intestinal  symptoms,  the  aspect  of  the  patient  in  the  advanced  stages 
the  condition  of  the  blood,  bone-marrow  and  spleen,  are  very  closely 
similar  in  both  affections.  Kala-Azar,  however,  in  the  following 
particulars,  apart  from  certain  clinical  features,  differs  from  the 
condition  to  which  we  have  called  attention 
(1)  The  presence  of  a  crusted  papular  eruption  or  of  ulcers  on  the 
limbs,  containing  the  parasite. 
(2)  The  presence  of  intestinal  ulcers,  chiefly  in  the  colon,  also 
containing  the  parasite  in  small  numbers. 
(3)  The  tendency  to  noma  and  local  areas  of  gangrene,  as  well  as 
to  internal  haemorrhages. 
(4)  The  condition  of  the  liver.  In  sporadic  Kala-Azar,  according 
to  Rogers  observations,  the  liver  showed  marked  cirrhotic  changes 
in  four  out  of  forty-eight  cases  examined  post-mortem,  while  slight 
degrees  of  fibrosis  were  observed  in  a  certain  additional  number. 
In  the  condition  we  are  describing,  however,  hepatic  changes  in  various 
degrees  form  an  integral  part  of  the  malady  at  different  stages,  and 
are  constantly  met  with.  Again,  the  type  of  cirrhosis  met  with  is 
portal  in  character  and  not  intralobular,  as  described  by  Rogers  for 
Kala-Azar.  And  lastly,  '  the  persistence  of  the  parasites  in  the 
advanced  cirrhotic  stage  of  the  organ,’  as  noted  by  Rogers  in  Kala- 
Azai,  is  a  feature  which  stamps  a  distinctive  character  on  the  liver 
in  this  affection. 
For  several  reasons  also  we  arc  unable  to  accept  the  view  that 
chronic  malaria  can  be  held  responsible  for  this  class  of  case.  Tlie 
comparative  rarity  of  malaria  in  Cairo  may  be  gauged  from  the  fact 
that  not  more  than  one  or  two  cases  are  seen  at  hospital  in  the  course 
of  a  year.  Further,  in  the  small  proportion  of  cases  of  splenomegaly 
and  ciiihosis  accompanied  by  distinct  fever  there  were  no  recurrent 
paroxysms,  nor  was  the  condition  ameliorated  by  even  considerable 
doses  of  quinine.  Other  reasons,  founded  on  the  pathological 
appearances,  are  the  followiiip- :  — 
o 
(1)  The  entile  absence  of  any  signs  of  malaria  parasites  (particu¬ 
larly  the  ‘gametes’  of  former  aestivo-autumnal  infections)  in  our 
numeious  examinations  of  the  blood,  and  more  particularly,  of  tlie 
-Spleen-pulp,  in  these  cases. 
(2)  The  absence  of  pigmented  leucocytes  in  the  circulation  or  in 
the  viscera. 
