in which joint symptomatology is of diagnostic and therapeutic
importance. A prolonged typhoid-like course with sudden and painful
swelling of various joints, hip, shoulder, ankle or costo-vertebral
articulations, if occurring in the endemic area of Malta fever,
would at once make one suspect this disease. Typhoid does not give
painful joints, dengue is not accompanied by joint swelling, while
gonorrhoeal polyarthritis will be accompanied by other evidence of
gonorrhoeal infection.
The neuralgias, sciaticas and painful joints, together with the
sweats which exhaust the sufferer from Malta fever, often tempt
both patient and physician to resort to narcotics. Acute or
subacute effusion into one or more joints is present in at least
40 per cent of cases of Malta fever according to Rogers. The Malta
fever joint is not red, which fact, taken with its evanescent
character, differentiates it from the arthritis of acute rheumatic
fever.
_Dengue._—Sporadic dengue is difficult to diagnose. In an epidemic
the characteristic pains referable to tendinous insertions about
joints are present in at least 50 per cent of cases and is of great
diagnostic value. There is no swelling of the joints although the
turgescence of the skin over them may give the impression of an
arthritis. The intensity of pain varies from a feeling of muscular
soreness to excruciating pain when muscles or joints are actively
moved. Passive movement is not usually painful. In addition to
the rachialgia, bone and joint pains, some writers have described
swelling of the joints. This in my experience is unusual. Joint pains
are so characteristic that they distinguish dengue from all other
eruptive fevers.
Joint pains during convalescence may produce stiffness and
crippling continuing for many weeks after the cessation of fever.
_Relapsing Fever._—Bone, muscle and joint pains are practically
always present in this disease. In addition rachialgia and headache
are prominent symptoms and the aching gnawing pains in loins or nape
of neck may make one think of beginning smallpox, dengue or yellow
fever. There is no swelling of the joints in relapsing fever. As
in dengue the pains in the neighborhood of the joints may be quite
persistent.
_Yaws._—This disease gives us bone, joint and muscle lesions
similar to those of syphilis. From the mother lesion to the tertiary
framboesioma the course and symptoms of the two diseases are
similar. Thus we may have the flying pains and osteocopic pains of
the early days of infection and, as later events, chronic synovitis,
frambroesial infiltration of perisynovial membranes, frambroesial
infiltration of synovial membranes, chondro-arthritis, epiphysitis
and chronic frambroesial periostitis. These pathological processes
cause such conditions as we know under the names dactylitis, saber
shin, mutilating oro-rhino-palato-pharyngeal ulcerations, Parrot’s
nodes and cranio-tabes.
The uncomplicated framboesioma must be pathologically similar
to the gumma. Certainly the later effects of bone and joint
destruction and scarring are wonderfully like some of the
middle-age European descriptions “when lues was in flower.” In
framboesial disease the damage from bone destruction or from
contracture following cicatrization may be so complete as to render
useless a finger, a hand, one of the large joints or even a whole
extremity.
_Bacillary Dysentery._—As far back as the 17th century (Sydenham)
it was noted that joint pains or actual arthritides were occasional
complications of dysentery. We now know that the bacterial types
of dysentery are those most likely to show joint complications.
Because the joint fluid in these lesions is usually sterile, it is
assumed that they are the effect of toxins (or a toxin) produced by
_B. dysenteriae_. Of the two hypothetical toxins of the dysentery
bacillus one is supposed to produce neuritis and joint complications.
Arthritides are more common in some epidemics than in others and
with certain strains of bacilli than with others. The Shiga strain
is the worst offender in this regard. Manson reports 27% of joint
involvement in one epidemic.
Clinically, dysenteric arthritis is more apt to affect one of the
larger joints, the knee, ankle and hip, being most affected. The
elbow, wrist or shoulder joint may be affected, though this is
unusual. The pain and swelling may be an incident of the early part
of the attack. Usually it comes on when the acute symptoms are
abating or as a sequela. The joint is distended with effusion and
this involves the ligaments around the joint. Given an arthritis
in the course of a frank dysentery there is nothing it could
ordinarily be confused with. It is well to remember, however, that
patients with dysentery may have also a concurrent gonorrhoea or
arthritis from some focal infection. The dysenteric rheumatism
ordinarily completely subsides with the cure of the colitis.
In hepatic abscess following _amoebic_ colitis pain of some type is
a frequent symptom. Rheumatic-like pains and swelling of the hands
occur rarely, rapidly disappearing when the abscess is evacuated.
_Filariasis._—Maitland and Bahr have noted a synovitis which is
apparently a complication of filariasis. Bahr has found a fibrotic
ankylosis often to follow such a joint condition. The synovitis may
be followed by pus formation with serious or fatal outcome.
_Guinea Worm Disease._—Very rarely the female _Dracunculus_ may
penetrate a joint and cause synovitis or arthritis.
_Leprosy._—Occasionally there is joint involvement, especially of
the wrist and ankle joints, in which erosion of the cartilage and
bone dislocation occur giving us a condition similar to the Charcot
joint.
It will be remembered that the Charcot joint is most often seen
in tabes and may give one of the greatest joint swellings. As a
rule only one joint, usually knee or hip, is involved in tabes and
the affection is generally painless. The progress may be acute,
subacute or chronic. Syringomyelia, a disease which may be confused
with leprosy, may also show joint involvement, usually of the upper
extremity.
BONE AFFECTIONS
_Mycetoma._—As the result of the invasion of an extremity—usually
the foot—with the causative fungi, disorganization of the tissues
involved takes place. The granulomatous process invades muscles
and bones and as a result of the sinus formation we have the bones
converted into a softened, cheesy mass. This disintegration of bone
and other tissues is attended with little or no pain. The granules
discharging through the sinuses make for a proper diagnosis.
_Goundou._—In goundou the nasal bones and the nasal processes of the
superior maxilla are the seat of symmetrical swellings of the nature
of an hypertrophic osteitis. These exostoses may be quite large so
that there is interference with vision. There is little or no pain
connected with the bony growths and there is no invasive tendency.
_Big Heel._—There has been observed in natives of the Gold Coast
an affection of the os calcis somewhat like that involving the
superior maxillary bones in goundou. The disease begins with pain and
tenderness of one or both heels. The enlargement may involve only one
os calcis or affect both bones. There is no joint involvement but
locomotion is interfered with. There are periods of improvement which
are followed by return of the pains.
_Ainhum._—In this disease there is thinning or absorption of the
bones of the toe. A fibrous cord replaces the bony structures.
_Oroya Fever._—In this very serious disease of certain areas of Peru
the bone pains may be excruciating. These bone pains are especially
marked in the sternum but also involve the long bones.
_Trench Fever._—Pain over the shin bone is a prominent complaint in
this affection so that the term “trench shin” has been employed.
_Relapsing Fever._—Bone pains, especially referred to the knees, are
complained of by patients with the bilious typhoid of Griesinger.
This is a type of relapsing fever occurring in Egypt.
_Leprosy._—The bone affections of leprosy are considered under the
muscles.
MUSCLE INVOLVEMENT
_Leprosy._—In this ancient disease the course of which is marked
by anaesthesia, atrophy, absorption and accidents (cigarette burns,
etc.), the lesions of bones, joints, muscles and indeed of all other
tissues are, in great part, due to infiltration of nerves by the
organism of leprosy. The effects are secondary and trophic on the
one hand, and on the other partly due to secondary infection of
the leproma by various bacterial agents. Leprosy was for centuries
confused with other diseases in which ulceration and mutilation
are features. The value of mercury in differentiating syphilis,
the recognition of the importance of anaesthesia in this disease,
together with the discovery of the bacillus of leprosy and of the
etiological factors of several other confusing diseases, have made of
leprosy one of the easiest of all diseases to diagnose correctly. It
is, however, essentially a laboratory diagnosis.
In nerve leprosy we often get atrophy of the small muscles of the
hand and of the muscles of the forearm. The contracture which
takes place under these circumstances gives the “claw hand.” In
tubercular and mixed forms of leprosy we may get in addition
trophic disturbances of the fingers and toes and also extraneous
infections which may ultimately result in amputation of fingers
or toes. This process, going on over a considerable time or being
repeated, results often in stumping of fingers or hands or toes and
feet.
In addition to these openly destructive processes there is often
seen in leprosy a condition of subcutaneous absorption of all the
tissues. In this way the distorted finger nail may come to occupy a
seat over the knuckle or even (though rarely) further up the back
of the hand or arm. Briefly in leprosy we have, as representing the
pathology, muscular atrophy from nerve involvement, periostitis
and arthritis, interstitial absorption of bone and contractures
resulting in mutilation of fingers, toes, hands and feet from
trophic disturbance and intercurrent bacterial infection.
_Beriberi._—In this disease we have muscular atrophies, especially
of the muscles innervated by the peroneal and ulnar nerves, similar
to those following other forms of peripheral neuritis.
_Amoebiasis._—There have been reported very rarely disintegrating
lesions of muscles and cutaneous tissues in which amoebae have been
found.
_Heat Cramps._—In those working in firerooms or steel-mills,
the excessive heat to which they are subjected may cause various
manifestations of heat prostration, among which the painful muscle
cramps are prominent. These cramps are similar to those which are
such a feature of Asiatic cholera and in each instance are supposed
to be the result of dehydration of muscle tissue.
