T0XIC JAUNDICE OF UNKNOWN / ORIGIN IN THE ANDAMANS.

y By A. BAYLEY de CASTRO, Junior Medical Officer, Haddo, Port Blair.

In the Indian Mcdical Gazette for July, 1913, there is an article by Major Woolley, i.m.S.

entitled "

Malaria in the Andam;ans : Fever with Jaundice Cases " which had not been seen by me when I wrote about what I termed

" A Case

of Acute Catarrhal Jaundice" in the Indian Medical Gazette for December, 1920. This case of mine bore some resemblance to that of Major Woolley, except that the pulse was not rapid.

I have however within the last two months had a series of five cases which showed in addition to the symptoms enumerated by Major Woolley, two others, namely, acute pain and tenderness in the muscles of the thighs, and an exhausting and persistent hiccough for a couple of days at the

height of the disease. The case I described in December, 1920, also had hiccough, and in addition hsenrorrhage from the bowels, while one of my recent cases who also succumbed to the

malady had haemorrhages from the bowels, stomach, and nose.

I briefly give here the notes of three cases :? No. 38,083. Admitted from Palwrgaon, working in

cane jungle. Previous admissions.?Malaria 4. Coryza 1. Contus-

ed wound 1. Date of present admission.?15th November, 1921. History.?Fever for two days with rigor. Spleen

enlarged to two inches below costal arch. Liver normal. Heart and lungs normal. Tongue coated. No malarial

parasite, Rod like bacilli found. Blood Count.?Polymorphs : 60.8 per cent. Eosino-

phils 5.4 per cent. Mononuclears 9.6 per cent.

Lymphos 24.9 per cent. Complains of severe pain in the knees, feet, and back.

17 th November, 1921.?Special complaint, pains in the thighs. Conjunctivae jaundiced. Tongue coated. Cal. gr. iii, Sodi Bic. gr. xv. Divided into six parts. One part every four hours to be followed by Mist.

S?.iine 1 oz. in the morning. Tenderness of liver ; no

enlargement detected. Urine, 1020, Acid. No albumen, sugar or bile. Leucocytes 18,750. Serum injection to

be given. 18th November, 1921.?Urine contained about 50 per

cent, of albumen. 19th November, 1921.?Eyes jaundiced. Hiccough

every now and again. Pulse 108-114. Cal. gr. iii this

Aug., 1922.] TOXIC JAUNDICE IN ANDAMANS: BAYLEY de CASTRO. 293

evening. Mist. Saline 1 oz. in the morning. Blood to

be counted on 21st November, 1921. 4 p.m. Serum M.

XX injected intravenously. (Auto-Serum). 20th November, 1921.?Patient passed no urine from

2 p.m. of the 19th November, 1921, slight spasmodic stricture. Tongue yellowish coated and dry?Scalp also yellowish. Stools watery with faecal matter. No

worms or ova found. Stools are also dark in colour.

Leucocytes 26,250. Reflexes?Knee-jerk diminished, ankle clonus present. Evening.?Jaundice in eyes increasing?vomited some

dark-coloured matter. Pulse 108 Hiccough at

intervals. Emetine gr. \ injected hypodermically. Blood cells found in vomited matter. 21 st November, 1921.?Eyes jaundiced more, also con-

gested. Tongue yellowish and furred. Low muttering delirium all night. Pulse 108 T. N. Passed about 1 oz. of blood per rectum. Emetine i gr. injected. Hiccough still present. Blister applied over 7th cervical vertebra. No subcutaneous haemorrhage,?Delirious. Demulcent drinks to be given. Good sponging B. D. Urine. Stellate and triple phospate, also ammonia phosphate crystals. Some renal epithelium.. Blood

cells, bladder cells. Noticed that the urine- on standing becomes green.

22nd November, 1921.?Has had a bad night. Four

hemorrhagic stools, also spat up some blood. Is semi- conscious. Jaundice stationary. Pulse 112 T. N. Slight but persistent hiccough. No more vomiting or epistaxis. Ordered 2 pts. warm Saline solution, also 1-8 gr.

Morphia and x m. adrenaline chloride solution. 12 noon. Laboured respiration. Pulse failing. 4-20 p.m. died.

