XXXIX. TYPHUS FEVER…

XXXIX. TYPHUS FEVER

DEFINITION AND SYNONYMS

=Definition.=—Typhus fever is an acute infectious disease, possibly caused by Rickettsia prowazeki. There is a fairly abrupt onset, with a continued fever lasting about two weeks, followed by a critical fall or rather rapid lysis of temperature. About the fifth day a rose spot eruption, similar to that of typhoid, first appears about the loins and abdomen later on extending over the trunk and extremities. The rash tends to become petechial and stands out rather prominently on a general cutaneous mottling. The stuporous state is a marked feature of the disease. It is transmitted by lice.

=Synonyms.=—Jail fever; Ship fever; Putrid fever; Petechial fever; Typhus exanthematicus. Ger. Fleckfieber; Fr. Typhus exanthématique; Sp. El tabardillo; Ital. Typho-esantematico.

HISTORY AND GEOGRAPHICAL DISTRIBUTION

=History.=—Hirsch notes that the history of typhus fever belongs to the dark pages of the world’s story, at times when war, famine, and misery of every kind are present. It is reasonable to suppose, according to this author, that many of the pestilences of ancient times and the Middle Ages were typhus fever. This disease was prevalent among the Spanish soldiers at the time of the conquest of Grenada and the designation of the disease then used (Tabardillo) is the one now given typhus fever in Mexico.

The disease was first described with sufficient accuracy by Frascatorius, in the 16th century, to enable us distinctly to differentiate it from plague; the stuporous states of the two diseases having previously caused them to be confounded. In England, in the 16th century, the disease was very prevalent in the jails and court officials attending the trials of prisoners often contracted the disease and died; hence the designation “black assizes.”

During the Thirty Years War, in the 17th century, typhus fever spread over central Europe.

Typhus fever was very prevalent at the time of the epidemic of plague known as the great plague of London and it is a matter of practical interest that the two diseases were not infrequently confounded by medical men. There were some very severe epidemics of the disease in Ireland in the 19th century.

Typhoid fever and typhus fever were only separated as distinct diseases by Gerhard, 1837. Huxham, however, had previously noted the marked difference between putrid malignant fever and slow nervous fever.

Until very recent times it was declared that typhus fever was among the most contagious diseases of man and innumerable instances were cited of frequent contagion of those attending or visiting typhus patients. In 1909, Nicolle, in North Africa, demonstrated that the disease was transmitted by lice and the recent experiences in the Balkan war and in the Servian epidemic of 1915 show that in the absence of such vermin the disease does not appear to be contagious.

=Geographical Distribution.=—The disease has largely been eradicated from European and other countries where hygienic measures leading to the destruction of vermin have existed.

During the recent war the disease became one of importance, owing to the difficulty of preventing the spread of body lice to the soldiers.

In the tropics the disease, when present, is usually found in regions of high altitude. In Mexico tabardillo, as typhus is there designated, is a disease of the elevated regions. This is also true of India.

Sporadic cases of typhus, known as Brill’s disease, have appeared from time to time in New York.

During the great war typhus first appeared in Servia, thence extending to Austria, Germany and Russia. Its nonappearance on the Western battle line must be attributed to the active measures of the Germans in attacking the lice problem. It is now widespread in Russia and Poland.

ETIOLOGY AND EPIDEMIOLOGY

=Etiology.=—Recent work by Anderson and Ricketts has shown that the blood of human cases is infective for monkeys. The virus does not seem to pass through a Berkefeld filter and the epidemiology points to the body louse as the sole transmitting agent. Nicolle reported the filterability of the virus. More recently he has considered this filterability as doubtful.

The guinea pig is susceptible to the virus as well as the monkey but only shows temperature rise. Nicolle has shown that lice do not become infective until about the tenth day after feeding on typhus blood. The virus is found in the blood of man and in the spleen and blood of monkeys and guinea pigs.

Plotz has isolated a Gram-positive pleomorphic bacillus from the blood of typhus patients which has been named B. typhi exanthematici. This organism is of historical interest only and apparently has nothing to do with the causation of typhus fever.

Hort states that only blood recently taken from typhus patients will cause the disease in monkeys while the same blood which has been incubated several hours or days fails to produce the disease. Others, as well as Hort, doubt the etiological relation of the organism of Plotz to typhus fever or to the mild form of the disease as seen in New York City and there known as Brill’s disease. Tabardillo or Mexican typhus is the same as typhus.

Rocha-Lima insists upon the etiological importance of short oval bodies, often showing polar staining with Giemsa preparations, and found in the epithelial cells of the alimentary tract of lice which have fed on the blood of typhus patients.

Ricketts noted similar bodies in such lice. They differ from the Plotz organism in that they are Gram-negative and apparently cannot be cultivated. Lice feeding on blood other than that of typhus patients fail to show these bodies and furthermore the blood of typhus cases during the period of convalescence fails to infect lice. When guinea pigs are inoculated with emulsions of lice containing such bodies they show the temperature reaction of typhus fever. Plotz states that his organism may be Gram-negative at first and believes these organisms to be the same. Wolbach and Todd take the view that the bodies described by Rocha-Lima and called Rickettsia prowazeki are the cause of typhus fever. Similar bodies have been found in trench fever and even in certain normal lice. These bodies, however, are extracellular and are more oval and stain more intensely than the typhus bodies. These Rocha-Lima bodies require a Romanowsky stain to bring them out. In man these bodies are found in the endothelial cells of the small blood vessels, occurring singly or in clumps. In the louse the epithelial cells of the intestine may be found distended with masses of these organisms.

It is not certain whether the virus is transmitted by the bite of the louse or by inoculation of faeces. Monkeys and guinea pigs can be infected by injection of emulsions made from infected lice.

Loewe and others have succeeded in cultivating the virus of typhus, using deep tubes containing 10 cc. of a rich ascitic fluid and a piece of sterile rabbit kidney. The medium was inoculated with 2 cc. of typhus blood, after which 0.3 cc. of a 20% dextrose solution was added and the culture sealed with liquid petrolatum. Its reaction was pH 7 to 7.4. Cultures were incubated at both room and body temperature.

As proving the culturing of the virus, it was noted that 1 cc. of a fourth-generation culture would infect a guinea pig. This would represent 0.00000016 cc. of the original typhus blood. The bodies cultivated differ in morphology from the bacillus of Plotz in that they are even more minute, of slight hazy outline and do not assume polymorphous involution forms. They vary also in cultural characteristics. Concerning the question as to the identity of the bodies with Rickettsia prowazeki, no definite decision is as yet permissible, nor were the authors able to decide whether the bodies are of bacterial or of protozoan nature.

=Epidemiology.=—Until recently authorities stated that typhus fever was the most contagious of all diseases. We now know that in the absence of body or possibly head lice the disease is only slightly, if at all contagious.

At the same time recent experience has shown that it requires the greatest care on the part of those having charge of louse destruction to avoid being infected while attending to this duty. The same is true of those examining patients with the disease prior to the eradication of the body lice of the sick.

A knowledge of the life history of the body louse is necessary. The body louse, Pediculus vestimenti, is slightly larger than the head louse, P. capitis, and is the species concerned in the transmission of Indian and North African relapsing fevers as well as typhus fever, although it is probable that the head louse can also transmit these infections.

While the head lice live among the hairs of the head and show their presence chiefly by the appearance of their pear-shaped eggs (nits) projecting from the hair shaft, the body lice attach themselves to the under surface of the garments worn next the skin, and holding fast to the undershirt, feed about twice daily on the human host. They are but rarely found on the skin. The female body louse is about ⅐ inch long and about 1/15 inch broad (3.5 mm. × 1.5 mm.). The antennae are somewhat longer than those of the head louse. Warburton found that the egg stage, in experiments, lasted from eight to forty days, the larval stage about eleven days, and that the male louse lived three weeks and the female four weeks. Of course, under natural conditions these periods may not hold. Development of the eggs takes place best at a temperature of 30°C.

Lice feed at once after being hatched and a young louse will die unless it feeds within 24 hours.

Lice will leave their host only when he has fever or when he dies but they may drop off a host or be brushed off. They are not apt to be found in bedding.

PATHOLOGY

Fraenkel, in 1914, first called attention to proliferative changes in the endothelium of the arterioles and arterial capillaries, followed by necrotic changes. These changes are chiefly manifest in the vessels of the skin, central nervous system and myocardium. In addition to the proliferation of the endothelial cells we have a perivascular infiltration of small round cells. Kurt Nicol notes that there is a combination of proliferative and inflammatory changes. These are microscopical and there is absence of characteristic macroscopic findings.

The petechiae are due to thrombosis of the smaller vessels and subsequent haemorrhagic manifestations. Bronchitis and broncho-pneumonia are extremely frequent and form the most common fatal complication. The brain lesions are most common in the basal ganglia, the cerebral cortex and the medulla.

The blood is dark-colored and the liver and kidneys show cloudy swelling. The spleen is somewhat enlarged during the early stages of the disease but tends to be normal in size later on. It is very soft and may rupture while being handled at autopsy. There are no changes in the Peyer’s patches and the mesenteric glands are not enlarged, thus differentiating from typhoid fever. The heart muscle tends to show degenerative changes.

SYMPTOMATOLOGY

The period of incubation varies from five to fifteen days, usually, however, about twelve days. The period of onset may cover about two days, during which time the patient has headache, giddiness, backache, anorexia, perhaps nausea, and general malaise. There may be rigors or chilly sensations.

About the end of the second day the temperature rises fairly rapidly to become 103° or 104°F. by the third or fourth day. With the rise of fever the face becomes flushed, the eyes injected and the expression apathetic. The headache is usually quite severe and may be frontal, occipital or generalized. The temperature remains elevated with slight morning remissions for from twelve to fourteen days when it may fall by crisis or more gradually by rapid lysis.

Well-marked prostration and cardiac weakness are early noted. There is a tendency to constipation and the mouth becomes foul and the teeth rapidly covered with sordes, unless the greatest precautions in oral cleanliness are observed.

There is a marked tendency to clouding of the consciousness. At times the disease shows an abrupt onset rather than that described above.

The eruption first appears about the fifth day and shows as slightly elevated rose spots, which at first disappear on pressure, but quickly tend to become permanent and later purpuric. The eruption first appears in the flanks and then extends to the abdomen, chest and later to the extremities.

The term mulberry rash is sometimes used to describe the rash of typhus. In addition to the above there is a subcuticular mottling.

Along with the appearance of the rash the symptoms become aggravated, the effect on the heart is more marked and the pulse becomes feeble. The face is often dusky. There may be a bronchial catarrh with an annoying cough.

By the end of the first week the delirious or stuporous condition becomes more marked with a tendency to muttering delirium, tremors and subsultus, the coma-vigil of the older writers. Terrifying hallucinations may cause the patient to jump from the window and kill himself. There is a tendency to parotitis and otitis media connected with the mouth condition. On account of the circulatory weakness there is a tendency to gangrene of the extremities, especially the toes, rarely the fingers.

In cases which recover there is a critical change in the apparently desperate condition of the patient about the end of the second week, the sudden striking change for the better being more marked in typhus fever than in any other disease. At this time the urine changes from a high-colored, often albuminous one, to an abundant secretion of more or less normal character.

The sporadic mild cases of typhus, which occurred from time to time over a period of years in New York, were known as Brill’s disease. According to Brill these cases showed intense headache, apathy and prostration, with a continuous fever, maculo-papular eruption and a rapid lysis or critical fall of temperature at the end of about fourteen days. The spots only rarely became purpuric. There was almost never marked delirium and the mortality was less than 2%.

Symptoms in Detail

The Eruption.—This first appears about the fourth day as macules about loins, then spreading over abdomen, chest and back. It is often more pronounced on the back than elsewhere. It almost never appears on the face but may occur on the palms and soles. It has a resemblance to the rash of measles. At first disappearing on pressure it soon becomes permanent and then petechial. The livid color of the rash has brought about the designation “mulberry rash.” The rash lasts from a few days to two weeks.

The Fever.—The fever rise following a chill is much more rapid than in typhoid fever, reaching its fastigium in about three days. A more or less continuous range of fever (103° to 104°F.) follows until about the fourteenth day, when there is often a rapid lysis or possibly crisis, at which time the patient tends to fall into a refreshing sleep and to show a rather marked diuresis.

The Alimentary Tract.—Constipation is usually noted. Very marked is the tendency of the mouth and tongue to become dry and sordes to collect on the teeth. The dry black tongue has led to the designation “parrot tongue.” It is difficult to get the patient to protrude his tongue when told to do so.

The Circulatory System.—Very outspoken is cardiac weakness due to myocardial degeneration. The heart sounds are very weak and the pulse feeble. The blood pressure is very low, especially the diastolic. Bradycardia may be marked during convalescence.

The Respiratory System.—Cough may appear in the first days, but usually is first troublesome about the time of the eruption. By the end of a week the cough becomes loose and râles of various types may be noted. Death often occurs from a terminal broncho-pneumonia.

The Nervous System.—Clouding of the consciousness is as marked in this disease as in plague. Dull aching frontal headache is marked and a dull stuporous state soon comes on. Delirium is marked in some cases. As in plague there are often the facies and mental state of alcoholic intoxication.

The Blood.—There does not seem to be anything very characteristic in the blood examination. Prowazek noted that the polymorphonuclears showed early fragmentation of the nucleus and that the cytoplasm stained very red with Giemsa’s stain. Robinowitsch noted that the leucocyte count fell in the first day or two, then gradually rose until the crisis and then again fell. The leucocytosis is only moderate, about 10,000, and the polymorphonuclears make up about 80 to 85%. Eosinophiles are decreased. Other observers have noted an increase in the large mononuclears.

