NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
( 55 )
Present condition.—Is still able to stand and walk, but
is very weak and emaciated. Her appetite is now fair. She
is anæmic, her feet are œdamentous, and her spleen is enlarged
to six fingers breadth below the ribs. Her skin does not
appear to have grown darker.
This patient seems to have improved somewhat; she does
not appear to have had any fever whatever during her stay in
hospital, which extended to two months and a half, but the
termination of the case is not recorded, as she appears to have
been still under treatment when the collection of cases was
sent in. This, too, is in all probability a case of anchylos-
tomiasis, at any rate the amount of splenic enlargement is
quite inadequate to account for the anæmia and anasarca.
The remaining 25 cases of Mr. McNaught's series include
several which there can be no doubt were instances of anchy-
lostomiasis. They also include one case of acute pneumonia,
two of acute dysentery, several cases of ordinary or remittent
fever, which of course yielded to treatment, and one or two
cases in which the evidence points to malarial cachexia, besides
some cases in which apparently anchylostomiasis and mala-
rial cachexia coexisted in various proportions. In some cases
from the police and jail hospital there is nothing to show that
the patients believed themselves to have kála-azár, and they seem
to have been classed as such, simply because they had fever.
It is quite evident that Mr. McNaught was on the verge
of discovering the true nature of the cases with which he had
to deal. The careful examination he made of Peyer's patches
in each case shows that he suspected some connection with
typhoid fever, but in place of the lesions characteristic of that
disease, he found changes in the upper part of the gastro-intes-
tinal canal which he saw were quite peculiar, but which,
owing to the non-discovery of the worms that cause them,
remained inexplicable. The preliminary washing necessary
for a careful examination of the mucous surface necessarily
washed away the worms, and left him only the changes pro-
duced by them to observe. All his dissections were made
several hours after death, or, in other words, at a period when
the worms would have become detached from the mucous mem-
brane, and so enveloped in the glairy yellow mucous of the
duodenum as to be quite invisible except to closest scrutiny,
directed especially to their discovery. Had he chanced to
have made one of his examinations immediately after death,
while the parasite is still fixed to the mucous membrane, he
could scarcely have failed to have found them and to recognize
( 66 )
the causal connection between them, and the peculiar, and
otherwise inexplicable lesions he had found in those portions
of the bowel occupied by them.
Case No. 26 (Dr. Nandi's series).—Manara, an Assamese
Muhammadan, aged 25. For the last five years has lived in
Gauháti as a domestic servant in a native family. Before this
he served as water-carrier, on a tea-garden for about two years.
About six months ago suffered from fever, and since then he
has got steadily worse, suffering mainly from dyspeptic
symptoms.
Present condition.—Is markedly anæmic and emaciated,
with a much enlarged spleen and slight anasarca of the feet.
Can walk a little. Urine s.p. 1,010, acid, no sugar or albu-
men. As he was suffering from diarrhæa, no purgative was
given, but he was at once placed upon slop diet and thymol
administered, four doses of 30 grains being given, at 6 a.m.,
8 a.m., 10 a.m., and noon. He passed one stool at 9.30 and
another at noon, and both were examined for anchylostoma,
as well as one passed at 4 p.m., the previous day, before the
administration of thymol, but no worms could be detected.
This and the following four cases are interesting, because
they are not originally contributed as examples of kála-azár,
but in compliance with a circular of the Sanitary Commis-
sioner, requesting an investigation as to whether or not anchy-
lostomiasis existed among Native Assamese as well as among
imported coolies. That the case was one of anchylostomiasis
there cannot be the slightest doubt, and the way in which the
discovery of the worms was missed is a good illustration
of the way in which misleading evidence has accumu-
lated. It will be observed that the last stool examined
was one passed about the same time as the administration
of the last dose of thymol, and only six hours after the first.
Food and badly soluble drugs such as thymol introduced into
the stomach remain there, as a rule, about four hours, so
that only two hours are left for the intestinal contents to
pass from the duodenum to defæcation, a time entirely
inadequate, even supposing the worms to be destroyed by the
first contact of the drug.
