28
Para. 17
Case 42.—Duki, m., 30, 4 months ill. Says fever has been coming daily with rigors at
noon. Examined 28th September. No symptoms at all observed. Blood, no parasites. Not
seen again.
Case 43.—Bhokon, m., 12, 4 months ill. Thought at hospital to be kala-azar. Several
people died of kala-azar in his house some years ago. Is well-known at hospital. Was
attacked 4 months ago with severe fever, which lasted without intermission for 10 days. The
fever then seems to have disappeared (?) for more than 3 months, but came on again with
violence six days ago. Examined 5th October at 9 A.M., temperature 100.8°F. Looks very
ill; is much anæmic, but not emaciated ; yellow colour. Spleen extends to within an inch of
umbilicus ; liver 2 inches below ribs and tender. Peripheral blood, not a sign of a parasite
nor a grain of pigment. Splenic blood ; cells obtained ; black pigment in almost every field,
recent and old ; not copious. Numerous parasites, exactly similar to those found in spleen
of Case 28 ; some of them have formed a few large spores ; probably æstivo-autumnal
tertian (paragraph 21). No small forms present, no crescents. No yellow pigment found. From
this date the temperatures were taken as often as possible and showed the " constant low fever,"
with a morning temperature of 99°—100°, and an evening one reaching 102°F. Seen again
on 17 October. Has been taking quinine, which seems to have improved his general appearance
while it has not removed the low fever. Spleen as before ; liver increased to 3 inches below
ribs; both organs tender. Very anæmic (? ankylostomes present—stools not examined). Pro-
nounced kala-azar at the hospital. Not seen again.
NOTE.—This would seem to be a typical case of kala-azar of the first to second stage. Parasites and
pigment were found in the spleen. No crescents.
Case 44.—Aziz Rahman, m., 10, 4 or 5 months ill. Is well known at the hospital.
His mother and sister died from kala-azar some years ago, and his young brother from fever
(? kala-azar) four months ago. Says he has had irregular fever for 4 or 5 months with
rigors ; it lasts a week or so, goes away for a while, and then recurs. His father is now getting
similar fever. Fever began again with violence on 30th September. Examined 3rd October
10 A.M.; temperature 98.0 °F. Looks sick and yellow ; considerably anæmic, but no emaciation
or oedema ; conjunctivæ yellow ; tongue good. Spleen to within an inch of umbilicus ; liver one
inch below ribs. Peripheral blood not examined. Splenic blood ; numerous cells obtained.
Black pigment, small but in profusion. i. e., some in every field. No yellow pigment. Two
typical, nearly mature, quotidian æstivo-autumnal parasites with marked definitions and a single
large clump of pigment found. No other forms, amœbulæ, or crescents, although much splenic
blood was examined. Temperatures taken from this date showed a nearly normal chart
rising occasionally, however, to between 99° and 100°F. Quinine given regularly. Seen
again on 17th October, considerable improvement was noted in him. Spleen 1 inch only, and
liver just palpable. Says no more fever since treatment was commenced. Has a tendency to
goitre, from which his mother suffers and his aunts now suffer. Peripheral blood, one pig-
mented leucocyte only (apparently crescent pigment). No crescents or other parasites present.
Not seen again. The case was looked on as one of kala-azar.
NOTE.—I think there may have been a very few crescents in this case (to judge from the pigmented
leucocyte), but I could find none on very careful search. There was not extreme enlargement of the organs.
Case 45.—Kolai, m., 8, 5 mouths ill. Well-known in hospital. Captain McNaught
thinks the case is probably kala-azar. No relatives have died of kala-azar, and no one in the
house is now getting fever. The boy's father says that the fever was originally very severe,
and adds, independently of questioning, that it usually came on every third day only, with
rigor, but that for the last two months it comes daily. He declares that the spleen has been
enlarged for 2 or 3 months. Examined 16th October, morning ; temperature 99.4° F. Looks
ill and is extremely anæmic and considerably emaciated. There is no œdema of the feet, but the
abdomen is protuberant in consequence of ascites. Spleen much enlarged (amount not noted),
liver 2 inches below ribs; both organs tender. Splenic blood ; numerous spleen-cells. In two
specimens traces of black pigment consisting of very minute granules enclosed in small cells of
about 4μ were found here and there—some in six fields or so ; no larger collections or
clumps. In the third specimen a mass of parenchymatous tissue was obtained, which contained
a vein of copious black pigment consisting of the above small collections, together with larger
and blacker clumps arranged in streaks. Yellow pigment in small granules of a bright yellow,
angular or rounded, found here and there in the cells, especially in the patch of parenchy-
matous tissue just mentioned No distinct parasites found, but some of the pigment clusters
look like quartan parasites recently taken up by the spleen-cells. Patient not examined again,
but several temperatures taken showed presence of the low fever.
KOTE.—Both pigments in spleen.
Case 46.—Jhuran, f., 4, 9 months ill. Well-known in hospital. Mother died in hos.
pital of kala-azar. Case diagnosed kala-azar. No history ; examined 1st October, morning,
temperature 100.4 °F. Fever now rising; pulsation of carotids ; nothing like rigor, and
patient does not look at all distressed. Spleen to pubes and nearly to umbilicus; liver half-
way to umbilicus. Much anæmia, considerable emaciation and some œdema of feet ; ascites.
Peripheral blood ; on this and several other occasions, no parasites nor pigment. Morning
temperatures above normal.
NOTE.—Presence of low continued fever suggested by the high morning temperatures. No parasites found.
Case 47.— Piruj, m., 3, 10 months ill. Known in hospital and diagnosed kala-azar.
Father says he has had fever for 10 months (?), and that it has been continuous for the last