222 



FEVERS IN THE Sl'DAN 



Noles of the 

 case 



Tuberculosis 



" Friihii/, Mail 28. Complained of headache and feeling generally unwell — tongue 

 was very furred and conjunctivie sliglitly congested. Temperature 101 !■'. On ])alpation, 

 no area of tenderness over abdomen. Bowels had not moved for two days, ('atomel, 

 grs. iii., given. Patient in lied, milk diet. Blood lihns taken. 



" Satiirdai/. T(M]i|)eraturo 995 F. in the morning. Felt better, jiowols had not 

 moved. A soap and water enema administered in th(^ afternoon witii good effect. 

 Headache had disappeared. IMood examination for malaiia negative. A careful examina- 

 tion of heart, lungs and abdomen was carried out but nothing abnormal was present. 



" Snndai/. Temperature 99 F. Patient felt very nnicli better. Complained of feeling 

 tired but had no pain or symptoms. 



" Monday. Temperature 99 F. in the morning. 100-2 F. in the evening. I'eeling 

 of lassitude. No subjective or objective phenomena observed. Calomel, grs. iii., again 

 given. 



" Tuesdai/. Temperature 992" F. Felt better, still a little tired, but wanted to 

 attend to his duties. 



" Tuesdaji afternoon. Patient at four o'clock was extremely drowsy, did not seem 

 inclined to answer questions. Temperature 103° F. Face somewhat cyanosed. 

 Conjunctiva; injected. Tongue furred, breatli foul. Had some diarrhrea in the 

 afternoon. Patient removed to hospital. General condition improved. 



" Wednesday. Mid-day, patient collapsed and infusion was carried out. Rallied 

 and died on Thursday morning. 



" Post mortem at 5 o'clock in the afternoon showed : — Lungs and heart normal. 

 Intestine in region of ileum marked by congested patches (Enteritis) not related to 

 lymphoid structui'es of gut. No ulcers. Spleen was slightly congested, not enlarged. 

 Liver normal. Cultures taken but contaminated witli ]K)st mortem bacilli. No pathogenic 

 organism isolated." 



Possibly cases of miliary tuberculosis in i^lgyptians or Sudanese are tlie most puzzling 

 of all. As shown post mortem, a man may be riddled, so to speak, witli tubercle ; his 

 lungs, liver and spleen full of nodules and foci of the disease and yet, unless his brain 

 or his intestines are affected as well, he may exhibit no physical signs at all and the spiky 

 fever chart, with weakness and emaciation, remain the prominent features of his case. 

 In more civilised countries the various tuberculin tests would clear up the diagnosis in 

 most instances, but here the differential l)lood count is often of most service, a marked 

 lymphocytosis arousing one's suspicions. I think tliat in any case of obstinate and long- 

 continued fever {vide Chart 4) it is well to bear the possibility of tuberculosis in mind and to 

 remember that tuberculosis may complicate other febrile disorders. One is too apt to look 

 for a single cause and to forget that two or more pathological states may act concurrently 

 in elevating tlie temperature and in producing complex and confusing clinical pictures. So far 

 the condition of Acute Tubeiculous Fever described from India by Roberts and Bhandarkar' 

 has not been encountered, but I do not know that it has iieen very persistently looked for 

 in the Sudan. I once suspected I had met with a case, especially as acid-fast bacilli were 

 present in the urine, but it turned out to be a pyelitis due to B. culi anil the mere presence 

 of acid-fast bacilli in the urine means notliing, for Philibert- has shown that some 13 species 

 exist normally in that secretion. Que must not overlook the possibility of the occurrence 



• Roberts, J. R., and Bhandarkar, R.S.P.R. (February. 1908), " Preliminary Note on the Existenre of an 

 Acute TubcrculouH Fever, in India, whirh lias been confused with Continuous and Remittent Fevers." — Biitish 

 Maliail Juiinial, p. 377. 



' Pliilibert-, Andri', /.<•« jiHniilii-hiirilliis aciiln-r/iitsliiiits. Paris, 1908. 



