Post-mortem examination.?Much emaciated ; head not exuntitled; heart small, pale and flabby ; lungs pale, but. norjnnl; the liver was enlarged and congested, as were also the kidneys, the cortex particularly being very vascular; the spleen was only slightly enlarged ; the mucous membrane of was pale, and that of the small intesthickly coated with mucus, and appeared sofrened; the mesenteric glands were a good deal enlarged, and one round worm of large size was found in the small intestine.
the stomach and intestines tines
was
was noticed in the state of the of tHe did not present any staining characteristic of amyloid degeneration on the application of iodine. Case 2nd.?A lad, named Rengs'a, aged 13 years, was admitted
Nothing
to arrest
and the
blood,
attention
solid
viscera
5th November, died 14th November 1876. Had been a long time ill with fever ; but, although living in the Beldar's village within the station till he
was
boundary, had not applied for treatment with ejectment from the village. He
menaced
presented the symptoms of anaemia degree?extreme paleness of the mucous
in
an
intensified
membranes ; puffiness of the face ; oedema of the ankles ; an anaemic bruit; and diminished appetite. He grew weaker, day by day, and before his death, with some slight complaint, of pain in the abdomen, he became alarmingly prostrate, out of all measure compared with the amount of pain complained of, and howing no si^ns of dyspnoea, but maintaining the sitting posture till completely exhausted Post-mortem
MALARIAL CACHEXIA IN THE GARO HILLS. J. Slane,
By
L.R.C.P., (Edin).,
Civil Medical A MALADY invested with
Officer,
Tura.
contained about half
deal of
good mysterious interest the K:ila occurs in the Garo Hills, popularly known as Hazar," a name probably suggested by a prominent feature of the disease?a progressive darkening and loss of the natural polish of the skin; and as it is the cause of great mortality, "depopulating whole villages," I beg to record a few notes of two cases, which proved fatal at the dispensary since I have had medical charge of the G-aro Hills district. I would premise that the disease occurs most frequently in the lower hills bordering on the plains, and on low marshy localities. It usually begins as an ordinary paroxysmal fever, tending, however, to the remittent type. The symptoms in the beginning are rarely violent, but from being protracted by neglect or absence of treatment, usually assume a very obstinate character, due to certain pathological changes which are set I trust, will be up, and of which the two following cases, found somewhat illustrative. Wliou these are established, the a
"
individual presents a well-marked cachexia, in which recovery is despaired of, and he is expelled from his village as one suffering under the anger of demons, of whom tue Garoa stand in fear. Case 1st
abject
boy, aged about 8 years, named September, died 12th November 1876. He had been under treatment nearly a month, when he came under my care, and had general oedema to a marked extent, the scrotum being much distended. His appetite was voracious, and he had suffered from frequent attacks of diarrhoea, sometimes dysenteric in character, but there was complete absence of fever, and the diarrhoea and ceiiema had quite left at the time of death, which was the result of pure asthenia. The treatment employed in his case consisted of astringents, chalybeate tonics, and an astringent lotion to Diet was liberal with stimulants, but he resisted scrotum. all attempts to give him milk if he detected it, the Garos was
a
Dingmun, admitted
little
on
the 23rd
bavin" for it an unaccountable aversion.
examination.?Great
emaciation ;
head
not
examined ; the heart was enlarged, pale and flabby, and the blood in its cavities thin and serous, resembling in appearance port.wine and water, the weight of the organ was 7 oz. ; the right lung was adherent ar, apex, and the pleural cavity with
coagula
of
a
lymph,
pint
of
sanguinolent
the latter
being of
colour, and of the consistence of calf's feet jelly
;
mixed
light, cherry the left,
lung
very much enlarged, weighing 2 lbs. 14 oz., and the nutmeg character on section was well marked. The free margin was more obtuse than natural, and its substance was unduly firm to the feel. The gall-bladder was
healthy;
the liver
serum, a
was
thin green bile, and the blood in the was distended with inferior vena-cava presented the same impoverished appearance as that observed in the cavities of the heart; the spleen was
enlarged and increased in density, weight l? lbs ; supracapsules were apparently healthy; the kidneys were very pale, and on section resjtnbled the cut surfaces of a raw potato in colour?in short, all appearance of natural structure had disappeared in the lardaceous change?weight of each 4 oz.; the stomach and intestines appeared somewhat
much renal
contracted, and the coats of the ileum were almost membraneous in tenuity. The mucous membrane of stomach
appeared healthy, but that of small intestines was softened thickly coated with mucus, and the mesenteric glands were much enlarged and vascular. The iodine test was applied to the liver and kidneys, and the reaction was sufficiently characteristic to indicate the amyloid change. Among the lesions presented in these two cases, some two or three appear to me noteworthy as affording indications for treat-
and
First I may notice the softened state of the mueous membrane of the small' intestines overladen with a thick coating of In this condition absorption must be a work of extreme mucus. difficulty, and the indication therefore is for the use of fluid
ment.
