Transactions of the Royal Society of Tropical Medicine and Hygiene/Volume 1/Kala-Azar in the Royal Navy
KALA-AZAR IN THE ROYAL NAVY.
By Fleet-Surgeon P. W. BASSETT-SMITH, D.T.M. and H. Cantab.
February 21st, 1908.)
While employed in a naval hospital at home, and dealing with diseases from foreign stations, occasionally it is one's fortune to meet with some of the more obscure cases of irregular fever and cachexia, the etiology of which is unknown, or only partially known. Of the latter, the disease called kala-azar, Dum-Dura fever, etc., is of peculiar interest, especially when attacking Europeans, or when it has been possible to demonstrate the parasitic organism. That the disease is more common than is usually supposed is very likely. I can look back on four cases that have been under treatment in my wards, in which the clinical evidences were very strong, though it is only in the present one that proof has been obtained, and for want of this proof the cases were returned as "splenic anaemia." In the latest account of the disease, by Leishman, the original endemic centre in Assam and Bengal has been widely extended, though definite cases from other regions are not common. He mentions Southern India, Ceylon, Burma, China, Egypt, Tunis, and Algeria.
In my four cases, the first contracted his illness in South Africa; the second was originally a merchant seaman, and had been much to India. In both the symptoms were typical, with very large spleens, very low white blood counts, and relative very low polymorphonuclear counts. In both, 2 cc. of blood were drawn off from the spleen, with negative results. These cases were fully reported in the British Medical Journal, November 11th, 1905. I attribute the want of success in finding any parasitic organisms then to the large quantity of blood drawn off, and not to their being absent from the organ.
Case 3 was a chief stoker, aged thirty-eight. There was a history of chronic anaemia, commencing while in South Africa, attended with slight fever, recurrent haemorrhages from nose, stomach, and bowel (at times severe), great enlargement of the spleen, a reduction of the red cells to 2,000,000, the white being 2,100, and haemoglobin 40 per cent. The polymorphonuclears were relatively much decreased. In this case no parasitic bodies were found in the peripheral blood, and he refused to have any drawn off from either spleen or livor. Therefore, although all the symptoms pointed to kala-azar, it was not proved.
Last November a fourth case was received, being admitted for malarial cachexia. He gave the following history : From 1894 to 1896 he served on the East and West Coasts of Africa, and contracted malarial fever. From 1896 to 1901 he was on the Australian Coast. During 1902-03 he was on the East Indian station, and lived on shore in Bombay and Trincomalee. From 1904-06 he was in China, being quite well. He lived on shore at Hong Kong and Wei-hai-wei. He visited Shanghai, Tientsin, Hankow, Siam, etc. On arriving in England in 1906 he began to feel ill. He was treated for influenza for a month, then, improving, went to the Mediterranean. After three months, vomiting, anorexia, loss of flesh, pallor, headaches, and fever set in. He was treated for malaria, and invalided to England. On admittance to Haslar, he was seen to be a very old, cachectic-looking man; the skin was dry and earthy, he complained of headache, dyspepsia, epistaxis, and general weakness. His spleen extended to within 1 in. of the middle line and nearly down to the crest of the ilium, it was smooth and hard; the liver was also enlarged; the urine was non-albuminous. The blood gave 3,800,000 red cells, and 2,000 white cells. A relative count gave polymorphonuclears 48 per cent., large lymphocytes 27 per cent., small lymphocytes 25 per cent.
There was irregular fever and a fast pulse. These symptoms continued, the fever being of an undulant character. During the height of the fever a small quantity of blood was drawn off from the liver, and Leishman bodies, both singly and in groups, were found. He was put on atoxyl, calcium lactate, iron, and bone-marrow; under this treatment, the atoxyl being pushed to 12 grains a day, the haemorrhages stopped, the fever passed off, and he is now gaining weight.
A glance at the chart (p. 124) will explain how possible it is in such a case to confuse this condition with Mediterranean fever, as Bentley did, more particularly so, as I have myself had one case of eighteen months' standing, with such marked cachexia and splenic enlargement that I drew off some blood from his spleen to seek for the bodies, which blood instead gave a pure culture of the Micrococcus nielitensis. Only 0.5 cc. was drawn off from the liver of the present case; it contained some liver cells, fairly abundant Leishman bodies, most of which are single and pyriform in shape, but collections of eight to fifty were found. The blood was sterile bacteriologicall}'. A portion of the fluid drawn off was mixed with a citrate solution incubated at 20 deg. C, and daily examined for developmental forms. On the second day fission forms were seen, but from that day the bodies rapidly broke up, the swollen nuclei alone taking up the stain. The attempt at culti-
vating the organism was then only partially successful; the bodies on the second and third day were like some seen on slides of Indian cases which were given me by Leonard Rogers; they also resemble very much some stage in the evolution of trypanosomes as seen in rats. 
I have ventured to bring these short notes forward, as further study and a better look-out for examples of these interesting diseases are required, for such cases may possibly be passed as malarial cachexia, etc.; also the marked improvement in his condition, at least for a time, under atoxyl treatment is noteworthy; lastly, all positive evidences of such diseases are worth recording.
The patient made so great a recovery that he has now returned to Australia, being quite free from fever and other serious symptoms for two months.