A discussion on ankylostomiasis / G.M. Giles [and others].

Date:: 1900

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Licence: Public Domain Mark

Credit: A discussion on ankylostomiasis / G.M. Giles [and others]. Source: Wellcome Collection.

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with a case of filarial disease escape infection ? The presump¬ tion is that the whole community would become affected sooner or later. Yet many escape. THE HOT WEATHER DIARRH(EA OF INDIA, By Major W. J. Buchanan, I.M.S., Superintendent, Central Prison, Bhagalpur. My object in writing this paper is to call attention to a very severe form of diarrhoea with watery stools, which is certainly not cholera, but in many cases somewhat resembles it. It is not difficult to understand that as hot weather in Europe is an important, if not the chief, factor in the production of “summer” diarrhoea the extreme heat of India should be a priori even more so. Bowel complaints of all kinds are common in Bengal, but it is here intended to refer only to one particular form. It might be called thermic diarrhoea, and it has been called “choleraic •diarrhasa.” It bears, however, the same relation to cholera ABiatica as does English summer diarrhoea or “cholera nostras.” Clinically though it is very common in adults it has a strong resemblance to what is called “cholera in¬ fantum.” Before going further it may be well to give a short account of the clinical featurfs of an acute case: The onset of the attack is always sudden, the patient having been apparently in his asual health up till a few hours before, then suddenly at night or in the early hours of the morning he is attacked with violent purging and vomiting, at first the stools are loose and fseculent, and the vomit contains the remains of the last meal; soon, however, the stools become abundant more or less colourless, and pour out from the rectum as if from a tap. The patient becomes collapsed with a shrunken cyanotic appear¬ ance, resembling, but in a somewhat less degree, that of cholera. The urine may be suppressed for several hours, the stools may number ten, twenty, or even fifty in the first half- dozen hours. In old or feeble persons the result may even be rapidly fatal. More usually the violence of the attack grows less in the course of the day ; a reaction sets in, which, how¬ ever, is not so marked as is the reaction stage of cholera, the temperature may rise from 1010 or io2°F., the stools become fseculent and only loose or semi-solid, and in uncomplicated cases the recovery is usually rapid. In a few instances the inflammation of the small intestine goes on to an ileo-colitis and 8tools resembling dysentery persist for a few days. This is especially liable to occur if the patient has formerly suffered from dysentery. One might quote dozens of cases, but the following three will illustrate the different degrees of severity: 1. Mild.—3. S., aged 24, weight 107 lbs. On April 6th, 1899. admitted to hospital at 5 A.M., with violent loose watery diarrhoea—10 to 15 stools in the hour. Urine passed, no cramps, no collapse; voice good, recovery rapid in the course of about six hours. a. Severe.—B. D., aged 38. came to hospital on March 23rd. at 5 a m., passing thin, very watery stools with uriDe, vomiting frequent, partially collapsed and cold. When seen by me at 6 a.m. he was in this state; no urine for the past hour, but frequent scanty stools ; very restless, face shrunken, voice clear, pulse rapid but perceptible; no cramps, tongue clean, urine remained suppressed for 21 hours. On second day the stools were semi-solid, and next day he was practically convalescent. 3. Fatal —N. K., an old man, came to hospital at the same time as No. 2 above. Stools very watery, vomiting and nausea frequent; no urine passed, body cold, but pulse was just perceptible. In a few hours he was quite collapsed passing lrequent watery brown-coloured stools. Tongue econ became dry, the thirst was great. The stools never resembled “ rice Fater-,”. Tlle diarrhoea continued, and he died at 4 P.M., after about 12 hours' illness. At the necropsy old pleural adhesions were found. The spleen waB enlarged (8 by 5 by 2 in.), no rice water stools in the intestine but drab-coloured faecal matter; one old patch of ulceration at the sigmoid flexure. Albuminuria is often found in these cases, but does not last usually longer than a few days, where the kidneys have been previously sound. Constipation for a few days after recovery is common. Microscopic examination of the stools shows abundance of epithelium, starch grains, particles of grain and husk and numerous bacteria. Treatment.