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Olinical and Othm' Notes J R Army Med Corps: first published as 10.1136/jramc-14-03-09 on 1 March 1910. Downloaded from Olinical and othm' Notes 313 sample of his serum and sent it together with a capsule of the vaccine to the Divisional Laboratory, where a positive reaction was obtained with all dilutions up to 1 in 5,000; at 1 in 10,000 there was very slight, if any, reaction. NOTES ON A CASE OF KALA-AZAR. By CAPTAIN CHARLES WHITE. Royal Army Medical Corps. NUMBER 32173 Bombdr. B., aged 25, was admitted to Station Hospital, Jalapahar (Darjeeling), on June 2nd, 1909. History of the case up to the date of his being admitted to the Station Hospital, J alapahar :- Patient first had fever in October, 1907, at Barrackpore, diagnosis being "ague"; notes on medical history sheet are: "Bilious remittent; excessive vomiting; hrematemesis." The fact of this" bilious remittent" fever starting in October is important, as Major Rogers points out that European cases of kala-azar usually commence in the cold weather, and that infection is limited to this time of the year. A statement of the Protected by copyright. patient's worth noting in connection with the theory of the spread of the disease is that" the bed-bugs were very bad at Barrackpore, in fact, so bad that on Thursdays the men were put on special duty in the barrack-room for the purpose of washing the beds with carbolic, &c., and so trying to get rid of this plague of bugs." The man landed in India, February 10th, 1905, so that he was only two years and nine months in India when attacked, For the first admission of fever patient was in hospital seventeen days, was discharged and readmitted in about six weeks with very severe vomiting (so severe that he was reported dangerously ill), was detained in hospital about seven weeks, was then discharged " to attend" and was all right for seven or http://militaryhealth.bmj.com/ eight, months. At the beginning of August, 1908, he was again admitted with" malaria," was discharged, and admitted about two months later with symptoms of ptomaine poisoning. He had two or three more admissions for malaria, vomiting and diarrhcea. Patient left Barrackpore on November 18th for Barkacha Camp, was sent in from camp to AlIa­ habad Station Hospital, again with fever and vomiting, remaining in hospital eight days, and then returned to camp. The Battery arrived at Cawnpore on March 1st, 1909; he kept" fit" till March 28th, when (an important fact) his nose bled profusely for an hour without any apparent cause. Next day he was admitted to hospital, again being diagnosed on September 27, 2021 by guest. "malaria." From Cawnpore he was transferred to the Station Hospital here (Jalapahar). Symptoms on admission to hospital (Jalapahar): High fever, but no mental dulness or delirium; cough with blood-stained expectoration; spleen'greatly enlarged, extending to ~elow navel; liver also enlarged, but J R Army Med Corps: first published as 10.1136/jramc-14-03-09 on 1 March 1910. Downloaded from 314 Olinical and other Notes to less extent; very anremic and debilitated, and complained of profuse nightly sweats, and pains in the limbs. Physical examination of chest revealed nothing. The microscopical examination of the sputum for tubercle biwilli proved negative-the sputum was examined on several different occasions, but tubercle bacilli were never found. Examination of blood specimens-slides for malaria parasites and blood capsule for Widal's reaction-also gave negative results; blood slides were taken on several different occasions, but malarial parasites were never present. Patient was put on a course of intramuscular injections of quinine but the irregular high fever still continued. The case did not respond to the three pathognomonic tests of malaria, viz., (1) pyrexial periodicity, (2) amenability to quinine, (3) presence of the hremamrnbre of malaria in the blood . .JUL.1909 DATE 16 17 18 19 20 21 22 23 24 25 26 47 4 4 0 I .5 .. 6 .~ . ~M ~M i6i'Z 4i 6!12 4ie!,~ 4!8i 12 41 8112 4[8jl !' " " :! :: i: :! Protected by copyright. U ': :! 104" "i : ' , 1: i;j 1, i ': I ,; , :::: :: i : ('I '" ; ';, 1 101' :: ':' : f1 ,fA, l' (I , ' :' ill 100' 1 f f'\ : I ! :\1 i, i i IV\ ' 99' _L ,\I ,\/ 1] ! I' 1 It; ," " _, \I PULSE RESP. ~~~~~:~~~~:~~g~:~~2~re~~2~~~~~~~~~~~~~~~~NO~~~~~£~2~2~~~:~~~~ MOTIONS 01 2. 