156 TROPICAL MEDICINE AND HYGIENE 



The liver and spleen continue to enlarge, the latter 

 often attaining enormous dimensions. Emaciation, 

 anaemia and debility are progressive until the condition 

 already described is attained, and the stage of cachexia 

 supervenes. 



As the end approaches the patient's condition is 

 wretched in the extreme. He is terribly emaciated, and 

 so weak that he can hardly move, he suffers from 

 diarrhcea or dysentery, though his appetite may be 

 ravenous to within a day or two of death. By this time 

 the fever may have given place to subnormal tempera- 

 ture, and the spleen and liver, though still considerably 

 enlarged, may be smaller than formerly. Death is most 

 commonly due to dysentery, which appears to be an 

 integral feature of the last stage of the disease, rather than 

 an added complication. As already stated, however, 

 patients sometimes die from mere asthenia, while not 

 uncommonly death is due to some intercurrent disease, 

 of which lobar pneumonia, phthisis, and cancrum oris 

 are those most frequently met with. 



The duration of the disease varies from three or four 

 months to two years, but is most commonly a year or 

 eighteen months. Of this period the stage of initial fever 

 lasts a month or two, and that of low fever six months 

 to a year. 



While the description given above applies to most 

 cases of kala-azar, variations from this type of the disease 

 are met with. In some instances the period of initial 

 fever seems to be absent, the patient gradually becoming 

 weak and ill without any definite symptoms beyond loss 

 of flesh and enlargement of the liver and spleen. In 

 other cases the onset may be very acute, and the patient 

 may be carried off by fever or dysentery before the 

 development of cachexia. 



For so serious a disease the symptoms other than those 

 mentioned are remarkably slight. Besides headache, those 

 referable to the nervous system are chiefly a diminution of 

 nervous energy and occasional muscular tremors, resulting, 

 for example, in educated patients, in inability to write. 



