21
Para, 16
The blood was searched for parasites in every case but two. In many of
the out-patients I was able to make only one examination ; but that was always
a very careful one, especially if the parasites were absent or scarce. I employed
the classical unstained mode of preparation as being generally enough for
diagnosis. This is quite sufficient for the detection of all the older parasites,
but, as Marchoux points out [22, p. 6], the smaller unpigmented forms are so
transparent that they often escape detection unless coloured. Hence, in many
of the examinations I employed also a method of wet-staining with Loeffler's
blue for the purpose. A minute drop of blood is taken up on a cover-
glass and is placed in the middle of a small drop of the stain placed on
the slide. If done skilfully this gives a very beautiful demonstration. Com-
parison with an unstained liquid preparation of the same blood confirms
Marchoux's observations, and shows that the youngest amœbulæ, especially of
the æstivo-autumnal varieties, are seen much more readily in the stained speci-
men. All the sanie I find no difficulty in detecting those parasites by the usual
method. The pigmented organisms can, of course, be seen at a glance anywhere.
In cases where the parasites or pigmented leucocytes could not be
discovered after one or two examinations of the peripheral blood, recourse was
had to the spleen or liver, if the patient allowed it. A stout hypodermic needle,
kept free from rust in oil and sterilised before use, was inserted into the organ
and then twisted and slightly withdrawn, so as to encourage the entry of
some of the hepatic or splenic cellular tissue with the rush of blood. If this
failed, a second or third puncture, combined with haustellation by means of
syringe, was had recourse to. It is absolutely necessary to obtain some of
the parenchymatous substance for these observations, particularly because the
yellow pigment is contained only in it ; but in some cases I failed to secure
it, owing to the rush of blood into the needle from the highly congested organ.
In some cases, moreover, I could obtain no tissue nor even blood, even after
several punctures. If the first puncture failed there was always the danger
that the patient would refuse to permit a second. Nevertheless, success was
generally obtained. The blood and tissue thus procured were entirely used up
in making numerous specimens, stained or unstained, and of various degrees
of thickness, for the detection of pigment in the mass ; and all these specimens
were invariably searched exhaustively. I never observed the slightest ill-effect
from this operation.
The out-patients were examined as frequently as I could persuade them to
come to hospital. Observations of the in-patients were made more regularly.
The temperatures of the out-patients were generally taken only during
examination, the hour being noted. In some cases, however, reliable sections of
charts were obtained. The charts of the in-patients were recorded by Hospital
Assistant Ashab Ali, whose services were very kindly placed at my disposal by
Colonel Calthrop, Principal Medical Officer of Assam. His thermometry
is to be relied on, as I took every precaution that it should be so. I did not think
it advisable to attempt nocturnal temperatures, as they were not absolutely
necessary and there were obvious difficulties in the way of checking them.
In the autopsies, as in other observations, I was obliged to confine
myself to the leading features—chiefly to the pigments. The human body is
such an enormous organism that anything like an exhaustive survey of the
pathological anatomy and histology is almost an impossibility to a single observer,
especially when he has to deal with numerous other cases on the day of the
autopsy.
All the patients, except Case 66, were poor people—mostly inhabitants of
Nowgong.
The cases are generally arranged in an order depending on the duration
of the illness ; but this principle has been departed from in Cases 16 and 17,
which belonged to the same family, and again in Cases 18,19, 20, 21 and 22,
for the same reason. I have also grouped together, near the end of the list, a
series of in-patients suffering from well-established kala-azar, whose tempera-
ture charts are given in Appendix C, and have collected similarly the group
on which autopsies were performed.
It should be understood that, while the duration of the illness can be
ascertained with something like certitude from, the patients when the illness is a
recent one, it is impossible to do so in old cases. In such we must content
ourselves with a rough record of months or years.