Signs and symptoms

Significance of cedema

Diagnosis

Differential diagnosis

Malta fever

a difficulty

114 OBSERVATIONS ON KALA-AZAR IN KASSALA PROVINCE

CLINICAL FEATURES. In all, marked weakness and general emaciation were very evident.

Pain was absent, except in three cases where it was insignificant (one splenic pain, and two pains in tibia).

All the positive cases showed splenic enlargements, six to a marked degree, while five showed the liver increased in size, three markedly. In four cases the conjunctive were noticeably yellow without bile being present in the urine, while three were jaundiced. In

four cases albumen, from a trace to large quantities, was present, and in all cases the urine was of low specific gravity, the average being 1012.

Pigmentation of the skin was not seen in any case, but was present in Case XI., Table ‘‘B.’’ In all cases the tongue remained comparatively clear, and the appetite and digestion good, except just before death.

The complications noted were :—Pseudo-diphtheritic tonsillitis and epigastric pain due to duodenal ulcers (1).

Terminal persistent epistaxis (2). Terminal diarrhoea (2). (Hdema of feet and legs (4). General cedema (1). In all cases where cedema appeared, death occurred within a few days, although the

patient’s general condition seemed no worse than before, and in my short experience

the appearance of cedema is a premonitory sign of approaching death.

In no cases was ascites encountered, and in the case of general cedema there was no albumen, and the quantity of urine passed in twenty-four hours was normal.

DIAGNOSIS. This appears to be of considerable difficulty, owing to the prevalence

of malaria.

The main points noted in these cases were progressive emaciation and weakness ; enlargement of liver and spleen; absence of pain; albumen and bile in the urine; and

refusal to react to quinine.

My experience is that malaria met with in this province (malignant tertian I believe to

be very rare) seldom leads to liver enlargement, and if due to this cause the patient rapidly improves On quinine ; and I am of opinion that every case with liver enlarged, together with

the spleen, should be looked upon with the gravest suspicion, provided that local conditions can be excluded.

A positive spleen puncture settles the diagnosis, but a negative result is useless, for the

parasites are so few, and so may easily be missed or be absent. Major Rogers, I understand, now considers spleen puncture unnecessary for diagnosis, but the risks are so small that this,

together with the impossibility of finding the parasite peripherally, seems to me to justify

this procedure.

The presence of albumen in the urine is important, for in the severer cases of 2,000 odd malaria patients last autumn albumen was never found except where something else was present to account for it, such as bilharziosis.

The yellow coloration of the conjunctive is helpful, but natives, especially Sudanese,

often have a naturally yellowish tinge to their conjunctive.

The presence of Malta fever enhances the difficulty, especially as the essentials for serum diagnosis are wanting in Kassala.

A difficult example was Case III., Table A, who was admitted to hospital on August 14th,

1907, with fever 102°, a spleen enlarged one inch below the costal margin, and no noticeable enlargement of the liver.