_Trichinosis._—Acute muscle pain is a feature of the stage of muscle
penetration by the larval _Trichinella spiralis_. In the disease we
have a fever suggestive of typhoid fever and oedema about the face.
A marked eosinophilia is characteristic. Another helminthic parasite
which may invade the muscles of man is the larval _Taenia solium_.
This must be of extreme rarity because infection with the adult _T.
solium_ is most rare and it is only accidental that the embryonic
stage would occur in man. It is a fact that the common tapeworm of
man, _Taenia saginata_, is found in the human host only as a sexually
mature parasite in the intestines; there is never a cysticercus stage
in the muscles.
_Myositis purulenta tropica._—We may have a suppurative myositis
with a single abscess formation or with disseminated foci or a
diffuse purulent infiltration. The attending fever and toxaemia
are similar to those attending any deep abscess formation. Abscess
formation in the muscles has been reported from various parts of
the tropics, especially the Gold Coast. It is possible that _F.
bancrofti_ infections are concerned in some of these conditions.
_Filariasis._—Filarial abscesses were found in the ilio-psoas
muscles in four cases. Wise and Minett found evidences of adult
filarial worms (_F. bancrofti_) in 22 out of 28 deep-seated
abscesses, which were examined by them.
CHAPTER LII
NEUROLOGICAL CONSIDERATIONS IN TROPICAL DISEASES
There is a great tendency in the tropics to ascribe neurological
manifestations to beriberi or malaria. It must be acknowledged,
however, that various sensory and motor phenomena, which may show
themselves from time to time, in those who have suffered from
beriberi, are common and prove sources of confusion in diagnosis.
Tropical sunlight with its ultra-violet rays had a vogue which held
sway for a brief period as explaining most nervous conditions in
Europeans in the tropics. At present we are inclined to believe
that excesses in eating and drinking and late hours may be more
potent in the production of nervous breakdowns than are factors less
cosmopolitan.
While syphilis is rampant in many parts of the tropical world the
usual views are that the luetic neurological manifestations, so
common in temperate climates, are more or less nonexistent. At the
same time it would seem advisable with this point in view to study
the cases attributed to other causes along the line of laboratory
investigations of the cerebro-spinal fluid.
Clinically there are many points of difference between syphilis
as seen in the native races of tropical regions and as observed
in Europeans at home, and it would seem advisable to do more work
along the line of spinal fluid examinations. The examination of the
spinal fluid for syphilis should include a Wassermann test using
several concentrations ranging from 0.2 to 1.0 cc., a globulin
estimation, cell count and Langes colloidal gold reaction,—the
last not being necessary however, unless positive findings are
obtained in one or more of the other tests. Of course the most
important test is the Wassermann of the spinal fluid and every one
should bear in mind the marked complement fixation power of the
spinal fluid of paretics. In such a fluid we almost always obtain a
positive reaction where quantities of 0.2 cc. or less are employed,
while with locomotor ataxia or cerebro-spinal lues amounts of 0.5
to 1 cc. are generally required to give a positive test. It is not
necessary to inactivate spinal fluid.
These tests can only be carried out in a well equipped laboratory
and the same is true of the colloidal gold one. The tests for cell
increase and globulin increase, however, can be made by anyone
prepared to do ordinary clinical laboratory work.
_The normal spinal fluid_ is as clear as water, has a specific
gravity of about 1.010 and is under a pressure of about 5 to 7 mm.
of mercury or 60 to 100 mm. of water. The sugar content is about
0.07% and the proteid content about 0.03 to 0.04%.
CEREBRO-SPINAL FLUID EXAMINATIONS
To withdraw spinal fluid for bacteriological examination or
cytodiagnosis we use a sterile needle about 4 inches long for an
adult, preparing the skin as described for blood cultures from
a vein (see page 516). The patient is placed on the left side
with knees drawn up and head and shoulders carried forward to
give the greatest possible space between the spinous processes by
arching the spine. A line at the level of the iliac crests passes
between the third and fourth lumbar vertebrae. Select a point
midway between the spinous processes of these lumbar vertebrae
and enter the needle two-fifths of an inch to the right of this
point, pushing the needle inward and upward. Collect the material
in two or three sterile test tubes, to avoid contamination of the
entire sample by a drop of blood which may come out in the first
portion. The presence of blood in very slight amount interferes
with cytodiagnosis and globulin tests and, if present in more than
a trace, it makes the colloidal gold test practically worthless.
Make cultures on blood serum at the earliest possible moment.
Centrifugalize a portion of the fluid at high speed and examine
the sediment for bacterial content. After the puncture the patient
should drink a glass or so of water and remain in bed for a day,
preferably with the head lower than the feet.
In general terms, excluding syphilis, it may be stated that:
1. A lymphocytosis indicates a tuberculous or poliomyelitis process.
With these diseases, the fluid will probably be clear.
2. An abundance of polymorphonuclear and eosinophilic leucocytes
indicates an infection with pyogenic organisms, in which cloudy fluid
is the rule.
Meningism shows very few cells.
Trypanosomiasis gives a cellular increase very similar to syphilis.
In the work of the French Sleeping Sickness Commission five cells per
cubic millimeter was taken as normal.
Not only may trypanosomes be found in the spinal fluid, when
they mark the setting in of the “sleeping sickness” stage of
trypanosomiasis, but a case has been reported of the presence of
_Trichinella_ embryos in the spinal fluid. Recently a few cases
have been reported of anthrax meningitis, in which anthrax bacilli
have been found in the spinal fluid.
=Cell Count.=—A method of examination considered by neurologists as
of differential diagnostic value is to count the number of cells in a
cubic millimeter of the cerebro-spinal fluid. The technic is to use a
gentian-violet-tinged 3% solution of acetic acid. This is drawn up to
the mark 0.5, and the cerebro-spinal fluid is then sucked up to 11.
After mixing, the cell count is made with the haemacytometer.
Count all the cells appearing in the entire ruled area (9 large
squares) and add one-sixth of this number to find the approximate
total number of cells per cubic millimeter of spinal fluid
examined as above. It is advisable to make the cell count of the
fluid as soon after obtaining it as possible, the cells tending
to degenerate or adhere to the glass of the tube. The latter can
be minimized by vigorous shaking before withdrawal of the fluid
for counting. Normally we have only two to ten cells per cubic
millimeter, but in tabes and general paresis this is increased to
50 or 100 cells, greatest at onset of disease.
_Pleocytosis._—Miller gives the following table as to pleocytosis:—
AVERAGE INCIDENCE OF LYMPHOCYTOSIS IN THE SPINAL FLUID
(Plaut, Relim and Schottmuller)
--------------------+-----------+-------------------------------------
Clinical diagnosis | Frequency,| Remarks
| per cent. |
--------------------+-----------+-------------------------------------
Cerebro-spinal lues | 85-90 | Counts often over 100—may reach
| | 1000 per c.mm.
--------------------+-----------+-------------------------------------
Tabes dorsalis | 90 | Counts usually under 100.
--------------------+-----------+-------------------------------------
General paresis | 98 | Counts average 30-60 cells per c.mm.
--------------------+-----------+-------------------------------------
Secondary lues | 30-40 | Moderate increase as a rule.
--------------------+-----------+-------------------------------------
Multiple sclerosis | 25 | Border-line counts.
--------------------+-----------+-------------------------------------
Cerebral haemorrhage| {Frequency|
Cerebral tumors | { is | Cellular increase is apt to be a
Sinus thrombosis | { variable| very moderate one.
--------------------+-----------+-------------------------------------
_Globulin Increase Tests._—Noguchi’s butyric acid test is very
satisfactory, but because of the objectionable odor of the butyric
acid, we use the Ross-Jones and Pandy tests routinely in our
laboratory.
For the Ross-Jones method, one cc. of saturated solution of
ammonium sulphate is placed in a small test tube and one cc. of
spinal fluid placed on top of this column. If globulin increase
is present a turbid ring appears within a few seconds at the
junction. Normally there is no sign of a ring. This test is a
modification of Nonne’s Phase 1 reaction. For Pandy’s test, prepare
a saturated solution of carbolic acid crystals in distilled water.
Place 1 cc. of this reagent in a small test-tube and add 1 drop of
spinal fluid. In a normal fluid, only the faintest opalescence is
observed; but in a fluid with globulin increase a smoke-like white
cloud develops instantly where the drop comes in contact with the
reagent.
=Colloidal Gold Test (Lange’s).=—It is now generally accepted that
this test is more diagnostic of general paresis than any other single
test. The color changes in the first five tubes (1-10 : 1-160)
are so constant that the term “paretic curve” is applied to such
findings. Of less diagnostic value are the so-called cerebro-spinal
lues curves where the color changes, though of less intensity than
the paretic ones, are most marked in the third, fourth, fifth and
sixth tubes (1-40 to 1-320). In various types of meningitis, other
than luetic, the color changes are at times more marked in the tubes
with the higher dilutions of spinal fluids (from 1-320 to 1-2560).
The paretic curve of the colloidal gold test generally runs
parallel with a spinal fluid Wassermann and globulin increase. This
agreement does not exist at all constantly for positive blood serum
Wassermann tests and increased cell counts.
It may be stated that this test is of more importance in paresis
than any single one of the four reactions of Nonne, viz.: (_a_)
blood serum Wassermann; (_b_) spinal fluid Wasserman; (_c_)
globulin increase, and (_d_) increased cell count of spinal fluid
(pleocytosis). Of course, all of these tests should be carried out.
