8
Para. 6
Enlargement of spleen and liver begins from the commencement of the
illness. It is possible, however, that the tumefaction of the liver may be
subsequent to that of the spleen. In my experience in Nowgong the liver was
almost always enlarged.
Anæmia and emaciation set in early, being, I think, augmented after each
attack of fever.
I am of opinion that oedema of the feet may appear even as early as the
end of this stage.
About the darkening of the skin I cannot speak with any authority ; but
it would seem to appear early in some cases.
As the disease progresses the enlargement of the spleen and liver increases.
The organs are tender on pressure as a rule, and a patient often complains of
pain in them.
The second stage is that of established and still acute tumor of the spleen
and liver, accompanied by a constant low fever ; recrudescences of high fever
may, however, still occur at longer and longer intervals, but I think are often
entirely absent.
The splenic dulness generally occupies most of the left half of the abdomen,
while the liver extends to two or three inches below the lower end of the sternum
in the median line. The enlargement may often be less or greater than this in
the case of both organs. There is generally tenderness of one or other, or of
both—not acute, but sufficient to make the patient wince on pressure of them ;
while pain is frequently complained of, especially in the hepatic region. In
most of the cases seen by me tumor of the liver was a marked feature. In
some of the worst cases there was very evident thoracic breathing. A slight
degree of icterus is often present.
The fever has two notable characteristics; the diurnal curve remains
almost exactly the same day after day for weeks or even months, and the
amplitude is not much—in other words, the type is extraordinarily constant,
and the temperature has, comparatively to some other fevers, only a small
range of variation. Several charts of this fever are given in connection with
the cases in paragraph 17, and these characteristics will be noted in them.
The history is not that of recurrent conflagrations of fever interrupted by
intervals of apyrexia ; it is that, so to speak, of a continuous chain composed
of links always similar to each other. This fever will be discussed at length in
Section IV ; it is certainly the kind of pyrexia found by me in nearly all the
cases in which exact thermometric observations were made under my own
superintendence ; and it is referred to by all the medical officers whose state-
ments I have taken. I should add here that the diurnal exacerbations are not
as a rule ushered in by rigors or even a feeling of chilliness, and that quinine
appears to have no effect on the chart.
Anæmia is certainly pronounced at this stage, but in my experience it is
not excessive. In nearly all the cases studied by me the tongue and conjunc-
tivæ remained fairly red. So far as I could judge from mere qualitative exami-
nations of the blood, the degree of anæmia remained constant at this stage.
Neither did I find the emaciation to be always extreme. A group of
children suffering from pronounced kala-azar in the Civil Hospital at Nowgong
were, most of them, quite fat, although their livers and spleens were enormously
enlarged, and they suffered from the constant fever just described. This
symptom would appear to depend largely upon the alimentation, and possibly
on the degree of helminthiasis present.
Epistaxis is common at this stage.
A certain amount of ascites is almost always present in connection with
the enlargement of the organs. The anasarca not unfrequently extends to the
feet at this time ; rarely to the face.
As the disease advances, if death has not occurred, the further enlargement
of the organs ceases ; they lose their tenderness ; the fever gradually declines—
ushering in the third stage.
The third stage is that of cachexia. The liver and spleen, still much
enlarged, lose their tenderness, and may even, I think, return to their normal
dimensions. The fever has disappeared, giving place perhaps to a continuously
subnormal temperature. Ascites has generally increased, but, on the other hand,
dropsy of the feet is, when present, less than before. The anæmia is not very