Complications.—A bronchitis is very common and later on there may be such a profuse expectoration that the patient cannot get rid of it and may become cyanotic. Broncho-pneumonia is a very frequent cause of death. Otitis media and parotitis are not infrequent complications. Deafness is often marked.

Thrombosis of various vessels may be noted.

Gangrene of the extremities, especially the toes, is frequently present. Gangrene of areas subjected to pressure, as over the sacrum, is not infrequent. There does not seem to be the same tendency to gangrene of the genitalia as in spotted fever of the Rocky Mountains.

DIAGNOSIS

The more gradual course of the fever and the less marked stuporous condition, together with positive blood cultures, should differentiate typhoid fever.

Plague has the same picture of alcoholic intoxication as typhus, but is without the rash. Influenza, with its acute onset, is confusing but does not show any increase in leucocytes.

Other than a moderate leucocytosis and marked acid staining of the polymorphonuclears there is not much that is of help from the laboratory. When guinea pigs are inoculated with typhus virus the period of incubation is from 7 to 10 days.

Weil-Felix Reaction.—In the diagnosis of typhus fever we attach great importance to an agglutination reaction (Weil-Felix reaction) which the serum of typhus patients has upon certain organisms designated as X_{2} and X_{19}. These correspond in characteristics to certain strains of Proteus vulgaris, producing indol in peptone solution, and acid and gas in glucose, maltose and saccharose, but not in lactose or mannite. They digest gelatine and blood serum somewhat more slowly than typical cultures of Proteus vulgaris.

Although these organisms have been isolated from the urine of several typhus cases, it seems certain that these X bacilli are neither causative organisms nor secondary invaders. The reaction is therefore heterologous and not specific.

The reaction appears during the first week of the disease but becomes quite marked in the second week and during convalescence. Thus a titre of 1 to 25 on the fifth day usually rises to 1 to 200 or higher by the end of the second week. The test is made either with living or dead cultures and is carried out as for typhoid agglutinations, preferably by the macroscopic method.

PROGNOSIS

Old people are apt to succumb, as do also those who show marked delirium. In childhood it is a very mild disease.

An increase of eosinophiles is favorable while an absence of these cells makes for a grave prognosis.

The death rate runs from 15 to 60% in many epidemics while Brill’s disease only gives 1 or 2% of deaths.

PROPHYLAXIS AND TREATMENT

PROPHYLAXIS.—This consists almost exclusively in the destruction of body lice, or preventing their access to the person.

Those attending cases should wear gowns, closely fitting at neck and wrists, and rubber gloves. Better than a gown would be “unionalls,” with stocking extremities to go over the shoes. The typhus case should be deloused with the greatest thoroughness, and his clothing sterilized.

For ridding the body of lice, the following steps are essential:

1. The hair of the body and head should be clipped.

2. The subject should be bathed, there being used freely kerosene-emulsion soap, prepared by boiling 1 part of soap in 4 parts of water, and then adding 2 parts of kerosene oil. The resultant jelly, when mixed with 4 parts of water, makes a liquid soap that is convenient to use and which may be applied effectively.

3. Following the bath, the body may be anointed with kerosene, special care being devoted to the hairy parts. Skin irritation may, however, require early removal of the oil.

4. It has been found that lice on clothing removed from the body may remain alive nine days and their eggs as long as forty days. The clothing therefore should be disinfected by one of the following methods:

(a) Steam; (b) boiling for five minutes; (c) 5% compound cresol solution for 30 minutes; (d) chemicals such as cyanide or chlorpicrin.

5. In the absence of facilities for carrying out the steps described, or to prevent infestation subsequently, dusting powders are sometimes used. Of these the N.C.I. powder, containing commercial naphthalene, 96 Gms., creosote, 2 cc., and iodoform, 2 Gms., is the most widely known; but Moore’s powder—creosote, 1 cc.; sulphur, 0.5 Gm., and talc, 20 Gms.—is less irritating and is said to be six times as effective. It has also been recommended to wring out the underclothes in 5% compound cresol solution, then drying thoroughly, or to impregnate them with substances such as the halogenated phenols.

TREATMENT.—There is no disease in which careful nursing is so important. This applies especially to the care of the mouth. It is very necessary to maintain the recumbent position.

A mouth wash of equal parts of boric acid solution, glycerine and lemon juice should be used to swab out the mouth several times daily. Constipation should be controlled by enemata.

It is best to give the patient abundance of fresh air so that tent treatment is to be recommended. Cool sponging lessens the nervous manifestations as well as lowering temperature. Ice bags to the head relieve the headache. Cardiac stimulants are indicated, as caffein and camphor. Thyroid extract has been recommended. Lumbar puncture has given amelioration of symptoms. Abundance of water should be given and the diet should be milk and broths.

The virus of typhus is present in all the organs of an infected guinea pig and Nicolle has prepared a serum by injecting horses with emulsions of spleen and adrenals of such animals. The serum has apparently given good results in human beings when employed early in the disease, the temperature falling with each injection. The dosage was about 20 cc. daily.

Spotted a typo or a problem in this chapter? Tell us

XL. TRENCH FEVER

DEFINITION AND SYNONYMS

=Definition.=—Trench fever is a specific, acute infectious disease, probably caused by Rickettsia quintana, acquired usually through the agency of the body louse, characterized by an abrupt onset, a febrile period of about five days often followed by one or more relapses, and ending in complete recovery.

Trench fever was one of the most widespread diseases occurring in the forces of the World War. It is transmitted by contamination of a skin abrasion or of a louse-bite wound with the faeces of an infected louse, although Strong and his colleagues reported the bite of an infected louse as a demonstrated method of infection.

Clinically, it shows an abrupt onset, with fever, headache, pain on moving the eyeballs, soreness of the muscles of the legs and frequently hyperaesthesia of the shins. As a rule the initial fever is followed after a few days by a single short rise but there may be a fever course of many relapses with apyretic intervals. Recovery is complete, death practically never occurring; but convalescence may be protracted, and incapacitating after-effects, such as neurasthenia, cardiac disturbances and myalgia, may be noted.

=Synonyms.=—Pyrexia of Unknown Origin (P. U. O.), Meuse fever, Volhynian fever, Shin fever, Quintan or five-day fever.

HISTORY AND GEOGRAPHICAL DISTRIBUTION

=History.=—It is remarkable that so striking and communicable a disease as trench fever should have been an unrecognized entity prior to the recent war. While resembling dengue in some respects, and relapsing fever in others, as well as various well-recognized exotic fevers, there is no satisfactory account of the prior existence of such a type of fever. Werner was of the opinion that a quintan fever of the Middle Ages might have been trench fever, and it has been suggested that a quintan fever described by Hippocrates may have been of this nature, but the evidence is not convincing. Some have thought that the miliary fever reported in France from 1821 to 1855 might have been a type of trench fever since it had no mortality.

=Geographical Distribution.=—During the war, trench fever was reported not only in Flanders, but also among the troops fighting in Macedonia and Mesopotamia, and in the forces of the Central Powers on the German and Austrian fronts. It is remarkable that since the war this louse-borne disease seems to have disappeared, although other diseases transmitted by lice, as typhus fever and relapsing fever, continue to occur widely in Poland, Russia and the Balkans.

ETIOLOGY AND EPIDEMIOLOGY

=Etiology.=—It now seems rather definitely settled that trench fever belongs to the group of diseases caused by Rickettsia bodies, and this species has been named Rickettsia quintana. Like the other organisms of the group, these bodies are very small (0.3 to 0.5 by 1.5 to 2 microns), Gram-negative, nonmotile and stain best by Giemsa’s method. As these bodies with their coccal or bipolar staining characteristics, when observed in the eggs of ticks infected with the virus of spotted fever of the Rocky Mountains, showed the so-called chromatin staining, Ricketts regarded them as chromatin-staining bacteria. Since, however, they are transmitted by an arthropodan host, we believe now that they are probably protozoal in nature.

Bradford and his colleagues stated that they were able to culture these organisms by Noguchi’s method for culturing the organism of syphilis, but Strong failed to obtain growth. As the organism of typhus fever has recently been cultured by the same method, it would appear that the trench fever organism also is cultivable. The virus is present in the whole blood, in the plasma and in the washed erythrocytes; it is nonfilterable, and withstands a temperature of 56°C. for 20 minutes but not one of 80°C. for 10 minutes. These organisms in the alimentary tract of the louse are extracellular, and not contained within the cells of the epithelium of the gut of the louse. The trench fever bodies differ from those of typhus in that they are plumper and stain more deeply with ordinary aniline dyes.

=Epidemiology.=—The ordinary method of transmission is by the agency of infected lice, but the disease can be produced artificially by the injection of the blood of an infected person. It is probable that urine also may be a factor in transmission, as Strong brought about infection by smearing skin abrasions with urinary sediment from trench fever cases.

It is now considered that the bite of the louse is noninfectious, although Strong succeeded in transmitting the disease by this means in five cases. The accepted explanation of the mechanism of infection is that it takes place through contamination of an abrasion or wound of the skin with louse faeces or with the juices from the crushed bodies of infected lice. In this connection, excoriations of the skin resulting from the scratching of scabies-infested areas makes a scabies patient peculiarly liable to trench fever infection. The louse faeces become infective only after seven days from the time of feeding on trench fever cases, this fact indicating a developmental cycle in the louse.

PATHOLOGY

As the disease of itself is never fatal, there have been no opportunities for studying the pathological changes.

SYMPTOMATOLOGY

The period of incubation is usually given as from two to three weeks. In the experimentally produced cases of the American Red Cross Commission, the incubation period varied from five to thirty days; thus with intravenous injection of blood it varied from five to twenty days, and with inoculation of scarified areas with louse faeces the period was between seven and eleven days.

The onset is quite abrupt with headache, dizziness and pain on motion of the eyeballs. There is pain also in the back and limbs. The conjunctivae are injected. The fever rises rapidly to 102°-104°F. and falls rather abruptly to normal at about the fourth day. In most of the cases a secondary rise occurs so that we may have a saddle-back type of temperature chart.

The temperature charts tend to be grouped in three classes: (1) Those with a short febrile course of a few days, followed by a fall to normal, with or without a subsequent rise; (2) those with a more or less sustained type of fever, extending over five or six weeks without distinct relapses, and (3) those more typically of a relapsing type, with five or six distinct febrile periods.

In more than one-half of the cases there occurs an eruption of small (2 to 4 mm.) erythematous spots, which disappear on pressure. They are usually located on chest, back or abdomen, appear on the second day of the fever, and fade out by the fourth day. Constipation and anorexia are usually noted. The spleen is often somewhat enlarged. There is frequently a trace of albumin in the urine, but it is not accompanied by casts. The cutaneous hyperaesthesia over the shins is a prominent feature, but the same disturbance of sensation may be complained of over the ulna or fibula. Usually we find a leucocytosis but many cases show a normal white count or even a slight leukopenia. During the apyrexia there is an increase in mononuclear percentage. The pulse is rather slow for the temperature.

DIAGNOSIS

Notwithstanding the intensive study given this disease during the war, we do not seem to have any constant or reliable laboratory test.

In some of the cases where muscle pains of the neck are marked there may be a stiffness of the neck that is suggestive of cerebro-spinal fever. Similarly, pain of the abdominal muscles may cause a suspicion of appendicitis and lead to an unnecessary operation.

The onset of trench fever is very like that of dengue or influenza.

In epidemic jaundice, the occurrence of the jaundice and marked albuminuria should differentiate.

PROGNOSIS

This is most favorable as to ultimate complete recovery, but some cases show a prolonged convalescence with manifestations of irritable heart or neurasthenia.

PROPHYLAXIS AND TREATMENT

Prophylaxis consists in attacking the louse problem, although attention should be given to the disinfection of the urine.

Acetylsalicylic acid may be given to relieve the headache and the muscle pains; and some laxative for the usual constipation. There is no specific treatment.

Spotted a typo or a problem in this chapter? Tell us

XLI. HEAT STROKE AND HEAT PROSTRATION

GENERAL CONSIDERATIONS

It has been customary to differentiate etiologically, as well as clinically, the two most common manifestations of the effects of high temperature. Clinically we note cases (1) with a rapidly rising temperature, which often reaches a very high point, together with a hot, dry, reddened skin, heat stroke; and again we note cases (2) with pale clammy skin, marked evidences of cardiac weakness and a normal or subnormal temperature, heat prostration.

Brooks in a most excellent discussion of the subject applies the designation diathermasia to the former group of cases and regards them as connected with an undue retention of heat within the body. To the latter group, which he considers to be connected with exposure to the actinic rays of the sun, he applies the designation phoebism.

In diathermasia he considers that we have so great a strain on the thermotaxic mechanism that there is loss of balance between the heat discharge and heat producing centers, while in phoebism there is primarily an acute cerebral or cerebro-spinal congestion followed by a chronic inflammatory condition of the meninges and due to damage from the actinic or ultra-violet rays of the sun.

While admitting that there may be cases where the effects of certain rays of the sun are responsible for clinical manifestations varying from death of striking suddenness to vague complaints of irritability, headache and defective memory, yet the generally accepted views are that high temperature, high relative humidity and lack of evaporation from the skin, whether from excessive humidity or from lack of circulation of the surrounding air, can and do produce at one time heat stroke and at another heat prostration. Such factors as muscular exertion, disease conditions, alcoholism and dietary indiscretions undoubtedly play a part in the production of and variance in the clinical manifestations brought about by the effects of heat.

Sambon has suggested that there is a possibility that heat stroke or, as it is also designated thermic fever or siriasis, is due to a germ infection, but without advancing any particular evidence in favor of such an hypothesis.

