114 
ORRKTIVATIONS OX KALA-AZAB IX KASRALA PllOVIXCE 
Si"ns and 
symptoms 
Significance 
of oedema 
('IjIXR'AL features. In all, inarkod weakness and ifeneral eniaciation were very 
evident. 
Pain was absent, except in three cases where it was insignificant (one s})lenic pain, 
and two pains in tibite). 
All the positive cases showed splenic enlargements, six to a marked degree, while live 
showed the liver increased in sine, three markedly. In four cases the conjunctiva? were 
noticeably yellow without bile being present in the urine, while three were jaundiced. In 
four cases alljumen, from a trace to large quantities, was present, and in all cases the urine 
was of low specific gravity, the average being 1012. 
Pigmentation of the skin was not seen in any case, but w’as present in Case XI., 
Table “B.” In all cases the tongue remained comparatively clear, and the appetite and 
digestion good, except just before death. 
The complications noted were:—Pseudo-diphtheritic tonsillitis and epigastric pain 
due to duodenal ulcers (1). 
Terminal persistent epistaxis (2). 
Terminal diarrhoea (2). 
G-ldema of feet and legs (4). 
(leneral oedema (1). 
In all cases where oedema appeared, death occurred within a few days, although the 
patient’s general condition seemed no w'orse than before, and in my short experience 
the appearance of oedema is a premonitory sign of approaching death. 
In no cases was ascites encountered, and in the case of general oedema there was no 
albumen, and the quantity of urine passed in twenty-four hours was normal. 
Diagnosis 
Differential 
diagnosis 
Malta fever 
a difficulty 
UIAGNOSTS. This appears to be of considerable difficulty, owing to the prevalence 
of malaria. 
The main points noted in these cases were progressive emaciation and w'eakness ; 
enlargement of liver and spleen ; absence of pain ; albumen and bile in the urine ; and 
refusal to react to quinine. 
i\[y experience is that malaria met with in this province (malignant tertian I believe to 
be very rare) seldom leads to liver enlargement, and if due to this cause the patient rapidly 
improves on quinine ; and I am of opinion that every case with liver enlarged, together with 
the spleen, should be looked upon with the gravest suspicion, provided that local conditions 
can be excluded. 
A positive spleen puncture settles the diagnosis, but a negative result is useless, for the 
parasites are so few, and so may easily be missed or be absent. Major Rogers, I understand, 
now- considers spleen puncture unnecessary for diagnosis, but the risks are so small that this, 
together with the inqjossibility of finding the parasite peripherally, seems to me to justify 
this procedure. 
The presence of albumen in the urine is inqjortant, for in the severer cases of 2,000 odd 
malaria patients last autumn albumen was never found except where something else w'as 
])resent to account for it, such as bilharziosis. 
The yellow coloration of the conjunctiva? is helpful, but natives, especially Sudanese, 
often have a naturally yellowdsh tinge to their conjunctivic. 
The presence of Malta fever enhances the difficulty, especially as the essentials for 
serum diagnosis are w'anting in Kassala. 
A difficult example was Case III., Table who w'as admitted to hospital on August I4th, 
1907, wuth fever 102°, a spleen enlarged one inch below the costal margin, and no noticeable 
enlargement of the liver. 