description, and there is none so milk, with the addition of rice congee. To this I have resorted, therefore, in three cases of malarial anaemia Ihave subsequently treated, and with very gratifying results. The impover-
nourishment of the blandest suitable
as
ished state of the blood, and enlargement of the mesenteric glands and spleen, shew a large increase of the white cells, diminution of the red corpuscles, and
proportionate
tending
THE INDIAN MEDICAL GAZETTE.
124 to
effusions and
passive
diarrhoea, and
calorific
defective
by ferruginous tonics and as the sulphate of iron, quinine, strychnia, and the dilute sulphuric acid?the last in excess?given in combination with the infusion of cliiretta, as well as small quantities of stimulants, with an additional blanket in the cold season. But in the first instance the diarrhoea, if present, should be effectually arrested, and this I have found best effected by a pill of tannic acid, opium, ipecacuanha and The last-named medicine having been suggested santonine. to me by a case in which its exhibition was followed by the expulsion of eighteen round worms. processes, which astringents, such
Of fourteen
best combated
are
of this
cases
year in the Tura recovered ; of these,
cents, and only
malady,
treated
during
dispensary, eight proved
the and
fatal
past six
occurred either in children or adolestwo recovered. Of the remaining six, varying
eight
in age from 24 years to 60, four recovered, and two died. Of the two deaths one was the sexagenerian. Regarding the question of the nature of "Kala Hazar," it
appears to me to be malarial cachexia, pure and simple, advancing by successive stiiges from visceral congestions with an impoverished condition of the blood, tending to dropsical effusions susceptible of remedy, to amyloid degeneration of the blood-elaborating glands and impaired vitality of that fluid, which stage in its progress treatment appears to be of little It would be a mistake too to suppose it to be a disease
at
avail. sui
generis,
peculiar
or
to the Garo Hills.
1 have
seen
it at
Hawal Pindee, in the child of a friend, as a sequel of the malarial fever of Pesliawur. Dr. West notices an analogous affection in his lecture on " Albuminoid Enlargement of the Liver and,
doubtless, it was famliar enough to the Medical Officers who were employed in the investigation of the epidemic fever of Burdwan. I may remark on the similarity presented by my cases in the state of the intestines, to the appearances described by Dr. Aitken as occurring in lardaceous degeneration of the alimentary tract. There were the same pale softened state of the mucous membrane, and extreme tenuity of the coats of the ileum, the latter appearance suggestive of erosion, but there was no ulceration, for the establishment of which probably a In order more prolonged illness would have been necessary. of occurrence Dr. Aitken describes the intestinal lesion as following the amyloid change in the liver, spleen, and kidneys,, and
if this be
useful
as
so
forming
in
the
a
albumen in the urine is
of malarial
cachexia, it would be prognosis, as the presence of considered a sign of evil portent by
case
guide
to
Dr. West, and the existence of diarrhoea and anorexia in conjunction with it would be of still graver significance. The absence of alburhen from the urine would be, on the other hand, a sign imparting hope, as indicating the exemption of the kidneys from disease, and probably too of the intestines. It is
consolatory to know that when limited to the liver and spleen degenerative change rarely produces a fatal result, and that is only in its extension to the kidneys that it ceases to be
the it
amenable
to
treatment.
In conclusion it may be as well to add, known, that the solution of iodine
generally
as
it may not be for the
employed
degeneration, should be an aqueous one, help of the iodide of potassium, and that, the affected portions when applied to an amyloid organ, a deep reddish brown colour: this is not permato change nent, hit gradually passes off and the part regains its former of the iodine is followed by appearance. If the application the cautious addition of sulphuric acid, a blackish blue or violet tint is produced." The application of the latter reagent is, however, not essential, as "fortunately the reaction with hints which I have iodine alone is perfectly characteristic" obtained trom Dr. Green's little book on pathology aud morbid recognition
of this
made with the
"
anatomy.
