THE TREATMENT OF KALA-AZAR

WITH TARTAR EMETIC.

By E. MUIR, M.D? F.B.C.S. (Ed.), Mission Hospital, Kalna.

In the Tropical Diseases Bulletin for April 1915 there appeared a review of an article by G.

Cristana and G-. Caronia, who had successfully

treated some cases of infantile kala-azar with tartar emetic after the publication by Grasper Manna of cases of dermal leishmaniasis treated

successfully with the same drug in South America. Having at the time some cases in hospital of

adult kala-azar, I at once began to treat them- in the same way, and was surprised at the result. Indeed, with the exception of emetin in amoebic

dysentery I have never seen a specific work a more rapid and striking result in any disease.

Up to the first week of August I have treated twelve cases with tartar emetic, in nine of which the diagnosis was confirmed by finding the parasite in spleen punctures, and of these, with the

exception of one who came in the very last stage, all have either recovered or are recovering.

The method of treatment is the following:? A one percent, solution is injected every second

day intravenously. With a little experience this is done quite easily and practically painlessly, the smallest child even submitting to it without

crying. Care has to be taken that none of the

fluid escape into the subcutaneous tissues, other- wise a most painful swelling is produced. This

can, however, be obviated by seeing that a thin

stream of blood is running into the syringe before the piston is pushed home. The dose should

begin with 4 cc. and be increased each time by 1 cc. up to 10, unless there are signs of nausea when it should be decreased by 1 cc. and then

gradually increased again. I have found with the one exception mentioned

above that there is marked improvement after

even the first injection, that after the second

injection there is always a consuming appetite and the spleen is markedly decreased in size, while the colour of the patient changes rapidly from the characteristic black colour, which gives the name to the disease, to a normal colour.

I still continue to use in conjunction with tartar emetic the turpentine intramuscular injection, which I used formerly alone, and find that it

increases the rate at which the spleen diminishes. The turpentine injection consists of a solution

of turpentine one part in camphor-creosote one

part of each and olive oil two and a half parts. Of this up to ten minims is injected into the

muscles of the back on either side of the body. I have invariably noted that if such an injection

is given to a patient at all advanced in the

disease before the tartar emetic treatment is begun there is little or no reaction and swelling.

If, however, it is given after a week's treatment with tartar emetic, there is a very marked reaction, the part injected swelling and causing consider- able pain. Spleen punctures taken at a week's interval show first marked diminution and then

complete disappearance of the parasites. I should have liked to wait before publishing

this article till I could produce a complete set of cases which had stood the test of a year's time

366 THE INDIAN MEDICAL GAZETTE. [Oct., 1915.

without recurrence. But I have thought it right to publish the following few recent cases which

have been apparently cured or are rapidly im- proving, as I think it important that this form of treatment should be widely known without any ?delay, as it is undoubtedly a specific for the form of kala-azar found in the Hooghly and Burdwan Districts.

Case I.?B. C., aged 20. Admitted to hos-

pital on October 13th, 1914. lie had been ill

with fever, accompanied by enlarged spleen, for

some considerable time ; it was difficult to make

out how many months.

Spleen was enlarged to beyond the umbilicus. Patient emaciated, but not complaining of any

pain or discomfort. He was treated at first with

quinine, both by mouth and hypodermically, but without any result. On December 7th Leish-

man-Donovan bodies were found in the spleen. On December 13th an injection of G min. of

turpentine was given intramuscularly. There-

after the temperature remained normal till the

2nd of January, 1915. On the 4th of February L. D. B. were found in the peripheral blood. Thereafter he was treated with frequent injections of turpentine solution, under which he made

some improvement, the spleen retreating to above the umbilicus. On April 3rd he had a severe

attack of pneumonia from which he recovered

with difficulty. From the lltli April, when he recovered from

the pneumonia, his temperature remained normal till the 30th. On April 19th his weight was 5st. 9|lbs. On May 1st it wasa^lb. more. The

turpentine solution injections continued, and on May 22nd he was Gst. 2ilbs. On May 27th the tartar emetic injections

began, and were given regularly every second day till the 16th of June. On June 1st his weight was Gst. lOlbs. and on the 8th 7st. lib. Within

a fortnight the spleen was reduced to a third of

the size it was when the tartar emetic injections began._

Since then he has remained extremely well. On the 5th of August his spleen was level with

the costal margin and a spleen puncture failed to reveal any parasites. His weight was 7st.

