Skip to main content

Full text of "Medical services; diseases of the war"

See other formats


1 

-- : 






HISTORY OF THE GREAT WAR 

BASED ON OFFICIAL DOCUMENTS. 



MEDICAL SERVICES 
DISEASES OF THE WAR. 



VOL. I 



EDITED BY 

Major-General Sir W. G. MACPHERSON, K.C.M.G., C.B. 

Major-General Sir W. P. HERRINGHAM, K.C.M.G., C.B. 

Colonel T. R. ELLIOTT, C.B.E., D.S.O. 

AND 
Lieutenant-Colonel A. BALFOUR, C.B., C.M.G. 




LONDON : 

PRINTED AND PUBLISHED BY 

HIS MAJESTY'S STATIONERY OFFICE. 

To be purchased through any Bookseller or directly from 

H.M. STATIONERY OFFICE at the following addresses : 

IMPERIAL HOUSE, KINGSWAY, LONDON, W.C.2, and 

28, ABINGDON STREET, LONDON, S.W.I ; 

37, PETER STREET, MANCHESTER ; 
^1, ST. ANDREW'S CRESCENT, CARDIFF ; 

23, FORTH STREET, EDINBURGH 
or from EASON & SON, LTD., 40-41, LOWER SACKVILLE STREET, DUBLIN. 

Price i\ Is. Od. Net. 



CONTENTS. 



CHAPTER PAGE 

List of Contributors . . . . . . . . . . v 

Preface . . . . . . . . . . . . vii 

I. General Aspects of Disease during the War .. .. 1 

II. Enteric Group of Fevers .. .. .. .. ..11 

III. Dysentery 64 

IV. Cholera 116 

V. Typhus Fever 133 

VI. Cerebro-Spinal Fever 147 

VII. Influenza 174 

VIII. Purulent Bronchitis and Broncho-Pneumonia . . . . 212 

IX. Malaria : ^Etiology, Incidence and Distribution . . 227 
X. Malaria (contd.) : Pathology, Symptoms, Diagnosis and 

Treatment 264 

XI. Blackwater Fever 294 

XII. Trypanosomiasis . . . . . . . . . . . . 305 

XIII. Relapsing Fever (Spirochaetosis) .. 316 

XIV. East African Relapsing or Tick Fever 329 

XV. Phlebotomus Fever 345 

XVI. Trench Fever 358 

XVII. Jaundice 374 

XVIII. Scurvy . . 409 

XIX. Beri-ben 430 

XX. Famine Dropsy . . . . . . . . . . . . 450 

XXI. Pellagra 470 

XXII. Nephritis 485 

XXIII. Cardie-Vascular Disorders 504 

Index 539 

iii 
(2306) Wt. 38692/4589/902 1,500 4/22 Harrow G. 51. 2 



LIST OF COLOURED PLATES. 



TO FACE 
PLATE PAGE 

I. Cerebro-spinal Fever : 

Erythematous Rash (Fig. 1) 

Petechial Rash (Fig. 2) 152 

1 1 Cerebro- spinal Fever : 

Macular Rash . . .. .. ..154 

III Cerebro- spinal Fever : 

Purpuric Rash 156 

IV Influenza: 

The "Heliotrope Cyanosis" of I nfluenzo- pneu- 
monic Septicaemia . . . . 180 

V. Influenza : 

Whole Lung in a Case of Influenzal Pneumonia . . 198 

VI Jaundice: 

zht Lung from a Case of Spiroctaetal Jaundice 
(Ictero-hxmorrhagicu :*92 






CONTRIBUTORS TO SUBJECTS IN VOLUME I. 



Balfour, Andrew, C.B., C.M.G., M.D., B.Sc., 
F.R.C.P.E., D.P.H., Lieut.-Col. R.A.M.C.(T), 
Member of the Advisory Committee Eastern 
Mediterranean 1915-16; President of the 
Advisory Committee, Mesopotamia, 1916-17 ; 
Member Medical Mission, Expeditionary Force, 
East Africa, 1917. 

Bradford, Sir John Rose, K.C.M.G., C.B., C.B.E., 
D.Sc., M.D.. F.R.C.P., F.R.S., Major-General 
A.M.S. (T), Consulting Physician B.E.F., 
France. 

Byam, W., O.B.E., L.R.C.P., Brevet Lieut.-Col. 
R.A.M.C. 

Dawson of Penn, Rt. Hon. Lord, G.C.V.O., 
K.C.M.G., C.B., B.Sc., M.D., F.R.C.P., Major- 
General A.M.S. (T). Consulting Physician, 
B.E.F., France. 

Foster, Michael G., O.B.E., M.A., M.D., F.R.C.P., 
Colonel A.M.S.(T), Consulting Physician to 
Troops in France and Flanders. 

French, Herbert, C.B.E., M.A., M.D., F.R.C.P., 
Lieut.-Col. R.A.M.C. (T), Consulting Physician 
Queen Alexandra Military Hospital, Millbank, 
London. 

Gordon, Mervyn H., C.M.G., C.B.E., M.A., B.Sc., 
M.D., Lieut.-Col. R.A.M.C.(T), Member of Army 
Pathological Advisory Committee ; Consulting 
Bacteriologist for Cerebro-Spinal Fever, and 
Officer in Charge of the Central Cerebro-Spinal 
Fever Laboratory. 

Hay, John, M.D., F.R.C.P., Lieut.-Col. R.A.M.C. 
(T.F.) ; Specialist Cardiac Disorders, Western 
Command. 

Herringham, Sir Wilmot P., K.C.M.G., C.B., M.D., 
F.R.C.P., Major-General A.M.S.(T), Consulting 
Physician B.E.F., France, 1914-1919. 

Hume, W. E., C.M.G., M.D., F.R.C.P., Colonel 
A.M.S.(T), Consulting Physician, B.E.F., France. 

Hunter, Wm., C.B., M.D., F.R.C.P., Colonel 
A.M.S.(T), Consulting Physician Eastern Com- 
mand ; President Advisory Committee Eastern 
Mediterranean ; Officer in Charge British 
Sanitary Mission, Serbia, 1915. 

Lelean, P. S., C.B., C.M.G., F.R.C.S., Brevet-Col. 
R.A.M.C., Professor of Military Hygiene 
R.A.M.C., A.D.M.S. (Sanitation) Egypt. 

Manson-Bahr, P. H.. D.S.O., M.A., M.D., D.T.M. 
& H., M.R.C.P., Brevet-Major R.A.M.C.(T), 
Officer in Charge Malaria Diagnosis Stations 
and Military Laboratories Egyptian Expedi- 
tionary Force. 



Relapsing Fever. 

East African Relapsing 

or Tick Fever. 
Phlebotomns Fever. 



Purulent Bronchitis and 

Broncho- Pneumonia. 
Nephritis. 

Trench Fever. 
Jaundice. 



Cerebro-Spinal Fever. 



Influenza. 

Purulent Bronchitis and 
Broncho-Pneumonia. 

Cerebro-Spinal Fever. 



Cardio- Vascular Dis- 
orders. 

General A spects of Disease 

during the War. 
Influenza. 
Trench Fever. 

Cardio- Vascular Dis- 
orders. 

Typhus Fever. 
Jaundice. 



Pellagra. 



Dysentery. 

Malaria (Pathology, 
Symptoms, Diagnosis 
and Treatment). 



CONTRIBUTORS TO SUBJECTS IN VOLUME I. 

Cholera. 

Blackwater Fever. 
Trypanosomiasis. 

Famine Dropsy. 



Mitchell. T. J., D.S.O.. M.D.. Major R.A.M.C.. 
D.A.D.M.S.. 15th Indian Division, Mcs. K 

Newham. H. B., C.M.G.. M.D., M.R.C.R, D.P.H.. 
ol. R.A.M.C.(T). Consultant in Tropical 
East African Forces. 



Nixon, J. A., C.M.G.. M.D.. F.R.C.R, Colonel 
M.S.(T), Consulting Physician B.E.F., France, 

and Rhine Array. 
Robinson, O. L., C.B., C.M.G.. K.H.P., M.R.C.P., 

D.P.H., Colon- 

Torrens, J. A., M.D , F.R.C P.. Major R.A.M.C.(T). 

Waterston, J.. M.A.. D.Sc., Captain R.A.M.C. 

. 

Wenyon. C. M.. C.M.G., C.B.E.. B.Sc., M.B.. B.S., 
Colonel A.M.S.(T). In charge Malaria Investi- 
gations. Macedonia. 

x. Sir \\ H., K.C.I.E., C.B., C.M.G., B.Sc., 
U.C.P., Colon. I), Consulting 

Physician to Forces in Mesopotamia. 



Cholera. 

Enteric Group of Fevers. 

Malaria (List of 
Mosquitoes). 

Malaria (^Etiology, 
Incidence and 
Distribution). 

Scurvy. 
Bert-beri. 



Note. (T) means temporary commission. 

(T.F.) means Territorial Force commission. 






PREFACE. 

chapters of the volumes on the Diseases of the 
War have been prepared by officers who held regular, 
territorial force or temporary commissions in the Royal Army 
Medical Corps, and who had special knowledge and personal 
experience of the diseases about which they write. The 
material contained in official documents, supplemented by the 
numerous references appended to each chapter, has been at 
their disposal. 

In the present volume a considerable amount of repetition 
will be found, notably in the chapters on influenza and purulent 
bronchitis, consequent upon these diseases having been 
considered from two separate standpoints, namely, the 
experience of the epidemic amongst the troops in France and 
the experience of the epidemic in the United Kingdom. 

The second volume will contain chapters on nervous 
disorders, venereal and skin diseases, in addition to chapters 
on the medical aspects of aviation, gas warfare, and mine 
gas poisoning. Although these latter subjects have a wider 
significance than that of actual disease and might of 
themselves have formed a separate volume, it has been found 
convenient to introduce them into the volumes on the Diseases 
of the War. 

The measures for preventing disease, and the methods and 
results of laboratory research are fully detailed, in the 
volumes which will be published separately on Hygiene 
and Pathology during the War, and reference must be made 
to them for fuller information on these subjects. But it has 
been considered advisable to introduce a certain amount of 
detail with regard to preventive treatment and pathology 
into the present volumes. 

It has been preferable, in an historical record such as 
this, to adopt the form in which the subjects are now 
presented rather than the form which is customary in text- 
books or articles in journals. The chapters are based chiefly 
on such work as was done during the progress of the war. 
There has been little opportunity for further analysis and 
study of the accumulated records of medical cases. 
Consequently the final nature of the invalidism produced 
by the various diseases has not been described with that 
measure of accuracy which can only come when the 

vii 



viii MEDICAL HISTORY OF THE WAR 

documents now in the hands of the Ministry of Pensions 
are analysed in detail. Moreover, even in respect of dealing 
with actual clinical experience, the contributors to the present 
volume have been handicapped by the fact that papers 
published during the war were comparatively few. This 
restriction of papers and consequently of clinical and path- 
ological studies was due to the general military policy which 
of necessity governed the publication even of medical reports. 

The chief work of editing the chapters has been carried out 
by Major-General Sir Wilmot Herringham, Colonel T. R. 
Elliott, and Lieut. -Col. Andrew Balfour, who have devoted 
an immense amount of valuable time and care to doing so. 
They desire to acknowledge the able assistance which they 
received from Major T. J. Mitchell R.A.M.C., and the staff 
employed in the office of the Medical History of the War. 

Acknowledgments are also due to the British Medical 
Journal, Journal of the Royal Army Medical Corps, Lancet, 
Quarterly Journal of Medicine, the Medical Society of 
London, the Royal Society of Medicine, the Medical Research 
Council, the Cambridge University Press, and Messrs. Bailliere, 
Tindall and Cox for permission to use blocks of various charts, 
illustrations and coloured plates, which have already appeared 
in their publications. 

W. G. M. 




CORRIGENDA. 



(1) P. 12, Table I. France 1916: The correct 

number of cases is 2568, not 2668 as printed. 

(2) P. 56, Line 14 : The correct date is January, 

1916, not January, 1915, as printed. 

(3) Plates facing pp. 194 and 200 should be 

marked Figures 1 and 2, instead of Plates III 
and IV as printed. 



DISEASES OF THE WAR. 



CHAPTER I. 



GENERAL ASPECTS OF DISEASE DURING THE WAR. 



DURING war popular attention finds its chief interest in 
the number of the wounded, and concerns itself much 
less with the amount of sickness amongst the troops, although 
in every war of which we have records from the days of 
Sennacherib onwards the inefficiency from disease has out- 
numbered many times the losses from killed and wounded. 
Medical science has advanced so much that the figures of wars 
fifty and sixty years ago afford no useful bases of comparison. 
Those of the last two great wars are as follows : 



Annual Ratio per 1,000. 





Wounded. 


Sickness. 


Admissions. 


Deaths 

(incl. killed). 


Admissions. 


Deaths. 


South Africa, 
1899-1902 

(31 months). 


34-2 


14-4 


843-0 


24-58 


Manchuria, Russo- 
Japanese War, 
Japanese Force, 
1904-1905 
(18 months). 


391-6 


137-3 


589-6 


41-2 



The ratios in the table below are the total sickness rates and 
are calculated in the same way as those of the South African 
and Russo-Japanese Wars. 



Year. 


France. 


Italy. 


Macedonia. 


Egypt & 
Palestine. 


Mesopo- 
tamia. 


East 
Africa. 


1915 




















1916 








982-7 


618-7 


1409-7 





1917 








837-9 


745-2 


1301-3 


1403-5 


1918 


533-1 


670-8 


1011-7 


1000-1 


980-9 


2310-6 



(2396) 



2 MEDICAL HISTORY OF THE 'WAR 

But these figures do not indicate the proportion of sick and 
wounded, and for comparing them the actual admissions in 
certain years are as follows : 





Wounded. 


Sickness. 




Total 
Admissions. 


Total 
Deaths 
(incl. killed). 


Total 
Admissions. 


Total 
Deaths. 


France, 1918 


574,803 


46,084 


980,980 


8,988 


Egypt and Palestine, 
1917-1918 


32,255 


9,451 


359,855 


3,360 


Macedonia, 1917- 
1918 


12,552 


2,843 


331,753 


3,031 


Italy, 1918 


4,671 


470 


54,626 


661 


Mesopotamia, 1916- 
1918 
(White troops only] 


16,793 


6,752 


242,159 


2,752 



These figures show that the admissions for disease in other 
theatres than France were 14*6 times as numerous as those 
for wounds (988,393 : 66,271), while even in France, though the 
perfection of instruments of warfare and the constant fighting 
greatly increased the number of wounded, the admissions for 
disease were still much the more numerous. It was indeed 
anticipated that the disproportion would be even greater. The 
admission rates for sickness per 1,000 of strength in 1909, a 
year of peace, are given as : 

In the United Kingdom . . . . . . . . 378 4 

In Egypt 672-9 

In West Africa 1026-1 

Further, in the Royal Army Medical Corps Training Manual 
published in 1911, it is stated that in wartime the excess of 
sickness admissions over those for injuries received in action 
will probably be as twenty-five to one, and that though the 
fatality of injury is greater than that of disease, the deaths 
from disease are usually five times the more numerous. 

To the mere statement of numbers given above three other 
factors should be added before the effect of wastage from disease 
during the war can be realized, namely, the average number of 
days that patients remained in hospital, which in France was 
found to be 45*, the cost of transport and maintenance of the 

* But this average refers only to those cases treated and discharged in 

Many of the severer cases were transferred to England, and these 

probably took much longer to convalesce. Thus cases of dysentery treated 






GENERAL ASPECTS OF DISEASE 3 

patient, and the cost of the training and transport of the man 
sent up to take a patient's place in the ranks. 

These considerations are sufficient to show the importance of 
disease as a cause of inefficiency in an army, and the vast 
expense which it entails upon the country. 

The natural circumstances of each country differ so widely 
that the prevalence of diseases varied much in the different 
theatres of the war, as is shown in the following table. 

Rates per 1,000 of strength. 





France. 


Italy. 


Mace- 
donia. 


Egypt & 
Palestine. 


Mesopo- 
tamia. 


East 
Africa. 


Enteric 














1915 .. 


3-1 











__ 





1916.. 


2-3 





6-3 


14-2 


54-4 





1917 .. 


7 





2-5 


7 


14-2 


4-76 


1918.. 


2 


1-48 


8 


9 


6-3 


6-80 


Dysentery 














1915.. 


03 

















1916.. 


4-09 





63-89 


31-19 


50.94 





1917.. 


3-76 





28-89 


23-13 


60-34 


486-56 


1918.. 


79 


9-54 


58-23 


21-80 


51-12 


116-51 


Malaria 














1915.. 




















1916.. 


05 





331-47 


8-10 


68-61 





1917.. 


48 





353-18 


44-66 


94-20 


2880-9 


1918.. 


1-77 


2-90 


369-29 


134-40 


95-79 


1278-0 


Nephritis 














1915 .. 


7-16 

















1916.. 


8-46 

















1917 .. 


9-51 

















1918.. 


4-17 


















The enteric rate of admissions was nowhere over 10 per 1,000 
of strength except in Egypt during 1916, and in Mesopotamia 
during 1916 and 1917. Dysentery was very prevalent in 
East Africa, Egypt and Mesopotamia. Malaria was exceed- 
ingly prevalent in East Africa, Macedonia and Egypt. Its great 
prevalence in Macedonia in 1916, and in Egypt in 1918, coincides 
with the advance into the infested valley of the Struma and 
plain of Esdraelon. This distribution was on the whole 
expected from previous experience. 

Nephritis is not mentioned in other statistics than those of the 
forces in France, where it formed an appreciable item, nor was 
trench fever made a notifiable disease elsewhere, though it was 

in France averaged 42-3 days under treatment, while those which were 
transferred to England averaged 118-3 days. The 45 days mentioned in the 
text is much less than the average number of days for all cases of illness 
contracted in France. 



4 MEDICAL HISTORY OF THE WAR 

seen in Macedonia after divisions had gone there from 
France. 

Although a war carried on in many areas and climates cannot 
be closely compared as a whole with previous wars confined to 
one country, the admission rate for sickness in France in 1918 
(533- 1 per 1,000 of strength) compares favourably with those of 
the South African War (843-0) and the Russo-Japanese War 
(589 6) . The climatic conditions in Manchuria were favourable 
to health, and Japanese sanitary methods as regards cleanliness 
of person and sanitary discipline were extremely good. Most 
of the Japanese sickness was due to beri-beri, from deficiency of 
vitamine in their ration, the chief constituent of which was 
polished rice. On the other hand, however, if there were in 
France, in the wet climate and in the conditions of trench war- 
fare, factors unfavourable to health, there were also in the 
absence of extreme temperatures and of endemic disease, in the 
shortness of the lines of communication and the consequent 
abundant supply of food, and in the facilities for sanitation and 
early treatment of illness, points which might be expected to 
tell heavily on the other side. 

In other theatres of the war the sick rate was very much 
heavier. On the whole, a more favourable theatre than France 
could hardly be expected, and while an improvement on the 
Japanese figures may be regarded as eminently satisfactory, 
it is necessary to inquire whether in France the results could 
not have been better, and why in other countries they were 
much worse than the Japanese ratios. This is all the more 
necessary since of the epidemic diseases which are known to 
have been the scourges of previous campaigns dysentery, 
malaria, enteric, smallpox and typhus the last two have been 
practically absent amongst the British troops, and enteric was 
very much less prevalent than in any previous war.* Nor 
was there any disease, except malaria in certain theatres of 
war, which caused the same amount of inefficiency as beri-beri 
did in the Japanese armies. 

The extraordinary improvement in the figures for enteric 
fever as compared with those in the South African War is 
remarkable. During the 31 months of the South African War, 
in which ration strength was probably never more than 250,000, 
there were 59,750 admissions for enteric, with 8,227 deaths. 
During 53 months of war in France, during which the ration 

In France, during 1914-1918, there were only eleven cases of smallpox, none 
of typhus. In Italy, in 1918, there were two cases of smallpox and none of 
typhus. The only theatres of war where there was any degree of prevalence 
of smallpox or typhus were Egypt, Palestine and Mesopotamia. Details 
regarding the former will be found in the volumes on the hygiene of the war, 
and regarding the latter in the chapter on typhus in this volume. 



GENERAL ASPECTS OF DISEASE 5 

strength rose from 269,711 in 1914 to 2,528,400 in 1918, the 
total number of admissions for enteric fever, including typhoid 
and the para-typhoids, as noted in Chapter II, was 6,907, 
and the number of deaths 260. Since enteric was prevalent 
among the civilians in the area which the British occupied 
during 1915, and since the French troops had a large number 
of cases up to the time at which they altered their system 
of prophylactic inoculation, it is fairly certain that the 
British troops would have been attacked but for the three 
measures specially designed to prevent it: the prophylactic 
inoculation, the strict water control, and the vigilant 
search for " typhoid carriers." The great improvement 
in the French figures which followed on the alteration of 
their system of inoculation is evidence that this measure played 
an important part. The small incidence of enteric was not 
confined to the expeditionary force in France. Except in 
Mesopotamia and in Egypt during 1917 the rate nowhere rose 
to double figures, and in every area except East Africa it sank 
lower year by year. 

The same cannot be said of dysentery. In France the admis- 
sions for this disease did not reach any large total, but in other 
parts of the world, notably in East Africa, they rose to very high 
figures. These facts may indeed be used as evidence of the 
effect of inoculation as a preventive of enteric, for the channel 
of infection is the same in both diseases, the same sanitary 
precautions were taken for both, and in both the affected men 
were separated as quickly as possible from the healthy. But 
on the one hand the diagnosis of dysentery is more uncertain, so 
that segregation is more difficult, and on the other there is no 
prophylactic yet discovered for it. A lesson may be learnt, 
however, for the future. In France the diagnosis of dysentery 
was at first based upon bacteriological evidence alone. It was 
soon found that in a large number of cases the bacilli were not 
recovered and accordingly the presence of blood and slime in 
the motions were regarded as sufficient evidence for a diagnosis. 
But cases showing these symptoms in the trenches might show 
simple diarrhoea by the time they reached the casualty clearing 
station, and in that event, in spite of orders to the contrary, the 
diagnosis was not infrequently altered, although, as the sub- 
sequent course of the case in base hospitals showed, the original 
diagnosis of dysentery was correct. If wastage by dysentery 
is to be reduced in future, it is of the utmost importance to 
segregate all infected men at the earliest possible time, and it 
should be clearly understood that medical officers should strive 
not to minimize the number of cases or to refuse all but the 
most rigid proof, but rather to watch for and at once discover 



6 MEDICAL HISTORY OF THE WAR 

and segregate all cases which may fairly be suspected. An 
army will lose far fewer men eventually by adopting this 
procedure. 

The figures for malaria in Macedonia, Egypt, and Mesopo- 
tamia were not much more satisfactory, while in East Africa 
they were so excessive that an official enquiry into the causes 
was instituted. Although there may have been failure on the 
part of individual administrators, the questions of interest in 
the present connection are the deficiencies in existing knowledge, 
the limits which circumstances must sometimes set to the 
application of such knowledge as exists, and the means, if any, 
whereby, in the future, methods of prevention may be increased 
and treatment improved. The life history of the infection of 
malaria is of course known, and the building of the Panama 
Canal is evidence of what can be accomplished in the prevention 
of insect-borne disease when conditions admit of the necessary 
measures. But measures such as would be taken in Panama 
cannot be carried out in actual warfare. If troops are pushed 
forward into infected areas, destruction of breeding places may 
in some kinds of country be quite impossible, and almost equally 
impossible may be the protection of the soldier in the open 
while on sentry duty or in advanced posts, and even perhaps in 
bivouac, tent or billet. It is generally allowed that quinine is 
of little use as a prophylactic in war time, and it must be recog- 
nised that the occupation of a malarious area will inevitably 
cause a high malarial sick-rate. 

In considering the possibility of a long campaign in an area 
such as that of Macedonia, it must be realised that at present the 
medical services cannot control the outbreaks of malaria, which 
are bound to occur, and that to occupy a malarial district for 
long will be as serious a drain on the strength of an army as to 
hold a shell-swept front, such as that of the Ypres sector in 
France. Moreover, the price of malarial casualties continues to 
be paid for many years after the campaign itself. In the autumn 
of 1920 malaria was still responsible for 13 per cent, of the total 
number of men drawing pensions for disabilities due to diseases 
contracted in the war, and was indeed the chief source of all the 
chronic forms of disability. 

The history of scurvy in Mesopotamia is interesting from 
several points of view. In the first place its incidence brought 
to light the fact that the ordinary peace diet of the Indian 
soldier, which was provided by himself out of a money allowance 
and not as a Government ration, lacked many essentials of a 
scientific dietary, so that many of the men who arrived in 
Mesopotamia were noticed from the first to be anaemic, debili- 
tated and below the proper level of health, and were liable to 



GENERAL ASPECTS OF DISEASE 7 

feel at once the slightest further deprivation which difficulties 
of communication might entail. In the second place, it is clear 
that the earlier war ration was not sufficient to overcome this 
tendency ; it, like the peace diet, had no surplus value available. 
Thirdly, the outbreak of the disease revealed that the remedies 
on which reliance had been placed, namely, dried vegetables and 
lime juice, were practically useless, whereas the really efficient 
substances, whether of old standing such as orange and lemon 
juice, or lately* discovered such as germinating pulses, were not 
available. Lastly, it is worthy of note that these commodities 
were eventually obtained, and also that by means of Arab 
and Indian gardeners a large amount of green vegetables was 
produced in the country. 

But, after all, these infections count for little in the total 
sick-rate. It took a long time to realize that when the serious 
maladies were held in check it was time to attend to the minor 
diseases that made up the great total of wastage. In France a 
list of 21 diseases including all the eruptive fevers, together 
with the diseases just mentioned and some others, only 
accounted for 27-51 out of a total rate of 533-1 for 1918 ; in 
Mesopotamia in 1918 the dysentery and malaria rates amounted 
to 146-91 only, out of a total of 980'9 ; in Macedonia 
dysentery, malaria, and pneumonia with influenza made an 
aggregate rate of 538*85 out of a total rate of 1,011-7. 

There are no official statistics as yet available to show what 
diseases constitute the remainder. A series of figures, however, 
was obtained from the casualty clearing stations of one of the 
armies in France during 1917, and was analysed by Colonel 
Soltau. The admissions numbered 106,267. As the total sick 
admissions for all the armies in France for 1917 are not known 
it is not possible to say what proportion Colonel Soltau's figures 
bear to the whole ; but they are little more than 10 per cent, of 
the total for 1918. Nor is it possible to compare his figures with 
the rates given above, since the strength of the army to which 
his figures refer is not available. But Colonel Soltau compares 
various diseases and classes of disease with one another under 
eight groups, and produces the following results : 

Group " A ", which includes scabies, skin diseases, boils, and 
cases classed as inflammation of connective tissue, accounts for 
26,879 of the admissions. " The main fact that emerges from 
a study of group ' A ' is that some 25 per cent, of the sick wastage 
was due to simple skin lesions, that of them the vast majority 
were due to scabies or some form of pyodermia, and as such were 
very largely preventible by careful inspection and personal 

* But see note in Chapter XVIII. on Scurvy, page 420. 



8 j MEDICAL HISTORY OF THE WAR 

cleanliness of the men, and that even where infection was 
established, prompt treatment was efficacious in greatly 
reducing the loss of time." 

Group " B," which includes pyrexia of uncertain origin, 
trench fever, myalgia and rheumatism, accounts for 26,024 
admissions. Colonel Soltau considers that fully 20,000 of these 
were really trench fever, and, adding to this figure 1,500 of the 
cases of disordered action of the heart which is a frequent sequel 
of the fever, he ascribes 2 1,500 of his cases to trench fever, or, 
in other words, to infestation by lice. 

From the two groups combined he concludes that 44 per cent, 
of the total admissions were due to diseases caused by dirt or 
lice and therefore preventible by sanitary measures. 

Uncleanliness and verminous infection have consequently 
been brought into special prominence during the war as causes 
of sick wastage from this group of disease. In the South African 
War, diseases of the connective tissue and diseases of the skin 
together accounted for an admission rate of 46-83 out of the 
admission rate of 843 for all classes of sickness ; and, although 
these diseases may not in other areas and in other conditions 
rise to so large a proportion, yet they must in future be regarded 
as so powerful a cause of inefficiency that great efforts to 
prevent them are not only justifiable but necessary. 

During the war four conditions, one hitherto undescribed by 
military surgeons and the other three barely mentioned, 
attracted much attention in France. Trench foot can be 
recognized in Larrey's notes of the winter campaign in East 
Prussia in 1806, and nephritis occurred to a considerable extent 
among the troops in the American Civil War, but trench fever 
is a form of disease which has escaped notice until now, and 
though gas gangrene had been occasionally seen in civil practice 
there is, according to Sir Anthony Bowlby, hardly any descrip- 
tion of it in military surgery. Upon all these a great deal of 
original and experimental work was expended, and if in 
nephritis no great advance has been made towards its prevention 
or cure, much has been gained in the other three cases. Trench 
foot was at once studied with the greatest care. Many experi- 
ments were made in various forms of boots and leggings, and 
eventually by the use of long loose thigh boots, by the strict 
application of prophylactic treatment to preserve proper circu- 
lation, and by improvements in the trenches, its incidence was 
greatly reduced. It still, however, in 1917 accounted for 3,294 
of Colonel Soltau's admissions. Trench fever is an excellent 
instance of the practical value of research to an army in the 
field. It was recognized in 1915 and proved to be infective by 
inoculation of volunteers early in 1916. Had that method 



GENERAL ASPECTS OF DISEASE 9 

been pursued at the time, the pathology of the disease and the 
means by which it was spread would soon have been discovered, 
but the use of volunteers for the needful experiments at the 
time was not permitted, and accordingly these discoveries 
were postponed till 1917-1918, when, with the help of 60 or 70 
volunteers, the American pathologists settled the question in 
three months. The delay probably meant that about 200,000 
cases might have been prevented had the experiments taken 
place earlier. Another striking instance may be drawn from 
the surgical triumphs which immediately followed upon the 
knowledge gained in the pathological laboratories regarding 
the anaerobic infections which produced gas gangrene. 

What, then, are the lessons which may be learnt from such 
figures, imperfect though they are, and how can the experience 
of the war teach us to lessen sickness and consequent wastage 
in future campaigns ? 