V,
the stomach and intestines tines
was
was noticed in the state of the of tHe did not present any staining characteristic of amyloid degeneration on the application of iodine. Case 2nd.?A lad, named Rengs'a, aged 13 years, was admitted
Nothing
to arrest
and the
blood,
attention
solid
viscera
5th November, died 14th November 1876. Had been a long time ill with fever ; but, although living in the Beldar's village within the station till he
was
boundary, had not applied for treatment with ejectment from the village. He
menaced
presented the symptoms of anaemia degree?extreme paleness of the mucous
in
an
intensified
membranes ; puffiness of the face ; oedema of the ankles ; an anaemic bruit; and diminished appetite. He grew weaker, day by day, and before his death, with some slight complaint, of pain in the abdomen, he became alarmingly prostrate, out of all measure compared with the amount of pain complained of, and howing no si^ns of dyspnoea, but maintaining the sitting posture till completely exhausted Post-mortem
MALARIAL CACHEXIA IN THE GARO HILLS. J. Slane,
By
L.R.C.P., (Edin).,
Civil Medical A MALADY invested with
Officer,
Tura.
contained about half
deal of
good mysterious interest the K:ila occurs in the Garo Hills, popularly known as Hazar," a name probably suggested by a prominent feature of the disease?a progressive darkening and loss of the natural polish of the skin; and as it is the cause of great mortality, "depopulating whole villages," I beg to record a few notes of two cases, which proved fatal at the dispensary since I have had medical charge of the G-aro Hills district. I would premise that the disease occurs most frequently in the lower hills bordering on the plains, and on low marshy localities. It usually begins as an ordinary paroxysmal fever, tending, however, to the remittent type. The symptoms in the beginning are rarely violent, but from being protracted by neglect or absence of treatment, usually assume a very obstinate character, due to certain pathological changes which are set I trust, will be up, and of which the two following cases, found somewhat illustrative. Wliou these are established, the a
"
individual presents a well-marked cachexia, in which recovery is despaired of, and he is expelled from his village as one suffering under the anger of demons, of whom tue Garoa stand in fear. Case 1st
abject
boy, aged about 8 years, named September, died 12th November 1876. He had been under treatment nearly a month, when he came under my care, and had general oedema to a marked extent, the scrotum being much distended. His appetite was voracious, and he had suffered from frequent attacks of diarrhoea, sometimes dysenteric in character, but there was complete absence of fever, and the diarrhoea and ceiiema had quite left at the time of death, which was the result of pure asthenia. The treatment employed in his case consisted of astringents, chalybeate tonics, and an astringent lotion to Diet was liberal with stimulants, but he resisted scrotum. all attempts to give him milk if he detected it, the Garos was
a
Dingmun, admitted
little
on
the 23rd
bavin" for it an unaccountable aversion.
examination.?Great
emaciation ;
head
not
examined ; the heart was enlarged, pale and flabby, and the blood in its cavities thin and serous, resembling in appearance port.wine and water, the weight of the organ was 7 oz. ; the right lung was adherent ar, apex, and the pleural cavity with
coagula
of
a
lymph,
pint
of
sanguinolent
the latter
being of
colour, and of the consistence of calf's feet jelly
;
mixed
light, cherry the left,
lung
very much enlarged, weighing 2 lbs. 14 oz., and the nutmeg character on section was well marked. The free margin was more obtuse than natural, and its substance was unduly firm to the feel. The gall-bladder was
healthy;
the liver
serum, a
was
thin green bile, and the blood in the was distended with inferior vena-cava presented the same impoverished appearance as that observed in the cavities of the heart; the spleen was
enlarged and increased in density, weight l? lbs ; supracapsules were apparently healthy; the kidneys were very pale, and on section resjtnbled the cut surfaces of a raw potato in colour?in short, all appearance of natural structure had disappeared in the lardaceous change?weight of each 4 oz.; the stomach and intestines appeared somewhat
much renal
contracted, and the coats of the ileum were almost membraneous in tenuity. The mucous membrane of stomach
appeared healthy, but that of small intestines was softened thickly coated with mucus, and the mesenteric glands were much enlarged and vascular. The iodine test was applied to the liver and kidneys, and the reaction was sufficiently characteristic to indicate the amyloid change. Among the lesions presented in these two cases, some two or three appear to me noteworthy as affording indications for treat-
and
First I may notice the softened state of the mueous membrane of the small' intestines overladen with a thick coating of In this condition absorption must be a work of extreme mucus. difficulty, and the indication therefore is for the use of fluid
ment.
