)ienic 

 puncture 



REMARKS ON KALA-AZAE 133 



L'aiii was never a marked symptom, though several complained of attacks of pain 

 over the splenic region, these attacks apx^areutly 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. 



Epista.cis was troublesome in one case, and bleeding gums were encountered on 

 several occasions. 



Ksemoptysis was complained of by one patient, who showed no physical signs of impossibility 



.... T ,, -1 11 ,. ■ ,. 1 .1 ,. , of performing 



phthisis, and there was no avaiiable sputum tor examination when the patient was seen. ^ mortems 

 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 fnhl being usually in a 



compound occupied by many other people, and the prejudice against such a procedure 



very strong. 



Figs. 32-35 {puije 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 ^P'^ 

 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 tlian 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. 



Eecently in Egypt, a doctor told me of two fatal cases, one from splenic and the Dangers of 

 other from liver puncture, but in these two cases such a svringe and needle had been '^^" 'y*"^ 



^ . o nique 



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. 