In the first place, while the standard of sanitary discipline 
was excellent in such matters as water supply and disposal of 
excreta, the immense effect of uncleanliness in the production 
of disease must be recognized in future far more than it has 
been hitherto. Men are often crowded in dugouts and cellars, 
can only change their clothes or bathe at rare intervals, and 
are continually feeding in conditions which must convey 
infection if there is any infection to convey. The result is a 
sick rate from dirt diseases which amounts to nearly 50 per cent, 
of the total sickness in an army. That is sufficient to warrant 
the greatest possible effort to provide more baths, more 
laundries, more vermin destroyers, and to see that the men 
have opportunities of using them. Although measures to 
exterminate lice were energetically pursued from an early stage 
in the war, and the means of disinfestation constantly increased, 
it was not until the trench fever committee reported that the 
infection was carried by lice that the sanitary branch obtained 
the full equipment and facilities of which it had long been 
desirous. 

Secondly, the war has shown the immense services which 
original research can render to preserve the efficiency of an army. 
The examples of trench fever, of cerebro-spinal fever, of gas 
poisoning, and of gas gangrene showed what wonderful results 
could be obtained by the union of clinical and pathological 
research not only at home, but also in the actual area of military 
operations. The mobile bacteriological laboratories were 
designed chiefly as aids to diagnosis and special treatment, but 
they went far beyond these limits and played a large part in the 
fresh discoveries of medicine and surgery. It cannot be 
doubted that in the future a prophylactic against dysentery 



10 MEDICAL HISTORY OF THE WAR 

will be discovered, and it can only be discovered by scientific 
experiment ; it is even possible that by the same method we 
may improve our means of preventing malaria. 

Thirdly, the facts prove that in planning campaigns, especially 
in regions little known, the general staff should take the wastage 
by sickness into account as much as the wastage by wounds, and 
that not only should the army medical authorities be consulted 
concerning the probable loss from sickness and the consequent 
need for reinforcements, but their opinion should also be 
required concerning the best methods of prevention, including 
such local questions as sites for camps, destruction of insect 
carriers of disease, and purification of water, and also the wider 
and more general subjects of the provision of proper dietary, 
clothing and equipment. The medical side of the planning of 
a campaign is just as necessary for efficiency as the military, and 
the neglect of it must inevitably lead to an enormous amount of 
preventible wastage. 

Lastly comes the great lesson of the war with regard to 
disease that, while to an army medical officer the fullest know- 
ledge of all that tends to prevent disease is of the utmost 
importance, the treatment of patients admitted to hospital for 
injuries or disease, in other words, the clinical medicine and 
surgery of war time, is not of necessity rough in method or 
imperfect in attainment, but is susceptible of a high and 
exquisite perfection and affords scope for the finest scientific 
work. 

BIBLIOGRAPHY. 

Bowlby . . . . The Hunterian Oration. British Mili- Lancet, 1919. 

tary Surgery in the time of Hunter Vol. i, p. 285. 
and in the Great War. 

Macpherson . . Russo-Japanese War. Medical and 1908. 

Sanitary Reports. Report No. 15. 

Simpson . . . . The Medical History of the South Jl. of R.A.M.C., 
African War. 1910. Vol. 

xiv, p. 23, 
et. seq. 

Soltau . . . . A Note on Sick Wastage . . . . Jl. of R.A.M.C., 

1920, Vol. 
xxxv, p. 152. 



CHAPTER II. 

ENTERIC GROUP OF FEVERS. 

THE enteric group of fevers includes typhoid fever, due to 
infection with Bacillus typhosus of Eberth, and the 
paratyphoid fevers, due to infection with either Bacillus para- 
typhosus A or Bacillus paratyphosus B. The paratyphoid 
section may have to be enlarged to include at least one other 
variety, Bacillus paratyphosus C, which has strong claims to 
be considered as a definite and specific infection. 

In the early months of the war there was confusion in the 
nomenclature of these diseases, owing to the lack of precision 
with which the term " enteric fever " was used by different 
medical officers ; by some it was considered synonymous with 
typhoid fever, by others it was only considered to imply a 
group infection.* 

It was not until March 1915 that official sanction was granted 
by General Headquarters in France for the use of the diagnosis 
" Enteric Group " on clinical grounds, with the obligation to 
change it later to typhoid, paratyphoid A or paratyphoid B 
when the precise nature of the infection had been determined 
in the laboratory. 

A certain number of cases, in which, for various reasons, 
accurate bacteriological or serological diagnosis cannot be made, 
retain the diagnosis " Enteric Group." In describing this 
group of diseases, as they occurred during the war, the term 
enteric fever comprises the group infection considered as a 
whole. The terms typhoid and paratyphoid A or B indicate 
specific infections by their respective bacilli. 

Enteric fever has long been recognized as likely to be more 
deadly to an army on active service than the bullets of the 
enemy, and the truth of this is shown in the statistics from 
previous campaigns. 

In the South African War the British Army employed 
557,653 men, with an average strength of 209,404, and there 
were 59,750 cases of enteric fever, with 8,227 deaths. This is 
equivalent to an admission rate of 285, with a death rate of 36 
per thousand of average strength. 

* The nomenclature which army medical officers were required to follow 
was the official nomenclature of diseases drawn up by a joint committee 
appointed by the Royal College of Physicians. According to it enteric fever 
is a synonym for typhoid fever, and includes the sub-groups of paratyphoid 
A and B. 

11 



12 



MEDICAL HISTORY OF THE WAR 



In the Spanish-American War the American Army employed 
107,973 men and there were 20,738 cases of enteric fever, with 
1,580 deaths. This is equivalent to an admission rate of 88*5 
per thousand for the year 1898. Sternberg, in " Sanitary 
Lessons of the War/' gives the annual death rate per thousand 
from typhoid fever at 14' 8 in the American camps in 
Florida and Virginia during this war. 

In the Franco-German War the Germans despatched 
1,146,000 men across the frontier ; these showed 73,393 cases 
of enteric fever, with 6,965 deaths. 

In the French operations in Tunis, from a total strength of 
20,000 men there were 4,200 cases of enteric fever, with 1,039 
deaths. 

In the Russo-Turkish War, the Russian Army of the Caucasus 
comprised 246,000 men and showed 24,475 cases of enteric fever, 
with 8,900 deaths. 

No attempt was made in previous campaigns to differentiate 
typhoid from paratyphoid fevers, hence a considerable number 
of cases from which the foregoing statistics were compiled were 
probably paratyphoid. In view of the much lower mortality 
from paratyphoid fever it follows that the true percentage 
mortality of typhoid cases in previous wars has been higher 
than has been stated above. 

With regard to the incidence of enteric fevers in 1914-1918, 
the official figures for the British Armies offer a welcome 
contrast to the experiences of previous campaigns. 

The incidence of the enteric fevers in the expeditionary forces 
in the various theatres of war is shown in the following table : 

TABLE I. 



Theatre of 
War. 


Year. 


Number 
of Cases. 


Incidence 
per 1,000 
of Ration 
Strength. 


Number 
of Deaths. 


Death 
Rate 
per 1,000 
of Ration 
Strength. 


Total 
Case 
Mortality 
per cent. 


Mean 
Ration 
Strength 
of Force. 


France 


1914 


388 




47 




12-1 






(Aug.-Dec.) 
















1915 


2,351 


4-0 


130 


22 


5-5 


588,000 




1916 


2,668 


2-0 


30 


02 


1-12 


1,274,200 




1917 


1,166 


61 


33 


012 


2-8 


1,884,100 




1918 


334 


12 


20 


007 


5-9 


2,528,400 


E. Africa . . 


1917 


102 


5-0 


27 


1-3 


26-4 


20,600 




1918 


116 


7-8 


33 


2-2 


28-4 


(appro*.) 
14,700 
















(approx.) 


Salonika 


1916 


1,105 


11-79 


40 


42 


3-62 


93,684 




1917 


529 


2-61 


19 


09 


3-78 


202,260 




1918 


135 


84 


6 


03 


4-44 


159,947 


Italy 


1918 


141 


1-5 


15 


15 


10-6 


94,000 


Egypt (exclud- 
ing officers 
and Indian 


1916 
1917 
1918 


2,950 
505 
401 


17-35 
2-82 
1-87 


66 
22 
51 


32 
12 
23 


2-2 
4-3 
12-7 


170,000 
179,000 
213,000 


troops) 

















ENTERIC GROUP OF FEVERS 
TABLE I. cont: 



13 









Incidence 




Death 


Total 


Mean 


Theatre of 
War. 


Year. 


Number 
of Cases. 


per 1,000 
of Ration 
Strength. 


Number 
of Deaths. 


Rate 
per 1,000 
of Ration 
Strengfh. 


Case 

Mortality 
per cent. 


Ration 
Strength 
of Force. 


Mesopotamia 


1916 


1,266 


_ 


110 


_ 


8-6 







(22 weeks 
















only) 
















1917 


1,211 


14-4 


91 


1-08 


7-5 


84,000 
















(approx.) 




1918 


640 


6-0 


70 


55 


10-9 


106,000 
















(approx.) 


Gallipoli 


1915 


4,241 





uncertain 





9-0 


Not 














(approx.) 


available. 



No attempt has been made in the above table to differentiate 
between typhoid and paratyphoid fevers, and the totals do not 
represent all the cases of enteric fever that occurred in the 
British forces throughout the war, since cases occurring in 
Indian troops and native labour corps are not included, but it 
is believed that the figures are as accurate as can be determined 
at present for the periods and theatres of war concerned. 

The total number of cases and deaths in this table shows 
that in upwards of four years and in six theatres of war, with an 
average mean ration strength of nearly two million troops, there 
were only 20,149 cases of typhoid and paratyphoid fever with 
1,191 deaths, giving a total case mortality of 5*4 per cent. 

The relative incidence of the three infections in the various 
theatres of war, as far as it was possible to identify them with 
certainty, is shown in the following tables : 

TABLE II. 

Incidence of the Enteric Group of Diseases. 



Theatre 




Number of Cases. 


Incidence per 1,000 
of Ration Strength. 


of War. 


Year. 


Typh. 


Para. 
A 


Para. 
B 


En- 
teric 
Group 


Typh. 


Para. 
A 


Para. 
B 


En- 
teric 
Group 


France 


1914 


253 


5 


31 


99 












1915 


805 


281 


1,043 


222 


1-3 


47 


1.7 


3 




1916 


729 


580 


1,009 


350 


57 


45 


7 


27 




1917 


227 


173 


471 


295 


12 


08 


24 


15 




1918 


90 


43 


156 


45 


03 


015 


06 


015 


Salonika . . 


1916 


97 


212 


203 


593 


1-03 


2-26 


2-16 


6-32 




1917 


81 


136 


92 


220 


40 


67 


45 


.1-08 




1918 


30 


47 


20 


38 


18 


29 


12 


23 


Italy 


1918 


33 


23 


61 


22 


35 


25 


6 


26 


Egypt . . 


1916 


99 


187 


143 


2,521 


58 


1-1 


84 


14-83 




1917 


13 


70 


74 


348 


07 


38 


41 


1-94 




191S 


31 


66 


46 


258 


14 


3 


21 


1-2 



14 MEDICAL HISTORY OF THE WAR 

TABLE III. 

Incidence of Enteric Group of Diseases in Mesopotamia and 

Gallipoli. 



Theatre 
of War. 


Year. 


Typh. 


Para. A 


Para. B 


Enteric 
Group. 


Proved 
Cases. 


Mesopotamia 


July-Dec. 
1916 


12-3% 


74-4% 


13-2o/ 


1,018 


446 


(quoted from 
Ledingham) 


Jan. -June 
1917 


8-9% 


77-2% 


13-8% 


239 


101 




July-Dec. 
1917 
Jan.-June 
1918 


21-3% 
36-6% 


72-5% 
50-4% 


6-0% 
12-8% 


544 
170 


197 
101 




July-Dec. 
1918 


37-7% 


47-2% 


14-90/c 


209 


127 


Gallipoli 
(Based on a 
report by 
Martin and 
Upjohn) 


1915 


7-0% 


61-0% 


32-0% 







The information afforded by these tables is not of equal value 
in all the theatres of war. The chief difficulty lies in the widely 
different proportion of cases which remain classified " enteric 
group." 

Considering the great difficulties under which all bacterio- 
logical work laboured throughout the eastern campaigns, it is 
inevitable that the proportion of " group " to proved cases 
should be particularly high in these areas, while the figures for 
France are the most reliable owing to the low proportion of 
these undiagnosed cases. 

It is nevertheless reasonably certain that the above tables 
represent with fair accuracy the relative incidence of typhoid 
and the two paratyphoid fevers. 

It will be seen that only in France was typhoid fever 
responsible for as many as one half the total cases and that in 
the other campaigns the proportion was usually less than one 
quarter ; but that whereas in France and Italy paratyphoid B 
was about three times as frequent as paratyphoid A, in Salonika 
paratyphoid A was more frequent than paratyphoid B in the 
proportion of 32 to 27 ; in Egypt the proportion of para- 
typhoid A to paratyphoid B was as 9 to 7, while in Mesopotamia 
paratyphoid A was five times as frequent as paratyphoid B 
and three times as frequent as typhoid until 1918, when 



ENTERIC GROUP OF FEVERS 4 15 

there was a notable increase in typhoid and diminution in 
paratyphoid A. 

It would not be fair to assume that the relative proportions 
of the three infections shown above obtained in previous cam- 
paigns because there can be no doubt that, taken as a whole, 
prophylactic inoculation has conferred a greater mass immunity 
against typhoid fever than against either of the paratyphoids. 
This must be so if only because triple vaccine was not introduced 
in any theatre of war until January 1916 and cannot have 
become efficiently established until the end of that year. 

At the outbreak of war typhoid fever was endemic in every 
theatre. Paratyphoid B was very rare in England, but it was 
fairly common on the continent, especially in Flanders, Alsace, 
parts of Middle Europe and Macedonia, while paratyphoid A 
was practically unknown except in India, Africa, Asia Minor, 
Turkey and possibly a few seaport towns like Marseilles, 
where there is a constant interchange between Europe and 
Africa. 

The natural sequence of events as regards the British forces 
in France would be that typhoid should develop within the 
first few weeks or months, accompanied or closely followed by 
paratyphoid B, both acquired locally from water or carriers, 
but that the advent of paratyphoid A should be delayed until 
contact had been established by our troops from England 
with men who had served in India or the East, or alternatively 
with French troops who had served in Africa or been associated 
with French colonial forces. This is precisely what occurred ; 
cases of typhoid fever developed in the latter part of September 
1914, and were attracting serious attention by the second week in 
November,but it was not until December 5th that an undoubted 
case of paratyphoid B was detected, and the first proved case 
of paratyphoid A was admitted to hospital on December 14th ; 
further, it is noteworthy that the early cases of paratyphoid A 
were all in troops who had either come to France from India or 
who had been in close contact with such troops. 

The steady relative increase in the number of paratyphoid 
cases in France, especially paratyphoid B for paratyphoid A 
was always numerically insignificant as well as the steady 
decline in all forms of enteric fever in the last quarter of 1915 is 
shown in Table IV, compiled from the admission and 
discharge books of No. 14 Stationary Hospital, which dealt 
with more than half the total number of cases from the entire 
force during the period under review. This table also shews 
that with properly organized laboratory work the proportion 
of cases in which final diagnosis is impossible is relatively small ; 
the percentage of cases under the heading " enteric group " 



16 



MEDICAL HISTORY OF THE WAR 



I 



** 

'i 



c/) 
Tf 



> !2 



3 fe 

^ ^ 
PQ s 



I I 



<N CO n O5 m W W <N 



I IX CO <N CO <N t> 1C O 



O5 < O I>(N O O CO CO ^ 



I I 



M W CO CC C<1 <N ~ 



Mil 



O ID t^ O5 00 00 C<l N 



| | 



1 t^ 
1 00 



CO Tf CO rt Tf CO CN <N Tj< T-, *-, 



CO CO Tf C^ CO C^ 









ENTERIC GROUP OF FEVERS 17 

drops steadily as the efficiency of the laboratory workers and 
the co-ordination between clinician and bacteriologist increase. 

At the same time there will always be a small residuum, up to 
5 per cent., in which the clinical picture is that of enteric fever 
but the bacteriological and serological findings do not support 
the diagnosis. This difficulty was apparent in 1915 and 
was increased considerably in later years by the adoption 
of triple inoculation ; the question will be considered again 
when the diagnosis of the enteric group is under discussion. 

Just as paratyphoid A was conveyed to the western front 
from India and Africa, so was paratyphoid B conveyed to 
Mesopotamia by the divisions which proceeded thither from 
Europe and Egypt in 1916. Prior to the arrival of these 
troops the Mesopotamia force was composed exclusively of 
troops from India where, as in Mesopotamia, paratyphoid B 
was practically unknown ; so that enteric fever was re- 
stricted in 1915 and the early part of 1916 to typhoid and 
paratyphoid A. Boney, Grossman and Boulenger state that 
paratyphoid B was not diagnosed till March 1916, which 
coincides with the arrival of a British division from Gallipoli 
and Egypt. These authors find from an analysis of 650 cases 
after this date that the proportions were : typhoid 21 per cent., 
paratyphoid A 65 per cent., paratyphoid B 14 per cent., so 
that paratyphoid B obtained a firm foothold when once it 
had been introduced ; indeed, for 1918 the incidence per 
thousand of paratyphoid B, including Indian troops, is 
nearly twice that for 1917. 

Figures dealing with the incidence of the enteric group in the 
Gallipoli expedition are not very reliable, owing to the nature 
of the campaign and the extreme difficulty of evacuating the 
sick, as well as the long distances between the fighting zone and 
the hospital bases. Coutts gives clinical notes of 66 cases of 
paratyphoid B and 63 cases of paratyphoid A ; Martin and 
Upjohn found paratyphoid A to be nearly twice as frequent as 
paratyphoid B. It is noteworthy, in connection with this 
campaign, to find that a considerable number of cases evacuated 
as dysentery were ultimately proved to be suffering also from 
paratyphoid fever, especially paratyphoid B. 

In Salonika, paratyphoid A was more frequent than either 
paratyphoid B. or typhoid ; and paratyphoid B was more 
numerous than typhoid till 1918, when it became the least 
common of the three. 

In Italy, in 1918, the relative proportions resembled those 
obtaining in France, except that paratyphoid A was rather 
higher ; the actual incidence of enteric fever per 1 ,000 of ration 
strength was, however, more than ten times as high. 

(2396) B 



18 



MEDICAL HISTORY OF THE WAR 



In Egypt the very large proportion of group cases in 1916 
makes comparison difficult, but it appears that paratyphoid A 
was numerically preponderant, both paratyphoid A and para- 
typhoid B being higher than typhoid. In 1917 typhoid was 
seven times less common than either paratyphoid A or para- 
typhoid B but paratyphoid B was fractionally higher than 
paratyphoid A ; in 1918 typhoid was still the least numerous, 
but paratyphoid A was definitely higher than paratyphoid B. 

Mortality. 

The total case mortality per cent, for the three varieties of 
enteric fever grouped together can be determined fairly accu- 
rately, and, as has been shown in Table I, it varies considerably 
with the different campaigns but may be summarised as follows : 

TABLE V. 

Summary of case mortality from the enteric fevers in different- 
theatres of war. 



France 

Salonika 

Egypt 

Mesopotamia 

Italy 

East Africa 



3-8 per cent. 

3-9 

6-4 

8-7 
10-6 
27-4 



The high death rate in East Africa may be explained by the 
extreme rigour of that campaign and the necessity for operating 
at a great distance from a properly equipped base in a very 
unhealthy climate. It is also probable that many mild cases 
of group infection were overlooked, and it is certain that many 
of the deaths were due rather to the presence of a coincident 
infection, such as malaria or relapsing fever, than to the enteric 
infections. 

There is one point of special interest in the mortality columns 
in Table I., namely, the fact that the low water mark of per- 
centage case mortality was reached in 1916 and that a notable 
increase occurred in both 1917 and 1918. This increase was 
more or less apparent in every theatre of war where reliable 
figures are available, as follows : 

TABLE VI. 

Showing increase in case mortality after 1916. 





1916. 


1917. 


1918. 


France 


1-12% 


2-8% 


5-9% 


Salonika 

Egypt 

Mesopotamia 
East Africa 


3-62% 
2-2% 
10-9% 


3-78% 
4-3% 
7-5% 
26-4% 


4-44% 
12-7% 
10-9% 
28-4% 



ENTERIC GROUP OF FEVERS 19 

It is necessary to enquire briefly into the possible reasons for 
this increase in case mortality. It will be remarked that the 
increase dates from the adoption of triple vaccine, so that it 
might be thought that triple vaccine to some extent decreases 
the immunity conferred against typhoid fever. If this were so, 
one would expect to see a definite increase in the case mortality 
from typhoid in protected men, and also to find that the 
increase is chiefly in typhoid as opposed to paratyphoid cases. 

The increase in typhoid mortality is as follows : 

TABLE VII. 

Case mortality from proved cases of typhoid. 
(Western Front.) 





Protected by 
Inoculation. 


Unprotected by 
Inoculation. 


1915 
1916 
1917 
1918 


7-54% 
1-58% 
7-73% 
13-84% 


23-2% 
8-3% 
12-12% 
24-0% 



A similar increase is thus shown in the figures for those 
who are unprotected, and it is obvious that there must be some 
other factor at work to explain the drop to 8-3 per cent, in the 
unprotected in 1916 with the subsequent rise to 24 per cent, in 
1918. The difficulty of getting satisfactory re-inoculation at 
the end of 1917 and throughout 1918 would tend to produce a 
higher death rate among the partly protected. 

The points which seem to be of great importance in this 
connection are, first, the undoubted lowering of all powers of 
resistance to infection in the nation as a whole and in the troops 
in particular by four years of continuous warfare, and, secondly, 
the increased average age and lower physical categories of an 
army which became to all intents and purposes a nation under 
arms. 

In attempting to arrive at the individual case mortality of 
the three enteric infections, there is the difficulty, already men- 
tioned, of including the cases of the enteric group in which no 
final diagnosis has been possible. To ignore these cases might 
in some cases give unduly high results by eliminating a consider- 
able number of cases with a low death rate. It is probable that 
a fairly correct result will be obtained by assuming that the 
enteric group cases are made up of typhoid, paratyphoid A, 
and paratyphoid B in like proportion to the proved cases for 
the same area during the same period of time, and that the 
infections causing death in group cases are relatively propor- 

B2 



20 MEDICAL HISTORY OF THE WAR 

tionate to those causing death in proved cases. This method 
gives the following results for France, Italy and Egypt : 

TABLE VIII. 

Approximate percentage case mortality from typhoid, 
paratyphoid A and paratyphoid B. 



Theatre of 
War. 


Year. 


Typhoid. 


No. of 
Cases. 


Para. 


No. of 
Cases. 


Para. 
B. 


No. of 
Cases. 


France 


1914 


13-5 


340 




7 


4-9 


41 




1915 


12-0 


889 


6 


314 


2-9 


1,148 




1916 


1-6 


839 


1-5 


668 


7 


1,161 




1917 


6-5 


304 


8 


233 


1-9 


529 




1918 


15-5 


104 


2-6 


50 


1-4 


180 


Italy 


1918 


22-3 


39 


3-7 


28 


6-4 


72 


Egypt 


1916 


3-7 


659 


2-03 


1,287 


1-6 


1,004 




1917 


Sufficient data" not available as no deaths were 






recorded in proved cases of paratyphoid. 




1918 


37-0 


87 


6-3 


179 


7-8 


135 



The returns from Salonika and Mesopotamia do not permit 
of analysis on these lines. 

For purposes of comparison the death rate from proved cases 
of the three infections is shown in the following table : 

TABLE IX. 

Percentage case mortality from proved cases of typhoid and 
paratyphoid. 



Theatre of 
War. 


Year. 


Typhoid. 


No. of 
Cases. 


Para. 
A. 


No. of 
Cases. 


Para. 
B. 


No. of 
Cases. 


France 


1915 


13-0 


805 


71 


281 


1-91 


1,043 




1916 


1-9 


729 


1-7 


580 


7 


1,009 




1917 


8-3 


227 


56 


173 


2-1 


471 




1918 


16-5 


90 


2-3 


43 


6 


156 


Italy 


1918 


24-2 


33 


4-2 


23 


6-5 


61 


Egypt 


1916 


6-06 


99 


3-2 


187 


2-08 


143 




1917 


23-0 


13 





70 





74 




1918 


41-0 


31 


6-06 


66 


8-6 


46 


Mesopotamia 


1916 


-| 














1917 


>1 1 -4 


320 


3-6 


532 


7-5 


120 




1918 


[ 













The value of the figures in the foregoing tables depends largely 
on the totals of the cases, for when there are few cases the value 



ENTERIC GROUP OF FEVERS 21 

is slight ; but it is evident that the case mortality from all the 
enteric infections varies within wide limits from time to time 
in the same theatre of war, and also varies directly with the 
efficacy of the general hygiene, transport, and medical arrange- 
ments. 

The proverbial severity of these infections in hot climates is 
noticeable in the figures from Egypt and Mesopotamia. The 
theory held by many who had worked in India that paratyphoid 
A was practically negligible as a cause of death appears to be 
fallacious when applied to active service conditions in the East, 
for there was in 1918 a case mortality of over six per cent, from 
this disease in the Egyptian forces, and in France the death rate 
for the same year was more than two per cent. This high 
death rate in Egypt was in part explained by an outbreak of 
malignant tertian malaria which complicated the enteric 
infections. 

The relative mortality from paratyphoid A and B appears 
to vary greatly with time and place, as shown in Table IX., 
but here again the totals are often too small to be reliable, 
and the only safe deduction seems to be that they are both 
very much less severe infections than typhoid under like 
conditions. 

The total figures available at present for proved cases from 
France, Italy, Egypt and Mesopotamia give a mortality table 
approximately as follows : 

TABLE X. 

Typhoid 9-8% mortality in 2,472 cases. 

Paratyphoid A 2-6% 2,023 ,. 

Paratyphoid B 1-55% ,,3,160 

Total Paratyphoid 2-1% 5,183 

This is striking in one particular, namely, that the figure for 
paratyphoid A is considerably higher than that for paratyphoid 
B, a fact that is opposed to the general impression as gathered 
from the analyses of smaller series of cases made before the 
introduction of triple vaccine. Thus, in 1915, Torrens and 
Whittington found the mortality to be four per cent, for para- 
typhoid B, and less than one percent, for paratyphoid A, while 
Boidin in January 1916 reported a series of cases in the French 
Army with a mortality of six per cent, for paratyphoid B and 
1-4 per cent, for paratyphoid A. Rathery in a large series of 
cases of paratyphoid B found a mortality of over six per cent. 

A possible explanation of this difference in the mortality of 
the two infections is that the vaccine used from 1916-1918 
conferred more protection against paratyphoid B than against 



22 MEDICAL HISTORY OF THE WAR 

paratyphoid A, a suggestion that is to some extent supported 
by the low titre to paratyphoid A, so often shown after triple 
inoculation ; or again the severity and frequency of paratyphoid 
A in tropical and sub-tropical climates may more than counter- 
balance the greater relative severity of paratyphoid B on 
the Western Front. Hence it may well be that in a civilian 
uninoculated population in Western Europe, an epidemic of 
paratyphoid B would be found to be attended with a higher 
death rate than would one of paratyphoid A, with a figure for 
either disease of from three to five per cent. 

JEtiology. 

With regard to the various factors affecting the aetiology of 
these diseases there is no reason to suppose that any which may 
be said to predispose to typhoid fever predispose also in any 
greater or less degree to either of the paratyphoid infections. 
The predisposing causes can be considered under two headings ; 
first, those of environment, which influence the presence and 
distribution of the infective material, and secondly, those of 
immunity, which influence the individual's capacity to neutralize 
a given dose of infective material. 

Although a tropical or sub-tropical climate does not favour 
the growth of the bacilli of enteric fever outside the body, it 
nevertheless favours their distribution by flies and in dust, 
while the defective sanitary arrangements amongst the inhabi- 
tants of the East and Near East make enteric fever widely 
endemic in these regions. Before the war typhoid and para- 
typhoid A were very prevalent throughout the East, while 
paratyphoid B was practically unknown, so that in a sense it 
might be said that a tropical climate predisposes to typhoid and 
paratyphoid A rather than to paratyphoid B, and conversely 
that a cold or temperate climate predisposes to paratyphoid B 
rather than to paratyphoid A. Whether paratyphoid B will 
speedily die out in the East and paratyphoid A in the West, 
now that their respective sites of election have been enlarged, 
remains to be seen. Although epidemics may start at any 
time of the year, the summer and autumn are always likely to 
show the greatest number of cases and also the most severe ones. 
The effect of the external temperature is undoubted. Enteric 
fever is more frequent and more severe along the Mediterranean 
littoral than in the more northern parts of Europe ; for the 
same reason the disease persists in a serious form in Egypt, 
India, Central America, and the Philippines. 

The number of bacilli present in subsoil water increases 
with the utmost rapidity as soon as men are occupying the 
surface of the soil. Vincent gives the follo\ving analysis from 






ENTERIC GROUP OF FEVERS 23 

a camp in which typhoid was constantly occurring. Before 
the arrival of the troops the water was very pure and contained 
only 100 ordinary bacteria per c.c. Six days later there were 
770 bacteria, forty days later 6,960, sixty days later 14,900, and 
three months afterwards 38,000 per c.c. 

In highly cultivated districts there is a great likelihood of the 
subsoil water becoming infected as a result of the practice of 
manuring the earth with human excrement. It is true that the 
typhoid bacillus does not survive in drinking water more than 
three to five days, but under suitable conditions the water is 
constantly being re-infected with fresh relays of virulent 
bacilli from a saturated soil. The importance of drinking 
water as a cause of enteric fever has been proved in numerous 
epidemics, and in war time in the field all drinking water should 
therefore be sterilized efficiently before use. 

It has been shown that flies can carry typhoid and other 
pathological bacilli in their stomachs, on their feet, and on 
their probosces. Although the curve of enteric fever does not 
follow closely that of the fly pest, and the extent to which flies 
may be responsible for the spread of enteric fever is not fully 
established, these insects and the fingers of the " carrier " may, 
however, be regarded as playing the leading parts in causing 
the dissemination of typhoid infected material in war time. 
The specific bacilli are always likely to be present owing to the 
existence of some recent case in the neighbourhood or to the 
presence of a " carrier " among the population. A man sick- 
ening for enteric fever may be infectious for three or four weeks 
before he realizes he is ill. A " carrier " may convey infection 
for months or years after he has recovered from the disease 
and the bacilli may live in faeces or urine under favourable 
conditions of moisture for 100 days, and for upwards of 
40 days in the absence of moisture. 

