393 
(3)  The  absence  of  visceral  pigmentation  in  those  situations 
commonly  so  affected  in  malaria. 
(4)  The  character  of  the  changes  in  the  bone-marrow. 
(5)  The  achmnced  degree  and  coarse  character  of  the  cirrhotic 
changes  in  the  liver.  It  is,  in  our  opinion,  extremely  doubtful  whether 
malaria  of  itself,  however  severe  or  prolonged,  can  give  rise  to  such 
pronounced  cirrhotic  change. 
The  cliff ei entiation  of  this  disease  Irom,  or  the  determination  of 
its  possible  relationship  with,  other  forms  of  splenomegaly,  such  as 
chronic  splenic  anaemia,  Eanti’s  disease,  and  that  found  in  marasmic 
infants  suffering  from  gastro-enteritis,  presents  very  considerable 
difficulties.  To  these,  and  closely  allied  to  the  last  form,  must  be 
added  a  very  similar  but  incompletely  investigated  condition,  known 
under  the  name  of  ‘  Ponos,’  and  met  with  in  certain  islands  of  the 
Greek  Archipelago. 
That  all  these  conditions,  including  that  with  which  we  have  to 
deal  in  Egypt  are  referable  to  intestinal  infection  or  toxaemia,  is  hi 
the  highest  degree  probable ;  and  the  view,  so  frequently  urged  by 
Continental  writers,  that  certain  of  them  (viz.,  the  splenomegaly  of 
marasmic  infants,  chronic  splenic  anaemia,  and  Banti’s  disease)  may 
all  represent  chronologically  different  stages  of  essentially  the  same 
disease,  may  ultimately  be  found  to  be  true.  But,  until  the  essential 
identity  and  continuity  of  this  prolonged  process  has  been  more 
regularly  and  constantly  established,  it  appears  necessary  to  retain  the 
name  ‘  chronic  splenic  anaemia  ’  for  what  must  be  regarded,  from  the 
point  of  view  of  this  hypothesis,  as  the  intermediate  stage  of  the 
process. 
The  condition  which  we  describe  is  thus  seen  to  differentiate 
itself  at  once  from  splenic  anaemia  by  the  regular  coincidence  of 
hepatic  changes  which,  up  to  a  certain  stage,  advance,  pari  passu, 
with  those  in  the  spleen,  and  taking  the  lead  in  the  later  stages, 
become  larg-ely  responsible  for  the  train  of  events  leading  to  a  fatal 
issue. 
Ihere  remains  the  question  of  its  identity  with,  or  relation  to, 
Banti’s  disease.  It  may  at  once  be  said  that  the  existing  records  of 
the  latter  disease — comparatively  restricted  in  number — do  not  permit 
of  any  differentiation  between  the  two  conditions.  For  the  present, 
therefore,  we  may  be  content  to  remark  that,  closely  comparable,  if 
