CHAPTER XLVI

THE CIRCULATORY, RESPIRATORY AND LYMPHATIC SYSTEMS TOGETHER WITH ANAEMIA, HAEMORRHAGES AND OEDEMA IN TROPICAL DISEASES

THE CIRCULATORY SYSTEM

_Beriberi._—Almost as important in diagnosis as the weakness of the legs, with anaesthetic and oedematous areas, is the early palpitation of the heart upon the slightest exertion. Later on as the vagal degeneration becomes more prominent we have a loss of the normal cardiac rhythm, to even become embryocardial, together with dilatation of the right heart, pulsating jugulars and various blowing murmurs, which are propagated into the vessels of the neck. The pulse is weak and rapid and this combination of a tumultuous heart action and weak pulse is striking. Blood pressure is below normal.

Cardiac involvement is also a feature of _ship beriberi_ as well as _infantile beriberi_. In the latter a marked hypertrophy of the right heart is characteristic.

In _yellow fever_ we have at first a high blood pressure. The pulse rate, which at first corresponds with the rise of temperature, soon shows Faget’s law—a falling pulse with a constant temperature or a constant pulse with a rising temperature. It is a markedly slow pulse after the third day. The blood pressure is low in the asthenic stage.

In _dengue_ we do not have the rise in blood pressure but the slow pulse is quite a feature of many of the dengue-like fevers.

In _blackwater fever_ the pulse is rapid and soon becomes weak and of low tension.

_Plague_ shows a striking toxic action on the heart muscle so that we soon get a soft, dicrotic pulse, rapid from the first and soon becoming thready. Patients with plague may die from cardiac failure upon getting up from bed.

A rapid pulse, especially in the morning, is thought to be a feature of _active leprosy_.

In _cholera_ the pulse is rapid and feeble during the stage of evacuation and with the onset of the algid stage we practically have a cessation of the circulation. The systolic pressure may fall as low as 65 or 70 mm.

_Hookworm anaemia_ shows early and marked cardiac palpitation. The pulse rate averages about 110 and the blood pressure is low. There is often some right-side dilatation of the heart.

_Malaria_ generally gives a small, rapid, high tension pulse in the cold stage to become full and bounding in the hot stage. A cardiac type of pernicious malarial fever has been described, particularly by the French.

Both _Malta fever_ and _bacillary dysentery_ tend to have a toxic effect on the heart.

_Typhus fever_ is a disease which tends markedly to affect the heart. Along with faint heart sounds we have a rapid, low tension pulse. In _bacillary dysentery_ the tendency to an increase in pulse rate is of some value in differentiating it from amoebic dysentery.

_African trypanosomiasis_ shows a rapid pulse rate whether the case shows temperature or not. In _Brazilian trypanosomiasis_ the parasites may tend to invade the cells of the heart muscle thus producing manifestations of myocardial disease. The parasite (_Schizotrypanum cruzi_) may also affect the adrenals, causing a low blood pressure along with other signs of Addison’s disease.

THE RESPIRATORY SYSTEM

_Sputum Examination._—We should make a routine of examining a fresh specimen of sputum as well as stained smears. It is in such a specimen we search for the ova of the lung fluke.

Frequently the material submitted for examination as sputum is simply buccal or pharyngeal secretion, or more probably secretion from the nasopharynx, which has been secured by hawking. It should always be insisted upon that the sputum be raised by a true pulmonary coughing act, and not expelled with the hacking cough so frequently associated with an elongated uvula. When there is an effort to deceive, some information may be obtained from the watery, stringy mucoid character of the buccopharyngeal material and also from the presence of mosaic-like groups of flat epithelial cells (often packed with bacteria).

The pulmonary secretion is either frothy mucus or mucopurulent material, and if the cells are alveolar they greatly resemble the plasma cells. At times these cells may contain blood-pigment granules (heart-disease cells).

In the microscopic examination a small, cheesy particle, the size of a pin head, should be selected. This should be flattened out in a thin layer between the slide and cover-glass and should be examined for elastic tissue, heart-disease cells, eggs of animal parasites, amoebae, and fungi. _Echinococcus_ hooklets, Curschman spirals besprinkled with Charcot-Leyden crystals, and haematoidin and fatty acid crystals may also be observed.