I have seldom, if ever, found any worms until some eight
hours after the last dose, and it would have been truly
surprising if they had been found in this case. The next case,
in which Dr. Nandi succeeded in discovering the worms, illus-
trates this point.
( 57 )
Case No. 27.—Domoho, an Assamese Hindu convict, age
about 32, has been in jail about a year, previously to which, with
the exception of a month, during which he served in Gauháti
as a servant, he had resided at Nomati in the Nalbari thána.
About four months ago, had fever and cough, and has not
been well since, suffering much from palpitation of the heart,
dyspepsia, occasional diarrhoea, alternating with costiveness,
with rumblings, and occasional abdominal pain.
Present condition.—Marked anæmia and weakness, with
some emaciation. Feet just pit on pressure. After the ad-
ministration of a preliminary saline purgative, the patient
was given three 30-grain doses of thymol at 7 a.m., 9 a.m.,
and 11 a.m. followed by a second saline purge.
At 5-30 p.m. (i.e., 6½ hours after the last dose), he passed
a stool containing 25 anchylostomes.
At 6 a.m. a stool containing only two ascárides.
„ 8 p.m."] passed stools, which were collected in a single
„ 9 ,,
vessel, and found to contain a number of
,, 10 „ ) anchylostoma and one ascaris.
It will be observed that it is not till nine hours after the
last dose that the bulk of the worms appear. It is improbable
that he contracted the disease in jail, so that it was probably
contracted in his native village, a fact which would seem to
point to a somewhat prolonged period of incubation, during
which the worms were slowly growing to maturity. My
experiments on monkeys, though not conclusive, would seem
to point to a similar conclusion.
Case No. 28.—Kikhor, aged 20, a resident of Gauháti,
but in the habit of making trips to upper Assam in pursuance
of his calling, as a boatman. For the last six months
has been suffering from abdominal pain, alternating diarrhoea
and constipation, with palpitation of the heart. Is anæmic and
weak, feet œdematous, face to a less extent so. Has enlarged
spleen, and the hepatic region is rather full, with pain in left
hypochondriac and umbilical regions, and winces on pressure
over hepatic region. Urine high coloured, no albumen.
Treatment—Calomel, grains ii., every four hours, for four
times, followed next morning by thymol, grains xxx, at
6 a.m., 8 a.m., and 11 a.m. He passed one stool at noon, and
a second at 1 p.m., which were examined, but no anchylostoma
were found.
The patient died four days after, and a post-mortem exam-
ination was made. The description of the changes recorded
F
( 58 )
reads much like some of Mr. McNaught's cases, with the addition
that nearly the whole length of the intestinal mucous mem-
brance was closely scrutinized, but no anchylostoma found.
Here, again, the last examination of the stools was made
only an hour after the last dose of thymol, and however many
worms may have been ejected by it, they would not be dis-
coverable in the stools until many hours after. After such
a thorough dosing with thymol and purgatives, the close search
for anchylostomes was hardly likely to be rewarded, as all
would be, almost infallibly, cleared out of the intestine.
Case No. 29.—Jugil Kachari, aged 13. Has served
for the last three years on a tea-garden, whence he
was admitted to the charitable dispensary, Gauháti. About
a year ago suffered from fever, and two months after this his feet
commenced to swell, and he gradually became very weak.
Present state. Is anæmic, suffers from palpitation of the
heart, pulse 100. Spleen enlarged, feet œdematous, face slightly
swollen. Appetite bad. Suffers- from alterating diarrhoea and
constipation. Liver slightly enlarged. Thymol was given in
15 grain doses (a quantity I have personally found inade-
quate), and the last stool examined was passed five hours after
the last dose.
Under the circumstances, it is not surprising that no worms
were found. Here is a regular case of tea-garden beri-beri, yet
observe the identity of the symptoms with those recorded in
kála-azár, even to the fever and hepatic and splenic enlarge-
ment, and notice the double fallacy involved in the assumption
that no anchylostomes were present.
