1296 THE KALA-AZARS AND PSEUDO-KALA-AZARS 



vasion by pathogenic bacteria, for septic infections, such as cancrum 

 oris, or lung infections — for example, pneumonia, phthisis, and 

 pleurisy — or abdominal troubles of the nature of diarrhoea, dysen- 

 tery, and cystitis, are not uncommonly met with, and may cause 

 the death of the patient. Sometimes, after a severe attack of 

 septicaemia or some other complication, the disease is found to be 

 cured, but this is rare. 



Diagnosis. — The only certain method of diagnosis is to find the 

 parasite, and as Donovan and Patton have reported its frequent 

 occurrence, even in early stages, in the peripheral blood, this should 

 be possible, especially if aided by dilution with normal saline 

 solution, and centrifugalization and examination of the leucocytes. 

 In our experience, the search for the parasite in the leucocytes of 

 the peripheral blood requires an extremely long time, and is often 

 negative. If the parasites cannot be found in the blood, an attempt 

 may be made to find them by the examination of the exudate 

 obtained by exciting artificial pustulation of the skin by some 

 irritant, as suggested by Cummins. Faihng this, there is puncture 

 of the spleen or of the liver, and withdrawal of blood, which 

 can be examined by the microscope. The diagnostic puncture 

 of the spleen in the tropics is, however, not to be undertaken 

 lightly, because splenic enlargement due to leukaemia is by no means 

 unknown, and puncture of the spleen in this disease, or, indeed, 

 in that of chronic malaria, may lead to most unfortunate results. 

 The blood of the peripheral circulation should therefore be examined 

 to exclude leukaemia. 



Certainly, the first thing to do is to examine the peripheral blood 

 and exclude leukaemia. Secondly, the coagulability of the blood 

 should be tested by Wright's method, and if found to be decreased, 

 the puncture should not be performed. Thirdly, if the puncture 

 is to be carried out, the liver should be chosen for exploration, not 

 the spleen, particularly in the later stages, in which haemorrhages 

 are to be feared. In the early stages there may not be so much 

 risk, but it must be done with the greatest care, aseptically, and the 

 patient must be kept at rest for some time afterwards, the site of 

 puncture being covered with an aseptic pad and a firm bandage. 

 The syringe should be sterile, and perfectly dry. Rogers recom- 

 mends that a dose of 30 grains of calcium chloride in a couple of 

 ounces of water be administered directly after a puncture, in order 

 to promote coagulability of the blood. Attempts at cultivation 

 from the blood and inoculations into susceptible animals may also 

 help, rats and monkeys being used by preference. 



Differential Diagnosis. — In the early stages the diagnosis has to be 

 principally made from acute malaria and typhoid, when the positive 

 signs in favour of kala-azar are : — (i) Presence of the characteristic 

 daily double remission of the fever; (2) absence of constitutional 

 symptoms, proportional to the severity of the fever; (3) absence of 

 malarial parasites and Widal's reaction, though, of course, the latter 

 reaction is negative in true typhoid during the first week ; {4) marked 