There is undoubtedly, however, much in favor of the views of those who regard heat stroke and heat prostration as due to an auto-intoxication from the accumulation of toxic substances resulting from increased metabolic activity due to excessive heat retention and having a selective action on the nerve cells.

Others think that as the result of more active metabolism there is a retention of carbonic and lactic acid with a demand on the alkali content of the blood resulting in an acidosis. As a matter of fact treatment of heat stroke cases with intravenous or rectal injections of sodium bicarbonate seems to be of marked value.

It would seem advisable to take the ground that heat retention resulting from lack of heat radiation and insufficient skin evaporation causes various manifestations of discomfort or bodily injury. Aron in Manila showed that monkeys exposed to the sun died in about one hour but that a control monkey, similarly placed, but kept in a current of air from an electric fan, suffered little or no injury. The reason that monkey and man react differently to exposure to the sun is on account of the more numerous and more active sweat glands possessed by man which give rise to increased evaporation and resulting loss of heat of the body.

High relative humidity is a potent factor in checking evaporation. The rectal temperature in Haldane’s experiments showed a rise of a little over 1°F. when the wet bulb was at 90°F., 2°F. when at 94°F. while at 98°F. it was about 4°F. per hour. Leonard Hill has noted that the air surrounding the victims of the Black Hole of Calcutta became saturated with water vapour and heated to the temperature of the body so that it was heat stroke and not suffocation that caused death. The power of air to hold water vapour and its evaporative power increase rapidly with rising temperature; thus at 50°F. a cubic foot of air holds 4.08 grains water, at 80°F. 10.9 and at 100°F. 19.7 grains. Hill states that the limit of an Englishman’s power to keep cool is passed when the wet bulb exceeds 88°F. in the still air of a room even when stripped to the waist and resting. If muscular work is performed the limit may be 80°F. Walking in a tropical climate, wet bulb 75° to 80°F., dry bulb 80° to 90°F. may raise the temperature 2° to 3°F. and send the pulse up to 140 to 160. All the students of ventilation stress the importance of circulation of the air in promoting evaporation and comfort. According to Hill with the air saturated and the wet bulb reading 89°F. the wet ‘Kata’ readings would be 3.3 with still air, 8.0 with the wind moving 1 meter a second and 15.1 with a velocity of 9 meters per second. In tropical parts of the world when the wet bulb not infrequently reaches 90°F. the circulation of air by punkahs or electric fans becomes a necessity. There is great variation in capacity for sweating which, according to Hearne, is the basis of heat stroke. He notes that sweating is suppressed from 1 to 48 hours before the attack. With sweating suppressed the body temperature rises until, when 108°F. or more is reached, unconsciousness and convulsions develop. Hearne thinks that the inhibition of sweating is local in the sweat glands, and not central, as diaphoretics fail to cause sweating once it has stopped. As a practical point Hearne watched subjects for dryness of the skin and when discovered they were stripped, covered with a wet sheet and evaporation promoted by a current of air from an electric fan. Doctor Leonard Hill has noted the inefficiency of the application of pieces of ice to the hyperpyrexial body as compared with evaporation. Thus water evaporation at body temperature abstracts 0.59 calories per gram while melting ice only takes away 0.08 calories. Furthermore the application of ice constricts the capillaries and interferes with evaporation. He also notes that 70 grams of water evaporated from the skin takes away as much heat as 1000 grams of ice water used as an enema.

PATHOLOGY

Pathologically, there is usually congestion of the brain and meninges, that of the brain being particularly marked about the region of the medulla. There may even be punctate haemorrhages and the nerve cells show chromatolysis. These changes are much more evident in heat stroke than in heat prostration.

McKenzie and LeCount have noted the following autopsy findings: Generalized passive hyperaemia of brain and lungs, oedema of brain and lungs as well as petechial haemorrhages of various mucous membranes and the skin.

Susceptibility to Heat Stroke.—As a matter of fact in a body of men exposed to identical conditions of heat of sun and relative humidity we note certain cases exhibiting typical heat stroke while other men will only show evidences of heat prostration.

Alcoholism, obesity, diseases of heart and lungs, overcrowding, muscular fatigue, insufficient circulation of air, with the wet bulb about 90°F., and not drinking a sufficient amount of water, predispose to heat injury.

It must always be kept in mind that the hyperpyrexial type of malignant tertian malaria may give a clinical picture of heat stroke.

Fiske has noted that in oil-burning firerooms, even with a temperature of 140°F., 10° higher than on similar ships burning coal, there were no cases of heat prostration. He attributes this to the less fatiguing work in tending oil-burning furnaces and the smaller number of men required, this reducing overcrowding.

SYMPTOMATOLOGY

In heat stroke there are usually prodromata of dizziness, dry skin, headache, and somnolence, following which the body temperature shoots up to 105°F. or even above 110°F. There is a desire for frequent micturition, which may be considered as a prodromal warning of embarrassment of the sweating function. The skin is hot and dry and the pupils may be contracted. The pulse which is at first full and rapid, soon becomes irregular. There may be delirium or coma or convulsive seizures. The patient is unconscious with irregular or Cheyne-Stokes respiration.

Hiller divides these cases into (1) those showing an asphyxia syndrome, as characterized by cyanosis and collapse, with cessation of respiration and enfeebled circulation. Prolonged artificial respiration is required in such cases. (2) A paralytic type with deep coma, recurring convulsions and extreme hyperpyrexia. These cases exhibit oedema of lungs and brain and necessitate venesection. (3) A psychopathic type in which there is delirium often of a violent type with delusions of persecution. Such cases often commit suicide.

In heat prostration we have giddiness and possibly nausea with pale face, often bathed in cold perspiration and dilated pupils. The pulse is very weak and syncope may ensue. The temperature is not elevated and may be subnormal. Rarely the temperature is slightly elevated. The respiration is shallow and sighing. Headache is often complained of after recovery. Following this or the more dangerous heat stroke we may have lack of mental concentration or loss of memory with recurring headache upon even moderate exposure to the sun.

Heat Cramps.—Among those working in firerooms on board ships cruising in tropical waters, there is met frequently a condition characterized by cramps of the voluntary muscles, chiefly those of the extremities and abdomen.

Ill health and individual susceptibility appear to predispose toward attacks, but apparently hard physical labor, in conjunction with the environmental conditions, is the factor that determines the occurrence of the cramps. Their causation is usually attributed to dehydration of the tissues, or to accumulation of metabolic products, but some believe that they represent a condition differing from all other conditions recognized as being due to heat. Cases, probably identical in nature and having the same causative factors, have been noted as occurring among workers in steel-mills.

The cramps are usually preceded by fibrillation of the muscles later to be affected. When frankly spastic attacks are developed, they recur at intervals of from 2 to 10 minutes, and may be severe and very painful. The pupil is dilated, but so far as known, no other organs are involved. The cramps are commonly accompanied by signs of heat prostration. This, however, is not necessarily so, there often being absolutely no thermal disturbance.

The treatment is in general that of heat prostration. Immediate relief may be obtained by sudden slapping of an affected muscle. For mild cases, immersion in a warm bath is recommended. Apomorphine in sub-emetic doses is said to confer immediate relaxation.

TREATMENT

With heat stroke we have a condition in which every moment lost before the institution of proper treatment reduces the chances of recovery. The two important measures are reduction of temperature and elimination of toxic material. For the former ice packs or ice baths are the most efficient. When the temperature starts down it may fall with great rapidity and collapse result. Consequently when giving these ice packs or baths the treatment should be discontinued when the temperature by rectum reaches about 103°F., the patient then being removed from the bath and covered with a blanket. If the temperature again shoots up the ice bath can be repeated. Many have reported great benefit from the use of enemata cooled with ice. Some prefer to apply ice to the head and rub the body with pieces of ice. This can be carried out on a rubber sheet placed on a cot. If there is no ice available a sheet wet in dilute alcohol, plus the effects of a current of air from the electric fan or otherwise, may be tried. In a case with marked cyanosis venesection may be necessary. In asphyxial types of sun stroke prolonged artificial respiration is indicated.

Above has been noted the inefficiency of ice in reducing temperature and the far greater effect from evaporation, brought about by directing the current from a fan on the body covered with a wet sheet.

To promote elimination of toxic products venesection plus the use of intravenous injections of normal saline is the best treatment. In those terrible paralytic type cases which show a mortality of more than 50% it is well to think of acidosis and give slowly about a liter of a 1 or 2% solution of sodium bicarbonate. (See under treatment of cholera.) The use of alkaline enemata often gives good results, about a liter of a solution containing 2% of sodium chloride and 2% of sodium carbonate or bicarbonate.

As soon as possible after the more urgent hydrotherapeutic methods have controlled the case we should give calomel followed by salines. The coal tar products should be avoided as far as possible, from the danger of cardiac depression.

In the nonfebrile heat prostration the treatment is entirely eliminative and stimulant. The patient should be placed on his back in a cool shady place and tight clothing released, particularly about the neck. Rubbing the limbs as for any syncope-type affection, with hot water bottles if the collapse is marked, should be one line of treatment. Many give a little aromatic spirits of ammonia or whiskey but a hypodermic of strychnine would be better in a severe case.

Calomel and salines should be given after cardiac weakness disappears. To avoid these dangers of the tropical heat one should keep the body clean to promote good action of the sweat glands. The clothing should be light and loosely fitting and should permit a free circulation of air to assist evaporation. There does not seem to be any indication for the wearing of orange-colored clothes as the actinic rays are apparently unimportant. Puntoni recommends green-colored clothing for neck and spine. The green cloth should be covered with white material.

The head and nape of the neck should be protected by a light well-ventilated helmet. Alcohol should be avoided, or at any rate absolutely so, until evening. Water or lemonade should be taken freely and a siesta in the middle of the day is an important conserver of one’s resisting powers.

Spotted a typo or a problem in this chapter? Tell us

Chapter XLII

CLIMATIC BUBO, AINHUM, GOUNDOU, JUXTA-ARTICULAR NODULES AND VISCERAL MYCOSES

CLIMATIC BUBO

General Considerations

The naval surgeons of various countries have for many years been interested in a condition where inguinal buboes develop which have no relation to venereal infection.

All attempts to find any organism in these lesions have so far failed. Cultures from excised glands or from the necrotic centers of such glands fail to show any growth.

Stained smears and India ink preparations alike fail to show any causative organism. The Wassermann test is also negative. The disease seems much more common in the West Indies than elsewhere, statistics showing it to be about 10 times as often contracted by sailors in those waters as by crews in the seaports of China. In a recent article Rost states that he thinks there is evidence to show that the disease is contracted by sexual intercourse with prostitutes of the colored races. Of his 17 cases all had exposed themselves in this way.

Children never show climatic bubo and it seems peculiarly to affect the young adults composing the crews of ships. Even among the native prostitutes such a condition does not seem to exist and climatic bubo does not affect the male natives.

There may or may not be a periadenitis but there is thickening of the capsule and fibrous septa of the glands. At times an apparently healthy gland may show a necrotic centre, the contents of which, however, will be found to be sterile. One often notes in sections haemorrhagic infiltrations and oedema in the region of the peripheral lymph sinuses. A point of differentiation from ambulant plague buboes is the great increase in plasma cells in climatic bubo. It will be remembered that Cantlie suggested that climatic bubo was an attenuated plague but this idea has never been accepted. It has been suggested that malaria might cause climatic bubo.

Symptomatology

The period of incubation is a rather long one, Rost in a well-controlled case noting a period of at least five weeks. The onset is very gradual, so the first intimation of a swelling in the groins may be when a sense of heaviness is noted in that region after prolonged work. For this reason they have been called “fatigue” glands.

The glands of one side of the groin are usually involved although the swellings may affect both sides. The deep iliac glands also often show marked increase in size but the glands of the other parts of the body, as axillary or cervical, are practically never involved.

The swollen glands are only slightly tender and at first are discrete and not attached to skin or underlying tissues. Later on with the development of a periadenitis they may be firmly attached. In size they are usually as large as a hen’s egg but may become much larger.

The overlying skin is as a rule normal and one may at times palpate a soft center in an otherwise hard gland. Fever tends to come on as an irregular remittent type and I have seen cases showing temperature curves covering periods of two or three months which were not unlike those of Malta fever. With increase in size of the buboes there would be a two or three weeks’ rise to be followed, with the subsidence of the swelling, by lysis and later on to be renewed with reappearance of the bubo.

Climatic bubo runs a protracted course and does not respond at all well to treatment. The cases often develop a moderate secondary anaemia, which is most often noted in the relapse cases.

Diagnosis and Treatment

The history aids in differentiating gonorrhoeal, chancroidal and syphilitic buboes. There is not the hardness and marked absence of tenderness we get in syphilitic inguinal glands, and the reddened overlying skin of the other veneral buboes should differentiate.

Plague buboes are exquisitely tender and the patient usually manifests signs of extreme illness. In climatic bubo the patients rarely seem sick.

Surgical treatment is usually recommended and some advocate a radical enucleation of all glands in the region involved as we find at times apparently normal glands to show necrotic centers. My objection to enucleation is that the deep iliac glands are also often involved and it is not only impossible to remove all affected glands in such an inaccessible region but the surgical risks of wounding the deep veins are great. I have seen this accident occur more than once. Again the radical removal of all glandular structures in the groins, with subsequent scar tissue formation, obstructs lymph return so that elephantoid conditions result.

Rest in bed and hot compresses are of value when periadenitis sets in. When softening occurs the aspiration of the pus with an aspirating syringe and the subsequent injection of glycerite of boroglycerine containing 10% of iodoform are to be recommended. Some apply ointment of ichthyol, others pressure by shot bags. X-ray treatment has been recommended.

