NationalLibraryOfScotland/medical-history-of-british-india huggingface dataset:
( 45 )
been ailing for four months only. A son, aged about four
years, died six months ago of the same disease. Their illnesses
began with strong, fever, which still attacks them every now
and again. [The fever is intermittent from the description
given]. These three unfortunates are at present very ema-
ciated and very anæmic. The father has oedema of both feet
(very marked) and puffiness about his eyes. The youngest
boy has also oedema of both feet and a collection of fluid in
his abdomen and scrotum. The abdomen is so much distended
that he is scarcely able to stand. The superficial veins of his
abdomen are markedly distended. Both boys have very large
spleens. The father's spleen is not enlarged. The livers in
all cases are normal. The father alone has suffered from diar-
rhoea at times during his illness. At present the bowels of all
three are irregular, and they all complain of great weakness and
loss of appetite. They have noticed nothing abnormal about their
urine, which seems right in colour and quantity. The man
has lost all virile power for over two months. 1 failed to find
any pigmentary deposits about this family, in fact, they are all
of a light brown tint. They have never had any bleeding from
the nose. The father and youngest boy are scorbutic. Their
food consists of dhal and rice, and, from what I could gather,
very little of it. The hut they occupied was a miserable
one, low and dark, and thickly surrounded with jungle and
rank vegetation. This family is in very needy circum-
stances."
These are all three typical cases of anchylostomiasis
in an advanced condition. In the case of the two children,
it is complicated with malaria, but the father is free from
it. Here, too, is an instance of the way in which the disease
spreads through a family.
Case No. 7 "is that of a Gáro woman, said to have
had fever for the last four or seven months every now
and again. She is slightly emaciated, but very anæmic.
Her tongue is pale and flabby, appetite pretty good. Has
never had diarrhœa, oedema, or bleeding from the nose. Her
spleen is not enlarged. Her great distress seems to be due
to an intensely severe pain over the left half of her head.
This has troubled her for six weeks, and is scarcely ever
absent. She is at present suckling an infant seven months old."
A typical case of anchylostomiasis moderately advanced,
and without a sign of malarial complication.
( 46 )
Case No. 8 " is that of the Agia school-master. He
has had fever (intermittent) almost daily for the last four
months. He frequently feels feverish and out of sorts,
although no fever is actually present. When I saw him, his
temperature was 100.2F., pulse normal, never had diarrhoea,
is very scorbutic, his gums were bleeding. Bled from the nose
fifteen days ago, and again after three days : on both occasions
the bleeding was profuse. His spleen was normal. His appetite
bad, his bowels somewhat constipated. His conjunctivæ were
very white. He is rather a dark-skinned individual."
Clearly a case of anchylostomiasis, again without any
signs of malarial cachexia.
Case No. 9 " is that of a girl aged 14 years, who had
been ill for ten months or more with fever, which she gets
rid of for a time only, as she suffers from it off and on. She
had diarrhoea, but no dropsy or epistaxis. She is slightly
scorbutic. Her spleen is much enlarged. Appetite good.
Bowels regular for some time past. Tongue clean. Her
complexion is light brown, and she is intelligent and cheerful.
She had attended the dispensary two mornings, with long
intervals between the two visits, but, as she did not improve,
the father informed me there. was no necessity for her doing
so any more. I attempted to show him the absurdity of his
ideas, but he held to his own opinion, on the subject."
An ordinary malarial case, but which hardly can be
said to have reached a cachectic condition.
Case No. 10 "was that of a man, aged about 23, who
had suffered from fever for the past eighteen months. He does
not get it near so frequently of late, nor is the fever so severe
as it used to be. He is weakly. His gums have bled some
months ago, but he has no scorbutic symptoms at present. He
has a fair skin, a huge liver and spleen, and oedema of both
feet. His pulse is slow and weak. He is anæmic. His appe-
tite is very good. He usually eats dhál and rice, and only
rarely does he eat fish or fresh vegetables. He will not go to
dispensary. He is at present being treated by a ' Kobiraj.'
The treatment consists in keeping a spot on the crown of his
head (about the size of a rupee) shaved, and into it daily is
rubbed some preparation, the object being ' to cool the
blood.' The application does not burn or smart in the least."
