9
Para. 7
extreme. Emaciation depends on the degree of alimentation. Intercurrent
affections—diarrhoea, dysentery, pneumonia—appear to be common; the
diarrhoea, however, may be a part of the pathological process of the disease itself
at this stage, and seems in many cases to be followed by a rapid reduction of the
liver and spleen.
If death has not yet occurred from fever or an attack of some complicating
disorder, it may now follow as the result, apparently, of pure asthenia. On the
other hand, recovery may ensue, but only from the early part of this stage—the
tumefaction of the organs, especially of the liver, is gradually resolved, the
blood regains its corpuscular richness, the emaciation, fever and ascites disappear.
When, however, cachexia is once firmly estalished, recovery appears (?) to be
impossible.
To sum up—the characteristics of the three stages are recurrent conflagra-
tions of high fever with rapid enlargement of the liver and spleen in the first
stage ; great tumefaction of the organs with constant low fever in the second
stage ; and cachexia in the third stage.
It is impossible to fix exactly the duration of each stage. I am disposed to
put the first stage at one or two months only, and the beginning of the third
stage at nine months or a year, or even more, from the commencement of the
illness.
In the above description—which I must confess is far from a full one—I
have purposely avoided reference to many secondary symptoms, such as cardiac,
nervous, renal, or digestive ones. Any sufficient study of these requires a long
observation of the disease ; and a consideration of them is not essential to the
main object of this report.
7. Diagnosis.—Are there any diseases in the Nowgong District with which
kala-azar as just described may be confounded? There are two—paludism,
and a species of anæmia generally complicated with dropsy. The differential
diagnosis (if there be any difference) must be considered in full only after the
pathogenesis of kala-azar has been examined. At present I will confine my-
self to a few remarks on the subject.
It will have been already noted that the symptoms of kala-azar as just
given are, if not identical with, yet very closely similar to those of ordinary
malarial fever (better called paludism). I have frequently observed that when
I have shown a case of fever in its earlier stages to a medical officer or his
subordinates in the Nowgong District, and have asked for a definite pronounce-
ment as to whether the case was one of kala-azar or not, the statement could
not be given. On showing more advanced cases, however, in which the liver
and spleen were much enlarged, the answer was generally ready enough, and in
the affirmative. It would appear then that kala-azar can only be diagnosed
when it has reached the second stage.
Here again the same difficulty occurs, because a similar second stage of
enlargement of the organs is met with also in chronic paludism. How make
the distinction even here ? It would appear from the statements that a history
of the relatives of the patient having suffered from a like malady, the refrac-
toriness of the disease to quinine, and perhaps, according to Price but not
according to Macnamara, the great enlargement of the liver, are relied on for
the diagnosis.
It will be confessed that these means of diagnosis are scarcely convincing.
It would appear as if early cases of fever, which recover before tumefaction of
the organs has occurred, are cases merely of ordinary fever, while those in
which the tumefaction has taken place are cases of kala-azar. I noticed also
that there were scarcely any recorded cases of "malarial cachexia" in the
district, though from the number of cases of recent malarial infections more
of these may have been expected to exist there. Are old cases returned as
kala-azar ?
These questions will be dealt with best when the actual relations between
kala-azar and paludism are discussed.
With regard to the anæmia with dropsy just referred to, I may remark
that I saw several cases of the disease in the Nowgong District, and that the
medical men in the province are perfectly familiar with it. The symptoms
are profound anæmia, and, generally towards the later stages, a considerable
degree of dropsy, extending to the face ; but there is no history of high fever
c