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68
COMMENTS ON KALA-AZAR WITH A REPORT ON THREE GASES.
By Major JOHN MAcKAy-DrcK, M.B., Ch.B., M.RC.P. Edin.,
.
Royal Army Medical Corps.
[Received March 7, 1945.J
IN this war some of us have been fortunate enough to familiarize ourselves with diseases
not commonly found amongst United Kingdom Service personnel. To me the most intriguing
new disease has been kala-azar. I first met with visceral leishmaniasis (kala-azar) in Eritrea
in 1941 just after the Imperial Forces had taken that country. In all, I saw six cases of kalaazar before I left for Syria and in each case, four of· whom had reported sick with malaria.,'a
clinical diagnosis of kala-azar was made, as it can be, before conclusive evidence was demonstrated.
As far as I am aware these were the first cases of Sudan kala-azar to be diagnosed in British
troops in the Middle East in this war. The patients had all served in the Gedaref-Gallabat
areas of the Anglo-Egyptian Sudan and kala-azar is endemic in these areas. At this time
numerous troops, who had fought in these areas, were being rushed back to the Western D~sert
in an attempt to resist' Rommel's progress through Cyrenaica. The consultant physician,
M.K, was warned that kala-azar had started to spow itself amongst British troops who had
.served in the Anglo-Egyptian Sudan and that their comrades were back in Egypt once again.
Hospitals were warned to be on the look-out for Sudan kala-azar in cases of prolonged P.U.O.
and soon kala-azar of the Sudan type was being diagnosed amongst British troops in Egypt.
This emphasizes the great importance of asking every case of P.U.O. in'what countries he has
served. and in what areas of these countries. In this way a constant awareness of kala-azar is'
maintained.
I wish to present notes on three cases of kala-azar which occurred in British other ranks
who had contracted the disease whilst serving in North Africa (Tunisia, Tripolitania and
Algeria).
'
In two cases, the diagnosis was made on clinical grounds. over eighty days before the
demonstration of the Leishman-Donovan bodies in one case, and the therapeutic response to
stilbamidine in the other case, left no doubt about the diagnosis. In the third case kala-azar
was seriously considered four months before conclusive proof had been obtained. This third
case is the most interesting case of all and many invaluable lesspns are to be learnt from it.
All these cases of kala-azar (Mediterranean) are similar to the cases of kala-azar of the Sudan
variety seen by me in 1941 and that is why they were more or less diagnosed at sight on purely
cliriical grounds, For various reasons treatment was not exhibited for a long time.
Notes in each case will be as brief as possible. In all cases the following investigations
were carried out repeatedly and with negative results: blood culture; stool and urine culture;
routine stool and urine examinations; agglutination reactions for B. abortus and Br. melitensis;
Paul Bunnell reaction; Weil-Felix reaction; Kahn F.T.; X-ray chest; screen diaphragm.
No malaria parasites or Sp. recurrentis were found in Cases A and B.
In addition, Cases A and B received a thorough and prolonged course of treatment as for
malaria. So did Case C but he had proven malaria. Captain W. R Gauld, RA.M.C., supervised the treatment adopted which was on the lines advised by Professor S. Adler of the
Hebrew University, Jerusalem, in a personal communication to Lieutenant-Colonel T. E.
Gumpert, RA.M.C. This scheme of treatment will follow the case reports.
, Case A.-Lance-Serjeant D.F.-Aged 29. Service: 3 years.
Admitted to a General Hospital on 25.12.43. For'one week previously he had been complaining of general weakness, anorexia, nausea and a little vomiting. He finally decided to
report sick and he was found to have a high temperature. On admission he was febrile,
there were bronchitic signs, in the chest and a slight icteric tinge in the sclerotics .. At this
time the edge of the spleen was just palpable and there was hepatic discomfort. However,
by 19.3.44 the spleen was easily palpable threefi.n~ets breadth below the left costal margin and
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John Mackay-Dick
69
the liver was a full hand's breadth below the right costal margin. At this time the earthy
pallor of the skin was obvious. The behaviour of the blood-counts before and after treatment
are of interest.
26.12.43: W.B.t. 2,600 ..
1.1.44 : W.B.C. 3,000, P. 62 per cent, L. 36 per cent, M. 2 per cent"
17.1.44: W.B.C. 8,000, P. 64 per cent, L. 31 per cent, M~ 4 per cent, E: 1 per cent.
1.2.44: W.B.C. 7,000.
