_Enteric Group of Fevers._—In fevers of atypical course in the

tropics one must always remember that _typhoid_ and the _paratyphoid

fevers_ are anything but uncommon and blood cultures should always be

made when such suspicion arises. In some tropical regions paratyphoid

A infections seem most common although the usual experience is to

encounter the paratyphoid B infection more frequently. In temperate

climates the noting of a moderate leucopenia with an absence of

eosinophiles is important in the diagnosis of typhoid, but in the

tropics there are so many intestinal parasites and skin infections

productive of eosinophilia that we cannot attach any importance to

such a finding.

_Typhus Fever._—Plotz attaches importance to the culturing of

_B. typhi exanthematici_ from the blood of typhus cases, but the

relationship is now regarded as not causal. _Rickettsia_ bodies,

which can be demonstrated in the louse or in capillaries at autopsy,

are now considered to be the exciting organism.

A mononuclear leucocytosis has at times been reported.

_Spotted Fever of the Rocky Mountains._—Injection of the blood of

the patient into guinea pigs produces the disease in the animal.

Frick has reported the finding of chromatin-staining bodies in the

red cells of such pigs and Wolbach has found chromatin-staining

bacteria in the endothelial cells of such animals. These bodies are

now classed as _Rickettsia_.

These findings cannot as yet be considered of diagnostic value.

_Various Helminthological Infections._—In the earlier stages of

ancylostomiasis and schistosomiasis we have a rather notable increase

in the percentage of eosinophiles but with the advanced stages of

these infections, with severe anaemia, the eosinophiles may even be

absent.

One should always keep in mind the very characteristic and marked

eosinophilia of _trichinosis_ when such a blood finding is

encountered. There is often a leucocytosis of 15,000 to 20,000 in

this disease.

In the _urticarial fever_ stage of _Japanese schistosomiasis_

the marked eosinophilia is of great assistance in diagnosis. One

trouble about attaching importance to eosinophilia in the tropics

is the confusion which is difficult to eliminate and which arises

from infections with the more common but less important group of

intestinal parasites such as _Ascaris_, _Trichuris_, etc.

The eosinophilia-producing characteristics of many skin diseases

must also be kept in mind.

CHAPTER XLVI

THE CIRCULATORY, RESPIRATORY AND LYMPHATIC SYSTEMS TOGETHER WITH

ANAEMIA, HAEMORRHAGES AND OEDEMA IN TROPICAL DISEASES

THE CIRCULATORY SYSTEM

_Beriberi._—Almost as important in diagnosis as the weakness of

the legs, with anaesthetic and oedematous areas, is the early

palpitation of the heart upon the slightest exertion. Later on as

the vagal degeneration becomes more prominent we have a loss of the

normal cardiac rhythm, to even become embryocardial, together with

dilatation of the right heart, pulsating jugulars and various blowing

murmurs, which are propagated into the vessels of the neck. The pulse

is weak and rapid and this combination of a tumultuous heart action

and weak pulse is striking. Blood pressure is below normal.

Cardiac involvement is also a feature of _ship beriberi_ as well

as _infantile beriberi_. In the latter a marked hypertrophy of the

right heart is characteristic.

In _yellow fever_ we have at first a high blood pressure. The pulse

rate, which at first corresponds with the rise of temperature, soon

shows Faget’s law—a falling pulse with a constant temperature or a

constant pulse with a rising temperature. It is a markedly slow pulse

after the third day. The blood pressure is low in the asthenic stage.

In _dengue_ we do not have the rise in blood pressure but the slow

pulse is quite a feature of many of the dengue-like fevers.

In _blackwater fever_ the pulse is rapid and soon becomes weak and

of low tension.

_Plague_ shows a striking toxic action on the heart muscle so that

we soon get a soft, dicrotic pulse, rapid from the first and soon

becoming thready. Patients with plague may die from cardiac failure

upon getting up from bed.

A rapid pulse, especially in the morning, is thought to be a

feature of _active leprosy_.

In _cholera_ the pulse is rapid and feeble during the stage of

evacuation and with the onset of the algid stage we practically have

a cessation of the circulation. The systolic pressure may fall as low

as 65 or 70 mm.

_Hookworm anaemia_ shows early and marked cardiac palpitation. The

pulse rate averages about 110 and the blood pressure is low. There is

often some right-side dilatation of the heart.

_Malaria_ generally gives a small, rapid, high tension pulse in the

cold stage to become full and bounding in the hot stage. A cardiac

type of pernicious malarial fever has been described, particularly

by the French.

Both _Malta fever_ and _bacillary dysentery_ tend to have a toxic

effect on the heart.

_Typhus fever_ is a disease which tends markedly to affect the heart.

Along with faint heart sounds we have a rapid, low tension pulse. In

_bacillary dysentery_ the tendency to an increase in pulse rate is of

some value in differentiating it from amoebic dysentery.

_African trypanosomiasis_ shows a rapid pulse rate whether the

case shows temperature or not. In _Brazilian trypanosomiasis_

the parasites may tend to invade the cells of the heart muscle

thus producing manifestations of myocardial disease. The parasite

(_Schizotrypanum cruzi_) may also affect the adrenals, causing a

low blood pressure along with other signs of Addison’s disease.

THE RESPIRATORY SYSTEM

_Sputum Examination._—We should make a routine of examining a

fresh specimen of sputum as well as stained smears. It is in such a

specimen we search for the ova of the lung fluke.

Frequently the material submitted for examination as sputum is

simply buccal or pharyngeal secretion, or more probably secretion

from the nasopharynx, which has been secured by hawking. It should

always be insisted upon that the sputum be raised by a true

pulmonary coughing act, and not expelled with the hacking cough

so frequently associated with an elongated uvula. When there is

an effort to deceive, some information may be obtained from the

watery, stringy mucoid character of the buccopharyngeal material

and also from the presence of mosaic-like groups of flat epithelial

cells (often packed with bacteria).

The pulmonary secretion is either frothy mucus or mucopurulent

material, and if the cells are alveolar they greatly resemble the

plasma cells. At times these cells may contain blood-pigment granules

(heart-disease cells).

In the microscopic examination a small, cheesy particle, the size

of a pin head, should be selected. This should be flattened out

in a thin layer between the slide and cover-glass and should be

examined for elastic tissue, heart-disease cells, eggs of animal

parasites, amoebae, and fungi. _Echinococcus_ hooklets, Curschman

spirals besprinkled with Charcot-Leyden crystals, and haematoidin

and fatty acid crystals may also be observed.

Curschman spirals indicate bronchial as against cardiac or uraemic

asthma. Charcot-Leyden crystals have no special significance,

except in certain tropical diseases when these crystals often are

present in paragonomiasis sputum and in the pus of amoebic liver

abscesses discharging by way of the lungs.

It may facilitate the examination of the sputum for elastic tissue

and actinomycosis and other fungi to add 10% sodium hydrate to the

preparation.

To make smears for staining, the sputum should be poured on a

flat surface, preferably a Petri dish, and a bit of mucopurulent

material selected with forceps. A dark background facilitates

picking out the particle. A toothpick is well adapted to smearing

out such material on a slide. After using the toothpick it can be

burned. When dry, the smear is best fixed by pouring a few drops

of alcohol on the slide, allowing this to run over the surface,

and then, after dashing off the excess of alcohol, to ignite that

remaining on the film in the flame and allow to burn out.

In _beriberi_ we have shortness of breath with the early cardiac

palpitation. In acute pernicious beriberi the pulmonary congestion

and oedema divide with the heart the terrible manifestations of such

an attack. The diaphragm may become paralyzed in beriberi. Some

authors refer to the dyspnoea of beriberi as the beriberic corset.

_Paragonomiasis_ gives rise to a chronic cough attended with

the expectoration of more or less bloody sputum containing ova.

Haemoptysis is not infrequent. The physical signs on percussion are

slight but may be more marked on auscultation.

_Hirudiniasis._—In Northern Africa, as well as in many islands of

the Orient, the drinking water of ponds may contain leeches and

these water-leeches tend to attach themselves to the pharyngeal

mucosa. They may also attach themselves to the tissues about the

larynx. In these cases we not only have cough and haemoptysis

but dyspnoea from laryngeal oedema. It is probable that cases of

dyspnoea called _halzoun_, and due to the attachment in the region

of the larynx of flukes (_Fasciola hepatica_), as the result

of eating raw liver, may often be due to leeches, as the two

affections occur in the same regions.

_Plague pneumonia_ is characterized by profound prostration in a

patient whose physical signs do not seem to justify such extreme

illness. The rather abundant and watery sputum soon becomes

sanguinolent. Herpes labialis is absent. Besides primary plague

pneumonia which develops directly from contact with a former case we

have a secondary pneumonia which develops in the course of a typical

case of bubonic plague.

In _malaria_ we have a slight bronchitis in the ordinary types and

many recognize a pulmonary type of pernicious malaria.

_Malta fever_ tends to show a bronchial involvement about the twelfth

day of the disease. Crepitant râles, a moderate cough and slight

dyspnoea may be noted. It was the presence of pulmonary signs along

with the profuse sweating and anaemia of the disease that justified

the designation Mediterranean phthisis.

In _liver abscess_ the crepitation at the base of the right lung,

following congestion incident to the abscess of the right lobe of

the liver, is of value in diagnosis. Rupture of a liver abscess

into the lung occurs in about 10% of cases.

In _heat stroke_ we may have Cheyne-Stokes respiration and

pulmonary oedema.

_Japanese river fever_ often shows bronchial involvement and cough

at the time of the height of the fever.

In _ancylostomiasis_ cases with cough and bronchitis have been

reported and it seems probable that such manifestations may be

connected with the course of the larvae through the pulmonary

passages to reach the intestinal tract.

The filarial embryos of _F. bancrofti_ remain in the lung capillaries

during the day and recently such embryos have been found in blood

coughed up from the lungs.

_Katayama disease_ may show a localized bronchitis early in the

attack and from its rapid appearance and disappearance would seem

to be a sort of patchy pulmonary oedema. This is connected with the

passage of the larvae through the lungs.

Broncho-pneumonia is probably the most common complication of

_typhus fever_.

An affection known as _gangosa_ or _rhino-pharyngitis mutilans_

causes great tissue loss about nasal and buccal cavity. The voice has

a peculiar nasal quality. It is possibly a manifestation of tertiary

yaws.

_Kala-azar_ patients are often carried off by a terminal pneumonia

probably connected with the leucopenia and marked diminution of

polymorphonuclears.

In _leprosy_, also, the victims are frequently carried off by

pulmonary tuberculosis.

_Relapsing Fever._—In relapsing fever there is frequently a moderate

bronchitis at the time of the first febrile accession.

_Bronchial Spirochaetosis._—There is a condition which more or

less resembles lobar pneumonia, even to rusty sputum, but without

signs of consolidation, and with negative Roentgenograms, when

we find spirochaetes in the sputum. Another type of _bronchial

spirochaetosis_ is when the clinical picture is more that

of pulmonary tuberculosis. There is question whether these

spirochaetes are causative or only accidental.

Cases have been reported where a phthisis-like condition was due

to a mould infection (_Monilia_). While such a condition may be

primary it is more often secondary in cachexias as may be the

case with buccal _Monilia_ infections (thrush) which occur in the

victims of cachectic states.

_Guha._—In Guam there is also a rather fatal capillary bronchitis

affecting young children which goes under the name of epidemic

asthma or, as termed by the natives, guha. This affection comes on

during the rainy season and is attended with marked dyspnoea and

slight elevation of temperature.

_Nasal Myiasis._—In the tropical and subtropical parts of North and

South America a fly, _Chrysomyia macellaria_, is apt to deposit its

eggs about the nasal orifices of persons with an offensive discharge

from the nose. The fly seems to be attracted by foul odors. The

larvae which develop are called “screw-worms” on account of the

segmental bands of bristles and tend to invade the various sinuses,

causing great destruction of tissue.

The case sets in with signs of a very severe coryza, together with

fever and marked frontal headache. The face becomes swollen, red,

and tender in the region of the nose. As the larvae reach maturity

they come out of the nose. A nasal douche of 15 parts chloroform in

100 parts milk is often efficacious in bringing away the larvae. At

times _Sacrophaga_ larvae may be found.