Hence the most important factors predisposing to the occur- 
rence of enteric fever in war are the manifest impossibility of 
securing an absolutely perfect disposal of all faecal and urinary 
matter and the difficulty of excluding all " carriers " from an 
army. It has been shown experimentally that a large per- 
centage of men soil their fingers both during micturition and 
def aecation, especially the former ; and the contamination of 
food or water is more than likely to result. 

Fletcher investigated bacteriologically one thousand men who 
were convalescent from enteric fever ; he found that prophy- 
lactic inoculation diminished the frequency of " carrier " 
development amongst infected men but did not abolish it, and 
that 0-6 per cent, of all convalescent male enteric cases are 
" carriers." Small epidemics have, in peace time, frequently 



24 



MEDICAL HISTORY OF THE WAR 



been traced to cooks, waiters and others, who were " carriers/' 
and the same source of infection has been proved repeatedly 
during the war to explain a sudden crop of cases in the same 
unit when neighbouring units have been relatively or absolutely 
free. 

With regard to individual immunity, there are numerous 
personal factors upon which immunity from enteric fever seems 
to depend. A previous attack confers a very great though not 
absolute immunity from re-infection with the same bacillus. It 
is estimated by Vincent and Muratet that not more than two 
per cent, of persons who have had typhoid fever can contract 
it a second time. But there is no experimental evidence that 
typhoid fever confers any immunity from paratyphoid fever 
or vice versa. 

Prophylactic inoculation with triple vaccine confers rela- 
tively great immunity against typhoid and both forms of 
paratyphoid fever, the degree of immunity increasing up to a 
point with the number of injections employed. 

Real immunity is only relative, but it appears that the 
Japanese and Chinese are not so susceptible as Europeans. 
Enteric fever, for example, has been stated to be less frequent 
in the Japanese than in the Russian Army in the Russo- 
Japanese War, and there was a similar experience in the Chinese 
expedition of 1901. The Hindu races appear to suffer but 
slightly from enteric fever in spite of their primitive hygienic 
and sanitary arrangements. It is held by some that the 
immunity of the Eastern races is apparent rather than real, as 
it is thought that the bulk of the population gets infected in 
childhood. This apparent relative immunity from enteric 
fever amongst the Asiatic races is borne out by the figures 
from our forces operating in Egypt and Mesopotamia. 

TABLE XI. 

Showing relative incidence in British and Indian Races. 





Incidence per 1,000 of 
Ration Strength. 


Case mortality per cent. 


Egypt : 


British. 


Indian. 


British. 


Indian . 


1916 


17-35 


1*15 


2-2 





1917 


2-8 


9 


4-3 


7-6 


1918 


1-87 


5 


10-4 


9-5 


Mesopotamia : . . 










1917 


2-5 


4 


10-8 


22-3 


1918 


2-5 


8 


6-4 


18-3 



The Indian figures for Mesopotamia, however, include a large 
number of followers, of whom only 20 per cent, were protected 
by inoculation in 1917 and 50 per cent, in 1918. Of the Indian 



ENTERIC GROUP OF FEVERS 



25 



troops proper about 80 per cent, were protected in 1918 and 50 
per cent, in 1917, and of the British troops 75 per cent, in each 
year. If we exclude the Indian followers, in order to obtain a 
better standard for comparison with British troops, we find that 
the mortality for Indians in 1917 was 22 per cent, and in 1918 
12-8 per cent., with an incidence of 0-3 and 0-5 per 1,000 
respectively. It thus appears that in the Indian races there is 
a real insusceptibility to acquiring enteric fever, but that there 
is a tendency for the infection when acquired to be exceptionally 
severe. 

On the other hand, the high death rate in Indian troops can 
to some extent be discounted by the probability that many 
mild cases were never reported as enteric fever, but were allowed 
to run their course as pyrexia of uncertain origin. 

If this apparent racial insusceptibility is due principally to 
immunity acquired as the result of disease in childhood, it 
would be expected that the incidence of paratyphoid B in 
Indian troops would be more nearly that obtaining in the British 
troops, at any rate in 1918 when the paratyphoid B infection, 
which was at first confined to the British troops who brought 
it with them to the country, had become more widely dis- 
seminated. This view is supported to some extent by the 
official figures for 1917 and 1918, dealing only with men 
unprotected by triple vaccine. 

TABLE XII. 





British. 


Indian. 


Incidence of Paratyphoid B~] 
per 1,000 of ration strength ^ 
in unprotected men J 


1917 


3-92 


02 
(one case only) 


1918 


64 


4 



The conclusion that enteric fever has run a graver course 
when it has attacked the Indian troops than when it has 
attacked the British is upheld by Ledingham, who published 
the following figures from Mesopotamia for 1916-17-18. 

TABLE XIII. 

Case Mortality in British and Indian Troops. 



British. 



Indian. 



Typhoid 
Paratyphoid A 


11-4 percent. 
3-6 


27-2 per cent. 
11-3 


Paratyphoid B 


7-5 


16-6 


Enteric Group 


10-0 


20-7 


Enteric Fever as a whole 


8'7 


20-5 



26 MEDICAL HISTORY OF THE WAR 

Age is recognized as playing an important part in the suscep- 
tibility to the enteric infections. No age is immune, but 46 -5 
per cent, of all cases occur between the ages of fifteen and 
twenty-five 3 7 ears. The statistics of the city of Paris for thirty 
years show that men are most frequently attacked between the 
ages of twenty and twenty-four years, while the liability to 
infection remains high up to thirty years of age. Further, 
between the ages of twenty and twenty-five, the death rate is 
nearly twice as high in men as in women, 67 1 per cent, to 37 '6 
per cent. An army is therefore composed largely of those 
members of the community who are most liable to become 
infected with enteric fever in a severe form. 

There are three other personal factors of great importance as 
predisposing in wartime both to a high incidence of, and to a 
heavy death-rate from enteric fever ; they are physical fatigue, 
mental strain, and the necessity for a more or less prolonged 
journey after the infection has begun to show its symptoms. 
No one who has worked amongst enteric fever patients can 
have failed to notice that those cases are most severe which 
have been longest delayed in transit to the enteric fever 
hospital. 

As regards the exciting causes in the aetiology of enteric fever, 
the disease as at present understood includes infection by one 
of three specific micro-organisms and thus comprises three 
distinct though very similar diseases, namely : 

Typhoid Fever due to infection by Bacillus typhosus. 

Paratyphoid A Fever due to infection by Bacillus para- 
typhosus A. 

Paratyphoid B Fever due to infection by Bacillus para- 
typhosus B. 

The specificity of these three micro-organisms has been proved 
beyond doubt by biochemical and serological tests. Bacillus 
typhosus was identified by Eberth in 1880-81, but it was not 
until 1896 that Achard and Bensaude gave the first account of 
a bacillus other than Bacillus typhosus recovered from the urine 
of a case of apparent enteric fever. This organism is now 
recognized as being Bacillus paratyphosus B. In 1898 Gwyn 
recorded a similar experience ; in his case the bacillus was 
recovered from the blood stream. In 1900 Gushing described 
an organism not Bacillus typlwsus, which he recovered from 
the pus of a chondro-costal abscess following an attack of 
apparent enteric fever. In 1900 and 1901 Schottmiiller 
described organisms which biochemically were intermediate 
between Bacillus typhosus and Bacillus coli and which did not 



ENTERIC GROUP OF FEVERS 27 

agglutinate with typhoid serum. In 1902 Buxton split the 
paratyphoid organisms into two groups A and B, A being 
closely allied to Bacillus typhosus and B to paracolon. In 
1904 Firth described fully paratyphoid A as it occurred in 
British troops in India, work which was later amplified by 
Harvey, Grattan, Wood and other officers of the Royal Army 
Medical Corps. 

In 1904 Bainbridge in the Milroy lectures differentiated 
clearly between the paratyphoid bacilli A and B on the one 
hand, and the organisms of food poisoning, Bacillus suipestifer, 
isolated in 1885 by Salmon and Theobald Smith, and Bacillus 
enleritidis on the other. A third member of the food poisoning 
group Bacillus aerlrycke was first described in 1898 by Durham 
and de Nobele, working independently ; this organism, though 
closely allied to Bacillus paratyphosus B, is nevertheless 
specifically distinct, as is shown by Perry and Tidy in their 
report on an epidemic of this nature published in 1918. Most 
bacteriologists now hold the view that Bacillus suipestifer and 
Bacillus aertrycke are identical. 

Although we can thus dissociate completely from enteric fever 
a considerable group of infections by allied bacilli, there is 
nevertheless a distinct possibility that the legitimate para- 
typhoid group is not absolutely restricted to the two members 
A and B. Apart from blood infection with members of the 
food-poisoning group of organisms which, clinically, do not as 
a rule very closely resemble paratyphoid fever, there is a rare 
class of case which clinically is enteric fever but in which the 
agglutination curve of the patient's serum offers no corro- 
boration of the diagnosis. Occasionally in such cases a bacillus 
will be recovered from the blood, urine or faeces, which bacteri- 
ologically is not Bacillus typhosus, or paratyphosus A or B on 
the one hand, or a member of the food poisoning group on the 
other. This bacillus, however, agglutinates with the patient's 
own blood serum and is therefore almost certainly responsible 
for the infection concerned. Such bacilli are commonly 
reported by the bacteriologist to be culturally indistinguishable 
from Bacillus paratyphosus B. It is reasonable to regard such 
cases as being a variety of paratyphoid fever as yet unclassified. 
This view is corroborated by the experience of Mackie and 
Bowen, and MacAdam in Mesopotamia ; these workers, inde- 
pendently, while investigating cases of clinical enteric, isolated 
from a series of cases a bacillus culturally indistinguishable 
from Bacillus paratyphosus B which proved by agglutination 
and absorption tests to be an additional member of this series. 
A specific high titre serum was successfully prepared for this 
bacillus by Mackie and Bowen for the purpose of diagnosing 



28 MEDICAL HISTORY OF THE WAR 

other cases of the same infection. Ledingham regards this 
bacillus as an Eastern variant of Bacillus paratyphosus B but, 
in view of its persistent inagglutinability to ordinary para- 
typhoid B serum, it seems that the name Bacillus paratyphosus 
C, as suggested by Hirschfeld, would be justifiable. Ledingham 
states that he has lately received a strain of this organism from 
East Africa. 

Similar cases have been reported from Macedonia, where 
Willcox found that 10 per cent, of the cases of clinical enteric 
were due to a non-agglutinable Bacillus paratyphosus B. 

Archibald describes eight cases in Sudanese soldiers clinically 
resembling enteric fever, but proved by blood cultures to be due 
to organisms unidentified but definitely not typhoid or para- 
typhoid. 

On the whole, it would be well to keep an open mind for the 
present on the question of the eventual enlargement of the true 
paratyphoid group of diseases. 

Morbid Anatomy. 

With regard to the morbid anatomy of the disease, the post- 
mortem appearances in cases of typhoid fever are too familiar 
to need description here, and all the lesions ordinarily described 
have found a place in the records of the fatal cases of the war. 
A great diversity of possible lesions is naturally to be expected 
in a disease like typhoid fever, which is essentially a baciUaemia 
at the time of onset of symptoms and often for the first two or 
three weeks of its course, as^well as during part of any relapses 
that may occur. Further the bacilli do not leave the system 
when they cease to be present in the blood stream, for in fatal 
cases they are always to be recovered after death from the gall 
bladder, nearly always from the spleen and bone marrow, usually 
from the mesenteric glands and frequently from the kidneys, 
the fauces, and the lungs if pneumonia has been a feature of 
the case. 

The persistence of the bacilli in the body tissues is shown by 
the percentage of cases about 2 per cent, in uninoculated 
persons who remain either faecal or urinary carriers for 
months or years, and also by the fact that sub-periosteal and 
other abscesses occurring late in convalescence can often be 
shown to contain the specific organism. 

Though fatal cases of typhoid as a rule show very marked 
intestinal lesions, yet the extent or severity of the utceration in 
the intestines is not necessarily an indication of the severity of 
the disease from the point of view of general systemic intoxi- 
cation. The following case illustrates this point : 



ENTERIC GROUP OF FEVERS 29 

Rfm. H., age 22. (Not protected by inoculation.) Admitted on tenth 
day of disease with a positive diagnosis of typhoid fever by blood culture. 
Clinically a very severe typhoid fever of toxic type, the rapidity of 
respirations being due to toxaemia rather than any local pulmonary 
condition. There was a plentiful crop of spots and moderate enlargement 
of the spleen, also a tendency to diarrhoea till the sixteenth day. The rate 
and character of the pulse indicated an unfavourable issue. The patient 
remained semi-conscious and delirious from the time of admission until he 
died seventeen days later on the twenty-seventh day of illness. The 
agglutination reaction to Bacillus typhosus was negative on the tenth day, 
positive on the fifteenth day and weakly positive on the eighteenth 
day. 

At the post-mortem examination there was no trace of any ulceration 
of the intestines, nor were the mesenteric glands soft or swollen with the 
chocolate discoloration usual in typhoid fever. The liver was pale, soft 
and rather larger than normal, the spleen weighed 8 oz. and was soft and 
diffluent. The lungs showed capillary bronchitis at the bases. The 
heart was dilated and the myocardium showed fatty change. There 
was a row of recent soft, fleshy vegetations along the three aortic cusps 
indicating commencing ulcerative endocarditis ; Bacillus typhosus was 
recovered from the bile after death, but not from smears of the cardiac 
vegetations. 

It is relatively rare for ulceration to be practically restricted 
to the large intestine in typhoid fever, though far from unusual 
in paratyphoid B. 

The following notes illustrate such a case : 

Gr. C., age 22. (Inoculated January 13th and January 23rd 1915.) 
Taken ill January 23rd, 1915. Admitted to hospital on sixteenth day of 
illness. Clinically a severe toxic case presenting no special features until 
the thirty-first day when there was a smart haemorrhage ; there was a 
smaller haemorrhage the next morning and a large one the same evening 
from which the patient never rallied. The bowels had been opened freely 
throughout the illness but there was no profuse diarrhoea at any time, 
nor was there tenesmus. 

Post-mortem there were only six healing ulcers in the lower part of ileum ; 
the whole of the large gut from caecum to sigmoid, and especially the 
latter, was crowded with large ragged unhealthy looking ulcers, the general 
appearance being somewhat reminiscent of dysentery. Bacillus typhosus 
was cultivated from the gall bladder and from the spleen; no bacterio- 
logical evidence of dysentery was obtained, in spite of a most thorough 
investigation. 

Prior to the war but little was known as to the differences, if 
any, in the morbid anatomy of the paratyphoid fevers 
as contrasted with typhoid. It has now been established 
that there is no essential difference ; any lesion that may be 
met with in typhoid may be encountered in either of the 
paratyphoids. 

Since the gross mortality of paratyphoid is probably less than 
one quarter that of typhoid, it is obvious that the average lesion 
will be less intense in the former, but since only the very severe 
infections prove fatal it is natural that the post-mortem findings 
should approximate closely to those of typhoid. As a matter 
of practical experience they are indistinguishable. Dawson and 
Whittington, in an analysis of fourteen fatal cases of 



30 MEDICAL HISTORY OF THE WAR 

paratyphoid B and two of paratyphoid A summarized the 
cause of death as follows : 

Perforation . . . . . . 2 cases. 

Peritonitis from infected appendix 2 cases. 

Haemorrhage 2 cases. 

Haemorrhage and toxaemia . . 3 cases. 

Toxaemia 4 cases. 

Pneumonia . . . . . . 2 cases. 

Splenic abscess 1 case. 

The same writers also noted the tendency for paratyphoid B 
to affect the large intestine as well as, or to the exclusion of, 
the ileum ; thus in two of their cases the large intestine alone 
was involved, in seven both small and large gut were affected, 
in four the small intestine only was concerned. In three cases 
of this series, two paratyphoid B and one paratyphoid A, 
the appendix was acutely inflamed and had determined the 
incidence of peritonitis ; in two cases, one paratyphoid B, one 
paratyphoid A, there was definite enteric ulceration in the 
appendix. 

There is also a distinct tendency for metastatic pus formation 
in infections from Bacillus paratyphosus B ; thus in the fifteen 
cases mentioned above there were two spleen abscesses, two 
lung abscesses, one of which had caused a secondary empyema, 
and one abscess in the liver. 

Since there are only two cases of paratyphoid A in this series, 
it is obvious that it is impossible to deduce very much as to the 
morbid anatomy of this disease. In a number of fatal cases of 
paratyphoid A, observed in Mesopotamia in 1916 by Torrens, 
the lesions were in the main identical with those of typhoid 
fever. Some predilection for the large intestine was noticeable, 
especially to the exclusion of the lymphoid tissue, but metastatic 
abscesses were not conspicuous. In some of the cases in which 
death occurred, rather from a complicating heat stroke than from 
the primary infection, the intestinal lesions were very trilling, 
sometimes amounting to no more than hyperaemia of Peyer's 
patches in the lower part ot the ileum ; occasionally even this 
was wanting. 

Carles discussing a series of 170 cases of paratyphoid in the 
French Army, with eight deaths, confirms the frequency of the 
involvement of the large intestine, as also the tendency for 
abscess formation ; he also observes that there may be no 
intestinal lesion present even in fatal cases. MacAdam records 
a fatal case of paratyphoid B complicated by thrombosis of 
the upper end of the left internal carotid artery extending 
upwards into the middle cerebral artery and the lenticulo-optic 






ENTERIC GROUP OF FEVERS 31 

and lenticulo-striate branches. There was also thrombosis of 
the cortical branches of the right middle cerebral artery. No 
venous thrombosis could be made out in the brain or elsewhere, 
but the spleen showed two large haemorrhagic infarcts in which 
purulent softening had commenced. 

Scott and Johnson describe a small brain abscess in the 
right optic thalamus, found post mortem in a case which 
developed left hemiplegia during the course of paratyphoid B 
infection ; unfortunately no attempt was made to recover 
Bacillus paratyphosus B from the abscess contents, so the possi- 
bility of a coincident infection cannot be absolutely excluded. 

The great severity of the toxaemia as well as of the specific 
lesions in certain fatal cases of paratyphoid fever is shewn in a 
case of paratyphoid B published by Hichens and Boome. 
Clinically the patient presented all the features of advanced 
typhus fever including a maculo-petechial rash on the trunk. 
Death took place on the 14th day of the disease. Post mortem 
there was haemorrhagic infarction in the lungs with early grey 
hepatisation at the right base. The entire intestine, large and 
small, showed acute inflammatory change but no ulceration. 
The mesentery was inflamed, the mesenteric glands swollen and 
haemorrhagic, both kidneys were riddled with abscesses and the 
bladder showed acute purulent cystitis. The swollen spleen 
showed haemorrhagic areas on section. This man had had 
antityphoid inoculation in 1915 and two doses of triple vaccine 
in June 1917, three months before the onset of his fatal illness. 



Symptoms. 

As regards the clinical features of typhoid fever as seen in 
unprotected men in war time, these do not show any material 
differences from the clinical features noted in the many classical 
descriptions of this infection. The average of such cases was 
severe, very much more so than the average case seen in civil 
hospitals in England during the ten years preceding the war. 
The mortality was far higher and the graver complications were 
more frequent than in the civilian cases. This severity of 
infection is explained by the age and environment of the fighting 
man, the fatigue and hardship he is undergoing at the time of 
infection and the inevitable delay before he reaches the infectious 
diseases hospital. 

On the other hand the average case of typhoid fever in a 
fully protected man is very much less serious, indeed it was 
difficult, if not impossible, in 1915 to judge clinically in certain 
cases whether the infection was typhoid modified by inoculation, 
or paratyphoid fever. In like manner during the later years of 
the war the clinical picture of the average paratyphoid case 






32 MEDICAL HISTORY OF THE WAR 

was itself modified by the use of triple vaccine, so that in certain 
cases there was practically no clinical indication that an enteric 
infection was present. 

For the Western Front the figures show that typhoid fever, 
even in protected men, was decidedly more severe than para- 
typhoid, the case mortality being : 

1914 Protected typhoid . . 5 -8 per cent. 

Paratyphoid .. .. 2-0 

1915 Protected typhoid .. 7 '5 

Paratyphoid .. .. 1*6 ,, 

Again in 1915, according to Willcox, the Gallipoli cases showed 
a paratyphoid mortality of not more than 5 per cent. There 
can be no doubt that the rate in protected typhoid cases was 
higher than this. 

In a disease like enteric fever, which naturally varies in 
severity and duration within very wide limits, it is most difficult 
to state in precise terms the exact effect of a measure like 
prophylactic inoculation ; the general lessening of severity has 
been established and, as would be expected, analysis of individual 
cases tends to show that the average duration of fever is 
distinctly lessened in protected persons. In the cases observed 
by Torrens the average duration of fever in typhoid cases was 
five days less and in paratyphoid cases three days less in 
protected than in unprotected men. 

There is no necessity to describe here the clinical manifes- 
tations of typhoid fever, but the following notes describe the 
paratyphoid infections and their differences from typhoid fever. 
It may be stated, however, at once that to distinguish clinically 
between paratyphoid A and paratyphoid B is impossible. 

It is difficult in war time to establish the actual date of 
infection in any given case. General experience in the recent 
war has shown that, whereas the incubation period of typhoid 
fever is usually from 12 to 16 days, it may be much shorter or 
much longer in the paratyphoid infections. The shortest tune 
observed by Torrens was, apparently, five days and the longest 
twenty-eight. Most observers are agreed that the average 
incubation period for paratyphoid fever is less than for typhoid. 
Vincent gives it as from nine to fifteen days. Sacquepee states 
it may be reduced to five or six days, Lenglet from three to 
eight, while Miller considers from twelve to twenty days to be 
most usual. The length of incubation does not appear to be 
affected by prophylactic inoculation. 

The onset of paratyphoid fever may be either gradual or 
sudden ; the gradual type, 20 per cent, of the cases, is rarely so 
gradual as in typhoid the fever usually being at its height by 



ENTERIC GROUP OF FEVERS 33 

the fourth day. The common early symptoms are general 
malaise, increasing headache, pains in back and legs and 
chilliness. The sudden type of onset, 60 per cent, of the cases, 
is commonly ushered in with fainting, vomiting, or a rigor. 
There is yet a third type of onset affecting 20 per cent., in which 
a period of trifling malaise, not sufficient to interfere with 
the performance of duty, and probably practically afebrile, 
terminates on the third or fourth day by sudden collapse 
with high fever and obvious illness. 

As a general rule the cases with a sudden onset run a shorter 
course than those which develop gradually. 

Fortescue-Brickdale has summarized the symptoms and early 
signs in 385 cases of paratyphoid B as follow : 

Headache . . .90 per cent. Generalized Pains . 25 per cent. 



Diarrhoea 
Shivering 
Abdominal Pain 
Backache 



45 ,, Vomiting 

37 Cough . 

32 Epistaxis 

26 Vertigo 



17 
13 
10 
9 



Sore Throat 

Labial herpes is stated to be common. 

The diarrhoea is not often persistent or severe ; it occurs 
early in the disease and is usually replaced by constipation after 
two or three days. Hence in war time the patient but rarely 
comes under observation while the diarrhoea is present ; when 
he does do so the stools have a putrid odour and the appearance 
and consistency of the ordinary typhoid fever stool. 

The shivering does not often amount to a true rigor, though 
repeated rigors may occur just as in typhoid. Recurrent 
rigors appear to be more frequent in paratyphoid A than in 
either typhoid or paratyphoid B. Care must, of course, be 
taken to exclude a coincident malarial infection. Abdominal 
symptoms, apart from diarrhoea, are very much less conspicuous 
than in typhoid ; in upwards of 70 per cent, of cases there is 
no abdominal pain after the first two or three days ; quite often 
there is none throughout the whole disease. 

Sweating is frequent and sometimes causes considerable 
exhaustion. Epistaxis, though only noted in 10 per cent, of the 
cases, is probably more frequent, but is often very slight and 
occurs so early in the disease as to be forgotten by the time the 
history is taken. 

The average degree of toxicity is much less than in typhoid 
fever, therefore the typhoid state is the exception rather than 
the rule. Pronounced nervous symptoms may occur, but are 
relatively infrequent, confusional psychoses have been described, 
as also hemiplegia with sensory disturbance. 

Meningismus of such degree as to simulate meningitis is far 
less common than in typhoid fever. Often the general 

(2396) C 



34 MEDICAL HISTORY OF THE WAR 

appearance of the patient shows nothing more striking than a 
slight flush, some dilatation of the pupils and a general air of 
heaviness, even though the temperature may be 104 F. The 
tongue tends to be dry and coated, with dorsal slabs of fur, and 
red tip and edges ; this appearance depends largely on the diet 
and on the hygiene of the mouth. In very severe cases the 
tongue is dry, glazed and cracked, just as in typhoid. 

The abdomen is often normal ; sometimes there is a certain 
sensation as of elasticity or tumidity on palpation. Caecal 
gurgling and tenderness are rare, but tenderness under the left 
ribs is fairly common. 

The spleen is enlarged in more than 60 per cent, of cases ; it 
is palpable in nearly half of all the cases at some time during 
the illness. Quite often the spleen may not be felt until the 
third week or even later ; as a rule, however, the enlargement is 
apparent about the sixth day. Opinions differ as to whether 
the average splenic increase is so great as in typhoid. In the 
experience of Torrens the spleen of paratyphoid is harder than 
the spleen of typhoid, and for this reason it is easier to feel. 
The enlarged spleen is nearly always more or less tender, and 
sometimes there is perisplenitis with an audible friction rub. 
Fortescue-Brickdale noted a palpable spleen in 43 per cent, of 
his cases and the average weight in fatal cases was 6J ozs. 

Chevrel states that the liver is almost always increased in 
size. Miller says the liver edge is occasionally lower than 
normal, and pain on deep pressure over the gall bladder is 
fairly common. In Torrens' experience definite enlargement of 
the liver is rare, as also real tenderness over the gall bladder. 

The urine contains albumin in half the cases, apart from any 
co-existent bacilluria ; this, however, does not persist long and 
is of no special significance. 

The respiratory tract is not conspicuously affected by para- 
typhoid fever ; cough is present at the outset if there be initial 
sore throat or laryngitis ; bronchitis and nasal congestion, 
usually mild, are fairly common during the first ten days, 
especially in soldiers who have been subjected to any consider- 
able journey after going sick. A considerable proportion of 
very severe and fatal cases, as would be expected, show pneu- 
monia of lobar or more commonly of lobular distribution ; the 
sputum in these sometimes contains paratyphoid bacilli. 

Endocarditis and pericarditis, though recorded, must be very 
rare ; dilatation of the heart can but rarely be demonstrated 
by percussion and then only in the latest stages of severe cases. 
Shortening of the first sound, with some loss of intensity, is not 
infrequent during the second and subsequent weeks. The pulse 
is slow for the height of the temperature, relatively more so than 



ENTERIC GROUP OF FEVERS 



35 



in typhoid, and noticeably soft often to the point of dicrotism. 
The blood pressure is low, 80-95 mm., and remains subnormal 
well into convalescence. 

The temperature presents no very characteristic features. 
The rise may be abrupt or gradual ; the maximum is rarely 
more than 104 F. There is not the same tendency to plateau 
formation as in typhoid fever, and there is commonly a daily 
variation of nearly two degrees which produces a remittent or 
intermittent type of pyrexia. The duration of fever is very 
variable, from a few days to many weeks ; the average is 
difficult to state, probably about 20 days for both paratyphoid 
A and B. The termination is usually by lysis, but quite fre- 
quently by a form of modified crisis extending over about 
forty-eight hours. There is often a very marked disinclination 
for the temperature finally to settle down, even when convales- 
cence appears to be well established. Recrudescences are 
common and true relapses occur in about 10 per cent, of 
all cases. 

The sub-normal temperature during convalescence, which is 
so common in typhoid fever, is not so marked in paratyphoid 
infections, though it is present in a considerable proportion of 
cases. 

The following charts illustrate paratyphoid fever. Charts 
I. -VI. are from paratyphoid A. Charts VI I. -XI I. are from 
paratyphoid B. All these cases were proved bacteriologically, 
most of them by blood culture ; in none had triple vaccine been 
administered. 



^I06- 



100 



/ 



Resa 



Chart I. 



36 



MEDICAL HISTORY OF THE WAR 



Dauo/Dis 


7 


tt 


9 


1U 


1 1 


12 


13 


14- 


15 

ME 


\t> 


1 / 


18 


19 


'^0 


2] 


x."^! 


y;5 


24 


25 


26 


'<i7 


v.y 


2Q 


'50 


21 


'd'/d 


33 


Time 


M I. 


M E 


M E 


ME 


.-1 f 


M E 


g| 


ML 


ML 


Ht 


ML 


ML 


M C 


M E 


M L 


M [- 


M; 


MF 


n F 


MF 


if 


M F 


M F 


MF 


MF 


-i P 


1Ofi* 
























































fb t Q* * 
























































t 104;- 
























































k , OT* 
























































1*103 
i-102* 
















q 








































^5 1 1 - 


\ 




A 




1 


A 


A 


</ 


\ /\ 






































Q^j nn. 




V\ 


7 


/ 


I 


/ 


/ 






V^ 


^ 


































ft 00' 










V 


r 


1 










(" 


^ 






























Normal^ 
























\/ 


^ 


Jj 


,<A 






-f 




















98- 
9T 




























* 




^X 


vA 


/' 




/ 


-x 


y\ 


/ 




v" 


/| 


7 


P///CJD M 




































1 


Vv 








IF 










Fes/) ft 


"B3 


-73- 


-75- 


^ 


^1 


^ 


oo 


104 


1 16 


IO6 


96 


fl4 


ftri 


4 


W 


W1 


100 


-r 

JioJ 


w- 


ss 


7* 


^3- 
2j 


70 




6? 


^1 


"TO" 

1 6 



Chart II. 



Afi^/J. 


6 


r 


8 


9 


10 


M 


12 


15 


If 


13 


ts 


1 7 


18 


19 


5?0 


2! 


22 


X2T 


?.4 


25 


r/me. 