28.2.44: W.B.C. 10,000, P. 56 per cent, L. 40 per cent, M. 8 per cent, E. 2 per cent.
19.3.44: W.B.e. 4,400, N. 64 per cent, L. 31 per cent, M. 5 per cent.
R.B.C. 3,100,100, Hb. 60 per cent.
'
N.B.-Fluctuation in total white blood cell count without absolute neutropenia.
Also
marked fall in red cell count.
Solustibosan therapy commenced (14.5.44, i.e. 151st day of fever). Total 120 C.c. Temporary benefit but gradual relapse.
.
Stilbamidine therapy commenced (14.6.44, i.e. 181st day of fever).
26.6.44: R.B.C. 3,000,000, Hb. 79 per cent.
W.B.C. 8,200.
1.7.44: W.B.e. 11,000, N. 73 per cent.
21.7.44: W.B.e. 11,600, N. 52 percent, L. 36 per cent, M. 7 per cent, E. 3 per cent,
myelocytes 2 per .cent.
.
6.8.44: W.B.C. 10,000, N. 58 per cent, L. 3 per cent, M. 10. per cent, E. 2 per cent.
21.8.44: R.B.C. 4,500,000, Hb. 88 per cent.
, W.B.C. 11,000.
.
Before he became ill his weight was in the region of 65 kilos. On the 151st day of illness
when solustibosan therapy was commenced his weight was 47 kilos, while on 16.8.44 it was
61 kilos.
Other investigations carried out were : Formal Gel Test: Negative on 3.2.44, i.e. 48th day of illness.
Negative on 19.3.44, i.e. 93rd day of illness.
Negative on 14.4.44, i.e. 120th day of illness.
Sternal puncture: "Leishman-Donovan bodies present. Moderate increase of plasma
cells."
Icteric Index=4 (4.2.44).
Van den Bergh reaction: Negative.
Plasma proteins (Hebrew University, Jerusalem, by courtesy of Professor S. Adler) :
Totalproteins 5·98 per cent, albumin 3'54per cent, globulin 2·26 per cent, euglobulin 0·18 per
cent.
.
It will be seen that under stilbamidine therapy the patient returned to normal in all respects
and when he set sail for the U.K. the liver and spleen were just about 1-2 fingers breadth
below the respective costal margins.
Case B.-Lance-Corporal R.M.-Aged 28. Service: 4 years.
Admitted to a General Hospital on 4.2.44. For at least ten days previously he had been complaining of vague ill health, backache, occasional shivers and sweating. His friends remarked
how ill he was looking and on their repeated advice he reported'sick. He was· found to be
febrile and was observed for three days before admission to hospital. On examination he was
febrile, the spleen and liver were just palpable; with the passage of time the liver became
progressively enlarged to four fingers breadth below the right costal margin, but the spleen
never became larger than two fingers breadth below the left costal margin. In addition, the
skin gra:dually developed an earthy pallor, the sclerotics became icteric (icteric index was 15 on
15.3.44, 60 on 14.8.44 and almost normal by the time the patient embarked for the U.K.).,
The test for urobilinogen in the urine was strongly positive. There were also bronchitic signs
in the lungs. The behaviour of the blood-counts before and after treatment is of interest:6.2.44: W.B.C. 4,600.
13.2.44: W.B.C. 3,000.
13.3.44: W.B.C. 5,000, N. 48 per cent, L. 49 per cent, M. 3 per cent.
3.4.44: R.B.C. 2,890,000, Rb. 74 per cent.
W.B.e. 4,800, N. 61 per cent, L. 27 per cent, M. 10 per cent, E: 2 per cent.
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70
Comments on Kala-Azar with a Report on Three Cases
N.B.-No marked neutropenia but marked fall in red cell count.
115th Day of Illness (18.5.44): Commenced course of solustibosan therapy. Total 120 c.c.
159th Day ofIll1iess (28.6.44) : Commenced COurse of stilbamidine tht;rapy.
11.7.44: RB.C. 3,160,000, Rb. 66 per cent.
W.B.C. 7,000.
21.7.44 : W.B.C. 6,900, N. 67 per cent, L. 27 per cent, M. 6 per cent.
Before the stilbamidine therapy was commenced his weight was 58 kilos and on 26.8.44
after one course of stilbamidine therapy his weight was 62 kilos.
Other investigations which wefe carried out were:
15.3.44 (51st day of illness) : B.S.R=45.mm. in first hour (Westergren).