Emily strongly recommends the injection of 3 or 4 drops of iodoform ether (5%) into the center of the enlarged gland. This effects a rapid cure. The author also employs other measures such as rest in bed, wet compresses, and light mercurial ointment inunctions over the bubo at night.

AINHUM

General Considerations

This disease, equivalent clinically to a spontaneous amputation of the little toe, has been chiefly noted in the natives of the West Coast of Africa, especially among the Kroomen and in Brazil. Cases have been reported from the West Indies and rarely from the Southern States of the United States. It does not attack white people and the susceptibility of black races is probably connected with their tendency to keloid development.

There have been all sorts of suggestions as to etiology: (a) that it is related to leprosy, (b) that it is a tropho-neurosis, (c) that it results from wearing constricting bands or rings on the toe, (d) that it is connected with frequent injuries to the under surface of the little toe.

Pathologically we find a fibrous cord which has replaced the bony structures normally attaching the toe to the foot. We have, according to Unna, a ring-form sclerodermia with thickening of the epidermis causing an endarteritis with the production of a rarefying osteitis.

The disease is chiefly found in male adults between twenty-five and thirty years of age.

=Symptomatology and Treatment=

In 90% of cases the little toe is the one affected, more rarely the fourth toe or very rarely both the fourth and little toe. The little toes may be attacked at the same time but the condition usually first starts in one toe. At first we have a crack in the digito-plantar fold of the little toe. This extends laterally and finally appears on the dorsum. The distal portion of the toe enlarges and becomes bulbous so that it looks like a small potato. The connection between the foot and the bloated-looking toe is a limp fibrous cord which permits the toe to wabble in various directions and to interfere greatly with walking.

The course of the disease extends over several years if the toe is not amputated by cutting through the fibrous pedicle or as the result of ulceration from injury to the pedicle.

GOUNDOU

General Considerations

This is a disease which almost exclusively affects the black race and is chiefly found in the West Coast of Africa, where it is called big-nose or dog-nose. It is also found occasionally in China and the Malay Peninsula.

The prominent root of the nose is due to exostoses from the nasal processes of the superior maxillary bones.

Nothing definite is known as to etiology. Suggestions have been made that it is connected with yaws, syphilis or leprosy. Again that it is due to rhinoscleroma. Maclaud thought the hypertrophied tissues to be incident to irritation from dipterous larvae in the nasal fossae. Pathologically we have spongy bone covered by a thin layer of compact bone.

Symptomatology and Treatment

At first there is complaint of headache and an associated nasal discharge. At times the nasal passages may be obstructed by the developing growth, which however usually projects externally on both sides of the root of the nose just below the inner angle of the eyes. Breathing through the nose is not as a rule interfered with.

The bony exostoses develop in a downward and outward direction. The shape is generally oval. The disease commences in childhood and the bony outgrowths slowly increase in size so that by adult life they attain the size of a walnut. The overlying skin is normal and not attached to the bony tumor. As the tumors grow they tend to interfere with the vision of the patient. This is purely from obstructing the lines of vision as the growth does not usually invade the orbits. The treatment is entirely surgical and consists in chiselling away the bony outgrowth.

JUXTA-ARTICULAR NODULES

General Considerations

These nodular masses were first noted by Macgregor from cases in New Guinea but since then have been described from various parts of the tropical world.

These tumor masses were given the name juxta-articular nodules by Jeanselme, who studied the affection in natives of Siam. It may be stated that at present we know nothing definite as to etiology although several authors have reported fungi as the cause. This fungus has been stated to be a species of Nocardia. Some of the cases which have been reported would seem to be late manifestations of yaws.

Symptomatology and Treatment

These tumor masses vary in size up to that of a golf ball and are very hard in consistence. The skin over them is at first freely movable, but later on may become attached. They are located subcutaneously, especially about the external surfaces of the extremities and particularly in relation to the joints. They are not sensitive and rarely or never suppurate. The course is most chronic and but rarely do they become absorbed.

In those parts of Africa where the tumors due to Onchocerca volvulus are found there may be confusion in diagnosis but these filarial nodes are elastic. By aspirating the swelling microfilariae should be found in onchocerciasis.

The treatment of juxta-articular nodules is by excision should they give trouble.

VISCERAL MYCOSES

The majority of cases of visceral mycoses reported from tropical regions have been considered as caused by species of Monilia, but not infrequently fungi of the genus Cryptococcus have been incriminated. As a rule the mycosis is reported as occurring in cases which had been regarded as pulmonary tuberculosis. In some of the cases there were cutaneous lesions, enlarged glands and even generalized conditions as well as lung involvement.

Among the fungi reported for the lungs we have: Rhizomucor parasiticum, Nocardia pseudotuberculosis, Aspergillus fumigatus, Penicillium crustaceum, Monilia tropicalis, Monilia candida, Cryptococcus gilchristi, Coccidioides immitis and various other species. A satisfactory study of the true nature of the causative fungi has been made in only certain instances and a scientific investigation of this phase of tropical pathology is desirable.

Bronchomoniliasis.—Castellani has used this designation for two types of cases in which various species of Monilia have been reported as causative. In one type the symptoms are mild with but slight impairment of health, there being only a cough with expectoration of muco-purulent sputum. No fever is present. In the severe type we have the symptomatology of pulmonary tuberculosis with abundant reddish-gray sputum. In both types the diagnosis is made by finding the fungi in perfectly fresh sputum. This should be cultured in a hanging-block culture using Sabouraud’s medium. The mycelium and budding forms can best be studied in such a preparation. Negative findings for tubercle bacilli are important in diagnosis. Potassium iodide is recommended in treatment.

Sporotrichosis.—The infection with various species of Sporotrichum usually gives rise to gummatous lesions along the lines of the lymphatics of the extremities. These tumor masses break down and discharge a yellowish-brown pus. Rarely the process generalizes, then often invading the lungs. Culturing of the pus or sputum is necessary for diagnosis. In cultures the sporothrix shows a narrow (2µ) mycelium with grape-like clusters of oval spores at the end of a filament. The treatment recommended is iodide of potash.

Blastomycosis.—The causative organism, Cryptococcus gilchristi, is found in the purulent discharge as oval to round, doubly contoured, budding yeast-like cells 10 to 16µ. In cultures we have formation of a mycelium resembling that of an oidium. The lesions may be solely cutaneous or generalized in which latter case the lungs are apt to be involved giving a condition resembling pulmonary tuberculosis.

Coccidioidal granuloma.—This is a very rare and fatal infection caused by Coccidioides immitis, a fungus somewhat similar in cultures to C. gilchristi but differing in tissues in that it gives rise to endogenous spore formation in the cells found in the granulomatous material. The spores are about 3µ in diameter and contained in a large cell (30-60µ) which does not bud. We may have skin lesions accompanying visceral involvement or the latter alone. When involving the lung the infection closely resembles pulmonary tuberculosis. The spores metastasize readily by way of the lymphatics involved and we may have a picture of pyaemia. Skin lesions, when present, are ragged and punched out. About 40 cases have been reported, chiefly from California.

Spotted a typo or a problem in this chapter? Tell us

Chapter XLIII

DIAGNOSTIC PROBLEMS AND PROCEDURES TOGETHER WITH COSMOPOLITAN DISEASES IN THE TROPICS

In temperate climates we always keep in mind syphilis, tuberculosis and the pyogenic infections when a diagnosis is in question. In the tropics these conditions are just as common, if not more so, and added to them we have many other diseases with protean manifestations such as malaria, beriberi, leprosy, ancylostomiasis and other helminthic infections, pellagra and amoebiasis.

The common mistake made by the physician when he first arrives in a tropical country is to expect to deal chiefly with diseases designated tropical. Before going to any tropical country the most important preparation is the study of the statistical reports from that section, covering a number of years. Everyone taking up the study of tropical disease should first study the geographical distribution of such diseases and those practising in temperate climates should remember that the first question to be asked a man suspected of having a tropical disease is “Where have you been during the past months and years?” Then too the same question should be applied as to intimate associates of the patient.

We all know how rare it is in temperate climates to find definite pathological conditions in people who are apparently well. In such people a definite finding of a cause sufficient to account for an illness is usually the key to the diagnosis. With those from the tropics, however, it is different. A single individual may be found upon examination to have amoebiasis, malaria, filariasis and syphilis, yet none of these infections prevent him from following his usual occupation. When such a patient comes to a ward it requires a correlating mind to eliminate four or five definite diagnoses, and fix upon some disease which is common to both tropics and temperate climates, as for example, typhoid fever.

In diagnosis in the tropics it is necessary to have at one’s fingers’ ends the various physical signs and subjective symptoms more or less characteristic of every disease of man as well as the laboratory findings. It is only when one has at hand all obtainable information that the solution of the medical problem becomes possible.

Furthermore, it is necessary to be familiar with the fact that certain infections, which at times give rise to marked alterations in the health of a patient, may at other times, and in particular when different races of man are concerned, give rise to no recognizable interference with health. This is particularly true of certain helminthological diseases, as for instance the slight effects often noted in hookworm infection in the African races as against the marked damage to those of the white race harboring such parasites.

While the medical man is apt to have superabundant energy during the first few months of his tropical service this later gives way to the opposite state and in particular to a lack of initiative. It is possible to do that which is absolutely demanded in the daily work, but this is along the lines of routine requirements and to the exclusion of new and difficult methods of diagnosis.

Consequently, while in possession of full energy and zeal one should cultivate thorough and modern methods of study of his cases and make these matters of routine, to use in the listless period to follow.

We do not usually fully appreciate the assistance the history of the present illness as well as personal and family history of a patient gives us, although it is generally recognized as the first line of approach in diagnosis. In the tropics, when dealing with natives, we have the difficulty of language to contend with as well as with native superstition and popular ideas as to nature and causation of disease. When employing a native interpreter it is always well to keep in mind the fact that such assistants will rarely admit of ignorance of the language of the medical man and, furthermore, they try to twist the answers of the patients to make them agree with what they may think is in accordance with the desire of the examiner. Again in carrying out the physical examination it is difficult to be certain that the findings as to location or degree of pain, sensations, or time of appearance of lesions, as well as data as to pulmonary, renal and alimentary tract disorders, are correct.

For these reasons it would seem advisable to reverse the ordinary methods of diagnosis when employed in the tropics. Instead of making a tentative diagnosis following the physical examination, and then confirming or adding to evidence with laboratory data, it is better to first secure the findings as to blood, faeces, urine, sputum, etc., and then check up such indications as to the diagnosis by a final and thorough physical examination.

This method of procedure has been criticised by some of my friends and in fact is a source of criticism on my part when, as a laboratory worker, I have been asked by a purely clinical colleague to make a routine laboratory examination of one of his patients without any previous study of the case on his part. Every laboratory man recognizes the assistance a tentative diagnosis on the part of the clinician gives him in that it suggests the examinations which should be gone into with particular care.

The present trend, even in temperate climate practice and always with the tropical internist, is to have familiarity with laboratory technique and interpretation as well as with the methods of physical diagnosis; consequently the tropical practitioner makes no dividing line between the diagnostic information obtained in the laboratory and that gotten at the bedside.

It is not difficult to train a native helper to make and stain good blood smears as well as to examine such preparations, and the same holds for the urine and faeces preparations. The skill in making preparations, the familiarity with pathological findings and the patience in studying a preparation on the part of these assistants is at times a matter of surprise. Thus in a few minutes the physician can check up these findings or the lack of findings and have them at hand to assist him in his study of his case.

=Laboratory Examination.=—In the laboratory the routine examination should embrace, first, a study of a stained blood smear. It is essential that the smear be well made and the Romanowsky stain used a good one.

While more difficult to make than a smear on a slide the cover-glass smear method of Ehrlich has the advantage that the white cells are more evenly distributed and consequently the differential count more reliable. Furthermore, after a little practice, one can approximate the white count of a patient by examining the stained smear with a low power objective (16 mm). In my experience I get a better general impression of a large mononuclear increase with the low power than I do with the oil-immersion. As a matter of fact one can make his differential count with a low power objective after some practice. Next, using a high dry or immersion objective, we search for malarial parasites. It must be remembered that even when there is nothing diagnostic in a stained blood smear there is much information to be obtained in the way of diagnostic exclusion. Furthermore, while looking over the preparation some diagnosis may suggest itself and there is nothing more important in diagnosis than to have possibilities of diagnosis in mind. It is often stated in connection with the diagnosis of liver abscess that one should always suspect liver abscess in a tropical patient and this will hold for other diseases and thus the careful examination of a blood smear may be suggestive if not diagnostic.

Next the faeces should be examined both in an ordinary preparation and in one mounted in Gram’s iodine solution.

In the preparation made from a particle of faeces, emulsified in salt solution, we can note any excess of fatty acids or soap crystals and lack of normal digestion of meat fibres as well as presence of ova of intestinal parasites. Again such a preparation is necessary for noting amoeboid activity of amoebae as well as for the motility of flagellates and Strongyloides embryos. In the preparation mounted in Gram’s iodine solution we have distinctly brought out the nuclear division of encysted amoebae, our most practical means of differentiating between the pathogenic and nonpathogenic amoebae. This method also brings out flagellate characteristics. Again, any undigested starch grains show up distinctly by reason of their blue color. Blood cells and yeast cells stain a golden yellow.

In the examination of the urine it is well to take up with a pipette the entire sediment from a centrifuged tube of urine and deposit it on a slide.

