7

cases in the lungs. In the blood of the large veins they appear to be fairly
numerous included in various types of cells.

             The Clinical and Pathological nature of the disease.

       In the first report I drew attention to certain very constant clinical features
in cases of systemic infection by the parasite. These were—

           (1) A great enlargement of the spleen.

           (2) Emaciation.

           (3) An irregular high temperature.

           (4) Abdominal symptoms.

I have since been able to add the following which appear to be equally charac-
teristic.

           (5) A tendency to noma and local gangrenes.

           (6) The frequent presence of a papular eruption and small or large ulcers
of the skin.

           (7) The occurrence of hæmorrhages.

       Enlarged spleen.—Enlargement of this organ has been very constant. In
Madras, bodies are almost always found on puncture in spleens which are so
enlarged as to project several inches below the costal margin. On the other
hand, in a few cases the spleen has been only moderately enlarged. In two cases
there was a high temperature and severe constitutional disturbance associated
with considerable enlargement of the spleen. Bodies were found, but were
extremely scanty in both cases.

       Emaciation.—Although emaciation is generally present, it is not invariably
so, and death may occur from several causes connected with the disease without
wasting being a prominent sign.

       Temperature.—An irregular temperature has been noted as a feature of the
disease. This is almost always present in the final stages. But even when
splenic enlargement is considerable and emaciation marked, a high temperature
may be absent, or slight rises only above the normal may occur. The most
frequent type of temperature is that shewing irregular rises to 102° or 103° F.; at
times a temperature of 104º or even 105° is reached. The two charts which
accompany this report, for which I am indebted to Major Robertson, I.M.S.,
are typical of the disease as most frequently seen. There appears to be an
acute form of the disease. In two cases in which the spleen reached half way to
the umbilicus there was high fever which afterwards fell to normal as in enteric
fever. In both cases it was very noticeable that the bodies were present in
very small numbers in blood drawn from the spleen. Major Robertson, I.M.S.,
informs me that such cases are frequently readmitted to hospital with similar
attacks.