‘The method recommended for puncture Appearance of the blood withdrawn 134 REMARKS ON KALA-AZAR The method employed for splenic puncture was careful cleansing of skin, hands, and sterilisation of an all-glass hypodermic syringe, with a hypodermic needle about 14 inches long. The site of puncture was carefully located before the little operation. The patient was told to take a deep breath and hold it; several preliminary exercises were carried out, so that he fully understood what was required and that he was not to let go his breath till the needle was withdrawn. The needle was then inserted rapidly and at right angles to the spleen, and several drops of blood were at once drawn off. The proceeding did not cause pain to any degree, and the whole performance was finished in about five seconds or less.

In some cases the lax and thin abdominal wall allows of the spleen being more or less fixed against the lower ribs by inserting the hand under its edge and pressing firmly upwards and outwards, and in these cases inspiration need not be employed. The cases where danger may occur are those who are very nervous or very young; my small experience does not seem to point to advanced anemia being a cause of danger; many patients punctured were extremely anemic. In such cases, should sudden expiration take place, it is of the utmost importance, I believe, to hold the syringe very loosely, so that the movement of the syringe in the direction of the long axis of the spleen is in no way hindered, and thus the needle with the spleen is not fixed; if held firmly and fixed, the needle might be very liable to cause a rupture of the splenic capsule.

It was found that if the syringe rapidly filled with blood, the chances of finding parasites were small, and the blood usually had more or less the characteristics of peripheral blood; probably in these cases the blood came directly from a splenic sinus.

In a few cases it was found almost impossible to draw off any blood, in one case even after three punctures; usually, however, enough was obtained, though not sufficient to make a good film. In these cases it was noticed that the spleens were not easy to puncture, and the difficulty was probably due to a thickened capsule. By giving a few slight lateral movements to the needle the splenic pulp is slightly damaged, and blood can, in some cases, be drawn off, as in puncture of a lymphatic gland, though such a procedure should be avoided unless absolutely necessary.

A positive spleen puncture settles the diagnosis, but a negative result still leaves one in doubt.

In three definite cases, and in several that were clinically kala-azar, the blood withdrawn had, to the naked eye, the appearance of slightly clouded serum, though undoubtedly coming from within the spleen itself; this was noted especially in severe and rapid cases of kala-azar.

The method employed for splenic puncture has been given in some detail, but it must be kept in mind that this method was used with natives, who are not highly strung, and either do not show or do not feel pain as the civilised white races do. Hence the method of taking a deep breath and holding it, by means of which the spleen is depressed. and held downwards towards the pubis, might quite well with a hyper-sensitive white person be most dangerous, as the natural inclination of a person who has not full control of himself would be to let go his breath on puncture, and thus a more serious tear occur in the splenic capsule than if no previous deep inspiration was taken.

In dealing with an individual of a white race, especially if of a nervous temperament, I would suggest that it would be better to produce a réflex cessation of respiration by telling him to take a series of deep breaths and so produce a condition of apnoa for the puncture.