THE LYMPHATIC SYSTEM

_Plague._—The buboes are the most characteristic feature of the

more common form of plague, bubonic plague. There may also be slight

enlargement and tenderness of the glands in septicaemic and pneumonic

plague but many such cases fail to show any evidence of superficial

glandular enlargement. In pestis minor the only feature suggestive of

plague is the glandular enlargement.

Very characteristic of the glandular involvement in plague is

the marked tenderness of such glands. The slight pressure of

palpation causes some pain and a sharp punch over an affected

gland, excruciating pain. So exquisitely painful are these buboes

that the patient with groin or axillary buboes will flex the leg or

extend the arm to relieve pressure. In about 70% of cases the bubo

is located in the groin, with 15% to 20% for axillary involvement

and 5% to 10% for the submaxillary or cervical region. There may

be involvement of both deep and superficial glands of a region,

such buboes giving a large area of induration. As a rule there is

a single bubo. The bubo is formed not only by the glands but by a

periglandular oedema which fuses the glands into a solid mass. The

buboes tend to suppurate about the commencement of the second week,

so that gland puncture with subsequent culturing for plague bacilli

and animal inoculation should be carried out before this time as

pyogenic organisms replace the plague bacilli upon suppuration

taking place.

_Trypanosomiasis._—One of the characteristics of the disease

recognized as diagnostic more than 100 years ago is enlargement of

the glands of the posterior cervical triangle (Winterbottom’s sign).

There may be general enlargement of the lymphatic glands which

are rather hard, discrete and not bound down to the overlying

skin. These glands may be somewhat tender or entirely painless.

One of the most valuable methods of diagnosis of trypanosomiasis

is by gland puncture, the juice obtained therefrom being examined

in smear or inoculated into a monkey or guinea pig. Brazilian

trypanosomiasis also shows glandular involvement.

_Filariasis._—Varicose groin glands are frequently associated with

lymph scrotum, chylocele or chyluria. The glandular masses are soft

and doughy. The consistency is often that of a lipoma.

The overlying skin slips over the glandular mass. These glands are

often mistaken for inguinal hernia. They do not give a tympanitic

note and disappear slowly upon firm pressure with the patient lying

down but return even with the pressure maintained upon assuming the

upright position. There is no impulse on coughing. If a sterile

hypodermic needle be inserted into the mass a chylous fluid slowly

and persistently comes out of the needle drop by drop and this

material may show filarial embryos.

The filarial worms _Onchocerca volvulus_ obstruct the lymphatics and

may give rise to swellings of considerable size along the course of

the lymphatics.

_Climatic Bubo._—The onset is gradual often accompanied by a low

remittent type of fever. There is an absence of venereal sore.

These glands are only slightly tender and are often called fatigue

glands as they produce a feeling of weariness after even moderate

exercise. The inguinal glands of one or both sides are the ones

involved but the overlying skin does not show the redness of a

chancroidal or gonorrhoeal bubo. There is often a softening in the

center of the affected glands.

_Tsutsugamushi._—The glands which drain the area in which is located

the ulcer at the site of the bite of the Kedani mite show swelling

and tenderness.

_Rat bite fever_ also shows glandular enlargement in the glands

tributary to the healed infecting bite of the rat.

In _tularaemia_ the lymph glands draining the site of the infecting

bite become inflamed and swollen, often suppurating.

In _leprosy_ the glands draining involved regions become enlarged

but do not show a tendency to suppuration. The glands most

frequently involved are the cervical and groin glands.

In _kala-azar_ the recommendation has lately been made to excise the

somewhat enlarged glands and make smears from a piece of such gland

and then examine the smear for leishman bodies. Gland puncture has

not given as satisfactory results.

It is often stated that the superficial cervical glands are

enlarged in _dengue_ but not in dengue-like fevers. I have not

observed in the cases I have seen either constant or well marked

glandular enlargements.

In _yaws_ there may be glandular enlargement. According to Finucane

the cervical glands are often involved in Fiji children. These glands

do not tend to break down.

In _pediculosis_ of the hairy scalp the scratching back of the

neck may result in pus infection with enlargement of the tributary

cervical glands.

_American leishmaniasis._—Not only is there often enlargement of

the lymphatic glands but likewise we may have lymphangitis lines

leading from the ulcer to the glands. The glands may be large and

painful and may remain enlarged after the recovery of the patient.

ANAEMIA

The old idea that tropical life produced an anaemia is no longer

held, the view now being that such anaemic conditions are almost

invariably due to some well recognized cause, the most important of

which is malaria. Natives of the tropics may appear bleached out but

show a normal red count and haemoglobin percentage. Chamberlain’s

observations have shown that a residence in the tropics of

approximately two years has no appreciable influence on the red cell

count or haemoglobin content of the blood of white men and that the

actinic rays do not seem to be operative in producing anaemia.

_Malarial Cachexia._—Although the malignant tertian infection

has the greatest tendency to produce anaemia yet any type may,

when untreated, bring about the more or less profound anaemia with

earthy skin, enlarged spleen, dyspnoea on slight exertion, and

oedema of the ankles characteristic of malarial cachexia.

_Oroya Fever._—In this disease we have what might well be termed

a fulminating pernicious anaemia. The rod-shaped protozoon which

attacks the red cells seems to be peculiarly active in the bone

marrow, excruciating bone pains being quite a feature of the disease.

There may be a reduction in red cells to one million per c.mm.

within a few days. Normoblasts are abundant and megaloblasts may be

observed in the more severe cases. The anaemia is intense and 20%

to 40% of cases die within two or three weeks. A severe anaemia in

which the blood picture is that of pernicious anaemia may accompany

infections with the _Balantidium coli_.

_Blackwater fever_ may produce a fall in red cells almost as marked

as in Oroya fever.

_Sprue_ shows a slowly progressive anaemia which in the later

stages of the disease may become extreme, going down to one

million, with a fairly high color index.

_Ancylostomiasis_ is along with malaria the disease to be first

thought of in connection with anaemia. The splenic enlargement of

malaria should be thought of, although the view has recently been

advanced that the spleen may be enlarged in hookworm disease.

In advanced cases of hookworm disease, showing a picture of

profound anaemia, there may be so few worms present that the

method of making diagnosis by finding ova may be unsuccessful. I

have seen a case of typical aplastic pernicious anaemia, confirmed

by autopsy, undoubtedly following a vicious cycle set up by the

hookworm infection, in which scarcely a worm was to be found in

searching the intestines.

_Kala-azar_ gives a marked anaemia with an earthy color of the skin.

The leucopenia and splenic enlargement are characteristic and the

finding of parasites confirmatory.

_Malta fever_ is usually followed by a moderate anaemia.

The _helminthic infections_, besides hookworm disease, are always

to be thought of in the presence of anaemia. Very important among

these are rectal and vesical schistosomiasis as well as that from

the Japanese schistosome, together with liver and lung fluke

disease. Even the ordinary round-worm, _Ascaris lumbricoides_, is

to be thought of in a tropical anaemia.

Cases of anaemia, in which no other demonstrable cause has been

noted, have been thought to be due to _trichocephaliasis_.

_Tropical dysenteries_ are often responsible for anaemia and in

liver abscess the patient becomes quite earthy in color, provided no

operation is performed. In chyluria there is a marked drain on the

patient.

The anaemia in _liver abscess_ is not so great as the muddy

complexion would indicate. The emaciation is greater than the

anaemia.

HAEMORRHAGES

The loss of blood through haemoglobinuria and haematuria has been

taken up under the urine. The haemoglobinuria is the pathognomonic

symptom of blackwater fever. There is also recognized a haemorrhagic

form of pernicious malaria with epistaxis and alimentary tract

haemorrhages. Moderate haemoglobinuria may be found in severe cases

of malignant tertian infections.

_Yellow Fever._—During the asthenic period of the disease, which

sets in about the fourth day, we have, as a result of the damage to

the endothelial lining of the capillaries, various haemorrhages.

Of these the best known and most dreaded is that from the stomach,

black vomit. The bleeding from the gums is apt to appear before

that from the stomach. Not only may bleeding occur from the

intestines but from any mucosa, as that of the nose, conjunctiva or

vagina.

In _vesical and rectal bilharziasis_ the perforation of the terminal

branches of the portal vein by the terminal or lateral spined eggs

gives rise to haemorrhages.

In _dengue_ we may have an epistaxis at the time of the crisis of

the first febrile paroxysm.

In _dysentery_ the blood-admixed mucous stools are of diagnostic

importance.

In _endemic haemoptysis_ the operculated eggs of _Paragonimus

westermanni_ are to be sought for in the sputum.

In _leprosy_ epistaxis may be an early sign.

The damage to the endothelial lining of capillaries in _plague_ gives

rise to frequent haemorrhages into the skin.

There is a question whether the hookworms abstract blood from the

intestines, although tests for occult blood are deemed important by

some authorities in the diagnosis of this disease.

The granulomatous lesions of _verruga_ are markedly haemorrhagic.

Some consider _ship beriberi_ to be of the nature of _scurvy_ in

which case one should have in mind spongy, bleeding gums and the

intramuscular haemorrhages of scurvy.

_Typhus Fever._—The petechial rash of this disease (mulberry rash)

is a distinctive feature.

OEDEMA

Oedema, especially about the ankles, is to be looked for in all

the secondary anaemias of the tropics, particularly malaria and

ancylostomiasis.

_Beriberi._—The oedema begins at first about the feet, especially

about the dorsal junction of phalanges and metatarsus. It is

characteristically pretibial. It may remain confined to the shin or

go up to knees, scrotum, sternal region or trunk. It is generally

symmetrical but may be unilateral. It may become a general anasarca,

even in forty-eight hours.

The swelling of the face is at times enormous, the eyelids being so

oedematous that the patient can see only by separating them with

the fingers. The oedema is more solid than that of nephritis. It

not only rapidly appears but disappears as rapidly.

The oedema of beriberi may involve the glottis (oedema of glottis).

Oedema of genital regions is less marked than in nephritis or

cardiac disease. We may also have localized areas of oedema 3 or 4

inches in diameter.

_Ship beriberi_, which has points in common with both beriberi and

scurvy, shows oedema which may be limited to the lower extremities

or generalized. _Epidemic dropsy_ is a type of beriberi in which

there are fever and an erythema over the dropsical areas.

_Calabar Swellings._—These seem connected with infections with

_Filaria loa_. The swellings originate suddenly and disappear in

three or four days. They are hard and do not pit on pressure. These

smooth swellings, often 2 to 4 inches in extent, are most often seen

on arms, face or ankles.

In _trypanosomiasis_ oedema of the face and especially of the

eyelids may be striking. There may also be patches of oedema

elsewhere.

In _Katayama disease_ the urticarial areas of oedema have given it

the name of urticarial fever.

A peculiar disease of North China, known as _atriplicism_, is

caused by the eating by the very poor of a weed, _Atriplex_, common

around Pekin. There is itching of the fingers, quickly followed by

swelling. This tends to extend to the back of the hands and up the

outer surface of the forearm. The face becomes so swollen that the

eyelids may be closed.

CHAPTER XLVII

JAUNDICE AND THE LIVER AND SPLEEN IN TROPICAL DISEASES

JAUNDICE

Although the appearance of jaundice immediately suggests a disease of

the liver yet as a matter of fact those diseases of the tropics in

which the liver involvement is the sole or chief feature rarely show

marked jaundice.

In _tropical hepatitis_ or congestion of the liver or, as it is

often termed, tropical liver, there is rarely a distinct jaundice

and if such occur it is only temporary. Such terms as earthy,

muddy, sallow, sub-icteric or pale lemon tint are more often

applied than jaundice.

_Liver abscess_ rarely gives rise to a definite jaundice unless the

abscess be so situated as to cause pressure on the bile ducts.

In _clonorchiosis_, or the liver fluke disease of man, jaundice is

not a feature of the disease except in the very late stages.

In those liver cirrhoses associated with _Katayama disease_,

_malaria_ or _kala-azar_ there is no typical jaundice.

The tropical diseases in which jaundice is an important diagnostic

feature are yellow fever, blackwater fever, bilious remittent fever

and relapsing fever.

_Yellow Fever._—There are cases which succumb without having shown

jaundice but immediately following death the yellowish discoloration

has been noted. At autopsy the yellow fever cadaver is almost

invariably deeply jaundiced.

