﻿ETIOLOGY OF DENGUE FEVER. 139 



Meningeal symptoms may, according to Guiteras and Cartaya, so 

 alter the chart as to make it unrecognizable. We have not seen such 

 cases. Our most severe case, and the one in which we observed the 

 most marked nervous symptoms, showed an almost "typical" chart (see 

 Case 10). 



Pulse. — The resemblance between beginning dengue and beginning 

 yellow fever, and the dissociation of pulse and fever in the latter disease, 

 give to the pulse of dengue an importance it would not otherwise merit. 

 Guiteras and Cartaya, who studied and wrote of the disease with its 

 differential diagnosis from yellow fever as their main theme, summarize 

 their observations on the pulse by saying that "in general it is not 

 slow as in yellow fever, and especially not in the first days, but that 

 dengue shows a tendency to slow pulse." 



We have seen in no case a markedly slow pulse, and think that in 

 general the pulse follows the temperature fairly well, although the ten- 

 dency to slowness is most apt to be manifested by a relatively small rise 

 in pulse rate. Writing with little experience with yellow fever, we should 

 consider the pulse a valuable diagnostic feature. 



Pain. — Pain is usually described as the earliest symptom. This is true 

 in nearly all cases, so far as the patient knows, but as before stated, 

 it is often preceded for several hours by a rising temperature. The pain 

 is frequently severe, infrequently excruciating and immediately disabling. 

 Also in a few instances it is trifling and very rarely it may be absent. It 

 is in nearly every case manifested as headache and almost as frequently as 

 lumbar pain. In a smaller number, but still a large majority of all 

 cases, it is also present in the limbs, especially in the calves of the legs; 

 less often, but still not rarely there is abdominal pain. 



The headache may be frontal, vertical, temporal, occipital or post- 

 orbital. Of these varieties we should place frontal headache as first in 

 order of frequency, post-orbital second, temporal third, and vertical and 

 occipital as least frequent. Movement of the eyeballs is often a cause of 

 pain, particularly in patients complaining of post-orbital pain. 



The pains in the lumbar region, trunk and limbs are of var} r ing severity, 

 in many cases giving rise to most bitter complaint, in others only being 

 mentioned in response to inquir}\ Such inquiry will in the vast majority 

 of instances, practically all, elicit an account of pain. This is described 

 by Guiteras and Cartaya as being localized in the deep insertions of the 

 muscles. This seems to be the condition at times, but almost as fre- 

 quently the bodies of the muscles are affected, especially of those in 

 the legs, where the fleshy calf is often very painful. In spite of the fact 

 that the disease is called "break-bone fever," we have seldom had patients 

 complain of pains in the bones. 



Joint pains are not infrequently complained of, especially in the 

 knees. In only one case did we see marked redness or swelling of the 

 joints; in this one the wrists were involved. 