Examination with diminished illumination and using the two-thirds objective quickly enables us to ascertain presence and character of casts. This same sediment is then treated with Gram’s iodine solution and a cover-glass applied. Such a preparation, using the one-sixth objective, brings out distinctly the differentiation of pus cells from renal epithelium as well as showing clearly golden-yellow red blood cells. While centrifuging one can test for albumin. A qualitative test for sugar takes only a few moments to make.

These simple quick tests of blood, faeces and urine suffice for the preliminary laboratory work in a case. Following the physical examination we can carry out more elaborate laboratory tests as indicated by the tentative diagnosis obtained from the physical examination and preliminary laboratory investigations.

=Physical Examination.=—As regards the physical examination it must be remembered that in the tropics glandular enlargements and skin eruptions are so essential in diagnosis that the rule generally adopted in skin clinics should be adhered to, that is an inspection of the entire body surface, either by stripping the patient or removing clothing from one part at a time.

The sphygmomanometer is of value in the diagnosis of tropical affections as well as those of temperate regions. Similarly, functional tests of the heart and kidneys, basal metabolism determinations, chemical examination of the blood, and tests for acid-base equilibrium may give definite information—in one climate as in another.

Palpation is peculiarly important in the diagnosis of the enlarged spleen, liver and glands of many tropical affections as well as for mapping out intestinal thickenings. Again in going over the patient for outlining heart, liver, etc., palpatory percussion is more satisfactory than the usual mediate percussion.

I find the use of the entire palmar surface of the middle finger, gently tapped over the surface, to give better results than any other method. In this way the percussion note is well elicited and the sense of resistance most satisfactorily obtained. The use of the tips of the index, middle and ring fingers, with a piano playing stroke, also should be employed.

One should always determine the character of the reflexes. Of these the most important are the patellar and biceps ones. This latter reflex is normally rarely obtained.

The pupillary reactions also require little time for eliciting and are of much value in differentiating a peripheral neuritis from a cord lesion.

COSMOPOLITAN DISEASES IN THE TROPICS

In considering the matter of the general prevalence of disease in the tropics it has seemed advisable to present statistics from the standpoint of deaths rather than admissions for disease, the probability of accuracy in diagnosis being greater where there may be the assistance of an autopsy.

In the following table I have selected three tropical places under American sanitary control, the city of Manila, the city of Panama and the Island of St. Thomas, Virgin Islands. The statistics embrace the calendar years of 1918, 1919 and 1920 The statistics of Manila relate solely to the Filipino population resident in Manila, it does not include Americans or other nationalities. The Filipino population of Manila in 1920 was 263,386. The three years covered had respectively a death rate of 49.97, 28.66 and 27.48 per 1000.

-----------------+------------------+-----------------+----------------- | City of Manila | | St. Thomas, Vir- Place | (Filipinos only) | City of Panama | gin Islands of | | | United States -----------------+------------------+-----------------+----------------- Population | | 263,386| | 60,500| | 10,191 No. of deaths |11,840|7,378|7,238|1,314|1,211|1,297| 248| 176| 185 Rate per 1000 | 49.97|28.66|27.48|21.41|19.73|21.44|24.33|17.27|18.15 Calendar year | 1918| 1919| 1920| 1918| 1919| 1920| 1918| 1919| 1920 -----------------+------+-----+-----+-----+-----+-----+-----+-----+----- Typhoid fever | 180| 171| 226| 0| 3| 2| 4| 0| 0 Malaria | 64| 46| 75| 14| 10| 4| 1| 1| 0 Smallpox | 837| 31| 1| 0| 0| 0| 0| 0| 0 Measles | 16| 3| 12| 2| 0| 1| 0| 0| 0 Whooping-cough | 7| 0| 5| 1| 7| 2| 0| 1| 1 Diphtheria | 14| 16| 9| 4| 10| 5| 0| 0| 0 Influenza | 424| 42| 31| 7| 1| 29| 8| 1| 0 Asiatic cholera | 108| 328| 2| 0| 0| 0| 0| 0| 0 Dysentery | 678| 390| 253| 3| 9| 5| 2| 1| 0 Leprosy | 2| 2| 3| 3| 1| 2| 0| 0| 0 Purulent | | | | | | | | | infection and | | | | | | | | | septicaemia | 26| 23| 28| 9| 9| 7| 0| 1| 0 Tetanus | 82| 83| 84| 3| 2| 1| 1| 1| 0 Pellagra | 0| 0| 0| 6| 5| 5| 15| 4| 0 Beriberi | 551| 324| 548| 1| 2| 1| 0| 0| 0 Tuberculosis of | | | | | | | | | the lungs | 1,605|1,334|1,340| 223| 206| 169| 20| 20| 27 Cancer and other | | | | | | | | | malignant tumors| 80| 73| 65| 26| 34| 44| 6| 11| 6 Alcoholism | 3| 3| 2| 2| 1| 2| 0| 1| 0 Diabetes | 6| 6| 11| 3| 3| 0| 0| 0| 0 Simple meningitis| 448| 292| 300| 12| 11| 14| 1| 2| 0 Cerebral | | | | | | | | | hemorrhage | 109| 99| 93| 27| 39| 40| 10| 9| 4 Convulsions | | | | | | | | | (infants) | 224| 148| 91| 3| 4| 5| 4| 1| 1 Acute | | | | | | | | | endocarditis | 46| 29| 28| 17| 14| 7| 0| 1| 2 Organic diseases | | | | | | | | | of the heart | 118| 95| 93| 63| 37| 45| 9| 17| 27 Diseases of the | | | | | | | | | arteries | 18| 23| 15| 15| 27| 34| 9| 7| 9 Acute bronchitis | 975| 335| 630| 34| 14| 17| 0| 0| 0 Chronic | | | | | | | | | bronchitis | 286| 331| 235| 4| 1| 3| 0| 0| 0 Broncho-pneumonia| 872| 293| 372| 86| 109| 108| 15| 10| 6 Pneumonia | 220| 86| 101| 60| 62| 59| 5| 8| 8 Diarrhoea and | | | | | | | | | enteritis (under| | | | | | | | | two years) | 642| 365| 365| 156| 136| 162| 13| 4| 11 Diarrhoea and | | | | | | | | | enteritis (over | | | | | | | | | two years) | 429| 253| 164| 9| 16| 13| 9| 4| 5 Acute nephritis | 159| 88| 102| 18| 21| 14| 0| 1| 1 Chronic nephritis| 265| 248| 156| 72| 63| 63| 15| 16| 21 Intestinal | | | | | | | | | parasites | 16| 12| 5| 0| 2| 0| 1| 0| 0 Congenital | | | | | | | | | debility | 614| 460| 611| 32| 13| 21| 13| 14| 6 Senility | 531| 451| 357| 17| 7| 9| 13| 0| 1 +------+-----+-----+-----+-----+-----+-----+-----+----- |10,655|6,483|6,413| 932| 879| 893| 174| 136| 136 -----------------+------+-----+-----+-----+-----+-----+-----+-----+-----

The population of the city of Panama during the year 1920 was 60,500. The death rate during the years covered was 21.41, 19.73, and 21.44 per 1000, respectively.

It may be stated that the average population of the Canal Zone during 1920 was 27,459, with 242 deaths, giving a death rate of 8.81 per 1000.

The population of St. Thomas during 1920 is estimated at 10,191. The death rate during 1918 was 24.33, during 1919, 17.27 and during 1920, 18.15 per 1000.

The diseases in the table of deaths do not account for all the deaths, the others having been from other diseases, accidents, etc.

In studying the Manila statistical reports more in detail we note that during 1920 there were reported 64 cases of diphtheria, 387 of measles and 577 of typhoid fever. The reasons for the high death rate in 1918 are clearly seen, namely, the epidemics of influenza and smallpox. As is the case in nearly every epidemic of influenza, the increase in deaths from this disease was accompanied with a large increase in deaths from acute bronchitis and the various pneumonias, conditions that in many cases should have been ascribed to influenza. The smallpox epidemic during 1918 was brought under control by a very extensive vaccination campaign. Only one death from this disease occurred in 1920.

During 1920, there were reported in Panama 95 cases of diphtheria, 313 of influenza, 154 of measles, 9 of typhoid fever, 4 of scarlet fever, 14 of smallpox and 311 of tuberculosis.

During the same period there were reported in St. Thomas 6 cases of chickenpox and 40 cases of tuberculosis. No cases of influenza, smallpox, measles or typhoid fever occurred. From reports for the year of 1921, it is noted that an extensive although not severe epidemic of measles has been present in the Virgin Islands during said year.

From the above tables we note that as far as actual causes of deaths are concerned the cosmopolitan diseases play a more important rôle than those we designate tropical diseases. Tuberculosis ranks first, other respiratory infections come a close second. Organic diseases of the heart and other degenerative diseases, such as chronic nephritis, are also noted for their frequency. The gastro-intestinal infections, typhoid fever, dysentery, diarrhoea, probably serve as a barometer of the sanitary conditions of a city.

But there are many other diseases whose importance from an economic standpoint may not be fully appreciated from mortality tables. Notable among these are venereal diseases, malaria, filariasis, yaws and hookworm diseases. Further it may be noted that many diseases without being the direct cause of death have a distinct bearing on the mortality. Amongst these we note particularly the various worm-infestations. The experience in Bilibid prison is an illustrating example. The mortality amongst the prisoners dropped markedly after the inmates had been cured of their various worm conditions.

=Rheumatic Fever and Scarlet Fever.=—From a study of the statistical reports and from the writings of various authorities there would seem to be two cosmopolitan diseases, which are of extreme rarity in the tropics, rheumatic fever and scarlet fever.

It is true that in the Gold Coast report for 1911 there are noted 614 cases of rheumatic fever with one death.

There does not, however, appear to be any striking increase in admissions for valvular disease of the heart as would naturally be expected.

In Calcutta, in 1911, there were 74 deaths from rheumatic fever.

As regards scarlet fever, statistical reports from various parts of the tropical world fail to show cases.

In a report from Shanghai, which can hardly be considered as a tropical city, there is a statement that this disease first made its appearance in 1900, since which time it has spread among the Chinese, exhibiting marked virulence. Again in a Basutoland report there were quite a number of cases reported (67), but as this colony is in the extreme south of Africa it could hardly be called tropical.

=Typhoid Fever.=—When reliance for diagnosis rested almost solely on clinical manifestations, it was held that typhoid fever was rare or unknown in the tropics.

Since the advent of laboratory methods of diagnosis it has become known that typhoid and the paratyphoid fevers are quite common. The paratyphoid infections are more common in the tropics than in the temperate regions. The fever course and clinical picture of typhoid in the tropics are distinctly atypical. It was formerly common to consider cases of typhoid as malaria and in the southern states of the United States it was a common thing to diagnose typho-malarial fever.

Of course, latent malaria is apt to flare up in a person sick with typhoid, but the idea that there was a symptom-complex partaking of the characteristics of typhoid fever and malaria is now classed with historical data.

It is a remarkable fact that in many of the cities of the Orient conditions favoring infection with typhoid fever, such as neglect of the most elementary measures of disposal of faeces and lack of safeguarding of water supplies, exist and yet the natives seem to have an immunity to organisms causing alimentary tract diseases. It must be that such immunity is acquired by attacks of the disease in childhood. Certainly, Europeans in such communities have no protection unless they are vaccinated. It must be remembered that the protection from vaccination against the enteric group of bacteria can be relied on for not longer than a period of two years.

It would seem that typhoid fever in tropical countries is more serious than in temperate climates—thus the death rate in India is about twice as great.

In the absence of laboratory tests the chief reliance in the clinical diagnosis of typhoid should rest in the rather gradual onset of a continued fever, with a rather apathetic toxaemia. Of course atypical cases may have a fairly abrupt onset. An important point in the diagnosis is the rather slow pulse rate for the temperature elevation.

Marris Atropine Test.—Manson-Bahr regards the Marris atropine test as of the utmost value in the diagnosis of the enteric group of fevers. In this test one gives a hypodermic injection of grain 1/50 of atropine sulphate. Should the case be typhoid or paratyphoid the pulse rate is practically uninfluenced during the period from 25 to 50 minutes after the injection. In other infections or in normal individuals, the pulse rate drops at first but after 10 or 15 minutes rises to exceed the pulse rate before the injection by 30 or 40 beats during the period of 25 to 50 minutes following the injection.

In the laboratory tests the prime reliance must be placed in blood culture, which of course should be made during the first ten days of the illness. Blood cultures give positive results in the inoculated as well as in those not protected by vaccination.

Agglutination tests are the ones of choice after such a period, but one must discount agglutination in those who have been vaccinated previously. Of course the rising agglutination titre during the course of the disease gives valuable information, and the Dreyer technique, where simultaneous tests are made on emulsions of typhoid, paratyphoid A and paratyphoid B at intervals of 4 days, noting a distinct rise for one of these organisms, is based on this factor. At the same time this technique is exacting and does not seem to have given the results that were at first expected.

Culturing the urine is of more value in diagnosis than that of the faeces. Bacilluria may be expected in about one-fifth of cases after the second week. Faeces culturing gives positive results in a smaller proportion of cases and is attended with much difficulty.

The Paratyphoid Fevers.—The paratyphoids would seem to be more prevalent, in proportion to typhoid, in the tropics than in temperate climates, thus in India, of 1886 British soldiers, convalescent from enteric fevers, 791 were diagnosed as typhoid, 633 as paratyphoid A, 136 as paratyphoid B and 326 as enteric cases of uncertain etiology. Paratyphoid B cases seem more frequent in temperate climates than paratyphoid A ones, as noted during the war in France. Cruickshank, and Lafrenais, in a study of carriers, among the 1886 cases noted above observed that 49 became carriers and of these 34 were from paratyphoid A cases, 9 from typhoid convalescents and 6 from paratyphoid B convalescents. Of 13 chronic carriers (those carriers excreting organisms after a period of six months) 8 were carriers of paratyphoid A, 4 of typhoid and 1 of paratyphoid B.

