1484 



COSMOPOLITAN FEVERS 



ing 2 per cent, are generally mononuclears. As the day goes on there may be 

 pains in the limbs and some slight catarrhal symptoms in the nose and throat. 



Slight Remission. — On the second day there is often, but not always, a 

 slight remission of the symptoms, which may be assigned to the treatment, 

 but which is really part of the disease. 



Course. — On the third day, if there has been some slight remission the 

 symptoms all return, as violent as before, the temperature continues to be 

 high, but the pulse varies — it may be quick or it may be slow — the respirations 

 are irregular, vomiting returns, and there is an intolerance of light and noiie, 

 while the stiffness of the neck, the retraction of the head, and Keinig's sign, 

 become well marked, and headache, insomnia, restlessness, and delirium 

 may be present, or the patient may be huddled up in a state of resistant stupor , 

 from which he can be temporarily roused. 



This is about the time at which a rash should appear, but this must te 

 extremely rare in the tropics, as we have never yet met with it in this ordinary 

 acute type of the illness. Flushing may be present and herpes of the lips 

 may develop, but the petechial rash is extremely rare. The leucocytosis is 

 now more marked. 



Terminattions. — During the fourth and fifth days death is not uncommon, 

 but the symptoms may persist and death occur later on, somewhere al.out 

 the sixth to eighth day or later; the temperature may decline, the symptoms 

 abate, and the patient become convalescent. 



Varieties. — Such is the common course of the disease, but there are other 

 types— fi.^., the fulminating type, spotted fever type, chronic type, abortive 

 type, infantile type. 



The Fulminating or Septiccemic Type is associated with a sudden attack, 

 rapid development of coma, and death in^ few hours. It is often associated 

 with a purpuric rash, with petechial or large haemorrhages. The cerebro- 

 spinal fluid may be quite clear when first examined, but it contains a number 

 of meningococci, and in a few hours has a typical appearance and shows poly- 

 morphonuclear leucocytes. 



Usually by the time death has taken place there is sufficient evidence of pus 

 at the vertex of the brain to support the diagnosis, even without microscopical 

 examination. There are, however, cases which die before this pus is formed, 

 and then the brain and meninges are congested, but the pia mater at the base 

 shows patches of cloudiness due to pus cells. 



Spotted Fever Type. — Somewhere between the first and the fifth day 

 generalized petechiar eruption may appear, which is most marked on the inner 

 side of the knee, but it may also be found wherever there is pressure — e.g., 

 the great trochanter, the points of the shoulder, etc. It is a sign of severe 

 toxaemia, and when exaggerated becomes the purpuric rash. Other rashes 

 are: — A macular rash appears at times after the second day. It comes out 

 in one crop, and is seen on the lower part of the abdomen and the thighs, but 

 may occur on the forearms, legs, hands, or feet, 



A fugitive erythema or blush has already been mentioned. 



Chronic Type. — The acute symptoms of an attack pass away, the tempera- 

 ture may become normal, but the patient does not improve, ajid fever of an 

 irregular type may or may not return, while opisthotonus may occur, wasting 

 set in, and the patient slowly die of exhaustion, the amount of cerebro-spinal 

 fluid obtained by puncture becoming less and less and thicker and thicker 

 as time passes on. 



Abortive Type. — These are cases which, though beginning with the ordinary 

 symptoms, undergo the remission on the second day, are much better on the 

 third day, and convalescent on the fourth day or thereabouts. 



Infantile Type. — This is the so-called cervical opisthotonus of infants, a 

 symptom which is en evidence by the fourth day, while as a rule there is little 

 or no fever, but considerable and progressive wasting and marked vomiting. 

 It is chronic and has a high mortality, death commonly ensuing in four to 

 six weeks after the onset. 



Mimicry. — At times the disease imitates enteric fever, broncho-pneumonia, 

 gastro-»nteritis, or rheumatic fever. 