_Test._—The test is carried out by preparing a series of ten
test tubes containing dilutions of spinal fluid in 1 cc. of
normal saline, ranging from 1-10 to 1-5120, and adding 5 cc. of
the colloidal gold reagent to each tube and to a control tube
containing salt solution alone. The successful application of
the test is dependent upon (_a_) care in the preparation of the
reagent; (_b_) absolute cleanliness of all glassware used, and,
(_c_) on the entire absence of blood from the spinal fluid. Before
using a new colloidal gold solution, it should be tested with
spinal fluid of known reaction, so that it may be discarded if
too sensitive or not sufficiently so. The color changes usually
start almost immediately and if there is no change evident in half
an hour, there will probably be none later. The maximum change
occurs after several hours, so that readings are made after the
tubes have stood overnight at room temperature. The proper color
of the control in tube 11 should be salmon-red or old rose and the
fluid should be perfectly transparent. When the color is changed
in tubes containing dilutions of the spinal fluid we record one
showing a bluish tint as 1. When the change is to a lilac we record
it as 2. A distinct blue is marked as 3 and a pale blue as 4. When
decolorization is complete there is the highest color change, which
is noted as 5.
_Mastic Test._—The mastic test as devised by Cutting is apparently
of value as an aid in the diagnosis of syphilis of the nervous
system. The test is made by treating six dilutions of spinal fluid
in test tubes with an alcoholic extract of pure gum mastic, diluted
with distilled water before using. Its great value lies in the ease
of preparation from an effective gum mastic, and in the keeping
qualities of the stock alcoholic extract. After standing at room
temperature for twelve to eighteen hours or at 37°C., for six to
twelve hours, readings are made. In positive cases (paresis) the
mastic will be precipitated in the first one, two, three or four
tubes (higher in strongly positive cases) leaving the supernatant
fluid clear, with the mastic as a white flocculent precipitate at
the bottom of the tube. In some positive reactions the opalescence
of the fluid persists with a fine white precipitate at the bottom.
The control tube must remain unchanged.
SHOWING THE AVERAGE FREQUENCY OF THE VARIOUS REACTIONS IN SYPHILIS OF
THE CENTRAL NERVOUS SYSTEM (MILLER)
-----------------------+---------------+----------------+---------------
| Paresis | Tabes dorsalis | Cerebro-spinal
| per cent. | per cent. | syphilis
-----------------------+---------------+----------------+---------------
Blood Wassermann | 98-100 | 70 | 70-80
Spinal fluid Wassermann| 97 | 60-80 | 85-90
Pleocytosis | 98 | 85-90 | 85-90
Positive globulin test | 100 | 90-95 | 90-95
Colloidal gold test | 98-100 | 85-90 | 75-80
| Paretic curves| Luetic type of | Luetic curve
| | curve |
-----------------------+---------------+----------------+---------------
_Other Chemical Constituents._—Normally the fluid reduces Fehling’s
or Benedict’s qualitative copper solutions. It is well for one to
gain experience with the degree of reduction to be normally expected
as the test is but slightly marked. Quantitatively, the reducing
substance is equivalent to 60-70 mg. glucose per 100 cc.
The urea is practically the same as in the blood, parallels any
change in the latter, and has the same significance. Creatinine
is about half that of the blood, and has apparently no clinical
significance. Uric acid is present in still smaller proportion.
DELIRIUM AND COMA
It is difficult to make a sharp distinction between a disease showing
delirium and one showing coma as delirious states tend to be followed
by coma or such conditions may alternate.
In _yellow fever_ the alert, suspicious mental state may give way
to one of marked delirium requiring close watching to prevent the
patient throwing himself from his bed.
In _plague_ there is more of a mild delirious state in which the
patient has a great tendency to wander about. The mental state is
rather that of an intoxicated person with the thickness of speech
and retardation of mental processes.
_Typhus fever_ and _spotted fever of the Rocky Mountains_ tend to
produce stuporous states.
A delirious state, especially at night, is often noted in
_tsutsugamushi_.
_Rat bite fever_ also tends to show delirium.
In the ordinary paroxysm of _malignant tertian_ there is quite a
tendency to flightiness during the prolonged hot stage. In the
cerebral types of pernicious malaria there may be violent delirium
followed by coma or the patient may be comatose from the onset of
the paroxysm. Such conditions are often mistaken for sun stroke. In
the comatose form of malaria we have a high temperature with sighing
or stertorous breathing and at times Cheyne-Stokes respiration.
Following upon the algid stage of _cholera_ we may have a stage of
reaction without the disappearance of anuria, in which a typhoid
state, with low muttering delirium or even with an acute delirious
state, supervenes.
Toward the end of the sleeping sickness stage of _trypanosomiasis_
we have a subnormal temperature with a comatose state.
Comatose states following upon the acute confusional psychoses of
_pellagra_ are not uncommon. Pellagra may show an acute collapse
delirium.
In _heat stroke_ we may have either delirium or coma. There is no
more difficult problem encountered in the tropics than the one of
differentiating cerebral malaria from heat stroke.
_Oroya fever_ is frequently accompanied by delirium.
In _typhus fever_ (tabardillo) delirious or stuporous states are to
be expected about the end of the first week or even earlier. This
is a disease in which the clouding of the consciousness is almost
as marked as in plague. Delirium is more apt to occur at night.
In very toxic cases of _bacillary dysentery_ there may be a mild
delirium.
=Insomnia.=—Sleeplessness or, at any rate, a condition where the
patient only dozes is often seen in _dengue_. This mental alertness
and wakefulness may also be noted in _yellow fever_. In malaria,
possibly connected with quinine administration, we may have marked
insomnia although cases have been reported of insomnia due to malaria
which has been relieved by quinine.
Just as cardiac decompensation from any cause will be attended by a
distressing insomnia so is this also a feature of _beriberi_ where
cardiac involvement is marked.
_Liver abscess_ may be attended with insomnia.
_Malta fever_ is often attended with a weariness from suffering with
the various joint and nerve pains so that insomnia is often marked.
Even in _trypanosomiasis_ insomnia may be present at first.
Insomnia is also one of the early neurasthenic manifestations of
_pellagra_.
=Somnolence.=—The disease in which this symptom is best known is
_sleeping sickness_. The patient may go to sleep lying in the bright
sunlight or in the midst of eating a morsel of food. These cases can
be easily aroused but quickly drop off to sleep afterwards. They
often deny that they were asleep. Later on in sleeping sickness the
patient may sleep from 24 to 36 hours continuously and a more marked
tendency to somnolence may be present by day than by night.
In the prodromal stage of _leprosy_ somnolence is often marked and
accompanied by a sensation of unaccountable weakness. Sweatings and
accessions of fever may also be noted at this time.
In _plague_ the rather stuporous state of the patient may give the
impression of somnolence.
CEPHALALGIA, RACHIALGIA AND OTHER PAINS
_Yellow fever_ is marked by pains in the lumbar region, the _coup de
barre_ of the French. It is as if the patient had been beaten over
the small of the back with a bar of iron. The headache is rather
orbital and is often excruciating. There are also frequently heavy,
dull pains of the extremities.
_Blackwater fever_ also has marked pains in the lumbar region giving
expression to the kidney damage done by the haemoglobin detritus
plugging the tubules.
In all forms of _malaria_, but especially in the paroxysms of
malignant malaria, there are severe headaches and pains in the
extremities. Intermittent neuralgia is often regarded as malarial.
_Dengue_ gives rise to a marked post-orbital soreness rather than
pain. There is also a marked rachialgia with pains in the limbs
often referred to the regions of the joints, which, however, are not
swollen.
In _Malta fever_ the neuralgias, especially sciatica, often
associated with suddenly appearing, painful joint swellings, are
prominent features.
In _trypanosomiasis_ headache is often marked, together with a
characteristic deep hyperaesthesia, so that the striking of a limb
against a hard object gives rise to excruciating pain, there being,
however, a delay in the experiencing of the painful sensation.
In _relapsing fever_ the headache is often intense with pains in the
back and bones.
In _cholera_ one of the most striking phenomena of the disease
is the terrible cramping of the muscles, especially those of the
calves and feet. These pains actually torture the patient. Cramps
of abdominal muscles as well as those of extremities are often
noted in _heat stroke_ in men in firerooms.
In _beriberi_ there is often pain in the epigastric region so that
the slightest touch causes great distress. This epigastric tenderness
is also a feature of yellow fever. The calf muscles are also
markedly hyperaesthetic in beriberi.
In _leprosy_ the neuralgic pains may be very severe while the nerves
are being pressed upon by the connective tissue increase of the
endoneurium and perineurium. Mention has been made of excruciating
pains of toes, especially the big toe, even suggesting gout.
The excruciating pains of _Oroya fever_ are connected with the
changes taking place in the bone marrow. There is probably more
rapid alteration in the blood picture in this disease than in any
other. It might be designated a fulminating pernicious anaemia.
Pain on pressure on dorsal or lumbar spine is common in _pellagra_.
_Plague_ may be associated, during the first day or two, with an
excruciating headache. This may even be prodromal but tends to
disappear with the rapidly developing stuporous state of the patient.
In _typhus fever_ boring headache, oppressive rather than
lancinating, is a feature of the first days. It is usually frontal
or temporal.
In _malignant tertian_ the headache is often quite intense during the
prolonged hot stage. The headache of malaria is usually frontal or
suboccipital.