Also a malarial case, but which is in all probability
complicated with anchylostomiasis.
( 47 )
Case No. 11. " was that of a young man aged 23, who
was greatly emaciated. He had suffered from fever for
several years, but only during the last eight months has
become very ill. His spleen is enormous, his abdomen is
greatly distended, both by his spleen and dropsical fluid.
Very marked dropsy of both lower limbs as far up as
the knees. The superficial veins of his abdomen are very
prominent. He has frequently, at different times of his illness,
suffered from diarrhoea, but it has clung to him with great
pertinacity for the last six weeks. His urine is of a reddish
brown colour, and he passes the usual quantity. He has never
bled from the nose. He is scorbutic, and his gums have bled at
times. On his trunk are purpuric spots and extravasations of
blood. The mucous lining of his mouth shows a black pigment-
ary deposit. He is very anæmic,, has no appetite. Now passes
his stools involuntarily, Is not able to stand. His complexion
is of a light brown colour. His brother says he has become
black, whereas, in point of comparison, I remarked he is very
fair for a native, and much fairer than this own brother of his."
A case of anchylostomiasis in its last stage, complicated
with malaria and scurvy.
Case No. 12 " was that of a boy aged five years, who has
been ailing for eighteen months. It began with fever, but after
about four months the fever left. He is now in the same state
very nearly as when I saw him on the 8th December last, the
only change being a slightly greater enlargement of his
spleen, which is truly enormous. His liver is also enlarged.
His conjunctivæ are yellow. His abdomen is so greatly enlarged
owing to the state of his viscera and dropsical effusion,
that the poor little fellow, on being made to stand began
to cry, lest he should fall down, as he was not able to
support himself. When allowed to be seated on the ground,
he was perfectly happy. The superficial veins of his abdo-
men were distended and prominent. There was no oedema
of legs or feet. There was great emaciation. Complexion was
of a rich brown colour."
A case of pure malarial cachexia. Observe how, in this
case, ascites precedes oedema of the lower extremities. In
anchylostomiasis oedema usually precedes ascites. In mala-
rial cachexia of course, oedema often appears later on, but
naturally ascites appears first, due, as it mainly is, to mechani-
cal obstruction to the portal circulation by the pressure of the
( 48 )
enlarged spleen and liver on the vessels. In anchylostomiasis,
on the other hand, the dropsy is of hæmic origin, and naturally
commences in the parts most distant from the heart.
Case No. 13 "is that of a policeman whose home is in
North Salmara. His present illness dates four months back,
but there is an old history of fever. He says he is unfit to do
his work. He is emaciated and has an enlarged spleen ; occa-
sionally suffers from diarrhoea, but has never had dropsy or
bleeding from the nose. The least amount of work quite
knocks him up. He is anæmic, but not scorbutic."
A case probably of anchylostomiasis and malaria, but it
is difficult to say which factor predominates.
Case No. 14 " is that of a Eabha man, age not known,
who has been ailing for fourteen months. His illness began
with a strong fever (intermittent) which lasted for three months.
At the end of this time he had diarrhœa for ten days. At pre-
sent he complains of having a great disinclination to do work
of any kind, and, should he do any work, he finds a trifling
amount quite fatigues him. His spleen is slightly enlarged,
and his conjunctivæ are very white. Pulse 70, but not
strong."
This, again, is clearly a case of anchylostomiasis in a
moderately early stage, with trivial malarial complication.
This man's sister was also ill, but Dr. Dobson was not allowed
to make any proper examination of her case.
Case No. 15 " is that of a Eabha man aged about 30
years. He was somewhat fairer in colour than his neighbours,
and was suffering from oedema of both feet and seemed very
weak. I was told by his friends that he had been ailing for
a long timé and that he had kála-azár. This man at the time
of my visit was busy making a sacrifice."
This too is pretty certainly a case of anchylostomiasis,
though the data are rather scanty.
Case No. 16 "is that of a boy aged 12 years. He has
had fever for over a year. Fever present when I saw him.
Very anæmic, liver and spleen both enlarged, the latter very
much so. Conjunctivae very yellow. Never had diarrhoea.