Case No. 30.—Shaik Hyat, an Assamese Muhammadan,
aged about 40. Has served off and on in tea-gardens, was in
hospital five or six months ago with syphilis. Has lately become
weak, and has, for a long time, suffered from diarrhoea and
dyspepsia. A little while ago had an attack of melæna, lasting
two or three days, during which he passed much blood, quite
unaccompanied by pain or tenesmus.
Present condition—Emaciated, weak, and anæmic. Feet,
legs, and scrotum œdematous; a little ascites. Breathing
laboured, appetite bad. No enlargement of liver or spleen.
He was given thymol at 6 a.m., 8 a.m., and 10 a.m., and stools
passed at 9 a.m. and 11 a.m. were examined for worms, but
naturally enough none were found. The case, of course, is a
typical one of anchylostomiasis. What other disease indeed
will account for the painless melæna ?
( 59 )
To this collection I add two of my own cases observed in
the charitable dispensary, Gauháti, which illustrate certain
points which are not noticed in any of the preceding cases.
Case No. 31.—Api, aged 4, an orphan, can give no account
of herself, but is a Kachári, a class whose diet is of a mixed
character, and in fact will eat almost anything.
The child is extremely weak; cannot stand without assist-
ance ; there is general oedema and ascites; and the face is
very puffy, but there is no special prominence of oedema along
crest of tibia. There is no sign of paresis or of diminished
sensation, and the special senses appear normal. Complexion
moderately dark, skin dry and hard. She is anæmic to the
last degree, tongue clean, but deadly pale, pulse 102, very
weak. Bowels loose, but motion not dysenteric. The lower
part of the chest contains fluid, but the lungs and heart are
otherwise normal. The liver dulness extends barely to the
costal margin: above, its limits are masked by the presence of
fluid in the chest. The spleen appears much enlarged, but,
owing to the presence of ascites, and much flatus, it is difficult
to define its exact limits. The blood was very watery, and poor,
in red corpuscles, which did not exhibit the normal uniformity
of size. Ño micro-organisms could be detected in it, and
attempted cultivations gave negative results.
A few days after she came under observation, the post
mortem in which anchylostomes was first found, occurred,
and, 011 examining her dejecta, large numbers of ova were
discovered. She was given thymol, and a large number of
anchylostomes and a few lumbrici were expelled. No good,
however, resulted, and I am even inclined to think that the
fatal termination may have been accelerated. She gradually
sank, and died about three weeks after she came under my
observation. There were a few irregular elevations of tempera-
ture, but otherwise the temperature was constantly subnormal.
Post-mortem examination, made three hours after death.
Total weight, 30 pounds. Body emaciated, but extremely œde-
matous, the distended cellular tissue being an inch deep over
the chest, and, like all the other tissues, excessively anæmic.
Abdomen, pluræ and pericardium full of fluid. Brain 2 pounds ;
some fluid in ventricles, otherwise healthy. Heart 2¼ ounces ;
muscle rather œdematous, right side contains a large ante-mor-
tem clot, a tail of it extending into the pulmonary artery.
Valves healthy, with the exception of three small hard granu-
lations (old) on posterior flap of mitral.
F2
( 60 )
Lungs—Right 4 ounce, left 3½ ounce. Both very œde-
matous ; a few scattered miliary tubercles on surface of right;
none on left.
Liver, 1 pound 5 ounces, of normal appearance, gall blad-
der much dilated, containing, greenish, glairy bile.
Spleen, 9 ounces, dense, and harder than normal; no
adhesions on the surface.
Kidneys, weigh together 4 ounces. Capsule peels easily in
both, right with convex border congested, interior pale. Left
pale throughout, cortex somewhat atrophied.
Stomach shows scattered petechiæ. Greater curvature of
a dull bluish red colour.