ML 


gj 


^E 


M t 


n 


Mt 


ME 


M C 


n E 


Mf 


n t 


r,L 


Mt 


M t 


M E 


n L 


M L 


ME 


ME 


n t 


mfl 










































S> 105 . 










































J; f *. 








































^ 1 1 ?* 


\ 




f| 














8 




















^ . 




l^s 


^1 


\* 


A 


A 




























S . 












i 


*" 


^ 


fl 








































v 


tt 




















^ 100 
ft 99. 




















\ 




















Mmna/ 




















-U 




















98 






















l v 




* 


V 


\ 


V^ 


yi 


v*< 


V- 


Pu/re W 
Resp & 










































104 


96 


104 


ioe 


100 


94 


92 


84 


96 


2e 


/a 


ea 


7t> 


6 


5^ 


56 


bO 


64- 


bO 


100 


104 

Ji4 


100 


IOO 


94 


9t , 


rfe 


88 


100 


102 


7b 


72 





tiO 


^ 


^ 


S8 


JsfL 


if 





Chart 111. 



106 



104- 



102 
10 1 



JVormal 
98' 



M\ ze | so 



100 ^B| 6S ao 72 100 Z2JJ 



Chart IV. 



ENTERIC GROUP OF FEVERS 



37 



20 1\ 11 23 24 i 5 26 \Z7 28 29 30 31 32 33 34- 35 36 37 38 39 







Chart V. 




|g ia \$_ 1 5 .1 6 IT" 18 J9 20 21 2?. 23 2^ ZS Z6_ 27 29 29. 3O 



3I_ 32 55 



106- 



105- 
>( 
^103- 
102 
101'- 
MOO'- 

*- 
Normal 
96' 

97'- 



Pufsfi 
ffeso. 






Chart VI. 



9 MO 



1HE 



n! 



Li EL 



ML 



^106- 
'5 105- 

1 104- 
I _o 



100 



99 
Norms/ 
98 

97 



7 






Chart VII. 



38 



MEDICAL HISTORY OF THE WAR 



^ 



tfff/S. 



m 



m 



m 



Mt 



-IL 



H t 



L 



EME 



l0i 



Mt 



1 



HE 



106? 



z 



V. i Q2- 
101' 

joo' 

99' 



AW^/ 



^ii<o4'ir-i^^i^orTu^OBtif ^sfc->jT.i^'i^^ji'^iA'jii B-t'ii?ji-iiiijf-r'j^ii^iriJ 



Chart Vlfl. 



^/06' 
|,03' 



? 



iJ02' 



\/ 



ft 



99. 





ENTERIC GROUP OF FEVERS 



39 



7><)</o/3'S 15 14 13 16 17 



7/me 



102 " 
101- 

ioo 



98 
97- 



IE 3 



Oa *3b 9fc> 



8 19 2O 2 1 22 




26 ?./ r 28 29 I 



tHE 



31 32 3o o^ 

H|MEF|r2_E 



V? 



Chart XL 




Chart XII. 

The rash in paratyphoid fever is present in about 60 per cent, 
of cases ; it does not conform so strictly to type as does the 
typhoid roseola. Miller describes the following varieties : 

(1) Rose-pink papules as in typhoid, occurring in successive 

crops, and most evident on the lower part of the 
chest and abdomen. 

(2) Larger spots of irregular outline, red with a bluish tinge, 

raised, and not completely fading on pressure. This 
variety is characteristic of paratyphoid fever, when 
present ; the spots may be very profuse and have 
been mistaken occasionally for measles, German 
measles, varicella, and even smallpox. 

(3) A rare variety of rash, which may occur alone or in. 

association with the other types, consisting of 
cyanotic sub-cuticular patches of irregular shapes 
and sizes and indicating a severe infection. 



40 MEDICAL HISTORY OF THE WAR 

The spots vary in number from two or three to several 
hundreds ; they may be noticed any time from the end of the 
first week well into convalescence. Their first appearance may 
be delayed till the temperature has been normal for several days. 
An analysis of several hundred cases showed that the twelfth 
day is the most usual date for spots to appear. A feature of 
most paratyphoid cases, shared with a fair number of typhoid 
cases that have been inoculated, is to feel and look quite well 
about the twelfth day of illness even though the fever continues 
for another fortnight. 

Convalescence in paratyphoid fever, even in quite uncom- 
plicated cases, is apt to be disappointing ; all goes well till the 
patient gets up and about ; thereafter progress is tedious. There 
is a great tendency for complaints to be made of persistent 
lassitude, headache, lack of appetite and insomnia. There is 
often considerable variation between morning and evening 
temperature and the latter may be slightly above normal. 
This is not an indication for further rest in bed ; these cases do 
better if encouraged to be out of bed and taking a reasonable 
amount of exercise. A small but definite proportion of patients 
manifest true cardiac dilatation during convalescence ; still 
more show the characteristic features of disordered action of 
the heart, praecordial pain, dyspnoea on exertion, tachycardia 
and palpitation, without any demonstrable lesion in valves or 
myocardium. In this last type of case there is usually vaso- 
motor instability, as shown by cold and livid hands and feet 
and tendency to perspiration without cause. 

Definite neurasthenia is a not uncommon sequel to para- 
typhoid fever, but it is hard to say how much of this depends 
on previous war experiences and how much, if any, is directly 
attributable to the specific infection. 

On the whole, convalescence from paratyphoid fever differs 
rather strikingly from that of typhoid fever, but principally in 
the subjective feelings of the patient, who does not manifest 
that sense of well-being and eagerness to be up and doing that 
is so often a feature of typhoid convalescence. 

From the above brief clinical description it may be gathered 
that paratyphoid fever, whether A or B, is a miniature edition 
of typhoid fever so far as the average case is concerned ; it 
cannot, however, be too strongly emphasized that a severe case 
of paratyphoid fever is just as severe as the most serious case 
of typhoid, and that every complication or accident which 
may attend the latter may equally well be encountered in the 
former. 

Serious complications are not so frequent in paratyphoid as 
in typhoid ; minor complications are not so serious when they 



ENTERIC GROUP OF FEVERS 41 

do occur. In a disease showing so many diverse clinical signs 
as paratyphoid, it is difficult to say where legitimate manifes- 
tations cease and complications begin. The preponderance in 
certain groups of cases of certain manifestations or complications 
has led some writers to attempt to classify paratyphoid fever 
into various clinical types ; thus Miller recognizes typhoid, 
dysenteric, biliary, rheumatic, respiratory, influenzal, and 
septic aemic types. 

The typhoid type is by far the most common variety, and 
the foregoing remarks principally apply to it. 

The dysenteric type, which is only admissible when co- 
existent dysentery has been rigidly excluded, is relatively 
infrequent, but is more common in paratyphoid B than in 
paratyphoid A. It is remarkable that it is not more often met 
with in severe cases, in view of the relative frequency of con- 
siderable large gut ulceration in paratyphoid B. Paratyphoid 
fever can, however, begin with symptoms that clinically 
closely resemble those of true dysentery, so that a certain 
amount of haemorrhage in quite the early days does not 
necessarily negative the diagnosis. At the same time, the great 
majority of this type of case was reported from the Eastern 
theatres of war, so that the possibility of double infections, 
especially paratyphoid grafted on to a bacillary dysentery, is 
difficult to exclude. 

With regard to the biliary type there is great divergence of 
opinion as to the frequency with which infection of the bile 
passages and gall bladder, to the extent of causing signs or 
symptoms referable to these organs, may occur. Rathery 
comments on the rarity of jaundice or biliary symptoms in his 
series of 1088 cases of paratyphoid B. Torrens and Whittington 
state that jaundice and biliary symptoms were conspicuous by 
their absence on the Western Front in 1915. Torrens could not 
trace any special connection between the camp jaundice, which 
was common in Mesopotamia, and enteric fever. On the other 
hand, Dawson and Hume record twenty-four cases of infective 
jaundice attributable to enteric fever, namely, in typhoid, six 
cases ; in paratyphoid A, four cases ; and in paratyphoid B, 
fourteen cases. 

It is probable that the paratyphoid fevers of the Gallipoli 
campaign were accompanied by jaundice and biliary symptoms 
in larger proportion than the same fevers in other areas. Morley 
and Battinson Smith record a case of " epidemic jaundice " 
which showed acute gangrenous cholecystitis ; Bacillus para- 
typhosus B was recovered from the stools and bile of this 
patient. Sarrailhe and Clunet recovered an inagglutinable 
paratyphoid bacillus from the blood of a number of cases of 



42 MEDICAL HISTORY OF THE WAR 

camp jaundice in Gallipoli ; subsequent investigation showed 
these organisms to be, for the most part, paratyphoid A. 

Acute cholecystitis is met with from time to time, usually 
after the third week. 

In the rheumatic type, acute articular rheumatism has been 
noted in a few cases of paratyphoid fever. Arthralgia and 
myalgia, without objective evidence, occur in close on 10 per 
cent, of cases. Nobecourt and Peyre consider articular rheu- 
matism to be a common manifestation, especially of paratyphoid 
B. Synovitis simulating infective arthritis and giving rise to 
suspicion of gonorrhoea was noted by Miller in several cases. 

In the respiratory type, rapidity of respiration may be due 
simply to toxaemia, but some bronchitis is commonly present. 
Lobar and broncho-pneumonia are seen in cases either at the 
onset or at any time during the course ; in only a small pro- 
portion of these cases can the paratyphoid organism be recovered 
from the sputum, or from the lungs after death. Pleurisy is far 
from uncommon in paratyphoid fever ; often a little dry 
pleurisy is noted for a few days, and clears up completely. 
Sometimes an effusion develops very rapidly ; this may be 
lymphocytic in nature, and suggests a tuberculous process. On 
the other hand, a polynuclear effusion which rapidly goes on to 
empyema is not unlikely, especially in paratyphoid B. It is 
rare to recover paratyphoid bacilli from the simple pleural 
effusions, but they have been found in some of the empyema 
cases according to Weeks and others. 

It has been suggested that paratyphoid infections may light 
up a latent tuberculosis ; certainly lymphocytic effusions with 
transient signs at the apices suggesting tuberculosis have been 
described, but more evidence is wanted on this point. Jol train 
and Petitjean noted 19 cases of pleurisy in 310 cases of para- 
typhoid fever; 18 were due to Bacillus paratyphosus B and 
1 to Bacillus paratyphosus A, 15 were sero-fibrinous, 2 were 
purulent and 2 were dry. 

In the influenzal type, paratyphoid fever can simulate closely 
the respiratory, the gastro-intestinal, or the nervous forms of 
influenza. This is especially the case in protected men. 
Isolated examples of these varieties are very likely to escape 
detection in a busy general hospital, since it is impossible to 
keep all such mild cases under observation sufficiently long to 
exclude enteric infections by serological tests. 

The septicaemic type is rare. In it death occurs early in the 
disease ; often there are no local lesions found post mortem, 
nothing but the general features of septicaemia. Job and Ballet 
record three such cases and Sawasaki has met with similar ones 
in Japan. Gangrene of the extremities may precede death. 



ENTERIC GROUP OF FEVERS 



43 



Some of the complications of paratyphoid fever have been 
sufficiently discussed in the foregoing clinical description. 
There remains a large number of which only three require 
special notice here. Haemorrhage occurs in less than 5 per 
cent, of all cases ; there seems little doubt there is a greater 
tendency to haemorrhage in paratyphoid B than in para- 
typhoid A. Perforation is definitely less common than in 
typhoid fever, but appears to be somewhat more frequent in 
paratyphoid B than in paratyphoid A. Nearly all published 
figures show that more than one quarter of the deaths are 
due to haemorrhage or perforation. Webb Johnson gives 
the incidence and mutual relationship of perforation and 
haemorrhage of a series of cases in France. 

TABLE XIV. 











Haemorrhage 




Number of 


Haemorrhage. 


Perforation. 


and 




cases. 






Perforation. 


Typhoid 


1,118 


50 


9 


3 


Paratyphoid A . . 


344 


1 


2 





Paratyphoid B . . 


1,038 


16 


3 


1 



Apart from dilatation of the heart and the symptoms of 
simple disordered action, a small proportion of cases give 
evidence of more definite damage to the heart muscle. For 
example, heart block, auricular flutter and auricular fibrillation 
may all occur. The lesions giving rise to these phenomena 
may be transient or permanent, and it is important from the 
patient's point of view that the clinician should be alive to 
these possibilities in order that appropriate treatment may be 
instituted as early as possible. The fact that typhoid patients 
may die quite suddenly when apparently doing well, almost at 
any period of the disease, has long been recognized ; the same 
mode of death is observed, but less frequently, in paratyphoid 
fever. It seems possible that the actual cause of death in these 
cases may be the sudden development of ventricular fibrillation. 

The incidence of the remaining complications of paratyphoid, 
compared with the same in typhoid, is shown in Table XV., 
taken from Webb Johnson's report. The figures are based on 
the analysis of 2,500 cases of enteric fever treated in hospital at 
Wimereux, and it must be borne in mind that, just as the case 
mortality was far higher in other theatres of war, higher also, 
without doubt, was the incidence of the in dividual complications. 
The table, however, is of interest since it deals with a large 
number of cases all treated under practically uniform conditions, 



44 



MEDICAL HISTORY OF THE WAR 



rt 
2-3 



GO CD ^"t CM 05 01 O 

CD 10 o I-* o i-< co 



Tt'Tf'OCOICMCNCDOOaCGCOlCDOOOTl'aecOO 

oo-<t i '-'C<;ioco;oocDt>.'-ioic^c^ coc^ 



(MOOOOCO 



OOOO^OOOOOOr-i 

II il II II II II II II II II II II il II II II 



666 l^666666cM^6666^6 ! 
II I! II II II il II II II II II II II II il II II i| 



.< 

1 O CM 



CO 



< 



Paratyphoid B 
inoculated. 



p-y 

8 
g 

oJ O 

cu a 



Paratyphoid 
inoculated. 



II 

A o 



i! 



a, 3 



-xO 

0^ 



i-* us *+ ** 

-^C<I -^f 

o - 1 1 16 Mo 1 

!l II II II 



10 CN 



-vP"vP 

o"^o^ 
iO O) 






O "O 1C O O 

6^6 1 loo! I 6 I 6 

li i| II II il II il 



i ! 1 ! ! 1 -1 1 6 i i 1 i I 1 i i 1 II M 1 



S 



CO o^o - 
TgcB 



CO CD CO CO CO O O 

16 61 |6^"l6'^(NCM|c0^i6l6^H6'-^ 

II II il II II II II II II II II II II II II 



O5 

CD ^c 

r^ t>> o 

lO O5 1C O5 
CO CM i-< 

G> 







CM CM * lO CD 

T-t r-< CM 00 CO 

66 166 166 



ES 



II II 



oco-* 1 i-i ft 



i >-<<N r>co 



IT> r-4f*G* 

*% 






t 






^^ ^ eg 
rt "73 

iil|iilliiii4i 

|QPMtJ> 



Cases 
Deaths 
Mortality 



ENTERIC GROUP OF FEVERS 45 

and it shows the effect of prophylactic inoculation alike on 
typhoid and paratyphoid fever, as regards not only general 
severity but also incidence of complications. 

When a number of men are exposed at the same time to the 
risk of infection by three specific micro-organisms, no one of 
which has the power of conferring immunity against the others, 
it is certain that mixed infection with two or all of the infecting 
agents will occur in a proportion which can be expressed 
mathematically. 

A number of such cases have been recognized, but it is 
inevitable that many should escape diagnosis, since further work 
would not be undertaken as a routine in any case so soon as the 
presence of one infection had been established. It is probable 
that certain of the cases of anomalous course or of unduly 
prolonged duration, as well as those showing unexpected ag- 
glutination curves in fully protected men can best be explained 
on the hypothesis of mixed infections. An interesting case of 
mixed infection has been reported by Dawson and Whittington 
as follows : 

The patient had a double infection by the Bacillus paratyphosus A 
and the Bacillus typhosus. He had thrombosis of the left femoral and 
left external iliac veins. Four relapses occurred. In the last relapse he 
had pulmonary infarction, and death was due to the subsequent severe 
lung affection on the 127th day from the onset. 

The following points are noteworthy : The patient had had no pro- 
tective inoculations. Admitted on the twelfth day of the illness, he 
appeared to be typical of a rather severe enteric group infection, and 
his blood gave a pure culture of Bacillus paratyphosus A. The serum 
on this day and on the eighteenth day strongly agglutinated the stock 
paratyphoid A bacillus, and gave no reaction with Bacillus typhosus 
or Bacillus paratyphosus B. . By the twenty-second day the patient was 
obviously improving and during this time he had a swinging temperature 
(rather characteristic of paratyphoid A infection) from 99 to 102. On 
the twenty-third day, however, the temperature range became steadier, 
remaining between 102 and 104 for five days. On the twenty-fourth 
day the serum agglutinated Bacillus typhosus as well as Bacillus para- 
typhosus A . It gave the same reaction on the twenty-ninth day, but the 
reaction with Bacillus paratyphosus A had much diminished. On the 
twenty-seventh day thrombosis of the left femoral vein was first noted. 
The duration of this primary attack of fever lasted forty-eight days. 

The patient had four relapses with four, twenty, sixteen and ten days' 
pyrexia respectively. During the second relapse he was given two 
injections of paratyphoid A vaccine without obvious effect. In the 
middle of the third relapse a blood culture was negative. At the post- 
mortem a pure culture of Bacillus typhosus was grown from every viscus 
examined (gall-bladder, spleen, mesenteric gland and thrombosed vein), 
thus proving the presence of a second infection. 

The date of the second bacillary invasion is not quite clear. The 
agglutination reactions suggest that it was before the twenty-fourth day, 
but not much before the eighteenth day ; also the temperature range 
altered on the twenty-third day. Thus it seems likely that when the 
patient came to hospital he had reached the twelfth day of a paratyphoid 
A attack and was in the midst of the incubation period of typhoid, that 
for a while the two infections reigned together, and later the para- 
typhoid A disappeared, leaving the typhoid to reign alone. The relapses 
were thus probably due to Bacillus typhosus. 



46 MEDICAL HISTORY OF THE WAR 

The increased severity of enteric fever in the East and Near 
East is in part explained by the greater frequency of its asso- 
ciation with malaria or dysentery, as well as the liability to 
hyperpyrexia or even true heat-stroke. Latent malaria may 
be lighted up, often in a virulent form, by an enteric infection, 
while the extra strain of even a mild paratyphoid infection may 
determine a fatal issue in a case of dysentery of only moderate 
severity. A certain number of paratyphoid A cases developed 
heat-stroke in Mesopotamia in the hot weather of 1916 ; the 
majority of these proved fatal, sometimes during the first week 
of illness. At this time ice was not available. 

A number of cases of combined infection with typhoid and 
diphtheria was noted by the French authorities. The mortality 
in these was very high. The severity of this double infection 
was confirmed by experience of a small number of similar cases 
in the British forces. 

Prognosis. 

The prognosis in enteric fever has been shown to vary with 
the specific infection, with the amount of time that elapses 
between " going sick " and reception into a hospital for per- 
manent treatment, with the climate, with the rigours of active 
service to which the individual has recently been exposed, and 
also with the presence or absence of protective inoculation 
against the particular infection which has been acquired. These 
factors have already been discussed ; but there are certain 
clinical features which may lead the clinician to regard any 
given case as likely to do well or badly and also indicate 
the average duration of " invalidism." It is important to 
estimate the proportion of cases likely to be unfit for further 
military service and the probable incidence of symptoms 
sufficiently serious to justify a more or less prolonged pension. 

With regard to the clinical features bearing on prognosis, in 
all enteric infections the most reliable guide as to the patient's 
actual state of well-being is the pulse. The quality of the pulse 
is significant ; a pulse so soft as to be " dicrotic " betokens a 
relatively intense infection, but apart from the quality the all- 
important factor is the actual pulse rate. So long as the pulse 
rate is no more than 100 per minute the patient's condition is 
not likely to be very urgent; a pulse rate of 110 is serious 
and when the rate reaches 120 the prognosis becomes extremely 
grave. In adult male patients a pulse rate of more than 120 
per minute continued for longer than 36 to 48 hours means 
death in all but a few very exceptional cases. The intensity of 
toxaemia, as shown clinically by the dry skin, flushed face and 
mental lethargy, has an obvious bearing on prognosis, but the 



ENTERIC GROUP OF FEVERS 47 

importance varies with the nature of the infection and period 
of disease to which the toxaemia persists. In paratyphoid fever 
manifest toxaemia persisting after the twelfth day indicates a 
severe infection ; for typhoid fever the same degree of toxaemia 
might be expected till the twentieth day. 

Spots are most frequently seen in the more severe infections ; 
but Torrens considers that, granted a severe infection, a plentiful 
crop of spots is of favourable import and that such a case is 
likely to do better than a similar case in which spots are scanty 
or absent. 

The degree of splenic enlargement does not seem to be of 
special import, except in so far as a big spleen usually indicates 
an infection of at least moderate severity. 

A high temperature, apart from hyperpyrexia which is always 
serious and particularly likely to occur in the tropics, is not a 
sign of danger unless it is associated with a rapid pulse, when 
the prognosis should be based on the pulse rate rather than on 
the degree of pyrexia. 

The chief risk of a relapse is that it prolongs the period in 
which perforation and haemorrhage may occur. 

The complications of enteric fever, with the exception of 
pneumonia, haemorrhage and perforation, influence prognosis 
principally as regards the probable length of invalidism required 
before any work can be undertaken. Pneumonia, haemorrhage 
and perforation, however, are complications rather apart from 
all the rest ; they may all three, but especially haemorrhage 
and perforation, occur without any warning in the course of a 
case which has to all seeming been quite a mild infection. The 
advent of any one is of very grave prognostic import, but 
perforation is infinitely the most serious, since it is probable 
that not more than one in fifteen can be saved under active 
service conditions. 

In a series of seventeen perforations observed, only one sur- 
vived, although practically all were operated upon within a 
very few hours of the complication occurring. In another 
series perforation was responsible for 14 out of 103 deaths in 
2,500 cases according to Webb Johnson. 

Haemorrhage is probably responsible for one-fifth of all deaths 
from enteric fever. 

Invalidism. 

The following table indicates the average duration of invalid- 
ism. It is based upon 2,000 cases treated in Addington Park 
Hospital and shows the number of days' treatment necessary 
for cases of enteric fever from the different theatres of war. It 



48 



MEDICAL HISTORY OF THE WAR 



is noteworthy that the length of treatment appears to vary 
directly with the distance from England of the country where 
the infection was contracted. 

TABLE XVI. 

Duration of Treatment of Enteric Fever. 



Force from which derived. 


No. of cases. 


Average number of 
days under Treatment. 


France 
Gallipoli 
Egypt 
Salonika 
Malta 
East Africa 
Mesopotamia 
India 
Miscellaneous Cases 


1122 
143 
206 
192 
117 
10 
11 
3 
196 


102-92 
140-59 
151-36 
152-69 
156-44 
208-30 
234-00 
227-00 
126-52 


Total number of Cases. 
2000 


Total number of days 
under treatment. 

244,520 


Average number of 
days under Treatment. 

122-26 



The average length of treatment is seen to be 122*26 days so 
that it is reasonable to suppose that an ordinary case is fit to 
resume duty six months after the date of infection. A further 
two to three months may have to be added to this period for 
those patients who were infected in the East. A small per- 
centage of all cases become carriers and therefore useless for 
further military service. In the unprotected this proportion is 
fully 2 per cent. In those protected by triple vaccine it is pro- 
bable that the proportion is much lower. The percentage of 
typhoid carriers is higher than that of paratyphoid, while that 
of paratyphoid B is higher than that of paratyphoid A. 

The other principal reasons for discharge from military 
service after enteric fever are complications or sequelae affecting 
the cardio-vascular system, and neurasthenia. 

Phlebitis and thrombosis occur in not more than 4 per cent, 
of all cases ; a small but definite proportion of these cases are 
left with permanent oedema of the limb and are unfit for 
further military service. 

Disordered action of the heart is a more frequent reason for 
discharge, since symptoms may persist to the extent of pre- 
cluding any but a sedentary occupation for several years, in 
spite of careful treatment by graduated exercises. Such 
cases, however, should not be discharged for at least a year, 
since a large proportion will recover under suitable conditions. 



ENTERIC GROUP OF FEVERS 49 

Those few cases which manifest a more definite cardiac lesion, 
such as heart block, auricular flutter, or auricular fibrillation are 
probably unsuited for further military service. 

The number of soldiers now receiving pensions for disabilities 
which are directly attributable to enteric fever is not great, 
either absolutely or relatively. The only cases of this sort 
seen by Torrens during 1919 may be grouped under the 
headings general debility, disordered action of the heart, 
other cardiac conditions, effects of thrombosis and affections 
of the gall bladder. In all these, with the exception of the first, 
a pensionable disability may persist for many years. 

Statistics are not at present available to show the exact 
percentage of enteric cases who were discharged from the army 
or who are now drawing pensions. 

Diagnosis. 

The diagnosis of enteric fever depends upon its clinical 
manifestations and laboratory investigations. With regard to 
the former it is established that clinical signs can take one no 
further than a diagnosis of enteric fever ; the attempt to say 
that a given case is either typhoid or paratyphoid fever can 
only be a guess, since typhoid can be as mild as paratyphoid, 
and paratyphoid can be as severe as the worst case of typhoid. 
This statement applies alike to protected and unprotected 
persons, the only difference being that the experienced observer 
is more likely to guess correctly in the latter case than in the 
former. 

Any case presenting several of the characteristic enteric 
features headache, continued fever, slow pulse, diarrhoea, 
tumid belly, spots, enlarged spleen and mental lethargy must 
at once be referred to the laboratory for more precise diagnosis ; 
but these are not the important cases, as they would justify a 
clinical diagnosis anywhere, and there is no risk of their failing 
to be isolated for an adequate period. The important cases 
are those which are so mild and atypical that, clinically, they 
do not suggest an enteric infection, for these may well dissemi- 
nate infective material should they be returned to duty while 
in a " carrier " condition. In the majority of cases there will 
be one or two isolated signs or symptoms that may put the 
wary observer on the track : such as, the quality of the pulse, 
a suggestion of undue lethargy, a history of looseness of the 
bowels or epistaxis at the onset of the illness, an increase in 
the area of splenic dullness, or a doubtful spot or two about the 
shoulders or abdomen. 

It is well to remember that in the tropics malaria is more 
often confounded with typhoid than with any other disease. 

(2396) D 



50 MEDICAL HISTORY OF THE WAR 

In view of the large number of cases which are not enteric, 
and in which the diagnosis of pyrexia of uncertain origin can 
never be replaced by one more scientific, as well as a host of 
trench fever and influenza cases, it is obvious that the ideal 
method of treating every case of unexplained fever of six days' 
duration as suspected enteric group is not practicable. Actually 
then the onus of diagnosis rests on the clinician, who must 
appreciate that any case of unexplained fever may be enteric, 
and who must be unceasingly alert to distinguish those lesser 
signs which may lead him to seek the aid of his bacteriological 
colleague only in those cases which will yield a reasonable 
proportion of positive results. 

The atypical forms only of influenza or trench fever are likely 
to give rise to doubt and may be clinically indistinguishable 
from the modified varieties of enteric fever. An enumeration 
of leucocytes may serve to eliminate a certain number of 
" suspect " cases ; a definite leucocytosis excludes enteric fever, 
while a true leucopenia, (4,500 cells or less), is very suggestive 
of an enteric infection, especially when associated with a definite 
mono-nuclear increase. A mono-nuclear leucocytosis may 
persist throughout convalescence. Counts of from 5,000 to 
7,000 white cells are, however, often found in influenza or 
trench fever. 

The atropine test, introduced by Harris, is a useful aid to 
diagnosis, but its value lies chiefly in the fact that a series of 
negative results excludes enteric fever ; unfortunately it has 
been found that a positive result may be obtained in about 20 
per cent, of cases of trench fever and possibly other febrile 
disorders as well, certainly also in cases of infection by B. 
aertrycke. The test depends on the variation in the pulse 
rate of the suspect after the hypodermic injection of 1/33 gr. of 
atropine sulphate. The injection is given one hour after a 
meal, the patient being recumbent, the pulse is counted every 
minute till it is of uniform rate, the atropine is injected and the 
pulse rate noted minute by minute for from 30 to 35 minutes. 
The maximum increase due to the atropine is thus ascertained. 
If the increase does not exceed 14 beats per minute, the 
reaction is positive. The test is applicable from the fifth to 
fourteenth day of fever ; it is not reliable when the initial pulse 
rate is over 100 beats per minute and should not be employed 
in patients over 50 years of age or those who are markedly 
art erio-scler otic. 

It is thus possible by clinical means to earmark two classes 
of cases, first those that can be considered as certainly enteric 
fever, and secondly those that must be regarded as suspect cases 
till the diagnosis can be confirmed or refuted. Both classes 



ENTERIC GROUP OF FEVERS 51 

must be referred to the bacteriologist without delay for 
confirmation and for the identification of the specific infective 
agent. Topley, Platts and Imrie claim that about 5 per cent, 
of the cases invalided from the Western Front as pyrexia of 
uncertain origin were in reality suffering from enteric fever ; it 
is probable, however, that this figure is too high. 

Cases of disease due to the food poisoning group of organisms, 
Bacillus enteritidis, Bacillus aertrycke and Bacillus suipestifer, 
can generally be diagnosed clinically from enteric fever by the 
sudden onset with severe diarrhoea and vomiting, the occurrence 
in epidemic form of several cases at exactly the same time, the 
short duration of fever and the absence of the classical features 
of enteric fever. Perry and Tidy, discussing an extensive 
epidemic due to Bacillus aertrycke, noted a latent period of 6 
to 28 hours, sudden onset with diarrhoea and abdominal pain 
in many cases apyrexial, fever when present rarely lasting more 
than two days, tongue clean throughout and stools watery 
with but little faecal matter. 

A considerable epidemic of disease due to Bacillus suipestifer 
was noted in Egypt in 1917. The cases resembled in the main 
those due to Bacillus aertrycke but vomiting was more pro- 
nounced a feature and the temperature remained high for 96 
hours, thereafter falling by crisis. 

With regard to laboratory diagnosis this is easy in unpro- 
tected persons. The specific bacillus can be recovered from the 
blood in most cases up to the fifth day and often for longer. If 
the blood fails, cultivation of the stools or urine will often give 
a positive result in the second and third weeks of the disease. 