No other symptoms noticeable; complexion is of the usual
brown colour. The peculiarity about this case is, he is said
to have kála-azár and yet reputed to have got a yellower colour
than he was when in health. His father asserts ' he has not got
blacker, but fairer.'"
( 49 )
Appears to be a case of ordinary malarial cachexia, perhaps
complicated with anchylostomiasis.
Case No. 17 "is that of a Eabha man aged 40, although,
according to his own statement, he is not more than 20.
He has suffered from fever for ten days. It is intermittent in
type. He is altogether a debilitated subject and anæmic, his
chief complaints being weakness and total loss of virile power,
during the last three days only. He further stated this is usual
in kála-azár, and that when the women get, kála-azár their
menses cease."
There is nothing here to account for the · anæmia, but
anchylostomiasis especially as the condition of the spleen is not
stated, but enlargement cannot have been very marked, or it
would have been noticed, as in the other cases.
Case No. 18 " is that of a Eabha man who has had fever
for over two years. For the first four months he suffered most,
and then he found he had a large spleen. The fever still
attacks him occasionally. He now suffers from great weak-
ness, and is quite unable to move beyond his door. He is
extremely emaciated, his conjunctivas are very anæmic. He-
has suffered from diarrhoea for the past two months. Never
bled from nose. Is scorbutic. Belly greatly distended with
fluid,the superficial veins of abdomen are prominent, spleen enor-
mous. Liver seems normal. Great oedema of both feet.
Puffiness about the face and eyes. Complexion light brown,
but on. the mucous lining of his cheeks there is a fair amount of
bluish black deposit, which is very distinct. This man has
two children aged about four and two and a half years of age.
Both these youngsters have large spleen, and are thought to be
healthy. The father has lost all virile power for the past four
months only."
A case of anchylostomiasis in the last stage, the oedema
affecting even the face. There is malarial and scorbutic com-
plication.
Case No. 19 "is that of a chaukidar in charge of the Public
Works Department rest-house. He has had intermittent fever
daily for the last three· months. He has become very thin and
weak, and has no desire to do anything. He is very anæmic.
His spleen is not yet enlarged. His appetite is very poor.
He says he has ' kála-azár. ' He is of a light brown colour. He
objects to take our drugs. I saw this poor fellow again some
days ago, and he then had strong fever, 103°F."
( 50 )
A case of anchylostomiasis, with an intercurrent attack
of malarial fever, but in the. absence of any signs or history
of chronic malarial disease, he certainly cannot be said to be
a subject of malarial cachexia.
Case No. 20 " was a child eight years old who had fever
two years ago, which lasted for several months, and which left
the child very weak and emaciated and with a large spleen.
The weakness is daily getting worse, and a few days at most will
see the end. No further symptoms discernible, nor could I
obtain any further history relative to this case."
This, on the other hand, is probably an ordinäry malarial
case.
While on this tour, Dr. Dobson, apparently mistrusting the
sufficiency of malarial poisoning to account for what he had
seen, examined 42 children to all appearance quite healthy and
reputed to be so, and found that 21, or half the number, had
enlarged spleen, the organ in some cases being very large. This
accords with my own. experience in the Chaygaon district,
where I examined the spleens of a large number of people repu-
tedly healthy. The proportion was about the same, but unfortu-
nately I have lost the slip on which the notes were made. If
then half the reputedly healthy population show more or
less splenic enlargement, is it surprising that it should be
found also in kála-azár ? The reverse would indeed be as-
tonishing, and in the face of such a fact it is obviously
absurd to attach any pathognomonic importance to this
symptom in connection with the etiology of kála-azár.
The next cases are from Mr. McNaught's series, but,
owing to the detailed mass of daily notes, it is impossible
to insert them in full, so that an abstract only is given:—
Case No. 21. Mantang, cultivator, age about 30, living
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at Kalputa in the Gáro Hills. Father died when he was a
child, mother about a month ago. Is married, and has two
children, said to be healthy. His village consists of about
16 houses, all inhabited by Gáros. A large number of people
had died of kála-azár in neighbouring villages, but his
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village was not attacked till about a year ago. The disease
was believed to have been brought from Khilonbari, which
is within sight of Kalputa. A man called Thodang was the
first person attacked, and, though ill, he still lives. This
man's grown-up niece, and some of his children have since
( 61 )
become affected. After this, a man called Melcha took the
disease. Then Illal's household became affected, and four of
his people are still ill. Two men died of the disease in
separate houses, but the family of one of them were not
affected. This illness commenced about a month ago with
feverish symptoms and diarrhoea, then his spleen became
enlarged and he began to lose flesh.