This evidence would indicate that paratyphoid A, once introduced, would spread more widely than the other enteric affections.

Clinically, paratyphoid A cases resemble typhoid ones rather closely, although as a rule less severe in course. With paratyphoid B the course is less severe than with the other enteric organisms but it often shows an abrupt onset and is frequently similar to cases of meat poisoning. This organism and the Gärtner bacillus are common excitants of the so-called ptomaine poisoning cases. Paratyphoid B cases show a tendency to localize in the pelvis of the kidney or elsewhere and may cause a broncho-pneumonia.

Colon Infections.—Such infections seem to be rare in temperate climates other than as localized conditions especially of the urinary bladder. Cholecystitis is not infrequently due to a colon bacillus infection. In the tropics, however, especially following bacillary dysentery, we may have a generalized infection which may result in a fatal septicaemia. In such cases abscess formation in the kidneys is usually found.

Cases diagnosed as mild typhoid fever have as a result of blood cultures been found to occasionally be due to a colon bacteriaemia.

In temperate climates as well as in the tropics pyelitis is often due to a colon infection and probably 10% of cases of appendicitis are caused by the colon bacillus alone, although it is extremely frequent in association with streptococci or staphylococci.

Bacillus alkaligines faecalis infections. Cases similar to typhoid fever have been found to be due to infections with this member of the typhoid-colon group of organisms.

=Tuberculosis.=—The negro race seems to possess a greater susceptibility to tuberculosis than the white one, a fact well recognized in the United States, where the colored population suffers far more severely than their white neighbors. The yellow races also show marked susceptibility to the scourge and in the Philippines it is easily the greatest cause of death.

In tropical regions the natives of the sea-level regions suffer more than those of the mountain plateaus and where the humidity is high rather than in arid sections. Thus tuberculosis is very rare or almost unknown in the dry desert-like regions of upper Egypt and the Sahara desert.

The disease gains headway in the rainy season and diminishes in prevalence during the dry season.

One factor in the great spread of the disease is the intimate contact of natives living together in a small room.

It is generally recognized that susceptibility is greater in childhood and that infection by way of the alimentary tract is common in children.

When one notes the habit of expectorating anywhere and everywhere on the part of people untrained in hygienic rules, it is easy to recognize the opportunity babies and young children have of ingesting tuberculous material taken up on their hands while they are crawling about.

During the war there was a great deal of tuberculosis among the native African troops serving in France, and a study of the disease in these men has furnished us information as to the existence of two clinical types among them. In the soldiers from Morocco and Algiers, the type observed was similar to that occurring in Europeans, and this was explained on the basis of the opportunity that had been given the people of the areas from which the troops came to acquire tuberculosis from contact with white colonists and during a period of many years to have acquired a certain degree of resistance to the invasion of the tubercle bacillus.

In connection with the Senegalese troops and some others coming from sections of Africa where tuberculosis was rare or nonexistent another type was observed which corresponded with the tuberculosis one sees in a young child or a guinea pig.

In these cases the disease starts with enlargement of the glands at the roots of the lungs. This finding of course would require an X-ray plate but it was found that the enlargement of the supraclavicular glands at a point near the insertion of the sternocleidomastoid was one of the best early signs. The glandular stage lasted about five to ten weeks during which time the general health did not seem to be materially impaired. Following this stage and lasting only about two weeks or up to two months a stage of generalized tuberculosis sets in with fever, emaciation, caseous pneumonia or manifestations of miliary tuberculosis. There was no tendency to fibrosis or cure of the process, death almost invariably occurring. Borrel, who studied the disease in these natives, states that if put at rest and placed on a generous diet, while the case is in the glandular stage, one-half of them may recover. It was noted that sputum examinations of these cases were almost invariably negative.

=Smallpox.=—This disease may justly be considered the greatest scourge of the natives of tropical countries. It is responsible for much of the blindness noted in natives of sections where vaccination has not been employed.

In some of the countries of the Orient smallpox kills more people than cholera, plague and dysentery together. Many reports have shown that as many as 80 to 90% of a native population may be attacked in an outbreak and of these practically one-half die. In such communities the disease is more one of young children, the adults possessing a certain degree of immunity from attacks in childhood during previous epidemics. It has frequently been noted that the native colored races do not seem to acquire as marked an immunity as is observed among the white races of temperate climates following an attack of the disease. Again it has been insisted that the immunity following vaccination is not as marked as that obtaining in European countries. This point would seem not well founded because efficient and universal vaccination has apparently caused smallpox in the Philippines to be of no more importance than it is among any other well vaccinated people. It is striking to note the great number of pitted faces among adult Filipinos, whereas this condition is practically absent in the generation following the general vaccination introduced by the Americans.

In tropical natives the most severe forms of smallpox are observed—confluent and haemorrhagic.

Opportunities for the spread of the disease are most favorable in many parts of the tropical world by reason of intimate association, religious festivals and pilgrimages.

Under the name alastrim or Kaffir milk-pox, a disease similar to a mild form of smallpox has been reported from Africa and the West Indies. Various points were raised to differentiate it from smallpox, but in a recent epidemic in Jamaica and Haiti proof was adduced to demonstrate its identity with smallpox. In Haiti the epidemic was controlled by vaccination with smallpox vaccine, and those individuals exposed to the infection but properly vaccinated, uniformly escaped. Among the soldiers of the Marine Corps in Haiti there were only two cases and these occurred in men who gave no evidences, of successful vaccination.

=Varicella.=—This disease is of common occurrence in the tropics and does not seem to give rise to greater mortality than it does in temperate climates.

In the Philippines I have been struck by the resemblance it bears to cases of varioloid, inasmuch as we frequently note as numerous lesions on the face as on the body. In fact I have been sure that the pustular lesions of the face of such cases were those of smallpox, until I noted typical varicella lesions on the body.

=Mumps.=—This disease is found in many parts of the tropics and presents similar features to the epidemic parotitis of temperate climates.

In the Philippines there seem to be cases similar to mumps but without the contagious feature so characteristic of the disease in Europe.

=Glanders.=—This rare disease of Europe and the United States seems to be much more common in many tropical countries. In the Philippines it generally shows itself in the acute form and is much dreaded by reason of its great infectiousness.

=Diphtheria.=—Formerly there was an idea that diphtheria, like scarlet fever, was extremely rare or unknown in the tropics.

The assistance of the laboratory has shown that this old idea is incorrect and that the disease is fairly prevalent in many tropical regions.

=Vincent’s Angina.=—While not rare in temperate climates, various affections of the oral mucous membrane due to the fusiform bacillus in symbiosis with various species of spirilla are fairly common in the tropics. The best known condition is one in which the tonsils show somewhat the appearance of a follicular tonsillitis but ulceration is more common and severe, with however, less evidence of toxaemia.

The temperature in a case of pure Vincent’s Angina rarely exceeds 101°F. but if there is a mixed infection with other pyogenic organisms the temperature and other signs of a severe infection may be more marked. There is usually more or less swelling of tributary glands. Associated with the angina or alone we may have a gingivitis in which the spongy gums more or less resemble those of scurvy or of pyorrheoa alveolaris. In fact these Vincent organisms have been considered as factors in the development of pyorrhoea alveolaris. In the tropics there have been many reports of organisms of the type of those described by Vincent occurring in skin ulceration or affection of the mucous membranes other than the oral ones, more particularly the pudendal mucous membranes.

The infections are readily and easily diagnosed by a smear stained with any simple aniline dye. Care must be taken not to accept such a finding as the sole cause, as an underlying diphtheria, syphilis or other dyscrasia may be more important.

=Malignant Tumors.=—It is usually stated that malignant tumors are very rare among tropical natives. The proper solution of this question, however, is complicated by the frequent lack of careful autopsies.

=Pneumonia.=—Just as with the tubercle bacillus so does the black race seem to have less resistance to the Pneumococcus than does the white one.

Great engineering works employing tropical natives are frequently associated with very fatal epidemics of pneumonia, especially broncho-pneumonia. Again in the black races the infection tends to become generalized rather than localized in the lungs. It is more toxic and insidious in its course than is true of the infection in the white man; it has the fatal trend of pneumonia of the aged. Another tendency is to invasion of the meninges.

=Influenza.=—In temperate climates we associate this disease with bronchial and coryzal manifestations. In the tropics types almost unrecognized in Europe are noted, especially the gastro-intestinal and nervous ones. The similarity in the clinical picture of dengue with slight eruption and tropical influenza is striking.

During the recent pandemic of influenza there was a frequent complication of influenza pneumonia; many of these influenza bronchopneumonias resembled plague pneumonia.

=Tetanus.=—This infection is far more prevalent in tropical than in temperate climates. It is particularly fatal to infants, the infection occurring from errors in the dressing of the cord at the time of childbirth.

=Syphilis and Other Venereal Diseases.=—Syphilis is rampant in many parts of the tropical world. Jeanselme has noted that syphilis among tropical natives often starts with an extra-genital lesion which tends to become phagedenic and that the secondaries are but slightly marked. It is in the tertiary stage that the disease shows itself in its malignancy.

All tropical workers have noted the absence of tabetic and paretic manifestations in the native syphilitics. LeDantec notes that he has not observed parasyphilis in any European who had contracted syphilis from a native woman and brings up the question of a difference in strains of syphilis.

The American Naval Surgeons at Guam and Samoa have been struck with the absence of primary lesions of syphilis among the natives of these islands and Butler has suggested that this is due to an immunity received as result of contracting yaws in childhood. There certainly are many reasons for considering syphilis and yaws as closely related.

Soft chancre is common in many tropical seaports and shows itself in a rather virulent form. In particular it is apt to be complicated by suppurating buboes.

In tropical gonorrhoea it would seem that involvement of the testicles is more common than in temperate climates.

=Endocrine Disturbances.=—Internists in all parts of the world are beginning to appreciate that many of the puzzling complaints of ill-health are connected with abnormal functioning of the ductless glands. The conditions resulting from excessive or diminished functioning of the thyroid gland are well understood and the determination of the basal metabolism rate is now a standard laboratory procedure. There are many types of apparatus on the market and the determination is within the reach of any hospital staff.

Hyperthyroidism is now rarely unrecognized as is also true of myxoedema but sub-states of thyroid functioning are less frequently recognized.

McCarrison has stressed the importance of endocrine disturbances in dietetic deficiencies and notes atrophy of all the glands of internal secretion in such conditions with the exception of the adrenal which tends to hypertrophy. There is possibly some hypertrophy of the pituitary in males. The oedema which accompanies most of the food deficiency diseases he associates with the adrenal enlargement and hyperactivity of function, although oedema does not invariably result from such hypertrophy. In pellagra there is a low blood pressure, possibly due to adrenal hypofunction. Goitre is found in many parts of the tropical world and Castellani states that this disease is met with frequently in Ceylon and various regions of Africa. Disturbances of the internal secretion of the pancreas, resulting in diabetes, are common in parts of Asia.

Determination of Basal Metabolism.—In the study of cases where abnormal thyroid functioning is suspected the most accurate method of such determination is by estimating the percentage of the patient’s metabolism as above or below the normal average.

Basal metabolism is that caloric value which an individual produces while resting in bed and prior to taking breakfast—in other words when the effects of food and exercise on caloric output are least operative. Basal metabolism is expressed in terms of calories per hour per square meter of body surface. It varies with different ages. It is proportionate to body surface which is calculated from the height and weight of the individual. Normally this metabolism should not vary more than 15% above or below accepted normal figures. The use of the respiration calorimeter is the most accurate method for determination of heat production but it has now been found that the oxygen consumption during short periods gives data for calculation of such heat production (indirect calorimetry). In the Benedict portable respiration apparatus the patient breathes into and out of a confined volume of air circulating through a series of purifiers which remove the carbon dioxide. A determination of the volume of oxygen consumed is made from the decrease in the total air volume. The heat production resulting from the absorption of one litre of oxygen is relatively constant whether used to burn fat or carbohydrate and gives an accurate index of total heat production. The Benedict apparatus can also be employed for determining carbon dioxide excretion and thereby giving data for the respiratory quotient. The determination of the heat produced in the excretion of carbon dioxide is less accurate although easier of determination. In marked cases of hyperthyroidism the basal metabolism ranges 75% above the normal figures, between 50 and 75% for severe cases and less than 50% for mild cases. In hypothyroidism the figures are usually 20 to 40% below the normal averages. The average respiratory quotient is taken as O.82 and the calorific value of oxygen at this respiratory quotient is 4.825 per litre. We multiply the litres of oxygen by 4.825 to compute the heat output. It must be remembered that patients with high fever give 30 to 40% heat production over normal figures. Severe cardiac and renal conditions as well as leukaemias also give high values. The average calorie output per square meter of body surface per hour based on the Du Bois “height-weight” formula, is 39.7 for man and 36.9 for women between the ages of 20 and 40, being greater in youth and less beyond forty.

=Focal Infections.=—In recent years our attention has been directed to the importance of certain localized bacterial foci which may extend through blood or lymph channels and give rise to various systemic or localized diseases. Most important of these diseases are various types of arthritis together with endocarditis, myocarditis and pericarditis. Next in importance are renal infections, chiefly of the glomerulonephritis type.

