KALA-AZAR 159 



mistaken diagnosis of hepatic abscess, and exploratory 

 punctures, while the microscopic examination has shown 

 the presence of the characteristic parasites of kala-azar in 

 the fluid abstracted. While the enlargement is usually 

 progressive until towards the end, variations in the size of 

 the liver and spleen sometimes occur, diminution being 

 usually coincident with temporary general improvement 

 in the patient's condition. The slight degree of ascites 

 not infrequently met with is probably due, at least partly, 

 to the obstruction to the circulation caused by the en- 

 largement of the liver and spleen. 



The urine is normal in most cases of kala-azar, though 

 towards the end it may contain a little albumin. Haema- 

 turia is a rare complication. 



Respiratory System. A liability to congestion of the 

 respiratory passages, as evidenced by sore throat or by 

 slight bronchitis, is common in patients suffering from 

 kala-azar, and there seems to be a special liability to 

 pneumonia during the later stages of the disease ; the 

 pneumonia is of the ordinary lobar type. True tuber- 

 cular phthisis is one of the causes of death in kala- 

 azar. The parasites may occur in the lungs, and in that 

 case nodules resembling tubercles will be present. The 

 cases of this description, described by Darling in Panama, 

 are associated with parasites with a thicker capsule, and 

 in which the two chromatin masses are not always pre- 

 sent. He called the parasite Histoplasma. Some authori- 

 ties consider them more allied to yeasts than to the 

 parasites of kala-azar. 



Cutaneous System. Darkening or pigmentation of the 

 skin is sometimes very marked, especially among dark- 

 skinned patients. The skin of Europeans suffering from 

 this disease often has a dull, dirty appearance. Except 

 for occasional petechiae, there are no special skin erup- 

 tions in kala-azar. 



Cancrum oris is frequently met with in the last stages of 

 kala-azar, especially in children. Although nearly always 

 fatal, cases have been recorded in which its appearance 