Present condition is weak, thin, and anæmic. Has slight
anasarca, appetite bad, slight looseness of the bowels; spleen
enlarged to 10 fingers below the ribs. Abdominal pain.
The man remained 3½ months in hospital, and, in spite of
continuous anti-malarial treatment, grew steadily worse, had
repeated bowel attacks, and died from an attack of pneu-
monia.
He is recorded as having fever pretty regularly at
some portion of the 24 hours. In spite of this, his tempera-
ture, with one or two slight rises, remained subnormal during
the whole of his stay in hospital, often not reaching the nor-
mal for a week together. During the last fatal attack of inter-
current pneumonia, it ran up to 103°, and remained, above
normal for some days. It had, however, been again subnormal
(95.8°.) for some days before his death. The Hospital-Assistant's
puzzlement at having to do with a case of fever, which the ther-
mometer persistently belied, is betrayed by such phrases as "No
fever now, but had fever during the night," never apparently
suspecting that the man had no fever at all, and that his saying
he had had it, merely meant that he felt ill, and that, like most
sick people, he felt worse at certain periods of the 24 hours
than at others. Anti-malarial treatment had a fair trial in this
case. Quinine in 16 grains doses, arsenic, iron, and iodine were
all tried, and persevered in ; but, in spite of the fact that the
man 's case was at first by no means serious, and had only
lasted a month, under this treatment the man steadily grew
worse instead of better. Considering that the only symptom-of
malarial poisoning in this case was a moderately enlarged
spleen, such as is found in immense numbers of Indians, to
all appearance enjoying very fair health, this result is by
no means surprising.
Post-mortem examination twelve hours after death.—
Body emaciated, not darker than usual. Feet œdematous.
Section of tissues anæmic.
Thorax left plural cavity contained fluid of a slightly
turbid character, pleura congested and rough. Posterior
( 52 )
part left lung in a state of gray hepatization, no fluid in right
pleural cavity.
Heart contained P. M. clots ; structurally healthy.
Abdomen contains a moderate amount of pale serum.
Liver of normal size, not congested, of firm consistence,
" otherwise of normal appearance." Spleen enlarged to three
times normal size, lobulated, section firm, capsule thick and
corrugated, no infarcts.
Kidneys—right congested, medullary portion slightly
granular; left of similar appearance. Suprarenal capsules
appear normal.
Stomach contains thick white mucous adhering to
mucous membrane, the surface of which is brownish and cor-
rugated., but not ulcerated ; mesenteric glands of normal size ;
section anæmic.
Intestines—the duodenum and about 2 feet of the jejunum
were of somewhat slaty colour, which became lessened gradually in
the lower parts.—Lower down the bowels were considerably
thinned with patches of dotted congestion, sometimes extending
through Peyer's patches in streaks, but not over the whole
surface, but no ulceration, and there were other Peyer's
patches quite healthy.
Here we have described a typical case of -anchylosto
miasis alike in symptoms, progress, and termination. Post-
mortem—the appearances found after death in such cases
are all described, except the worms, which, as I well know,
are much more easily overlooked than found, even when
one is actually searching for them; but the condition of
the stomach, and of the duodenum and upper part of
the jejunum are most typical, and a similar combination will
hardly be found in any other disease than anchylostomiasis.
The thinning of those parts of the intestine not the seat
of active irritation from the parasite, is of course only a part
of the general emaciation, while the reddish streaks found were
probably only patches of hypostatic congestion.
Case No. 22, Khejan, a Gáro cultivator, Æt. about 1.5
years, came from Kerapara in the Gráro Hills. " The usual
history " of illness for some time, with enlarged spleen, fever,
gradual wasting, and inability to work.
Present condition, is anæmic, thin, and weak, but can still
get about. Gets fever irregularly. Bowels regular, chest
healthy, pulse quick, tongue pale, appetite fair, spleen slightly
enlarged. None of his relatives have had kála-azár.