Cholecystitis, appendicitis, pancreatitis and various skin lesions may also have origin in a focal infection. The primary foci may be localized in any part of the body but those seated in the tonsilar, peridental membrane, nasal and accessory sinus tissues are the most common and important. Focal infections of the genito-urinary tract may also give rise to generalized conditions as is also true of such foci in the alimentary tract. In the tonsils we should particularly examine the material of crypts for various streptococci and likewise the bacterial flora of tooth abscesses or pyorrhoea alveolaris.

TABLE SHOWING NUMBER OF TIMES EACH FOCUS WAS CONSIDERED A PROBABLE SOURCE OF INFECTION IN A SERIES STUDIED BY BILLINGS AND ASSOCIATES

No. Tonsil 336 Teeth 136 Sinus 12 Bronchi 5 Uterus and tubes 12 Prostate and genito-urinary tract 24 Gallbladder 3 Enterocolitis 2 Appendix 1 Middle ear 1

Spotted a typo or a problem in this chapter? Tell us

Chapter XLIV

ONSET AND THE TEMPERATURE CHART IN THE DIAGNOSIS OF TROPICAL DISEASES

While a knowledge of the variations in type and course of the body temperature in the various tropical diseases is of great value in diagnosis, yet such information is liable to lead one astray, unless such data are controlled by a careful consideration of the other and, in my opinion, more important factors of physical diagnosis and laboratory examinations.

The idea that there is a scientific exactness in the employment of the clinical thermometer tends to make one overestimate its value in diagnosis.

It must be remembered that the high air temperature one encounters in the tropics affects the clinical thermometer, which is of the maximum type. This is particularly true when the sun may be shining on the container in which the thermometer may be kept. Even if one shakes down the column of mercury before putting it in the mouth, the glass of the instrument will quickly cause the mercury column again to rise. It should be a practice to place the instrument in cool water before inserting it in the mouth and we must not forget that a sufficient retention in the mouth, from two to five minutes, should be insisted upon before accepting the temperature reading.

For practical purposes we may divide tropical diseases, from a standpoint of body temperature, into two classes. (1) Those diseases in which the absence of fever in the general course of the illness is the rule, and (2) those diseases in which the presence of fever in the general course of the illness is the rule.

=Nonfebrile Diseases.=—Among the nonfebrile diseases we may note the following: Beriberi, sprue, pellagra, cholera, leprosy, amoebic dysentery, hookworm disease, filariasis, bilharziosis, endemic haemoptysis or paragonomiasis, liver fluke disease, malarial cachexia, yaws, verruga, oriental sore and ulcerating granuloma of the pudenda, as well as the various tropical skin diseases.

One should always keep in mind the fact that a latent malaria often gives way to frank malarial manifestations when some intercurrent disease still further reduces the body resistance. This is not infrequently the explanation of a febrile onset in the course of a disease typically afebrile. In the tropics if a fever chart does not show a characteristic periodicity one can often obtain indications of periodicity even in a continued or remittent fever course by the greater elevation of temperature every third day (tertian periodicity).

Another disease which often flares up following conditions which lower vitality and giving rise to fever and manifestations of toxemia is tuberculosis, a disease as common in the tropics as elsewhere. Then too, one must always keep in mind febrile manifestations not unrarely marking syphilis. This triad of diseases, malaria, tuberculosis and syphilis, must always be thought of, as well as septic conditions, when fever is present in a disease typically afebrile.

There are certain exceptions in the above list which may be here noted.

Beriberi.—There has been considerable discussion as to whether a disease with fever and a rash, but otherwise resembling wet beriberi, is the same disease or a distinct disease entity. The fever in epidemic dropsy; as it is called, is rarely over 102°F., usually ranging from 99° to 101° and accompanying the dropsy.

Pellagra.—While there may be slight variations from the normal yet the ordinary case of pellagra fails to show a distinct febrile course, so much so that the appearance of fever in a case of pellagra makes for an unfavorable prognosis. In the so-called typhoid pellagra, an acute, rapidly fatal form of the disease, a high temperature curve may be obtained. At the same time this condition has been noted by Italian and German writers as being present in patients not showing any rise in temperature. It is possible that the development of enteric fever in a pellagrin may at times be the explanation of the fever.

Cholera.—Instead of a favorable stage of reaction there may set in a condition with low muttering delirium, dry brown tongue and with an elevated temperature, the so-called typhoid state, which is speedily fatal.

Rarely a rise of 3 or 4 degrees which does not last more than forty-eight hours may be present in a stage of reaction going on to a favorable convalescence.

It must be remembered that the rectal temperature in the majority of cases of cholera may show elevation of temperature approximating 100°F., while the axillary temperature may be as low as 95°F. When there is a great difference between the rectal and axillary temperatures, instead of the more common 4 or 5 degrees of a typical case of cholera, the prognosis is bad. The temperature taken by mouth may be as low as 86°F.

Leprosy.—Among the prodromata of leprosy, along with epistaxis, feeling of great weakness, somnolence and occasional sweats, there may be recurring attacks of fever. These are at times diagnosed as malarial manifestations. With the appearance of typical lesions the course is apt to be nonfebrile with the exception that febrile accessions often accompany the early macular manifestations.

Amoebic Dysentery.—Unless complicated by hepatitis or some bacterial infection of the amoebic lesions the disease progresses without fever.

Sprue.—While sprue is certainly one of the most typical of afebrile diseases yet a form of sprue is recognized which begins as an acute entero-colitis with fever. This must be most exceptional, or only a coincidence, as sprue is characterized by a very insidious onset.

Ancylostomiasis.—The occasional reports of fever being present are probably connected with bacterial infection at the site of attachment of the hookworm.

Filariasis.—There is a febrile manifestation of filarial disease which is attended by rigors and high fever. This is a lymphangitis which causes an erysipelatous appearance about the region involved. It is these recurring attacks of lymphangitis which gradually lead to the enormous thickening of the skin characteristic of elephantiasis. Such attacks are designated elephantoid fever. They are often diagnosed as malarial chills and in Barbadoes, where there is no malaria, such attacks are called “ague.”

Lymph scrotum is the filarial condition in which elephantoid fever is most frequently noted.

Schistosomiasis.—In the vesical type of the disease we may have as a complication a pyelitis which could give rise to febrile manifestations. In Japanese schistosomiasis the disease sets in with fever and urticaria. Before this combination of symptoms was recognized as belonging to schistosomiasis we designated it urticarial fever.

Malarial Cachexia.—Attacks of an irregular type of fever are frequently noted in the malarial cachectic, especially setting in upon some exposure to dampness or chilling, to alcoholic excesses or to excessive fatigue. Cases are also met with in the tropics, particularly among natives, where fever plays no apparent part in the profound anaemia of these ague-cake victims. It is this absence of fever which many consider the evidence of immunity to malaria in the native with his anaemia and large spleen.

Such cases often show crescents in their blood and act as reservoirs of virus for mosquito infection.

Latent Malaria.—Following treatment, or even when quinine has not been exhibited, cases of malaria often cease to show clinical symptoms or even laboratory findings until a relapse develops in case a cure has not been effected. As noted elsewhere, these relapses, in which the febrile manifestations are prominent, often follow exposure to tropical sunlight, wetting, etc. Besides such frank manifestations, we may have numerous symptoms, that exhibit periodicity, arising in the course of nonfebrile latent malaria.

Yaws.—While fever of a more or less irregular type frequently occurs at the onset of both primary and secondary stages, especially just before the secondary general eruption, yet the course of yaws as it runs over months or years is afebrile.

Verruga.—The recent views as to verruga being a separate condition, and not the secondary stage of a typhoid-like fever, Carrion’s disease, removes from its clinical features the fever characteristics generally noted.

=Diseases with Subnormal Temperatures.=—There are certain diseases in which marked lowering of the temperature may be a feature of some stage.

The algid stage of cholera is that which gives to cholera the picture of a living death with the cadaveric features and icy breath. Again in the choleraic type of algid pernicious malaria we may have a subnormal temperature.

In infections with Shiga’s bacillus of bacillary dysentery we may have cases showing extreme toxaemia with algid manifestations and a subnormal temperature.

During the last stages of sleeping sickness a lowering of the temperature is fairly constant.

In heat prostration the temperature tends to be subnormal. Clinically this condition with its pale clammy skin is just the opposite of heat stroke with its turgid countenance and hyperpyrexia.

In the Indian type of relapsing fever we may have a fall to subnormal temperatures at the time of the crisis of the first paroxysm, often attended with manifestations of collapse.

Sprue cases tend to run a subnormal temperature during the terminal period.

=Febrile Diseases.=—The diseases in which the presence of fever, in the general course of the illness, is the rule, may be considered in two groups:

1. Those in which the temperature chart is of prime importance in diagnosis.

2. Those in which the character of the fever gives but little assistance in diagnosis.

DISEASES IN WHICH THE TEMPERATURE CHART IS OF PRIME IMPORTANCE IN DIAGNOSIS

Benign Tertian and Quartan Malaria.—The presence of a fever of tertian or quartan periodicity is absolutely characteristic of malaria. In rare cases however of meningococcus sepsis, without cerebral localization, we may have a tertian or even quartan periodicity. Such cases are apt to show petechial spots and blood cultures give the diagnosis. There is also a polynuclear leukocytosis. As the result of the introduction by infected mosquitoes, on successive days, of two generations of malarial parasites in benign tertian or of three generations in quartan malaria, a quotidian periodicity may obtain.

Such a type of fever is observed in tuberculosis, liver abscess and various pyogenic infections. The rise of temperature in benign tertian and quartan malaria takes place in about one-half the cases somewhat early in the day, while the daily rise in tuberculosis, septic conditions and liver abscess, is more apt to occur in the evening, the evening rise being almost the rule in such diseases. Hectic fevers generally show a less distinct cycle of chill, hot stage and sweating than do the benign malarial paroxysms. At the same time the enlarged spleen, presence of parasites in the peripheral circulation and response to quinine are diagnostic points in malaria which must always be thought of. When quinine administration has caused the parasites to be temporarily absent from the blood the increase of large mononuclears is very suggestive.

Dengue.—In this disease the extremely sudden onset with a fever rising rapidly to 104°F. or more and remaining elevated for three or five days, to fall by crisis to normal and, after an apyrexial period of one or two days, to be succeeded by a second febrile accession, gives a fever chart which is quite characteristic—the saddle-back chart.

The typical dengue eruption does not appear until towards the end of the primary fever or about the commencement of the secondary one. Intense postorbital soreness is a striking feature in dengue. The comparative slowness of the pulse may be noted in dengue as well as in yellow fever. Leucopenia and polymorphonuclear percentage reduction are rather characteristic.

Relapsing Fevers.—These fevers, when there are three or more relapses, can perhaps be more easily diagnosed from the temperature chart alone than is the case with any other disease, excepting malarial fevers showing tertian or quartan periodicity. With an abrupt rise of temperature, which remains elevated for from three to seven days and drops by crisis to normal, to be followed by approximately a week of normal temperature, with two or three repetitions of the fever and apyretic intervals we have an extremely characteristic temperature chart.

Unlike malaria and yellow fever the onset is apt to be towards evening rather than in the morning hours.

The spleen is apt to be enlarged during the pyrexia and less so when the temperature is normal. The spirochaetes are to be searched for while fever is present as they disappear from the peripheral circulation during the apyretic intervals. In tick fever numerous relapses are frequent in the European and less common in the native.

Malignant Tertian Malaria.—While benign malarial infections are more common in temperate climates malignant tertian is the one which usually prevails in the tropics.

While the Italian designation of this type of fever as aestivo-autumnal has more general acceptance yet Koch’s term, tropical malaria, is eminently appropriate. The onset in malignant tertian is rather insidious so that the case may be suspected as one of typhoid fever. At the same time the first paroxysm is apt to show a tertian periodicity while subsequent ones, by only remitting, and not showing an intermission, give the temperature picture of a continued fever in which periodicity is not easily noted. At the same time a study of such a chart will probably show that the curve tends to approach normal every other day. The suggestion of periodicity is almost of as great value as the actual drop to normal in the intermission. The remittent or even continuous type of fever in malignant tertian tends to yield to an intermittent one after a week or more of such fever.

Very characteristic of malignant tertian paroxysms is that they set in with chilly sensations rather than a frank chill. It is for this reason that the so-called “dumb chill” is recognized as more serious than the frank unmistakable chill.

The main feature of malignant tertian paroxysms is the pronounced and prolonged hot stage, which frequently lasts from twenty to thirty-six hours and may run over into the rising temperature connected with the development of the succeeding generation of parasites.

The terms anticipation and postponement are frequently used to explain the drawn-out fever of this type of malaria.

There is great irregularity in time of development so that we get the impression of completed cycle before the accepted forty-eight hours as shown by a rising temperature within thirty-six hours—anticipation; or, instead of showing indications of a completion of cycle in forty-eight hours the fever still keeps up—retardation.

The descent of the fever curve is much more gradual than the rise at the onset of the paroxysm. The fine hair-like rings of the tropical parasite are the only schizont stages usually found in the peripheral blood. As the rings enlarge they fail to appear in the peripheral blood so that blood examination at such times will be negative. The finding of crescents is proof of a malignant tertian infection.

In view of the fact that one is likely to fail to find parasites just before or just after a paroxysm search should particularly be made for the pigment-carrying phagocyte—the melaniferous leucocyte.

In certain of the pernicious manifestations of malignant tertian, especially the hyperpyrexial type of cerebral malaria, the temperature may reach a very high degree, 107°F. to 110°F., and it is often mistaken for sun stroke by one not familiar with the fact that so-called sun stroke is often only this fatal form of malaria.

In algid pernicious malaria the axillary and, in particular, the rectal temperature remain elevated even with a subnormal surface temperature.

