226 I'EVEUS IN THK SUDAN 



•' I'lrnf III lliitlinij. l''ov tlie lust two inonths patient has had frcfiuent attacks, every 



4 or 5 ilays, of extromoly severe pain in the left side accouipanied by chill and higli 

 fever and severe vt)riiitiiij,' ; these attacks, instead of lasting one day as before, now last 

 2 or 3 days and are much more severe. They come on usually after 4 p.m. 



" Phyxical Examiiiatinn. Patient much emaciated. Heart normal. Luinjs normal. 

 No enlargement of liver or splei-n. Alimentarij Tract normal. Genito- Urinary Tract. 

 Tenderness over left kidney increasing during attacks, also slightly duller on percussion ; 

 no swelling ; superficial veins of left side engorged. Urine. The urine is very peculiar 

 in that it is not liquid like water, but it has the consistency of the white of an egg; if 

 freshly examined it contains no precipitates, has a neutral reaction, and a low specific 

 gravity, 1010-1015. The amount of urine increases during the attacks ; it amounted to 



5 pints in 24 hours during this last attack. During the attacks and for a day or two 

 afterwards the urine contains albumin. I regret I have no microscope here and can have 

 no microscopic examination of the urine made." 



From reading this, one would think at once that the patient is suffering from attacks 

 of pyelo-nephritis. At the same time a look at the temperature chart would suggest 

 relapsing fever. I am personally inclined to think that the patient is suffering from 

 inflammation of the kidney and its pelvis, and hope that the blood examination will throw 

 more light on the subject. There is no history of syphilis or gonorrhcea or bilharzia. 



On examining the blood film I found a distinct increase in the polymorphonuclears and 

 noted the presence of a few myelocytes. Further search revealed a streptococcus. I only 

 found one specimen in the two blood films sent, but it suggested a pathogenic form, and, 

 considering the history, the other blood findings and tlie peculiar temperature, 1 believe tlie 

 case to have been one of septicaemia, following some septic renal condition.* 



One must, however, remember that mild cases of B. aili infection of the urinary 

 tract are very apt to be overlooked and severe cases to be misunderstood. It is said 

 that after children have been ill for some weeks with infection of this kind their blood 

 sera in high dilutions will agglutinate the typhoid bacillus. (Porter and Fleischner.) 



Despite all advances in blood culture, blood work, bacteriological investigations, 

 increased knowledge in ])rotozoology and helminthology, there still remain in the Sudan 

 certain fevers of short duiation which Ijulllr the observer and are vaguely attributed to 

 sun, chill, or fatigue. In some cases such a diagnosis may be correct. There is no reason 

 for supposing that one or any of these agents may not upset the heat-regulating mechanism 

 in such a way as to produce a temporary bout of fever, but one would not expect such 

 fever to drag on from day to day — for say a week or longer. Here, for example, are some 

 records and charts very kindly submitted by Major Standish O'Grady, R.A.M.C., the 

 present S.M.O., British Troops in Khartoum, and well worthy of study. 



Notes on Thhkio Cases ok Pvkkxia ok Uncertain Ouigin 



a t ]\ 1 1 a k t o i' m 



These three cases, L. C. and W., were admitted to the Military Hospital, British 

 Troops, on, respectively, September 30, October 18 and 24, 1910. 



On admission. The appearance, symptoms and physical signs of each of these patients 

 on admission were practically identical, and the course of the pyrexia also, as shown by the 

 temperature charts, was very similar. 



* Dr. Squires bos since kindly informed mc that the case turned out to be one of stone in the kidney. 