Very important is the fact that the jaundice of yellow fever does

not appear until late, about the third or fourth day. When jaundice

appears earlier, as by the second day, the prognosis is almost

surely a fatal one.

According to Dutroulau the designation red fever would be more

appropriate for the deeply congested facies of a yellow fever case

in its first days.

The icterus is more marked about the face, neck and upper parts of

the trunk. The albuminuria precedes the jaundice.

_Blackwater Fever._—In a typical case of this disease we have within

a few hours a marked jaundice which tends to deepen. It is usually

more or less marked according as the haemoglobinuria may be. It does

not show the tendency to persist as does the jaundice of yellow fever.

_Bilious Remittent Fever._—The jaundice appears rather earlier than

that of yellow fever but is rarely seen on the first day of the

paroxysm as with blackwater fever.

Of great diagnostic value is the early appearance of bile-colored

urine as different from the haemoglobin-tinged urine of blackwater.

The albuminous urine of yellow fever is not apt to show any bile

coloring in the first three or four days of the disease.

_Relapsing Fever._—There is a clinical type of relapsing fever

associated with jaundice and a high death rate which was first

described by Griesinger from Egypt. This icteric type is not

infrequent in Asia. This jaundice is late and the disease much

resembles yellow fever. The enlarged painful spleen and the finding

of spirochaetes in the peripheral circulation are essential to

differentiation.

_Weil’s disease._—Much interest has been recently aroused in

_Weil’s disease_, or epidemic jaundice, on account of the frequency

of the disease in soldiers in the Balkan campaign. While a

spirochaete has been shown by Inada and others to be the cause, yet

many workers have isolated paratyphoid B organisms from the blood

of such cases. Frugoni obtained cultures of this organism from the

duodenal fluid of 11 cases from 48 cases investigated. The accepted

cause of true Weil’s disease is _Leptospira icterohaemorrhagiae_.

The jaundice begins about the third day of an irregular fever.

Like yellow fever these cases showed injection of the conjunctivae

and albuminuria. There were, however, usually a leucocytosis and

enlarged spleen.

In severe cases of _spotted fever of the Rocky Mountains_ we may

have a generalized jaundice. Rarely cases of _typhus fever_ may show

jaundice.

ALTERATIONS IN SIZE OF THE LIVER

There is only a slight enlargement in the ordinary case of tropical

liver but in some cases it may extend 3 or 4 fingers’ breadth below

the costal cartilages or rarely to the umbilicus.

In _liver abscess_ the enlargement is a rather late feature, and

the condition should be diagnosed before we have the assistance of

protruding ribs and distention of the intercostal spaces. As the

abscess is usually located in the upper portion of the right lobe

the enlargement is usually upwards and is best made out with the

X-ray, showing the cupola-like projection.

In _kala-azar_ the liver does not begin to enlarge until after about

three months from the time of onset at which time the spleen will

be quite large. Decided enlargement is generally noted by the sixth

month.

The liver cirrhoses due to _schistosomiasis_ or _malaria_ may show

slight enlargement or no particular change.

_Sprue_ is a disease which gives a decided atrophy of the liver.

Some authorities have noted a decrease of the size of the liver in

cholera. The liver of _yellow fever_ is of normal size and is not

associated with splenic enlargement.

In the tropics one must always keep in mind the possibility of a

liver enlargement being due to _syphilis_.

PAINS OF THE LIVER

In _tropical liver_ there is more a sensation of weight than one

of pain. In _liver abscess_, however, there are painful dragging

sensations and, at times, with abscess of the upper right lobe, pain

referred to the right shoulder. There is a marked tendency to splint

the liver as shown by the costal breathing and moderate rigidity of

the right rectus. The patient tends to lie on his back as shifting

to either side, especially the left, causes pain. The legs are drawn

up to relieve tension. Any jolting of the liver in palpation is

exquisitely painful.

When active suppuration is going on in the liver the pain may be

of an acute throbbing character. With abscess of the left lobe the

pains may suggest gastric disease while with an abscess of the

concave surface of the liver there may be referred pain in the

appendix region.

In _blackwater fever_ and _bilious remittent fever_ there may be

tenderness of the liver as well as the more prominent pain in the

spleen.

_Epidemic jaundice_ shows tenderness of the liver.

In _plague_ there is a marked congestion of the liver as of other

viscera and there may be some tenderness.

The liver becomes tender as well as showing enlargement in

infections with _Clonorchis_.

SPLENIC ENLARGEMENTS AND PAINS

Splenic puncture has been carried out for diagnosis chiefly in

kala-azar, malaria and Malta fever. Some authorities have reported

fatalities from spleen puncture in kala-azar approximating 1% so that

many advise the safer liver puncture to that of the spleen.

Spleen puncture would only exceptionally be called for in malaria

as there is usually no difficulty in making the diagnosis from a

blood smear. Malta fever can usually best be diagnosed by blood

culture taken at the height of fever and recent work by Wenyon and

others would indicate that blood cultures on N. N. N. medium might

take the place of spleen puncture in kala-azar.

_Kala-azar._—The splenic enlargement is the most conspicuous change

in the disease, the spleen often reaching the umbilicus by the third

month and later possibly filling up the entire left side of the

abdomen. The coincident emaciation of the patient makes the splenic

tumor more apparent. When first enlarging the spleen may be the

source of considerable pain and tenderness.

Fluctuations in the size of the spleen have been noted in the

course of the disease, diminution in size often attending severe

diarrhoeal attacks. In spleen or liver puncture the needle must be

dry so that the parasites shall not suffer distortion.

_Malaria._—Splenic enlargement and tenderness are important points

in diagnosis of malaria.

In acute malignant tertian infections the spleen is often diffluent

so that it is liable to rupture upon slight injury. One should

even exercise care not to palpate the spleen too violently and the

possibility of accident should be thought of in making a spleen

puncture.

The typical malaria spleen is the _ague cake_ of malarial cachexia.

Here we have a greatly enlarged spleen with a thickened capsule and

firm consistence. This spleen may fill up one side of the abdomen.

_Malta Fever._—The splenic enlargement in this disease usually

corresponds about to that of typhoid fever. At times, however, the

size may be so great as even to suggest kala-azar.

_Relapsing Fever._—Splenic enlargement and tenderness are marked

features in this disease, often being noted early in the course.

_Blackwater Fever._—The spleen is painful and enlarged. The

splenic enlargement in this disease and relapsing fever is

important in differential diagnosis from yellow fever, a disease in

which the spleen is unaffected.

The spleen may be enlarged in _Japanese schistosomiasis_ as well as

in rectal schistosomiasis.

Darling has recently noted that it may be difficult to

differentiate the anaemia of malarial cachexia from that due to

hookworm disease. As a matter of fact most authorities note a

diminution in the size of the spleen in _ancylostomiasis_ rather

than an increase and splenic enlargement would certainly favor a

diagnosis of malarial anaemia.

One point of distinction between spotted fever of the Rocky Mountains

and typhus fever is that the spleen of the former disease is enlarged

three or four times the normal, while that of _typhus fever_ shows no

increase in size. The palpable spleen of _Rocky Mountain fever_ is

firm instead of soft as with typhus fever.

CHAPTER XLVIII

THE CUTANEOUS SYSTEM AND THE ORGANS OF THE SPECIAL SENSES

THE SKIN

_Ringworm infections_ of the skin are so common in the tropics

that one should always make an examination for the causative fungi

when doubt as to the nature of the lesion exists. Another point is

that many hyperaemias, incident to other diseases, seem to furnish

a favorable soil for fungi; thus, not infrequently I have found

abundant spores and mycelial structures in scrapings from the

erythema of the early syphilitic secondaries. Again pruritic lesions

may become infected with fungi as the result of scratching, which

scratching may not only have this result but furthermore may obscure

the dermatological characteristics of the primary disease.

The most expeditious way to examine for fungi is to treat the

scales or hairs with a 10% solution of caustic potash or soda.

Then crush between two slides; heat moderately over the flame and

examine after from 10 to 30 minutes.

A very satisfactory method is to scrape the scales with a small

scalpel, and smear out the material so obtained in a loopful

of white of egg or blood serum on a glass slide. By scraping

vigorously the serum may be obtained from the patient. After the

smear has dried, treat it with alcohol and ether to get rid of

the fat. It may then be stained with Wright’s stain or by Gram’s

method. The ordinary Gram method may be used or the decolorizing

may be done with aniline oil, observing the decolorization under

the low power of the microscope.

_Hanging-block cultures._—To make these, pour melted agar in a

Petri dish and cut from the film so formed sections 1 cm. square.

Place a section on a slide, inoculate and drop on a cover-slip.

Another method is to allow a drop of melted agar, previously

inoculated, to spread over a cover-slip which is then inverted on a

concave slide.

_Prickly heat_ is another condition extremely common in the tropics

and the scratching to relieve the itching often leads to infection

with fungi or pyogenic cocci.

_Pellagra._—In no other general disease is the skin eruption of such

importance in diagnosis and it is practically impossible to make

a sure diagnosis of pellagra in the absence of an eruption or the

history of an eruption.

The eruption tends to show itself in the spring but may first

appear in the early fall. The lesions resemble a sunburn and burn

instead of itch. The characteristics of the eruption are bilateral

symmetry and sharp delimitation from the sound skin.

As a rule the lesions are dry and atrophic but more rarely, and

usually in severe cases, the eruption may be moist and oedematous.

The backs of the hands are the most common sites for the eruption

but frequently there is an extension up the forearm. The neck,

the bridge and alae of the nose, the region back of the ears and

the front of the chest are often involved. In children the feet

and legs are frequently involved. Scrotal eruptions are early

manifestations.

_Leprosy._—In _nodular leprosy_ we have the appearance of macules

of greatly varying size and shape with a tendency sooner or later to

symmetry. They tend to appear and recur in association with febrile

accessions and, even when they have become permanent spots, they show

increased redness, infiltration and tension when there is fever.

The color is rather that of a sunburn and may be uniform or the

center may be pale with copper-colored periphery. These spots

appear by preference on face, backs of hands, buttocks, extensor

surfaces of extremities and back. They may mark the location of

later developing nodules. At first they are oily rather than scaly.

We soon note a disappearance of hair within the spot. These spots

soon tend to become anaesthetic. The tubercles of leprosy are

usually of a reddish-brown color.

In _nerve leprosy_ the spots tend to appear on parts of the body

usually covered by clothing, as scapular region, shoulders, arms,

thighs or buttocks. The outline is ovoid rather than round and the

spots may at first be hyperaesthetic rather than anaesthetic, as they

later tend to become.

In circinate eruptions we often note a pale center with

brownish-red borders. These borders may be hyperaesthetic while the

centers show anesthesia. Bilateral symmetry is more common in this

than in nodular leprosy.

Besides the spots nerve leprosy may show blister-like lesions on

backs of hands and feet especially in the region of the knuckles.

Ulceration may follow.

_Malaria._—The most common cutaneous manifestation of malaria

is herpes labialis. This is more common in benign types than in

malignant ones. Urticaria is next in frequency. Malaria has seemed to

be the cause of certain cases of purpura simplex.

In attributing skin manifestations to malaria one must always have

in mind the scarlatiniform, urticarial and erythematous rashes due

to quinine used in treatment.

_Urticarial Fever._—In Japanese schistosomiasis the earliest

symptoms are the urticarial rash and fever.

_Plague._—Rarely cases of bubonic plague may show a small vesicle

marking the site of the flea bite. Areas of necrosis of the skin,

which are really sloughing patches, and incorrectly designated

“carbuncles,” may be noted, especially over the site of the buboes.

In the later stages haemorrhages into the skin (petechiae) are

common.

_Trypanosomiasis._—Patchy areas of erythema are often noted in

Europeans affected with this disease. These are frequently circinate

with fading in the center and tend to appear on the trunk.

In natives a dry skin is more often noted.

_Rat Bite Disease._—An eruption of purplish spots may accompany the

fever. There is a resemblance to erythema multiforme.

_Dengue._—The true eruption of dengue is the one that appears about

the fourth or fifth day as a measles-like eruption, starting about

wrists or ankles.

_Kala-azar._—There is a darkening of the colored skin of the natives

suffering from this disease and it is to this feature that the

disease owes its name.

