288 APPENDICES 



manently ; in others they remain enlarged, but seldom 

 suppurate. Local oedemas and affections of the skin 

 are frequently seen ; the latter commonly take the 

 form of papular eruptions and of large patchy ery- 

 themas, of a curiously fleeting character. Some of 

 the eruptions are painfully irritating, and lead (in 

 negroes) to scratching, which produces large and very 

 intractable sores. 



The later symptoms of trypanosomiasis — those 

 which constitute the condition known as sleeping 

 sickness — probably indicate the beginning of the infec- 

 tion of the nervous system. There may be an interval 

 of years — as many as seven years (it is said) — between 

 the primary infection and the commencement of the 

 sleeping sickness symptoms ; but in the majority of in- 

 stances the period is probably much shorter. The 

 duration of the sleeping-sickness stage varies from 

 three or four months in some cases to three or four 

 years in others. In these latter cases there are often 

 prolonged intervals, during which the patient seems 

 to have recovered his normal health ; but sooner or 

 later a relapse occurs, and in every case, whether it is 

 acute or chronic, it is terminated by death. 



The onset of the sleeping-sickness symptoms is 

 indicated by an accentuation of the symptoms ot 

 trypanosomiasis already existing. *The physical 

 languor finds expression in disinclination to exertion ; 

 a slow, shuffling gait ; a morose, vacant expression of 

 countenance ; a relaxation of features ; a hanging of 

 the lower lip, and a puffiness and drooping of the eye- 

 lids ; a tendency to lapse into sleep, or a condition 

 simulating sleep ; a slowness in answering questions ; 

 a shirking of the day's task. Dull headache is also 

 generally present. Later there may occur such 

 symptoms as fibrillary twitching of muscles, especially 

 of the tongue, and tremor of the hands, more rarely of 



