THE DIAGNOSIS OF A TROPICAL FEVER 



3. Pale dusky red papules or macules, fading into the 



normal skin, but slightly elevated, disappearing on 

 pressure, at the margins of the axillse, wrists, flanks, 

 chest, back, shoulders, arms, and legs, with sub- 

 cuticular mottling. Exclude malaria b}^ blood 

 examination — Typhus fever. 



4. Large red papules on face on the fifth to seventh day 



of illness, spreading over body as macules, after a 

 visit to Akitaken and Nugataken, of the Island of 

 Nippon, Japan. Enlarged lymphatic glands in some 

 area of the body, and a few vesicles on area drained 

 by lymphatics going to these glands, are indicative 

 of bites by Microtromhidium akamushi — Tsutsuga- 

 mushi fever. 



(b) Constitutional symptoms not severe and not following recent 



vaccination : — 



1. Rash of maculo-papules, circular, discrete; not as 



bright or as elevated as measles. No Koplik spots. 

 Occipital and other lymphatic glands enlarged. 

 Pink eye present — German measles, 



2. Fever slight or, at times of epidemic, absent in some 



cases. Rash general, composed of bright pinhead 

 papules or red macules {i.e., morbilliform), associated 

 with itching and with a few macules on the palms 

 and soles — Papular fever (Cast ellani and Chalmers). 



(c) Constitutional symptoms not severe, following recent vac- 



cination : — 



Rash composed of papules and papulo-vesicles, of large 

 pinhead size, appearing, some seven to nine days after 

 vaccination — Vaccine lichen. 



3. URTICARIAL ERUPTIONS. 



[a) Fever slight, after ingestion of certain foods^ — Febrile 



urticaria. 



(b) Worms present— Helminthic febrile urticaria. 



4. PURPURIC ERUPTIONS. 



Purpuric puncta may be caused by flea-bites and pediculi, and 

 have nothing to do with the fever. Many drugs, ptomaine poison- 

 ing, and snake-bite produce purpuric spots or patches. Very rarely 

 serum injections produce purpuric eruptions about seven to nine 

 days after the injection. The leukaemias, chronic alcoholism, 

 Bright 's disease, and jaundice, may be associated with purpuric 

 rashes. In fevers as a rule it points to septicaemia, and is more of a 

 prognostic than of a diagnostic value, even in epidemic cerebro- 

 spinal meningitis, in which, in our tropical experience, it is rare. 

 Peliosis rheumatica, with its associated tonsillitis and pains in the 

 joints, is very rare. It will be remembered that in scurvy there is 

 no fever. With these provisos we make the following suggestions : — 



