96 REVIEW—TROPICAL MEDICINE, ETC.

that the majority of cases begin with rigors, but a good account is given of the changes in the spleen and liver. The former is usually hard and, in very chronic cases, its firm edge may project so as to be evident to sight through the abdominal wall. The rapid increase, and the still more striking rapid decrease, which may occur in the size of the spleen are described. In very chronic cases an actual cirrhosis of the liver may occur. The surface of the organ is smooth, and microscopically there is a very diffuse intra-cellular cirrhosis in the fibrocellular tissue of which shrunken parasites of kala-azar may still be visible with a high power. Advanced cases are accompanied by ascites.

The chief blood change is a great relative reduction of the leucocytes which may be extreme even at & very early stage. There is usually also a marked increase in the percentage of the large mononuclears. This, be it noted, rarely occurs early in typhoid, and hence is a useful diagnostic aid.

Possibly improved technique will be able to demonstrate parasites in the peripheral blood even early in the disease. As regards the general course of the fever, many charts are given showing the different types of fever. A double remittent passing into a low fever is common, while the low continued type also occurs. Both high continued and the high remittent forms are much more rare.

Blood changes.

1. Marked anzmia is only characteristic of the later stages.

2. Relative leucopenia is very marked and may be pathognomonic. It is less marked during high fever than during remissions or low intermittent pyrexia. It is important to note that a great degree of leucopenia may be absent in kala-azar, (a) during any inflammatory complications such as pneumonia, dysentery, cancrumoris, meningitis, phthisis, etc.; (6) during high remittent pyrexia occasionally ; (c) during the very earliest stages of the disease such as the first month of fever, or in recovering patients who have been free from fever for some time.

3. Increase in the large mononuclears. Note that kala-azar differs from malaria in that this increase seems to occur more frequently when there is high remittent fever than when it is intermittent or absent or when the temperature is normal. In malaria it is less marked or even absent during pyrexia. An increase of the large mononuclears in typhoid during fever is very rare, hence this sign is valuable in early kala-azar with high remittent fever which closely simulates that of enteric.

4. Decrease in the polynuclears. This, which is marked, is of significance in two directions. (a) As a rognostic sign, the prognosis becoming progressively worse as the polynuclears become fewer and fewer. b) As a factor predisposing to the secondary inflammatory complications, often coccal or bacterial in origin, which so often prove fatal. This is easily understood when it is remembered that there may be a loss of nine-tenths of the phagocytic polynuclear leucocytes.

5. There is increase of the lymphocytes and decrease of the eosinophiles, but these changes are of no special import.

As regards treatment, Rogers upholds the utility of quinine given in large doses and for months together if necessary. He has repeatedly seen a high remittent fever reduced to a comparatively harmless low intermittent one by increasing the quantity of quinine given, say, up to 60 grains or even 90 grains a day. He also points out that a considerable number of cases wholly recover. . The parasite is then fully considered. It may be found in practically every organ of the body, but is most numerous in the spleen, bone-marrow and liver. Christophers’ work is mentioned. It showed that the parasites multiplied mainly in the large endothelial or macrophagic cells of the spleen and bone-marrow, especially until the invaded cells bulge into the lumen of the vessels. Hence, when splenic puncture is performed, the larger capsulated forms are obtained.

It has been found that the parasite is absent from the body in diseases other than kala-azar.

The flagellated stage of the parasite is then discussed and its resemblance to Herpetomonas noted. These discoveries and observations are so well known that there is no need to refer to them here at any length. One important point, however, is the optimum temperature for the cultivation and development of the parasite. This is between 20° C. and 22°C. Hence, in working with bed-bugs, it is well to carry out the feeding experiments during the cold season. It was Rogers who determined that the reaction of the fluid in the stomach of the bed-bugs, after they had sucked human blood, was distinctly acid, and this led him to employ an acid medium (citrated human spleen blood plus sterile citric acid) for observing the development of the parasite. Prophylaxis on plantations and in villages in India is fully considered. Segregation of the sick, building of new lines and the destruction of old houses and purification of old sites by fire are advocated, as is the destruction of bed-bugs by sulphur fumigation, washing beds with strong boiling carbolic lotion, boiling . clothes in the same or destroying them altogether and burning blankets.

Rogers,! in a recent paper, enters more fully into the question of the cirrhosis of the liver present in cases of kala-azar, and concludes that :— ; te wae most chronic cases of kala-azar not infrequently terminate their course with ascites due to cirrhosis of the liver. A 2. The cirrhosis is of a peculiar intralobular type of uniform distribution, and with a smooth surface to e organ.

1 Rogers, L. (July Ist, 1908), “A Peculiar Intralobular Cirrhosis of the Liver produced by the Protozoal Parasite of Kala-azar.” Annals of Tropical Medicine and Parasitology, Series T.M., Vol. II, No. 3.

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