12ilbs. on the same date. Case II.?Pareshnath, aged six. Was admitted

on November 27th, 1914. The spleen was two and a half inches below

and to the right of the umbilicus. He was

treated with turpentine injections till the 11th of February, 1915, but as he seemed to have

gone too far, and there was no improvement up to that date, he was sent home to die. Spleen punc- tures were taken upon several occasions and the

spleen pulp was always found to be swarming with L. D. B. His aunt, who was very much devoted to him, persisted in bringing him to our out-

patient department, where he was still treated, but

continued to get worse. On June 11th he was

again admitted to hospital and 5 cc. of tartar emetic given intravenously. He was, however, so weak that another injection

was not given till the 24th. During this period of about a fortnight his temperature became

normal for the first time for several months. On

the 24th, 28th, and 29th injections of 2icc. were given, and thereafter every second day. till the 13th of July, when 4cc. was given every second day till the 21st. Small injections of turpentine solution were also given from time

to time intramuscularly, producing a marked

reaction where they had produced little effect

before. The temperature remained normal all

this time except where the turpentine iuduced a

temporary rise for a day or two. The spleen became reduced in size from inches below

the umbilicus to H inches below the costal mar-

gin. His weight increased from 1st. lOlbs. on

the 11 tli of June to 2st. 2ilbs. on the 19th of

July. From after the first injection he had a tremen-

dous appetite, although he could only be induced to take the simplest food with the greatest difficulty before. The colour of the skin and the whole expression of his face became so quickly changed that I had difficulty in recognising him one morning when I went to pay my ward visit. On August 1st a spleen puncture was taken, but no parasites were found.

Case III.?Suresh, aged 30. Had had fever off and on for 2^ years. He had lived in a house where a former kala-

azar patient of ours had lived and had probably got the infection there. He was admitted and a

spleen puncture taken on April 4th, 1915. The spleen extended to the umbilicus and was

found to be swarming with L. T). B. The spleen diminished to about half the size under injec- tions of turpentine solution. There was still, however, occasional fever and the patient was weak and unable for work.

Tartar emetic was begun on June Gth and continued more or less regularly every second day till the 21st, during which time he much im-

proved in health and appearance and the tempera- ture continued normal. He then had to go home and did not return till the 28th. He then came back with an attack of fever, which was probably malaria. Thereafter tartar emetic was given in

increasing doses every second day till the present date. August 16th. He is now working as a mali in our hospital

compound and feels perfectly strong and well. The spleen is still slightly below the ribs, but is

steadily diminishing. Patient has had a very large appetite since the beginning of the tartar emetic injections and is increasing steadily in weight. On August 5th a spleen puncture was

Oct., 1915.] TARTAR EMETIC IN KALA-AZAR. 3G7

asain taken and a few L. D. B. were found, where D 7

before they had been swarming. Case IV.?Yakub Sheik. Admitted on the

22nd of June. Spleen reaching below the

umbilicus. General anasarca. Extreme anaemia, wasting, and inanition. Suffering from extreme

dysenteric symptoms. Tartar emetic was begun on the 30tli of June and 2|cc. given every second

day. The spleen diminished rapidly in size, patient gained weight, the dysenteric symptoms disappeared, the anasarca disappeared more

gradually. It had not been considered safe on

admission at first to take a spleen puncture, but, when this was done after the patient had improved under treatment, L. D. B. were found, thus con-

firming the diagnosis. At the present date, August 16th, the patient is in good health, with a good appetite, no bowel symptoms, spleen less than an inch below the ribs. Patient was also injected with turpentine solution, which, in our opinion, accelerated the result.

This along with Case I and the next case are

the most striking, as they came under our treat- ment during what we have been accustomed to

consider as the last stage of the disease. Yakub's

age is eleven.