Van den Bergh reaction: Direct: negative.
31.3.44: Formol Gel Test: Positive in thirty minutes (67th day).
3.4.44: Plasma protein 6.8 gm. per cent, albumin 3·8 gm. per cent, globulin 3·0 gm. per
cent.
.
Sternal puncture repeatedly negative.
Prior to embarking for the U.K. the patient was returning to normal in every way and his
liver and spleen were very much smaller and just palpable.
Case c.-Corporal N.G.-Aged 31. Service: 13 years.
This patient,admitted to a General Hospital on 15.2.44, had recently served inTunisia and
Algeria in precisely the same places as Cases A and B. On admission to hospit3.1 he was found
to be suffering from malaria B.T. but in spite of adequate anti-malarial therapy, carefully
controlled by Tdnrets Test, and including intravenous quinine therapy, fever continued and the
clinical picture resembled typhoid fever except that rose spots never appeared. The patient
became so ill that he was. placed on the Dangerously III List. The illness had the following
.characteristics :(1) Essentially a continued fever lasting roughly twenty days.
(2) Slight but persistent splenomegaly.
(3) Liver not palpable but discomfort in hepatic region.
(4) No rash.
(5) Average pulse rate in late eighties.
(6) Leucopenia. W.B.C. 2,400, N. 68 per cent, L. 30 per cent, M.2 per cent.
(7) B.S.R 31 mm. in first hour (Westergren).
.
(8) Formol gel test negative.
He was given a therapeutic test course of emetine hydrochloride as for amrebiasis but
without benefit.
He visibly lost weight and became very weak. His skin developed an earthy pallor.
Gradually he improved, gained in weight and strength and on 26.4.44 was sent to a convalescent
.
depot.
A diagnosis of kala-azar had been carefully considered but in view of the apparent cure we
were driven to consider the case as being one of the enteric group fever-a diagnosis which I '
dislike making. When the patient went to the convalescent depot his spleen was just palpable.
He was readmitted to the general hospital from the convalescent depot on 15.6.44 complaining of " pain in his spleen," which was perfectly true as he had a gross splenic friction
rub due to perisplenitis, upper abdominal discomfort and attacks of weakness and" blackouts."
On examination.-(l) Afebrile on first examination but subsequently found to have low
grade irregular pyrexia. Maximum temperature was 99.4 0 F.
.
(2) Spleen enlarged, firm and tender and easily palpable more than a hand'sbreadth
-D"lO',T/ :~",Jeft costal margin. Extensive and easily palpable splenic friction rub.
(3) Liver enlarged, firm and palpable at least four fingers breadth below the right costal
'
margin.
(4) Average pulse rate in the eighties.
(5) Earthy pallor.
(6) 15.6.44: R.B.C. 3,600,000, Rb. 65 per cent, W.B.C. 5,700, P. 56 per cent.
18.7.44 : W.B.C. 2,600, N. 64 per cent,L. 30 per cent, M. 5 per cent, E. 1 per cent.
B.S.R.=18 mm. in first hour (Westergren). No correction made for amemia.
Icteric Index =4.
Van den Bergh reaction: De,layed; direct.
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John Mackay-Dick
71
Formal gel test: Positive in thirty minutes.
Fractional test meal: Within normal limits.
Urine: No excess urobilin.
Fragility of R.B.C. : Commences at 0·4 per cent NaCl and is complete at 0·35 per cent.
Reticulocytes: 0·4 per cent. No spherocytes seen.
Blood films and thick drops after adrenalin show no malarial parasites.
Spleen puncture : Leishman-Donovan bodies seen.
" Fairly numerous motile leptomonas forms seen in culture after sixty hours' growth at
room temperature. The nucleus, kinetoplast and flagellum are clearly distinguishable in
nearly all individuals." Following one course of treatment with stilbamidine started on
28.7.44, the spleen was scarcely palpable, the liver palpable two fingers breadth below the
right costal, the patient had gained four kilos in weight, was feeling very well and making
excellent prQgress.
31.7.44: W.B.C. 3,600.
5.8.44: W.B.C. 4,400.
21.8.44: W.B.C. 4,800.
10.9.44: R.B.C. 4,400,000, Hb. 89 per cent, W.B.C. 6,600, N. 62 per cent, L. 26 .per
cent, M. 8 per cent, E. 4 per cent.
The patient was fit to travel to the U.K. to complete his treatment on 10.9.44.
