TRYPANOSOMIASIS EXPEDITION TO THE CONGO 67 
On the other hand we have Cases 20, 26, and 32 all showing- trypanosomes 
repeatedly in the cerebro-spinal fluid, and all conspicuous for sleep or other head 
symptoms, more marked in the later days. 
Examples of long-continued mild mania are not infrequent, of which class 
Case 33 is a good example. This man's blood was examined on many occasions, 
but no trypanosomes were found until the lumbar puncture revealed them in his 
cerebro-spinal fluid. 
On the whole one cannot say more than that the presence of the parasites in the 
cerebro-spinal fluid apparently tends to increase the gravity of the case, and pre- 
disposes to the more severe head symptoms and other complications likely to bring 
about a fatal termination. Only in such cases as 8 and 17 do I think the parasite 
can be said to be solely accountable for the death. In the vast majority of cases 
death is the result of complications, mainly bacterial. 
As in the blood, where the appearance of a large number of parasites is frequently 
coincident with an unusually high rise of temperature, if the patient is not too far 
advanced in the disease to be irresponsive, so also the rare discovery of large numbers 
of parasites in the cerebro-spinal fluid is, I have found in several instances, coincident 
with an unusual rise in the temperature curve. This no doubt accounts for the 
occasional unexplained rises of temperature and aggravation of symptoms occurring 
where few or no parasites can be found in the circulation. An access of temperature 
is probably in these cases always coincident with the collection or the development 
of a crop of parasites in one or other of the organs or fluids of the body. 
All cases punctured, whether with or without parasites in the cerebro-spinal 
fluid, had well-marked fever, characterized by an afternoon rise and a morning fall 
to near the normal, showing that no connexion can be traced between the commence- 
ment of the fever and the entry of the parasites into the cerebro-spinal fluid from the 
blood. Some of the cases in Table I died without ever having trypanosomes in their 
cerebro-spinal fluid, but showed nevertheless the characteristic temperature curve. 
It would appear from Cases 26, 28, and 38, that just as in the blood, the 
parasites may come and go in the cerebro-spinal fluid irrespective of their presence or 
absence elsewhere in the system. 
Case 23 shows that they may be in enormous numbers in the blood without 
appearing in the cerebro-spinal fluid, where, however, they do occur occasionally in 
large numbers as is seen in Cases 28, 38, 44, and 49, but in this fluid they are most 
frequently very scanty. 
The amount of fluid drawn off is no indication of the total amount present. 
Occasionally the pressure is considerable, and in these cases very marked temporary 
benefit is often derived from the puncture. 
Cerebro-spinal fluid with no admixture of blood or increase of white cells is as 
clear and limpid as distilled water. According to the amount of mixture with red 