Case V.?Bhaddeshwar. Admitted on May 2Gth, 1915. Patient was extremely emaciated. There were extreme dysenteric symptoms, which did not yield to emetin, castor oil emulsion, or

any of the ordinary remedies. The spleen reached to a point an inch to the

right of and below the umbilicus. Patient was so emaciated that he could not either stand or sit

up and could only with difficulty turn round in bed. Patient's age is six. On admission he had a high, remittent tem-

perature, which did not yield to quinine, given in

large doses by mouth and hypodermically. The abdomen was swollen with flatulence, and

the feet and faceshowed anasarca. Tartar emetic was begun on the 31st May, and carried on with

occasional breaks till the present date, August 10th. The dosage was raised from 2cc. to 4^cc. A larger dose caused slight nausea.

At present the patient is able to walk about. The spleen is only half an inch below the ribs.

Patient has a large appetite and seems to be able to digest rice and fish and most of the other

articles of Bengali diet. He still, however, has one or two motions a day

containing mucus. The abdominal swelling has gradually dimi-

nished and is now almost normal. Temperature has been normal since July 13th.

Case VI.?Khudiram. Admitted July 21st, 1915. Age eleven. Had had fever for about

(iight months. It had begun in the winter, been better in the hot weather, that is to say there had been no high fever, but had become worse again in the rains. A spleen puncture showed abundant

L. D. B. The spleen was an inch to the right of and below the umbilicus. Patient had the

typical black colour and dry, scaly skin of kala- azar. Tartar emetic was given every second day. In a week the spleen was reduced to 2 inches from the costal margin. A second spleen puncture showed a very much diminished number of L. D. B. The appetite became very great after the second injection. At the present date.

August 16th, the spleen is about half an inch

below the costal margin, temperature is normal

and patient feeling extremely well.

Case VII.?Patal. Spleen about 2 inches

beyond the umbilicus. He was treated with

injections of turpentine solution. Under these

the spleen very much diminished in size. He

then developed necrosis of the lower jaw, and during this time, although he was very ill, the spleen diminished in size still further. The

temperature remained normal after a large piece of necrotic bone had been removed from the jaw. The patient was however still very weak and

thin. On June 2nd the tartar emetic treatment

was begun, and the patient soon developed a very large appetite and rapidly put on weight. He has now been in robust health, with no

spleen palpable for more than a month. Besides the above cases we have at present in

our hospital four cases, in which L. D. B. have

been found on taking spleen puncture and which are all improving rapidly, though they have

scarcely been long enough under treatment to record their cases in full. There is also a small

boy who was suffering from an enlarged spleen, a fever intractable to quinine though treated

for about six weeks. He also had very much

enlarged and matted cervical glands. Some

improvement was given by injections of turpentine solutions, but the fever again returned, and the child could not stand the pain of the injections.

Five injections of tartar emetic were given at

two-day intervals. After the second injection the temperature remained normal, the cervical

glands disapppeared, the spleen, which had been

two inches below the ribs, almost entirely disap- peared below the costal margin. The usual

appetite and increase of weight and sense of

robust health also rapidly appeared. It is impossible to say for certain that this w

a case of kala-azar, but the presumption is that

it was such.

With one exception we have so far saved or are saving every case that has come to us since we

began this treatment, and this one case was

utterly beyond any possibility of improvement. We shall be glad to give further notes on the

improvement of these cases, and our experience with further cases, to any who may be interested.

Observations made on September 9th, 1915 :? Case I ? Continues well.

368 THE INDIAN MEDICAL GAZETTE. [Oct., 1915

Case II.?Has still further improved, has put on weight, and spleen is hardly palpable below the costal margin.

Case III.?Spleen is no longer palpable below the

costal margin. He is doing a full day's work. Case IV?Is improving rapidly. The spleen has

reached the costal margin and patient is strong and well. His bowel complaint has practically disappeared. He

has put on weight. Case V.?Has made most striking progress. His weight

has increased from 2st. to 2st. 21bs. in the last three weeks. The dysentery and prominence of the abdomen have almost gone. He is able to go about freely and his temperature remains normal.

Case VI.?A spleen puncture was again taken on the 26th of August and no L. D. B. were found, although the slide was full of spleen cells. The spleen is now level with the costal margin. His weight has increased from 3st. lib. on August 6th to 3st. 51bs. on present date. He is perfectly well and runs about playing all

day long. Case VII Continues in excellent health.

