CHAPTER XLIV

ONSET AND THE TEMPERATURE CHART IN THE DIAGNOSIS OF TROPICAL DISEASES

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

[Illustration: FIG. 145.—General type of fever onset in the various tropical diseases.]

_Malarial Cachexia._—Attacks of an irregular type of fever are frequently noted in the malarial cachectic, especially setting in upon some exposure to dampness or chilling, to alcoholic excesses or to excessive fatigue. Cases are also met with in the tropics,

## particularly among natives, where fever plays no apparent part in

the profound anaemia of these ague-cake victims. It is this absence of fever which many consider the evidence of immunity to malaria in the native with his anaemia and large spleen.

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

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

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

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

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

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

[Illustration: FIG. 146.—General type of termination of the febrile course in the various tropical diseases.]

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

During the last stages of _sleeping sickness_ a lowering of the temperature is fairly constant.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

_Typhoid fever_ and the _paratyphoid infections_ are far from uncommon in the tropics and present clinical courses at variance with those observed in temperate climates. The temperature charts in such cases are irregular and atypical.

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

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

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

##