7
Para. 6
night" [Lavertine, Price, Ross]. "A low form of fever, which remains for
weeks or even months, " sets in [McNaught, Ross]. After the first attack of
fever there are " slight attacks of fever which become more and more frequent,
until eventually the temperature never falls to normal, lying between 99° and
101 F., though the patient is generally unconscious of it" [Macnamara].
This condition remains for months [McNaught, Ross]. There may some-
times be, however, intercurrent attacks of high fever [McNaught, Price, Ross].
Ascites and œdema of the feet, more rarely of the face, may be present [all].
There is often undoubted darkening of the skin [McNaught, Lavertine,
Price, Macnamara].
Epistaxis frequently occurs [McNaught, Ross]; Macnamara has not noted it.
A stage of cachexia now sets in, during which the low fever disappears, while
the spleen and liver decrease in size ; the emaciation and darkening of the skin,
however, remain, accompanied by extreme weakness [McNaught, Ross].
Lavertine and Price, while admitting the existence of this stage, do not note
decrease of the organs. Lavertine observes now a subnormal temperature.
Macnamara is doubtful on the point.
Diarrhœa and dysentery are common intercurrent affections. Pneumonia
also occurs [McNaught, Price] ; does not occur [Macnamara, Lavertine].
Death may happen at any stage [all, except Macnamara] ; at the beginning
from high fever ; later from diarrhoea, pneumonia or asthenia, or [Lavertine]
cancrum oris. It is more frequent in the later stages.
Quinine has little or no effect [McNaught, Lavertine, Macnamara].
Price says, however, " I think that quinine does do good ; it is difficult to say,
because when a case is cured we have our doubts whether it has been kala-
azar. "
The disease is communicable from the sick to the healthy [all] ; only in-
directly so [Price].
Further interesting details will be found in the Statements.
Owing to the acknowledged difficulty of distinguishing the early symptoms
of the disease from those of malarial fever, they must be generally ascertained from
enquiries of patients—a method which scarcely yields exact results, though, as
has been shown, a general history of severe fever is always given. Such enquiries,
while individually they are frequently unreliable, constitute in the aggregate à
mass of evidence which it is impossible any longer to resist. I have depended
for the facts not only on the four medical officers referred to, but many others—
notably on the Reverend Mr. Moore, of the American Mission in Nowgong, who
has seen very many cases in that establishment. In my experience, however,
the evidence be sifted, it always returns to the facts just given.
We may now proceed to a more formal symptomatology based more upon
my own conclusions.
I adhere to the division of the history into three periods, implied in the
statements of Dr. Lavertine and Captain McNaught.
The first stage is that of recurrent accessions of acute fever separated by
periods of apyrexia. It has not been possible to determine exactly the type of
fever, nor to what extent it is preceded by rigors, nor whether the apyrexia is
complete or not. To judge, however, from the evidence of Sri Jut G-unahash
Gasswami, which is much more reliable than that commonly extracted from
patients, usually peasants, the fever may be first remittent and afterwards inter-
mittent, rigors being frequent. I have often obtained the same history from
other patients, and am of opinion that rigors are more common than is supposed.
Still I think that they may often be entirely absent. In many cases there is
a history of an entire cessation of fever for intervals of weeks or months, fol-
lowed by relapses ; in others, again, a continuous low fever sets in almost imme-
diately after the first attack of severe fever, and continues throughout, being,
however, frequently interrupted by severe exacerbations. Macnamara's descrip-
tion of slight attacks succeeding the first fever, and becoming more and more
frequent until a continued low fever is established, would suggest a progressive
tendency towards something like Torti's subintrant fever ; I think it more likely
that in such cases the continued but low fever is really established early and
exists throughout—see case 35, paragraph 17. It is useful to distinguish
sharply between this persistent low fever and the frequent relapses or conflagra-
tions of severe fever which McNaught and Price refer to.