description, and there is none so milk, with the addition of rice congee. To this I have resorted, therefore, in three cases of malarial anaemia Ihave subsequently treated, and with very gratifying results. The impover-
nourishment of the blandest suitable
as
ished state of the blood, and enlargement of the mesenteric glands and spleen, shew a large increase of the white cells, diminution of the red corpuscles, and
proportionate
tending
THE INDIAN MEDICAL GAZETTE.
124 to
effusions and
passive
diarrhoea, and
calorific
defective
by ferruginous tonics and as the sulphate of iron, quinine, strychnia, and the dilute sulphuric acid?the last in excess?given in combination with the infusion of cliiretta, as well as small quantities of stimulants, with an additional blanket in the cold season. But in the first instance the diarrhoea, if present, should be effectually arrested, and this I have found best effected by a pill of tannic acid, opium, ipecacuanha and The last-named medicine having been suggested santonine. to me by a case in which its exhibition was followed by the expulsion of eighteen round worms. processes, which astringents, such
Of fourteen
best combated
are
of this
cases
year in the Tura recovered ; of these,
cents, and only
malady,
treated
during
dispensary, eight proved
the and
fatal
past six
occurred either in children or adolestwo recovered. Of the remaining six, varying
eight
in age from 24 years to 60, four recovered, and two died. Of the two deaths one was the sexagenerian. Regarding the question of the nature of "Kala Hazar," it
appears to me to be malarial cachexia, pure and simple, advancing by successive stiiges from visceral congestions with an impoverished condition of the blood, tending to dropsical effusions susceptible of remedy, to amyloid degeneration of the blood-elaborating glands and impaired vitality of that fluid, which stage in its progress treatment appears to be of little It would be a mistake too to suppose it to be a disease
at
avail. sui
generis,
peculiar
or
to the Garo Hills.
1 have
seen
it at
Hawal Pindee, in the child of a friend, as a sequel of the malarial fever of Pesliawur. Dr. West notices an analogous affection in his lecture on " Albuminoid Enlargement of the Liver and,
doubtless, it was famliar enough to the Medical Officers who were employed in the investigation of the epidemic fever of Burdwan. I may remark on the similarity presented by my cases in the state of the intestines, to the appearances described by Dr. Aitken as occurring in lardaceous degeneration of the alimentary tract. There were the same pale softened state of the mucous membrane, and extreme tenuity of the coats of the ileum, the latter appearance suggestive of erosion, but there was no ulceration, for the establishment of which probably a In order more prolonged illness would have been necessary. of occurrence Dr. Aitken describes the intestinal lesion as following the amyloid change in the liver, spleen, and kidneys,, and
if this be
useful
as
so
forming
in
the
a
albumen in the urine is
of malarial
cachexia, it would be prognosis, as the presence of considered a sign of evil portent by
case
guide
to
Dr. West, and the existence of diarrhoea and anorexia in conjunction with it would be of still graver significance. The absence of alburhen from the urine would be, on the other hand, a sign imparting hope, as indicating the exemption of the kidneys from disease, and probably too of the intestines. It is
consolatory to know that when limited to the liver and spleen degenerative change rarely produces a fatal result, and that is only in its extension to the kidneys that it ceases to be
the it
amenable
to
treatment.
In conclusion it may be as well to add, known, that the solution of iodine
generally
as
it may not be for the
employed
degeneration, should be an aqueous one, help of the iodide of potassium, and that, the affected portions when applied to an amyloid organ, a deep reddish brown colour: this is not permato change nent, hit gradually passes off and the part regains its former of the iodine is followed by appearance. If the application the cautious addition of sulphuric acid, a blackish blue or violet tint is produced." The application of the latter reagent is, however, not essential, as "fortunately the reaction with hints which I have iodine alone is perfectly characteristic" obtained trom Dr. Green's little book on pathology aud morbid recognition
of this
made with the
"
anatomy.
V,