In _trench fever_ we may have a cutaneous hyperaesthesia over the
shins. _Rocky Mountain fever_ shows joint pains.
TREMORS AND CONVULSIONS
It is in _trypanosomiasis_ that we have the most important tremor.
It is the fine tremors, which first are noticeable in the tongue
and later in hands and even legs, that mark the onset of the stage
of sleeping sickness with the trypanosomes in the cerebro-spinal
fluid. At times an intention tremor may be noted in advanced cases
of sleeping sickness. In addition we have epileptiform seizures in
sleeping sickness.
In cerebral manifestations of _pernicious malaria_ there is a type
characterized by epileptiform convulsions.
In the acute stage of _Brazilian trypanosomiasis_ we may have
almost any type of cerebral or cord lesion.
Tremors of tongue and hands may be present in the second stage of
_pellagra_.
Fibrillary tremors have been noted in the main-en-griffe of
_beriberi_ but tremors of the tongue and hands, so common in
alcoholic neuritis, are rare in beriberi.
Convulsive seizures are not uncommon in the hyperpyrexial type of
_heat stroke_.
In infantile beriberi the child often becomes rigid. There is not
a true convulsion but such cases are at times thought to have
meningitis.
In _schistosomiasis_ and _paragonomiasis_ as well as in infections
with the larval stage of _Taenia solium_ we may have brain
involvement and manifestations of Jacksonian epilepsy.
ALTERED REFLEXES INCLUDING SENSORY AND MOTOR DISTURBANCES
_Beriberi._—It is usually stated that the tendon reflexes of the
lower extremity, especially the patellar reflex, are absent. While
this is generally true they may at first show an exaggeration and
some cases do not seem to show any decided change. There may be
striking variation from day to day in the reflexes. The superficial
reflexes, especially the cremasteric, are as a rule more active than
normally.
The sensory changes in beriberi are less marked than those of the
motor side. There is rarely complete anaesthesia but rather a
blunting of sensation. Hyperaesthesia, particularly of the muscles of
the calf of the leg, is well marked when the muscles are grasped with
the hand.
The anaesthesia is earliest noted over the shin bone and dorsum of
the foot. A loss of tactile sense is often noted about finger tips
making it difficult for the patient to button his coat.
The most striking motor phenomena are the foot and wrist-drop,
especially the former. The extensor muscles are more markedly
involved than the flexors. There is marked muscular weakness of
foot as well as hands. The weakness of the muscles of the leg is
often the first symptom to be complained of. The type of palsy in
beriberi is mainly paraplegic although hemiplegic and monoplegic
types have been reported. The paralysis of the diaphragm is the
most serious of the muscle palsies.
Contractures of the muscles of the foot or calf of the leg may occur.
Contractures of the muscles of the upper extremity are more rare.
Muscular atrophy of the leg muscles is often marked. In the upper
extremity the muscles of the hand are most frequently atrophied.
_Pellagra._—There is considerable variation from time to time in the
reflexes. Some authorities attach diagnostic value to the appearance
of an exaggerated reflex on one side and a diminution or absence
of the corresponding reflex on the other side. Ankle clonus may be
present.
Paraesthesias and in particular a burning sensation of the
erythematous areas are often noted. Hyperaesthesia of the dorsal
and lumbar regions is often noted. Pruritus is at times complained
of in the region of the perineum. We have muscular weakness.
_Sleeping Sickness._—The deep reflexes are usually exaggerated and
the superficial ones diminished or absent.
There is no distinct alteration of motor or sensory function except
that of deep hyperaesthesia (Kérandel’s sign). There is usually
marked weakness of muscles of locomotion.
_Leprosy._—The usual statement is that there is an exaggeration of
the deep reflexes. Ankle clonus has been rarely reported.
Anaesthesia is the most important symptom in the diagnosis of
leprosy. This loss of sensation is often for pain and temperature
with retention of tactile sense (dissociation of sensation—a
prominent symptom of syringomyelia). The anaesthesia is not only
found in the spots but associated with the leprous neuritis which
chiefly involves the ulnar, facial and peroneal nerves. Muscle
palsies and atrophies are common and the main-en-griffe appearance
of the hand is seen.
In _lathryism_ we have spasticity and an exaggeration of the
reflexes.
A very remarkable disease called _kubisagari_ or _paralytic
vertigo_ has been observed in Japan. This disease is thought to
affect those living in stables. The attacks only last a few minutes
and at other times the patient seems normal. An attack shows ptosis
and diplopia, speech disturbances and palsy of muscles of back of
neck, causing the head to fall forward. There may also be some
paresis of muscles of extremities. The disease is not fatal. Cases
have been observed in Switzerland.
THE GAIT
There are no gaits in tropical diseases which can strictly speaking
be regarded as special types of gait. In beriberi we often note the
designation _tripod gait_ of _beriberi_. This simply refers to the
manner in which a case of the paraplegic type of beriberi uses a
stick held by his hands to assist him in dragging along his atrophied
and enfeebled legs. The legs are widely separated and the stick
placed in front makes the two legs and stick resemble a tripod.
It is true that beriberics show the steppage gait of multiple
neuritis as, owing to more or less foot-drop and lack of power to
extend the toes, the patient lifts his foot high from the ground to
avoid scraping the toes, and bends to the other side. It is as if a
man were walking through a mire.
When other groups of muscles than the foot extensor ones become
involved the gait is that of extreme weakness—a shuffling one.
In _sleeping sickness_ it is a shuffling gait. It is as if one were
dragging the feet along from pure muscular weakness.
In _pellagra_ we may see a gait in which the patient separates his
legs rather widely and uses a stick in front, shuffling his feet
along with knees slightly bent and soles of the feet scarcely raised
from the ground.
Some cases show a typical spastic paralytic gait.
We often note under _dengue_ the designation dandyfied gait. This
refers to the stilted, mincing gait of a dandy and is probably the
explanation of the derivation of the word dengue. The pains about
the site of the insertions of muscles with the slightest movement
make these patients walk in a stiff, self-conscious manner.
PSYCHIC AND NEURASTHENIC STATES
A very remarkable fact is that in many tropical and subtropical
regions where syphilis is rampant among the natives there is slight
or absent incidence of general paresis and locomotor ataxia.
Jefferys and Maxwell state that the parasyphilitic manifestations
were absent in thousands of cases observed by them in Formosa.
In the Philippines one sees occasionally typical cases of these
parasyphilitic diseases but of course standard methods of treatment
of syphilis have been employed there for many years.
In China, where there is practically no treatment for syphilis,
luetic ulcerations are exceedingly common and it has been suggested
that insufficient treatment cures the skin lesions but adds to
the effects on the nervous system. It will be remembered that
skin and nerve tissue arise from similar embryological layers
(epiblast) hence a suppression of toxic effect on one tissue may
add to the burden on the other. It has been suggested that if the
surface lesions are allowed to develop to maturity, the skin,
which is the great elaborating center for antibodies, will produce
enough adequately to protect the whole body; whereas, if the
surface lesions are aborted, there is a diminished stimulus with
consequent diminished elaboration of protective bodies. The brain
is then liable to parenchymal invasion, since chemicals, owing to
difference in their physical properties, cannot replace natural
antibodies in controlling the disease in this location. This theory
takes no reckoning of differences exhibited by variant strains of
treponema in their tendencies toward selective localization. It has
been noted that the form of syphilis endemic in certain regions is
much less virulent than is the cosmopolitan form.
_Pellagra._—Very important in diagnosis is a more or less
prolonged prodromal period of neurasthenia which is apt to be more
marked in the winter at a time when the skin and alimentary tract
manifestations are in abeyance. Along with the anxiety and unrest of
this neurasthenia we have lack of mental concentration and depression
of spirits.
A melancholic state is almost always present in the psychosis
of pellagra. There is not the indifferent, satisfied, more or
less happy mental state of the case of general paresis. Some
consider the pellagrous psychosis to belong to the toxic group,
as from alcohol or cocaine, while others place it in the group of
infective psychoses, as the post-influenzal one. Gregor regards it
as belonging to the infective-exhaustive group. The insanity of
pellagra is that of an acute confusional one.
In the final cachexia there is a dementia.
_Sleeping Sickness._—It may be many months or even years before the
mental changes follow the trypanosome fever stage. At first a change
in disposition is noted, the patient becoming listless and apathetic.
There is great impairment of mental concentration and memory. There
may be later on catatonic manifestations as echolalia, mutism or
flexibilitas cerea. There may at times be paranoid manifestations
to be succeeded by states of profound melancholia. In the terminal
stage a comatose state overshadows the psychical manifestations.
_Malaria._—Leaving out of account the acute delirious states which
accompany cerebral malaria there have been reported cases showing
various manifestations of psychic disturbances even to maniacal or
melancholic forms of insanity.
It is a common practice to attribute the irritability and lack of
mental concentration of those who have lived for a long time in
the tropics to the damage done the cerebral cortex by the malarial
parasite. It is certainly more reasonable to attribute these minor
psychic disturbances to malaria rather than to actinic rays of the
sun.
There is no doubt but that quinine, given either for treatment or
prophylaxis of malaria, is a cause as potent as alcohol and tobacco
in tropical neurasthenia.
_Insolation._—It is popular to assign neurasthenic manifestations to
the actinic rays of the sun or the tropical heat, as these influences
operate on every resident of the tropics. It is very necessary to
exclude derangements of the digestion due to errors in diet with
resulting exhaustion of the pancreatic and hepatic functions.