1:1 I I I 2. 2 The fever continued day after day. No malarial or other parasites http://militaryhealth.bmj.com/ .were found in the blood, and repeated examinations for tuberculosis, liver 'abscess, and other septic conditions also proved negative. These negative results suggested the probability of the case being one of the imperfectly known continued fevers, such as kala-azar. The differential diagnosis between malarial cachexia and kala-azar is not always easy, as the history of this case shows; however, the long­ continued irregular fever, tbe fact that quinine had no effect on the fever, the great weakness and progressive emaciation, all pointed to the case being one of kala-azar rather than malarial cachexia; also the temper­ ature, which was now taken every four hours, showed a marked double on September 27, 2021 by guest. rise; "tbe double remittent type of fever," noted by Rogers as being characteristic of kala-azar. (See temperature chart.) Suspecting the case to be one of this disease, the liver was punctured in the mid-axillary line, the patient receiving 30 grains of calcium chloride immediately after the operation. Blood slides were made from the liver J R Army Med Corps: first published as 10.1136/jramc-14-03-09 on 1 March 1910. Downloaded from Olinical and othe1' Notes 315 blood and sent to Lieutenant Morison, LM. S., at liasl1uli, wbo very kindly stained and examined the fi lms Cor me, and reported that in all of the sJides sent Leishman-Donovan bodies were present; this was confirmed at Knsauli by Captain Christopher, I.M.S. Sub,equent examination of blood films from the peripheral circulatiou showed the characteristic ma.rked leucopenia, with low polynuclear and high proportion of lyropho­ cytes and large mononucIears. No Leisbman-DoDovan bodies ,vere found in the slides of the peripheral blood, though looked for on several occasions; but as tbe parasites of kala-azar when found in the peripberal circulation are almost invariably situated in the polynuclear leucocytes (being carried by them to the spleen, liver, and bone-marrow), they rarely can be detected in an ordinary slide of the peripheral blood, especially when the proportion of polynuclears is low. The treatment subsequent to the finding of the parasites has been long continued full doses of quinine by mouth; this hELd to be discontinued occasionally on account of gastric trouble, but then I continued its administration by intramuscular injections. These long. continued and full doses of quinine certainly appear to keep down the fever, and to Protected by copyright. somewhat improve the general condition. IIowever, the patient ha.s been slowly getting weaker and more debilitated. I tbink the chief points of interes~ are ;- (1) The case commencing in the cold weather at Barrackpore. I think there can be little doubt that the first entry for bilious remittent fever was really ka,}a·a.zar infection. (2) The lact of hed-bugs being present in the barrack· rooms, showing the prob.ble chaunel through which this patient was infected. (3) The fact that the man was only 29; two years in India when attacked. I believe it is stated by Rogers that the shortest time after arrival in India before attack is eight years, as, unlike malaria, kala-a.zar http://militaryhealth.bmj.com/ shows a. predilection for the acclimatised-the natives and old residents. (4) ~'be slightness of general symptoms as compared with the higb fever; the absence of any marked mental dulness and delirium, or of any urgent and distressi ng symptoms. (5) The b<eIDorrhago from nose wbich might suggest the onset of enteric; and the b..emoptysis associated with fever and profuse diaphoresis which might very well make one think at first that the case was one of phthisis. (6) The e~se with which ea,-ly kala-azar infection may be mistaken for malarial cachexia; however, in the later stages of the disea.se, the history, on September 27, 2021 by guest. tbe great enlargoment of the spleen, the double remittent type of fever, and leucopenia. on peripberal blood examination, render the diagnosis easy. .
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