P. M. Notes.

On opening the abdomen and thorax, all viscera were found to be of a yellow colouration.

Pericardial Sac?2 oz. serosanguinious fluid. Heart?10 oz. Very soft, stained yellow?Rt.

ventricle dilated and flabby. Left Lung.?15 oz. Firmly adherent to chest wall,

lower lobe congested, upper lobe yellow in colour. Right Lung.?23 oz. lower lobe congested, upper lobe

yellow. No adhesions. Liver? 60 oz. soft, a few superficial vessels under

the capsule yellow. Not dry on section. Gall-bladder had about 4 oz. of brownish bile. Kidneys Right and Left.?8 oz. each, large, soft,

flabby, slightly congested. The right had a ha:mor-

rhagic infarct.

Spleen.?12 oz. soft, and discoloured yellow. Stomach.?Congestion of anterior wall, about the

lesser curvature. Some venous engorgement also noticed along the lesser curvature. Small Intestines.?Nothing special, except that there

was some slight degree of congestion. Large Intestines .?Slaty grey in colour or else normal.

No. 40,226. Pahargaon. Cane file work in jungle. Admitted 29th October, 1921.

Previous admissions?Malaria 3.^ Wound 1. On admission patient gave, a history of. fever for

two days. Weakness all over the body, but especially in the

legs. Eyes slightly congested._ Both liver and spleen slightly enlarged. Blood negative to malaria. Rod like bacilli found, Albumen in urine?Sp. gr.?1010.

Blood Count.?Polymorphs .. 82.7 per cent.

Eosinophils .. 6.4 per cent.

Mononuclears .. 11.8 per cent.

Lymphos .. 4.7 per cent.

30th October, 1921.?Pulse morning and evening 96? 108. Respiration 24-30. No albumen in urine.

1st November, 1921.?E. T. 97.4. Pulse 108. Com-

plains of pain in the legs (thighs). Yesterday there was blood in the stools, b"t to-day the amount is

considerably reduced, but pieces of epithelium, almost like casts are found in the stools. Tongue coated but moist. ...

Lcucocytcs 8,125.?Intramuscular injection of quinine Bihyd. gr. XV. .

2nd November, 1921?Pain in calves to-day?very restless?pulse 108. Had two stools which contain

sloughs?jaundice is also apparent. Tongue moist, and cleaner than yesterday. Urine a trace of bile, reac-

tion acid. Haemoglobin Index 70 per cent.

3rd November, 1921?Pulse 112, good in volume.

Urine 2i lbs. in 24 hours. Patient states that he is

a bit better to-day. Is rather somnolent. Stools normal.

Has developed a troublesome hiccough since last

evening. To be given an emetine injection this

evening, and Mist. Chlorine 1 oz. T. D. S.

4th November, 1921.?Pulse 96, was very bad with

hiccough from 3 to 6 a.m. Expectoration this morning was bile stained. Is' very> drowsy. Emetine and

Chlorine mixture to be continued.

Evening ?Very persistent and distressing hiccough. E. T. 100.6. Pulse 108. Has been passing large

quantities of urine all day. , ...

5th November, 1921.?Was given an injection of

Morphia last night to stop the hiccough. Slept: m

snatches At 1 a.m. the temperature rose to 1Q1?.

Passed scvbalous masses after an enema this morning. From 7 a m hiccough started again. Pulse 96 not of

very good volume. Sinapism to stomach. Morphia and Emetine injection given. ^ .

Urine. 1010?Acid. Increase of bile. Chlorine

Mixture stopped. 10 a.m. vomiting small gushes of

fluid bile-like vomit. Evening. T. 101. Pulse 104, no hiccough from

3 6th

'

November, 1921? Pulse 88. Temperature 98.2.

Hiccough stopped. Abdomen bloated. Condition fair.

Evening T. 98.4. Pulse 86.

7th November, 1921.-T. 98. Pulse 138, full and

bounding Passed a yery offensive motion. Urine

changed to a lighter colour, turbidity much reduced.

Patient slept well, no hiccough since 4 p.m. yesterday..

Complained of great thirst, and has been drinking a

lot of water. Congestion of eyes gone, only jaundice rema^No pain in the thighs.

.