Curschman spirals indicate bronchial as against cardiac or uraemic asthma. Charcot-Leyden crystals have no special significance, except in certain tropical diseases when these crystals often are present in paragonomiasis sputum and in the pus of amoebic liver abscesses discharging by way of the lungs.

It may facilitate the examination of the sputum for elastic tissue and actinomycosis and other fungi to add 10% sodium hydrate to the preparation.

To make smears for staining, the sputum should be poured on a flat surface, preferably a Petri dish, and a bit of mucopurulent material selected with forceps. A dark background facilitates picking out the particle. A toothpick is well adapted to smearing out such material on a slide. After using the toothpick it can be burned. When dry, the smear is best fixed by pouring a few drops of alcohol on the slide, allowing this to run over the surface, and then, after dashing off the excess of alcohol, to ignite that remaining on the film in the flame and allow to burn out.

In _beriberi_ we have shortness of breath with the early cardiac palpitation. In acute pernicious beriberi the pulmonary congestion and oedema divide with the heart the terrible manifestations of such an attack. The diaphragm may become paralyzed in beriberi. Some authors refer to the dyspnoea of beriberi as the beriberic corset.

_Paragonomiasis_ gives rise to a chronic cough attended with the expectoration of more or less bloody sputum containing ova. Haemoptysis is not infrequent. The physical signs on percussion are slight but may be more marked on auscultation.

_Hirudiniasis._—In Northern Africa, as well as in many islands of the Orient, the drinking water of ponds may contain leeches and these water-leeches tend to attach themselves to the pharyngeal mucosa. They may also attach themselves to the tissues about the larynx. In these cases we not only have cough and haemoptysis but dyspnoea from laryngeal oedema. It is probable that cases of dyspnoea called _halzoun_, and due to the attachment in the region of the larynx of flukes (_Fasciola hepatica_), as the result of eating raw liver, may often be due to leeches, as the two affections occur in the same regions.

_Plague pneumonia_ is characterized by profound prostration in a patient whose physical signs do not seem to justify such extreme illness. The rather abundant and watery sputum soon becomes sanguinolent. Herpes labialis is absent. Besides primary plague pneumonia which develops directly from contact with a former case we have a secondary pneumonia which develops in the course of a typical case of bubonic plague.

In _malaria_ we have a slight bronchitis in the ordinary types and many recognize a pulmonary type of pernicious malaria.

_Malta fever_ tends to show a bronchial involvement about the twelfth day of the disease. Crepitant râles, a moderate cough and slight dyspnoea may be noted. It was the presence of pulmonary signs along with the profuse sweating and anaemia of the disease that justified the designation Mediterranean phthisis.

In _liver abscess_ the crepitation at the base of the right lung, following congestion incident to the abscess of the right lobe of the liver, is of value in diagnosis. Rupture of a liver abscess into the lung occurs in about 10% of cases.

In _heat stroke_ we may have Cheyne-Stokes respiration and pulmonary oedema.

_Japanese river fever_ often shows bronchial involvement and cough at the time of the height of the fever.

In _ancylostomiasis_ cases with cough and bronchitis have been reported and it seems probable that such manifestations may be connected with the course of the larvae through the pulmonary passages to reach the intestinal tract.

The filarial embryos of _F. bancrofti_ remain in the lung capillaries during the day and recently such embryos have been found in blood coughed up from the lungs.

_Katayama disease_ may show a localized bronchitis early in the attack and from its rapid appearance and disappearance would seem to be a sort of patchy pulmonary oedema. This is connected with the passage of the larvae through the lungs.

Broncho-pneumonia is probably the most common complication of _typhus fever_.

An affection known as _gangosa_ or _rhino-pharyngitis mutilans_ causes great tissue loss about nasal and buccal cavity. The voice has a peculiar nasal quality. It is possibly a manifestation of tertiary yaws.

_Kala-azar_ patients are often carried off by a terminal pneumonia probably connected with the leucopenia and marked diminution of polymorphonuclears.

In _leprosy_, also, the victims are frequently carried off by pulmonary tuberculosis.

