Transactions of the Royal Society of Tropical Medicine and Hygiene/Volume 1/A Case of Kala-Azar: Recovery
A CASE OF KALA-AZAR: RECOVERY.
By Sir PATRICK MANSON, K.C.M.G.
(February 2lst, 1908)
The Rev. I. C., aged forty-four, a missionary, was admitted into the Seamen's Hospital Society's Branch Hospital, Royal Albert Dock, on November 1st, 1906, suffering from fever, night sweats, and enlargement of the liver and spleen.
The more important points of his previous medical history are as follows : He had had two spells of service in India, the first of seven and a half years (November, 1889, to March, 1897), the second, after eighteen months' furlough in England, of five and a half years (October, 1898, to April, 1904). While in India he was stationed at Calcutta and the Nuddea District, about eighty miles north of Calcutta. His duties took him about the surrounding country.
In May, 1890, he is said to have had enteric fever with a relapse. During his furlough in 1897-98 he suffered from neurasthenic symptoms—head tiredness, lapse of memory. Similar nervous symptoms supervened again towards the end of his second tour of service in India, induced, apparently, by severe domestic affliction.
The commencement of his present illness seems to date from about September, 1903, when he had the first of a long series of febrile attacks, which recurred, with considerable regularity, about once a fortnight. These continuing and his general condition gradually deteriorating, he was sent home, arriving in England in April, 1904. Dr. Harford, who saw him during the following July, informed me that at that time there was no enlargement of liver or spleen. Subsequently Dr. Tirard saw the patient and reported that the febrile temperatures still kept recurring, although the night sweats from which he had suffered had ceased, and that he had gained weight.
Soon after this, temperature became steadily normal; weight went up, to 11 stone 2 lb., and in November, 1904, he was again able for clerical work in this country, although at times he suffered from feelings of mental fatigue. With the exception of during a short neurasthenic attack about the end of 1905 he kept at work till March, 1906.
The old febrile symptoms recurred, however, toward the end of March of that year (1906), and he was again obliged to give up work. On May 4th he was reported to be suffering from enteric fever. This diagnosis was evidently erroneous, the fever being of a very irregular character, sometimes having two or three rises in the twenty-four hours. The nocturnal sweatings again set in and were profuse. Later, on the supposition that the fever was malarial, large doses of quinine were administered, both by mouth and hypodermically, and kept up over a long period, but without permanent effect. On June 27th, 1906, the spleen was found to be enlarged and malaria parasites were reported as having been present in the blood—an observation, the correctness of which I doubt. Notwithstanding the continuance of the fever the tongue was clean, the appetite good. On the other, hand anaemia and wasting became pronounced.
When admitted to hospital on November 1st, 1906, he was seen to be markedly anaemic, sallow, wasted (9 stone 12 lb.). The tongue was clean, the appetite and digestion fair, bowels normal. A systematic examination of the various organs gave only negative results, except in the case of the liver and spleen, which were much enlarged, the former extending an inch below the costal margin in the mammary line, the latter extending almost to the umbilicus. A blood count gave the following : —
Red blood corpuscles - 3,100,000 White blood corpuscles ... ... 3,700 Haemoglobin ... ... ... ... 70 per cent.
Differential. count of white blood corpuscles : — Polymorphonuclear ... ... 37.5 per cent. Large mononuclear Lymphocytes Transitionals 24 29.5 9
On November 8th the liver was punctured with a fine needle, and in the liver tissue and blood so procured Leishman bodies were found in abundance. Diagnosis was now clear, the patient was suffering from kala-azar.
Treatment by intramuscular injection of atoxyl was at once begun, the dose being gradually raised from 10 minims of a 7^ per cent, solution to 34 minims, about 3 grains. The injections were made usually every second day, sometimes every day.
On January 16th, 1907, in consequence of the appearance of symptoms suggesting arsenical poisoning, coryza, inflammation of the fauces and bleeding from the gums, the injections of atoxyl were suspended till February 15th, when the arsenical symptoms having subsided, the injections were resumed and continued till March 11th. On the latter date, the patient apparently making no progress, bone marrow tabloids were substituted for the atoxyl, but as the tabloids seemed to upset the digestion they, too, were stopped at the end of a fortnight.
The patient was now exceedingly weak, and had fallen in weight to 9 stone 1 lb., notwithstanding a fair appetite and good digestion. He had an irregular temperature, and, almost nightly, profuse sweats. He complained also of pains and numbness in his legs, and also appeared to be in a hopeless condition. He left hospital on March 26th. I confess I expected to learn of his death within a few weeks.
From time to time I heard from him. At first the reports were not encouraging, but, as the summer advanced, they told of gradual improvement, of fever and sweats diminishing, of these being sometimes altogether absent, and, finally they spoke of decided improvement. From the beginning of July, 1907, there was no fever, although for a month or two longer the daily range of the thermometer was still abnormally large (96 deg. to 99 deg.).
After October the temperature became normal or subnormal. The nocturnal sweats had ceased in August. Weight steadily increased to 11 stone, the spleen and liver diminished in size, and he began to get about.
Wishing to satisfy myself that the good accounts I had received were well-founded, I visited the patient at his home in Norfolk on January 19th, I was gratified to find that there had been no exaggeration. The patient, who had left hospital the previous March, apparently in a dying condition, was indeed practically well. He could walk at a stretch about one mile, his weight was 11 stone 1 lb. (now 11 stone 3 lb.), his liver was of normal dimensions, and his spleen, which, when he left hospital, had extended well to the right of the umbilicus, though still enlarged was very much reduced, the anterior border being at least 3 in. to the left of the umbilicus. He complained a little of various paraesthesiae, especially in his calves, sensations of wet, cold and stiffness; his knee jerks were somewhat exaggerated, and there was a suspicion of left ankle clonus. In other respects, though not vigorous, he was well, and he was craving to be at work again.
Several points of special interest have induced me to bring this case before the Society. There can be no question about the correctness of the diagnosis : the clinical symptoms, together with the microscopical findings, are conclusive for kala-azar. The points of interest I desire to call attention to are as follows:—
1. After a chronic febrile illness lasting over one year (September, 1903, to October, 1904) complete cessation of all febrile symptoms, followed by restoration of weight, and some, though not full, return of physical vigour.
2. After a spell of comparatively good health for at least fifteen months (November, 1904, to March, 1906), recurrence of all the symptoms and in aggravated form.
3. After this severe relapse, during which the patient nearly died, apparent complete recovery.
4. Although at the time the drug did not appear to be of much service, the possibility that the atoxyl brought about or conduced to the recovery.
I may mention in conclusion, although I do not think it could have had anything to do with the fortunate issue of the case, that while in hospital the patient was inoculated with scrapings from a Delhi boil (Oriental sore), in which the characteristic parasite had been found some weeks previously. Two students were inoculated from the same boil at the same time as the patient, but in neither patient nor students did the inoculations "take." This failure may be attributable to the fact that at the time the inoculations were made the boil may have been in the involution stage, for shortly afterwards, I am informed, it began to show indications of healing.
Discussion.
Sir R. Havelock Charles, K.C.V.O., said he did not propose to criticise the very interesting paper to which they had listened further than to cite a case of successful treatment of the same disease. The symptoms the Presi