The infection in latent malaria is most often a malignant tertian one. Such cases often develop paroxysms following surgical operations or at time of pregnancy or childbirth. Clark has noted the abundance of parasites in smears from the placenta taken at time of delivery when the peripheral blood showed few or no parasites. Such an examination is of enormous value in differentiating a malarial paroxysm from puerperal sepsis.

Malta Fever.—In this disease, in which the wave-like febrile periods during every three or four weeks are so characteristic as to give it the name of “febris undulans,” there is a very insidious onset. For a week or ten days the temperature climbs up step-ladder-like and then descends in like manner to be followed by a few days of apyrexia with succeeding similar relapses. The case would suggest an attack of typhoid with relapses.

The course of the disease is attended by rather marked anaemia and physical and mental depression. Very characteristic are the fleeting joint pains which involve chiefly the knees, hip, ankle and shoulder joints. There are pain and some swelling but without redness. Neuralgic pains are also common. There is often a bronchitis which, when associated with the rather common night sweats of the disease, is suggestive of phthisis.

The cardiac muscle seems to be especially liable to the toxic effects of the disease so that a weak heart and intermittent pulse are often noted. It has a very protracted course of, on the average, about four months.

An astonishing fact is that so severe and a prolonged fever should give such a slight mortality (2%).

Occasionally, a case shows a high continued or remittent fever and aggravated symptoms, going into a typhoid state. Such cases are often fatal. There is an increase in the lymphocytes but no increase in total leucocytes.

The wave course of the fever, with afebrile intervals and increasing anaemia, is suggestive of kala-azar, particularly when there is a greater enlargement of the spleen than is usual in the disease. Ordinarily the splenic enlargement about corresponds to that of typhoid fever but at times it may be so much enlarged as to suggest the splenic tumor of kala-azar.

DISEASES IN WHICH FEVER IS AN IMPORTANT FEATURE BUT GIVES LITTLE ASSISTANCE IN DIAGNOSIS

Kala-azar.—This disease has a peculiarly insidious onset because, with a fairly high remittent fever, it may cause but slight feeling of illness in the patient.

Rogers insists upon the importance of taking the temperature every four hours so that one may note the fact of there being two distinct rises in the twenty-four hours instead of the single evening rise of typhoid fever.

At first it is confused with malaria as well as typhoid. The spleen becomes greatly enlarged by the third or fourth month and later on we also have enlargement of the liver. Periods of fever and apyrexia occur irregularly and over a period of months or even longer than a year.

There is a marked leucopenia and the presence of the leishman-donovan bodies, often in huge numbers, in the juice from spleen or liver puncture, makes for a certain diagnosis.

Yellow Fever.—With a sudden onset and rapidly rising fever, which often occurs in the early morning hours, in a patient who has gone to bed feeling well, we have a markedly congested face and neck with injected conjunctivae and intense headache and backache. The fever tends to remain elevated for about three days after which there may be noted a fall in temperature or even an intermission. This, which has been termed the period of calm, is often slight and of short duration. About this time the jaundice and haemorrhages show themselves and the temperature tends again to rise although less marked than with the sthenic fever of the first two or three days. Of great importance is the fact that the pulse rate falls with a maintained temperature or does not increase in rate as the temperature rises (Faget’s law). A very slow pulse is quite characteristic of yellow fever after the third day.

Important in the diagnosis of yellow fever from bilous remittent fever and blackwater fever is the absence of splenic enlargement in the former. In particular must it be remembered that jaundice does not show itself in yellow fever until about the third day, following which we may have bleeding from the gums and black vomit.

Melaena and haematuria may also be noted. The presence of a marked albuminuria is one of the leading characteristics of yellow fever.

Blackwater Fever.—The onset is usually quite sudden with a rather severe chill and marked lumbar pain.

The temperature rises rapidly to about 104°F. and may fall in a few hours to a point but little above normal accompanied by profuse sweating. The fall in temperature is not followed by a feeling of improvement. On the other hand there may be a fever course of remittent or even continuous type. That which is most characteristic and which in the majority of cases enables the patient to make his own diagnosis is the passage of dark or porter-colored urine.

The urinary sediment is simply granular débris, there are no intact red cells. It is a haemoglobinuria and not a haematuria. If there is any blood in the urine in yellow fever it is in the form of a haematuria. The urine in both blackwater fever and yellow fever is highly albuminous. In some cases the haemoglobinuria seems to result from quinine administration alone, in which case there is not the high fever of typical blackwater fever. As distinguishing it from yellow fever we have a marked jaundice which comes on in a few hours or even with the first appearance of haemoglobinuria instead of being delayed until the third day, as in yellow fever. Again, the blackwater paroxysm is intensely prostrating, it is markedly asthenic, while the onset of yellow fever is quite sthenic in character. The enlarged tender spleen of blackwater fever is also a prominent feature, which is absent in yellow fever. Bilious vomiting is an early and severe feature of blackwater fever but not the black vomit of yellow fever which does not come on until after the third day.

The jaundice of bilious remittent fever does not appear before the second day and the urine shows bile pigments instead of haemoglobin.

Plague.—The fever rapidly rises, so that the maximum temperature of 104°F. or more may be attained on the first day of the disease. In general the type of fever is continuous with a rather marked remission about the third day, following which, the fever again goes up with the appearance of the glandular involvement (bubonic plague).

In fatal cases the temperature may shoot up just prior to death. The drawn anxious countenance, the mental state and speech as of one suffering from alcoholic intoxication, and the early cardiac involvement, with very weak and irregular pulse, give one a clue to plague even before the buboes appear. Smears and cultures from the buboes make the diagnosis.

In plague pneumonia there is nothing characteristic about the rather continuous fever which sets in suddenly and continues elevated until death, which generally occurs about the third or fourth day. The marked mental involvement, the extreme illness of the patient, with but slight physical signs of the involvement of the lungs, should make one suspect a plague pneumonia during an epidemic. The abundant, rather watery sputum, which later becomes sanguineous, gives us a diagnosis by reason of its being loaded with bipolarly stained plague bacilli. This material should be rubbed on the shaven abdomen of a guinea pig to make the diagnosis absolutely sure.

In septicaemic plague, if such be considered a distinct type, there is very little that is manifest except a fever in a profoundly ill person. The powers of resistance may be so overwhelmed that the temperature response is slight and the chart not show temperature records above 100°F. or 101°F. Blood cultures make for the diagnosis in septicaemic plague.

Typhus Fever.—While the classical temperature chart is usually described as one with a rapid rise, reaching the maximum of 103° or 104° by the second day, with a fastigium of twelve to fourteen days, followed by a critical fall, yet many cases recently observed in the Balkans show a fairly gradual onset with a fall by lysis.

A stuporous condition with, about the fifth day, a rash first appearing about abdomen and flanks, to soon become petechial, are important in diagnosis. There is a leucocytosis with marked acid staining of the granules of the polymorphonuclears.

Trypanosomiasis.—The fever of trypanosomiasis is markedly irregular and may exist in natives without preventing them from carrying on their duties as porters. The onset is on the whole insidious.

In this first stage of trypanosomiasis or trypanosome fever, when trypanosomes are found only in the glands and peripheral circulation, what may probably be considered as leading peculiarities of the fever are the great daily oscillations, a normal morning temperature being succeeded by an evening rise up to 102°F. or 104°F.

While the febrile course is usual in Europeans it is often absent in natives. With them the febrile manifestations are noted in the sleeping sickness stage.

Again a very rapid, low tension pulse is present, whether the temperature be low or high. These febrile accessions are followed by apyrexial intervals.

Extremely important in diagnosis are the glandular enlargements of which those of the upper posterior cervical triangle are the most characteristic (Winterbottom’s sign). Gland juice is more apt to contain trypanosomes than the smear from the blood. Deep hyperaesthesia is also a very characteristic symptom (Kérandel’s sign).

When the trypanosomes are found in the cerebro-spinal fluid we have the second stage of trypanosomiasis or that of sleeping sickness. This is ushered in by a tremor of the tongue and mental symptoms of great apathy and listlessness. An irregular fever is present at times during the course of this stage of sleeping sickness but toward the end of the disease the temperature tends to be subnormal.

Progressive weakness and emaciation with finally a comatose state are features of the terminal weeks.

Brazilian Trypanosomiasis.—The disease begins acutely in young children with an irregular remittent fever. The parasites are not apt to be found except during the fever. The lymphatic glands become swollen. With repeated accessions of fever, followed by apyrexial intervals, the child becomes weaker and more anaemic. The spleen is enlarged. This infection is very fatal for children.

In adults the disease tends to assume a chronic type and often, from involvement of the thyroid, gives symptoms of myxoedema.

Bacillary Dysentery.—The onset may be quite sudden and the temperature rise to 102°F. or 103°F. There is apt to be some evidence of toxaemia as shown by headache, slight flightiness and gastric upset. The dysenteric stool is of a whitish, mucopurulent appearance and flecked or streaked with blood rather than showing the uniformly brownish or greenish gelatinous material of amoebic dysentery.

In very severe bacillary dysentery algidity may come on with a cold clammy skin, reminding one of cholera. At such times the temperature is subnormal.

Liver Abscess.—In the so-called pre-suppurative stage of amoebic hepatitis the only symptom may be an irregular remittent fever of moderate degree. This and a leucocytosis may be the only points noted.

In fully developed liver abscess we have a painful liver which is enlarged upward often with pain referred to the right shoulder and a crepitation at the base of the right lung. The fever is distinctly hectic in type with an evening rise and associated with profuse sweatings. The evening rise of temperature does not usually tend to exceed 102°F. and apyrexial intervals are frequently observed in the fever chart.

It must be remembered that liver abscess has been found at autopsy where fever had not been noted. A sensation of chilliness often accompanies the evening rise of temperature.

Heat stroke.—The onset may be as sudden as in apoplexy, although there are usually prodromata of dizziness and headache. The patient is unconscious with dry burning skin, labored or stertorous breathing, and a temperature of from 107° to 111°F.

The hyperpyrexial malarial paroxysm presents much in common with heat stroke.

Climatic Fevers.—From many parts of the tropical world there have been reported cases of fever supposed to be due to exposure to prolonged action of tropical heat. They are often designated as climatic or inflammatory fevers.

A careful study of the clinical manifestations tends to show that many of them are much like dengue. Some may be due to infection with the Gärtner group of bacteria.

Rat Bite Disease.—Following a rather long incubation period of from six to eight weeks, during which time the bite has healed, we have a rather sudden invasion with high fever, 103° to 104°F., chill and at the same time inflammation of the site of the bite with lymphangitis and some swelling of tributary glands.

After two or three days of high fever we have a fall by crisis with profuse perspiration. The temperature remains normal for a few days during which time the local swelling and inflammation subside. The fever again comes on, frequently with an eruption, to later on disappear and reappear. At such times the fever course is irregular. There may be as many as 12 of these febrile accessions.

Tsutsugamushi.—The disease sets in about a week after the bite of the Kedani mite with headache, chills and fever of about 101°F. There is also pain in certain lymphatic gland groups which will be found to drain the area in which is located a small necrotic ulcer, the site of the bite of the mite. The temperature continues to rise during the next two or three days to 104°-105°F. and remains as a high continuous fever for about a week, when an eruption of irregular dusky macules appears, first on the face and later on chest, extremities and trunk. About the tenth day the fever begins to go down by lysis and the eruption fades. Injection of the conjunctivae is marked.

Certain authorities have considered that there is a striking clinical similarity and possible relation attaching to tsutsugamushi, Rocky Mountain spotted fever, trench fever and typhus fever. At present we believe that tabardillo or Mexican typhus is the same as the well-known typhus of temperate climates, hence that which describes typhus fever obtains for tabardillo.

Spotted Fever of the Rocky Mountains.—In tabardillo the onset and termination of the fever is rather abrupt while in spotted fever of the Rocky Mountains it climbs up gradually for a week to reach its maximum and falls by lysis.

All these diseases are characterized by a more or less stuporous state.

Oroya Fever.—It was formerly supposed that this fever was the first stage of verruga, but it is now considered as a distinct disease entity, caused by a protozoon of bacillary form which invades the red cells. With pains of various joints and bones we have a gradual rise of temperature which after a few days reaches 103° to 104°F. and tends to become remittent or continuous.

There is a remarkable and excessive destruction of the red cells which may fall to a million or less per c.mm. The fever after about three weeks begins to fall by lysis. Enlargement of liver, spleen and lymphatic glands are common. Pain over the bones, especially the sternum, is often excruciating.

Epidemic jaundice shows an irregular pyrexia of from 102° to 103°F. with jaundice about the second or third day.

Trench Fever.—Cases of varying types of fever, some charts more or less resembling the dengue ones, while others show repeated relapses of short duration, have been designated trench fever.

In tularaemia we have an irregular fever course of rather rapid onset, extending over two or three weeks. There is very little evidence of toxaemia. Convalescence is tedious.

Typhoid fever and the paratyphoid infections are far from uncommon in the tropics and present clinical courses at variance with those observed in temperate climates. The temperature charts in such cases are irregular and atypical.

It must be remembered that paratyphoid infections may show marked gastro-intestinal symptoms and that the rose rash of such cases tends to be far more profuse than that of typhoid.

Intestinal Parasites.—There are many conditions which seem to be productive of febrile attacks as evidenced by the disappearance of the fever upon removing such cause. Thus patients presenting abdominal distress and a fever of varying type may be completely relieved of all symptoms upon evacuating the larvae of various flies following purgation. This condition is designated intestinal myiasis.

Abdominal pains and fever may also be caused by various helminths usually considered nonsymptom-producing as has been noted in heavy Ascaris infections.

Spotted a typo or a problem in this chapter? Tell us