In Europeans the appearance is more that one sees in old malarial

cachectics, an earthy gray color. The characteristics of cutaneous

leishmaniasis are discussed under that heading.

_Typhus Fever._—Gangrene is particularly a feature of _spotted fever

of the Rocky Mountains_ and _typhus fever_, chiefly of the scrotum

and prepuce with the former and of the extremities in the latter.

The distinctions of the eruptions of these two diseases and of

_tsutsugamushi_ are given on page 445.

_Tsutsugamushi._—A small necrotic ulcer with a dusky red areola,

often located in the armpits or region of the genitals, marks the

site of the bite of the infecting mite. From it a lymphangitis leads

to the swollen glands. About the seventh day a macular eruption,

which never becomes petechial, appears on face, then on trunk and

extremities.

_Tularaemia._—There is often a local lesion at the site of the bite

of the infecting _Chrysops_. The tributary glands are swollen.

In _ancylostomiasis_ the site of entrance of the infecting stage of

the larvae is marked by a dermatitis—ground itch.

Tibial ulcers are also features of this disease.

In _filariasis_ we not only have the bleb-like lesion of guinea

worm infection but also the calabar swellings of _Filaria

loa_. Elephantiasis and lymph scrotum are the best known skin

manifestations of _F. bancrofti_, but there may also be present

filarial abscesses. The tumors of _O. volvulus_ are most often on

sides of chest, are quite superficial with the skin freely movable

over them.

_Epidemic Dropsy._—It is a question, whether such a disease as

epidemic dropsy is distinct from beriberi. An erythematous eruption

about the face and a macular one of the trunk and extremities are

usually stated to be features of this disease.

_Juxta-articular Nodes._—This is a condition in which small tumors

form under the skin especially in the region of the elbows. These

bean to walnut-sized tumors of the subcutaneous tissues may also be

noted about the knees. A fungus has been reported as cause but the

present view is that the cause is unknown.

_Oriental Sore._—This form of cutaneous leishmaniasis is especially

common in Asiatic Turkey and Northern Africa. It begins as a small

papule which eventually ulcerates, the sore scabbing over from time

to time and again breaking down. Indolent granulations and a very

protracted course are rather characteristic features.

_American Leishmaniasis._—The most important point of

differentiation of this form of leishmaniasis from oriental sore

is the occurrence of ulcerating lesions of the mucous membranes of

mouth or nose subsequent to the appearance of the oriental sore-like

lesions on forearm, legs, trunk, or rarely the face. In Peru the term

_uta_ more properly belongs to the skin affections while _espundia_

is the designation applied to the lesions of the mucous membranes.

It may be stated that a form of oriental sore has been reported from

Greece where mucous membrane ulcerations have been associated with

the ordinary skin-type lesion.

_Dermal Leishmanoid._—Brahmachari has described a form of

generalized cutaneous leishmaniasis, bearing a superficial

resemblance to leprosy, which may develop a variable number of

months after apparent cure of kala-azar by antimony. Having found

leishmania bodies in the lesions, he conjectured that some of the

parasites survive the action of the drug, but with their virulence

so attenuated that they can give rise only to a milder disease,

a variant of cutaneous leishmaniasis, to which he gives the name

“dermal leishmanoid.”

NOTE.—The special tropical diseases of the skin are discussed

under their respective headings.

THE EYE

_Glaucoma._—According to Elliott glaucoma is very much more

common in the East than in Europe. He states that simple chronic

glaucoma is extraordinarily common in India. Often the only

symptoms are retraction of the field, cupping of the disc and at

a later stage impairment of the central visual acuity. He notes

that the advancement of the disease is often as unobtrusive as it

is relentless. These patients often only present themselves at the

clinic in the late stages of the disease; thus at the Madras hospital

the vision was only that of hand perception, or less, in 40% of cases.

_Cataract._—The general impression is that cataract is more frequent

in the tropical regions than in Europe and as bearing out this view

Elliott notes that cataract among those Europeans who have served

in India seems more frequent than among those who have remained in

England. Cataract is also more common in the southern part of China

than in the northern portion.

_Lachrymal Obstruction._—Elliott notes the extreme frequency of this

condition in India, and states that in the Madras Ophthalmic Hospital

125 operations for excision of one or both lachrymal sacs were

performed in 1907.

_Trachoma._—There are certain tropical countries where trachoma is a

disease of the greatest importance. Thus in China its prevalence is

great, as is also true of India, Egypt and Japan.

Outside of imported cases it is very prevalent in many parts of the

United States.

In this disease there is hypertrophy of the conjunctiva, granule

formation and subsequent cicatricial changes. Pannus and corneal

ulcerations are frequent complications.

The disease is contagious through transfer of the secretion by

hands or flies. It is usually considered as caused by the so-called

trachoma bodies or cell inclusions, which are best brought out by

Giemsa staining. The trachoma granules are yellowish, translucent

bodies set in the reddened conjunctiva.

_Leprosy._—The eye is more frequently involved in nodular than in

nerve leprosy. In the former we have infiltration of the conjunctiva

which may extend to the cornea.

The leprous nodules invading the palpebral conjunctiva tend to

ulcerate and bring about various distortions of the eyelids,

producing ectropion. Iritis, irido-cyclitis and irido-choroiditis

are less frequent than conjunctivitis and keratitis. The optic

nerve and the retina are only rarely involved.

In nerve leprosy the eye changes are chiefly connected with the

lesions of the fifth and facial nerves. Ptosis and paralytic

ectropion occur with frequency.

Ophthalmia and corneal ulcerations may lead to total destruction of

the eye. The cornea may be anaesthetic. Paralysis of one or more

ocular muscles may cause squint or diplopia.

_Malaria._—It is questionable whether the forms of conjunctivitis

and keratitis at times reported as due to malarial infection are not

rather of other origin.

Iritis is rarely a complication of malaria.

Retinal haemorrhages may occur in malarial cachexia and cerebral

types of pernicious malaria.

Another rare malarial complication is amblyopia. In this there is

an optic neuritis with grayish-red disc and the loss of vision is

not complete, while in quinine amblyopia the disc is white and the

vision completely lost for a time.

_Filariasis._—In that filarial infection caused by _Loa loa_,

at one time designated _Filaria oculi_, there seems a special

tendency for the adult worms to wander to the subcutaneous tissues

in the neighborhood of the eyes or under the palpebral or ocular

conjunctivae. When moving under the conjunctiva the worms cause

marked irritation and at times pain.

There may be considerable swelling so that the patient cannot for a

time see out of the invaded eye. It has been stated that the worms

may enter the anterior chamber of the eye but this is questionable.

It is believed that lesions of the cornea and iris may result from

the migrations through the body of the _Onchocerca volvulus_.

_Trypanosomiasis._—Eye lesions are quite frequent in this disease

these being keratitis, irido-cyclitis or conjunctivitis.

Oedema about the eyes is of importance in diagnosis. Eye lesions

seem more common in Rhodesian trypanosomiasis. The atoxyl treatment

of the disease may cause optic neuritis and blindness.

_Tick Fever._—In the relapsing fever of South Africa iritis has been

noted as occasionally occurring.

_Yellow Fever._—In the period of onset a feature of the so-called

“facies” of the disease is marked injection of the conjunctivae with

sensitiveness to the light.

Rush likened it to the eye of a wild animal as contrasted with

the less ferocious eye of bilious remittent fever which more

resembled that of a domesticated animal. About the third day the

earliest manifestation of jaundice presents itself in the ocular

conjunctivae.

_Ancylostomiasis._—Retinal haemorrhages may occur with marked

hookworm anaemia. Stiles notes a fixed stare in hookworm cases, the

eye itself somewhat resembling the eye of a fish.

Among other diseases showing ocular manifestations may be mentioned

one associated with fibrous nodules in the upper lid due to a

larval dibothriocephalid, _Sparganum mansoni_.

_Bacillary Dysentery._—Quite a number of cases have recently been

reported where along with an arthritic complication there has been

conjunctivitis. In 6 cases of dysenteric conjunctivitis, Maxwell

noted that 4 cases had arthritis and 3 of the latter showed anterior

uveitis. The conjunctivitis lasted about a week. Relapses seem liable

to occur. In none of the cases has there been recovered from the

conjunctival secretion the organism of dysentery.

_Cholera._—As a result of the loss of all body fluids the lachrymal

secretion is scanty or absent and we have various conjunctival and

corneal troubles unless the eye is frequently irrigated with normal

saline. Vitreous opacities and cataract may follow cholera.

_Beriberi._—In this disease there have been reported the following

eye complications: (1) retrobulbar neuritis; (2) paralyses of the

muscles of the eye and (3) decreased sensibility of the cornea and

conjunctiva.

_Night Blindness and Xerophthalmia._—Both of these conditions are

quite common in certain parts of the tropics and the view that the

heat of the tropics and the tropical sunlight were potent factors

had precedence until our study of vitamine requirements showed the

etiology to rest in deficiency of fat soluble A. It is now known that

cod-liver oil is particularly rich in this vitamine and that in this

agent we have our best preventive and curative agent for these eye

conditions. It is well known that rats fed on a diet deficient in fat

soluble A develop xerophthalmia.

Night blindness (nyctalopia) is best known among the crews of

sailing ships, especially when becalmed in tropical waters, and

some influence of sunlight was considered the cause, but we now

know that it is among such personnel that ship beriberi and scurvy

are prone to occur by reason of deficiencies in water soluble B and

the antiscorbutic vitamines. In such a dietary fat soluble A would

also probably be lacking.

In those parts of the tropics where famine conditions are common

both night blindness and xerophthalmia are frequent in young

children, not necessarily associated but frequently combined.

In a mild case of xerophthalmia there is a dry area of triangular

shape extending from either side of the cornea and covered with a

fine, whitish foam. In bad cases the whole eye may be dry, wrinkled

and opaque and eventually the cornea may slough away and bring

about destruction of the eye. There is very little pain attending

this frightful condition.

Elliot notes that from earliest times it was the custom in China

to treat these conditions with extracts of liver. We now know

that liver and kidneys are glandular organs rich in fat soluble A

although not so rich in this vitamine as cod-liver oil.

_Typhus fever._—There may be a rapid development of cataract of

the soft variety, particularly in young patients. Ocular palsies,

especially of the third and sixth nerves may occur during the febrile

period. Corneal ulcers are not uncommon during convalescence and may

be severe and very painful, often accompanied by conjunctivitis and

iritis.

THE EAR

_Aural Myiasis._—While the larva of _Chrysomyia macellaria_, known

as the “screw worm,” is the one most frequently reported from the

external auditory canal, yet many such cases have been connected

with the larvae of _Sarcophaga carnaria_, _Calliphora vomitoria_ and

_Anthomyia pluvialis_. These larvae are usually deposited in the

auditory canals of those with otorrhoea.

The symptoms are intense earache, giddiness and possibly

convulsions. The larvae tend to perforate the tympanic membrane.

Instillations of 10% chloroform in milk or the use of oils kill the

larvae.

In the stuporous states of _plague_ and _typhus fever_ there often

appears to be a state of deafness.

One must always keep in mind the ringing of the ears indicative

of the physiological action of quinine. Permanent deafness may be

produced by the long continued use of quinine.

In leprosy the lobes of the ears are special sites of preference for

the nodules and I always palpate the lobes where the nodules are not

distinctly visible.

THE NOSE

_Nasal Myiasis._—In cases of ozaena certain flies appear to be

attracted and to deposit their eggs at the nasal orifices. The larvae

developing from the eggs of _Chrysomyia macellaria_, a fly common

in tropical America, are known as “screw-worms” and cause frightful

destruction of the nasal structures.

They may bore into the adjacent sinuses. Marked frontal headache

and a purulent or bloody discharge are symptoms. Great swelling of

the nasal structures precedes the destruction of the cartilaginous

and bony tissues.

_Leprosy._—The nasal mucosa is apt to be the seat of leprous

nodules. Those located on the septum may ulcerate and material from

these ulcers show abundant leprosy bacilli. Alternations of dryness

and hypersecretion of the Schneiderian membrane are among the early

manifestations of the disease.

=Epistaxis.=—This is a feature of the early stages of _leprosy_

often associated with rhinitis, in particular the alternation of

coryza-like conditions with others characterized by dryness of the

nasal mucosa.