8 th November, 1921?Was given calomel last

evening and a saline purge this morning. Passed two

loose yellowish motions. There is an all-round re-

markable improvement in the patient in every way.

Jaundice clearing up, expression brighter and he

sleeps well. 3-15 p.m. pulse taken during sleep, 80 per

'"From now onwards the recovery was uninterrupted.

No. 40,798. Admitted from Hciddo, working in

',G'previous other admissions? Malaria 1. Diarrhcea 1.

Date of present admission?1st November, 1921.

History ?Fever for past two days with general malaise. No enlargement or tenderness of liver or

spleen. Mononuclears 6 per cent. Bowels said to be

moved daily but not fr\ee. 2nd November, 1921.?Blood count Polymorphs

618 per cent. Eosinophils 8 per cent. Mononuclears

^\rd*November, 1921.?Complains of pain all over the body and thirst.' Tongue coated but moist.

4th November, 1921.?Severe pains in the legs

especially the thighs. , . r

5th November, 1921,?Slight congestion of eyes, pain in thighs a bit less. Complains of pain in the chest.

Nothing adventitious in the heart or lungs. To be

given serum injection. (Serum from the patient's own

?6th^November, 1921-?Urine 1012. Acid. No albumen,

sugar, bile, pus, blood, V m: serum injected, no reaction. 7th November, 1921.?Patient considerably reduced.,

Complains of weakness and pain in the legs. 8th November, 1921?Serum XX m, injected. Eyes

congested. Patient prostrated. 9th November, 1921. Blood count.?Polymorphs

69.8 per cent. Eosinophiles 13.7 per cent. Mononuclears

294 THE INDIAN MEDICAL GAZETTE. [Aug., 1922.

7.7 per cent. Lymphocytes 18.6 per cent. Eyos congest- ed. Very drowsy. Has lost a lot of flesh.

11 th November, 1921.?Eyes very congested otherwise there is a (marked improvement. Leucocyte count 25,000. Eosinophils 5.0 per cent.

All treatment stopped. Diet for to-day 2 lbs. milk. To be treated for worms.* Improvement steady and good. Pulse 76 full and of good rythm.

12th November, 1921.?No worms passed, no ova

found. 14th November, 1921.?Congestion of eyes clearing

up, light work in the garden. Pulse 112, this for no aecountable reason. Motions twice daily healthy. Reflexes normal.

19th November, 1921.?Still pretty weak, but gaining slowly in an all-round manner daily.

2\st November, 1921.?Is weak but picking up rapidly now. The conjunctiva; still show an icteric dis- colouration, probably acholuric jaundice. No tender- ness or pain in the liver. From now to date of dis-

charge (31st November, 1921), there was an un-

interrupted progress. My case of 1920 was working in the cane

cutting file which means work in the jungles, three of my cases this year were doing the same work in the identical jungles ; while before I got these three cases into hospital I had two cases from the barrack where these men lived, but who were not on cane cutting work, admitted into

hospital for simple jaundice. I am for many reasons much inclined to con-

sider these cases entirely distinct from malaria and its causation. I have not as yet had the good fortune to find the parasites mentioned by Major Woolley in any of these cases, but in several fresh blood specimens taken from cases report- ing sick from the 'Pahargaon area (jungle work- area), I had often seen them. As remarked elsewhere I have only very recently

read Major Woolley's article. The differential diagnosis has to be considered

between dengue, seven-day fever, and yellow fever, and of course malaria must be excluded,

lastly toxic, and specific hcemoglobinuria. The resemblance to dengue is in the pains in the limbs, the high eosinophile count (see Differential Blood Count in Dengue by Capt. W. L. Harnett, i.m.s., Indian Medical Gazette, February, 1913), and the haemorrhage. But again dengue invariably assumes an epidemic character the temperature rises to 104 or 105. It is a three or four-day fever, with an apyrexial stage, and a terminal

rise, and lastly we must remember the rash. Seven-day fever belongs to the coast towns,

it is a sporadic fever, and makes a characteristic saddle back temperature chart of seven days' dura- tion. Yellow fever has its characteristic facial

expression, early albuminuria, and the pathognom- onic slow pulse with maintenance of elevation of temperature. Malarial fever has its well-known

phenomena, and the parasite can be found in m;ost cases with diligent searching. In the most intense types of malarial fever the colour of the skin is rarely changed within four or five days, albumen is rarely present as early as the 2nd

day and then never in such a large quantity. There is always splenic enlargement or at least

tenderness. Hemorrhage, particularly "

black vomit

" and bleeding from the gums is very rare. Remarks.?The salient features of the disease

may be summarised as follows :?

