174 TROPICAL MEDICINE AND HYGIENE 



Clinical Course. In many cases the first symptom noted 

 is diarrhoea, sometimes accompanied by vomiting. Later 

 there is irregular fever and steadily increasing anaemia. 

 There is loss of spirits, steady emaciation, and sometimes 

 attacks of epistaxis, bleeding from the gums or elsewhere. 

 As the anaemia becomes more marked oedema of the feet 

 becomes noticeable, and enlargement of the abdomen 

 from the increase in size of the spleen. The pallor of the 

 skin is of a peculiar yellowish white tint, not like that of 

 an equal degree of anaemia from other causes. Though 

 diarrhoea or other digestive disturbances are common, 

 the appetite, as a rule, is not affected. In uncontrolled 

 cases the prognosis is unfavourable, though it is rarely 

 fatal in less than six months, and may last for years. 

 Spontaneous recovery does take place. 



Pathology. The spleen and, to a smaller extent, the 

 liver, are enlarged, and the parasites, apparently morpho- 

 logically identical with those of kala-azar, are found in 

 numbers. The lymphatic glands are not enlarged. The 

 blood shows great reduction in the number of red 

 corpuscles, which may be as low as 1,000,000 per cubic 

 millimetre, and there is a diminution in the amount of 

 haemoglobin, not, as a rule, to the same extent as that of 

 the number of corpuscles. There is leucopenia in many 

 cases, but not to as extreme an extent as in Indian kala- 

 azar. The mononuclear elements are usually in increased 

 proportion. In many cases the increase is in the large 

 mononuclear elements. 



Treatment. Spontaneous recovery takes place in a 

 small proportion of cases, and recoveries have taken place 

 after injection of salvarsan, though in other cases the 

 results have not been satisfactory. 



Etiology. Nicolle, to whose work our knowledge of 

 this disease is largely due, discovered that in the districts 

 where this disease is endemic a certain proportion of 

 dogs are naturally infected with a similar parasite. In- 

 jection, either of the juices from the tissues or of cultures 

 of the organisms from them, are followed by infection of 