There is also a peculiar nasal tone to the voice of lepers.

In _yellow fever_ and _plague_ epistaxis is often the first sign of

the degeneration of the endothelial linings of the capillaries.

_Gangosa._—A disease of certain islands of the Pacific, especially

Guam, characterized by naso-pharyngeal lesions and a nasal voice,

is known as _gangosa_.

In _goundou_ we have exostoses from the nasal processes of the

superior maxillary bones.

CHAPTER XLIX

THE URINE AND THE GENITO-URINARY APPARATUS IN THE DIAGNOSIS OF

TROPICAL DISEASE

THE URINE

Of the chemical tests employed in the examination of urine that for

the presence of sugar is rarely of value, as there is no tropical

disease in which the presence or absence of sugar is of diagnostic

importance.

The determination not only of the presence of albumin in the urine

but, as well, of the variations quantitatively from day to day

is, however, most necessary in many of the tropical diseases and

particularly in yellow fever and blackwater fever.

=Tests for Albumin.=—The simplest and most reliable test for

albumin is the heat test with the subsequent addition of a

sufficient number of drops of 5% acetic acid to make the boiled

urine acid and incidentally to dissolve any phosphates which may

have separated out on boiling.

Ulrich’s test is a very simple one and only calls for reagents

which are usually at hand. Heat a saturated solution of common

salt, containing 2% of glacial acetic acid, and superimpose the

urine to be tested upon the hot reagent. A ring shows the presence

of albumin.

For Heller’s test, pour a small amount of nitric acid into a narrow

test tube and, while holding the tube at an angle of about 45°,

superimpose a layer of the urine to be tested, which is delivered

drop by drop from a pipette and allowed to flow down the side of

the tube.

This test can be converted into a quantitative one which is

sufficiently accurate for clinical purposes. It is based on the

fact that a specimen of urine containing 0.003% of albumin will

give a perceptible ring at the layering of the urine and acid in

two minutes. If the ring appears at once or in a few seconds the

albumin content is greater. From the qualitative test an idea can

be formed as to the amount of albumin which the urine contains,

a heavy ring forming immediately showing a considerable albumin

content. Probably the highest elimination of albumin is found in

chronic parenchymatous nephritis where it may run from 1 to 3%.

In an ordinary case of acute nephritis O.5% would be an average

content.

Recently I have been using for both qualitative and quantitative

albumin tests the following apparatus. This is simply a 5-inch

piece of ¼-inch soft glass tubing heated at a point 2 inches from

one end, drawn out for about 2 inches and bent to form a U-tube

with one end shorter than the other. This form of tube enables

one to perform two tests with the same column of nitric acid and

is easily cleaned and dried. They may be kept suspended around a

glass tumbler’s rim. Taking up a small amount of nitric acid with

a capillary bulb pipette it is deposited in the capillary curve

of the bent tube. This acid pipette should be kept attached to

the acid bottle. With a second pipette the urine is deposited in

the short arm of the U-tube and the presence of albumin shows by

a distinct ring at the junction of urine and acid in the clear

capillary tubing. The long arm will serve for the introduction of a

second specimen of urine for the albumin test.

For quantitative test we dilute the filtered urine with one or

more parts of normal salt solution according to the intensity of

the albumin ring. A very convenient way of making the dilution is

with a graduated centrifuge tube. Make a one to ten dilution of the

urine, mix and draw up with a bulb pipette and deposit in the short

arm of the U-tube. A distinct ring forms in two or three seconds.

Pour off one-half of the diluted urine and make up with an equal

amount of saline. Deposit this one to twenty dilution in the long

arm. The ring forms in about a minute. With further testing it is

found that a one to forty dilution shows a perceptible ring in

just two minutes. This final and successful dilution multiplied by

0.0033 gives the percentage of albumin in the urine (40 × 0.0033 =

0.13%).

Should it be desired to determine the nature of the proteids

present either in urine or in exudates or transudates the following

method is applicable. Determine the percentage of total proteid by

the method employed above. Then throw down the globulins by the

addition of an equal amount of a saturated solution of ammonium

sulphate, filter and estimate the proteid content of the filtrate.

The difference between that and the total gives the percentage of

globulin. The filtrate is now treated with 5% acetic acid until a

precipitate of nucleo-proteid ceases to form; the fluid is filtered

and the clear filtrate (which should not show any turbidity with a

drop of 5% acetic acid) is tested for its proteid content, which

represents the serum albumin. When the combined percentage of

globulins and serum albumin is subtracted from the total proteid

percentage we have the percentage of nucleo-proteid.

=Tests for Blood.=—Very important in tests of the urine are those

for blood. With an unaided eye a smoky colored urine, more or less

reddish-brown in color, is suggestive in cases of haematuria, while

in haemoglobinuria we usually have a more or less porter-colored,

turbid fluid which, however, shows a clear haemoglobin-tinged fluid

when centrifuged to throw down the haemoglobin casts and granular

débris of the disintegrated red cells. Upon shaking such urine we get

a pinkish foam instead of the yellowish one of icteric urine.

A strip of white filter-paper when partially dipped into urine

shows pinkish-colored waves which are more deeply colored at the

summit of the waves while the paper which absorbs bile-containing

urine shows the yellowish color and waves less yellow at the

summits of the colored waves.

For haematuria we may use either the microscopic method for the

recognition of red cells or chemical ones. The red cell is best

recognized by the double contour of the 7.5 micron disk. Spores of

moulds, which greatly resemble red cells, are smaller, usually not

more than 5 microns.

The following technic is of the greatest value not only because

it makes the red cells more distinct but because by staining the

various epithelial elements it gives us more exact information as

to distinction between the segmented nucleus of pus cells and the

single one of renal cells. Make a streak of vaseline across a slide

one inch from one end. Then deposit a drop of urinary sediment,

taken up from the centrifuge tube with a pipette, about ¼ inch from

the grease line. Then drop a large drop of Gram’s iodine solution

on this sediment and then apply one side of a square cover-glass

to the vaseline line and allow it to fall gently on the drop of

sediment and stain. There is no current motion, and casts and other

urinary elements remain under the cover-glass instead of floating

out beyond the margins. It is well to examine the unstained

sediment with a ⅔ inch objective before adding the iodine and

applying the cover-glass, as one gets a better idea of casts with a

low power and unstained than in any other way.

With haemoglobinuria we necessarily turn to chemical or spectroscopic

tests which are also applicable to microscopically doubtful cases of

haematuria.

For the detection of occult blood, the technique described on page

524 should be observed, and alkaline urines faintly acidified with

acetic acid before examination.

=Indicanuria.=—In _sprue_ and _pellagra_ we have a rather marked

increase in indican. It is probable that many cases of vague

manifestations of neurasthenia with loss of physical and mental

energy are connected with auto-intoxication rather than tropical heat

or intestinal parasites.

=Urobilinuria.=—In conditions where there is a great destruction

of red cells tests for urobilin are important. Plehn considers the

presence of urobilin as of importance in the diagnosis of _latent

malaria_, which is true, provided other causes for red blood cell

destruction are excluded. _Blackwater fever_ cases usually show

an intense urobilinuria. Urobilinuria is also a sign of deficient

functioning of the liver.

=Bile Pigment Tests.=—In conditions associated with the presence

of bile pigments in the urine we may conveniently employ the Gmelin

test in the following manner. Filter the urine several times through

the filter and then touch the moist inner surface of the paper with

a glass rod dipped in commercial nitric acid. A ring-like play of

colors, green, blue, violet and red circle out from the spot touched.

A green color must be noted for positive diagnosis.

Tests for bile acids seem to have but slight value in differential

diagnosis.

A very simple and apparently quite reliable test for deficiencies in

liver functioning is that known as Ehrlich’s aldehyde reaction. The

reagent is a 2% solution of p. dimethylaminobenzaldehyde in equal

parts of water and concentrated hydrochloric acid.

For the test treat 5 cc. urine with 5 to 10 drops of the reagent.

Agitate a few minutes and a positive reaction is shown by a fine

cherry-red color, thought to be due to urobilinogen.

The urine sample should be perfectly fresh and not long exposed to

light.

AMOUNT OF URINE IN 24 HOURS

Normally a man passes about 1200 cc. of urine in twenty-four hours,

a woman somewhat less. When the amount is under 750 cc. we have an

oliguria. To consider a polyuria as present the patient should pass

more than 3000 cc., as this amount may be considered the upper normal

limit. In anuria we have a cessation of renal activity.

The disease in which anuria is most characteristic is _cholera_.

During the stage of evacuation the urinary secretion becomes less and

less along with the progressive failure of circulation and, during

the algid stage, we have a suppression of urine.

The anuria seems to run parallel with an acidosis and intravenous

injections of bicarbonate of soda solutions tend to prevent anuria.

In the stage of reaction the favorable outcome is the reappearance

of urine, which increases in amount to become a polyuria. In

unfavorable cases the anuria continues.

In _blackwater fever_ anuria may result from the blocking up of the

renal tubules by haemoglobin casts.

Blackwater fever also shows an acidosis and alkaline treatment is

here indicated. Blackwater urine is irritating so that there is

vesical tenesmus with frequent urination.

The degree of renal involvement is of great prognostic value in

_yellow fever_, and those cases where the oliguria goes on to

suppression are apt to terminate fatally.

In _heat stroke_ there is an oliguria or anuria which may be

followed, during convalescence, by a polyuria. Marked irritation

of the bladder, associated with suppression of sweating, may be

indicative of oncoming heat stroke.

In _dropsical beriberi_ there is an oliguria or, rarely, an anuria

which with the rapid disappearance of the general body oedema may

become an excessive polyuria.

Rarely one may observe a critical flow of urine in _dengue_ at the

time of the fall of the primary febrile accession.

ALBUMINURIA

The disease in which this is of peculiar diagnostic and prognostic

value is _yellow fever_. We expect albumin about the second day with

a steady increase in amount during succeeding days of the fever.

The degree of oliguria or rather anuria is of greater prognostic

value than the degree of albuminuria. The albuminuria is of great

diagnostic value in differentiating yellow fever from dengue.

_Blackwater fever_ shows a great abundance of albumin with the

appearance of the haemoglobinuria and diminishes as the color of

the urine clears up.

In _malaria_ albumin was present in 38% of benign tertian

infections and 58% of malignant ones at Johns Hopkins Hospital.

The absence of albumin in _beriberic urine_ is important in

differential diagnosis from acute nephritis.

HAEMOGLOBINURIA

Paroxysmal haemoglobinuria or haemoglobinuria resulting from

potassium chlorate poisoning, severe burns, intravenous injections

of foreign sera, or—most commonly—syphilis, may be noted in the

tropics.

The vast majority of cases of true tropical haemoglobinuria, however,

are due either to blackwater fever or to the administration of the

acid salts of quinine to one predisposed to quinine haemoglobinuria.

While it must be admitted that haemoglobinuria may result from

quinine it is certainly so rare in subtropical countries, where great

amounts of quinine are administered in treatment of malaria, as to

be unimportant. It is only where the malignant tertian parasite

flourishes that we have the question of the importance of quinine in

producing haemoglobinuria brought up.

Certain persons have isohaemolysins in their blood which dissolve

the red cells of other persons and in paroxysmal haemoglobinuria

autohaemolysins may be present which can destroy the patient’s

own red cells. This auto-haemolysis seems operative only when a

low temperature is followed by a high one. When haemoglobinaemia

exists the liver converts it into bile pigment causing bilious

stools and jaundice. If one-sixth of the red cells are destroyed

haemoglobinuria results.

The dark, porter-colored urine of blackwater is diagnostic even to

the patient. The urinary sediment consists of granular débris with

occasional haematoidin crystals. Albuminuria runs parallel with the

haemoglobinuria. Pain in the loins, probably, from the plugging

of the renal tubules by the detritus of red cell destruction, is

a feature of blackwater fever. In blackwater fever we have the

early appearance, even in a few hours, in a patient who is markedly

asthenic and miserable, of jaundice, porter-colored urine and

albuminuria.

HAEMATURIA

Among tropical diseases that which immediately suggests haematuria

is vesical bilharziasis. The blood in the urine is in the form

of red cells; it is a haematuria and not a haemoglobinuria. The

passage of blood usually occurs at the end of micturition and it is

either in the last few drops of urine or in the sediment obtained

after centrifuging that we note the terminal spined eggs of _S.

haematobium_ which prove the diagnosis.

