162 TROPICAL MEDICINE AND HYGIENE 



most readily obtained by puncture of the liver or spleen. 

 The risk of haemorrhage following puncture of the spleen 

 may be great in kala-azar and has been fatal. It is 

 preferable to puncture the liver. The method of puncture 

 is as follows : 



The syringe and needle must be sterilized dry, as any 

 admixture with water may cause a breaking up of the 

 parasite. The skin over the site selected for puncture 

 must be thoroughly sterilized and the needle plunged 

 deep into the liver with a slight rotatory movement. 

 When well in the liver the syringe will move with the 

 respiratory movements. The needle should be kept in 

 position for about a minute and slightly withdrawn before 

 gentle aspiration is attempted. The less blood that is 

 present the more satisfactory is the operation, as the 

 parasites are not in the blood, and any blood present 

 only serves to dilute the fluid and render it more difficult 

 to find the parasite. 



The fluid withdrawn should be blown out on to a 

 series of slides, making as thin films as possible. These 

 films when dry may be stained with Leishman's method, 

 or, after fixation, with dilute, i in 4, freshly filtered carbol- 

 fuchsin. The parasites may be numerous in such films, 

 or scanty, and several films should be examined before a 

 negative diagnosis is given. They can be recognized by 

 the presence of two chromatin masses, one small, rod-like 

 and deeply staining, the other larger, oval, and staining 

 less deeply. Cochran has shown that in cases in China 

 the parasites may be readily found in the superficial 

 lymphatic glands even when they are very scanty in the 

 Jiver and spleen. 



Prognosis. The mortality of kala-azar is very high. 

 In Assam the mortality was estimated at 96 per cent., 

 but it is most likely that the remaining 4 per cent, of 

 the patients were suffering from malarial cachexia, the 

 difficulty in the differentiation of which from kala-azar 

 by clinical methods alone has already been mentioned. 

 In Madras the case mortality is recorded as 98 per cent. 



