Page:Transactions of the Royal Society of Tropical Medicine and Hygiene, volume 1.djvu/163

the diagnosis should be, but there could be no doubt that there was a Tropical disease with these signs which was not associated with Leishman's parasite. Workers in the Philippines had reported similar instances. He remembered such a case in the Seamen's Hospital : An old gentleman had come home from India with all the signs of kala-azar, and though liver and spleen were punctured on three or four occasions, the parasite was never demonstrated. The patient eventually left the hospital and died, with his disease undiagnosed, somewhere in the country where an autopsy was not possible. Still another similar case was that of a man from the West Coast of Africa, whose spleen was punctured three times and his liver twice, the Leishman parasite never being revealed in either viscus. The patient also eventually left hospital, and he did not know what became of him. More recently again he saw, privately, with the President, a case which clinically was undoubtedly very like kala-a^ar. The blood count varied from 2,000,000 to 3,000,000 reds, while the whites were exceedingly low, about 2,000, and the polymorphonuclears showed a decrease. Sir Patrick Manson suggested the disease might be kala-azar, and he agreed with that opinion. The spleen was twice punctured, though he should say that in the first instance there was some doubt as to whether the needle had actually penetrated the spleen, but anyhow no parasites were found ; and, although the liver was punctured on the third occasion, results were still negative. It was then thought the disease might be something else, but although the patient was carefully examined for other forms of fever no definite conclusion could be reached. Eventually he died, and fortunately he (Dr. Low) was able to obtain a post-mortem, at which it was found that there were double tumours of the adrenals, masses in each supra-renal capsule about the size of one's fist, the spleen was big, hard, and fibrous, and it weighed over 2 lb., but sections showed