_Relapsing Fever._—In relapsing fever there is frequently a moderate bronchitis at the time of the first febrile accession.

_Bronchial Spirochaetosis._—There is a condition which more or less resembles lobar pneumonia, even to rusty sputum, but without signs of consolidation, and with negative Roentgenograms, when we find spirochaetes in the sputum. Another type of _bronchial spirochaetosis_ is when the clinical picture is more that of pulmonary tuberculosis. There is question whether these spirochaetes are causative or only accidental.

Cases have been reported where a phthisis-like condition was due to a mould infection (_Monilia_). While such a condition may be primary it is more often secondary in cachexias as may be the case with buccal _Monilia_ infections (thrush) which occur in the victims of cachectic states.

_Guha._—In Guam there is also a rather fatal capillary bronchitis affecting young children which goes under the name of epidemic asthma or, as termed by the natives, guha. This affection comes on during the rainy season and is attended with marked dyspnoea and slight elevation of temperature.

_Nasal Myiasis._—In the tropical and subtropical parts of North and South America a fly, _Chrysomyia macellaria_, is apt to deposit its eggs about the nasal orifices of persons with an offensive discharge from the nose. The fly seems to be attracted by foul odors. The larvae which develop are called “screw-worms” on account of the segmental bands of bristles and tend to invade the various sinuses, causing great destruction of tissue.

The case sets in with signs of a very severe coryza, together with fever and marked frontal headache. The face becomes swollen, red, and tender in the region of the nose. As the larvae reach maturity they come out of the nose. A nasal douche of 15 parts chloroform in 100 parts milk is often efficacious in bringing away the larvae. At times _Sacrophaga_ larvae may be found.

THE LYMPHATIC SYSTEM

_Plague._—The buboes are the most characteristic feature of the more common form of plague, bubonic plague. There may also be slight enlargement and tenderness of the glands in septicaemic and pneumonic plague but many such cases fail to show any evidence of superficial glandular enlargement. In pestis minor the only feature suggestive of plague is the glandular enlargement.

Very characteristic of the glandular involvement in plague is the marked tenderness of such glands. The slight pressure of palpation causes some pain and a sharp punch over an affected gland, excruciating pain. So exquisitely painful are these buboes that the patient with groin or axillary buboes will flex the leg or extend the arm to relieve pressure. In about 70% of cases the bubo is located in the groin, with 15% to 20% for axillary involvement and 5% to 10% for the submaxillary or cervical region. There may be involvement of both deep and superficial glands of a region, such buboes giving a large area of induration. As a rule there is a single bubo. The bubo is formed not only by the glands but by a periglandular oedema which fuses the glands into a solid mass. The buboes tend to suppurate about the commencement of the second week, so that gland puncture with subsequent culturing for plague bacilli and animal inoculation should be carried out before this time as pyogenic organisms replace the plague bacilli upon suppuration taking place.

_Trypanosomiasis._—One of the characteristics of the disease recognized as diagnostic more than 100 years ago is enlargement of the glands of the posterior cervical triangle (Winterbottom’s sign).

There may be general enlargement of the lymphatic glands which are rather hard, discrete and not bound down to the overlying skin. These glands may be somewhat tender or entirely painless. One of the most valuable methods of diagnosis of trypanosomiasis is by gland puncture, the juice obtained therefrom being examined in smear or inoculated into a monkey or guinea pig. Brazilian trypanosomiasis also shows glandular involvement.

_Filariasis._—Varicose groin glands are frequently associated with lymph scrotum, chylocele or chyluria. The glandular masses are soft and doughy. The consistency is often that of a lipoma.

The overlying skin slips over the glandular mass. These glands are often mistaken for inguinal hernia. They do not give a tympanitic note and disappear slowly upon firm pressure with the patient lying down but return even with the pressure maintained upon assuming the upright position. There is no impulse on coughing. If a sterile hypodermic needle be inserted into the mass a chylous fluid slowly and persistently comes out of the needle drop by drop and this material may show filarial embryos.

The filarial worms _Onchocerca volvulus_ obstruct the lymphatics and may give rise to swellings of considerable size along the course of the lymphatics.

