104 
KALA-AZAll IN THK ANGLO-EdVrTlAN SUDAN 
A suggestion 
for facilitating 
diagnosis 
Diffcicnlial 
diagnosis 
Egyptian 
cirrhosis of 
liver and 
sjjleen 
Captain L. Bousfield in several of his cases, while Major Marshall, I.M.S., had great 
difficulty in finding the parasite in the case of the late Dr. MacTier Pirrie. In no case has 
the parasite been descried in the peripheral blood, though observers in India' have 
recorded finding it in 70 per cent, of their cases. The severity of the case appears 
to have little or no connection with the number of “ bodies ” found. 
Owing to the diminution of the number of leucocytes, the chances of finding the 
“ bodies ” in the peripheral blood are much diminished. To obviate this difficulty, I have 
twice had recourse to the following device :— 
The skin is well rubbed over a given area with ointment of tartarate of antimony, this 
being repeated daily until pustulation takes place. Films are made from the pustules, in 
which many leucocytes are to be seen ; and there w'ould appear to be a much greater 
probability of diagnosing a case by this means than by ordinary examination of the 
peripheral blood. In both my attempts I failed to find any parasites ; but I was dealing 
with a case where they were only found with great difficulty, even in the splenic blood. 
I think this method should be tried before having recourse to spleen puncture, but 
where it fails, I can thoroughly endorse Captain Boustieldis experience, that, if made with 
a small needle, the latter process is quite safe. 
DIFFEBENTIAL DIAGNOSIS. Leaving out of consideration such rare causes of 
splenomegaly as LeukcEiuia, Tuberculosis, etc., three conditions are likely to give rise to 
confusion in the diagnosis of kala-azar in the Sudan and Egypt. These are Malta Fever, 
Malaria, and Egyptian Cirrhosis of Liver and Spleen. This difficulty is greatly enhanced by 
the extremely small number of “ bodies ” to be found in many Sudan cases of kala-azar ; so 
that a positive diagnosis is often impossible, except post mortem. The diagnosis, by exclusion 
of other conditions, is also very difficult in the out-stations of the Sudan, wdiere Widal’s 
reaction for Malta fever is, at present, out of the question. I can only call attention to 
the “ Milroy Lectures ” by Major L. Rogers, I.M.S. (1907), where the question is most 
thoroughly treated. 
A continued fever, accompanied by enlargement of liver and spleen, resistant to 
ordinary doses of quinine, and tending, through i)eriods of wasting and debility, with 
eedema of extremities, to a fatal termination, usually determined by some septic complica¬ 
tion, is almost certain to be kala-azar. A point of great importance, and which can be 
demonstrated with no more complicated apparatus than a thermometer, is the double daily 
rise of temperature, when a four-hourly chart is kept. 
Where blood-counting is possible, a marked leucopcBuia is almost diagnostic of kala-azar. 
I cannot leave the subject of differential diagnosis without a reference to “Egyptian 
Cirrhosis of Liver and Spleen.” This, like kala-azar, is a chronic disease, wdth spleno¬ 
megaly and enlargement of the liver, ascites, oedema of the lower limbs, pigmentation of 
skin, resistance to quinine, and a tendency to a fatal termination. For a most interesting 
account of the disease, I would refer medical readers to the paper by Dr. L. Phillips, in 
the Records of the Egyptian Medical School, Vol. 11., 1904, entitled, “The role played by 
Malaria in the production of Ascites.” The reader will be at once struck by the close 
resemblance between the oases recorded and kala-azar. Although Dr. Phillips demon¬ 
strated the presence of malarial parasites in many of his cases, this is far from being proof 
that the disease is malarial, as malaria co-exists with everything in countries where it is 
prevalent. 
It is curious, too, that in the Sudan, where malaria is more severe than in Egypt, these 
cases do not occur ; or, at least, have not been noted, except occasionally in Egyptians. 
Patton, W. S. (19U7). Scientijic Reports of Government of India. 
