Soudan, was extremely interesting; but he would like to ask the readers ot' the papers to say whether and what special precautions should be taken in puncturing the liver and spleen. He would be very sorry indeed to ask Fellows present how many times they had seen accidents occur from those procedures. Personally, he had seen several, and as kala-azar was a disease which, with the possible exception of Colonel Leishman's pustular experiment, had to be diagnosed, as Dr. Low said, entirely by puncture of the liver or spleen, that was important. Although there was a patient present who had successfully weathered the operation of having his spleen punctured — and there must be hundreds who had done so — still there was some danger connected with the procedure, and he put it to the authors to state definitely their opinions as to whether the danger was real, and if so, what steps could be taken to avoid or mitigate it.
Fleet-Surgeon Bassett-Smith said, in reply, that two main points had to be considered, first of all diagnosis, and secondly, prognosis. With regard to the first, it seemed that the most important point was the distinction between so-called tropical spleno-megaly and kala-azar. Personally, he held it was quite wrong to make a negative diagnosis even after splenic puncture, without result, when other symptoms were clinically typical. Without post-mortem evidence one could not negative absolutely the possibility of the Leishman-Donovan bodies being present. On the other hand, there were undoubtedly cases where patients had lived abroad, and had fever there, where the blood was low in reds and whites, as in the case of Mediterranean fever that he quoted, and where the spleen was so large and hard that one thought Leishman bodies must be present. Such spleens were seen in Mediterranean fever and they might exist in other diseases and be due to other
