Descriptions of 10 cases of Kala azar, 1 case
of cutaneous Leishmaniasis, and 64 cases of Oriental
Sore are given. These are all cases which have been
for some time under my personal care or observation.
During my service at Chittagong, however, I had
almost daily opportunity of seeing several fresh
cases as out -patients or as patients in. the Civil
Hospital or Assam -Bengal Railway Hospital and this
experience has influenced my conclusions. `
I. KALA AZAR.
(1) Kala azar has a wider distribution than is
generally believed. I have seen cases in Dehra
Dun in the Western United Provinces which is a
semi hill station. Judging from the number of
cases occurring in Gurkhas on return from furlough it seems more than probable that this
disease occurs in Nepal.
(2) Certain symptoms and signs appear to be overrated and others not given sufficient prominence.
The 'double remittent' type of fever is more
often than not absent. In my series of cases
only two demonstrate this feature, and I have
seen it present in other diseases e.g. tuberculosis. The Chief Medical Officer of the Assam-Bengal Railway and the Civil Surgeon Chittagong
who both treat very large numbers of Kala azar
patients put very little reliance on this symptom.
Pigmentation is another sign which is not
reliable. It is hard to make it out in a dark-skinned individual and is very often present in
malarial cachexia. A clean tongue was almost
invariably present in all the cases which I
A feature which is seldom mentioned is the
brittle state of most Kala azar patients' hair.
In many cases it tends to fall out, especially
(3) The importance of full examination of the blood
cannot be emphasised too much. The principal
points to note are the marked leucopenia, the
reduction in proportion of polymorphs and relative increase in mononuolears and lymphocytes.
The proportion of whites to reds should always
be estimated. The .r proportion as generally
quoted is 1 white to 1500 reds. In my experience it is even less. Eosinophils are often
absent but associated worm infections cause them
to appear in quite considerable numbers.
(4) Present day treatment of Kala azar in India is
not as thorough as it should be. The majority
of large hospitals favour the rapid method of
injections. The patient, too, is not admitted
to hospital as a rule unless complications are
The result is that the patient ceases to
attend and only received a sufficient number of
injections to improve but not to cure his condition. This leads to relapses and I believe
to increased incidence of dermal leishmaniasis.
Whenever possible the patient should be kept
in bed and given intravenous injections of neostibosan or urea stibamine every second or third
day until at least fifteen injections have been
administered. Nourishing diets rich in vitamins
should be given. This prolongs the period of
treatment but produces a cure rather than a
(5) Judging from the number of admissions nowadays
as compared with ten years ago the disease appears
to be decreasing.
II. KALA AZAR WITH CAPTCRUM ORIS . (1) This is a common and serious complication of
Kala azar. Although quite often seen in adults
it is four times as common in children in whom
it is present in about 12 per cent of cases.
(2) Canerum oris is not due to the presence of
Leishmania donovani in Kala azar patients. In
spite of careful examination no Leishmania were
seen in scrapings taken from the lesions though
mixed infections were common. It is due to the
same causes which produce this condition in
other diseases e.g. diphtheria, measles, typhoid
etc. Probably lowered resistance due to prolonged fever allows the bacteria normally present
in the mouth to erode and invade the tissues of
the mouth and face.
(3) Blood counts show certain constant features.
The white blood corpuscles are increased in
number to between 7,000 and 16,000 per c.mm.
The increase in leucocytes is due to the increase in polymorphonuclea:rs. The haemoglobin
(4) The prognosis in C ancrum oris is bad. The
majority of cases die in a few weeks from toxaemia or intercurrent infection. Those in
hospital often show a marked improvement under
treatment but do not remain long enough to reap
the full benefit.
(5) The most effective treatment consists in intramuscular injections of neostibosan in children,
and intravenous injections of urea stibomine
in adults. Extensive erosions should be treated
with skin grafts once the ulceration has become as
nearly as possible aseptic.
III. DERMAL LEISHMANIASIS.
(1) This is a much commoner disease than the number
of hospital admissions would lead one to believe.
Now that the disease is better known more patients are coming for treatment.
(2) The disease can easily be mistaken for leprosy
and unless scrapings are examined from the
lesions many patients will be wrongly diagnosed.
Owing to the much more favourable prognosis in
dermal leishmaniasis this mistake should be carefully guarded against.
(3) The chronic nature of the disease and the large
number of injections which are often required to
effect a cure should be carefully noted. Treatment will always be successful even in the most
stubborn cases if persisted in.
(4) There is always the danger of spread of Kala azar
by means of sandflies feeding on these lesions.
It is a danger to the public therefore to allow
those patients to go about untreated.
IV. ORIENTAL SORE.
(1) Oriental sore is caused by a leishmania closely
allied to Leishmania donovani but less virulent
and only capable of producing skin lesions. It
is transmitted by a sandfly which is distinct
from the sandfly transmitting Kala azar, and
this sandfly is only capable of transmitting
(2) Each bite of an infected sandfly produces a sore
at the area bitten. It is not a systemic disease
whereas Kala azar is a systemic disease.
(3) Antimony in either its trivalent or pentavalent
form is the most effective and cheapest drug in
the treatment of Oriental sores.
The dose of potassium antimony tartrate
should be regulated according to the weight of
the patient and in any case should never exceed
gr.2 at one time. It must be carefully injected
to the sloughing it causes if allowed to
escape into the tissues. If an accident of this
kind does occur then iodex is a useful application and gives some relief.
Neostibosan is expensive but is not so
liable to cause sore arms or sloughing.
(4) In chronic cases emetine hydrochloride gr.0.5 to
gr.1 injected into the margins of the sores
hastens the healing process produced by the
antimony. This treatment is however rather
(5) Orisol (berberine sulphate) was not so successful
as one might expect from the results claimed for.
it. For single sores or small lesions before
they have broken down, this drug gives good results. This latter conclusion was also arrived
at by Napier (Knowles (68)) some years ago.
Results with large or multiple sores are almost
(6) Local dressings play a very important part in
the rapidity of cure. There were many examples
of patients who kept their dressings and sores
clean and healing occurred in from three to six
weeks. There were many examples of others who
were careless or ignorant and allowed their sores
to become secondarily infected. They then took
even as long as four months to cure.
Normal saline is a very satisfactory dressing
- followed by iodine once healing has started.
(7) Early treatment is most essential. The old-standing case is hard to cure: the recently developed
case is comparatively easy to cure.
(8) The total dosage of antimony required to effect
a cure can be reduced by the use of supplementary
emetine or orisol and rigid local treatment.