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organ  is  felt  slightly  enlarged,  of  a  firmer  consistence  than  normal, 
descending  one  or  two  finger-breadths  below  the  costal  margin  on 
inspiration.  Some  degree  of  anaemia  is  the  rule  rather  than  the 
exception  among  the  native  population  owing  to  the  prevalence  of 
ankylostomiasis,  but  is  not  a  special  feature  of  these  cases. 
Inquiry  among  patients  in  a  later  stage  of  the  disease  showed 
that  no  symptom  other  than  abdominal  enlargement  and  discomfort 
had  been  noticed  in  5  5  per  cent. ;  29  per  cent,  described  an  onset 
with  fever  of  an  irregular  type  persisting  a  month  or  longer,  while 
the  remaining  16  per  cent,  dated  their  trouble  from  an  attack  of 
dysentery  or  prolonged  diarrhoea.  The  exact  significance  of  such 
intestinal  disturbance  is  uncertain,  but  it  must  be  remembered  that 
amoebic  dysentery  is  one  of  the  commonest  diseases  of  Egypt. 
The  second  stage  of  the  disease  is  indicated  by  definite  hepatic 
involvement,  with  increased  enlargement  of  the  spleen,  accompanied 
by  local  and  general  symptoms.  The  blood  shows  the  special 
changes  described  in  a  later  section.  The  clinical  picture  now 
presented  is  by  no  means  identical  in  every  patient,  as  will  appear  on 
comparison  of  the  cases  illustrated  in  the  photos  A,  B  and  C.  The 
following  set  of  symptoms  are,  however,  found  in  every  case,  although 
they  may  vary  in  intensity  in  different  patients  or  at  different  times 
in  the  same  patient. 
(1)  Wasting.  In  most  patients  the  disease  is  suggested  by  their 
appearance.  Instead  of  the  extreme  pallor  with  retention  of 
fat  which  characterises  ankylostomiasis,  or  the  emaciation  with 
localised  pigmentation  distinctive  of  pellagra,  we  find  a  moderate 
anaemia  with  more  or  less  wasting.  The  combination  of  marked 
anaemia  with  wasting  in  an  Egyptian  generally  indicates  the  co¬ 
existence  of  ankylostomiasis  and  cirrhosis. 
(2)  Fever.  The  great  majority  of  cases  show  slight  fever  of  an 
irregular  type.  In  63  per  cent,  this  did  not  exceed  3;'5.  but  in  28  per 
cent,  there  were  excursions  up  to  38,  and  in  9  per  cent,  this  tempera¬ 
ture  was  exceeded.  Occasionally  patients  may  show  high  fever  for 
some  weeks  due  to  an  exacerbation  of  the  disease  itself  and  not  to 
any  complication.  The  temperature,  as  in  Case  C,  may  show  a 
double  remission  in  the  twenty-four  hours,  similar  to  that  described 
in  Kala-azar. 
TA  li  4 
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