In war time it often happens that cases do not get within 
touch of a properly equipped laboratory till the second week 
or later ; it is then necessary to test for specific agglutihins in 
the patient's blood serum. In a positive case these will 
appear from about the tenth to the twelfth day, though the 
paratyphoid A agglutinins may be delayed till the third 
week. 

In protected individuals the procedure is less simple because 
the percentage of cases in which the specific organism can be 
recovered from the blood, urine or faeces is much less, and the 
act of inoculation causes the specific agglutinins for the 
organisms, against which the person has been protected, to 
appear in the blood serum, quite apart from any infection 
having taken place. 

It has been shown, however, that by the use of special 
technique and standard bacillary emulsions, as advocated by 
Dreyer, a positive diagnosis can be made in nearly every case 
by noting the variations in agglutination titre to the different 



52 MEDICAL HISTORY OF THE WAR 

organisms exhibited by the patient's blood serum throughout 
the course of the disease. 

Infections due to Bacillus enteritidis may closely resemble 
some cases of paratyphoid B fever ; this organism possesses 
identical biochemical reactions with Bacillus paratyphosus B 
but can be distinguished readily by agglutination tests. 

Infections due to Bacillus aertrycke or Bacillus suipestifer are 
more difficult, as their biochemical and agglutination reactions 
are the same as for paratyphoid B. Absorption tests, however, 
serve to differentiate Bacillus paratyphosus B from the others. 

The diagnostic position of enteric fever may be summarized 
as follows : 

A diagnosis of enteric fever may be justified on purely 
clinical grounds even though unsupported by bacteriological 
or serological findings. The percentage of cases thus unsup- 
ported will be small, probably less than 5 per cent, in those 
protected by triple vaccine, and practically negligible amongst 
unprotected men, provided they are under observation 
sufficiently long for a series of agglutinations to be determined. 
An additional factor which applies also to unprotected men is 
the occurrence of infections by bacilli closely allied to, but not 
really belonging to, the typho-paratyphoid groups as at present 
defined. 

The isolation of one of the specific bacilli from the blood is 
the simplest and most conclusive proof of infection. This 
should always be attempted as soon as enteric fever is suspected. 
Bacillus typhosus has been recovered by Torrens from the blood 
on the 26th day of illness quite apart from a relapse. Recovery 
of the bacilli from the stools or urine is the next most satisfactory 
proof of infection ; this procedure is most successful in the 
second, third, and fourth weeks of the disease. 

If no bacilli can be recovered in those protected by triple 
vaccine, the accurate diagnosis must depend on the agglutina- 
tion curves of the patient's blood serum, as determined by 
three, four, or more successive readings at intervals of three, 
four, or five days. A variation of 150 to 200 per cent, or more 
in the agglutination titre to one of the bacillary emulsions 
between the twelfth and thirtieth days of illness implies an 
infection with that bacillus. A variation of as little as 100 per 
cent, is probably sufficient but may just fall within the limit of 
technical error. In unprotected men agglutination with any 
of the three bacilli in higher serum-dilution than 1-10 is proof 
of infection with that bacillus ; in the case of paratyphoid A a 
positive diagnosis is justified even if the maximum titre is no 
more than one in ten. To take these agglutination readings it 
is essential to use standard agglutinable bacillary emulsions, to 



ENTERIC GROUP OF FEVERS 53 

use the macroscopic method and to follow closely the technique 
laid down by Dreyer and Ainley Walker. 

Treatment. 

With regard to the general treatment of enteric fever the 
experiences of the war have done nothing to modify the old- 
established methods. The essential factors still remain, namely, 
good nursing, careful dieting, and enforced rest at the earliest 
possible moment in the nearest hospital set apart for the treat- 
ment of these cases. It cannot be too strongly emphasized 
that there is nothing so prejudicial to the interests of the patient 
as repeated transference from place to place or even from one 
ward to another in the same hospital. 

It is generally agreed that only fluids and jellies should be 
permitted during the height of the disease, with the possible 
addition of milk-chocolate and rusks after the tenth day in 
mild non-toxic cases ; there is, however, a tendency to permit 
solid food to cases of paratyphoid fever relatively early in the 
disease. Nothing is probably gained by this course, and it 
is safer to adopt the old rule that no case should have 
solid food till the temperature has been normal for seven days ; 
the convalescence of cases treated in this manner is speedier and 
less interrupted by relapses than when solids are permitted at 
an earlier stage. It is of the greatest importance to encourage 
the patient to drink as much water as possible during the height 
of the disease. 

No drug is of specific value in the treatment of enteric fever. 
An aperient should be administered if the case is constipated 
and seen in the first ten days ; after this date the bowels should 
be opened, if necessary, every other day by the administration 
of an enema of normal saline. Antipyretics and intestinal 
antiseptics are best avoided. Liquid paraffin may be given 
with advantage throughout the disease so long as there is no 
diarrhoea, as it tends to minimize the constipation which is 
often so obstinate during convalescence. Bromide is of service 
if insomnia is troublesome. 

Stimulants are but rarely necessary or desirable until con- 
valescence ; the pulse must be the guide. It appears that very 
severe cases can be kept alive a few hours or days longer than 
would otherwise be the case by the free exhibition of brandy, 
but that rarely, if ever, is a fatal issue avoided by this means. 
This does not apply to cases who have developed pneumonia or 
who have been operated on for perforation ; or to the occasional 
administration of a tablespoonful of whisky in a little warm 
milk to induce sleep. 

The foul condition of the mouth and the characteristic typhoid 



54 MEDICAL HISTORY OF THE WAR 

tongue can be greatly improved by careful attention, especially 
by encouraging the patient to use " chewing gum " which is 
an excellent prevention of the septic parotitis so frequently 
occurring in typhoid fever. 

Immersion in baths can rarely be practicable in wartime, 
even if it be desirable. Tepid or cold sponging is, however, of 
the greatest value ; it should be done as a routine measure 
every four to six hours to all patients whose temperatures are 
103 or over. Apart from the degree of pyrexia, sponging is the 
most valuable remedy for restlessness or insomnia. 

With regard to the treatment of complications, meteorism is 
best treated by stopping milk and allowing only whey or albumen 
water for 48 hours or longer. A simple enema may be of service ; 
the turpentine enema should be used with caution and not 
during the third week of the disease, since there is no means of 
estimating the extent of ulceration in the large intestine. 

Immediate operation offers the best chance in cases of perfor- 
ation. Peritonitis without perforation may be localized and 
unsuspected clinically ; such cases often recover. If generalized, 
operation should be undertaken as soon as the diagnosis is 
made. 

In the event of haemorrhage occurring all fluids should be 
stopped for at least 48 hours and sufficient morphia injected to 
keep the patient absolutely at rest. The mouth must be care- 
fully attended to during this time. Feeding, when recommenced, 
must proceed with the utmost caution. It is amazing what a 
large amount of blood can be lost without death ensuing. One 
large haemorrhage is often less serious than a series of smaller 
ones. When the haemorrhage seems definitely to have ceased, 
subcutaneous infusion with saline solution up to 30 oz. may be 
permitted, if the condition of the patient remains unsatisfactory ; 
and this may be repeated if no further bleeding takes place. 
It is well to attempt to anticipate the occurrence of haemorrhage 
by increasing the coagulability of the blood about the time 
when the sloughs may be expected to separate. For this 
purpose 30 gr. of calcium lactate may be given thrice daily from 
the sixteenth to the twentieth day of typhoid fever and from 
the fourteenth to the eighteenth day of paratyphoid fever. In a 
considerable number of cases treated in this manner, and 
checked by controls not so treated, the results appeared dis- 
tinctly to justify the measure ; haemorrhage was less frequent 
and, when it did occur, of less severity. 

In cases of thrombosis the administration of citrates is 
indicated. Marris claims excellent results from the intravenous 
injection of 10 oz. of 5 per cent. sod. citrate solution. 

Pulmonary complications must be dealt with on their merits. 



ENTERIC GROUP OF FEVERS 55 

Cholecystitis and gallstones may require surgical intervention. 
The former will usually yield to aspirin and urotropine. 

In addition to these general methods, certain special methods 
of treatment have to be considered. 

Various writers have advocated from time to tune the 
therapeutic use of vaccines in enteric fever. A great variety 
of different forms of vaccine have been employed, varying from 
stock killed cultures, as used for prophylactic inoculation by 
Wiltshire and MacGillicuddy, to an autogenous living vaccine 
used by Bourke, Evans and Rowland. The dosage has varied 
within wide limits and the vaccine has been given subcuta- 
neously, orally, or intravenously. In most cases the evidence 
adduced in favour of vaccine treatment fails to carry conviction. 
The cases are few in number and there is no record of specially 
selected similar control cases treated at the same time without 
vaccines. 

In January 1915, Torrens believed he was favourably influ- 
encing certain cases by injection of stock antityphoid vaccine ; 
many of these cases were later proved to be paratyphoid fever 
running their normal course. Subsequently, a considerable 
experience of vaccines both stock and autogenous led him to 
the belief that equally good results were obtained in both 
typhoid and paratyphoid fever without the use of such vaccines 
as he was able to procure. As regards the use of stock anti- 
typhoid vaccine for cases of Bacillus typhosus infection, 
Whittington has shown in a careful analysis of controlled cases 
that the results are no better with vaccine than without it, 
that there is " a distinct suspicion that the vaccine increases the 
incidence of haemorrhage," and that neither the duration of the 
fever nor the occurrence of complications is appreciably altered. 

It thus appears that there is not sufficient evidence to justify 
a dogmatic opinion on the value of vaccine treatment in enteric 
rver, but the probability is that it is of little value as hitherto 
>ractised, while it is certain that its beneficial effect is by no 
leans striking. 

Serum treatment, promising though it seems on theoretical 
rounds, does not appear to have been discussed in English 
icdical literature, although it has been used in France. 

Prevention. 

The measures employed for the prevention of enteric fever 
rere prophylactic inoculation and general measures of hygiene 

id sanitation. In August 1914, in conformity with the usual 
>rocedure by which troops were not inoculated against enteric 
iver until they were proceeding on service abroad, only a small 
>roportion of the troops forming the expeditionary force was 



56 MEDICAL HISTORY OF THE WAR 

protected by inoculation at the time war was declared. But 
the work of inoculation was carried on energetically after the 
expeditionary force arrived in France, and eventually the 
proportion of inoculated men exceeded 90 per cent. The pro- 
gress of events during the five years of the war has proved 
conclusively that it is the best, most important and successful 
means at our disposal for combating typhoid fever. Inocu- 
lation and systematic re-inoculation at stated intervals should 
be rigidly enforced in every army. The success of anti-typhoid 
inoculation was assured by the autumn of 1915, and the question 
then arose as to the advisability of introducing a similar 
measure to deal with the paratyphoid fevers which threatened 
to become a distinct menace to the health of the army. 

In January 1915 inoculation with triple vaccine was adopted 
as a routine for all the British expeditionary forces. One c.c. of 
vaccine contained 1,000 million of Bacillus typhosus and 750 
million each of Bacillus paratyphosus A and B. Two injections 
were given at an interval of eight to ten days, the first dose 
being 0-5 c.c. and the second 1 -0 c.c. 

It was also ordered that re-inoculation, one dose of 1 c.c., 
should be performed as a routine measure after an interval of 
from eighteen months to two years. It had been shown 
that the result of simple anti-typhoid inoculation was not only 
to reduce the incidence of typhoid fever but also to diminish 
the severity of the infection when acquired, as well as the 
liability to complications ; but it was possible that some 
of these beneficial effects might be impaired or abolished by 
the addition of paratyphoid bacilli to the vaccine. In the 
event, however, the experiment was amply justified ; the inci- 
dence of each infection steadily decreased year by year and was 
always conspicuously less in those who had been protected by 
inoculation. The death rate per 1,000 of ration strength was 
also consistently lower for each infection amongst the protected, 
as also the case mortality per cent., except for paratyphoid in 
1918, when, however, there were too few cases to afford reliable 
evidence. 

The increase in the case mortality from typhoid fever in 
1917 and 1918 occurs in both protected and unprotected ; it 
therefore probably depends on other factors rather than on the 
adoption of triple vaccine. This has been referred to above, 
and even if it could be shown to depend entirely on triple vaccine 
the disadvantage would be many times counterbalanced by the 
very much lower incidence of the enteric infections in protected 
persons. The efficacy of prophylactic inoculation is shown in 
the following table, taken from the official returns for the 
Western Front from 1914 to 1918. 



ENTERIC GROUP OF FEVERS 
TABLE XVII. 



57 





1 


II 


CM C < 00 *-< CO CO-^tx 
^^ CO 00 00 ^* CO C^ ^* 
CM CM CM O CM CD 


8S 


1C CD O5 
CM CM 




"o 


Protected. 


^H 1 1 f* 1 1 CO CD CM 
1C ^H 1 O5 10 CD 
1C CD CM CO 


-^ O5 CD 
05 CO-* 

-< - 1 CO 


CD CO Cl 


. 


I 


OTJ 

M 4) 


CO 00 t>. 
COICM CMt^O) COt>>t> 


t!SS 


8 | , 


^ 





53 


t^. CO CO "-i 00 1-" 


<N CM CO 


S 


1 


Case Mortal 


1 


00 CO CM 
00 | | | | u-^cp 

1C l> '-"-' 


JC ^ !^ 


^f oo 

00 IN t^ 

CO CM 


1 


1 


it 


CO 


CO CO CO 

i-< O - 


cS 1 ) 




b 

PH 
O 


0* 


1-1 






1 


-M 

2 

1 


I 

8 


CO CM 
88 


00 O CO 

SS8 


88 

O O O 


S) 


P 











i 


| 


|| 


^^CN 


822 


O5 r< M 
-<0<N 


i 


i 




' ' ' ^ ' co<^ 


i i i i ^< 




3 


1 

'C 


1 


III CO 1 1 !>>-" 
Ill 05 1 1 ICCMCO 


o i>a- 


Soc5 


'"i 


a 
























t 


( 


! 


li Si i 


fijjjj 


jH 

figg 




1 


i 


Tf* 1C CO 

- -H t 

O5 O5 O5 


O5 


00 

s 




Theatre of 


M 

PS 




1 







58 MEDICAL HISTORY OF THE WAR 

It will be seen from this table that the influence of protective 
inoculation on the liability to infection from enteric fever is 
undoubted, and equally undoubted is the very much lower case 
mortality in typhoid fever. It is difficult to say from these 
statistics whether triple vaccine has any pronounced effect on 
the case mortality of paratyphoid fever. The 1917 figures 
suggest that it had, but the 1918 figures do not confirm this. 
It must be noted, however, that in this latter year the total 
number of cases of paratyphoid fever on the Western Front 
was too few to be of much value. Only two deaths occurred, 
one in paratyphoid A and one in paratyphoid B, and it is 
probably quite accidental that both these happened in protected 
men. The incidence of complications seems to be lowered in 
all three infections by the use of triple vaccine. 

Since one result of infection by one of the organisms of enteric 
fever is the appearance of specific agglutinins in the patient's 
blood serum and identical agglutinins are produced by the 
injection of the appropriate vaccine, it is reasonable to suppose 
that the amount of agglutinin to Bacillus typhosus, Bacillus 
paratyphosus A and Bacillus paratyphosus B, respectively 
present in the blood serum after prophylactic inoculation with 
triple vaccine, affords some approximate idea of the relative 
immunity conferred against each of the three infections. It 
must be remembered, however, that the infections themselves 
do not produce identical amounts of agglutinin in every case 
and that the response to paratyphoid A is habitually very 
much less than that to either paratyphoid B or typhoid ; so 
that a quite low agglutination titre to paratyphoid A might 
conceivably indicate the same actual degree of immunity as a 
much higher agglutination titre to paratyphoid B or typhoid. 

It might appear from the preceding remarks that prophylactic 
inoculation was the only necessary preventive measure against 
enteric fever. This is far from being the case, and the success 
of the campaign against enteric fever has been in no small 
measure due to the unremitting care and energy of the army 
sanitary authorities. 

For the details connected with the diverse sanitary measures 
rendered necessary by the varying features of the different 
campaigns, reference must be made to the volumes on the 
Hygiene of the War; but the general principles may be 
summarised here. 

The water supply must be beyond reproach ; in the case of 
the trenches this can best be secured by the daily provision in 
tins of an adequate supply which must be chlorinated before 
use, or by the individual use of bisulphate of sodium tabloids. 
Water which has not been either boiled or sterilized in this 



ENTERIC GROUP OF FEVERS 59 

manner must be used for no personal purpose whatsoever. 
Behind the line the precautions must be equally strict ; but it 
is, of course, easier there to arrange for the provision of large 
tanks of properly chlorinated water. All vessels used for the 
carrying of water for cooking and for washing up must be kept 
scrupulously clean and covered up. In European countries the 
town water supply usually requires careful testing and super- 
vision. At Rouen, Boulogne and elsewhere in France the 
supply was by no means safe, and it was found necessary to 
install a chlorinating plant at the source of supply. 

In the Eastern theatres of war the troops may often be 
compelled to rely on a single water supply such as a river with 
its subsidiary canals ; such water is highly dangerous and should 
only be used after sedimentation or clarification with alum and 
chlorination or after prolonged boiling. Since it may often be 
lecessary for large bodies of mobile troops to be several hours 

it of reach of their own water supply, the utmost care must be 
taken to ensure that their water bottles are clean, properly 
corked and as large as possible. Tablets of bisulphate of sodium 

ly be issued when there is a likelihood of temporary shortage 
>f chlorinated water ; these destroy cholera vibrios and all 

icilli of the coli group in twenty minutes. It is customary to 

ink large quantities of soda water in the East, and the very 

ictest supervision is necessary over all soda-water factories 
ensure that the returned bottles are properly washed in 

tlorinated water before being refilled, and that only properly 
terilised water is used for aeration. 

At the base and behind the line all excrement should be burnt 
in an incinerator ; the urine pails should be emptied twice 
daily into a suitable soakage pit. In the vicinity of the front 
line deep trenches must be dug when practicable, and should 
be covered with a board to exclude flies. The site of all ground 
used for this purpose must be carefully marked to prevent its 
being used again. All urine must be passed into special tins 
which are emptied regularly into properly constructed soakage 
pits. Cresol should be placed in every tin before it is used. In 
permanent camps urine must be disposed of in soakage pits or 
evaporated in incinerators. 

Latrines and cookhouses must be rendered fly-proof as far 
as possible by the use of canvas screens, wire gauze, etc. Special 
attention must be directed to the breeding places of flies, and 
manure must be suitably treated and disposed of. 

Vegetables and fruits must not be eaten uncooked except 
after efficient cleansing in pure water. 

Every case suspected to be enteric fever should be notified, 
isolated at once, and sent without delay to a hospital for 



60 



MEDICAL HISTORY OF THE WAR 



infectious diseases. The occurrence of a sporadic case should 
lead to strict investigation as to a possible carrier in the troop 
or company. Spot maps must be kept of all cases and their 
probable place of origin. Every patient should be kept 
isolated until he is definitely proved not to be a carrier. 

In the event of an outbreak of enteric fever in the civilian 
population of a town or district necessarily occupied by troops, 
special hospitals must be provided and all cases should be 
compulsorily sent to them. Infected houses and areas must 
be recognized and placed strictly out of bounds. Immediate 
notification to the sanitary authorities of all suspects is essential. 
The efficiency of the measures outlined above depends very 
largely on cordial co-operation between the combatant and the 
medical or sanitary authorities. This co-operation will be very 
much closer if steps are taken to explain the reason for the 
various rules and regulations. This can readily be accomplished 
by means of an occasional short address by the medical or 
company officer. 



BIBLIOGRAPHY. 
Achard & Bensaude Infections Paratypho'idiques . . 



Archibald 

Bainbridge 
Boidin 



Boney, Grossman & 

Boulenger 
Bourke, Evans & 

Rowland 



Buxton 
Carles .. 
Coutts 
Gushing 



Enterica in the Soudan 



Paratyphoid Fever and Meat 

Poisoning. 
Sur la mortalite des fievres 

typhoides 



Report of Base Laboratory in 

Mesopotamia. 
Autogenous living Vaccine in 

the treatment of Enteric 

Fever. 



. . La Fievre Typhoide du Com- 
battant 

. . Paratyphoid in the Army at 
the Dardanelles 

. . A comparative study of some 
members of a pathogenic 
group of bacilli of the hog 
Cholera or B. enteritidis 
(Gartner) type. 
Dawson & Hume . . Jaundice of Infective Origin . . 



Bull, et Mem. Soc. 

Med. des H6p. de 

Paris, 1896. 3e S., 

Vol. xiii, p. 820. 
Journ. Trop. Med., 

1918. Vol. xxi, 

p. 229. 
Lancet, 1912. Vol. i, 

pp. 705, 771, 849. 
Arch, de Med. et 

Pharm. Mil., Paris, 

1916. Vol. Ixvi, 

p. 514. 
Jl. of R.A.M.C., 1918. 

Vol. xxx, p. 409. 
B.M.J., 1915. Vol. i, 

p. 584. 

Journ. Med. Research, 
1904-1905. Vol.viii, 
N.S., p. 431. 

Journ. de M6d. de 
Bordeaux, 1916. 
Vol. xlvi, p. 65 

Can. Med. Ass. Journ. 
Toronto, 1917. Vol. 
vii, p. 97. 

Johns Hopkins Bul- 
letin, 1900. Vol. 
xi, p. 156. 



Quar. Journ. Med., 
1916-17. Vol. x, 
p. 90. 



ENTERIC GROUP OF FEVERS 



61 



BIBLIOGRAPHY cont. 



Dawson & Whittington Paratyphoid Fever, 
of Fatal Cases. 



Durham 



A Study Quar. Journ. Med., 
1915-16. Vol. ix, 
p. 98. 

Dreyer & Ainley Walker The diagnosis of the Enteric Lancet, 1916. Vol. ii, 
Fevers in inoculated indi- p. 98. 
viduals by the Agglutinin 
Reaction. 

Some theoretical considerations Jl. 
on nature of agglutinins, to- 
gether with further obser- 
vations on B. typhi abdomin- 
alis, B. enteritidis, B. colicom- 
munis, B. lactis aerogenis and 
some other bacilli of allied 
character. 
The Paratyphoid Problem in 

India. 
Paratyphoid Infections 



of Experimental 
Med., 1900-01. Vol. 
v, p. 353. 



Firth 



Fletcher 



Fortescue-Brickdale 
Glynn & Lowe 



Goodall 



Grattan & Harvey 
Grattan & Wood 
Gwyn 



Harvey 



Hirschfeld 



Hichens & Boome 
Job & Ballet 



Ledingham 
MacAdam 



Jl. of R.A.M.C., 1911. 

Vol. xvii, p. 136. 
Jl. of R.A.M.C., 1904. 

Vol. ii, p. 241. 
Jl. of R.A.M.C., 1918. 
Vol. xxx, p. 51. 



Report on Bacteriological Ex- 
amination of Soldiers conva- 
lescent from Diseases of the 
Enteric Group. 

Notes on the Symptomatology Lancet, 1917. Vol. i, 
of Paratyphoid Fever. p. 611. 

Observations on the Serum Re- Jl. of R.A.M.C., 1916. 
action of 300 Unselected Vol. xxvii, p. 663. 
Cases of Enteric from the 
Eastern Mediterranean, with 
the Oxford Standard Agglu- 
tinable Cultures. 

Enteric Fever in Flanders, 1914 Proc. Roy. Soc. Med., 
and 1915. 1918-19. Vol. xii 

(Epid. Sect.), p. 18. 

Inquiry into small Epidemic of Jl. of R.A.M.C., 1911. 
Paratyphoid Fever in Camp. Vol. xvi, p. 9. 

Paratyphoid Fever in India . . Jl. of R.A.M.C., 1911. 

Vol. xvii, p. 143. 

On infection with a paracolon Johns Hopkins Bui- 
bacillus in a case with all the letin, 1898. Vol. 
clinical features of Typhoid 
Fever. 

The Causation and Prevention 
of Enteric Fever in Military 
Service, with Special Refer- 
ence to the Importance of 
the Carrier. 

A New Germ of Paratyphoid . . 



ix, p. 54. 

Jl. of R.A.M.C., 1915. 
Vol. xxiv, p. 491 ; 
Vol. xxv, pp. 94, 
193. 



Vol. i. 



Lancet, 1919. 

p. 296. 
A fatal case of Paratyphoid B.M.J., 1918. Vol. i, 

B simulating Typhus Fever. p. 398. 
Contribution a 1'etude de Bull, et Mem. Soc. 
1'anatomie pathologique des Med. des Hdp. de 
fievres paratyphoides. . . Paris, 1915. Vol. 

xxxix, 3e S.,p.991. 

Dysentery and Enteric Disease Jl. of R.A.M.C., 1920. 
in Mesopotamia. Vol. xxxiv., p. 306. 

An account of an infection in Jl. of R.A.M.C., 1919. 
Mesopotamia due to a bacil- Vol. xxxiii, p. 140. 
lus of the Gaertner-para- 
typhoid Group. 



62 



MEDICAL HISTORY OF THE WAR 



MacAdam 
Mackie & Bowen 

Martin & Upjohn 
Marris 

Miller 

Morley & Battinson 

Smith 
NobScourt & Peyre . . 

Perry & Tidy 

Perry .. 

Rathery & Ambard . . 

Rodet . 



BIBLIOGRAPHY cont. 

Thrombosis of Cerebral Arteries Lancet, 1916. Vol. i, 

in Paratyphoid B. p. 243. 

Note on the characters of an Jl. of R.A.M.C., 1919. 

anomalous member of the Vol. xxxiii, p. 154. 

Paratyphoid Group met with 

in Mesopotamia. 
The distribution of Typhoid Jl. of R.A.M.C., 1916, 

and Paratyphoid Infection Vol. xxvii, p. 583. 

amongst Enteric Fevers at 

Mudros, Oct.-Dec., 1915. 
The use of Atropine as an aid B.M.J., 1916. Vol. ii, 

to the Diagnosis of Typhoid p. 717. 

and Paratyphoid A and B 

Infections. 
Goulstonian Lectures on Para- Lancet, 1917. Vol. i, 

typhoid Infections. pp. 747, 827, 901. 

Acute Gangrenous Cholecystitis B.M.J., 1916. Vol. i, 

p. 444. 
Complications observees au Bull, et Mem. Soc. 

cours des fievres typhoi'des Med. des Hop. de 

et paratyphoiides. Paris, 1916. Vol. xl 

3eS. 
A Report on an Epidemic Med. Research Comm. 

caused by Bacillus aertrycke. Spec. Report Series 

No. 24. London, 
1919. 
Illustrations of the Agglutina- Lancet, 1918. Vol. i, 

tion Method of Diagnosis in p. 593. 

Triple inoculated Individuals. 
Les Fievres Paratyphoides B Paris, 1916. 

a 1'Hopital Mixte de Zuyd- 

coote, de Dec. 1914 a Fev. 

1916. 
Serotherapie antityphoi'dique : Bull. Acad. de Med., 

preparation du serum. 



Rodet & Bonnamour. Serotherapy of typhoid fever . 



Serotherapy in typhoid fever 



Paris, 1916. Vol. 
Ixxvi, pp. 83-85. 

Serotherapie antityphoidique : Bull. Acad. de Med., 
application. Paris, 1916. Vol. 

Ixxvi, pp. 114-116. 
Bull. Acad. de Med., 
Paris, 1919. Vol. 
Ixxxi, p. 759. 
PresseM6dicale, Paris, 
1920. Vol. xxviii, 
p. 81. 

The Blood pressure in Typhoid Med. Press & Circular, 
Fever. 1916. Vol. i, p. 234. 

A new chromogenous bacillus Proc. Amer. Ass. Ad- 
vanced Sc., 1885. 
Vol. xxxiv, p. 303. 

Sarrailhe & Clunet .. La Jaunisse des Camps et 1'epi- Bull, et Mem. Soc. 
demie de Paratyphoide des Med. des H6p. 
Dardanelles. Paris, 1916. Vol. xl, 

3e S., p 45. 
Brain Abscess in a Case of Para- Lancet, 1915. Vol. i, 

typhoid B. p. 852. 

Report on the probable pro- M.R. Committee, 
portion of Enteric Infections Spec. Rep. Series 
among undiagnosed Febrile No. 48. London, 
Cases invalided from the 1920. 
Western Front since Oct., 
1916. 



Rolleston 

Salmon & Theobald 
Smith 



Scott & Johnston . . 
Topley, Platts & Imrie 



ENTERIC GROUP OF FEVERS 



63 



Torrens & Whittington 
Vincent & Muratet . . 

Webb- Johnson 

Weeks 
Whittington 

Willcox 

Wiltshire & McGilli- 
cuddy 



BIBLIOGRAPHY cont. 

A Preliminary note on the 
Clinical Aspects and Diag- 
nosis of Paratyphoid Fever. 

Typhoid Fevers and Para- 
typhoid Fevers. 



Hunterian Lecture on the Sur- 
gical Complications of Ty- 
phoid & Paratyphoid Fevers. 

Empyema due to infection by 
B. paratyphosus A. 

Report on the use of Stock Vac- 
cine in infection by B. ty- 
phosus, with analysis of 230 
cases. 

Paratyphoid Fever, its clinical 
features and prophylaxis. 

Experience in Treatment of 
Typhoid Fever by Stock Ty- 
phoid Vaccine. 



Jl. of R.A.M.C., 1915. 
Vol. xxvi, p. 359. 

Military Medical 

Manuals. Trans. 

by J. D. Rolleston. 

London, 1917. 
Lancet, 1917. Vol. 

ii, p. 813. 

Lancet, 1916. VoL 

ii, p. 433. 
Jl. of R.A.M.C., 1916. 

Vol. xxvii, p. 422. 



Lancet, 1916. Vol. i, 

p. 454. 
Lancet, 1915. Vol. ii, 

p. 685. 



Note. Vincent and Muratet also quote Chevrel, Joltrain and Petitjean, 
Lenglet and Sacquepee, and Miller quotes Sawasaki, to all of whom 
reference is made in the text of this chapter. 



CHAPTER III. 

DYSENTERY. 

THE subject of dysentery is very extensive and comprises 
the knowledge of a considerable number of parasites, 
bacterial, protozoal and metazoal, which may cause 
inflammation and ulceration of the intestinal canal. The term 
" dysentery" is in many ways inappropriate and indicates solely 
the passage of blood and mucus in the stools accompanied by 
abdominal pain and tenesmus, symptoms which are common to 
several infections specifically distinct. The war presented an 
opportunity hitherto unrivalled for the study of bowel diseases, 
and this has been made full use of by bacteriologists and proto- 
zoologists. Notable advances in our knowledge of these sub- 
jects have been recorded by workers attached to the British 
forces. 