Red blood cells in the urine may also be noted in the

haematochyluria of filarial disease.

When we have blood in the urine in yellow fever it is a haematuria

and comes on about the same time as the black vomit and other

haemorrhages resulting from degeneration of the endothelial linings

of the blood capillaries, which only takes place about the third or

fourth day of the disease.

Haematuria may also be noted in plague at the time when the

haemorrhages into the skin occur.

CHYLURIA

Vesical varices from lymphatic obstruction, due to filarial disease,

are the most frequent cause of the milky urine of chyluria. The

urine usually has a pinkish tinge from blood admixture so that the

condition is really a haematochyluria. The thoracic duct may not be

the seat of obstruction which has taken place elsewhere when the

condition is lymphuria instead of chyluria. Lymph and chyle differ

in fat content, the former having from very little to about 3% while

the latter has 5% or more of emulsified fat. Chyle has also more than

twice as much proteid as does lymph.

In chyluria the morning urine is often clear while that at

night is milky. On standing, chylous urine separates into an

upper cream-like layer with a pinkish sediment and, between, a

pinkish-white fluid in which floats a clot. Filarial embryos may or

may not be found.

KIDNEY FUNCTION AND ITS DETERMINATION

The ability of the kidney to excrete substances from the blood stream

is frequently affected by disease, especially such as disturbs the

kidney, and is usually diminished after the age of 50 years. Disease

of the kidney, however, does not necessarily imply an inability to

eliminate substances—the functional need not parallel the anatomical

lesion. Function may be normal especially when the changes are of

focal type.

Impairment of renal function does not affect the excretion of

different compounds to the same extent. It is well established

that functions for chlorides and for urea are independent of each

other. In any urinary examination, then, one should bear in mind

the possible effect of an impaired excretory power relative only to

the substance under consideration. In this connection, we speak of

the _kidney threshhold_ for a substance, i.e., the concentration

required in the blood stream before the kidney will excrete it, at

least in abnormal amounts. For chlorides, this is quite definite at

562 for blood plasma; for sugar, it is about 160-180 for whole blood.

The threshold is not necessarily absolute, but simply indicates

that with less sugar, for instance, only the normal traces will be

passed. Chloride excretion begins only when their concentration

passes the threshold value, and the rate of elimination depends upon

their excess. Other compounds, such as urea, for example, may have

no definite threshold value. Disease may affect the value, either

by raising it and causing abnormal retention, or by lowering it and

giving rise to depletion.

We can establish the status of the renal function in any given

case, and are then in a position to intelligently prescribe

dietetic and other treatment. Chemical analysis of the blood

indicates the metabolic products affected and guides us in the

adjustment of the diet, etc., to the excretory powers of the

kidneys. One must, however, not overlook the nutritive needs of the

body.

Many methods are employed for the determination of kidney function,

and their relative values are still debatable. Probably those

least open to criticism are chemical analysis of the blood, the

phenolsulphonephthalein test, and Mosenthal’s method. Ambard,

McLean, Van Slyke, and others have devised formulae to this

end, based upon chloride, urea, or sugar excretion, which have

many warm advocates as well as severe critics. A rough clinical

comparison of the two kidneys may be obtained by determining the

urea in specimens of urine simultaneously collected by the ureteral

catheter.

_Blood Chemistry_, now that its value has been established, is

generally given preference and allowed greater weight in case of

disagreement with other tests. It measures excretory function for

normal metabolic products, and has the additional value of an aid

in diagnosis and prognosis and a guide to treatment, especially

dietetic. It has the disadvantage of a possibly unfamiliar technique,

and does not afford a comparison of the two kidneys.

The substances usually considered are the nitrogenous compounds

(nonprotein nitrogen, urea nitrogen, uric acid, etc.), but

retention of others (sugar, chlorides, cholesterin, etc.) are

also of significance in this connection. Of the nitrogenous

constituents, the kidney excretes creatinine most readily, urea

next, and uric acid with the most difficulty. As a consequence, an

impairment of function results first in the retention of uric acid,

then urea, and, finally, creatinine is also retained. Owing to the

relatively small amounts of uric acid and creatinine present, the

nonprotein nitrogen, which includes the nitrogen in them as well

as in other compounds, is not appreciably affected except by the

urea increase. This is the basis of an intelligent interpretation

of the findings. The urea and nonprotein nitrogen are so markedly

affected by diet, especially among nephritics, that judgment must

be exercised when they are employed as indices of renal function.

This fact was not properly appreciated until recently, and probably

accounts for much of the discredit cast upon blood chemistry in

this connection. The uric acid, being less exogenous in origin,

is perhaps the most delicate and the safest index; the increase

appears early, and 3.5 may be considered the high normal value.

On the usual restricted hospital diet, over 20 for urea nitrogen

should be considered suggestive of impaired kidney function; over

75 speaks decisively for renal involvement and probably uraemia.

_Phenolsulphonephthalein (Phthalein, or Red) Test._—This was

developed by Rowntree and Geraghty, and its simplicity makes

it very useful, especially to the isolated practitioner with

limited laboratory facilities. It estimates only function for a

foreign substance, is not considered quite as reliable as chemical

analysis of the blood, and, of course, does not give the additional

information that the latter supplies. It is, however, of much

value, has no contraindications, and does compare the kidneys when

combined with ureteral catheterization or use of a separator.

Positive results are of more significance than negative, and it is

less affected by glomerular than tubular changes. Values of more

than 75% for 2 hours may be accompanied by diuresis, and Frank

considers such a finding suggestive of renal disturbance with

irritation if there is any corroborative evidence.

The technique comprises administration of the dye, determination of

the interval before it appears in the urine, and the amount then

excreted during definite periods. The dye is employed in solution,

and is conveniently purchased already sterilized in ampules, each

containing slightly more than 1 cc. of a solution of its monosodium

salt of the strength of 6 mg. per cc. The patient drinks 200-400

cc. water, and 6 mg. of the dye are injected intramuscularly

(lumbar muscles), or intravenously, 20 minutes later. The bladder

is immediately emptied, and the urine discarded. The succeeding

portions of urine may be collected by voiding, but it is more

accurate to catheterize the bladder or ureters, and catheterization

is practically a necessity for determination of the “appearance

time.”

The appearance time is the interval of time elapsing between

injection of dye and its appearance in the urine. It is determined

by allowing the urine to drip from the catheter into a receiver

containing a drop of 10% NaOH. The first traces of the dye will

cause a pink color.

The time interval chosen for calculating excretion is then computed

from the instant of this appearance. There is considerable

diversity in practice as regards this time interval, and it would

seem that shorter intervals and quicker results are gaining in

preference, as well as being considered equal in value to longer

periods.

The percentage excretion of the dye is now measured in each sample

of urine. To do this, prepare a standard solution, made by diluting

0.5 cc. of the phenolsulphonephthalein solution mentioned above

to about 200 cc. with water, adding 5-10% NaOH until no further

intensification of the red color is produced (requires a few cc.),

diluting to one liter, and mixing. This standard then represents

50% (3 mg.) of the amount of the dye injected. The color of the

urine sample is similarly developed with alkali, and the mixture

diluted to 1 liter, mixed, and compared with the standard in a

colorimeter. The per cent excretion in the specimen equals the

reading of the standard solution multiplied by 50 and divided by

the reading of the urine mixture, when the colors are matched in

the instrument.

For accurate work, it is desirable to balance in the standard the

urine color of the unknown, and this is accomplished by including

in the standard a volume of urine (dye-free) _proportional_ to that

in the unknown. Also, with a low excretion, it is better not to

dilute the unknown to 1 liter, but to some lesser volume that will

give a tint closer to that of the standard, and then allow for the

variation in the calculation.

[Illustration: FIG. 153.—Fibres, starch granules, etc., which may

be found in urine sediment. No. 12 gives appearance under microscope

of scratches on old used glass slides. No. 15 (_a_), _Tyroglyphus

longior_ a mite. No. 15 (_b_), _Trichomonas vaginalis_. No. 16

(_a_), Egg of _Eustrongylus_; (_b_), _Echinococcus hooklets_; (_c_)

_Schistosoma_ egg; and (_d_), _Filaria bancrofti_ embryo.]

Dunning has devised a simple, inexpensive colorimetric outfit with

permanent standards in ampules for this test. It is satisfactory

unless the colors of the standards fade.

After intravenous injection, the normal appearance time is 4-6

minutes, and the normal elimination is 35-40% in 15 minutes, and

totals of 50-65% for 30 minutes and 65-80% for 60 minutes; or, for

the first 30 minutes, it may be stated as about 1% per minute from

each kidney.

After intramuscular injection, the normal appearance time is nearer

10 minutes, and the normal elimination is 30-40% in 30 minutes, and

totals of about 50% (40-60) for 60 minutes, and about 80% (60-85)

for 2 hours, or 20-25% during the second hour. If the appearance

time is not determined, it is customary to allow for it, collecting

the first hour’s specimen at 70 minutes after injection of dye and

the second hour’s 60 minutes later.

Impairment of kidney function, of course, increases appearance time

and lessens excretion, serious cases not unusually excreting less

than 1% during two hours.

When the question of the kidney involved arises, the urine must be

taken by ureteral catheterization or by a separator.

=Starches and Fibres.=—In examining urinary sediments it is

important to be familiar with the various textile fibres and starch

grains which are so frequently present, the fibres coming from the

clothing and the starch grains from dusting powders. Wool fibre

fragments show bark or scale-like imbrications and are round.

Cotton fibres are flattened and twisted, while linen ones show a

striated flattened fibre with frayed segments as of a cane stalk.

Silk shows a glass-like tube with mashed-in ends.

Corn and rice grains are the most common of the starch grains and

their nature is immediately disclosed by their blue color when

mounted in iodine.

AFFECTIONS OF THE GENITO-URINARY ORGANS

In _blackwater fever_ we have marked pain in the region of the

kidneys due to the plugging of the tubules with haemoglobin casts.

Vesical tenesmus and pain along the ureters may also be present.

In _malaria_ Thayer states that nephritis occurs in about 2% of

malignant tertian cases.

In _bilharziasis_ the kidneys are involved secondarily—the change

being brought about by stone in the bladder and cystitis leading to

hydronephrosis and pyelonephritis.

Cases of cystitis occurring in dysentery have been reported which

showed amoebae in the sediment of the urine. Such cases probably were

connected with recto-vesical fistulae caused by amoebic ulceration.

In _cholera_ the kidneys are markedly affected, especially the

epithelial lining of the tubules.

_Malta fever_ may rarely be attended by an orchitis.

One of the manifestations of filarial disease is _lymph scrotum_ in

which the scrotum is covered with small blebs containing a chylous

fluid which may possibly contain microfilariae. It is associated with

recurring attacks of lymphangitis. There is also a filarial orchitis

and we may have a lymphangitis of the lymphatics of the cord. Again

filarial disease may show a chylocele in which the tunica vaginalis

contains a fluid similar to that seen in the varices of lymph

scrotum. This fluid may also show filarial embryos.

In _endemic funiculitis_ there is a sudden onset with high

temperature and pain in spermatic cord and epididymis. The general

condition rapidly becomes grave with a hard, tender, cylindrical

swelling along the cord and also pain and swelling of epididymis.

It is a streptococcus infection usually engrafted on a filarial or

bilharzial process and demands immediate surgical measures.

_Kala-azar_ may be accompanied by sloughing of the scrotum at the

time manifestations of cancrum oris are noted.

Cases of gangrene of the scrotum have been reported as connected with

_malaria_.

Gangrene of the scrotum and penis is not infrequently noted in

_Rocky Mountain fever_.

In puzzling febrile cases in the tropics one should always think of a

possible _pyelitis_. Then too keep in mind _renal tuberculosis_.

If _leprosy_ comes on before puberty the sexual organs remain in

an undeveloped condition. Leprous infiltrations are noted in the

testicles and ovaries. In nerve leprosy, which does not usually

come on until after puberty, the women may bear healthy children

and it is now thought that the view that leprosy markedly tends to

produce sterility is lacking in confirmation.

In _ancylostomiasis_ menstruation is markedly interfered with and

amenorrhoea is often a prominent symptom. Young men who have been

affected before puberty show lack of development of pubic hair

along with infantile genital organs. The girls do not show normal

breast development.