Since writing up the above cases I have the

following additional cases to add :? Case VIII.? Bhuloo, aged 17. Admitted on August

17th. Spleen was 2 inches below the costal margin, and was found to be swarming with L. D. B., one or two hundred to the microscopic field. She had had fever for

about two years, and was extremely ansemic. At present date temperature is normal, spleen is level

with the costal margin, patient feels well, and has gained in strength.

Case IX.?Esharon, aged 9. Admitted on August loth. Patient was suffering from ascites, and about 100 oz. of fluid were removed from the abdomen. A spleen puncture showed abundant parasites. The

liver on admission was about 3 inches below the costal

margin, and the spleen reached the umbilicus At

present date, the general condition of the patient is

very much improved. There is no further tendency towards ascites.

The spleen has receded 2 inches from the umbilicus, and the liver is much decreased in size. Patient had been suffering from fever for one year and had had fluid in the abdomen for three months. The temperature is

normal except where a rise is caused by injection of turpentine solution.

Case A'.?Martha, aged 9. Has been suffering from fever and enlarged spleen for the last four yens. Had

been treated with injections of turpentine from time to time as an out-patient. She was admitted on the 24th of

August. Spleen was then 3 inches to the right of and 2 inches below the umbilicus. At present date the

spleen is reduced to about two-thhds of the size it was at admission. Temperature is normal. Patient's gen- eral appearance and strength has much improved. In this case about 50 L. D. B. were found within one cell.

Case XI Bhudhar, aged 15 years. Was admitted on July 16th. On July 29th a spleen puncture was taken and parasites were found in quantity. On admission the spleen which was extremely hard,

was 1 inch beyond the umbilicus. It is now 1 inch short of it. During that time the weight has increased from 4st. to 4st. 41bs. Patient has very much improved in

strength and the peculiar black colour has entirely disappeared. A second spleen puncture taken on the present date

failed to show any parasites, while the slide was full of spleen cells.

Case XII. Habu, aged 30. Admitted on August 30th. L. D. B. found in abundance in spleen. Spleen on admission was 1 inch beyond the umbilicus and is now 1 inch short of it.

Patient had suffered from dysentery, which was in a quiescent state on admission. The appetite induced

by the tartar emetic injections lead to such excessive eating that the dysentery was again lit up and we had difficulty in stopping it. The only remedy to which it

yielded was large doses of magnesia sulphate in an acid solution. The temperature is now normal and the condition of

the patient is very much improved. Case XIII. Ananda, aged 12. Admitted on July

27th. Patient was very much swollen with anasarca.

The spleen was 3 inches below and '1 inches to the right of the umbilicus. At present date it scarcely reaches to the umbilicus. The anasarca has now completely dis-

appeared. A spleen puncture, taken on date of admis- sion, showed very large quantities of parasites, while a second puncture taken at the present date showed only very few. General condition of the patient is very good now, although he was undoubtedly in the last stage of kala-azar when admitted.

Case XIV ?Lalit. Had been under out-patient treat- ment for some time off and on. He was admitted on

September 6th. Very large quantities of parasites were found in the spleen. It is too soon to report on this case, but this and Case VIII show a peculiarity which should be remarked. They both showed parasites in far larger quantities than I have seen in any other

patient. They also develop a rigor after each injection of tartar emetic which lasts for about half an hour after the injection. This in Case VIII has gradually dimin- ished till there is now on a slight feeling of cold. Case XIV has only had two injections so far, but his rigor was less at the second than at the first.

In Case VI there is always severe coughing induced, due to the expectorant action of the

drug. If the injection is given on a full stomach and the patient is allowed to walk about imme-

diately after, there is often vomiting. ()therwise

I have so far seen no ill-effects from these in-

jections. Every cases treated so far, with the one excep-

tion mentioned above, has either been cured or

has shown rapid improvement from the very beginning of the treatment. Turpentine solution injections have been used in all cases, as the

recovery is much more rapid with them. I believe, however,that the turpentine injections

are not absolutely essential for the final recovery of the patient, which would, however, be delayed without them.