Alcohol is a potent factor for tropical neurasthenia as the
tendency is for excess in this direction in those who in temperate
climates are only moderate drinkers.
_Hookworm Disease._—The patients with this disease are apt to become
hypochondriacal and even melancholic.
There is a correspondence between the physical and mental
backwardness of children with this disease, a child of twelve, who
by the Binet-Simon test will only be rated at 7 will also not seem
larger or better developed physically than a child of seven years
would be.
_Malta Fever._—Owing to the neuralgic pains and insomnia patients
with this disease are apt to become neurasthenic. They are peculiarly
liable to form the morphine habit if this drug be placed in their
hands for the relief of pain.
The victims of _leprosy_ not only may show an indifference to their
condition but may also exhibit a moral apathy.
_Dengue_ often shows a rather marked neurasthenia during
convalescence and this may be protracted if the patient tries to
resume his active duties before his complete recovery.
In _latah_ there is echolalia and echopraxia, the patient repeating
words he hears and mimicking movements he sees. The mind is usually
clear. As a matter of fact the symptoms show similarity to those of
the catatonic form of dementia praecox. The disease is more common in
that part of the world centering in the Malay peninsula. Suggestion
is an important factor in this neurosis.
In _amok_, a sort of epileptiform seizure in which the patient is
obsessed with a desire to kill, there may be no recollection of the
running amok. After the attack the patient may be stuporous.
LUNACY IN THE TROPICS
Van Loon, having examined over 200 cases from among 1100 insane
patients in Java, found the most common types of mental disease to be
dementia praecox, general paresis, various manifestations of cerebral
syphilis and acute maniacal or confusional states. Not only were all
forms of mental disorder known in European countries represented,
but their comparative frequency and the types of conduct exhibited
were, on the whole, what might be expected in the study of a group of
similar cases encountered in any other part of the world.
Overbeck-Wright in his book—“Lunacy in India”—notes that 44% of
cases were under treatment for various types of mania, 15.9% for
melancholia, 4.8% for delusional insanity, 5.2% for idiocy, 5.7%
for dementia and 6.6% for insanity following the use of _Cannabis
indica_. It is noted that dementia praecox is not included in the
statistical returns, but the author states that in his experience
hebephrenia and katatonia account for a much larger proportion of
cases than melancholia.
Overbeck-Wright is of the opinion that general paresis is quite
common in India notwithstanding the fact that for many years the
opinion has obtained that syphilis of the central nervous system
and the parasyphilitic diseases were exceedingly rare among
tropical natives. He regards the incidence of cerebral disease
in syphilitic natives as less than with Europeans, attributing
this fact to the existence of an immunity acquired through the
prevalence of syphilis among these people during a period of
several centuries. Cases of general paresis are generally reported
under the diagnosis of chronic mania.
Van Loon also notes the mistake made in most books on tropical
medicine as to the rarity of general paresis. General paresis
being a disease in which we have such characteristic laboratory
diagnostic tests, especially the colloidal gold test, there should
be little difficulty in settling this question of its absence or
relative infrequency among natives of tropical regions.
INDEX
Acanthocheilonema perstans, 339
Acidosis, 525
in blackwater, 58
in cholera, 236
in heat stroke, 468
in kala-azar, 131
Aedes calopus, 105, 433
Agglutination tests, 517
in blood transfusion, 521
in cholera, 230
in dysentery, 184
in Malta fever, 244
Ainhum, 471, 595
Alastrim, 486
Albumin tests, 570
Albuminuria, 574
in blackwater, 61
in malaria, 39
in yellow fever, 110, 574
Alcohol, and neuritis, 270, 287
and liver abscess, 167
Alimentary tract, 586
American leishmaniasis, 138
Amoebae, 148, 158, 159
Amoebic dysentery, 147
Amok, 610
Anaemia, 553
Ancylostomiasis, 319, 493, 546, 548, 554, 563, 567, 609
ancylostoma in, 320
diagnosis in, 329
epidemiology of, 323
geographical distribution of, 320
ground itch in, 328
history of, 319
life history of hookworm, 321
pathology of, 324
prognosis in, 331
prophylaxis in, 331
symptomatology of, 326
Ancylostomiasis, symptoms in detail of, 328
treatment of, 332
Anopheline mosquitoes, 18, 20, 24
Antimony, administration of, 134
Arsenic and beriberi, 270
Arsphenamine, administration of, 96
Arthritis, infectious, 592
noninfectious, 592
Aspergillus fumigatus, 474
Atriplicism, 556
Aural myiasis, 568
Bacillus alkaligines faecalis, infection with, 485
dysenteriae, 175
icteroides, 101
leprae, 248
pestis, 190
Bacterium tularense, 214
Balch’s staining method, 513
Basal metabolism, 489
Benign malaria, 29
Beriberi, 268, 492, 547, 555, 596
acute pernicious, 282
and scurvy, 286
asylum, 279
atrophic, 280
definition of, 268
diagnosis in, 285
endocrine gland disturbances and, 274
epidemic dropsy, 278
epidemiology of, 276
etiology of, 269
food deficiency, 270
geographical distribution of, 269
history of, 268
infantile, 279, 287, 547
paraplegic, 282
pathology of, 277
Beriberi, polyneuritis gallinarum and, 275
prognosis in, 288
prophylaxis in, 288
rice in, 272
rudimentary, 280, 282
ship, 285, 547
symptomatology of, 278
symptoms in detail of, 284
synonyms for, 268
treatment of, 290
types of, 280
vitamines in, 271, 275
wet, 280
Berne, 421
Big heel, 595
Bilharziasis, 357, 360
Bilious remittent malaria, 34
Bilious typhoid of Egypt, 92, 111
Black death, 188
Blackwater fever, 55, 498, 541, 547, 553, 557, 560, 572, 574, 579
complications in, 60
definition of, 55
diagnosis in, 61
epidemiology of, 58
etiology of, 57
geographical distribution of, 56
history of, 55
pathology of, 59
prognosis in, 64
prophylaxis in, 64
symptomatology of, 59
symptoms in detail of, 61
synonyms for, 55
treatment of, 64
Blastomycosis, 474
Blood, chemical analysis of, 530, 576
groups of, 521
specific gravity of, 538
transfusion of, 521
Blood examinations, 504
acidosis in, 525
coagulation rate in, 537
counting cells in, 507, 508
culturing in, 516
differential count in, 514
Blood examinations, dried smears, 509
fresh preparations in, 509
haemoglobin in, 519
in blackwater, 541
in malaria, 39, 539
in kala-azar, 131, 543
staining films, 509, 512
thick films in, 511
wet preparations in, 509
Blood in tropical diseases, 504, 538
blackwater fever, 541
filariasis, 544
kala-azar, 543
liver abscess, 542
malaria, 539
Malta fever, 541
plague, 542
relapsing fever, 544
trypanosomiasis, 543
typhus fever, 546
Weil’s disease, 544
Boils, tropical, 420
Bone affections, 595
Brazilian trypanosomiasis, 80, 501, 548
diagnosis of, 84
epidemiology of, 81
etiology of, 80
prophylaxis in, 84
symptomatology of, 83
transmission of, 81
treatment of, 84
types of, 83
Bronchial spirochaetosis, 550
Bronchomoniliasis, 474
pulmonary tuberculosis and, 474
Bubas, 138, 564
Calabar swellings, 354, 556
Carriers, in cholera, 225
in dysentery, 153, 178
in malaria, 24, 47
Cephalalgia, 604
Cerebro-spinal fluid, 598
Chaulmoogra oil, 266
Chenopodium, 163, 334
Cholera, 218, 492, 547, 579, 597
agglutination in, 230
Cholera, autopsy findings in, 227
blood transfusion, 235
carriers in, 225
definition of, 218
diagnosis in, 230
disinfection in, 233
epidemiology of, 222
etiology of, 220
geographical distribution of, 219
history of, 218
pathology of, 226
prognosis in, 232
prophylaxis in, 233
sequelae in, 229
serum in, 236
symptomatology of, 227
symptoms in detail of, 229
treatment of, 235
vaccination in, 234
water transmission, 223
