Kala Azar, or febrile tropical splenomegaly, is a disease which begins like a malarial fever ; and most of the patients say they have malaria. Chills, fever, and sweating are common accompaniments. This is followed by a dormant period, then a renewal of the symptoms, then again a dormant period, and so on. This may go on for several months. The spleen and the liver commence to enlarge, the former often getting enormous. There is marked anwmia, langour, fatigue, and difficulty of breathing. The abdomen swells, emaciation becomes marked, the skin is sallow and dirty, and the patient becomes bedridden and usually dies in a few years. These cases have been grouped with the chronic malarial cachexias, which they resemble closely in their clinical picture. In spite of active medication by both quinine and arsenic, these patients become progressively worse, and all die. This disease has been epidemic in India, going from village to village at a rate of five miles a year or more, and has entirely depopulated certain parts of Assam. Just what the cause is, is still a matter of some doubt in the minds of the ablest pathologists, but Leishmann has described a blood-parasite found in those suffering from this disease, which has been assumed to be the cause. It is a trypanosome similar to that found in sleeping sickness, and at times resembling, in certain stages, the micro-parasite of malaria. This disease is now known to occur in India, in the Egyptian Sudan and Algiers, and in China ; it was communicated to soldiers of the German Army during the Peking campaign, and has also been observed in other Europeans. It is not at all unlikely that it may be found in some American tropical countries. Manson believes that the parasite probably leaves the body in ulcerated surfaces, which are very common in the disease, and may be conveyed by the bite of a flesh-eating fly. He further suggests the relation of kala azar to the so-called " Oriental sore," or " Bagdad boil." The Mediterranean Fever, also called rock-fever, Malta, Levant, and Neapolitan fever, is a fever of bacterial origin, prevailing in the Mediter ranean region and not unknown in America. It is known to occur also in India and in China, and has been found in Porto Rico and the Philippines. It is thought to be due to a Bacillus melitense. The disturbance arises in from ten to thirty days after infection, with gradual malaise, constipation, headache, loss of appetite, perspiration, etc. This lasts a few whereupon the patient passes into a long period of dull fever. He becomes apathetic and heavy. There is no delirium, but a marked develops. There is an alternating febrile and afebrile course, which may go on for some months, or even for a year or two. The patients usually recover.
Dengue, or break-bone fever, has already been described in its alpha betical place, as have also BUBO and LEPROSY.
Frambcesia, or the Yaws, is a name given to a widespread tropical disease which is chronic and contagious, and associated with diffuse granular, wart like eruptions on the skin. It occurs in South and Central America, and in the Antilles, and is distributed throughout tropical Africa and Asia and the Pacific Islands. At one time, especially during the height of activity of the slave-trade, it was common in Cuba and in certain ports of the Southern States of North America, from which it has now practically disappeared. The disease attacks all races, although the black and yellow races are more susceptible than the white. The cause is not yet known with definiteness. It is usually conveyed by direct inoculation, which is largely accidental, although it was at one time the custom to inoculate children under the wrong supposition that they had to have it anyhow.
The eruption breaks out after an incubation period of about two to three weeks, during which time there may be symptoms of general discomfort, headache, and rheumatic pains. This period is soon followed by the develop ment of the primary sore, which is a small papula, developing into a shallow ulcer. In about a week this is followed by a thickened scar. A period of
quiescence is then observed, lasting several weeks, which is followed by a general eruption scattered over the entire body. The face, neck, genitals, and trunk are the common sites of this eruption. The scalp and armpits are not often implicated. The mucous fringes of the mouth, sexual organs, and anus are most frequently attacked. The eruption is at first very fine and papular, like a pin-head, but this enlarges until it becomes the size of a pea or hazel-nut, whereupon the eruption spreads. The papule become purulent, and the skin cracks and tears and leaves a reddish, warty, rasp berry-like mass (framboise meaning raspberry). This, when active, exudes a thick, creamy pus, and the area is intensely itchy, although not painful. The resemblance to a certain form of syphilitic eruption is very marked, and some observers have suggested the similarity of origin of the two. After several weeks or months the after appearing in crops, dry up, and small scars are left, white in the negro, and pigmented in the white. Practi cally all the patients recover, and thenceforth are immune to a second attack. Iodide of potash is the best remedy for frambcesia. Care should also be taken to avoid contagion by paying attention to all cuts and abrasions, and by the avoidance of infected localities and dwellings.
Verugas Peruviana, or Peruvian warts, is a tropical disease which is more or less limited to the Pacific slope of the Andes, particularly in Peru, Chile, Bolivia, and Ecuador. It seems not to be found in the lower-lying countries, persisting only at an altitude of at least 3,00o feet above sea level. The soldiers of Pizarro's army in the sixteenth century contracted the disease from the natives, but it did not obtain any foothold in Europe. It is not an actively contagious disease, although small epidemics have been described. It is infectious, and can be directly inoculated. Moreover, it is found in fowls. The disease has been thought to be a form of yaws, and also a manifestation of syphilis, but both of these beliefs are untenable at the present time. Its exact cause is unknown, and it is in need of more exact methods of investigation. Like yaws and syphilis, there is a short incuba tion period (ten days), or, in rarer cases, much longer ; twenty-three days is the record of voluntary experimental inoculation of a medical student, who subsequently died of the infection.
The signs of the initial period are lassitude, general depression, and leg weariness. A fever then develops, at first in the evenings only, later becoming more violent. Chills and a marked intermittent character of the fever then commence, and violent joint-pains begin. These pains pass from joint to joint, and are more violent at night. Muscle-pains and contractures take place, and anaemia and emaciation occur. The skin becomes yellow and pale, the liver and spleen enlarge, and the patient is very ill. In about twenty days a general eruption develops, when all the symptoms subside somewhat. This breaking out is first in the form of small pinkish papul, which become dark blue in colour, and finally become wart-like. The face, particularly about the eyelids and nose, and the skin about the joints are the chief sites of the eruption. The warts may be very small, or they may be one to two inches in diameter, and they may be few or many hundreds in number. In some patients they are found on the mucous membranes ; and, as they bleed easily, they may cause serious anxmia. After four to six months, if the patient stands the strain, the eruptions subside, either drying up or ulcerating, leaving flat scars behind. The disease is usually fatal, especially in whites, 6o to 70 per cent. dying. The mortality of the native population is from ro to 20 per cent. The treatment is purely that of the symptoms. Quinine and hot drinks, descent to a lower altitude, and careful feeding are advisable.