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 ‘