Cholera red reaction, 232
Cholerine, 229
Chrysomyia macellaria, 422, 551, 568
Chyluria, 346, 575
Circulatory system, 547
Climatic bubo, 469, 552
diagnosis in, 470
symptomatology of, 470
Climatic fevers, 501
Clonorchiosis, 371
symptomatology of, 372
Clonorchis endemicus, 372
Coagulation rate, 537
Coccidioidal granuloma, 474
pulmonary tuberculosis and, 474
Coccidioides immitis, 474
Cochin China diarrhoea, 312, 374
Colloidal gold test, 600
Colon bacillus infection, 484
Color index, 520
Coma, 602
Conorhinus rubrifasciatus, 123
megistus, 80
Convulsions, 605
Cosmopolitan diseases, 480
Craw-craw, 424
Creeping eruption, 422
Cryptococcus gilchristi, 474
Culex fatigans, 432, 342
Culicine mosquitoes, 20
Culturing blood, 516
Cutaneous system, 561
Cyclops, 356
Danysz’s virus, 210
Delirium, 602
Dengue, 431, 495, 545, 563, 593, 608, 609
clinical types, 435
definition of, 431
diagnosis in, 436
epidemiology of, 432
etiology of, 432
geographical distribution of, 432
history of, 431
mosquitoes in, 432
pathology of, 434
prophylaxis in, 438
spirochaetes in, 432
symptomatology of, 434
symptoms in detail of, 436
synonyms for, 431
treatment of, 438
Dengue-like fevers, 438
Dermatobia cyaniventris, 421
Dermatophiliasis, 418
Dhobie itch, 414
Diagnosis in tropics, 477
Diarrhoea, 589
Diphtheria, 487
Dracunculus medinensis, 339, 355
Dysentery, 141
bacterial, 145, 174
ciliate, 143
definition of, 141
etiology of, 142, 148, 175
flagellate, 142
from animal parasites, 142
from poisons, 146
helminthic, 145
protozoal, 142
Dysentery, (amoebic), 147, 492, 554, 596
Charcot-Leyden crystals in, 157
complications in, 155
diagnosis in, 156
epidemiology of, 153
etiology of, 148
geographical distribution of, 148
history of, 147
pathology of, 154
prophylaxis in, 160
symptomatology of, 154
transmission of, 153
treatment of, 160
Dysentery (bacillary), 145, 174, 501, 545, 548, 567, 594, 603
chronic, 182
collapse types, 181
complications in, 181
diagnosis in, 182
epidemiology of, 177
etiology of, 175
gangrenous, 181
geographical distribution of, 174
history of, 174
pathology of, 179
prophylaxis in, 185
symptomatology of, 180
treatment in, 186
vaccination against, 185
Ear diseases, 568
Ekiri, 145
Elephantiasis, 347
of scrotum, 348
Emetine, 160, 171, 318
Endemic haematuria, 363
Endocrine disturbances, 489
Entamoeba coli, 149, 150
histolytica, 142, 148, 164
tetragena, 149
Eosinophilia, 533
Epidemic dropsy, 278
gangrenous rectitis, 589
Epistaxis, 569
Espundia, 138, 564
Eye diseases, 565
Faeces, 581
intestinal parasites, 583
occult blood in, 582
ova in, 583
Fasciolopsis buski, 373
Fever-free diseases, 491
Filaria bancrofti, 337, 341
Filariasis, 336, 493, 544, 550, 552, 564, 566, 575, 594, 597
abscesses in, 346
and chylous hydrocele, 351
chyluria, 346, 575
clinical types, 344
diagnosis in, 351
elephantiasis, 347
elephantoid fever, 345, 493
etiology of, 337
history of, 339
life history of F. bancrofti, 342
mosquitoes in, 342
orchitis in, 347
pathology of, 343
scrotum in, 345
varicose groin glands in, 345
Flagellate dysentery, 142
Flagellated body, 8
Fleas in leishmaniasis, 124
in plague, 192
Focal infections, 490
Framboesia, 384
Funiculitis, endemic, 346, 580
Gaits, 607
Gametes in malaria, 8
Gangosa, 395, 550, 569
and yaws, 395
diagnosis in, 398
epidemiology of, 397
etiology of, 395
geographical distribution of, 395
history of, 395
pathology of, 397
symptomatology of, 397
treatment of, 398
Genito-urinary system, 570, 579
Giardia, 142
Giemsa’s stain, 514
Glanders, 487
Glandular fever, 536
involvements, 551
Globulin increase, 600
Glossina morsitans, 67, 71
palpalis, 66, 69
Goundou, 472, 569, 595
Granuloma venereum, 404
diagnosis in, 406
etiology of, 404
history of, 404
pathology of, 404
symptomatology of, 405
Guha, 551
Guinea worm, 339, 340, 355, 595
Haemacytometry, 505
Haematoxylin staining, 514
Haematuria, 575
Haemoglobin estimations, 519
Haemoglobinuria, 574
haemoglobinuric fever, 55
paroxysmal, 61, 574
Haemolysis, test for, 521
Haemorrhages, 554
Haemosporidia, 4
Haffkine’s plague prophylactic, 211
cholera vaccine, 234
Heat prostration, 464, 467, 494
cramps, 467, 597
stroke, 464, 501, 550, 573, 603
etiology of, 464
susceptibility to, 466
symptomatology of, 466
treatment of, 467
Hill diarrhoea, 316
Hirudiniasis, 559
Hosts, 9
Impetigo, 419
Index of malaria, 9
Infantile beriberi, 279
scurvy, 287
Influenza, 488
Insolation, 464, 609
Insomnia, 603
Intestinal bacteria, 177
parasites, 503, 583
tract, 589
Jansky’s blood grouping, 515
Jaundice, 557
epidemic, 114
Jaundice, infectious, 114, 503, 544, 558
cultivation of Leptospira icterohaemorrhagiae, 115
definition of, 114
diagnosis in, 117
epidemiology of, 116
etiology of, 115
geographical distribution of, 114
history of, 114
pathology of, 116
prophylaxis in, 117
symptomatology of, 116
synonyms for, 114
treatment of, 117
Joint involvement in tropical diseases, 592
Juxta-articular nodules, 472, 564
Kaffir milk-pox, 486
Kala-azar, 121, 127, 498, 543, 552, 554, 558, 560, 563
diagnosis in, 131
epidemiology of, 127
etiology of, 123
history of, 121
pathology of, 128
prognosis in, 133
prophylaxis in, 133
symptomatology of, 128
symptoms in detail of, 130
synonyms for, 121
treatment of, 133
Katayama disease, 364, 550, 556
Kidney function and its determination, 575
Kubisagari, 607
Lamblia, 142
Lamus megistus, 81
Large mononuclear increase, 536
Latah, 610
Latent malaria, 35
Lathyrism, 288, 607
Laverania, 5
Leishmania donovani, 123, 127
infantum, 123, 127
tropica, 123
Leishmaniases, 121
American, 138, 553, 564
canine, 123
cutaneous, 135, 564
infantile, 130
post-antimonial, 564
relationship, 126
visceral, 127
Leishmanoid, dermal, 564
Leishman’s staining method, 513
Leprosy, 246, 492, 539, 555, 562, 565, 569, 580, 595, 596, 605,
607, 609
bible and, 247
cultivation of bacillus, 249
definition of, 246
diagnosis in, 261
epidemiology of, 249
etiology of, 248
geographical distribution of, 247
history of, 246
lepra cells in, 253
nerve, 257
nodular, 255
of rats, 252
pathology of, 252
prognosis in, 264
prophylaxis in, 264
symptomatology of, 254
symptoms in detail of, 260
synonyms for, 246
transmission of, 251
treatment of, 265
Wasserman reaction in, 262
Leptospira icteroides, 98
icterohaemorrhagiae, 115
morsus-muris, 118
Leucocytosis, 534
Leukopenia, 533
Liver, alterations in size of, 558
pains of, 559
tropical, 166
Liver abscess, 164, 501, 542, 550, 557, 558, 559
Liver abscess, complications in, 166, 168
diagnosis of, 169
emetine in, 171
etiology of, 164
geographical distribution of, 164
history of, 164
operation for, 172
pathology of, 165
prophylaxis in, 171
rupture of, 166
symptomatology of, 166
symptoms in detail of, 168
treatment of, 171
Liver fluke disease, 371
Loa loa, 337, 352, 566
Lunacy in the tropics, 610
Lymphatic glands, in trypanosomiasis 76, 551
system, 551
Lymphocytosis, 536
Lymph scrotum, 345
Lyon blood tube, 516
Maize in pellagra, 296
Malaria, 1, 493, 494, 495, 496, 539, 548, 553, 560, 562, 566, 574,
579, 602, 605, 609
algid, 34
anaphylaxis and the paroxysm in, 18
cachexia, 36
cerebral, 33
cultivation of parasite, 16
definition of, 1
diagnosis in, 40
discovery of parasite, 2
epidemiology of, 24
etiology of, 4
geographical distribution of, 4
heredity in, 16
history of, 1
immunity in, 17
in animals, 5
index of, 9
latent, 35, 493
life history of parasite, 7
malignant tertian, 28, 30
masked, 36
mosquitoes in, 6, 18
pathology of, 25
perniciousness in, 31
prognosis in, 42
prophylaxis in, 42
provocative measures in, 41
quinine-affected parasites, 16, 17
relapses in, 35
sequelae of, 37
symptomatology of, 27
symptoms in detail of, 37
synonyms for, 1
toxin in, 7, 16
transmission of, 7
treatment of, 47
variations in cycle, 27
Malignant tumors, 488
Malta fever, 237, 497, 541, 550, 554, 560, 579, 580, 593, 603,
604, 609
clinical types of, 242
complications in, 242
definition of, 237