Intestinal disorders, especially dysentery, furnished a con- 
siderable proportion of casualties on all fronts ; more especially 
was this the case in the tropical and subtropical theatres of 
war. In Gallipoli, Salonika, Egypt, Palestine, Mesopotamia, 
East Africa, and even in France and Flanders, dysentery at 
different times and seasons raged in epidemics of great magni- 
tude, and as a cause of invaliding and death it supplanted the 
enteric fever of British troops in more recent wars, though, 
taking the magnitude of the forces into account, there is no 
evidence to show that its incidence was higher than in the 
South African War. 

So far as figures are available the incidence of dysentery in 
British Expeditionary Forces is shown in the following table : 



Table of Incidence of Dysentery (both Bacillary and Amoebic), 

1914-1918. 





Aug.-Dec. 
1914 


1915 


1916 


1917 


1918 






Ratio 




Ratio 




Ratio 




Ratio 




Ratio 




Total 


per 


Total 


per 


Total 


per 


Total 


per 


Total 


per 




Cases 


1000 


Cases 


1000 


Cases 


1000 


Cases 


1000 


Cases 


1000 


France 
East A/rica . . 


11 


05 


20 


03 


5,754 


4-09 


6,031 
9,369 


3-76 
486-56 


12,211 
1,646 


79 
116-51 


Salonika 










5,987 


63-89 


5,842 


28-89 


9,318 


58-23 


Italy 


















897 


9-54 


Egypt 










5,599 


31-19 


4,341 


23-13 


4,906 


21-80 


Mesopotamia 










1,839 


50-94 


4,960 


60-34 


5,445 


51-12 



64 



BACILLARY DYSENTERY 65 

Three types of dysentery, correlated to three different kinds 
of parasites, are now recognized. They are not mutually 
exclusive ; one type may be superimposed upon and complicate 
another. The principal types and their associated parasites 
are as follows : 

Bacterial . . . . Bacillary or epidemic dysentery. 

Bacillus dysenteries (Shiga and 

Flexner-Y). 
Protozoa! . . (a) Amoebic dysentery and hepatic 

abscess (amcebiasis) . 

Entamceba histolytica. 
(b) Balantidial dysentery. 

Balantidium coli. 
Verminous . . (a) Bilharzial dysentery. 

(Schistosoma mansoni, S. hcema- 

tobium and S. japonicum) . 
(b) " Dysentery " associated with 

(Esophagostomum apiostomum, 

Ascaris lumbricoides, and Ankylo- 

stoma duodenale. 

Of these only the first two are of military importance, namely, 
the epidemic or bacillary, and the endemic or amoebic forms. 
They require, therefore, more lengthy consideration ; the re- 
maining types, together with the other conditions which they 
may simulate, are of importance chiefly in connection with 
differential diagnosis. 

BACILLARY DYSENTERY. 

The characteristics of bacillary dysentery are the acuteness 
of its onset, a well-marked initial pyrexia, severe abdominal 
pain and tenesmus, the presence of Bacillus dysenteries in the 
stools, and a tendency of the disease to occur in epidemic form. 
After recovery from the initial attack, there is little tendency 
to relapse. The . pathological process consists of an initial 
diphtheritic necrosis of the large intestine, together with a 
toxaemia of varying degree. 

This type of dysentery was prevalent throughout the whole 
war. It first claimed serious attention when it broke out in 
epidemic form in Gallipoli in August 1915, where in three 
months it was responsible for a high proportion of the 120,000 
casualties evacuated from the Peninsula on account of sickness. 

From that date onwards it was much in evidence in all the 
Eastern theatres, being responsible for at least 90 per cent, of 
the acute clinical dysentery recorded. 

In France and Belgium a milder form of bacillary dysentery 

(2396) E 



66 MEDICAL HISTORY OF THE WAR 

commenced in July 1916 and reached its maximum in September 
of that year ; similar epidemics also occurred in the autumn of 
the succeeding two years of war. The maximum incidence 
recorded was 126-62 cases per 100,000 troops in September 1916. 

In the other theatres of war it was also prevalent : the ad- 
mission rate to hospital per 100,000 of ration strength varied 
from 7,900 in Mesopotamia in 1916 to 1,300 in Egypt and 990 
in Salonika in 1919 ; it exhibited also a distinct seasonal 
incidence, occurring in epidemic form as a disease of the late 
summer and autumn with a maximum prevalence in October, 
though minor outbreaks were noted during the spring months 
of March and April. Sporadic cases were apt to occur through- 
out the whole year ; but, on the other hand, during the hot 
summer months in Macedonia, Egypt, and Mesopotamia, the 
disease was almost entirely in abeyance. The case mortality 
rate is difficult to estimate ; probably it assumed its greatest 
virulence during the Gallipoli epidemic, though even there the 
death rate cannot have exceeded 5 per cent. ; statistics show 
that in Macedonia, Egypt and Mesopotamia from 1915 onwards 
it rarely exceeded 2-7 per cent. 

The true importance of this disease, as a military factor, is 
not to be reckoned solely from the point of view of the death 
rate, but from the amount of invalidism it causes, for in indi- 
viduals recovering from a severe attack the mucous membrane 
of the intestine may be so damaged as to render them unfit for 
further service. 

Mtiology. 

With regard to its aetiology, circumstances which predispose 
to the development of bacillary dysentery are just those which 
are unavoidable under the conditions of modern warfare ; that 
is, close contact of one man with another, physical exertion, a 
monotonous diet of preserved food, and one must add to these 
another factor upon which sufficient importance does not seem 
to have been laid, namely, the mechanical irritation of the 
intestinal mucous membrane by dust or sand ingested in the 
food. In desert warfare, or in arid regions such as Gallipoli 
and Egypt, it is almost impossible at times to avoid swallowing 
a considerable amount of sand with the food. This in itself is 
sufficient to produce a lienteric diarrhoea and so prepare the 
way for the activities of the dysentery bacillus, which is 
mainly disseminated by means of flies and polluted water. 

The first outbreak of dysentery on a large scale in France 
occurred during the first battle of the Somme, when the British 
occupied ground from which the enemy had been driven. It 
was known at the time that dysentery was prevalent in his 



BACILLARY DYSENTERY 67 

lines, and it was suspected that one source, at any rate, of the 
disease was the contamination of this ground. In 1918 dysentery 
prevailed at the time of the British advance under the same 
conditions. Indeed, at every phase of active movement and 
almost at any time in the fighting line, sanitary regulations 
could hardly be carried out with complete accuracy. Latrines 
could not be dug or kept so well as desirable, garbage and 
faeces could not be burnt, and the provision of water was often 
difficult. Under the latter difficulty the use of disinfecting 
water tablets was largely increased. Experience goes to show 
that all these dangers are increased when enemy lines are 
captured and occupied. 

Another cause that temporarily predisposed towards in- 
creasing the spread of the disease was found in the crowded 
state of the infantry base depots in France. Camps designed 
for 1,200 men sometimes contained between 2,000 and 3,000. 
In the event of carriers being present an accident which, in 

)ite of all precautions, occurred and always will occur such 

mditions of overcrowding materially aided the spread of the 

>ease. 

It is known that epidemics occurred amongst British prisoners 
)f war in Germany, a fact which was brought to the notice of 
War Cabinet by the Admiralty, War Office, Air Ministry, 

)lonial Office and Prisoners of War Department in a special 
>int memorandum dated 25th September, 1918. 

The dysentery bacillus was discovered in Japan in 1897 by 
)higa, and in 1900 an organism, morphologically similar, but 
differing in its power of fermenting mannite, was isolated by 
Flexner in the Philippines. Since that date a great deal of 
attention has been paid to this subject, with the result that 
many variants of these two organisms have been described. 
The bacteriology of bacillary dysentery attracted a considerable 
amount of attention during the war. Interest centred chiefly 
around the mannite-f ermenting bacilli first described by Flexner 
and afterwards elaborated by Hiss and Russell, Strong and 
others. This work was important mainly from the point of 
view of laboratory diagnosis and the preparation of effective 
anti-sera, and it was undertaken by Murray, Gettings, Dudgeon, 
Andrewes and Inman. 

The species of bacteria which are now recognized in bacillary 
dysentery are : Shiga's bacillus, the Flexner-Y group of bacilli, 
and certain atypical bacilli. 

Shiga's bacillus, fermenting glucose only amongst the sugars 
and alcohols* employed as tests, and forming no indol, has 

* The fermentable substances of real service in the classification of the 
dysentery group are four in number : glucose, mannite, lactose and dulcite. 



68 MEDICAL HISTORY OF THE WAR 

been abundantly proved to be the cause of dysentery. Being 
much the most toxic of dysentery bacilli, it is responsible for 
the most serious cases and for the greater number of fatalities. 
It was recorded commonly from all theatres of war. In the 
East it accounted for about half the number of cases and showed 
no special epidemic prevalence ; in France and Belgium, on 
the other hand, it apparently played a minor part, on the whole 
accounting for 15 per cent, of the dysenteries. It predominated 
at the commencement of the epidemic in August and September 
1916, but was more or less replaced by Flexner bacilli later on 
in the late autumn. In about 2 or 3 per cent, of bacteriologi- 
cally diagnosed cases both Shiga and Flexner bacilli co-existed. 

The Flexner-Y group of bacilli apparently belongs to a single 
species, fermenting glucose and mannite, but not lactose or 
dulcite. As in the case of the former organism, the evidence 
connecting this species with dysentery is complete. The 
researches of Gettings, Murray, Andrewes and Inman 
undertaken on a large scale have indicated that serological 
races of the species exist. It may be regarded as a 
group formed of at least four distinct antigenic components 
which have been provisionally lettered V, W, X and Z. 
Any of these four components may so preponderate in 
different strains as to impart a distinct serological facies. 
The corresponding agglutinins are not mutually absorbed, 
except in a slight degree. In addition to the four serological 
races thus denned, there remains the true Y bacillus of Hiss and 
Russell, which presents differences in its agglutinability and 
agglutinogenic capacities. These bacilli are not nearly so toxic 
as is Shiga' s bacillus and are responsible for the milder and 
more chronic forms of the disease, though occasionally they may 
become virulent and cause death. That is to say, two species, 
namely the Shiga and the Flexner-Y bacilli of various sero- 
logical races, are responsible for the vast majority of cases of 
bacillary dysentery. 

Other organisms which have been described during the war* 
and have been called atypical bacilli are bacilli resembling 
Flexner's bacillus but fermenting dulcite and separable 
from the latter on serological grounds, and a bacillus 
resembling Shiga' s in its sugar reactions, but forming indol and 
not agglutinating with Shiga antiserum, first described by 
Schmitz, in Austria, as the cause of dysentery and apparently 
identical with the B. ambiguus of Andrewes and the one 

* Dumas has lately shown that the atypical organisms may be distinguished 
further by their power of producing fluorescence in media impregnated with 
neutral red, as well as by reduction of 1 per cent, lead acetate, thereby produc- 
ing a black line in a stab culture of agar containing this substance. 



BAGILLARY DYSENTERY 69 

described by Remlinger and d'Herelle. Together with these may 
be grouped organisms which ferment lactose early and differ 
serologically from the Flexner-Y group. There is no evidence 
for inculpating either of these groups, and they may be 
classified as " atypical" or " inagglu tumble " strains. 

These latter need not claim the serious attention of the expert 
bacteriologist, though they constitute a source of fallacy to the 
beginner. 

Morbid Anatomy. 

With regard to the morbid anatomy of bacillary dysentery, 
the gross pathological appearances of the organs vary con- 
siderably according to the acuteness of the process in different 
individuals, and indeed in different epidemics, though the under- 
lying process is essentially the same in all cases. It is probable 
that no such opportunity has ever before presented itself for 
studying the effects of the dysenteric toxins upon the intestinal 
mucosa as was afforded to pathologists in the Eastern theatres 
of war. In mild cases it is naturally difficult to define the 
exact appearances of the earliest lesions ; the inflammatory 
changes originate in the first instance in the solitary lymphoid 
follicles of the large intestine. From these, superficial " snail 
track " liberations spread across the bowel, especially upon the 
free transverse folds, and the surrounding mucous membrane 
is involved in a greater or lesser degree with hypersecretion 
of viscid mucus. The abdominal viscera do not exhibit any 
striking changes. 

In veryacute cases, succumbing to an overwhelming infection, 
the chief change is seen in the intestinal mucosa, but there are 
present as well abundant signs of a widespread toxaemia in 
other organs of the body. At first the process consists of acute 
hyperaemia of the mucosa of the large intestine, which, should 
life be sufficiently prolonged, ends in colliquative necrosis of 
the mucosa with involvement of the last two feet of the ileum 
though, rarely, the whole of the ileum and the greater part of 
the jejunum may be similarly affected. 

It is not generally realized that the specific lesions are most 
developed in the lower part of the intestinal canal, especially 
the rectum and pelvic colon. On opening the abdomen a 
paralytic distension of the large intestine is often found ; the 
mucosa is bright red in colour, very friable, and may actually 
drip with blood. Few, if any, intestinal contents will be found 
and the lumen may be occupied by viscid blood-stained mucus, 
or it may be pure blood and serous fluid. A general lymphoid 
peritonitis has been observed with the escape of free serum into 
the peritoneal cavity and the deposition of lymph flocculi on 



70 MEDICAL HISTORY OF THE WAR 

the peritoneal surface, together with oedema of the mesentery, 
especially at its posterior attachment. Post-mortem intussus- 
ception may occur. The mesenteric glands are inflamed and 
diffuse. The right side of the heart is engorged, the liver en- 
larged and congested with consequent parenchymatous changes. 
The gall bladder usually contains scanty and viscid amber- 
coloured bile. The spleen is generally dark, engorged and 
slightly diffluent, weighing about ten ounces. The suprarenal 
glands are congested and may show central necrosis. 

In cases which do not run such a rapid course the intestinal 
mucosa is of plum-red colour, stippled with submucous 
haemorrhages, and the whole gut wall infiltrated and cedematous. 
Should the patient survive a week or more, these inflammatory 
changes result in colliquative necrosis of the mucosa ; the 
mucous membrane is converted into an olive-green, or it may 
be blackish, substance, rigid to the touch, and often honey- 
combed in a peculiar manner ; this substance represents the 
dead and functionless mucous membrane and it is therefore 
incorrect to describe it as " diphtheritic " dysentery, a term 
used by German authors. Exceptionally, the whole bowel 
wall may be converted into such a gangrenous substance. The 
peculiar green tint which this necrotic mucosa assumes is 
thought to be due to staining of the defunct tissues by bile 
pigments. 

The intestinal contents in these cases generally consist of a 
dark-grey fluid containing much altered blood without the 
addition of mucus, which cannot be secreted when once the 
destruction of the goblet cells has taken place. The colli- 
quative necrosis may have a patchy distribution and may be 
confined to limited areas, as for instance, the hepatic and 
splenic flexures, or the descending and pelvic colons. 

Should the patient survive, as he seldom does, such an exten- 
sive destruction of the bowel wall, the now defunct membrane 
is exfoliated in much the same manner as a diphtheritic mem- 
brane, exposing a raw, bleeding, granulated surface underneath. 
In a bowel which has undergone such disintegration complete 
regeneration of the mucosa does not take place ; restoration 
of the mucous membrane proceeds from islands of mucous 
membrane which escape unscathed. The whole process of 
repair would appear to constitute a struggle between proli- 
feration of the specialized epithelium and fibrosis. 

Chronic ulceration of the large bowel in bacillary dysentery 
takes place in varying degrees of severity. The smallest lesions 
consist of lenticular ulcerations of the mucous membrane, 
involving the mucosa alone ; the more advanced lesions consist 
of ulceration of limited tracts of the mucosa, rarely penetrating 



BAGILLARY DYSENTERY 71 

beneath the muscularis. That ulceration may, although very 
rarely, proceed to ante-mortem perforation appears to be beyond 
doubt. The ulcers are roughly ovoid in shape, and run 
transversely to the long axis of the gut. 

The ulcers of bacillary dysentery may be distinguished from 
lesions in dysentery of amoebic origin by the fact that they 
commence on the free edge of the transverse folds and run 
transversely, not longitudinally, to the long axis. In shape they 
are irregular in outline, with ragged undermined edges, often 
intercommunicating with neighbouring ones in contradis- 
tinction to the oval and rather regular shaped, isolated amoebic 
ulcer. The intervening mucous membrane is hyper aemic, 
cedematous and plum-coloured and there is no compensatory 
thickening of the gut. In amoebic ulcers, on the other hand, 
the intervening mucous membrane is healthy and there is 
considerable hypertrophy of the gut wall. 

Another pathological condition, which is the direct sequel of 
chronic bacillary dysentery, and has so far attracted little 
attention, is the presence of tapioca-like mucus-retention cysts, 
varying from microscopic proportions to the size of a cherry 
stone, which jut out on to the mucosa and are situated beneath 
the scars of old ulcers. These cysts become secondarily 
invaded by B. coli organisms and frequently a peculiar B. coli 
septicaemia results, leading to formation of pyaemic abscesses 
in the cortex of the kidneys and very often to a fatal termination. 
They appear to be formed as the result of an adenomatous 
downgrowth of Lieberkiihn's follicles into the submucosa. 
Apparently in the formation of scar tissue part of the fundi of 
the crypts is nipped off. 

Polypoid outgrowths reaching f to 1 in. in length, scattered 
throughout the rectum, have been observed as the result of a 
chronic bacillary infection. 

Typical dysentery bacilli can be isolated from the gut in all 
stages of the disease. When the mucous membrane is necrotic, 
it is necessary to remember that successful isolation depends 
upon procuring material from beneath the necrotic tissue, where 
alone the bacillus can be found ; for this purpose one should 
sear the tissue with a red-hot knife and then scrape it away. 
Failure to remember this results in the isolation of putrefactive 
organisms, such as B. pyocyanem, which are found in necrotic 
tissue and which have nothing whatever to do with the patho- 
genesis of acute dysentery. 

The bacillus has been recovered from the mesenteric glands, 
but never from the bile or blood post-mortem, though Flexner-Y 
organisms have been isolated from the blood-stream during life 
by Ledingham, Boyd, and others, and it is recorded that Wilson 



72 MEDICAL HISTORY OF THE WAR 

in France recovered the bacillus on three occasions by 
haemoculture of 88 acute Shiga cases. He also obtained both 
organisms, Shiga three times, Flexner eight times, out of 1,113 
urines cultured. 

In the most acute stage the mucous membrane is infiltrated 
with lymphocytes and plasma cells, the capillaries are engorged 
and the submucosa is the seat of numerous capillary haemor- 
rhages. The goblet cells show signs of great secretory activity. 
The inflammatory changes are most intense in the lymphoid 
follicles. 

In the necrotic stage the whole mucosa has undergone 
coagulation necrosis and is converted into a structureless layer, 
in which only polymorphonuclear leucocytes with disintegrated 
nuclei can with difficulty be distinguished. The submucosa is 
greatly thickened to twice or three times its normal dimensions 
owing to oedema and haemorrhage. In fact, the chief feature 
would appear to be the destruction, or endothelial spoiling, of 
the nutrient vessels. 

In the majority of microscopic sections of such an intestine, 
numbers of large macrophage cells, derived apparently from the 
endothelium of blood capillaries and lymphatics, may be 
distinguished. These cells are often of a considerable size, 
15 to 20 microns in diameter, and may contain ingested leucocytes 
and red blood corpuscles. When voided in the stools they 
constitute a characteristic feature of the cellular exudate and, 
owing to their large size, refractility and phagocytic propen- 
sities, are apt to be mistaken for Entamceba histolytica, a point 
which will be referred to later. 

Amongst Eastern peoples who are subject to recurrent 
attacks of bacillary dysentery, acute lesions are occasionally 
seen in a bowel which has recovered from a previous attack, 
with consequent scarring and fibrosis. The amount of destruc- 
tion to which such a bowel may be subjected, compatible with 
life, has to be seen to be believed. Some of the large intestines 
of Turkish prisoners for instance resembled pieces of parchment 
with radiating fibrotic scars, the result of healed dysenteric 
ulcers. 

Amoebic ulceration may be superimposed upon a healed 
bacillary dysentery, though it is more usual to find an acute 
bacillary process terminating the more chronic amoebic disease. 

Symptoms. 

The incubation period of bacillary dysentery is probably 
2 to 7 days. The clinical symptoms are never so 
characteristic that the clinician can afford to neglect the 
advantages of a laboratory diagnosis, and there is no disease 



BACILLARY DYSENTERY 73 

in which the mutual co-operation of the clinician and path- 
ologist is so necessary. All degrees of severity may occur, 
from a mild diarrhoea of three days' duration with passage of 
blood and mucus in the stools, to fulminating cases with 
death supervening in the same period. 

On clinical grounds, bacillary dysentery can be classified into 
five types (a) mild, (b) acute, (c) toxic or fulminating, (d) re- 
lapsing, and (e) chronic. 

The fulminating type may be divided into two sub-groups 
the choleraic and the gangrenous. The onset is acute, generally 
with vomiting ; collapse with its attendant phenomena sets in 
early. The temperature is subnormal, the tongue dry and 
glazed, the skin cold and clammy, and the patient may 
complain of cramps. There is an initial watery diarrhoea, 
which is soon replaced by dark-red mucus containing a high 
proportion of blood or, it may be, serum alone. It is hardly 
necessary, from their superficial resemblance to cholera, to 
emphasize the importance of these cases. 

The gangrenous form also commences suddenly with a rigor, 
headache and vomiting and other evidences of a severe toxaemia. 
The face is flushed ; the pulse rapid and bounding. The ab- 
dominal pain and tenesmus are very severe, but as the toxaemia 
increases these wear off. This is a point in prognosis, and one 
should be suspicious of patients with pyrexia who become 
insensitive to abdominal pain ; it is by no means a favourable 
omen. The stools at first resemble " meat-washings," but 
towards the end are composed of dark-grey offensive fluid, 
containing much altered blood. The underlying pathological 
cause of the absence of mucus is to be found in the total 
destruction of the goblet cells. 

Important points to remember about the chronic form, 
which is more frequently seen in debilitated natives, are its 
intractability and the nature of the stools, which may show no 
external signs of blood or mucus for many months at a time. 
The great improbability, amounting sometimes to an 
impossibility, of isolating a dysentery bacillus from the faeces, 
though the organism may be present in the intestinal wall and 
can be found at autopsy, renders the diagnosis of these cases 
during life a matter of very great difficulty indeed. 

Several complications occur in connection with bacillary 
dysentery. Of these arthritis is the most frequent ; it generally 
affects one joint alone, but cases have been recorded in which 
both knees, wrist, fingers and even the temporo-mandibular 
joint have been involved. It is apparently quite common in 
some epidemics, and one small series of cases was observed in 
Egypt in which no less than 27 per cent, developed poly- 



74 MEDICAL HISTORY OF THE WAR 

arthritis. The joint effusion is ushered in by pyrexia, rarely 
during the acute stages of the disease, more generally after 
the tenth day of the disease when the stools have once again 
become faecal. The cases are usually Shiga infections, though 
Flexner cases have been recorded by Waller in Mesopotamia. 
The joint fluid is clear, never purulent, and is usually 
sterile on culture, though in one instance a culture of Shiga' s 
bacillus was obtained from the joint fluid by Elworthy. Waller 
has recorded that it usually contains specific agglutinins for 
this organism. In the majority of cases the fluid is completely 
absorbed and no permanent injury to the joint remains, albeit 
convalescence may be considerably protracted. 

General cedema was- noted in Salonika in acute phases of 
some Shiga infections, in which there appeared to be a flooding 
of the tissues with dysentery toxins. In late stages also cedema 
was noted together with the development of ascites. No 
evidence of a coincident nephritis was obtained. 

Conjunctivitis with pain, lachrymation and photophobia 
must now be regarded as due to the absorption of dysenteric 
toxins. It is liable to ensue from the 14th to the 34th day of the 
disease in convalescent cases and appears to have been specially 
common in Salonika. Iridocyclitis must also be regarded as a 
complication although a rare one. It bears no characteristic 
features and usually supervenes during convalescence. It is 
usually associated with arthritis. 

Parotitis, either uni- or bilateral, may supervene, though it 
is by no means certain whether it can be regarded as a true 
complication. 

Intussusception of the large intestine may occur, though it 
is more usually found in children. 

Collapse may occur early in the illness from toxaemia, or 
later in the third or fourth week apparently from physical ex- 
haustion and the draining of fluid from the body by continuous 
evacuations. The clinician should always be on his guard to 
forestall, if possible, this serious condition. 

Neuritis of one or both legs following bacillary dysentery 
has been noted in chronic cases. It is doubtful whether the 
complication is to be ascribed to dysentery toxins or to an in- 
dependent infection. 

The sequelae of bacillary dysentery may be the result of 
mechanical alterations to the bowel wall, or the direct effect of 
the absorption of toxins. In the former instance stenosis of 
the large intestine may occur leading to an obstinate post- 
dysenteric constipation with painful peristalsis and dyspeptic 
symptoms. 

Tachycardia subsequent to bacillary dysentery was 



BACILLARY DYSENTERY 75 

frequently observed in men in convalescent camps. It may 
be ascribed partly to the physical exhaustion this disease 
entails and partly to a toxic myocarditis. If neglected, or 
unrecognised, it may even lead to sudden cardiac failure. 

Enright and Manson-Bahr have shown that invasion of the 
blood-stream by Bacillus coli is liable to take place through the 
chronic bacillary lesions, leading to formation of metastatic 
abscesses in the kidneys. 

Prognosis. 

The prognosis in bacillary dysentery depends very much 

upon the virulence of the particular epidemic, the age and 

physical condition of the patient. The infection appears to be 

specially virulent in those races, who for generations past have 

not been exposed to infection. 

The prognosis is not good in cases with a subnormal tem- 
perature, rapid pulse, and a tendency to collapse ; while vomit- 
ing and persistent hiccough may be regarded as constituting 
almost invariably fatal signs. In the majority of cases, as 
regards expectation of life, the prognosis may be considered 
good, but it is otherwise as regards the permanent injury to 
the intestinal canal which this disease involves. 

A series of 70 cases specially observed in France by Captain 
H. Letheby Tidy may be quoted here as probably typical of the 
usual disposal of the patients. The cases fell into three groups : 

(1) Evacuated to convalescent depot. 50=71 per cent. 

(2) the United Kingdom 12=17 

(3) Method of evacuation doubtful .. 8=12 

In the cases of the first group the average duration from onset 
to evacuation to a convalescent depot was 30 days, and the 
average duration of diarrhoea 8 days, leaving 22 days in hos- 
pital after cessation of diarrhoea before the men were fit for con- 
valescent life. The factors which were found to be important 
in estimating such fitness were the condition of the bowels and 
the pulse. 

A man was considered to have diarrhoea if he had more than 
two motions daily. Until diarrhoea in this sense had been 
absent for one week he was not fit for solid diet, and only if one 
week on solid diet produced no relapse of diarrhoea was he fit 
for the convalescent depot. Softness of the motions appeared 
to be of much less importance than their frequency. No cases 
were sent to the convalescent depot unless the stools had been 
negative for three consecutive examinations. 

In some cases, usually in the fourth week, the pulse became 
rapid. When this occurred the patient needed a long convales- 
cence. 



76 MEDICAL HISTORY OF THE WAR 

The second group comprised all cases which had been classed 
as dangerous from their general symptoms, and all cases which 
on the 20th day from onset were still passing four stools daily. 
All such cases were found to need a long period of treatment 
and recovered very slowly. 

From the military standpoint all cases of the disease, even if 
apparently mild, should be considered unfit for duty until a 
microscopic examination of the faeces shows an absence of any 
inflammatory cells or desquamated epithelium and until com- 
plete restoration of the digestive functions has been established. 

Many clinically severe cases recover completely, while others 
continue to pass diarrhceic and dysenteric stools, it may be for 
several years after the initial attack ; in these the destruction of 
the bowel tissue is progressive and they ultimately end fatally. 
Cases initially acute with persistent diarrhoea should no longer 
be considered fit for active service. Those with chronic ulcera- 
tion of the bowel and continuous passage of mucopurulent 
stools are most intractable and distressing and should therefore 
be regarded as entitled to permanent pensions. 

It is questionable how far the mucosa can regenerate 
after such a severe destruction, but undoubtedly many cases, 
especially in the young and vigorous, completely recover and 
should be judged upon their general condition. In contra- 
distinction to the amoebic form, bacillary dysentery is not 
prone to relapse and need not necessarily be pensionable. 
But it should be borne in mind that a previous bacillary ulcera- 
tion undoubtedly predisposes to the development of amoebic 
colitis. Cases of this nature are being frequently encountered 
among pensioners who suffered undoubtedly from bacillary 
dysentery in the first instance, but whose subsequent relapses 
were due to infection with the Entamceba histolytica. 

Bacillary dysentery when complicated with other specific 
fevers is a dangerous combination ; in Gallipoli it co-existed 
frequently with paratyphoid fevers and it may be mentioned 
that subtertian malaria together with bacillary dysentery 
generally assumes a grave aspect and requires a most vigorous 
and thorough antimalarial treatment. A grave prognosis 
should also be given in cases complicated with lobar or broncho- 
pneumonia. 

The average duration of invalidism from dysentery may be 
gathered from the following tables. In the first, compiled from 
index cards and admission and discharge books by the Medical 
Research Council, a series of 3,000 cases of dysentery has been 
taken from the records of patients treated in military hospitals 
in France and Gallipoli in 1915, and includes cases both of brief 
and of long duration. The second table shews a series of 2,000 



BACILLARY DYSENTERY 



77 



cases from France, Salonika, and Egypt during 1917 and 1918, 
taken from the records of cases treated to a conclusion in the 
special convalescent depot for dysentery at Barton-on-Sea. 

Cases of Dysentery in 1915. 



Force from which 
derived. 


No. of Cases. 


Total No. of Days 
under Treatment. 


Average No. of 
Days under Treat- 
ment. 


France 
Gallipoli 

Total 


681 
2,319 


28,823 
175,365 


42-3 
75-6 


3,000 


204,188 


68-1 



Cases of Dysentery in 19171918. 



Force from which 
derived. 


No. of Cases. 