Intestine, duodenum and upper part of jejunum of a
peculiar slaty hue, closely spotted with marks of old and recent
bites. In duodenum and upper part jejunum ten anchylosto-
mes were found (eight females and two males) adherent to the
mucous membrane, most being found about three feet down
jejunam. Besides these, a number of shred-like bodies contain-
ing ova (probably dead, half-digested parasites) were found
in the intestine. The ileum contained a number of lumbrici, and
trichocephali were found in the cœcum, some lying coiled up
within ulcerated surfaces. Near the anus a number of oxyu-
rides.
Case No. 32.—Jagat Das, a Hindustani, who had lived
for some years in the neighbourhood of Gaháti. Age about 30.
ι?
Much emaciated. Height 5 feet 6 inches, weight 901bs. Can
scarcely stand, and is too apathetic to give any clear account
of his past history.
Face puffy, legs œdematous. No modification of sensory
or motor power, apart from extreme weakness and hebetude.
Is frightfully anæmic, and the tongue is very pale, but furred.
Skin dry and cold.
Area of cardiac dullness somewhat increased, but difficult
to define, on account of being merged below in the dulness
extending over the lower pulmonary area. A weak systolic
murmur, marked ascites, but no other abnormality of abdo-
minal organs. He is constipated, but complains of no pain.
Some kaladana was given to relieve the bowels, and the
dejecta were found to contain large numbers of ova, but the
food was passed mainly undigested.
This man lived only three days after admission. Thymol
could only have precipitated matters, and so was not given,
The temperature was persistently sub-normal, and, two hours
( 61 )
"before death, was only 90° in the rectum, the lowest tempe-
rature I have ever seen recorded in a living human being.
The blood was repeatedly examined at different periods of
the day, but no micro-organisms could be discovered.
Post-mortem examination four hours after death.—Ema-
ciated and anæmic, but very œdematous.
Chest.—A small quantity of fluid in each pleura, the
pericardium contained much fluid.
Lungs.—Bight 1¼lb., left l½lb. Both extremely oedema-
tons throughout, congested below, extremely pale above. The
larger branches pulmonary arteries contained ante-mortem clots.
Heart.—Eight side filled with an enormous ante-mortem
clot, which extended into the auricular appendix, and into
the pulmonary artery and its branches. Muscular substance
thin and pale. Mitral valve and adjacent endocardium some-
what thickened. Left ventricle empty.
Abdomen.—Contained a quantity of ascitic fluid. Liver
lib. 15½oz., pale, but otherwise normal, gall-bladder moderately
full.
Spleen 5oz., tissue of normal appearance, very firm.
Kidneys each 4oz. Pale, but otherwise healthy.
Intestinal canal.—Œsophagus pale, but normal. Stomach
dilated, pale, with a few reddened patches and petechiœ, the
walls of the organ are so thin as to be nearly transparent. The
bowel was loaded with alvine secretion throughout the upper
part, containing mucous streaked with blood. The ascending
colon containing soft fæcal matter, while the lower bowel is
filled with a hard mass. No ova could be found in the mucus
from the upper part of the bowel; they were extremely
numerous in the soft fæcal matter in the ascending colon,
while they were comparatively rare in the hardened mass.
The upper end of the small intestine must have contained
about a thousand anchylostomes. The first specimen was
found adherent immediately below the pylorus, and they
were adherent in great numbers to the whole of the duodenum,
and upper third of jejunum. The greatest numbers to be
found in the commencement of the jejunum, where 65 were
counted adherent to a piece of bowel eight inches in length ;
on this piece only 10 more recent bites than adherent worms
could be counted. About 3½ feet along the jejunum, only
30 could be counted in a similar length, while at 5 feet
only unadherent specimens could be found, and a few such
could be found throughout the greater part of the length
of the small intestine. No other entozoa were present. The
( 62 )
aorta and larger veins, as well as the thoracic duct, were
examined, but presented nothing abnormal.
At first sight, it might appear, from a perusal of this collec-
tion of cases, that we were as far as ever from being able to de-
fine what kála-azár is. It will be observed that it includes cases
of the most diverse character. For the most part, however, all
are chronic cases,. whose common leading characteristic is ca-
chexia. Even this characteristic, however, is not universal, for,
as we have seen, cases of acute maladies, such as dysentery
and pneumonia, are included.