diagnosis in, 243
epidemiology of, 239
etiology of, 238
geographical distribution of, 238
goat milk in, 239
history of, 237
pathology of, 240
prognosis in, 244
prophylaxis in, 245
sequelae in, 242
symptomatology of, 241
symptoms in detail of, 242
synonyms for, 237
treatment of, 245
Marris atropin test for fevers, 484
Mastic test, 601
Media, Aronson’s, 232
Teague, 582
Methylene blue, in malaria, 53
Mexican typhus, 452
Micrococcus melitensis, 238
Monilia Candida, 474
tropicalis, 474
Mosquito, anatomy of, 20
Anopheline, 18
destruction, 43
hibernation of, 21
in dengue, 432
in filariasis, 342
in yellow fever, 105
malaria transmitters, 6
Moss’ blood grouping, 521
Mouth, 586
Mumps, 487
Muscle involvement in tropical diseases, 592, 596
Mycetoma, 399, 595
diagnosis in, 402
epidemiology of, 400
etiology of, 400
geographical distribution of, 399
history of, 399
pathology of, 401
prognosis in, 403
symptomatology of, 401
treatment of, 403
Mycoses, visceral, 473
Myiasis, cutaneous, 421
intestinal, 590
larval characteristics, 590
Myositis purulenta tropica, 597
Nasal myiasis, 551, 568
Nausea, 588
Necator americanus, 320
Neo-arsphenamine, administration of, 95
Neurasthenia, 608
Neurological manifestations, 598
Night blindness, 567
N. N. N. medium, 517
Nocardia pseudotuberculosis, 474
Nose, diseases of, 568
Occult blood, 523, 571, 582
Oedema, 555
Oesophagus, 587
Onchocerca volvulus, 339, 341, 354, 552
Onyalai, 587
Opisthorchis felineus, 372
Oriental sore, 137, 564
diagnosis in, 139
epidemiology of, 136
etiology of, 123
geographical distribution of, 136
history of, 135
pathology of, 137
prophylaxis in, 140
symptomatology of, 137
synonyms for, 121
treatment, 140
Ornithodorus moubata, 89
talaje, 91
Oroya fever, 425, 541, 553, 595, 603
etiology of, 426
pathology of, 426
prophylaxis in, 428
symptomatology of, 427
treatment of, 428
Pappataci fever, 438, 545
Paragonimiasis, 368, 549, 555
diagnosis in, 371
etiology of, 368
history of, 368
symptomatology of, 369
Paragonimus westermanni, 368
life history, 368
Paralytic vertigo, 607
Paratyphoid fever, 484, 503, 545
Pediculi, 454
Pellagra, 291, 492, 539, 561, 572, 586, 588, 589, 603, 605, 606, 608
amino-acid deficiency in, 294
animal experimentation in, 298
blood in, 308
corn in, 296
definition of, 291
diagnosis in, 308
diagnostic triad in, 302
epidemiology of, 298
eruption of, 300, 303
etiology of, 292
experimental, 295
geographical distribution of, 292
history of, 291
moulds and, 296
Pellagra, mouth in, 586
pathology of, 299
periodic recurrences of, 302
prognosis in, 309
prophylaxis in, 309
protein deficiency in, 294
Simulium in, 298
stages in, 302
symptomatology of, 300
symptoms in detail of, 308
synonyms for, 291
treatment of, 310
urine in, 308, 572
Penicillium crustaceum, 474
Pernicious malaria, 31
Phenolsulphonephthalein test, 577
Phlebotomus fever, 438, 545
pappatassii, 439
Piedra, 420
Pinta, 416
Piroplasms, 58
Plague, 188, 499, 542, 547, 549, 551, 559, 575, 602, 604, 605
bubonic, 199
confusing organisms in suspected, 191
cutaneous, 200
definition of, 188
diagnosis in, 205
epidemiology of, 192
etiology of, 190
Flugges droplet method, 197
geographical distribution of, 189
guinea pig test, 207
Haffkine’s prophylactic, 211
history of, 188
pathology of, 198
pneumonic, 197, 201, 549
prognosis in, 208
prophylaxis in, 208
rat and, 191, 196
septicaemic, 203
symptomatology of, 199
symptoms in detail of, 203
synonyms for, 188
tokens in, 200
treatment of, 211
Yersin’s serum, 211
Plasmodium falciparum, 12
malariae, 11
vivax, 10
Pneumonia, 488
Polyneuritis gallinarum, 275, 277
Prickly heat, 561
Proteosoma, 4
Psychoses, 608
Quinine, 45, 47
administration of, 49
in blackwater, 64
idiosyncrasy to, 47
prophylaxis, 45
toxic effects, 47
Rachialgia, 604
Rand scurvy, 286
Rat bite fever, 118, 502, 552, 563, 602
definition of, 118
epidemiology of, 118
etiology of, 118
pathology of, 119
symptomatology of, 120
treatment of, 120
Rats and leprosy, 252
and plague, 191, 196
Reflexes, 606
Relapsing fever, 86, 494, 495, 544, 550, 558, 560, 596, 604
definition of, 86
diagnosis in, 93
epidemiology of, 89
etiology of, 87
geographical distribution of, 87
history of, 86
Panama and, 91
pathology of, 91
prognosis in, 94
prophylaxis in, 94
symptomatology of, 91
symptoms in detail of, 92
synonyms for, 86
transmission of, 87
by the louse, 88
by the tick, 87
treatment of, 94
Remittent fever, 28
Respiratory system, 548
Rheumatic fever, 482
Rhino-pharyngitis mutilans, 395
Rhizomucor parasiticum, 474
Rice and beriberi, 272
Ringworm infections, 561
Rocky Mountain spotted fever, 446, 502, 546, 558, 560, 563, 580,
602, 605
definition of, 446
diagnosis in, 449
epidemiology of, 447
etiology of, 447
history of, 446
pathology of, 448
prophylaxis in, 449
symptomatology of, 448
synonyms for, 446
treatment of, 450
Romanowsky stains, 513
Saline enemata, 65
infusions in blackwater, 65
in cholera, 235
in heat stroke, 468
Sand-fly fever, 441
Sarcopsylla penetrans, 418
Scarlet fever, 482
Schilling-Torgau’s differential count, 514
Schistosoma haematobium, 363
japonicum, 364
mansoni, 364
Schistosomiasis, 357, 493, 546, 555, 560, 563, 575, 579, 589, 590, 606
diagnosis in, 366
etiology of, 357
geographical distribution of, 363, 364
history of, 360
infection in, 357
Japanese type, 364
pathology of, 362
prophylaxis in, 367
rectal type, 364
symptomatology of, 363
treatment of, 367
urticarial fever in, 366
vesical type, 363
Schizogony, 7
Schizotrypanum cruzi, 81
Screw worm, 422, 568
Scurvy, 286
Seven-day fever, 440
Ship beriberi, 285
Simulium reptans, 292
Six-day fever, 441
Skin diseases, 561
eruptions, 561
Sleeping sickness, 66
Smallpox, 486
Somnolence, 603
Spinal fluid, 598
Spirillum cholerae asiaticae, 220
Spironema duttoni, 87
recurrentis, 86
Spleen, enlargements of, 559
pains of, 559
puncture in kala-azar, 132, 559
Sporogony, 8
Sporotrichosis, 474
Sporozoites, 8
Spotted fever of the Rocky Mountains, 446
Sprue, 312, 492, 538, 553, 559, 572, 586, 588, 589
and hill diarrhoea, 316
and pellagra, 316
diagnosis in, 316
etiology of, 313
history of, 312
pathology of, 314
stools in, 316, 589
symptomatology of, 314
symptoms in detail of, 315
tongue, 315, 586
treatment of, 317
Sputum examination, 548
Statistics of cosmopolitan diseases, 481
of intestinal parasites, 584
Stegomyia calopus, 105, 433
Stomach, 587
Strongyloides stercoralis, 374
Strongyloides stercoralis, life history of, 375
symptoms of infestation, 374, 590
treatment of infestation, 376
Syphilis and liver abscess, 170
and yaws, 392
and tropical ulcer, 407
in tropics, 488, 598
Tabardillo, 451
Table of arthropodan diseases, 382
cosmopolitan diseases, 481
filarial worms, 338
helminthic diseases, 379
intestinal bacteria, 177
malarial parasites, 14
protozoal diseases, 377
Tartar emetic, 53, 80, 134, 140
Temperature chart in blackwater fever, 498
dengue, 495
kala-azar, 498
liver abscess, 501
malaria, 493, 494, 495
Malta fever, 497
Oroya fever, 502
plague, 499
relapsing fever, 495
trypanosomiasis, 500
typhus fever, 500
yellow fever, 498
Tetanus, 488
Thick film smears, 511
Three-day fever, 441
Thymol treatment, 332
Ticks, 89, 447
Tinea cruris, 414
etiology of, 414
symptomatology of, 414
treatment of, 415
Tinea imbricata, 411
etiology of, 411
symptomatology of, 412
treatment of, 413
Trachoma, 565
Transfusion of blood, 521
Trematode diseases, 357, 368, 379
Tremors, 605
Trench fever, 460, 503, 596, 605
definition of, 460
diagnosis in, 462
epidemiology of, 461
etiology of, 461
geographical distribution of, 461
history of, 460
pathology of, 462
prognosis in, 463
prophylaxis in, 463
symptomatology of, 462
synonyms for, 460
treatment of, 463
Treponema pertenue, 384
Trichinosis, 534, 597
Tropical liver, 166
and syphilis, 170
etiology of, 166
symptomatology of, 166
treatment of, 167
ulcer, 407
Trypanosoma brucei, 68, 84
gambiense, 66, 68, 69
nigeriense, 68
