Page:Transactions of the Royal Society of Tropical Medicine and Hygiene, volume 1.djvu/169

had always been an exceedingly important and difficult one, and when some time ago Donovan made the statement that parasites could be frequently found in peripheral blood he made diligent search for them. Donovan had stated very distinctly that in extreme cachexia, particularly when intestinal symptoms were present, the parasite would certainly be found in the polymorphonuclear blood-cells, and in fact Donovan had shown him preparations in which parasites were actually to be seen in the polymorphonuclear cells.. But unfortunately, although he searched long and hard, he had hitherto failed to find them in undoubted cases of his own, so that the method could not be looked upon, in a negative sense, at all events, as a reliable means of diagnosis. The suggestion of getting a large collection of polymorphonuclears by inducing pustulation, and at the same time pleasing the patient, was a good one, and the next chance he got he intended to put it into practice. He did not think one was justified in making a splenic puncture in any case. His own practice now was to make a liver puncture, and it was done very carefully by a small needle. The puncture should not be too deep for fear of wounding the large vessels; and if deep respiration was prevented by means of a flannel binder and rest insisted upon, with perhaps a little pressure put on the binder afterwards, the risk from haemorrhage was very small indeed ; at all events, in his experience, no unfortunate consequences had resulted. But before attempting a puncture of the organ he thought it was exceedingly desirable to make a blood count, and not to proceed to splenic or hepatic puncture unless the blood count indicated a possibility or probability of kala-azar. If a large number of red and white blood-cells were obtained, and there was a good blood count, he did not think it was justifiable to make a puncture. Some years ago he had a very definite warning on that point, when a