TROPICAL KALA-AZAR 



1295 



Onset. — -The onset may be heralded by a rigor, which may be 

 repeated daily, and by an attack of irregular, high, remittent fever, 

 which may early show two remissions per diem in a four-hourly 

 temperature chart. This double remission is considered by Rogers 

 to be almost diagnostic of the disease. Towards the end of the third 

 to sixth week of the fever the temperature declines, and the initial 

 stage of the disease may be said to have terminated. During this 

 period, however, the spleen and liver will have enlarged, and may 

 be both painful and tender. Headache is present at times, but is 

 not severe. Nausea and vomiting are unusual, while the bowels are 

 regular, and there is no abdominal distension. The pulse may be 

 slow or quick. 



The attack, however, may begin with a continuous fever, which 

 shows two fluctuations in the twenty-four hours, which Rogers 

 considers as almost diagnostic of the disease. In other cases the 

 disease may begin with gastro-intestinal disturbances or with 

 dysenteric symptoms, or quietly, without any marked initial stage, 

 the patient gradually developing an enlarged liver and spleen, anaemia 

 and weakness. 



Course. — ^The course of the disease, after the decline of the tem- 

 perature, is marked by what is called an apyrexial interval; but it 

 appears that — ^in some cases, at all events — ^there is a slight daily 

 rise of temperature, not exceeding 100° F. After some weeks this 

 apyrexial interval ends in an attack of fever resembling the onset. 

 Periods of apyrexia and pyrexia now alternate with one another, 

 while the spleen, and sometimes the liver, enlarge. Anaemia com- 

 mences and increases, while asthenia not merely appears,but deepens, 

 until the wretched patient presents the typical appearance, which 

 may be described as follows : — He is thin and wasted, with the abdo- 

 men much swollen and protuberant, the chest so thin that the ribs 

 show clearly, the arms and legs wasted, the cheeks sunken, the nose 

 sharp, and the ankles puffy, while the skin and tongue are often 

 distinctly darker than they should be, the former being fur- 

 furaceous. 



On examining the swollen abdomen, the enlarged spleen may be 

 felt reaching almost to the pelvis, while the enlargement of the 

 liver may be marked or may be absent. In this condition intestinal 

 disturbances in the form of diarrhoea or dysenteric attacks are 

 common, and may be due to the actual disease or to complication 

 with true dysentery. Dyspeptic symptoms may also be present. 



Haemorrhages may occur from the nose, the gums, the stomach, 

 the bowels, or under the skin. Papular eruptions are to be seen, 

 especially on the thighs, and ulcers may be present. The weakened, 

 emaciated patient may now die of asthenia, but more usually the 

 long-drawn-out illness is brought to a close by some complication. 

 The total duration varies from about seven months to two years, 

 and generally ends fatally. 



Complieations. — ^It appears as though the reduction in the number 

 of the polymorphonuclear leucocytes laid the patient open to in- 