In the tropics and subtropics we find a diagnosis of enteric group fever frequently made in
the type of clinical picture presented by this case. On first admission to the General Hospital
such a diagnosis seemed reasonable, even in the absence of rose spots because these are not
constantly present. However, I do believe, and this case surely supports my belief, that no
case should be diagnosed as enteric group fever or undulant fever clinical, etc., until repeated
and adequate investigations for evidence of visceral leishmaniasis have been carried out,
e.g. smears and cultures from sternal puncture, spleen puncture and gland puncture. Furthermore, if these investigations are negative, the patient should be reviewed every six weeks for
six months by a physician and a pathologist-preferably a h<ematologist-both skilled in
tropical medicine. Of course, these remarks refer to patients who have served in kala-azar areas .
• TREATMENT.
Specific treatment consists of the exhibition of stilbamidine (isethionate) (M & B 744)
which may be given intramuscularly, when it gives rise to much discomfort, or intravenously.
Toxic reactions may be late or immediate. The former consists of the so called" diamidinostilbene neuropathy" (Napier and SenGupta). Immediate reactions. include burning
sensations all over the body, flushing of the face and slight giddiness. These are mild whilst
moderate reactions combine these symptoms with vomiting, epigastric distress, dyspncea,
feebleness of the pulse and sweating; finally, in severe reactions, the patient collapses with a
steep fall in blood-pressure and loss of pulse at the wrist. Wien showed that the fall in bloodpressure can be avoided by a' previous injection of calcium gluconate (B.M.]', May 27, 1944,
p. 724). Devine has described the toxic action of stilbamidine on the liver and kidneys in
rabbits; these animals showed transient hyperglyc<emia and marked nitrogen retention but
death took place in hypoglyc<emia. Wien, Freeman and Scotcher showed that in dogs and
rabbits the serum calcium and potassium levels both fell within a few hours. Some cases of
Sudan kala-azar died of signs suggesting hepatic failure (B.M.]., May 27, 1944, p. 724).
Nearly all of these toxic reactions can be prevented by using stilbamidine freshly made, every
day, immediately before use, and diluted in 10 per cent glucose in sterile distilled water and
given very very slowly intravenously.
In addition the following precautions should be taken : (1) Intravenous injections should be gIven one hour before the midday meal so as to prevent
vomiting.
(2) A high carbohydrate, high protein, high vitamin and restricted fat diet of high calorific
'
value should be given throughout the course of treatment.
(3) Adrenalin (1: 1,000) min. 7t-min. 15 should be given at once should immediate
reactions appear.
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72
Comme'!ts on K:ala-Azar with a Report on Three Cases
(4) Calcium lactate in large doses by mouth or calcium gluconate by injection should be
given daily. Absorption of calcium following oral administration is not very satisfactory
unless massive doses are given on an empty stomach first thing in the morning before breakfast
and last thing at night. The exhibition of calcium by the parenteral route is to be preferred
as its absorption is certain.
(5) Keep a close eye on the appetite. If this is good all is well but if it suddenly fails
stop specific treatment at once.
(6) Carry out complete blood-counts at weekly intervals.
One unfortunate and very trying complication of stilbamadine noticed by me in Eritrea
in 1941 was very troublesome and that was venous thrombosis, the result of intravenous
administration of the drug. Its occurrence was lessened and finally prevented completely
by using very dilute freshly prepared solutions of the drug and by giving the solution very very
slowly.
.
Stilbamidine is given intravenously every day in the following doses:1·5 mgm. per kilo body-weight for five days.
2·25 mgm. per kilo body-weight for five days.
3·0 mgm. per kilo body-weight for fourteen days.
N.K---We didnot adhere strictly to these doses in every case. I would suggest that the
drug should be dissolved in SO to 100 C.c. of 10 per cent glucose ill sterile distilled water and
given as slowly as possible intravenously by using a tube and funnel or the usual apparatus
for giving :fluid intravenously by the continuous drip method.
Two, and pm;sibly three, courses of treatment should be given at intervals of two to three
months in the absence of signs of onset of the diamidino-stilbene neuropathy, which should be
searched for diligently in every case, and following adequate liver function tests, as impaired
liver function, with or without jaundice, may be evident at this time.
The patient should be weighed weekly.
Tests of cure should include: (1) Spleen puncture as long as the spleen is palpable;
(2) gland puncture; (3) sternal puncture.
.