Total No. of Days 
under Treatment. 


Average No. of 
Days under Treat- 
ment. 


France 
Salonika 
Egypt 

Total 


1,586 
330 
84 


187,666 
82,672 
12,018 


118-3 
250-5 
143-1 


2,000 


282,356 


141-2 



The various forms of dysentery have not been differentiated. 

Diagnosis. 

Though acute dysentery, occurring in epidemic form in 
armies in the field, may be justifiably regarded as bacillary 
dysentery, yet it is always advisable to resort to laboratory 
diagnosis whenever possible. It was found, however, even in 
France, where the facilities for scientific work were probably 
greater than in any other of the theatres of war, that it was 
quite impossible for bacteriological examination to be applied 
to all cases admitted to casualty clearing stations. It was 
accordingly ordered that cases, in which the passage of blood 
and mucus was observed, should be diagnosed as " clinical 
dysentery," and that the bacteriologist's labours should be 
directed first to the cases in which these symptoms were not 
established. This examination presented many difficulties to 
the uninitiated. In order to economize in men and material it 
was advisable to employ as pathologists those who had been 
especially trained in this branch of work, for besides a knowledge 



78 MEDICAL HISTORY OF THE WAR 

of bacteriology, a considerable insight into cellular pathology 
and an intimate acquaintance with the varied protozoological 
fauna of the intestine are required. 

The gross character of the stools passed during different 
stages of the disease varies considerably and certain rules may 
be laid down for the guidance of the military clinician, though it 
must be admitted that exceptions occur. The acute bacillary 
stool consists of pure blood and mucus, or more accurately 
" bloody mucus." It is in fact mucus tinged with bright 
red blood, of extreme viscosity, and tending to adhere to 
the bottom of the bed-pan or containing vessel. It is 
odourless or bears a faint smell of spermin. It represents, in 
fact, an acute inflammatory exudate, derived from the mucosa 
of the whole or major part of the large intestine. The amoebic 
stool, from which it is necessary to differentiate it, is composed 
of blood and faeces intimately mingled, is very offensive, not 
viscid, and represents the exudate and sloughs derived from 
ulcers throughout the canal, the dark altered blood being 
derived from small intermittent haemorrhages at the bases of 
these ulcers. 

The diagnosis of bacillary dysentery can be made sufficiently 
accurate for all practical purposes by examination of the 
cellular exudate alone. In military practice what is most 
required is promptness ; it is necessary to diagnose early in 
order to save the patient's life. The clinician in a casualty 
clearing station cannot afford to wait twenty-four hours before 
applying the appropriate remedy. If a few hours' delay takes 
place, it may result in irreparable damage to the gut wall, and 
one cannot restore a once scarred and fibrosed intestine. 

A provisional laboratory diagnosis may be made by direct 
examination of the cellular exudate under the microscope, by 
recognition of the predominant type of cell and by exclusion 
of the Entamceba histolytica. As seen under the one-sixth lens 
the characteristic cellular picture is one composed for the most 
part of undamaged polymorphonuclear leucocytes. They 
constitute over 90 per cent, of all the cells in the exudate. 
Willmore and Shearman have noted that the ringing of the 
nuclei of these cells is specially distinctive. The large macro- 
phage cells, which, as previously mentioned, are derived from 
the submucosa, constitute about 2 per cent, of the cells and are 
present in the mucus, especially in the early stages of the 
disease. They are large hyaline cells 20-30 microns in diameter ; 
sometimes they are round, oval or even bi-lobed in outline and 
in their protoplasm they contain vacuoles and fatty globules of 
various shapes and even ingested red cells or leucocytes. The 
pathologist should make himself familiar with these cells as 






BACILLARY DYSENTERY 79 

they are extremely liable to be mistaken for Entamceba his- 
tolytica and consequently lead to a mistaken diagnosis. 

The following are the points which require attention, in order 
to avoid those mistakes in diagnosis which frequently occurred. 
In bacillary dysentery the macrophage cells are defunct and 
consequently non-motile ; they are by no means as refractile as 
is the Entamceba histolytica and their protoplasm has a bluish 
ground glass appearance. The characteristic endothelial 
nucleus can seldom be made out as it is usually undergoing 
chromatolysis. Columnar epithelial cells are frequently present 
with the macrophage cells and, in the later stages of the disease, 
intestinal protozoa such as Entamceba coli and intestinal flagel- 
lates ( Trichomonas and Chilomastix) may make their appearance. 
The Entamceba coli is specially liable to cause a fallacy in 
diagnosis, for, unless the pathologist is familiar with the morpho- 
logical characters of the non-pathogenic amoebae, a mistaken 
diagnosis, or even a suspicion of a double infection with the 
two main forms of dysentery, may arise. 

For successful laboratory diagnosis it is essential that the 
stool should be fresh and passed early in the course of the 
disease.* It should, if possible, be collected in a bed-pan 
without admixture of urine and brought straight to the 
laboratory. On no account should the selection of a portion 
of the stool suitable for examination be left to an attendant 
or orderly, for it may happen that an unsuitable portion may 
be chosen and unnecessary delay thereby caused. The 
dysentery bacilli are delicate and soon become overgrown by 
more hardy saphrophytic organisms ; in hot climates this 
decomposition takes place very rapidly, usually in a period 
of four to six hours. A better method, wherever it can be 
arranged, is for the pathologist himself to obtain a portion 
of blood and mucus direct from the patient by means of a 
rectal swab. 

Dysentery bacilli, especially Shiga's bacillus, grow less 
vigorously than other intestinal organisms and their growth 
may be easily inhibited by the employment of dyes or inhibiting 
agents. Probably the best medium for the purpose is litmus- 
agar containing 1 per cent, of lactose, though MacConkey's 
medium is widely used and gives satisfactory results. A 
small portion *of blood and mucus which, if contaminated with 
faeces, should be first washed in sterile water or saline, is 
spread upon the dried surface of the plate in a spiral manner. 

* The statistics of Martin and Williams show that, out of 1,050 efforts to 
recover the dysentery bacillus at various periods of the disease, 68 per cent, 
of positive results were obtained in the first five days, 17 '4 per cent, in the 
second five days, and 6 3 per cent, in the third five days. 



80 MEDICAL HISTORY OF THE WAR 

One need not be too sparing with the amount used, and no 
attempt should be made to incubate the mucus in ordinary 
bile broth preliminary to plating. The plate should be 
examined by means of a watchmaker's lens after 24 or pre- 
ferably after 48 hours, as the dysentery colonies become more 
obvious after prolonged incubation. They are transparent, 
of a small size and bluish colour. They generally occur in 
irregular chains interspersed between other more vigorous 
organisms. Considerable experience is necessary before one 
becomes so familiar with their appearance as to be able to 
differentiate them from those of B. facalis alkaligenes and 
the intestinal streptococci. 

For rapid identification of the bacilli under active service 
conditions it suffices to pick off a certain number of colonies by 
means of a platinum spud and, after making a dense emulsion 
in a small quantity of saline, to place them with drops of 
specific Shiga and Flexner-Y sera, in suitable dilutions, upon 
a Garrow's agglutinometer. On this instrument macroscopic 
agglutination takes place within five minutes, and is therefore 
of considerable practical importance. Should marked agglu- 
tination in one or other serum take place, subculture should 
be made on to agar, to be subsequently confirmed by sugar 
reactions. 

For more complete diagnosis subcultures should be made 
direct from the colonies on to agar, the organism stained by 
Gram and tested for absence of motility. Subcultures should 
be planted out on to four sugar media, viz., glucose, lactose, 
mannite, and dulcite, and the reactions recorded after 24 hours' 
incubation at 37C. The results obtained should be confirmed 
by agglutination, for which suitable polyvalent sera, embracing 
if possible the five chief types of Flexner-Y, are necessary, 
together with a Shiga serum. The macroscopic method must 
be resorted to, the microscopic being fallacious. Progressive 
dilutions of specific serum should be made in tubes until a 
titre of 1 : 2000 is reached, to which opalescent emulsions of 
the organisms should be added. It should be remembered 
that dysentery bacilli do not agglutinate readily, so that the 
time allowed should be at least four hours at 50C. in a water 
bath, and precipitation should be permitted to occur at the 
air temperature for which an additional 10 to 12 hours should 
be allowed. 

A reliable emulsion can be made from a 24-hour broth 
culture to which 0-1 per cent, formalin has been added. 
Paragglutination may occur by this means, so that it is best 
to neglect results not attaining to a quarter of the full titre 
of the serum. 



BACILLARY DYSENTERY 81 

Serodiagnosis is a method of diagnosis applicable only to 
convalescent cases ; it is obviously unsuited to acute cases 
in whose blood agglutinins have not yet formed. In skilled 
hands, however, it has proved its value. Dreyer's technique 
should be employed, on account of the standardization 
of the emulsions, and according to Martin gives useful 
information in about 50 per cent, of cases. In the case 
of Shiga dysentery, provided that ultra-sensitive strains are 
not used, the diagnosis is consistent, but in the case of 
Flexner-Y dysentery the results have been less encouraging, 
possibly because a sufficiently wide range of agglutinable 
emulsions has not so far been available. These emulsions 
should now consist of the five serological races of 
Andrewes and Inman, comprising the V,.W, X, Z, and the Y 
bacillus of Hiss and Russell. It is obvious that the employ- 
ment of so many emulsions must render this method of 
diagnosis a very laborious one, and therefore unsuited to 
routine use in times of pressure. The general opinion appears 
to be that in Shiga infections a positive diagnosis can be 
established by agglutination occurring in a dilution of 1 : 25 ; 
but in the case of the Flexner-Y group it it necessary that 
agglutination should occur in a considerably higher tit re, at 
least 1 : 50. In making such a diagnosis the possibility of the 
patient having suffered from an attack of dysentery previous 
to the one under consideration, and the possible effect of 
inoculation with dysentery vaccine, must be taken into account. 

Treatment. 

With regard to treatment, should bacillary dysentery be 
brought under treatment at an early stage of the disease, a 
cure is a matter of no very great difficulty ; this is especially 
true of the more acute types of the disease. In war, however, 
it is obvious that this cannot always be done, and, therefore, 
under these conditions a certain amount of destruction of 
the mucous membrane has already taken place before an 
opportunity for efficient treatment is secured. 

The main principles consist in placing the patient so that 
his intestinal canal is at rest and the diet he absorbs is as 
nutritious as possible, with the least amount of non-absorbable 
residue. 

Fulminating cases require the most vigorous measures, and 
the methods adopted may be applied with modifications to 
the less acute clinical forms. 

If collapse is imminent it is best to keep the patient warm 
with hot water bottles. When the passage of stools is almost 
continuous the patient should on no account be permitted 

(2398) F 



82 MEDICAL HISTORY OF THE WAR 

to exhaust his strength by straining on a bed-pan ; it is much 
better in these cases to pack him well with tow or cotton wool 
on a waterproof sheet, which can be changed every few minutes. 
It is most necessary to forestall, if possible, the advent of 
collapse, for when once this condition has been fully established 
it is too late to restore the patient. Intravenous injections of 
normal saline should be generously given, up to tw r o or three 
pints. Even more has been advocated. The injection of 
smaller quantities is followed by a temporary improvement 
only. To the saline solution may be added atropine, gr. J^Q in 
1 pint of water. Good effects have been obtained by intra- 
venous injection of Rogers' hypertonic saline (sod. chlor., grs. 
120, calc. chlor., grs. 4, pot. chlor., grs. 6, water, 1 pint, to 
which may be added glucose, grs. 35). This solution should 
be given slowly, and at a temperature of 104 F. 

It is customary to commence treatment by a preliminary 
purge in order to clear the large intestine of any remaining 
faecal contents ; the best for this purpose is J-ounce of castor 
oil containing about 15 minims of tinct. opii. The following 
morning routine treatment with saline aperients should be 
commenced. The best salt is the sodium sulphate, which 
should be given in drachm doses every two hours for the first 
twenty-four; thereafter, every four hours until the stools 
become faeculent. The routine use of opium in the treatment 
of bacillary dysentery cannot be too strongly deprecated. Its 
main uses are to procure rest and sleep, or to enable a patient 
to stand a long journey as, for instance, evacuation from a 
field ambulance, but it should on no account be regarded as 
a means of curing the disease. 

Tenesmus and dysuria are best relieved by a cocaine 
suppository ; if excessive, a morphia injection is permissible. 

The routine use of bismuth has many adherents, but it has 
little result save to clog up the bowel, which should be kept 
clear of contents as much as possible. 

In Central Europe, bolus alba-kaolin, with the addition 
of animal charcoal in doses of three tablespoonfuls of each, 
is used. It is said to check excessive diarrhoea and to act as 
an intestinal antiseptic. 

Intestinal antiseptics, such as salol or cyllin, do not appear 
to have much effect in the acute, though they have their 
uses in the chronic forms. 

Treatment by anti-dysenteric serum has been employed, 
and diverse opinions have been expressed regarding its value. 
The serum which is placed on the market is a polyvalent one, 
and, as pointed out by Dudgeon, its chief deficiency is in 
anti-Shiga immune bodies. If it were possible to obtain a 






BACILLARY DYSENTERY 83 

greater degree of anti-bacterial power towards Shiga's bacillus 
than is at present the case, the diversity of opinion which 
exists would probably soon disappear. In the future it may 
be more advantageous to issue a Shiga monovalent serum 
to field medical units, since the Shiga infections are clinically 
the most severe and therefore the most likely to require this 
form of treatment. The main point with reference to anti- 
serum is that it should be given early, if possible during the 
first five days, and in sufficient quantities. Bacillary dysentery 
has many points in common with diphtheria, and the action of 
anti-dysenteric serum may perhaps be regarded as analagous 
to that of anti-diphtheritic serum. Once the mucous mem- 
brane of the gut has become necrotic, it is doubtful whether 
the serum has any effect at all. It is obvious, therefore, that a 
field medical unit, and not a base hospital, is the proper place 
in which to administer it. 

In very acute cases, the intravenous route, in doses of 60 c.c., 
is the most efficacious. The next most efficacious method 
is the intramuscular route ; this proved to be a most con- 
venient method. A large amount of serum up to 120 c.c. can 
be injected with the minimum of pain into the adductor 
muscles of the thigh, where the intramuscular planes will 
accommodate large quantities. When it is necessary to give 
a very large dose, half the amount may be given into each 
side, care being taken to avoid the femoral artery. This is 
a much less painful method than injecting into the flanks or 
superficial tissues of the abdomen, and a more efficacious one. 

There is a danger a very remote one, it is true of 
anaphylactic shock supervening, especially after intravenous 
injection. This most alarming phenomenon has, however, 
occurred, although two cases noted by Manson-Bahr were 
not fatal. Before giving an intravenous injection of any 
magnitude, it would be well to enquire whether a dose of serum 
has been given some time previously. It is generally advised 
that an attempt should be made to desensitize all previously 
serum-treated patients by a preliminary injection of a small 
dose (2 c.c.) of serum six hours or so before the main dose is 
given. 

A certain mild reaction is apt to follow the injection of 
serum. It has been noted that, on the day following, even an 
exacerbation of the symptoms may take place, but these soon 
abate. Should toxaemic symptoms still persist, injections of 
the serum should be repeated at an interval of three days. 

Improvements in the method of storage of serum under 
active service conditions are required. In future it would 
be preferable to employ a strong anti- Shiga serum alone for 



84 MEDICAL HISTORY OF THE WAR 

severe cases, as these are generally infected with that organism, 
and it would be advisable to stock it in large phials of at least 
25 c.c. capacity each, in a more suitable form for massive 
dosage. Serum sickness is apt to supervene six to ten days 
after the injection ; this is specially the case when long-stored 
serum is used.. It cannot be sufficiently impressed upon 
officers in charge of base medical stores that all sera should 
be kept on ice, and stocks in the field should be frequently 
renewed. 

Statistics on the value of serum treatment are notably 
difficult to compile or adjudge ; but on the whole, the opinion 
of the majority of clinicians during the war has been favourable, 
though some consider that it predisposes to the development 
of arthritis. The latest figures given by Klein from France 
and Waller from Mesopotamia show that if given early in doses 
of 120 c.c., and preferably intravenously, it considerably 
diminishes the death rate and hastens recovery. 

It is quite unnecessary to regard milk as the one and only 
diet in intestinal disease ; as a matter of experience, plain 
milk, whether boiled or unsterilized, is badly borne by severe 
cases of bacillary dysentery, besides being unpalatable and 
monotonous. The casein is passed quite undigested, and 
appears as clots in the stool. The ideal diet should be 
un-irritating, easily digestible, and should be as valuable as 
possible from a nutritive point of view. The best method 
is to give small feeds every two and a half-hours, consisting 
of tea, albumen- water, jellies, bovril, Brand's essence of 
chicken tea in six to ten ounce doses. The introduction of 
solids into the diet too soon may lead to sudden collapse, or 
to a profuse diarrhoea in a case which is doing well. On the 
other hand, it is unnecessary to go to the other extreme and 
adhere to a too rigid diet of albumen -water for a week or more 
at a time. Useful additions to the diet are boiled arrowroot, 
cornflour shape and stewed fruit. A return to a meat diet 
should be made very gradually. This important point must 
be emphasized in convalescent depots, where special arrange- 
ments for dieting convalescent dysenteries must be made. 
A return to a tinned beef diet should on no account be 
attempted till an interval of at least six weeks has elapsed 
from the initial attack. 

As regards local treatment, the mouth should be kept clean. 
The abdominal pain is best relieved by hot water bottles or 
turpentine stupes. Vomiting and hiccough should both be 
regarded as symptoms of serious import. A patient in whom 
the latter symptom makes its appearance is not likely to 
recover. 



BACILLARY DYSENTERY 85 

The treatment of the less acute cases should, more or less, 
follow the lines already laid down, but it is probably unnecessary 
for all to receive serum treatment. The indications for the 
administration of anti-serum are the presence of signs of toxic 
absorption, the number of the stools exceeding 18 in the 24 
hours, and a remittent pyrexia, a rapid pulse, and great 
abdominal pain. 

The treatment of chronic bacillary dysentery is at the best 
unsatisfactory, and taxes all the resources and ingenuity of 
the physician. The course of treatment usually advocated 
is rectal lavage,for which protargol, 0-5 to 1 per cent, is con- 
sidered most preferable ; recent experience shows that freshly 
prepared eusol may be used with benefit. A well-lubricated 
stout rectal tube should be inserted, and solutions given by 
means of a funnel by gravitation, the patient being in the 
knee elbow position. Rectal lavage should be combined 
with abdominal massage, and small doses of salts given by the 
mouth. 

Vaccine treatment has been disappointing. In East Africa 
a mixed vaccine of Morgan's, Shiga's and Flexner bacilli, 
750, 250, and 500 millions per c.c. respectively of each, was 
used in doses of 2, 4 and 8 c.c. at intervals of a week. It is 
possible that the failure is due to non-administration of a 
homologous vaccine. It would be advisable, whenever possible, 
to make a vaccine from an organism isolated from the patient's 
own stools. 

The surgical treatment of chronic bacillary dysentery by 
means of appendicostomy has so far not proved to be satis- 
factory, but possibly with modifications and improvements 
in the fluid used for lavage it may be useful in alleviating 
this most distressing condition. 

More recently, however, caecostomy and the insertion of 
a Paul's tube with the formation of an artificial anus in the 
right iliac fossa has proved more satisfactory. By this means 
the large bowel may be placed at rest for a period of three 
months, and the opening then closed. 

With regard to complications, dysenteric arthritis is best 
treated by back splints, application of Scott's dressing, hot 
air treatment and massage. Should the joint cavity be 
greatly distended, aspiration with aseptic precautions will 
temporarily relieve the pressure. 

Conjunctivitis and iritis are best treated by atropine drops 
and the application of an eyeshade. 

When malaria, especially of the subtertian variety, is the 
primary infection, the case should be treated primarily from 
the malarial point of view, that is to say, quinine had best be 



86 MEDICAL HISTORY OF THE WAR 

given in 12-grain doses on three successive days by the 
intramuscular route ; in cases of benign tertian malaria, 
should the patient be capable of retaining it, quinine solution 
by the mouth will suffice. Anti-dysenteric serum in sufficient 
dosage should be injected at the same time as the quinine 
is administered. 

Prevention. 

With regard to preventive measures, the spread of bacillary 
dysentery from one man to another may take place by direct 
contact, or through faecal contamination of utensils, dishes 
or food. But this can only take place when the most ele- 
mentary rules of sanitation are neglected. As in all other 
cases of intestinal diseases, the prevention of bacillary 
dysentery in armies and in camps is directly dependent upon 
the method of sanitation. 

There can be little doubt that the disease is spread by the 
presence of actual carriers of the disease. From a military 
point of view it is most important to detect and control all 
such individuals, but it is doubtful whether, with the laboratory 
means at one's disposal and on account of the labour involved, 
this really can be done. From the various investigations 
made by Fletcher, Doris Mackinnon, Lepper and Perry, per- 
sistent carriers of dysentery bacilli, that is, individuals who 
continue to excrete dysentery bacilli longer than three months 
after the beginning of the illness, occur quite commonly, 
forming about 6 per cent, of dysentery convalescents. Carriers 
of the Flexner-Y bacillus appear to be four times as common 
as are Shiga carriers. The excretion of the bacillus appears to 
be very intermittent ; thus Fletcher records the discovery 
of the bacillus on the third and even the fourth attempt. The 
carrier state diminishes with time, and most individuals are free 
from infection after the ninth month subsequent to recovery. 
According to Perry, chronic carriers of both infections have 
been found to exist ; in Shiga cases they constitute 4 per 
cent, and Flexner cases 7 per cent, of total convalescents. 
With a view to ascertaining when a carrier becomes free from 
infection, a large amount of labour is necessary ; according 
to Fletcher stools should be examined daily until the results 
are negative for a period of four weeks. The average Flexner-Y 
carrier is generally in good health ; his motions may be formed, 
and he is fit to undertake work, unless subjected to very 
adverse conditions. On the other hand, the Shiga carrier is 
generally an invalid ; his stools contain blood and mucus 
and he is subject to frequent attacks of diarrhoea. The 
bacilli are present only in the mucus and not in the faecal 
matter, so that the presence of mucus in the stool of a con- 



BAGILLARY DYSENTERY 87 

valescent dysentery patient should be appreciated at its true 
value and no case discharged from hospital in this condition. 
For the same reason in military practice it is necessary for 
medical officers to detect and, if possible, evacuate mild or 
early cases of bacillary dysentery directly they report sick ; 
such cases probably constitute one of the most important 
factors in the spread of epidemics. In practice, it is advisable 
to place bacillary cases, in so far as is possible, in wards by 
themselves ; the spread of the infection in hospital, especially 
to surgical cases, has been frequently observed and every'effort 
should be made to prevent this. 

The transmission of bacillary dysentery by the agency of 
house-flies is undoubted. They play a very important part 
in its spread, and it is a matter of common knowledge that 
epidemics of bacillary dysentery generally coincide with the 
maximum prevalence of these pests. This was certainly the 
case in Gallipoli in 1915, and proved to be the same in Salonika, 
Egypt, Palestine and Mesopotamia. Buxton's figures from the 
last-named theatre of war show that 63 per cent, of flies caught 
in a British camp had human faeces in their intestinal canal. 
The actual isolation of the Shiga bacillus from the intestinal 
tract of flies caught in the open was first effected by Manson- 
Bahr in 1910, and it was proved that, under experimental 
conditions, dysentery bacilli can survive in the intestinal 
tract of that insect for at least five days ; these results have 
been in the main confirmed by Taylor in Salonika. Measures 
directed against the spread of dysentery must therefore 
necessarily include those especially directed against the house-fly. 
It is difficult to understand how the house-fly manages to 
obtain so great a concentration of Shiga bacilli in its intestinal 
canal as to enable them to be isolated on culture. The 
dysentery organism is very susceptible to sunlight and is 
rapidly killed off in the open desert, and the supposition is 
that flies feed upon dysenteric faeces when freshly passed. It 
is all the more surprising to find that the organism can be 
obtained from the intestine of flies captured many miles 
away from human habitation ; this, however, Manson-Bahr 
succeeded in doing in the Sinai desert in 1917. It therefore 
seems that some more intimate connection between the house- 
fly and the dysentery bacillus exists than at first sight appears 
to be the case. 

With regard to the contamination of water by dysentery 
organisms, experiments upon the vitality of the organisms 
have led to the conclusion that Shiga' s bacillus can survive 
and multiply in stored water for three weeks or more, especially 
at medium or low temperature, but cannot exist such a long 



88 MEDICAL HISTORY OF THE WAR 

time when exposed to the sun or when associated with large 
numbers of putrefactive micro-organisms. According to some 
observers, polluted water was responsible for the frequency 
and virulence of bacillary dysentery among the transport 
drivers in East Africa, and to a minor extent among troops 
in France during the later stages of the war. When all the 
drinking water is chlorinated, it is difficult to see what part 
water can play, though a false sense of security may be engen- 
dered by the belief that water, once chlorinated or sterilized, 
will remain so indefinitely. Dudgeon has shown that when 
once the effect of chlorination has worn off, water may become 
subsequently infected. Hence water once chlorinated must 
be efficiently protected from dust and flies. 

As regards the spread of dysentery by dust, it was shown 
in France that dysentery organisms could survive for a con- 
siderable period in dust, if protected from sunlight, and it 
has been suggested that in temperate climates they may be 
disseminated by means of powdered faeces, but there is by no 
means conclusive proof that this does really take place. 

Prophylactive inoculation against bacillary dysentery had 
until recently fallen into disfavour, mainly on account of the 
very severe local reaction which Shiga's bacillus produces. 
Graeme Gibson introduced a method of inoculation whereby 
the toxins of this bacillus were neutralized by a sufficiency of 
anti-Shiga serum, a procedure which considerably modifies the 
reaction. The vaccine and the serum are put up in twin phials, 
the bacillary emulsion being contained in one, the serum in the 
other. The first dose given is 0;25 c.c. containing 500 million 
Shiga organisms mixed with 0- 1 c.c. of serum ; the second dose, 
given ten days later, is 0'5 c.c. containing 1,000 million organ- 
isms with 0-2 c.c. of serum. The local reaction results in a 
painful inflammatory lump, though constitutional symptoms 
are absent. Gibson published a limited number of statistics 
in which the results appear to be favourable, and although this 
inoculation was largely used in France during the later stages 
of the war, it is still too early to make any general statement on 
the subject. The duration of the immunity conferred is not 
certain, though agglutinins can still be demonstrated in the 
serum after three months. A somewhat similar method was 
used in Germany and Austria during the war under the 
name of Boehncke's " Dysbakta." 

As an accessory measure it may be mentioned that the 
provision of a certain amount of oil in the diet may probably 
constitute a defensive measure as calculated to lessen the 
amount of intestinal irritation predisposing to bacillary 
dysentery produced by sand and an unsuitable dietary. 



BACILLARY DYSENTERY 89 

Details of the measures adopted in France and England for 
the segregation of dysentery patients may be usefully 
repeated. In 1916 the orders in France were that all cases 
of suspected dysentery were to be sent to field medical units 
set apart for infectious diseases, certain clearing stations being 
detailed for this purpose, and at least two bacteriological and 
protozoological examinations of the dejecta were to be made. 
If the results were positive the patient when convalescent was 
sent to England through hospitals at the base, and, if the 
results were negative, to a convalescent depot in France. 
In the latter case if after seven days' interval a final 
examination in the laboratory again proved negative, the 
patient when fully recovered was to be discharged to his 
base depot, but in each case the man's unit was to be 
informed that he had been suspected of dysentery, and must 
not be employed on food or water duties. 

In 1917 owing to a severe outbreak in a new division in the 
front line, orders were issued to the effect that all cases in the 
division which were suffering from diarrhoea were to be sent 
to a field ambulance for segregation and treatment. Any cases 
in field ambulances which showed blood and mucus in the stools, 
or were of any severity, were sent on at once to a selected 
casualty clearing station and dealt with as suspected dysentery. 

In one army the general plan was adopted of watching for 
diarrhoea cases, separating them at the earliest possible moment, 
and treating them as possible dysentery cases. In Etaples a 
similar plan was adopted for the temporary segregation of any 
diarrhoea case. 

These measures were subsequently made general throughout 
the forces on the Western Front in 1918. 

In 1917 it was decided, in order to avoid needless evacuation 
to England, that mild cases of dysentery admitted to base 
hospitals who were fit to convalesce in France, estimated at 
70-80 per cent, of the total admissions, should be sent either 
under special regulations to ordinary convalescent depots, or 
to special dysentery convalescent depots. 

In June 1918 certain casualty clearing stations were detailed 
as dysentery centres. The following order was then issued : 
"So far as the. military situation permits, cases of diarrhoea, 
except those of a trivial nature, will be at once sent from their 
units to field ambulances for observation and treatment, and 
cases suspected to be dysenteric will be evacuated without de- 
ay from the field ambulance to the dysentery centre. To ensure 
that the milder cases of diarrhoea, retained for treatment in 
field ambulances, are free from dysentery, rectal swabs should 
be taken and sent by the most expeditious means to the 



90 MEDICAL HISTORY OF THE WAR 

dysentery centre for bacteriological examination. Field am- 
bulances will obtain rectal swabs from the nearest mobile 
laboratory as required. 

" Suspicious cases, in which the stools contain muco-pus or 
blood and mucus, will be diagnosed "dysentery" whether the 
bacteriological examination is positive or not. Where large 
numbers of cases are occurring, bacteriological effort will be 
especially directed to the cases which are clinically uncertain, 
typical cases being diagnosed on clinical grounds alone. 

" Severe or protracted cases will be evacuated to the base, 
and as far as possible will be kept together on ambulance trains. 

" Where the military situation permits, slight cases may be 
retained for treatment at dysentery centres and, when fit, 
discharged for duty, provided that, on return to ordinary diet 
and exercise, dysentery symptoms do not recur and that three 
pathological examinations after the stools have become solid exclude 
the presence of dysentery bacilli or amoebae. When such cases 
are discharged, notification will be sent, in every instance, to the 
man's unit, stating that he has been under treatment at a 
dysentery centre, and that he must not be employed in the 
cooking or handling of food or on water duties." 

