Fig. 54.—Fever chart of a case of kala-azar reported by Bassett-Smith. This chart shows how easily one might confuse the temperature curve of this disease with that of Malta fever.
Rogers attaches particular importance to the fact that four-hour charts will show a double or even triple rise of fever in the twenty-four hours instead of the single one in typhoid fever. The patients also show a striking absence of typhoid malaise and apathy often stating that they feel well when the temperature may approximate 104°F.
The febrile accessions last from two to six weeks to be followed by periods of apyrexia and apparent improvement. Then follow further waves of fever and apyrexia so that the fever chart may resemble that of Malta fever.
In the early stages of the disease the loss of weight is apt to be marked. Later on, owing to improvement in appetite and increase in spleen, this is not so manifest.
The spleen begins to enlarge early in the disease and has usually reached the level of the umbilicus by the third month. In some cases there is little if any enlargement of the spleen even in the chronic stages. At times we note only an irregular fever with weakness, anaemia and emaciation. The liver does not usually become distinctly enlarged until about the sixth month.
The course of the disease in India is chronic often covering a period of one or two years. In the Sudan, however, Bousfield noted that the symptoms ran an acute course, the average duration being only about 5 months. Rarely he encountered chronic cases with greatly enlarged spleen.
As the disease progresses anaemia and emaciation become marked so that the bulging spleen and liver in a dusky or earthy colored, skeleton-like native (black fever) make a striking picture. The lymphatic glands of cases in North China show enlargement.
Symptoms referable to intestinal ulcerations, such as diarrhoea or dysentery, are often noted at the end. Bleeding from the gums and nose is not infrequently noted.
The marked leucopenia, with accompanying decrease in the polymorphonuclears (the bacterial phagocytes), makes septic infections and pneumonia especially common in the course of kala-azar.
These complications frequently bring about a fatal termination so that we do not get the typical terminal cachexia with emaciation, exhaustion, dry brittle hair, petechiae, oedema and ascites. On the other hand the tendency of a bacterial infection to cause a leucocytosis may bring about a cure.