112

Report on Kála-ázar.

with in the disease is so typical of that which is seen in cases
of malarial cachexia all over the world, that there are very few
points to which special attention need be directed. The
changes in the liver and spleen are characteristic of the disease.
The granular and fatty degeneration of the heart, together
with its atrophied condition, are of considerable importance in
determining the great fatality of the inflammatory complications
of the lungs, as the right ventricle becomes acutely dilated
when any extra work is thrown on it, as was seen in the two
post-mortems after death from pneumonia given in illustrative
cases in Section III. There was no change in the suprarenal
capsules such as could account for the darkening of the skin
so frequently met with in the disease. It is due partly to
the natural pigment of the skin being more apparent owing
to the anæmic condition of the patient, but more still to a
deposit of fresh pigment in the integument, which is derived
from the hæmoglobin of the broken-down red corpuscles, for
it may be very noticeable in chronic cases in which the anæmia
is slight.

      The atrophy and pigmentation of the mucous membrane of
the small intestine are changes which are of great significance
in relation to the high mortality of the disease, as they are the
result of an inflammation of the mucous membrane, which shows
itself clinically in the diarrhœa which so often begins during an
acute attack of the fever, and goes on, after the temperature
has fallen, in a most obstinate manner. Not unfrequently, as was
very well illustrated, in some cases of which the notes and tem-
perature charts were kindly recorded for me by Dr. Dodds Price,
a rapidly fatal form of diarrhœa sets in directly the temperature
falls after a severe and prolonged attack of remittent fever. In
these cases it must be set up by an enteritis, which occurs
coincidently with the high temperature, and it is well known
that this is a symptom of almost absolutely fatal significance.
It is in marked contrast, as already pointed out in Section
III, to the constipation, which is the general rule in anchy-
lostomiasis. These intestinal changes are the cause of the