—The treatment of these cases is not difficult, for attacks lasting only for a day food is not urgent, but boiled milk or milk and Mellin s food may be given. Brandy or rum will often be necessary. As regards drugs, it is unwise to interfere with Nature during the early stage of the diarrhoea, but by the time a patient is usually seen by a medical man many watery stools have been passed, so I usually at once give chlorodyne or camphoridyne (the tinct. chloroformi et morphinse co. of the new British Pharmacopoeia'), sometimes with small doses of brandy, enough to control the diarrhoea. Then when the diarrhoea has become much less a dose of castor oil will set the patient aright. Care should to be taken with the diet till the stools have become solid. Etiology.—As regards the etiology of the disease this resolves itself into (1) bacterial and (2) predisposing causes. I have nothing certain to say about the bacterial cause. It is believed by many that the specific micro-organism of what Dr. News- holme calls “epidemic diarrhoea” in Epgland is the bacillus enteritidis, but as this micro-organism has already had attributed to it two diseases so entirely different as the well- known “rice pudding” epidemic of St. Bartholomew's (a sudden widespread and non-fatal diarrhoea), and the so-called colitis of Euglish asylums (a fatal disease which anyone with tropical experience would not hesitate to call dysentery), it is clear that one should hesitate to attribute such a widespread disease as summer diarrhoea to it also. We are on safer ground in discussing the predisposing, or rather the “ exciting,” causes. Granted the presence of the organisms of decomposition and of fermentation in the intestinal tract the actual exciting causes are as follows: (1) Badly cooked food; (2) hastily eaten fool, or over-eating; (3) unripe or over¬ ripe food; (4) raw grain, eaten either carelessly or on pur¬ pose ; (5) drinking top much water after or before food ; (6) too rich food, curried and spiced; (7) badly prepared grain, especially maize when weevil-eaten, as it usually becomes by the end of March in India; (8) over indulgence in alcohol, especially drinking freely at a big dinner by one usually abste- mious, or a mixture of liquors—what is often called “upsetting the liver”; (9) excessive use of inferior fibrous vegetables, and many other similar causes. I have actually seen cases which were attributed to one or other of all the above causes. Some of them apply only to European habits and others to the habits of natives of India. In gaols I am always on the look¬ out for bad cooking when such cases occur, for example, on one occasion in Midnapur Central Gaol I remember finding, one morning in May, no fewer than 125 such cases of violent diar¬ rhoea admitted in one night; the cause was not far to seek. On the afternoon before a very violent cyclone had raged, with the result that the cooks were driven out of the cookhouse and the fires had to be put out, so that the evening meai of about 1,000 prisoners was Issued in a half cooked or rather half raw condition. On another occasion I had a series of 25 such cases admitted to hospital, owing, as I believed, to the temporary use of Borne bags of weevil- eaten maize, which were far worse than was expected. On this occasion it was remarkable that the cases only occurred from those on maize-flour diet, and not a single case among a large number of Bengali prisoners who got rice at all meals. Cases due to the use of over-ripe or half ripe fruit must have occurred in the experience of all who have lived in the tropics. One case I well remember. The patient confessed to having eaten the raw seeds of the jack-fruit tree, he suffered severely, having had suppression of urine for 36 hours and after the bowel complaint was over he suffered from successive crops of boils and his whole outer skin peeled off in handfuls, which symptoms I attributed to the endeavour made by the irritant poison to escape by the skin. But while such factors as unripe fruit, raw grain, etc., are certainly important, I do not think that they are the whole cause, something more is necessary, and this something is the influence which is exerted by the hot weather on putrefaction or fermentation in the intestines. My ress m for so concluding is as follows: I have seen all the above exciting causes in operation in cold season, but it is seldom or never that this violent form of diarrhoea is then produced, food may be badly cooked in the cold weather as in the hot. grain may be as badly husked, unripe fruit may be eaten, idle prisoners will eat raw grain in the cold weather as well as in the hot, but it is very rare for us to meet with these cases of diarrhoea in the cold weather. The same remarks apply to summer diarrhoea in England. Diagnosis.—It is obvious that these cases in India must often need to be diagnosed from cholera. In cases where a bacteriological examination is not possible one must rely on the following considerations : (1) The presence or absence of cholera in the neighbourhood; (2) the low death-rate for the diarrhoea, and the usually high initial death-rate for cholera;