REMARKS ON KALA-AZAR 133 Pain was never a marked symptom, though several complained of attacks of pain over the splenic region, these attacks apparently lasting several days and due, possibly, to sudden enlargement of the organ or to adhesions.

Headache, pains in the lumbar region and in the shins were sometimes encountered, but invariably accompanied by fairly high fever.

Epistazis was troublesome in one case, and bleeding gums were encountered on several occasions.

Hemoptysis was complained of by one patient, who showed no physical signs of phthisis, and there was no available sputum for examination when the patient was seen.

It is much to be regretted that no post mortem examinations were made, but this was next to impossible owing to there being no available place, the tukl being usually in a compound occupied by many other people, and the prejudice against such a procedure very strong.

Figs. 32-35 (page 135) illustrate various types of the disease as met with in the Sudan :— 1. A subacute case.

2. Comparison between chronic malarial and kala-azar patients.

3. Extremely acute case of kala-azar.

4. A doubtful chronic case of ‘“ kala-azar.” Owing to the very short time allotted, it was considered advisable to make a definite diagnosis by splenic puncture. The writer is well aware this procedure is open to criticism, but circumstances must be taken into consideration, and as patients were usually seen but once, even if blood-counts, etc., had been made, the diagnosis would still have been in doubt, and the slight risk to the patient had to be faced rather than leave a case at large to infect the general community. Altogether I have now performed over 120 splenic punctures without any dangerous symptoms or bad results. Calcium chloride was never administered and many cases walked away 15 to 30 minutes after puncture.

My experience of liver puncture, a procedure held to be safer, is small, and in the few cases in which I have employed it, I have been unable to find parasites. The cases had but slight splenic enlargement and therefore liver puncture was undertaken, but they may not have been examples of kala-azar.

When patients are under observation, probably liver puncture should be first employed, and, if negative, splenic puncture undertaken. I have met several instances where doctors have used a small exploring needle and syringe for splenic puncture, and to my mind this is but courting disaster, and quite unnecessary.

Recently in Egypt, a doctor told me of two fatal’ cases, one from splenic and the other from liver puncture, but in these two cases such a syringe and needle had been employed. Only three of my cases showed any symptoms after puncture and these were trivial :— 1. One case vomited and fainted ten minutes after puncture, but rapidly recovered and had no further unfavourable symptoms.

2. A case, whose maximum temperature had been 100° F., had a rise the evening after the puncture to 105° F., but then reverted to his former type of fever.

3. One case had pain for twenty-four hours over the site of puncture, but no accompanying signs.

I have never seen any signs or symptoms pointing to blood effusion into the peritoneal cavity.

Impossibility of performing post mortems Splenic puncture Dangers of faulty technique