The petechiae are due to thrombosis of t_The diagnostics and treatment of tropical diseases

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.

[Illustration: FIG. 142.—Female _Pediculus corporis._—(Schamberg

_After Kuechenmeister_.)]

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.

[Illustration: FIG. 143.—Temperature chart of typhus fever. (Pepper,

American Text-book of Medicine.)]

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.

CHAPTER 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.

CHAPTER 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.

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.

[Illustration: FIG. 144.—Juxta-articular nodules. (After Steiner;

from Mense.)]

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.

PART II

DIAGNOSTICS OF TROPICAL DISEASES

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

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

the lungs | 1,605|1,334|1,340| 223| 206| 169| 20| 20| 27

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

hemorrhage | 109| 99| 93| 27| 39| 40| 10| 9| 4

(infants) | 224| 148| 91| 3| 4| 5| 4| 1| 1

endocarditis | 46| 29| 28| 17| 14| 7| 0| 1| 2

of the heart | 118| 95| 93| 63| 37| 45| 9| 17| 27

arteries | 18| 23| 15| 15| 27| 34| 9| 7| 9

Acute bronchitis | 975| 335| 630| 34| 14| 17| 0| 0| 0

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

two years) | 642| 365| 365| 156| 136| 162| 13| 4| 11

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

parasites | 16| 12| 5| 0| 2| 0| 1| 0| 0

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

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_.

[Illustration: FIG. 145.—General type of fever onset in the

various tropical diseases.]

_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.

[Illustration: FIG. 146.—General type of termination of the febrile

course in the various tropical diseases.]

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.

The petechiae are due to thrombosis of the smaller vessels