_Granuloma of the pudenda_ is a disease which is rather frequent in

British Guiana.

_Dhobie itch_ is characteristically located in the crotch region.

BACTERIOLOGICAL EXAMINATION OF URINE

About the only tropical disease in which a bacteriological

examination of the urine is of particular value is that in connection

with _Malta fever_. It is advisable to cleanse the meatus with

alcohol and then having discarded the first ounce or so of the urine

to receive the remainder in a sterile salt mouth bottle. A drop of

this urine can be deposited on a poured agar plate and smeared out

over the surface.

As dysentery bacilli and cholera spirilla are practically absent

from the blood, urine examination for the causative organisms in

these diseases is fruitless.

The culturing of the urine to find paratyphoid or typhoid organisms

should be carried out, as well as blood cultures, where we are

dealing with puzzling fevers in the tropics. The Teague plating

medium described under the chapter on Faeces is a very satisfactory

one.

In culturing urine from a case of pyelitis blood agar is a most

excellent differentiating medium for streptococci.

CHAPTER L

THE FAECES AND THE ALIMENTARY TRACT IN TROPICAL DISEASES

THE FAECES

It is advisable to examine a stool macroscopically before taking up

the microscopical examination. Pus or blood in stools may often be

noted without the aid of the microscope.

The normal stool is sausage-shaped and soft.

The mucus of bacillary dysentery is opaque and grayish from the

great number of pus and phagocytic cells. It is well to remember

that Charcot-Leyden crystals, which are practically always absent

from bacillary dysentery stools, are not infrequent findings in

the amoebae-containing stools; of course, these crystals appear in

other intestinal parasite infections.

In obstruction of the common bile duct we have acholic, whitish,

foul-smelling stools. If the putty color be due to bacterial change

exposure to the air will restore the brownish tinge.

Sprue stools are whitewash to putty-colored, pultaceous, and filled

with air bubbles. The amount is excessive.

A very practical way of obtaining amoebae is to pass a rectal tube

or a piece of drainage tube with fenestrations into the bowel, and

amoebae may be found in the mucus filling the perforations in the

tube.

Ordinarily the stool is best collected in quart fruit jars

and examined as soon after evacuation as possible. The wooden

spatula-like tongue depressors are well adapted for handling the

specimen.

In examining a stool, it is well to color the drop of faeces, which

is to be covered with the cover-glass, with a small loopful of ½%

solution of neutral red. If diluting fluid is used, it should be

salt solution, and not water. The neutral red tinges the granules

of the endoplasm of amoebae and flagellates a very striking

brown-red color, thus differentiating them from vegetable cells or

body cells.

Encysted protozoa are difficult to diagnose, unless one possesses

considerable experience. In examining for encysted amoebae as well

as for bringing out the number of flagella of flagellates I now use

the following method: Take a clean slide and make a vaseline line

across it about 1 inch from the end. A drop of the iodine solution

is placed on the slide about ½ inch from the vaselined line and a

suitable portion of the faeces to be examined is emulsified in it.

The edge of a square cover-glass is then applied to the vaselined

line and allowed to drop on the preparation. By pressure suitable

thicknesses of fluid can be examined. There is an absence of

current motion.

Epithelial cells are generally more or less disintegrated. In

the mucus of bacillary dysenteric stools, however, large intact

phagocytic cells are frequent, which may be mistaken for encysted

amoebae, and the polynuclear cell count averages 90% as contrasted

with the average polynuclear count of 7.5% in amoebic dysentery.

When a smear preparation is desired, we may smear out a fragment

of mucus and stain by Romanowsky’s or Gram’s method. Beautiful

preparations may be made by mixing the faeces with water, then

centrifuging for one minute. This throws down vegetable débris

and crystals. Now decant the supernatant fluid, which holds the

bacteria in suspension, and add an equal amount of alcohol. Again

centrifuge, decant, and smear out and examine the bacterial

sediment.

Simply taking a small mass of faeces and emulsifying it with a wooden

toothpick on a concave slide in 70% alcohol—then, after the sediment

settles, taking up a loopful with platinum loop from the surface and

smearing out, gives a very satisfactory smear. Gram’s method, with

dilute carbol fuchsin counterstaining, gives the best picture.

To culture for typhoid, dysentery, cholera, or other bacteria,

take up the material in a tube of sterile bouillon and smear it

out with a swab over a lactose litmus agar plate or an Endo or

Conradi-Drigalski plate. Before streaking the plates they should

be very dry on the surface. This can be best done by pouring the

melted agar into a plate with a circular piece of filter-paper in

the lid and placing in the incubator for one-half hour to dry. The

filter-paper absorbs the moisture. Then inoculate the surface of

the plate with the faecal material.

=Teague Medium.=—We have formerly preferred the Endo plate for

typhoid work and the lactose litmus agar when culturing for dysentery

bacilli. More recently we have obtained most satisfactory results

with the Teague medium. The colon colonies, after eighteen hours,

are deep black and opaque while the typhoid-dysentery group show

colorless, transparent colonies.

The medium is prepared as follows: Nutrient agar is made in the

usual way, containing 1.5% agar, 1% Witte’s peptone, 0.5% sodium

chloride, and 0.5% Liebig’s meat extract, to the liter of distilled

water. It is cleared with egg-white, placed in flasks, and

sterilized in the Arnold sterilizer on three successive days. The

reaction is brought to plus 0.8. The agar is melted and saccharose

0.5% and lactose 0.5% are added. The medium is then heated for ten

minutes in the Arnold. To every 50 cc. of the medium are added 1

cc. of 2% yellowish eosin and 1 cc. of 0.5% methylene blue. The

mixture is shaken and plates poured. Eosin solution should be added

first.

=Occult Blood.=—In performing the test for occult blood, one

should exclude the possibility of blood reaching the bowels from an

extraneous source, such as ingested foods, mouth, nose, lungs and

vagina, and the absence of interfering substances should be ensured.

An absolute milk diet, or, at least, a diet containing neither meat

nor green vegetables, is indicated for two or three days prior to

the test, and all medication should be suspended. The technique noted

on page 524 should be followed scrupulously when dealing with faeces.

It has been suggested that the absence of occult blood from the

faeces may be accepted as an indication of cure in ancylostomiasis.

[Illustration: FIG. 154.—Cestodes and cestode ova.]

=Ova in Faeces.=—It is in the faeces we examine either for the

parasites or for their ova in connection with practically all the

flukes, except the lung fluke and the bladder fluke; for intestinal

taeniases and for practically all the round-worms, except the

filarial ones.

In the tropics, the examination of the faeces exceeds in value that

of urine and is possibly more important than blood examinations.

=Helminthiasis Statistics.=—There is one point in connection with

the statistical reports as to the presence of intestinal parasites in

a given section of the tropics that I desire to emphasize.

Because a limited district shows a certain prevalence of intestinal

parasites we should not conclude that the entire country from which

such findings emanate shows a similar extent and type of infection.

Take for instance the Philippine Islands.

[Illustration: FIG. 155.—Trematode ova.]

In 1910, there were made in Cavite Province 932 stool examinations

upon specimens from cases of sick people and of these only such

patients as it was thought required such an examination for

diagnostic reasons were made to bring such a specimen of faeces.

Of the 932 examinations, 135 or 14.4% failed to show the presence

of intestinal parasites or their ova. The remaining positive

examinations gave findings as follows:

-------------------+----------------------+---------------

Organism | Number of infections | Per cent.

-------------------+----------------------+---------------

_Ascaris_ | 627 | 67.2

_Trichocephalus_ | 607 | 65.1

Flagellates | 135 | 14.4

Amoebae | 111 | 10.9

Hookworm | 23 | 2.4

_Taenia saginata_ | 3 | 0.3

_Balantidium_ | 1 | 0.1

_Strongyloides_ | 1 | 0.1

-------------------+----------------------+---------------

At Bilibid Prison, Garrison encountered amoebic infection in 23% of

the cases. In the medical survey of Taytay, his findings were 2.7%.

Rissler and Gomez report only 0.39% of amoebic infection in their

examinations in Las Piñas and no cases showing such infections in

Tuguegarao and Santa Isabel. Such numbers are in striking contrast

with those of former investigators, some of whom have reported as

high a percentage of infection as 70.

[Illustration: FIG. 156.—Nematode ova.]

Our findings as regards flagellates (14.4%) corresponded fairly

closely with those of Garrison, namely, 21% at Bilibid and 5.5% at

Taytay.

Garrison, for _Trichocephalus_ infection, obtained 59% at Bilibid

and 77% at Taytay; Rissler and Gomez give 53% at Las Piñas; 25.9%

at Tuguegarao, and 6.23 at Santa Isabel. Our findings were 65.1%.

As regards _Ascaris_ we found a higher rate of infection than for

any other parasite (67.2%). Garrison encountered 26% at Bilibid and

82.9% at Taytay. The percentages of Rissler and Gomez are 77, 73,

and 60 respectively for Las Piñas, Tuguegaroa, and Santa Isabel.

Garrison noted at Bilibid an incidence second only to

_Trichocephalus_ for hookworm infection, namely 52%. His percentage

of infection at Taytay was 11.6. Rissler and Gomez found 11.14% of

all cases examined infected with hookworms at Las Piñas, 8.01%

in Tuguegarao, and 45.38% in Santa Isabel. We noted only 2.4% for

Cavite, San Roque, and Caridad.

Our findings as regards _Strongyloides_ (0.1%) were far below

those reported by Garrison at Bilibid (3%) and at Taytay (0.7%).

Rissler and Gomez found 2.24% infected in Las Piñas, but no cases

were encountered in Tuguegarao and Santa Isabel. The same factors

influencing hookworm infection in this locality may be operative

for _Strongyloides_. Garrison found 0.2% of the individuals

examined at Taytay to be infected with ciliates, while Gomez and

Rissler failed to find such infections at Tuguegarao or Santa

Isabel. We found a single case in the 932 examinations.

[Illustration: FIG. 157.—Microscopical constituents of faeces.

(_v. Jaksch._) _a_, Muscle fibres; _b_, connective tissue; _c_,

epithelium; _d_, leucocytes; _e_, spiral cells; _f_, _g_, _h_, _i_,

various vegetable cells; _k_, “triple phosphate” crystals; _l_,

woody vegetable cells; the whole interspersed with innumerable

microorganisms of various kinds.]

THE ALIMENTARY TRACT

The Mouth

In _pellagra_ we have moist fissuring at the angles of the mouth with

a large indented tongue with central coating and bare tip and sides.

There is often a glairy mucus covering these red borders on the side.

The fungiform papillae are prominent. Later on the tongue may become

fissured and uniformly red. The buccal mucosa shows a carmine flush.

The gums are tender but there is not the tendency to aphthous ulcers

one sees in sprue. The flow of saliva is frequently increased.

In _sprue_ there is at first great sensitiveness of the buccal mucosa

so that articles of moderate pungency give rise to painful burning

sensations. The tongue becomes quite sore with vesicle formation

along borders and tip which soon turn into ulcers. Ulcerations also

occur on the buccal mucosa, particularly at the site of the posterior

upper and lower molar teeth (Crombie’s ulcer).

The congestion causes a great increase in mucus especially about

the faucial pillars and pharynx. Ulcers are common about the

fraenum of the tongue. While the tongue is coated at first with

red ulcerated tip and sides it later becomes bare of any coating,

red and finally even glazed as though varnished. It is at times

fissured.

_Onyalai._—A very peculiar disease of Portuguese West Africa and

possibly the Soudan region, known as _onyalai_ is characterized by

the appearance of blood-distended vesicles of the mucosa of the

cheeks and hard palate. The tongue is often swollen. The skin may

show haemorrhages and haematuria is not infrequent. The mouth blebs

vary in size from that of a split pea to a diameter of ½ inch or

more. The cause is unknown.

_Herpes labialis_ is not so common in tropical as in temperate

climate malarias. It is absent in plague pneumonia.

In _leprosy_ the nodules which form on the inside of the cheeks and

fauces tend to show ulceration and thickenings. The discharges from

the ulcerations in the nose, especially that on the vomer, reach

the pharynx and such leprosy bacilli-containing discharges may be

expectorated and cause one to consider the material as coming from

the lungs.

