158 TROPICAL MEDICINE AND HYGIENE 



after separating the red corpuscles to again centrifugalize 

 the remainder and prepare films from it. Another 

 method is to make blood films terminating in a thick 

 edge ; leucocytes accumulate at this edge, and search for 

 the organism is thus facilitated. By this method a skilled 

 observer may be able to make his diagnosis certain by 

 examination of the peripheral blood alone. Unless the 

 case is complicated by malaria, no malarial parasites or 

 pigment will be present in the blood. 



Among the results of the blood changes are the haemor- 

 rhages from mucous surfaces already mentioned. Of 

 these epistaxis is the most common form, and is some- 

 times profuse and difficult to control ; in other cases 

 slight but persistent oozing of blood from the nasal 

 mucous membrane occurs ; bleeding of the gums is not 

 uncommon, and sometimes intestinal haemorrhages occur, 

 quite apart from those met with during the dysenteric 

 attacks of the final stage. Haematuria is occasionally 

 observed. 



Mention may here be made of the occasional presence 

 of slight .general anasarca; this and the transitory cedemas 

 sometimes met with are probably due to the condition of 

 the blood. The anasarca may be most marked in the 

 face, and may mask the emaciation. 



Digestive System. There is little to add to what has 

 already been said of symptoms referable to the digestive 

 system. During the early stages they are slight or 

 absent, this being in contrast to the condition usually 

 met with in malaria. 



While diarrhoea or dysentery are usually symptoms of 

 the final stage, attacks may appear at any period of the 

 disease. In some instances, indeed, soldiers have been 

 invalided from India to England for dysentery, and the 

 symptoms of kala-azar have supervened. 



The enlargement of the liver and spleen is usually pain- 

 less, though these organs are often tender, especially in 

 the early stage of the disease. Sometimes, however, there 

 is considerable pain in 1 the liver, which has led to the 



