1302 THE KALA-AZARS AND PSEUDO-KALA-AZARS 



minuria, or a decrease in the output of urea. The lymphatic glands 

 are as a rule not enlarged. 



The mental and physical activity of the child decreases as the 

 disease progresses; it emaciates, and becomes extremely pallid, 

 thereby assuming a prematurely aged appearance. The bones 

 become evident, especially the ribs and shoulder-blades, and the 

 child dies from exhaustion, often due to an attack of dysentery or 

 diarrhoea. Spontaneous recovery may take place, but this is rare. 



Complications. — Respiratory comphcations are not unusual. 

 Bronchitis is common, while broncho-pneumonia and pleurisy may 

 occur, as may a rapidly developing fatal dyspnoea, which is prob- 

 ably due to oedema of the glottis. Perhaps noma, as already men- 

 tioned, is a fairly common complication in Italy and Greece, and 

 should come in this place as a complication rather than a symptom 

 of the disease. Otitis media has been recorded not merely as a 

 complication, but also as a cause of death. Ankylostomiasis asso- 

 ciated with lipuria has been recorded as a complication. 



Diagnosis. — ^The symptoms more or less closely resemble those of 

 kala-azar, but differ in that this disease occurs in children and is in- 

 oculable into dogs, while kala-azar occurs mostly in young adults and 

 is with difficulty inoculable into dogs. The temperature chart may 

 resemble that of kala-azar, but is generally more irregular. The 

 characteristic clinical symptoms of the disease are the enlarged 

 spleen, the irregular fever, and the pallor occurring in a child. The 

 essential feature in the diagnosis is the parasite, which may be 

 obtained by splenic puncture, by liver puncture, by examination 

 of the bone-marrow obtained by a modified trocar and cannula, 

 as designed by Caccioppoli, to which a Potain's aspirator with a 

 strong pump is attached; rarely by blood examination. Other 

 methods are by vesication and examination of the fluid; and by 

 lumbar puncture, if there are cerebral symptoms. 



Having obtained the splenic or hepatic pulp, etc., the diagnosis 

 may be made by microscopical examinations and by cultivation 

 on the medium devised by Novy and McNeil, and modified by 

 Nicolle, usually known as the N.N.N, medium (p. 377)- 



It has been suggested by Cochrane that removal of one of the post-cervical 

 lymphatic glands might be adopted as a diagnostic method. The removed 

 gland is cut, and a smear made, when numerous parasites may be seen. This 

 method is said to be the most certain means of diagnosis. It is recommended 

 that the glands be removed under the influence of a local anaesthetic. 



Differential Diagnosis. — The differential diagnosis has to be made 

 from kala-azar, undulant fever, enteric fever, malaria, other forms 

 of splenic anaemia, and syphilis. 



Kala-Azar. — ^This fever occurs in adults, and is characterized by 

 the double daily rise of the temperature, and by the difficulty of 

 successful inoculation into dogs. In this disease the spleen is not 

 so markedly enlarged. 



Undulant Fever. — In contrast to undulant fever, in infantile kala- 

 azar the temperature is much less regular, never showing a typical 