In _yellow fever_ the bleeding from the gums usually precedes the

black vomit.

In _kala-azar_ and possibly in _malaria_ we may have gangrenous

conditions of the cheek, as cancrum oris.

In the miliary type of _verruga_ we may have the granulomatous

lesions appearing on the mucous membranes of the mouth.

In _typhus_ fever the mouth is strikingly foul with marked sordes

covering the teeth. The dry brown tongue in this disease is known

as the “parrot tongue.”

We may rarely have parotid gland enlargement in _Malta fever_,

_malaria_ and _tsutsugamushi_.

Parotitis is not uncommon in typhus fever. A type of parotitis

which differs from mumps in not being contagious has been reported

from the Philippines.

Stomach and Oesophagus

Very important in diagnosis is a tenderness in the pyloric end of the

stomach, which is brought out by attempting to palpate the epigastric

region. It is marked in yellow fever and acute pernicious beriberi

as well as in blackwater fever and bilious remittent fever. We also

frequently have epigastric tenderness, extending to the right, in

ancylostomiasis.

Hookworms patients are often “pot-bellied” and the craving for

eating unusual articles, as earth, may be connected with the

gastric hyperacidity which the patient desired to neutralize with

alkaline earth.

_Sprue_ gives a flatulent dyspepsia with gaseous eructations.

_Pellagra_ gives eructations and pyrosis and very common is a burning

sensation going up from the stomach along the line of the oesophagus.

The esophagus is raw in _sprue_ so that swallowing is painful.

Nausea and Vomiting

So many diseases are attended with nausea, besides those in which

nausea is accompanied by rather constant vomiting, that it would

hardly seem advisable to consider it alone. At the same time the

slight nausea which often accompanies _bacillary dysentery_, as one

of the manifestations of toxaemia, is of value in differentiating

this type of dysentery from the amoebic one.

In _yellow fever_ there may be early vomiting of whitish or

bile-stained mucus but the well-known black vomit is a later

feature, only occurring after the fourth day when the other

haemorrhagic manifestations set in.

Bilious vomiting is the feature in _bilious remittent fever_ which

causes the patient the greatest distress.

In _blackwater fever_ the frequent retching and bilious vomiting tend

to exhaust the patient and the persistent vomiting of green bile

often precedes death.

Bilious vomiting may be quite a feature of the icteric type of

_relapsing fever_.

_Vomiting sickness._—There is a disease known as _vomiting sickness_

which has been noted in Jamaica. It occurs chiefly in children

and has a sudden onset with marked vomiting followed by cerebral

symptoms and great mortality. Some have thought the disease to be

yellow fever but the fever and jaundice of that disease are absent.

Scott has thought it to be epidemic cerebro-spinal meningitis, but

more recently has suggested that it is possibly due to the eating of

some poisonous substance, plant or otherwise, and that it is not an

infectious disease. It is now recognized as due to ackee poisoning.

Vomiting is often a sign of dangerous vagal involvement in _acute

pernicious beriberi_. Some consider that the extreme dilatation of

the right heart, pressing on the stomach, may be the excitant of

this vomiting.

The vomiting of _cholera_ follows the diarrhoea. The material vomited

may be of the same character as the rice-water stools.

In _ptomaine poisoning_ vomiting precedes the diarrhoea.

Rarely a _liver abscess_ may burst into the stomach, in which case

we would have the vomiting of pus. Of course the more common route

is by the lungs in which case the chocolate-colored liver abscess

pus would be coughed up instead of vomited up.

The Intestinal Tract

It is usual to consider constipation as a clinical feature of

such diseases as plague, yellow fever, Malta fever, beriberi and

tsutsugamushi, as well as typhus fever.

Abdominal pains are most often connected with _dysenteric_

conditions and it is customary to state that the greater the

tormina, or intestinal griping, the nearer is the dysenteric

process to the caecum.

In _cholera_ the cramping of the abdominal muscles may follow that of

the calf muscles.

In _sprue_ we may have a doughy sensation on palpating the abdomen

due to the fermenting contents of the intestine.

In the algid type of _pernicious malaria_ the abdominal griping may

be severe.

Tenesmus is the condition which along with tormina gives a diagnosis

of some form of dysentery.

In rectal _schistosomiasis_ the thickenings and blood

extravasations, resulting from the eggs extruded by the fluke,

may give rise to prolapse of the rectum. This may also occur in

severe bacillary dysentery and in a disease of British Guiana

and Venezuela, known as _epidemic gangrenous rectitis_, prolapse

and gangrene of the rectum may occur. The symptoms are those of

gangrenous dysentery.

Diarrhoea

The chronic diarrhoeas of the tropics are often associated with

amoebic dysentery and in such cases we generally get a history of

recurring attacks of diarrhoea separated by periods of constipation.

In _sprue_ the condition generally sets in as a morning diarrhoea,

very profuse and painless. _Hill diarrhoea_ also shows frequent

stools of whitish color from early morning until about noon.

The typical stool of _sprue_ is a gas-permeated, putty-colored,

offensive mass, extraordinarily copious.

In _cholera_ the rice-water stool, which is not attended by pain,

causes an unusual sense of prostration even at the onset of the

stage of evacuation.

In _pellagra_ we often have a recurring diarrhoea or mild

manifestations of dysentery.

The stool of pellagra is darker and less copious than that of sprue

and shows only a normal fat content while that of sprue is very

fatty—as much as 30% of ingested fat appearing in the sprue stool

as against the 5% for the normal one.

In _Japanese schistosomiasis_, following the stage of urticarial

fever, we have our best diagnostic means in examining the

blood-tinged bit of mucus capping the stool for the spineless ova of

the fluke.

The _fluke diseases_ of the liver and intestines give rise to

various disturbances. The diagnosis is by the finding of the

specific ova.

In infections with _Strongyloides stercoralis_ there may be vague

manifestations of neurasthenia and diarrhoeal disturbances. Cochin

China diarrhoea was once thought to be a _Strongyloides_ infection.

Infections with amoebae, intestinal flagellates and ciliates are

discussed under dysentery.

Intestinal flagellates are so common in the stools of well people

in the tropics that one should be very careful in assigning a

pathogenic rôle to them.

It is now generally accepted that _Lamblia (Giardia)_ can bring

about exhausting diarrhoeas.

Intestinal Myiases

In the tropics vague intestinal disturbances or violent abdominal

cramping may be brought about by dipterous larvae in the intestinal

canal. The symptoms may be those of a dysentery and may be attended

with fever and malaise. The biliary tract also may be invaded. For a

more detailed statement of the several myiases, see Chapter XXV.

[Illustration: FIG. 158.—Larva of _Musca vomitoria_ (_Calliphora

vomitoria_); below: of natural size; above, enlarged. (Leuckart.)

(From Tyson.)

FIG. 159.—Larva of _Anthomyia canicularis_, enlarged. Rarely found

in the stool. (Gould.) (From Tyson.)]

The larvae usually obtain access to the alimentary tract in food

taken in by the mouth. Flies of the genus _Sarcophaga_ are prone

to deposit their larvae on food, especially meat that is somewhat

tainted. Other flies, as _Musca_ or _Anthomyia_, may lay their eggs

on food. Flies of the genus _Anthomyia_ tend to lay their eggs on

plants.

It is possible for a fly to deposit its eggs or larvae about the anus

while the man is at stool.

Great care must always be observed to assure one’s self that fly

larvae, which may be present in the stool, have not originated from

larvae deposited on the stool subsequent to its passage.

DETERMINATION OF DIPTEROUS LARVAE

There are certain points in the anatomy of dipterous larvae which

must be considered in recognition of the genus or family of the

flies concerned in the various myiases. The broad extremity is the

posterior one and the tapering one the anterior. The dark hook-like

processes, which may be in pairs or fused, project from the anterior

or head end and above them is a pair of projecting papillae. The

second segment from the head has on either side projecting hand or

fan-like structures with varying numbers of terminal divisions, 4 to

40 or more. These are the anterior spiracles.

The large terminal segment has on its posterior surface two

chitinized plates with 3 slits of various architecture in each.

These are the posterior stigmal plates and are the structures we

pay particular attention to in identification. In the early larval

stages there is only one slit; in the second stage there are two.

It is only in the fully developed larval stage that we note the

characteristic 3 slit stigmal plates. The presence or absence of a

rounded protuberance or button at the base of each stigmal plate

should be looked for. The area carrying the stigmal plates may be

sunken to form a pit. (See Fig. 135.)

KEY TO LARVAE OF THE MYIASES. (BANKS.)

1. Body with lateral and dorsal spinose processes Homalomyia.

Body without such processes 2

2. Body ending in two fleshy processes; rather small

species 3

Body truncate or broadly rounded at end 4

3. Processes bearing the stigmal plates; body about

5 mm. long Drosophila.

Processes not bearing the stigmal plates; body 10

mm. or longer Piophila.

4. But one great hook; posterior stigmal plates with

winding slits; no distinct lateral fusiform areas;

tip of body with few if any conical processes Muscinae.

With two great hooks; slits in the stigmal plate

not sinuous 5

5. No tubercles about anal area; no distinct processes

around stigmal field 6

Distinct tubercles above anal area; often processes

around stigmal field; lateral fusiform areas

usually distinct 7

6. Stigmal plates on black tubercles; lateral fusiform

areas distinct Ortalidae.

Stigmal plates barely if at all elevated; lateral

fusiform areas indistinct; stigmal plates often

contiguous or nearly so; slits long and

subparallel Trypetidae.

7. Slits in stigmal plates rather short, and arranged

radiately 8

Slits slender and subparallel to each other 9

8. Two tubercles above anal area; stigmal field with

distinct processes around it Anthomviidae.

Four or more tubercles above anal area; slits of

stigmal plates usually pointed at one end Muscinae.

9. A button to each stigmal plate; slits rather

transverse to body Calliphorinae.

No button to stigmal plates, slits of one plate

subparallel to those in opposite plate; plates

at bottom of a pit Sarcophagidae.

A specimen of stool containing fly larvae may be incubated in a moist

chamber in order to obtain the imago for species determination.

CHAPTER LI

THE JOINTS, BONES AND MUSCLES IN TROPICAL DIAGNOSIS

In considering the diagnostic significance of bone and joint

manifestations of tropical diseases, it is essential that the

practitioner in the tropics bear in mind the cosmopolitan

arthropathies.

It should be remembered that lesions of joints may accompany

or follow almost all infectious diseases, and that it is often

impossible to ascertain if the lesions be due to the actual

presence of organisms within the joint or to the action of toxic

substances elaborated elsewhere; so that infectious arthritis

is broadly defined as arising from the presence within the body

of a focus of infection. This definition is further expanded to

include joint affections of intestinal origin, and also those

in which neither the causal organism nor its focus of origin is

discoverable, but which by analogy we unhesitatingly recognize as

being due to an infective agent.

It is to be noted that the lesions of arthritis may develop either

in the intra-articular membranes or in the bony parts adjacent to a

joint, and that they may remain confined to their primary site or

eventually extend to involve other tissues.

INFECTIOUS ARTHRITIS

A. Of known etiology.

May be acute or chronic. Examples are: Gonorrhoea, typhoid,

tuberculosis, bacillary dysentery, pneumococcus infections,

pyogenic cocci, filariasis, Malta fever, secondary to any

recognized focus.

B. Of unknown etiology.

May be acute or chronic: Examples are: Acute articular rheumatism,

rheumatoid arthritis, four types beginning with acute symptoms, one

type having insidious onset. These are often due to unidentified

foci.

NONINFECTIOUS ARTHRITIS

A. Traumatic.

1. Acute, due to known traumatism.

2. Chronic, generally static in origin, or due to chronic strain

or irritation. Possibly includes villous arthritis of the knee and

hypertrophic arthritis in the young.

B. Trophic.

1. Metabolic. Examples are gout, psoriasis and probably

hypertrophic arthritis.

2. Senile.

3. Neuropathic. Examples are tabes, leprosy, syringomyelia,

Raynaud’s disease, and scleroderma.

4. Arteriosclerotic.

C. Blood dyscrasias, as haemophilia, anaemias and scurvy.

D. Toxic, as lead poisoning.

The diseases of more peculiar importance for the tropics in which

joint involvement must be considered in the diagnosis are the

following: