132 



UEMAKKb ON KALA-A>C.\1{ 



who lire naturally thin, are wasted, especially as many are jjoor aiul tliereloie badly led. 

 Emaciation was marked in eleven cases, slight in eight, and not evident iu three. 



Wi'dkiifug was noticeable in all cases, but especially in the very acute, while in the 

 subacute it was not very striking. 



I'rotttlwrance nf the Ahdainen. In thirteen out of the twenty-two cases the abdomen was 

 not prominent, while in several cases it was actually the reverse. Those who had large 

 abdomens were the chronic cases, and the average duration of these cases, when seen, 

 worked out to nineteen mouths. 



The fact that 59 per cent, showed no protuberance is, to my mind, highly suggestive of 

 a new disease, likely to take on an epidemic character. No chronic case was seen without 

 some protuberance of the abdomen, a condition probably essential, and due to nature 

 making accommodation for the greatly enlarged spleen and the enlarged liver. 



Enlargement of the Spleen. In nineteen cases out of the twenty-two the spleen was 

 enlarged to within an incli of the umbilicus or to a greater extent. In the remaining three 

 the spleen was palpable or extended one inch below the costal margin. In all cases the 

 enlargement was regular, the edge definite ; tenderness on palpation was complained of in 

 three cases. 



Very large spleens were always and only found in chronic cases ; the very acute having 

 but comparatively slight enlargement of this organ and no prominent abdomen. 



Enlargement of the Liver. In seventeen out of the twenty-two cases the liver was 

 distinctly enlarged though in most cases to no great degi'ee. The largest extended down- 

 wards to the level of the umbilicus and the liver duluess was increased upwards one costal 

 space. In no case was it noticed to be smaller than normal. 



Jaundice was found in tw^o cases, but in neither to a marked degree. 



The conjuncticie were distinctly of a yellowish tinge in seven of the twenty-two cases. 



Pigmentation was only once seen, and then it was doubtful if it was due to kala- 

 azar, and was confined to a curious bronzing of the face. There were no special changes 

 noted in the skin, hair, or nails, and the nervous system appeared normal in most cases. 



Mental depression was very marked in four cases, but all were acutely ill ; one case 

 was extremely deaf (no quinine had been taken), the power of speech was greatly 

 impaired, and there w'as marked mental dulness for tliree weeks before death. No 

 malignant tertian parasites were found in this case. 



Diarrhoea was a very marked and serious complication in twelve out of the twenty- 

 two cases. It was often, according to accounts, accompanied by the passage of blood 

 and slime in the stools. 



Undoubtedly several cases started their disease witli attacks of diarrhoea, and my 

 belief is that the majority had this complication early in the course of the disease. 



The frequency of diarrhoea, accompanied by the passage of blood and slime in the 

 stools, naturally suggests the possibility of infection through the alimentary tract, and is 

 a point that should be carefully investigated in the Sudan. 



(Edema of the legs was noted five times, one patient presenting oedema of legs, face 

 and a slight effusion into the peritoneal cavity, while another showed oedema of legs and 

 face. In the few cases where the urine was examined !io trace of albumin or liilc could 

 be found. 



Suppurative processes were practically absent. Only one proved case showed some 

 boils scattered over his legs, and one suspicious case had a suppurative condition of the 

 scalp ; this is no greater percentage than would be found amongst the genei-al 

 population. 