( 53 )
The after history of this case closely resembles the preced-
ing. He was submitted to anti-malarial treatment, under
which the spleen diminished in size ; but, in spite of this, he be
came steadily worse, and died from a violent intercurrent attack
of diarrhoea, after a stay in hospital of a little less than three
months.
A temperature of 101.8° is recorded once only, and with
this single exception, there was never any pyrexia during his
whole stay in hospital, and, as in the preceding case, the
temperature is often sub-normal.
The post-mortem examination showed the death to be
immediately due to enteritis. The same peculiar appearances
are recorded in the duodenum, and he also describes a large
number of " deposits of pigment of an inky hue varying in size
from that of a millet-seed to a split pea, many of them being quite
firm to the feel."
These are of course the well-known " bites " made by the
parasite, and consist of extravasations of blood into the mucous
and submucous tissues. It is instructive to note that, whatever
malarial element may have at first been present in this case, it
was in a fair way to cure at the time of his death.
Case No. 23, Nausi, a Gáro cultivator's wife, aged 26.
Kalá-azár had appeared in her village two years ago. She
has been ailing for a year, her child took the disease and died,
and her husband ran away from her, from fear of contracting
it. Her illness commenced with pain in the head and discharge
of blood from the bowels. She stated that her skin had become
darker. Her appetite is bad, she complains greatly of head-
ache. Her spleen is somewhat 'enlarged. She is thin and weak,
face and eyelids puffy, conjunctivæ of a "muddy" colour,
tongue pale and flabby. Base of lungs œdematous.
This woman remained nearly six months in hospital,
during which time she had repeated severe attacks of diarhœa,
the bowels being loose the greater part of the time. She grew
decidedly better, the diarrhoea ceased, and she was discharged
apparently in a fair way to cure.
This case is less clear than the preceding, but the
degree of enlargement of the spleen will not account for
the oedema, &c., and the general severe symptoms, and it
is probably one of anchylostomiasis also. It seems probable
that the violent and repeated attacks of diarrhoea may have
dislodged the worms. I am strongly inclined to believe that this
sometimes takes place, though I have not as yet been able to
( 54 )
find worms in such a case. My opportunities, however, have
been small, as I have nearly always given thymol after but
few days' observation.
Case No. 24, Dachi, a girl aged 12, daughter of a culti-
vator; was driven away from the village, because she had
kála-azár. Her parents had both died of it. She was found
on the road, and brought into Tura in a state of semi-
starvation.
Present condition.—Body thin, feet and face œdematous,
anæmic, bowels loose. Her spleen is very large.
This patient rallied at first, but suffered almost conti-
nuously from diarrhoea and severe abdominal pain. Her tem-
perature, though not of a malarial type, remained at one time
continuously between 101° and 102°. It is only recorded, how-
ever, for a few days, and the pyrexia was probably connected
with a severe attack of enteritis. She lingered on for three
months, and finally died from a fresh bowel-attack.
Post-mortem examination.—Body much emaciated, section
of tissues anæmic.
A little serum in pericardium and pleura, but thoracic
organs otherwise healthy.
Liver large, somewhat congested.
Spleen very much enlarged.
Duodenum somewhat thickened and large. Jejunum has
a darkened appearance caused by a remarkably fine dotted
pigmented deposit not ulcerated. There were arborescent
patches of congestion in the ilum, but Peyer's patches were
healthy, and so were all other remaining organs.
There can be of course no doubt as to the gravity of the
malarial complication in the case of this poor waif, but the post-
mortem appearances leave no doubt as to the case being one of
anchylostomiasis, and, as she died from the irritation to the
small intestine caused by the parasites, it was evidently this,
and not the malarial complication, that caused the fatal issue.
Case No. 25, a Gáro woman, aged 28, wife of a cultiva-
tor. Lives at Marapura, where three people had already
been attacked by kala-azar, one of whom has since died. She
was taken ill about a year ago, and since then, her husband
has become ill, and her child has died. The illness commenced
with fever, followed by enlargement of spleen. Has had
diarrhoea for two or three months, severe pain in the head,
lost flesh, and has become unable to work.