Clinical characters Absence of suppurative processes in the cases seen 132 REMARKS ON KALA-AZAR who are naturally thin, are wasted, especially as many are poor and therefore badly fed. Emaciation was marked in eleven cases, slight in eight, and not evident in three.

Weakness was noticeable in all cases, but especially in the very acute, while in the subacute it was not very striking.

Protuberance of the Abdomen. In thirteen out of the twenty-two cases the abdomen was not prominent, while in several cases it was actually the reverse. Those who had large abdomens were the chronic cases, and the average duration of these cases, when seen, worked out to nineteen months.

The fact that 59 per cent. showed no protuberance is, to my mind, highly suggestive of a new disease, likely to take on an epidemic character. No chronic case was seen without some protuberance of the abdomen, a condition probably essential, and due to nature making accommodation for the greatly enlarged spleen and the enlarged liver.

Enlargement of the Spleen. In nineteen cases out of the twenty-two the spleen was enlarged to within an inch of the umbilicus or to a greater extent. In the remaining three the spleen was palpable or extended one inch below the costal margin. In all cases the enlargement was regular, the edge definite ; tenderness on palpation was complained of in three cases.

Very large spleens were always and only found in chronic cases; the very acute having but comparatively slight enlargement of this organ and no prominent abdomen.

Enlargement of the Liver. In seventeen out of the twenty-two cases the liver was distinctly enlarged though in most cases to no great degree, The largest extended downwards to the level of the umbilicus and the liver dulness was increased upwards one costal space. In no case was it noticed to be smaller than normal. Jaundice was found in two cases, but in neither to a marked degree.

The conjunctive were distinctly of a yellowish tinge in seven of the twenty-two cases. Pigmentation was only once seen, and then it was doubtful if it was due to kalaazar, and was confined to a curious bronzing of the face. There were no special changes noted in the skin, hair, or nails, and the nervous system appeared normal in most cases.

Mental depression was very marked in four cases, but all were acutely ill; one case was extremely deaf (no quinine had been taken), the power of speech was greatly impaired, and there was marked mental dulness for three weeks before death. No malignant tertian parasites were found in this case.

Diarrhea was a very marked and serious complication in twelve out of the twentytwo cases. It was often, according to accounts, accompanied by the passage of blood and slime in the stools.

Undoubtedly several cases started their disease with attacks of diarrhea, and my belief is that the majority had this complication early in the course of the disease.

The frequency of diarrhcea, accompanied by the passage of blood and slime in the stools, naturally suggests the possibility of infection through the alimentary tract, and is a point that should be carefully investigated in the Sudan.

(Edema of the legs was noted five times, one patient presenting cedema of legs, face and a slight effusion into the peritoneal cavity, while another showed oedema of legs and face. In the few cases where the urine was examined no trace of albumin or bile could be found.

Suppurative processes were practically absent. Only one proved case showed some boils scattered over his legs, and one suspicious case had a suppurative condition of the scalp; this is no greater percentage than would be found amongst the general population.