(1) Slight initial rise of temperature for a

day or two.

(2) Marked increase in the pulse rate with a normal temperature.

(3) Congested condition of the eyes at first, later jaundice.

(4) Very acute pain in the thighs. (5) Jaundice of an intense degree. (6) Hiccough. (7) Haemorrhages, and lastly perhaps I may

add

(8) An increase in the eosinophile cor-

puscles. There are three remarks in Major Woolley's

article which I must mention.

(1) That the only excuse for including the disease under malarial fever being

" that many hold the opinion that it is malarial in origin, and we cannot yet say for certain that it is not."

(2) " An important fact to notice is that

when there is little or no malaria in the settle-

ment these cases do not occur. This being the case observers find it difficult to relinquish that they are of a malarial, or malaria-like nature."

(3) "

On the whole, it will, I think, be agreed that this disease appears to be distinct from

ordinary malarial fever." Our knowledge regarding the vagaries of mala-

rial fever and its sequelae m;ay still be considered to be in an infantile stage of development, and the occurrence of such cases in a highly endemic locality lends pretty strong, but not absolute

support to the probability of the disease being of a malaria-like nature. On the other hand, the

phenomena characteristic of malaria are quite absent. No parasites are found, and the percent- age of mononuclear cells remains low. Albu- men in the urine appears early in the disease; such an occurrence in a malarial attack is rare.

My first case inadvertently styled " Acute

Catarrhal Jaundice " occurred in August. 1920, during which month I had no less than 350 cases of malarial fever admitted to hospital, as opposed to 155 for 1921. In October, 1920, there were 155 admissions for malaria fevers as opposed to 52 for 1921, but it is during the month of such few admissions that my series of five cases have occurred. This however may be a mere

coincidence. As regards treatment, I must confess that I

know insufficient of the disease at present to make

any definite statement, save that a symptomatic line of treatment seems to be the best. I do not at all see the slightest indication for quinine. One of my cases did well on Hg. perchlor, Sodii Bic. and Pot. Iod. ; lone was put on Tr. Iodine and Emetine injections. One again benefited by Auto-Serum injections.

I especially in all cases resorted to hydro- therapy?very thorough sponging down morning All patients were systematically treated for worms.

TOXIC JAUNDICE OF UNKNOWN ORIGIN IN THE ANDAMANS.

By A. BAYLEY de CASTRO.

Junior Medical Officer, Haddo, Port Blair.

DATE

Day of Ois. 3 time Im.E

tempckatube

Cent. II Fahr.

JL?L5_

Pulse.

ReSp

23 S 6 I 7 | 8 J 9 I 10 I II

m.e m.e m.e m.e m.e m e m e m.e

zc

CHART I. CHART I.

%

12 ?2 52 **52

Pulse

Resp BowoU

CHART II. CHART II.

CHART III. CHART III.

Aug., 1922.] PRIMARY CARCINOMA OF THE LIVER. LEONARD FORSYTH.295

and evening?and abundant demulcent drinks. One patient had a craving for cocoanut milk and was given four nuts a day. Lastly, all the cases were kept out in the verandah where a north- east breeze blew all day and niglit. Out of my series of five cases I only lost one.

No Spirochseta icterohtemorrhagica was found in any of the several smears of blood examined. As regards the mentioned rod-like bacilli

I have not as yet been able to stain a specimen properly to be able to distinguish its several

parts. Some fresh specimens show an undoubt- ed bipolar enlargement and granules. They have a very active oscillating movement and thus> make their way all round or across a corpuscle. With Leishman's stain they appear as just symmetrical rods. In the fresh specimen a refractile margin is distinctly visible.

I do not think these bacilli specific of the disease as I have found them in very m;any other cases when the symptoms enumerated in the cases above, have been completely wanting.