1572 



VERRUGA PERUVIANA 



tumours almost cavernous in structure; hence the liabihty to 

 haemorrhage, which is such a marked feature of the disease. 



The subcutaneous fatty tissue is always inflamed. In addition 

 to these features, Letulle describes and figures some most peculiar 

 structures seen, under a magnification of 400 diameters, between 

 the cells of the epidermis, which he considers to be clasmatocytes. 



The growths appear to be often invaded secondarily with micro- 

 organisms, especially if ulcerated, while the eosinophiles disappear 

 and the mononuclears diminish. Myelocytes may be present, and 

 may number 0-5 per cent., and there maybe some large mononuclear 

 cells like macrophages. The nuclei of the polymorphonuclears are 

 simply bilobed. 



Symptomatology.— The incubation period is not definitely known, 

 and is stated to vary from eight to forty days, but to be most usually 

 from twenty to thirty days, during which time prodromata, in the 

 form of malaise, lassitude, and depression, may be experienced. 



Febrile Stage {Oroya Fever). — The invasion is gradual, the 

 prodromal symptoms increasing in virulence, while anaemia 

 becomes apparent, and peculiar rheumatoid pains appear in 

 different parts of the body. These pains are very striking 

 and very misleading, for they may in some cases be hmited 

 to a single region, or even to a single joint or muscle; on the 

 other hand, they may be more extensive, and lead to a diagnosis 

 of some nerve disorder. As a rule, but not invariably, fever 

 appears, and varies in intensity with the severity of the attack. 

 There is usually insomnia and often delirium. Usually it is inter- 

 mittent in character, the paroxysm beginning about noon with 

 chills, severe pains, much thirst, and a rise of temperature to about 

 104° F., with a quick, soft, compressible pulse, and ending in about 

 twelve hours by crisis, associated with sweating and an amelioration 

 of the pains. The liver and lymphatic glands enlarge, but accord- 

 ing to some authorities the spleen is not palpable. The patient 

 rapidly becomes very anaemic and feeble, and usually constipated, 

 but may at times suffer from severe diarrhoea. The destruction of 

 red cells, according to Monge, is enormous, the number falling to 

 900,000 per cubic millimetre, with microcytes in large numbers, 

 macrocytes, normoblasts (2,000 per cubic millimetre), megaloblasts 

 (200 per cubic millimetre), polychromatophilia, and poikilocytosis, 

 while the haemoglobin value is always increased. There is the pic- 

 ture of the blood in a pernicious anaemia. There is always a marked 

 leucocytosis, the count rising to 20,000 per cubic millimetre after 

 the first few days, and increasing later. The polymorphonuclear 

 leucocytes number about 75 per cent. The condition of the bone- 

 marrow has been studied by Corvallo, who finds excess of normo- 

 blasts and neutrophile myelocytes. 



Eruptive Stage [Verruga, sensu stricto). — In many cases, after the 

 febrile stage has lasted from twenty days to eight months, the 

 skin begins to itch, and an eruption appears on the face, neck, the 

 extensor surfaces of the arms and legs, and at times on the 

 conjunctivae, the lips, tongue, gums, palate, and pharynx. This 



