146 TROPICAL MEDICINE AND HYGIENE 



incapable of any work. Sometimes there is epigastric 

 pain. The appetite remains good, but there may be 

 perverseness such as "geophagy." There is no diminu- 

 tion of the subcutaneous fat. There are no nerve sym- 

 ptoms, though the patient may become lethargic. (Edema, 

 at first of the feet only, is the rule, and general anasarca 

 occurs in the later stages. 



Constipation is common ; the motions are usually 

 formed and appear normal to the naked eye. Sometimes 

 there is much mucus discharged which is not blood 

 stained. On microscopical examination eggs of the 

 ankylostome will be readily found. Fatty crystals are 

 frequently present, and in the later stages much un- 

 digested food. In other cases there is diarrhoea, and the 

 stools may then contain much undigested food. Chronic 

 intestinal catarrh is a frequent complication. The urine 

 is free from albumin, but occasionally, near the end, there 

 may be albuminuria. 



The most prominent symptoms are those of anasmia 

 and those due to fatty degeneration. 



The anaemia is produced so slowly that the patients 

 rarely seek advice till it is marked. Before this a certain 

 disinclination or disability to work will have occurred. 

 In native labourers, on piece-work, it is often found that 

 their earnings have been steadily diminishing for weeks 

 or months. In such cases the mucous membranes, not 

 only of the conjunctiva but elsewhere, may be almost 

 white and slightly cedematous. The tongue is very pale 

 and usually indented by the teeth. In coloured races the 

 pigmented patches, so common in that situation, but 

 difficult to see against the normal red tongue, are now 

 very clearly visible. The lips are pale and bloodless, and 

 in a European the skin appears to be absolutely white, 

 and often of a peculiar waxy appearance. No tinge of 

 colour will be seen under the nails. In the Negro the 

 pallor is obscured to some extent by the pigmentation 

 of the skin. In infections early in life growth is stunted 

 and the patients are heavy, lethargic and show little 