_Climatic Bubo._—The onset is gradual often accompanied by a low remittent type of fever. There is an absence of venereal sore.

These glands are only slightly tender and are often called fatigue glands as they produce a feeling of weariness after even moderate exercise. The inguinal glands of one or both sides are the ones involved but the overlying skin does not show the redness of a chancroidal or gonorrhoeal bubo. There is often a softening in the center of the affected glands.

_Tsutsugamushi._—The glands which drain the area in which is located the ulcer at the site of the bite of the Kedani mite show swelling and tenderness.

_Rat bite fever_ also shows glandular enlargement in the glands tributary to the healed infecting bite of the rat.

In _tularaemia_ the lymph glands draining the site of the infecting bite become inflamed and swollen, often suppurating.

In _leprosy_ the glands draining involved regions become enlarged but do not show a tendency to suppuration. The glands most frequently involved are the cervical and groin glands.

In _kala-azar_ the recommendation has lately been made to excise the somewhat enlarged glands and make smears from a piece of such gland and then examine the smear for leishman bodies. Gland puncture has not given as satisfactory results.

It is often stated that the superficial cervical glands are enlarged in _dengue_ but not in dengue-like fevers. I have not observed in the cases I have seen either constant or well marked glandular enlargements.

In _yaws_ there may be glandular enlargement. According to Finucane the cervical glands are often involved in Fiji children. These glands do not tend to break down.

In _pediculosis_ of the hairy scalp the scratching back of the neck may result in pus infection with enlargement of the tributary cervical glands.

_American leishmaniasis._—Not only is there often enlargement of the lymphatic glands but likewise we may have lymphangitis lines leading from the ulcer to the glands. The glands may be large and painful and may remain enlarged after the recovery of the patient.

ANAEMIA

The old idea that tropical life produced an anaemia is no longer held, the view now being that such anaemic conditions are almost invariably due to some well recognized cause, the most important of which is malaria. Natives of the tropics may appear bleached out but show a normal red count and haemoglobin percentage. Chamberlain’s observations have shown that a residence in the tropics of approximately two years has no appreciable influence on the red cell count or haemoglobin content of the blood of white men and that the

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

_Malarial Cachexia._—Although the malignant tertian infection has the greatest tendency to produce anaemia yet any type may, when untreated, bring about the more or less profound anaemia with earthy skin, enlarged spleen, dyspnoea on slight exertion, and oedema of the ankles characteristic of malarial cachexia.

_Oroya Fever._—In this disease we have what might well be termed a fulminating pernicious anaemia. The rod-shaped protozoon which attacks the red cells seems to be peculiarly active in the bone marrow, excruciating bone pains being quite a feature of the disease.

There may be a reduction in red cells to one million per c.mm. within a few days. Normoblasts are abundant and megaloblasts may be observed in the more severe cases. The anaemia is intense and 20% to 40% of cases die within two or three weeks. A severe anaemia in which the blood picture is that of pernicious anaemia may accompany infections with the _Balantidium coli_.

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

_Sprue_ shows a slowly progressive anaemia which in the later stages of the disease may become extreme, going down to one million, with a fairly high color index.

_Ancylostomiasis_ is along with malaria the disease to be first thought of in connection with anaemia. The splenic enlargement of malaria should be thought of, although the view has recently been advanced that the spleen may be enlarged in hookworm disease.

In advanced cases of hookworm disease, showing a picture of profound anaemia, there may be so few worms present that the method of making diagnosis by finding ova may be unsuccessful. I have seen a case of typical aplastic pernicious anaemia, confirmed by autopsy, undoubtedly following a vicious cycle set up by the hookworm infection, in which scarcely a worm was to be found in searching the intestines.

_Kala-azar_ gives a marked anaemia with an earthy color of the skin. The leucopenia and splenic enlargement are characteristic and the finding of parasites confirmatory.

_Malta fever_ is usually followed by a moderate anaemia.

The _helminthic infections_, besides hookworm disease, are always to be thought of in the presence of anaemia. Very important among these are rectal and vesical schistosomiasis as well as that from the Japanese schistosome, together with liver and lung fluke disease. Even the ordinary round-worm, _Ascaris lumbricoides_, is to be thought of in a tropical anaemia.

