152 TROPICAL MEDICINE AND HYGIENE 



China, the Straits Settlements, the Philippines, Panama, 

 Northern Africa, and the Soudan. 



The population of some of the places named is drawn 

 from so many sources that it is not possible to say at 

 present whether the disease is endemic in them or not, 

 but in most instances it appears to be endemic. 



Clinical Course. The clinical picture of a case of kala- 

 azar of some months' duration is very striking. The 

 patient, even if up and about, is obviously ill. He is a 

 wretchedly thin, tired-looking man, with a big abdomen 

 and shrunken limbs, and complains of having had fever 

 off and on for months, and that in spite of quinine and 

 various other medicines he has become gradually thinner 

 and weaker, while his abdomen has got bigger and bigger. 



A very slight examination of the patient's distended 

 abdomen will show that his spleen is enormously en- 

 larged, that his liver is also increased in size, and perhaps 

 that there is a little ascites present ; possibly the superficial 

 abdominal veins will be noticeably prominent, and if 

 attention be turned to the feet some oedema of the ankles 

 and dorsum will be found. Besides being thin, the 

 patient is also anaemic, and his skin, especially that of 

 the face, is darkened or pigmented. His hair is dry and 

 lustreless and may fall out in quantities, leaving him 

 almost bald. He is very easily tired and any little exer- 

 tion causes breathlessness. His intellect is generally 

 clear, and he may make little complaint except of his 

 gradually increasing weakness and wasting ; he may or 

 may not complain of present fever, but even in its 

 absence may say that he is disturbed at nights by violent 

 sweats, but for which he probably sleeps well. 



Not infrequently, however, patients at this stage of the 

 disease suffer from attacks of epistaxis, or of bleeding 

 from the gums or from other mucous surfaces. Some- 

 times, too, petechiae appear, more commonly in the 

 axillae than elsewhere. Attacks of bronchitis or sore 

 throat are not uncommon. Less common symptoms, 

 but of sufficient frequency to require mention, are 



