COMPUCA TIONS—DIAGNOSIS 



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smaller and harder. The skin becomes dry and rough, but may be 

 perfectly normal, though a papulo-pustular eruption may at times 

 be noted on the backs of the hands and forearms. Nutrition suffers, 

 and the patient generally becomes much emaciated. 



As the disease progresses the muscular weakness and emaciation 

 becomes worse and worse, the tremors more pronounced, the saliva 

 dribbles from the mouth, the urine and faeces are passed involun- 

 tarily, and bedsores form, while the intelligence becomes more and 

 more affected, and the patient passes into a state of coma, with a 

 permanently subnormal temperature and an absence of pulse at the 

 wrist, and in a short time is liberated from his sufferings by death. 

 The duration of the cerebral or sleeping sickness stage varies from 

 a few weeks to several months. Since the atoxyl treatment has 

 become of general use, Hodges has noted that convulsive and mental 

 symptoms are more prominent, and that death is often sudden, 

 without being preceded by a period of coma. 



Varieties. — ^When the disease is due to C. rhodesiensis, it generally 

 runs a more rapid course, seldom exceeding four or five months. 

 Lethargic symptoms may not appear, and the enlarged glands in 

 the posterior triangle of the neck may be absent, while enlargement 

 of the epitrochlear glands seems to be frequent. The disease caused 

 by C. gambiensis appears to be of a milder type than that due to 

 C. castellanii. 



Complications. — ^The patient is often infected by parasites other 

 than trypanosomes; thus, Plasmodium and Lavevania, Filaria, 

 Schistosoma mansoni, Ancylostoma duodenale, Ascaris lumbricoides. 

 Trichurus trichiura, Strongyloides stercoraliSy Trichomonas intesti- 

 nalis, T. vaginalis, Dermatophilus penetrans, and Loeschia may all 

 be found. The commonest complication during the last stage is a 

 cerebro-spinal meningitis, due to streptococci, the pneumococcus, 

 or the meningococcus. 



Pneumonia, laryngitis, and oedema, of the glottis are not rare, 

 while iritis is seen at times, and symptoms of mania, delirium, and 

 epilepsy may be observed. 



Diagnosis. — In the first stage (febrile or glandular stage) the 

 disease may be readily confused with malaria and other fevers, 

 but in endemic areas the true nature of the malady may be often 

 suspected on certain clinical data, the principal of which are the 

 attacks of fever not influenced by quinine, the erythematous erup- 

 tion in Europeans, the rapid pulse frequently present also during the 

 apyrexial periods, the asthenia, the deep hypersesthesia (Kerandel's 

 symptom), the fine tremor of the tongue (Low-Cast ellani's symp- 

 tom), the cervical polyadenitis (Winterbottom's symptom). Dur- 

 ing the sleeping sickness stage the clinical diagnosis is based, in 

 addition to the above symptoms, on the drowsiness and apathetic 

 appearance of the patient, on the remarkable wasting and debility, 

 and the more marked, and occasionally generalized, tremors. 

 The long course and, usually, absence of facial paralysis differen- 

 tiates clinically sleeping sickness from encephalitis lethargica 



