24
Para. 17
Says no fever since the 24th. No enlargement of liver and spleen. Peripheral blood, no para-
sites, nor pigmented leucocytes; no crescents. Examined again on 18th October. Has been
taking quinine and says he has had no fever since I saw him. There is no enlargement of the
organs, and the blood contains no parasites or melanin. Is no longer anæmic and looks quite
well.
NOTE.—No enlargement of organs and no crescents. A pigmented leucocyte was found with the amœbalæ
on the 24th, showing presence of melanin somewhere.
Case 17.—Dipkalia, f., 18, out-patient, one and a half months ill (entered here as she is
step-mother of the last case, and was taken ill about three weeks before him). Fever very
severe, with rigors. Still gets it daily. She and her step-son say that no people died of kala-
azar in their house, and other inmates are not getting fever. Examined 24th September,
7-30 A. M., temperature 102.4°F. Looks extremely ill and of a pale yellow; is hardly able to
walk; complains of pain all over the body and especially in epigastrium. Has become quite thin.
No œdema of feet. Spleen only just palpable below ribs as a small tumor, but the liver ex-,
tends to two inches below the costal arch and is certainly very tender. Peripheral blood,
numerous large unpigmented æstivo-autumnal amœbulæ with "tongues"; pigmented
leucocytes ; no crescents at all. Quinine in large doses. Seen again on 27th, 9 A. M., tem-
perature not recorded. Says fever better, but looks extremely ill and can only just walk.
Peripheral blood, a few large unpigmented amœbulæ with "tongues ;" one of the largest of
these, however, contains a few minute granules of pigment ; no crescents. Splenic blood, cells
obtained, fairly copious melanin, some in every field ; no crescents; pigmented sporulating
and full-grown forms precisely similar to Malchiafara and Bignami's æstivo-autumnal tertian
—that is, largish parasites with an undefined margin, containing a central clump of melanin
and producing a few rather large spores (paragraph 21). The smaller parasites have a few
small granules, as found in the finger-blood. There are two generations present, but there is
considerable graduation of sizes. Examined again on 29th, 8. A. M., temperature 97.2° F.
Says she has noticed no fever since I last saw her 27th. Peripheral blood, a pigmented leucocyte ;
no amœbulæ; no crescents. Looks a little relieved. The senior Hospital Assistant of the Civil
Hospital, who is very familiar with kala-azar, thinks the case may be one of that disease, but is
of opinion that the spleen and liver should have enlarged more by this time, as the patient has
been ill for a month and a half. Quinine regularly in large doses. Examined again on 30th.
Peripheral blood, no parasites. Looks very ill, but says no fever; temperature 97.0° F. at 9 A. M.
Enlargement of spleen and liver just as before. On the 4th October there was a marked im-
provement ; patient was rapidly regaining strength and colour, and said there had been no
fever at all. Tumour of organs has decreased rapidly ; spleen can no longer be felt at all, and
liver is only just palpable. Says is pregnant, and refuses to take quinine ; a decoction of
cinchona ordered. On the 19th October was seen for the last time. Was very much better,
but still rather weak and anæmic. Spleen not enlarged, but liver still noticeably so, and is
still certainly tender. Says no fever for a long time. Taking the decoction. Splenic blood,
copious parenchymatous tissue obtained ; not a single parasite, even a crescent ; not a single
particle of melanin. No yellow pigment found. Not seen again.
NOTE—This and Case 16 occurred in the same house one after the other, and contained evidently the same
parasite. It is remarkable that no crescents were found in either case. In spite of the serious nature of the
attack, especially in Case 17, the organs, particularly the spleen, were not affected to a great degree. Fairly
copious melanin found in spleen on 27th September ; none on 19th October.
Case 18.—Assir-u-din, m., 6, one month ill. This and the next four cases belong to the
same family. From careful enquiries of the parents it appears that that they had nine children,
of which four have died. One died of kala-azar three years ago ; two of "fever" and one
of "headache" about a year ago. Then the father and four of the remaining children
were attacked with fever one after the other, the mother and one child escaping hitherto.
The first attacked was Amir-u-din (Case 22), a year ago ; then the father, Bassur-u-din (Case
21), and another child, Hamad Ali (Case 20), both two months ago; lastly this case and
Saffir-u-din [Case 19], one month ago. The exact dates are not very reliable. Parents say
that their child who died of kala-azar had symptoms exactly like these surviving children,
but that in his case there was an extremely severe recurrence of fever after a month from the
beginning of his illness, from the effects of which he finally died. They add that in all the
cases the illness begins with continued fever for ten days or so, with numerous severe rigors.
The fever then gradually subsides, leaving enlarged spleen, but recurs frequently at various
intervals. For some time past the present child (Case 18) has been getting fever with rigor
every third day. Examined 7th October, 9 A.M., temperature 97'8° P. Looks extremely ill ; is
of a yellow colour and very anæmic; depressed expression ; no œdema; no emaciation. Spleen
3 inches below ribs and liver one inch (patient being a small child ); both tender on pressure.
Several Hospital Assistants familiar with kala-azar think that this case and Cases 19 and 20,
and possibly 22, are very probably cases of commencing kala-azar. Peripheral blood, numerous
quartan parasites of two generations ; some nearly mature, others a day younger. Many of
them are contained in small dark green corpuscles. The youngest parasites have very rapid
amœboid movements for quartan parasites, and pucker up the corpuscle as they change shape.
Examined again on 8th October, 9-30 A.M., temperature 96.9° F. Peripheral blood, same
parasites as yesterday ; one parasite on the point of forming nine large spores. Quinine. Seen
frequently again up to 19th October. Fever and parasites disappeared rapidly, but the
enlargement of the organs abated but little.
Case 19.—Saffir-u-din, m., 4½ one month ill. Brother of above, and parents say gets
the same kind of fever, but has slight dysentery and diarrhœa as well. Examined 7th October,