease, to be very
careful to ascertain that it is the only disease present : for perhaps in no other
disease is the character of the fever-curve so easily altered by the concomitant
presence of other diseases. Thus the fever-curve of the patient named Jettoo
(chart XV ) is characteristic only of the disease, pneumonia, from which he died :
and the fever-curve of the patient named Dookhawa ( chart XIV), who was
suffering from malaria as well as from kala azar, shows chiefly, if not entirely,
the characters seen in charts of that disease. In this case we should be
correct in making, in the first place, a diagnosis of malaria : at the same time
we should conjecture that the signs and symptoms present were too serious to
be accounted for by malaria alone ; and afterwards, when we had cured the