Putting these aside, however, the common symptom that
characterizes the greater number of the cases is anæmia, and the
prominence and importance of this symptom has been noted
by all observers, in illustration of which we may now with
advantage add some of the remarks as to the general symptoms
of the disease that have been made, from time to time, by
medical officers who have given special attention to the subject.
Deputy-Surgeon-General Clarke (Annual Sanitary Eeport,
1882), epitomizing the accounts he had received from various
sources, says " a disease commencing with pyrexial attacks,
ushered in with rigors, and followed by sweating frequently
recurring, accompanied by pains in the joints and continued-
headache, resulting in a condition of general anœmia with
splenic and hepatic enlargement. This is followed by extensive
anasarca of hæmic or renal characters affecting the face, eyelids,
abdomen, and feet ; occasionally by melanasma, epistaxis, diar-
rhoea, melæna, aphonia, and symptoms of laryngealand bronchial
catarrh. The disease generally terminates by death from gene-
ral asthenia. * * * Nearly all the preceding symptoms
seem to depend on one other symptom not yet mentioned.
That symptom is an intense anæmia, which shows itself at an
early period, and continues to increase in intensity as the
disease progresses."
Now, I have strong reason for believing that anchylosto-
miasis does often commence in a pyrexial attack, but putting
aside the pyrexial onset, could one possibly have a better
account of the symptoms of anchylostomiasis than is here given ?
Dr. Borah (Appendix to Annual Eeport of 1888) says
—" The train of symptoms appear in the following order :—
Anaemia, enlargement of the liver, loss of appetite, emaciation,
œdema of the feet, diarrhoea, ascites, and, in a very few cases,
cancrum oris (due to poverty of the blood), also enlarged
spleen and phthisis pulmonalis."
( 63 )
Here again, the description will apply well to cases of
anchylostomiasis and to no other disease. The order of appear-
ance of the dropsical symptoms, too, is given quite definitely
and accurately, and is, as I have already observed, the reverse
of what is found in malarial cachexia. The very small promi-
nence given to enlargement of the spleen in this description
is another indication of the carefulness of the observations
that underlie it, especially when we remember that the writer
was fully convinced of the malarial origin of the disease,
and, but for this predisposition, must have recognised that,
though anæmia may result from chronic malaria, it is a sequel,
and not a premonitory symptom, of the disease, as here
described. It is evident, indeed, that Dr. Borah strongly
suspected the true cause of the malady, for he states that he
used thymol in some cases, but failed to discover any worms.
That he did not find them is probably due to the fact that
it is quite useless attempting to find them by a mere inspec-
tion of the dejecta, unless they be present in quite exceptional
numbers, though it is equally possible that the cases on
which he happened to try the drug, may have been instances
of ordinary malarial cachexia, or other wasting disease.
Dr. P. M. Gupta, speaking of the disease, as seen in the
Gàro Hills, in the same appendix, describes the symptoms as
follows :—" Obstinate diarrhoea and dysentery, inflammation,
affections of the respiratory organs, enlarged spleen and
liver, epistaxis, with a general tendency to hœmorrhage, dread-
ful anæmia, dropsy, and general anasarca are the most pro-
minent complications." Here there is no attempt to describe
the order of appearance of the symptoms, but the general
description answers most thoroughly to the complications
that appear in the anæmia of anchylostomiasis.
To these pictures of the disease I can add but little, and,
as I shall have to refer more fully to this point when writing
of anchylostomiasis as such, I will not here insert observa-
tions, which would necessarily have to be repeated. It is
obvious that acute cases of ordinary tropical maladies, differ-
ing, as they do, in no way from cases met with all over India,
can have nothing whatever to do with the enhanced morta-
lity, and the same remark applies to chronic cases, such
as the instances of caries of the spine, of phthisis, and of
lardaceous disease which were brought me as kála-azár.
Really, the only common character of the cases is that
they believed themselves to be suffering from kála-azár, and,
in point of fact, it will be found in visiting a kála-azár-stricken