It is advisable to carry out at least two of these as it is' not uncommon to find a gland
puncture positive with negative splenic puncture and vice versa (Horgan, in personal com,
munication).
In the diagnosis of Mediterranean kala-azar, and I believe in Sudan kala-azar as well, the
following points are well worth bearing in mind.
(1) The not infrequent vague and insidious onset of the illness. Patients are found to be
walking around with high temperature and report sick because they feel out of sorts or their
friends tell them that they are not looking well or because of the appearance of some other
febrile illness, commonly malaria, which does not appear to respond to adequate therapythe reasons being that the patient also has kala-azar.
(2) Fever: Nearly all varieties of a prolonged continuous fever can be seen. Broadly
speaking, the fever is usually continuous and prolonged but there may be an initial febrile
illness which simulates enteric group fever very closely and a later recrudescence of fever
may suggest a relapse of enteric group fever.
In the usual t'ype of case there is prolonged fever with profuse sweats in the morning
but without joint pains or orchitis, etc.
Too much stress is laid on the double rise of temperature in the twenty-four hours. Like <!li
rarities it gains a! prominent place in the minds of many-the inexperienced many.
(3) SPlenomegaly: This is constantly present and is usually slowly progressive and fairly
marked but sometimes the spleen is just palpably enlarged and no more. It is said that the
spleen reaches the costal margin in two months and then enlarges by one F.B. every month
bu~ that is not necessarily so. Perisplenitis may occur (Case C).
(4) Hepatomegaly: This is also constantly present. It is also slowly progressive. It may
be marked but it is usually moderate and frequently the liver is just palpably enlarged.
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John. Mackay-Dick
73
(5) Lymphoglandularenlargement is not obvious but this should not prevent gland puncture
being carried out.
(6) Blood Changes: R.B.C.s usually fall to 3 or 4 million or even less. A leucopenia takes
some time to develop butits appearance is inevitable and progressive with the passage of time in
untreated cases. In the three cases here described the fall in the red cell count is most striking.
(7) Formol Gel Test,' This test, much lauded in India, is really useless as a diagnostic test.
It is a long time before it becomes rapidly positive, and that is when it is of significance.
(8) Jaundice may be present and may become slowly progressively worse in the untreated
patient.
(9) Appearance of an earthy pallor of the patient is very frequent but may be missed
because of its gradual appearance. It is more noticeable to the second opinion than to the
Medical. Officer in charge of the case.
(10) Appetite is frequently remarkably good in spite of long febrile illness with associated
profound and progressive lassitude and lack of energy.
(11) Dysenteric symptoms may occur and Leishman-Donovan bodies may be found in the
mucus.
(12) Hcematuria when it occurs is of ill omen.
(13) Bronchitis may be marked.
(14) With proper technique Leishman-Donovan bodies should be found in spleen puncture,
sternal puncture or gland puncture. .The parasite is not difficult to culture if correct technique
is used.
(15) Cutaneous leishmaniasis may be present and should be searched for diligently in all
cases.
(16) It is not uncommon for the patient to be admitted to hospital for some other disease
process, e.g. malaria, and when this does not appear to respond to adequate therapy it is only
then that this ofttimes insidious disease is suspected.
•
CONCLUSIONS.
(1) Three cases of kala-azar are presented.
(2) In each case a diagnosis was made on clinical grounds months before proof positiyewas
obtained that the patients were suffering from kala-azar.
(3) Each patient was from a different unit so there is every reason to believe that there
must be similar cases from these units wherever they may be;
(4) Kala-azar is a chronic disease which may exhibit e~acerbations which vary in severity
from mild, just necessitating avoidance of over-exertion, to very severe, necessitating the
patient~s name being placed on the Dangerously III List.
.
(5) In kala-azar spontaneous remissions may occur with inevitable relapse.
(6) In the diagnosis of cases of P.U.O. it is of vital importance to know in which countries
the patient has served, to familiarize oneself with the main diseases of these localities and to
keep inmind the possibility of kala-azar where there is persistent splenomegaly with or without
associated hepatomegaly ..
(7) A diagnosis of enteric group fever in the case of individuals who have served in areas
where kala-aza occurs should only be made after kala-azar has been excluded beyond all
shadow of doubt, especially in cases with persistent splenomegaly however mild that might be.
(8) In adequately investigated cases it is not difficult for an experienced physician to make
a presumptive diagnosis of kala-azar on clinical grounds alone.