rhodesiense, 67, 69
Trypanosomes in animals, 84
Trypanosomiasis, 66, 500, 543, 548, 551, 556, 563, 566, 603, 604,
605, 607, 608
Brazilian, 80
definition of, 66
diagnosis in, 77
epidemiology of, 70
etiology of, 67
geographical distribution of, 67
history of, 66
Kérandel’s sign in, 74
pathology of, 72
prognosis in, 78
prophylaxis in, 78
symptomatology of, 72
symptoms in detail of, 76
synonyms for, 66
treatment of, 79
Tsetse flies, 70
Tsutsugamushi, 442
diagnosis in, 445
epidemiology of, 443
etiology of, 443
symptomatology of, 443
Tuberculosis, 485
Tularaemia, 213, 503, 552, 563
definition of, 213
diagnosis in, 217
epidemiology of, 214
etiology of, 214
geographical distribution of, 213
history of, 213
pathology of, 215
prognosis in, 217
prophylaxis in, 217
symptomatology of, 216
synonyms for, 213
treatment of, 217
Tumbu fly disease, 423
Typhoid fever, 483, 545
Marris atropin test in, 484
Typhus fever, 451, 500, 546, 548, 555, 558, 560, 565, 568, 587, 602
definition of, 451
diagnosis of, 457
epidemiology of, 453
etiology of, 452
history of, 451
louse in, 454
pathology of, 454
prophylaxis in, 458
symptomatology of, 455
synonyms of, 451
treatment of, 459
Urine, 570
amount of, 573
bacteriology of, 580
bile pigment in, 572
blood in, 571
Erlich’s aldehyde test, 573
Urobilinuria, 572
in blackwater, 572
Urticarial fever, 364, 493, 546, 563
Uta, 138, 564
Varicella, 487
Veld sore, 408
Venereal diseases, 488
Ver macaque, 421
Verruga, 425, 428, 494
pathology of, 428
symptomatology of, 429
treatment of, 430
Viscerel mycoses, 474
Vincent’s angina, 487
Virus, filterable, in dengue, 432
Vitamines, 271, 275, 288, 290, 293, 567
Vomiting, 588
sickness, 588
Weil’s disease, 114, 544, 558, 559
Wright’s staining method, 513
Xerophthalmia, 567
Yaws, 384, 494, 539, 553, 593
and syphilis, 392
diagnosis in, 391
epidemiology of, 385
etiology of, 384
geographical distribution of, 384
history of, 384
inoculation experiments, 385
pathology of, 386
prognosis in, 393
prophylaxis in, 393
symptomatology of, 387
Yaws, tertiary, 389
treatment of, 393
Yellow fever, 97, 498, 539, 547, 554, 557, 560, 566, 569, 573, 574,
575, 602, 604
Bacillus icteroides, 101
black vomit in, 109, 110
Commission reports, 103
definition of, 97
diagnosis in, 111
epidemiology of, 105
etiology of, 98
experimental work, 99, 103
Faget’s law, 108
geographical distribution of, 98
history of, 97
immune sera, use of, 113
immunity in, 105
Leptospira icteroides, 98
pathology of, 107
prognosis in, 112
prophylaxis in, 112
Stegomyia in, 101, 105
symptomatology of, 108
symptoms in detail of, 109
synonyms for, 97
treatment of, 112
vaccination against, 112
Yersin’s plague serum, 211
Zygote, 9
TRANSCRIBER’S NOTE
Obvious typographical errors and punctuation errors have been
corrected after careful comparison with other occurrences within
the text and consultation of external sources.
For consistency four occurrences of P^2O^5 (superscripts) have been
changed to P_{2}O_{5} (subscripts).
For consistency a few occurrences of the ligatures æ and œ have
been replaced by ae and oe.
Some hyphens in words have been silently removed, some added,
when a predominant preference was found in the original book.
The wide table on page 159 has been split into two parts; the first
column has been duplicated in the second part. The wide table on
page 532 has been slightly restructured with no loss of text; the
first column has been put into CAPS for readability.
Except for those changes noted below, all misspellings in the text,
and inconsistent or archaic usage, have been retained.
Pg xii: ‘CHAPTER LI ... 392.’ replaced by ‘CHAPTER LI ... 592.’.
Frontispiece: ‘MALARIAL PARASITIES’ replaced by ‘MALARIAL PARASITES’.
Pg 17: ‘become chilled’ replaced by ‘becomes chilled’.
Pg 21: ‘completely convered’ replaced by ‘completely covered’.
Pg 26: ‘matter fo fact’ replaced by ‘matter of fact’.
Pg 44: ‘part salcohol)’ replaced by ‘parts alcohol),’.
Pg 50: ‘must be sterlie’ replaced by ‘must be sterile’.
Pg 58: ‘apearances may not’ replaced by ‘appearances may not’.
Pg 100: ‘about the infecton’ replaced by ‘about the infection’.
Pg 102: ‘it would negative’ replaced by ‘it would negate’.
Pg 102: ‘could t have been’ replaced by ‘could not have been’.
Pg 122: ‘bodies, Lavaran’ replaced by ‘bodies, Laveran’.
Pg 128: ‘spleen, parcicularly’ replaced by ‘spleen, particularly’.
Pg 128: ‘pulp tords’ replaced by ‘pulp cords’.
Pg 128: For consistency the heading ‘Symptomatology’ has been changed
from =bold= to an ALLCAPS heading.<br>
Pg 133: ‘place in diaganosis’ replaced by ‘place in diagnosis’.
Pg 137: For consistency the heading ‘Symptomatology’ has been changed
from =bold= to an ALLCAPS heading.<br>
Pg 152: ‘magnesium oxdie’ replaced by ‘magnesium oxide’.
Pg 172: ‘dressing froceps’ replaced by ‘dressing forceps’.
Pg 177: ‘B. enteritidis’ replaced by ‘B. enteriditis’.
Pg 185: ‘than prophylatic’ replaced by ‘than prophylactic’.
Pg 187: ‘praise yaghurt’ replaced by ‘praise yoghurt’.
Pg 223: ‘district and among’ replaced by ‘districts and among’.
Pg 233: ‘The most scrupuous’ replaced by ‘The most scrupulous’.
Pg 235: ‘was striken by’ replaced by ‘was stricken by’.
Pg 249: ‘that of Kedrowski’ replaced by ‘that of Kedrowsky’.
Pg 256: ‘cernea and iris’ replaced by ‘cornea and iris’.
Pg 262: ‘nodular ases’ replaced by ‘nodular cases’.
Pg 262: ‘of mixed lepcosy’ replaced by ‘of mixed leprosy’.
Pg 265: ‘and very rarley’ replaced by ‘and very rarely’.
Pg 269: ‘of Berberi’ replaced by ‘of Beriberi’.
Pg 279: ‘formicaton of the’ replaced by ‘formication of the’.
Pg 291: ‘exacerabtions but’ replaced by ‘exacerbations but’.
Pg 309: ‘do not parallel’ replaced by ‘does not parallel’.
Pg 314: ‘mind. sprue patient’ replaced by ‘mind. The sprue patient’.
Pg 316: ‘Hill Diarrhea’ replaced by ‘Hill Diarrhoea’.
Pg 331: ‘phenolphthalin test’ replaced by ‘phenolphthalein test’.
Pg 332: ‘and chenopodiun’ replaced by ‘and chenopodium’.
Pg 334: ‘Carbon tetrachlorid’ replaced by ‘Carbon tetrachloride’.
Pg 350: ‘dose not involve’ replaced by ‘does not involve’.
Pg 381: ‘Broad Rusian’ replaced by ‘Broad Russian’.
Pg 393: ‘or with Giemas’ replaced by ‘or with Giemsa’.
Pg 436: ‘cases occuring in’ replaced by ‘cases occurring in’.
Pg 452: ‘eradicted from’ replaced by ‘eradicated from’.
Pg 466: For consistency the heading ‘Pathology’ has been changed
from _italic_ to a separate ALLCAPS heading.<br>
Pg 469: ‘peculiarly o affect’ replaced by ‘peculiarly to affect’.
Pg 481: ‘Diarrhea and’ replaced by ‘Diarrhoea and’ (twice).
Pg 484: ‘a broncho-penumonia’ replaced by ‘a broncho-pneumonia’.
Pg 486: ‘is responsibile for’ replaced by ‘is responsible for’.
Pg 494: ‘with manifestaitons’ replaced by ‘with manifestations’.
Pg 501: ‘amoebic dystentery’ replaced by ‘amoebic dysentery’.
Pg 501: ‘that liver abcess’ replaced by ‘that liver abscess’.
Pg 507: ‘mixing throughly’ replaced by ‘mixing thoroughly’.
Pg 510: ‘Erhlich’s method’ replaced by ‘Ehrlich’s method’.
Pg 517: ‘ring of vsaeline’ replaced by ‘ring of vaseline’.
Pg 522: ‘pippette off the’ replaced by ‘pipette off the’.
Pg 527: ‘ension of alveolar’ replaced by ‘tension of alveolar’.
Pg 529: ‘are not synonomous’ replaced by ‘are not synonymous’.
Pg 530: ‘by bl d chemistry’ replaced by ‘by blood chemistry’.
Pg 532: ‘the ura ic, and’ replaced by ‘the uraemic, and’.
Pg 539: ‘febrile accesssions’ replaced by ‘febrile accessions’.
Pg 557: ‘liquor formaldehydi’ replaced by ‘liquor formaldehyde’.
Pg 573: ‘aldehyd reaction’ replaced by ‘aldehyde reaction’.
Pg 574: ‘adminstration of’ replaced by ‘administration of’.
Pg 590: ‘For more detailed’ replaced by ‘For a more detailed’.
Pg 596: ‘and multilation are’ replaced by ‘and mutilation are’.
Pg 598: ‘howevert, unless’ replaced by ‘however, unless’.
Pg 605: ‘endo- and perineurium’ replaced by ‘endoneurium and
perineurium’.