96 REVIEW — ^TROPICAL MEDICINE, ETC. 



Leish- that the majority of cases begin with rigoi's, but a good account is given of the changes in 



maniosis— the spleen and liver. The former is usually liard and, in very chronic cases, its firm edge may 

 cniitiiiued 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 tliere is a very diffuse intra-cellular cirrhosis in the fibro- 

 cellular tissue of which shrunken parasites of kala-azar may still bo visible with a high 

 power. Advanced cases are accompanied by ascites. 



The cliief blood change is a great rehitive reduction of the leucocytes which may be e-xtreiue even at a very 

 early stage. There is usually also a marked increase iu 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. 



Ijhiod chcuuft's. 



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



2. Relative leucopa?nia 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 leucopteuia may be 

 absent in kala-azar, (a) during any inflammatory complications such as pneumonia, dysentery, caucrumoris, 

 meningitis, phthisis, etc. ; (i) during high remittent pyrexia occasionally ; {<•) during the very earliest stages of the 

 disease such as the first month of fever, or in recovering patients who have iteen free from fever for some time. 



3. Increase iu 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 iu 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 

 prognostic sign, tlie prognosis becoming progressively worse as the polynuclears become fewer and fewer. 

 (A) 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 tliere may be a loss of 

 nine-tenths of the phagocytic polynuclear leucocytes. 



5. There is increase of the lymphocytes and decrease of the eosinophilcs, 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 

 n\iraerou6 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 

 Ilerpetomonas 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 Eogers who determined that the reaction of the tluid 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 : — 



1. The most chronic cases of kala-azar not infrequently terminate theii' course with ascites due to cirrhosis 

 of the liver. 



2. The cirrhosis is of a peculiar intralobular type of uniform distribution, and with a smooth surface to 

 the organ. 



' Rogers, L. (July Ist, 1908), " A Peculiar Intralobular Cirrhosis of the Liver produced by the Protozoal 

 Parasite of Kala-azar." Annals of Ti-opkul Medicine and Parasituluyy, Scries T.M., Vol. II, No." 3. 