Cases of anaemia, in which no other demonstrable cause has been noted, have been thought to be due to _trichocephaliasis_.

_Tropical dysenteries_ are often responsible for anaemia and in liver abscess the patient becomes quite earthy in color, provided no operation is performed. In chyluria there is a marked drain on the patient.

The anaemia in _liver abscess_ is not so great as the muddy complexion would indicate. The emaciation is greater than the anaemia.

HAEMORRHAGES

The loss of blood through haemoglobinuria and haematuria has been taken up under the urine. The haemoglobinuria is the pathognomonic symptom of blackwater fever. There is also recognized a haemorrhagic form of pernicious malaria with epistaxis and alimentary tract haemorrhages. Moderate haemoglobinuria may be found in severe cases of malignant tertian infections.

_Yellow Fever._—During the asthenic period of the disease, which sets in about the fourth day, we have, as a result of the damage to the endothelial lining of the capillaries, various haemorrhages.

Of these the best known and most dreaded is that from the stomach, black vomit. The bleeding from the gums is apt to appear before that from the stomach. Not only may bleeding occur from the intestines but from any mucosa, as that of the nose, conjunctiva or vagina.

In _vesical and rectal bilharziasis_ the perforation of the terminal branches of the portal vein by the terminal or lateral spined eggs gives rise to haemorrhages.

In _dengue_ we may have an epistaxis at the time of the crisis of the first febrile paroxysm.

In _dysentery_ the blood-admixed mucous stools are of diagnostic importance.

In _endemic haemoptysis_ the operculated eggs of _Paragonimus westermanni_ are to be sought for in the sputum.

In _leprosy_ epistaxis may be an early sign.

The damage to the endothelial lining of capillaries in _plague_ gives rise to frequent haemorrhages into the skin.

There is a question whether the hookworms abstract blood from the intestines, although tests for occult blood are deemed important by some authorities in the diagnosis of this disease.

The granulomatous lesions of _verruga_ are markedly haemorrhagic.

Some consider _ship beriberi_ to be of the nature of _scurvy_ in which case one should have in mind spongy, bleeding gums and the intramuscular haemorrhages of scurvy.

_Typhus Fever._—The petechial rash of this disease (mulberry rash) is a distinctive feature.

OEDEMA

Oedema, especially about the ankles, is to be looked for in all the secondary anaemias of the tropics, particularly malaria and ancylostomiasis.

_Beriberi._—The oedema begins at first about the feet, especially about the dorsal junction of phalanges and metatarsus. It is characteristically pretibial. It may remain confined to the shin or go up to knees, scrotum, sternal region or trunk. It is generally symmetrical but may be unilateral. It may become a general anasarca, even in forty-eight hours.

The swelling of the face is at times enormous, the eyelids being so oedematous that the patient can see only by separating them with the fingers. The oedema is more solid than that of nephritis. It not only rapidly appears but disappears as rapidly.

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

Oedema of genital regions is less marked than in nephritis or cardiac disease. We may also have localized areas of oedema 3 or 4 inches in diameter.

_Ship beriberi_, which has points in common with both beriberi and scurvy, shows oedema which may be limited to the lower extremities or generalized. _Epidemic dropsy_ is a type of beriberi in which there are fever and an erythema over the dropsical areas.

_Calabar Swellings._—These seem connected with infections with _Filaria loa_. The swellings originate suddenly and disappear in three or four days. They are hard and do not pit on pressure. These smooth swellings, often 2 to 4 inches in extent, are most often seen on arms, face or ankles.

In _trypanosomiasis_ oedema of the face and especially of the eyelids may be striking. There may also be patches of oedema elsewhere.

In _Katayama disease_ the urticarial areas of oedema have given it the name of urticarial fever.

A peculiar disease of North China, known as _atriplicism_, is caused by the eating by the very poor of a weed, _Atriplex_, common around Pekin. There is itching of the fingers, quickly followed by swelling. This tends to extend to the back of the hands and up the outer surface of the forearm. The face becomes so swollen that the eyelids may be closed.

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