(9) In the diagnosis of kala-azar sternal puncture should be carried out and repeated as
necessary. Smears and cultures should be made. Gland punctures should also be performed.
If all these procedures are attended with negative results then spleen puncture is indicated.
(10) An adequate therapeutic test course of stilbamidine should be given as a life-saving
measure in suspected cases of visceral leishmaniasis when repeated investigations have failed to
demonstrate the presence of Leishman~Donovan bodies and cultures have been carried out
with negative results.
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74
Comments on Kala-Azar with a Report on Three Cases
, (11) Stilbamidine is curative in cases of Mediterranean kala-azar which is very reminiscent
of the Sudan variety of kala-azar.
(12) The only disadvantage of stilbamidine if freshly prepared solutions are used, and given
with care, is venoUs thrombosis. It is felt that the incidence of this can be reduced by marked·
dilution in 10 per cent glucose in distilled water and by very .slow administration of the drug
intravenohsly.
(13) Leucopenia, when present in kala-azar, is due to the presence of that disease and is
cured by stilbamidine which should be exhibited at once no matter the severity of the initial
degree of leucopenia. It is doubtful if it is necessary to give pentose nucleotide at the same
time.
(14) Newcomers to the tropics and subtropics would be well advised to bear in mind the fact
that kala-azar is more common in areas where kala-azar is endemic than are acholuric jaundice,
lymphadenoma, aleukremic leukremia, certain types of malignant neoplasm and infective
endocarditis, etc., and that a leucopenia associated with progressive splenomegaly with or
without obvious hepatomegaly, in a febrile patient, is more common in kala-azar than in
septicremia, liver abscess or deep-seated cryptic osteomyelitis.
ACKNOWLEDGMENTS.
Major-General J. c. A. Dowse, C.B.E., M.C.,· D.M.S., M.E.F., and Lieutenant-Colonel
W. E. M. Mitchell, M.C., R.A.M.C., Officer Commanding a General Hospital, for permission to
forward these notes for publication.
Colonel H. T. Findlay, D.D.P., M.E.F., Lieutenant-Colonel W. E. M. Mitchell, M.C.,
R.A.M.C., and Lieutenant-Colonel T. E. Gumpert, RA.M.C., for their close interest and for
encouraging me to present these notes for publication.
Professor S. Adler, of the Hebrew University, Jerusalem, and Dr. E. S. Horgan, of the Stack
Laboratory, Khartoum, for their expert advice and their ever readiness to advise and help.
'
. Major J. W. Lacey, Major Joseph Fine and Captain H. B. Hewitt, RA.M.C., for the laboratory work entailed.
'
Captain W. R Gauld, RA.M.C., Graded Physician, for personally carrying out the specific
treatment.
Sisters J. W. Jack and V. 1. Young, Q.A.1.M.N.S.(R), and 7384130 Private B. R Holledge,
RA.M.C., for duplicating the temperature charts for me.
7361460 Serjeant A. J. Smith, R.A.M.C., for typing these notes for me.
[It has, unfortunately, not been possible to print the temperature charts sent with this paper.
Case A.-Admitted on December 25, 1943, with a temperature of 1040 F., this patient
remained febrile until June 22, 1944, and did not finally settle until July. .
Case B.-Admitted on February 4, 1944, with an initial temperature of 99 0. F., showed a
temperature swinging from 103° F. to 104° F. until May. With the administration of solustibosan it fell to nearly normal but ten days after the completion of the course was again rising.
During the course of stilbamidine then commenced, it rose each evening to about 103° F.; to
fall to normal at the conclusion of this course.
Case C.-This case showed a temperature round about 102 F. for about a monthFebruary 15 to March 19, 1944. The next appreciable rise was to 101 F. on July 23, when a
mildly irregular fever continued until after the third dose of stilbamidine started on August 12.
There was no further rise after August 20.
These charts show very graphically the protracted fever associated with the condition
described. A great deal of time and trouble was expended on their preparation for reproduction and we regret that it was not possible to print them. However, the excellent clinical
description given in the text leaves the reader in little doubt as to the chronicity of untreated
kala-azar.
Readers will find the article on kala-azar in the Memorandum on Tropical Diseases in
Tropical and Subtropical Areas of much interest if read in conjunction with Major MackayDick's article.-EDIToR.]
0
0
.
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Comments on Kala-Azar
with a Report on Three
Cases
John Mackay-Dick
J R Army Med Corps 1945 85: 68-74
doi: 10.1136/jramc-85-02-03
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