364 DISEASES OF UNCERTAIN ETIOLOGY 



tissue cells. The interareolar spaces contain polymorphs and macro- 

 phages. A non-ulcerative skin lesion shows the cells of the surface 

 epithelium swollen and distended with glycogen. The papillary layer 

 disappears, the dermis is infiltrated with round cells, there are numerous 

 small vessels which may become cavernous, hence the possibility of 

 much hemorrhage. 



The subculaneous fatty tissue is ahva}"S inflamed. 



Ulcerations favour secondary infections. 



SYMPTOMATOLOGY. 



Incubation is unknown. Perhaps eight to forty days. 



Prodromata, malaise, lassitude and depression. Gradual ancemia, 

 rheumatoid pains, local or general, sometimes morning fever which 

 may rise to i04°F., insomnia, and sometimes delirium. Pulse soft and 

 rapid. The fever terminates in about twelve hours with sweating and 

 cessation of pains. The liver and Ivmphatic glands are enlarged. 



There is constipation as a rule but some have diarrhoea. 



There is a great destruction of red cells to 900,000 per cm. 



The HB is increased. 



There is always a marked leucocytosis, 20,000. The polymorphs 

 being about 75 per cent. The bone marrcnv shows excess of normo- 

 blasts and neutrophile myelocytes. 



SEVERE TYPE (Carrion's Fever). 



The fever is marked, and is accompanied by severe pains and 

 diarrhoea. The urine is acid, dark, scanty, high specific gravity, never 

 blood, rarely albumin, reduces Fehling's solution. The anaemia is 

 profound to 500,000 in extreme cases (Monge). 



Death in from two to three weeks, 



MILD TYPE. 



The febrile stage is from one to eight months, the skin itches, the 

 eruption is on the face, neck, arms, legs, conjunctiva, about and within 

 the mouth. Small erythematous spots, sometimes with small vesicles, 

 rarely with bulU-e. The erythema develops into a papular eruption 

 about the size of split peas. These are discrete, red, firm, small warts, 

 liable to bleed, which may also occur on the mucous membrane and 

 viscera. vSome larger nodules may appear to be free under the skin, 

 then adhere, ulcerate, bleed, then becf)me large, red, fungating masses, 

 chiefly about the elbows and knees. 



There may not be any health v area of skin left. What there is 

 becomes oedematous, ilie fever declines with the presence of the 

 eruption, general symptoms abate, the patient feels better but the 

 anjemia is marked and haemorrhage from the nodules may cause death. 



