176 TlIK Af.KAI.ISITY or Tin-; HI,0()I> SKIU'.M IN lv\I,A-AZAU 



The patient was treated, soon after admission, with increasing doses of liquor 



argehivalin for a period of one month, and during this period little change was noted in 

 liis general condition. 

 *-''""-'*'. , In view of the fact that a diminution in the alkalinity of the serum was found, and 



;ippiicatioii of 



ihc findings that sucii clinical signs and symptoms in kala-azar as epistaxis, ulceration of the buccal 

 mucosa, petechiuj, etc., are common features in scurvy, Dr. Balfour suggested that an 

 alkaline treatment might be efficacious. 



Accordingly, calcium lactate in 30-grain daily doses was given, and in order at the 

 same time to obtain, if possible, a direct letlial action on the parasite, orsudan in 1-grannno 

 doses was administered intranniscularly four times a week. 



The calcium lactate was given in increasing doses until the patient was taking 50 grains 

 per diem. The spleen was found to be diminishing in size and the patient's general 

 condition improving slightly. The diarrhoea and epistaxis ceased. 



After three weeks' treatment the spleen had retracted to 1 inch above the umbilicus. 



The i)atient's serum alkalinity was again tested and found as follows :— 



Pooled normal serum ... ... 003 expressed as a fraction of normal 



Patient's scrum 0'026 „ „ „ 



The alkalinity of the patient's serum ha<l evidently increased after a month's treatment 

 with large doses of calcium lactate, and the general condition of the patient had improved ; 

 but judging from the blood count and the lucmoglobin percentage, it was apparent that 

 the prognosis was extremely liad. The count showed as follows : — 



Hcd blood cells 2,666,000 



White blood cells .. 3,125 



TTrpmc>?lf)liin .. . . 50 per cent. 



A differential count showed : — 



Polymorphonuclciir leucocytes ... 32 percent. 

 Large mononuclears . . . 44 „ 



Lymphocytes . . . L'l 



Transitionals 2 



Eosinophiles 1 ,, 



In addition to the calcium lactate, hsematinies were also administered, but at the end 

 of a fortnight the patient relapsed. 



Two days previous to death the hsemoglobin percentage had fallen to 25 per cent. 

 Post mortem The post mortem appearances of the spleen and liver were typical of kala-azar, both 



appearances oj-gans being enlarged and the liver cirrhotic. Smears revealed immerous Leishman 

 bodies. Ulcers were not present in the intestines. The mucosa of the small intestine was 

 very antemic and considerably atrophied, and resembled the consistency of thin tissue- 

 paper. This latter condition has been present as a constant pathological condition in 

 almost all tlie post niortems of these kala-azar cases. With such an atrophic condition 

 of the mucosa of the small intestine the physiological functions of this portion of the gut are 

 practically in abeyance, and consequently the emaciation of the patient progresses steadily 

 in spite of nil I'lTorts to comlint it. 