During the summer of 1918 a large number of dysentery cases 
were admitted to the Boulogne base from all parts of the 
fighting areas. These coincided with a heavy influx of other 
casualties from wounds and mustard-gas poisoning, and it was 
extremely difficult to arrange special hospital accommodation 
so as to retain in France the lighter cases of dysentery during the 
relatively long period of special invalid dietary and general 
care which were necessary on clinical grounds in order to 
prevent the recurrence of intestinal irritation and relapse into 
a state of chronic dysentery. 

Special centres were, however, established at No. 14 
Stationary Hospital and at No. 7 Convalescent Depot. Patients 
who had suffered from a severe clinical attack, or had had a 
persistently positive laboratory report, were evacuated as soon 
as possible to England. The special hospital none the less soon 
became overcrowded with milder cases, and relief was obtained 
by early transference of them to the convalescent depot after 
one negative examination of the dejecta. No men were dis- 
charged from the depot until a total of three laboratory exami- 
nations had been made with negative results. 

In the convalescent depot, which admitted casualties of all 
kinds, an area was marked off as a " Dysentery Isolation Area." 
In this area the patients had separate eating, sleeping and 
latrine accommodation. They wore hospital clothing as a mark 
of distinction at all times, and were then permitted to attend 






BACILLARY DYSENTERY 91 

physical drill and all recreations in common with other patients 
in the depot, but not the general canteens. The medical officers 
had power to order special invalid dietary for those who 
presented evidence of persistent abdominal pain or of abnormal 
stools. When a man was considered fit for discharge to duty 
a final laboratory examination of the dejecta was made. If the 
report was negative, discharge was accompanied by the usual 
notification to the man's unit, sent through the base depot, to 
the effect that he had been treated for dysentery and should 
not be employed in connection with the preparation and 
distribution of food or purification of water supplies. 

In England in 1916 a dysentery depot was established, to 
which convalescents were transferred from central hospitals. 
At the central hospital, the patient admitted from overseas 
was to be retained 14 days, and two laboratory examinations, 
bacteriological and protozoological, were made with an interval 
of seven days between them. If these examinations were 
negative and the patient required no active treatment, was on 
full diet with normal stools, and was fit to live in a hutted 
camp and to be drilled and exercised, he might be transferred 
to the dysentery depot. The reports of the laboratory 
examinations were at the same time to be sent to the depot. 
There he was to complete two clear months' convalescence 
from the time when he was first put on full diet and passed 
normal stools. Laboratory examinations were to be repeated. 
He might then be discharged to duty as from an ordinary 
hospital, but the unit was to be notified of the fact that he came 
from a dysentery depot. A notification was also to be sent to 
the medical officer of health of the district to which the patient 
went on furlough, and, when he proceeded overseas, a 
notification that he had suffered from dysentery was to be sent 
to general headquarters of the expeditionary force.* 

In 1917 the special control of the dysentery cases transferred 
to England from an expeditionary force was strengthened by a 
fresh order| directing that all such patients should be sent to 
certain selected hospitals. From these hospitals, after two 
negative laboratory reports over a similar period of 14 days, and 
when the patient satisfied the same conditions, he was trans- 
ferred to the dysentery convalescent depot at Barton-on-Sea. 
A third negative laboratory report, on an examination made 
three weeks after the last negative result or after the termination 
of specific treatment, justified the discharge to duty of a man 
otherwise fit, the form reporting his discharge being stamped with 
a warning that the patient was a convalescent from dysentery. 

* A.C.I. 1,354 of 1916. f A.C.I. 205, dated 3rd February, 1917. 



92 MEDICAL HISTORY OF THE WAR 

AMCEBIC DYSENTERY 

The term amoebiasis denotes an infection with Entamceba 
histolytica, a protozoon primarily causing ulceration of the 
intestinal canal, but which by invading the bloodstream is liable 
to form metastatic abscesses in other regions of the body, mainly 
the liver. When the disease is confined to the intestinal tract 
it produces amoebic colitis or amoebic dysentery, of which the 
most frequent complication is amoebic abscess of the liver. 

Amoebic dysentery, as compared with the bacillary disease, is 
insidious in its onset, chronic in its course, and very liable to 
relapse. The appearance of the lesions in the intestines is 
characteristic and easily differentiated from the acute inflam- 
matory lesions of bacillary dysentery. Formerly considered to 
be confined to the tropics and sub-tropics, it is now known to be 
widely spread throughout the temperate parts of Europe, and 
during recent years indigenous cases have been reported from 
England and France. Persistent carriers of the cysts of the 
parasite, E. histolytica, are quite common, and the spread of the 
disease is due to the presence of this form of the parasite in their 
faeces. 

Distribution and ^Etiology. 

The prevalence of amoebic dysentery amongst the various 
expeditionary forces, especially in Salonika, Egypt and Mesopo- 
tamia, has been extensively investigated. Investigations of 
this nature, however, have to be carried out by protozoological 
and bacteriological experts working conjointly, as the sources 
of error and fallacy are many. 

Before going into this question, certain generalizations are 
permissible. Bacillary dysentery is a disease of soldiers under 
conditions of active warfare, in closely crowded camps, and on 
the march, while the more chronic, relapsing amoebic form is 
much more evident in convalescents at the base, men whose 
symptoms were not sufficiently obvious in the field to require 
extensive bacteriological investigation ; therefore the ratio of 
amoebic to bacillary dysentery, as recorded by pathologists, 
will necessarily be higher in base laboratories than that obtained 
nearer to the seat of active operations. Add to this the facts 
that amoebic ulceration of the gut may exist for some consider- 
able time without causing any symptoms, and that amoebic 
infection frequently supervenes in those who previously suffered 
from the bacillary disease, and it will then be readily understood 
that amoebic dysentery assumes its main importance in military 
medicine as the aftermath of war. This is certainly the 
case amongst pensioned men. The difficulties attending the 
bacteriological diagnosis of the more acute bacillary disease, so 



AMCEBIG DYSENTERY 93 

important in the field, have already been alluded to ; moreover, 
one should remember that bacillary dysentery can only be 
diagnosed with certainty during the earlier stages, and there- 
fore cases have either completely recovered or are undiagnos- 
able, bacteriologically speaking, on reaching the base. Amoebic 
dysentery, on the other hand, on account of its chronicity and 
liability to relapse, is more easily recognized. 

It may be said that, taking a general view of the war as a 
whole, amoebic dysentery formed about 7 per cent, of all 
clinical dysenteries in the Eastern theatres of war, while in 
France and Flanders it played a very minor part. The official 
figures return it as 2*8 per cent, for these latter. Although 
it is recognized that this figure includes a number of relapses, 
yet a certain number of indigenous cases have been observed 
by French and British investigators. A point to be noted is 
that amoebic dysentery occurs at all seasons of the year ; 
whereas bacillary dysentery has a definite seasonal incidence, a 
fact which indicates the probability of the transmission of the 
former form of dysentery by polluted water, and of the latter 
by flies. 

Available figures indicate that amoebic dysentery was not so 
common in Salonika as elsewhere in the East. According to 
Graham and Ramsbottom it is probable that only about 3 per 
cent, of the cases of dysentery there were of the amoebic type. 
The accounts given by Delille, Paisseau and Lemaire on the 
French side, and Dudgeon on the British, also seem to indicate 
that it played a minor part. In Gallipoli, unfortunately, 
exact figures are not forthcoming, but it is estimated that 
amoebic dysentery accounted for 10 per cent, of the total 
dysentery admissions.* In Egypt and Palestine, amongst 
British troops the amoebic rate varied from 2 per cent, of all 
dysenteries in 1916 to 7 percent, in 1917 and 1918, according to 
Gunn, Savage, Woodcock and Manson-Bahr, while amongst 
Indian troops it was almost invariably higher, according to 
Woodcock as much as 15-7 per cent. In the latter part of the 
campaign the Palestine figures showed an even incidence of 
7 per cent. 

As might be expected from the climatic conditions, and the 
more intimate contact with Indian troops and native carriers 
of the disease, the amoebic incidence was certainly at its highest 
in Mesopotamia, as pointed out by Ledingham, Boney, Grossman 

* For many reasons the statements of Bartlett (Quarterly Journal of 
Medicine, Vol. X. p. 185) that "at least 79-4 per cent, of the clinical 
dysenteries from Gallipoli had amcebiasis," and the results of his post- 
mortem findings that 91-8 per cent, of the bodies had amoebic lesions, have 
to be discounted. 



94 MEDICAL HISTORY OF THE WAR 

and Boulenger. In the forward areas in that country the 
bacillary disease predominated,but amoebic dysentery accounted 
for 20 per cent, of acute dysenteries amongst British troops, 
while amongst Indian troops the rate of incidence was almost 
double. In the base area, on the other hand, the ratio of 
amoebic infections amongst British troops was very much 
higher, amounting to 40 per cent, at Basra. 

This was especially noted towards the close of hostilities, so 
that by that time amoebic dysentery could be regarded as 
endemic amongst the British, with a high proportion of relapses. 

Such statistics as are available from East Africa show a 
proportion similar to the records from Egypt, though the inci- 
dence of amoebic dysentery, according to Hughes, was higher 
amongst the native porters. 

Manson-Bahr's observations in Egypt and Palestine, as well 
as those of Gunn and Savage, indicate that the amoebic dysentery 
rate amongst troops in the field appears to be at its highest 
during the first three months of the year, that is, at a period 
when the bacillary disease is in abeyance, and, on the whole, the 
experiences of Mesopotamia would seem to bear this out. 

A vast amount of illuminating work, mainly by Wenyon and 
Dobell, has been done during the war upon the morphology and 
life history of the intestinal amoebae. 

The discovery of amoebae in dysentery stools was made by 
Losch in 1873, and since then they have been the subject of 
much study. It is now recognized that several distinct amoebae 
are present in the intestinal canal of man, of which only 
Entamceba histolytica is pathogenic. The others are harmless 
species. Owing to the number of species of intestinal amoebae 
and the necessity of being able to recognize the one pathogenic 
species with certainty, it is most necessary that, in making a 
diagnosis of amoebic dysentery, the pathologist should have 
some insight into modern intestinal protozoology. The main 
practical points to remember are that the Entamceba his- 
tolytica, if the cause of the dysentery, is generally very active 
and contains as a rule, ingested red corpuscles. The nucleus 
can rarely be distinguished in the unstained state ; most 
usually the organisms show a differentiation into a granular 
endoplasm and a clear hyaline ectoplasmic zone. 

The causes which predispose towards the development of 
amoebic dysentery are not yet accurately understood. They 
are probably in the main similar to those which produce the 
more acute bacillary disease. The experience of the war, 
supported by experimental data upon the survival of E. his- 
tolytica outside the body, supports the idea that the principal 
medium for the production of amoebic dysentery is a polluted 



AMOEBIC DYSENTERY 95 

water supply. A continuous high and moist temperature 
appears to be favourable to the development of the disease and 
would explain, in part at any rate, the undoubtedly greater 
prevalence of amoebic dysentery in tropical and subtropical 
countries. 

Morbid Anatomy. 

With regard to the morbid anatomy of amcebic dysentery, 
the action of the entamceba on the tissues is, to a great extent, 
mechanical, although there is, in addition, a localized lytic 
action, and death may take place in many ways, commonly 
through perforation of the gut wall, though it may be due to 
exhaustion or haemorrhage. The earliest lesions consist of 
minute yellow hemispherical elevations of the mucosa, which 
by breaking down become converted into the typical flask- 
shaped amcebic ulcer of which the tissues of the submucosa 
form the base. The ulcers are confined to the large intestine 
and generally commence in the caecum, but they may occur 
anywhere throughout the large intestine, especially in the 
transverse and pelvic colons. As the lesions progress in size 
they may coalesce to form large patches of several inches in 
extent. There is usually a considerable degree of compensatory 
hypertrophy of the bowel wall. 

In early cases the intervening mucous membrane remains to 
all appearance normal and healthy. In chronic cases the whole 
mucous membrane may be involved, with the formation of 
polypoid or even gangrenous masses, which project into the 
lumen of the bowel. 

The individual ulcers are generally covered with yellow, 
greenish or even black sloughs, which may adhere to the under- 
lying granulation tissue. Thrombosis of the blood vessels 
occurs at the bases of the ulcers, and as ulceration extends deeply 
a fair-sized blood vessel may be eroded and a severe or fatal 
haemorrhage may result. Perforation or even massive gangrene 
of the gut may terminate in purulent peritonitis. The site of 
perforation is usually the caecum or transverse colon. 

The entrance of the amoebae into the tissues is thought to 
take place through the crypts of Lieberkiihn into the submucous 
tissue, when, by means of cytolysins, which they secrete, they 
produce a gelatinous and cedematous tissue necrosis. As com- 
pared with the bacillary lesions the relative absence of inflam- 
matory cell-infiltration is to be noted. 

Symptoms. 

The incubation period of amcebic dysentery is probably a 
long one. The only experimental evidence in this direction is 



96 MEDICAL HISTORY OF THE WAR 

the classical work of Walker and .Sellards. There are many 
factors to be considered, but it is probable that from the time of 
entrance of the infecting material into the intestinal canal to 
the appearance of recognizable symptoms of dysentery a long 
period elapses an average of 64 days in the experiments cited 
whereas the characteristic cysts appeared in the faeces nine days 
after infection. It may therefore be justifiably stated that the 
more chronic protozoal, as compared with the more acute 
bacillary infection, has a correspondingly longer incubation 
period. 

The symptoms of amoebic dysentery are protean, for it has 
long been known, and has been emphasized by the post-mortem 
findings of Bartlett during the war, that a considerable ulceration 
of the intestine may be present without provoking any recog- 
nizable symptoms during life. Indeed, cases of this disease 
have been seen in which sudden perforation took place with few, 
if any, premonitory signs. For example, in the case of a 
medical officer in excellent physical condition, whose symptoms 
consisted solely of an occasional attack of diarrhoea, perforation 
of the caecum took place suddenly with a fatal result. 

The great majority of cases run a chronic course with frequent 
relapses, alternating with periods of chronic constipation. 
Acute and even choleraic clinical forms of amoebic dysentery do, 
however, occur, and in these cases the symptoms may be 
indistinguishable from bacillary dysentery. But as a general 
rule, the abdominal pain and tenesmus are much less acute and 
tend to be localized to certain spots, such as the caecum or 
transverse colon. The pain may closely simulate that of 
appendicitis, and may therefore suggest surgical interference, 
but the surgeon should always be on his guard against this. 

The stools are as a general rule larger than those of bacillary 
dysentery, but are usually not so numerous. They may contain 
a considerable quantity of dark and altered blood, which imparts 
to the motions a penetrating foetid odour, and when the gut has 
become gangrenous actual sloughs may be found. 

Unless the case is complicated by hepatitis, there is seldom 
any fever, and no symptoms of toxic absorption are present. 
The latency which this disease exhibits is one of its most 
striking characteristics. Often without treatment all symptoms 
may subside and the patient may regain condition, only to 
relapse again, it may be, after an interval of months or even 
years. 

The experience of the later period of the war has strengthened 
the idea that amoebic infection is specially prone to supervene 
upon a previous bacillary attack. It is well to bear in mind 
that chronic diarrhoea in a patient convalescent from the 






AMOEBIC DYSENTERY 97 

latter disease, whether mucus is present in the stools or not, 
may possibly be an amoebic infection. 

Death in amoebic dysentery may result from exhaustion, 
uncontrollable haemorrhage, perforation of the intestine or liver 
abscess. The haemorrhage may be sudden, profuse, and is 
often fatal ; it may even occur in men who have not previously 
shown evidences of infection. 

Prognosis. 

The question of prognosis in amoebic dysentery is a subject 
which is very difficult to treat adequately. It is impossible 
to prognosticate with any degree of certainty what the 
course of an amoebic dysentery is to be. Possibly the great 
majority of cases, if recognized early, are amenable to treatment, 
and these cases may be considered fit for further active service. 
On the other hand, a case which has relapsed more than once is 
unfit for active service, especially since recrudescences of the 
disease are produced by physical exhaustion and dietetic in- 
discretions. As a pensionable disease, undoubtedly amoebic 
dysentery has a greater claim to recognition than has the 
bacillary form. Convalescents from the latter usually en- 
tirely recover their digestive and absorptive faculties. 
Amoebic convalescents, on the other hand, especially if the 
faeces still contain the characteristic cysts, must be regarded 
as still infected and therefore liable to relapse. The possible 
dangers of sudden perforation or complication of liver abscess 
should also not be forgotten. Moreover, often actual mechani- 
cal alterations of the bowel wall, in the shape of adhesions, 
cicatricial bands, dilation of the colon and partial stenosis, 
may ensue as the result of extensive healed amoebic ulceration 
and may give rise to dyspepsia and chronic intestinal stasis. 
All these conditions and possibilities should be taken into 
account in assessing the pension of a man convalescent from 
amoebic dysentery. 

The clinical distinctions between the two main forms of 
dysentery cannot always be relied upon and the final decision 
must rest with the pathologist. Considerable assistance may be 
obtained from the macroscopic appearance of the stools, though 
it is a dangerous proceeding in military practice to consider this 
as final. The laboratory diagnosis depends upon the ability of 
the observer to differentiate Entamceba histolytica from the 
non-pathogenic amoebae and from macrophage endothelial 
cells. The entamoebae are not uniformly distributed through- 
out the stool ; they are most readily found in the mucus and 
are not usually present in the faeces. They may even be ex- 
creted intermittently. It is often possible to find them in 

2396) G 



98 MEDICAL HISTORY OF THE WAR 

large numbers in one specimen and to be unable to do so in 
subsequent examinations. Therefore any opinion based upon 
a single faecal examination is open to many fallacies. Should 
suspicion as to the nature of the case be aroused, it is as well to 
consider no result as negative until the stool has been searched 
on each of seven consecutive days. 

Considerable assistance may be derived from a study of the 
cellular exudate of the stools, a point upon which emphasis 
has been laid by Willmore and Shearman. As a general rule the 
amoebic exudate consists of large numbers of red cells in rouleaux, 
few pus cells or endothelial cells being present. On the other 
hand much evidence of tissue destruction, in the shape of frag- 
mented cells and extruded nuclei may be seen. Search should 
be conducted with a J in. lens and the Entamceba histolytica 
identified by its activity, its characteristic appearance, and its 
ability to ingest red blood corpuscles. When haemorrhage has 
been profuse, it may be impossible to detect any of the organ- 
isms. In the more chronic and latent stages the characteristic 
cysts may be present in large numbers and the detection in the 
stools is rendered easier by staining with Weigert's iodine, 
which shows up the nuclear structure, the contained chroma- 
toid bodies and the glycogen vacuoles. When doubt remains 
as to the diagnosis the cysts may be stained by a rapid 
method introduced by Dobell ; this is especially important in 
carrier cases.* The more extensive employment of the 
sigmoidoscope, by the routine use of which the characteristic 
amoebic ulceration in the lower part of the bowel may be 
recognized, even in cases where laboratory diagnosis has failed, 
is strongly recommended by Manson-Bahr. 

Treatment. 

The war led to several improved methods in treating amoebic 
dysentery. No hard and fast rule can be laid down for the 
treatment of every case, but as in the case of bacillary dysen- 
tery special symptoms must be met as they arise. The specific 
drug in this case is ipecacuanha or its derivatives. Although 
there are four alkaloids of ipecacuanha emetine, cephaeline, 
pyschotrine, and emetamine the first alone appears to exert 
any specific action upon E. histolytica ; but the manner in which 
it does so is not by any means understood, while it has no effect 
upon the non-pathogenic amoebae living in the intestine. The 
experimental work of Dale and Dobell upon this point has not 
confirmed the original observations of Vedder and Rogers upon 

* This method consists of fixation for ten minutes in Schaudinn's fluid, 
passing through two washes of 70 per cent, alcohol and iodine, ten minutes 
each, staining in Mayer's haemalum for fifteen minutes, blueing in water, 
passing up through alcohols and xylol and mounting in the usual way. 



AMCEBIC DYSENTERY 99 

the toxicity of emetine to entamoeba in vitro, but it is possible 
that direct observations of this nature do not constitute a sure 
guide to its action in the human body. All evidence shows that 
the judicious treatment of the patient with emetine in some form 
or other is the only measure likely to secure radical cure, but if it 
is given in insufficient dosage, or by unsuitable methods, the 
effects are temporary only. The drug should not, however, be 
given without due consideration being paid to its possible 
toxic effects. Experimental evidence, as well as clinical ob- 
servation, has shown that excessive doses may give rise to an 
intractable diarrhoea and considerable asthenia, with a curious 
desquamation of the skin. 

Emetine treatment should be controlled by means of frequent 
and repeated stool examinations. The drug is best given 
hypodermically, or intra-muscularly, in individual doses of 1 
grain each (1 gr. in 1 c.c. distilled water), and repeated daily for 
12 days. The efficiency of emetine is considerably supple- 
mented, according to Wenyon and O'Connor, if combined with 
oral administration of the same drug in |-grain doses by the 
mouth. Vomiting may be readily induced by this means but 
this does not necessarily hinder the action of the drug on the 
entamoeba. If the patient remains constipated, as he seldom 
does under emetine treatment, it may be advisable to combine 
it with small doses of sodium sulphate. 

The double iodide of emetine and bismuth (emetine bismuth 
iodide), which contains 26 per cent, of the emetine alkaloid, 
was introduced by Dale in 1916 and is especially useful in 
chronic intractable cases and in cyst carriers. The drug is 
given in three-grain doses in gelatine cachets every night for 
twelve consecutive nights, but, when taking it, the patient 
should remain in bed and have a liquid, preferably milk, 
diet. Treatment should be controlled by daily and repeated 
microscopic examinations of the faeces for cysts. In intractable 
cases it may be necessary to administer two or more courses of 
the drug with a week's interval between each. 

Specially difficult to deal with are those cases which resist 
every form of treatment by emetine. There are exceptional 
cases, which have continued to pass blood or mucus stools 
containing active entamcebae after five or even more courses of 
emetine bismuth iodide. One case has been observed which 
continued to do so after sixteen courses. In such cases, it is 
possible that intravenous injections of neoarsenobillon in 0*4 
grm. doses, combined with emetine bismuth iodide, as carried 
out by Brug, may help. 

Vomiting and nausea when taking emetine bismuth iodide 
may be prevented by small doses of tinct. opii 10-15 min. given 



100 MEDICAL HISTORY OF THE WAR 

half-an-hour beforehand. The action of emetine bismuth iodide 
is not yet understood. Dale and Dobell have shown that it fails 
to cure amoebic dysentery in experimentally infected cats, while 
it was inconclusive in puppies infected in the same manner. 

Some observers have recorded cures with chaparro amargosa, 
an infusion of the Mexican drug, Castela nicholsoni, in cases 
resistent to emetine. It is best given in the form of tea ; three 
teaspoonfuls of the powdered chaparro are boiled and strained. 
The oral administration may be supplemented by enemata of 
the same decoction given twice daily. 

During the course of an attack of amoebic dysentery or subse- 
quent to it, hepatitis, or actual hepatic abscess may supervene ; 
these constitute the most frequent complications of amoebiasis. 
Inflammation of the liver with considerable congestion and 
enlargement of the organ may occur in the height of the attack 
and is generally accompanied by evening pyrexia, and, it may 
be, rigors and sweats. Active treatment consists of repeated 
doses of emetine, saline aperients, fomentations, cupping and 
counter-irritants. There is considerable evidence that aspira- 
tion of the liver and abstraction of blood have a very 
beneficial effect in this condition. 

The relationship between amoebic dysentery and liver abscess 
is now unquestionable. The two conditions often co-exist in 
the same patient, and it has been abundantly proved that they 
are caused by the same parasite. In most cases of hepatic 
abscess a previous history of dysentery or prolonged diarrhoea 
may be obtained. As a general rule a period of several months 
elapses from the time of the dysenteric attack until the 
formation of the abscess, and, according to Low, an interval of 
even 20 years may intervene. It has generally, however, been 
considered a somewhat rare complication, and war experience 
has so far borne this out. Cases of amoebic abscess have 
been reported from Gallipoli, Egypt and especially from 
Mesopotamia, but probably a number of cases will occur two 
or more years after the original infection, and may therefore 
only reappear amongst men who have been demobilized and 
returned to civil life. 

The most important signs and symptoms of hepatic abscess 
are a history of a septic pyrexia, continuous or remittent with 
cachexia, anaemia and sweats, with a uniform enlargement of 
the liver, most usually in an upward direction, and it may be 
with local tenderness, rigidity over the right rectus, and signs of 
irritation or pressure at the base of the right lung. Very often 
a referred dull aching pain in the right shoulder, more noticeable 
at night time, is present. The leucocytosis, it should be noted, 
is generally moderate, on an average 18,000, but an increase 



AMCEBIC DYSENTERY 101 

of leucocytes is not necessarily present. Candler, for instance, 
has operated on one in which there was actually a leucopenia. 
X-rays, by demonstrating a limitation of movement of the 
right dome of the diaphragm, may assist in diagnosis. 

The amount of ulceration of the bowel associated with 
hepatic abscess may be minimal, and too much stress must not 
be laid upon the presence of histolytica cysts in the faeces of 
these cases, as they are often absent. When present they are 
to be regarded as supplying only confirmatory evidence of a 
suspicion based upon the clinical signs and symptoms. 

Absolute diagnosis should be made by aspiration in search 
for pus through an area of dullness, preferably between the 
7th and 8th ribs in the mid-axillary line. The needle should be 
thrust in an upward as well as inwards direction and sustained 
traction on the piston maintained as it is withdrawn. 

All evidence so far accumulated tends to show that, when 
once pus has formed, the condition can no longer be cured 
by emetine, though, from the success of the drug in amoebic 
hepatitis, the formation of pus may possibly be prevented. 

The recent work of surgeons on this subject would seem to 
indicate that, whenever the abscess is of moderate size and can 
be localized, the aspiration of the liver pus by means of a large 
aspirating syringe or evacuation by Potain's aspirator and 
subsequent injection of 3-5 grains of emetine in saline into the 
abscess cavity, with the idea of destroying the contained 
entamcebae, is preferable to the open operation. It is true 
that re-accumulation of the pus sometimes occurs, but the 
ease with which it can be located and evacuated once more 
renders the repetition of the operation a very simple matter. 
Recovery is very rapid ; there is no open wound and the 
risk of septic complication is reduced to a minimum. 

According to Armitage 48 cases of amoebic abscess of the 
brain have been recorded, for the most part from Egypt. The 
abscess is generally solitary and may be regarded as a metas- 
tasis of hepatic abscess. During life it gives rise to various 
cerebral pressure symptoms, and is invariably fatal. One 
such case, in a New Zealander, has been recorded during the 
war by Stout, Fenwick and Armitage. 

Prevention. 

As in the bacillary disease preventive measures directed 
against the spread of the Entamceba histolytica from one person 
to another depend upon general sanitary conditions, but there 
is a special point in which the control of the amoebic disease 
presents difficulties, and that is the carrier question. 

Carriers of E. histolytica may be divided into two classes, the 



102 MEDICAL HISTORY OF THE WAR 

contact carrier who has never suffered from amoebic dysentery, 
and the convalescent carrier who has recovered from such an 
attack and who continues to pass numbers of E. histolytica 
cysts in his faeces. 

The comparatively large number of contact carriers amongst 
the population of temperate as well as tropical countries, has 
been greatly emphasized during the period of hostilities, and a 
large amount of work has been devoted to this subject by British 
protozoologists. It is now easy to understand how it is that 
E. histolytica is the cause of amoebic dysentery and hepatic 
abscess and yet does not produce disease in the majority of 
individuals harbouring it ; and how these diseases are not 
contracted from the person in the acute stages of his illness but 
from the apparently healthy carrier. For every abnormal 
individual suffering from amcebic dysentery there are many 
comparatively healthy carriers passing cyst-containing faeces 
infective to others. 

There can be little doubt, however, that, whether E. histoly- 
tica causes dysenteric symptoms or not. it must live at the 
expense of the tissues of its host, and one must suppose that 
even the healthy carrier has the mucosa ulcerated, although 
the damage may be so minute as to be almost invisible. 

Amongst British soldiers after a year's active service in 
Egypt, which is notoriously a home of amoebic infection, 
Wenyon and O'Connor found no marked difference between the 
incidence of carriers among those who had previously suffered 
from dysentery and those who had not, the percentages being 
6-5, as against 4-5 per cent., though amongst native Egyptians 
it was considerably higher. 

The carrier rate will necessarily vary considerably, as Dobell 
has pointed out, according to the number of times each individual 
is examined, as it is known that E. histolytica cysts are but inter- 
mittently excreted ; it is probably necessary to examine the 
faeces on at least six separate occasions before pronouncing an 
individual free from infection, though it is estimated that 
two-thirds will be found at the first examination. 

Examining a series of convalescents in this manner, Dobell, 
Gettings and Jepps showed that the percentage of carrier cases 
was highest in the Mediterranean and Mesopotamian war zones. 

The figures are as follows : 

France .. .. .. 8 -37 per cent. 

Salonika 18-92 

Egypt 18-96 

Gallipoli 23-07 

Mesopotamia .. .. 20-51 ,, ,, 






AMOEBIC DYSENTERY 103 

One of the most surprising outcomes of the systematic 
faeces examination by protozoological experts during the war 
has been to show the widespread presence of histolytica carriers 
in England. Malins Smith has shown that 4-2 per cent, of 
the lunatics at Rainhill Asylum were carriers, and after an 
extensive enquiry amongst recruits under training he also 
found that 5-6 per cent, were carriers, and amongst naval 
ratings the rate was estimated at a slightly lower figure. 

From a consideration of the above-stated facts, it would be 
a counsel of perfection to examine large bodies of men under 
active service conditions, so as to identify the carriers of in- 
fection and to seek to eliminate them by effective treatment 
with emetine bismuth iodide. Obviously, this is quite imprac- 
ticable and, besides, one cannot by any means control the highly 
parasitized natives of countries such as Egypt and Mesopotamia 
with whom the soldier may be brought into daily contact. 
The majority of the carriers are perfectly healthy ; the 
percentage of those who actually develop a condition of amoebic 
dysentery is not accurately known. When every able-bodied 
man is needed for war service, it is unreasonable therefore to 
detain any individual, whether convalescent from dysentery or 
not, just because he happens to be a carrier of E. histolytica. 
It is possible, however, to ensure that no gross carrier is 
employed as a mess cook or in any way connected with water 
duties. 

The actual method of transference of E. histolytica from one 
man to another is as yet a matter of conjecture. Probably 
a considerable amount of infection takes place through 
mechanical transference by house-flies, as has been shown by 
Wenyon, O'Connor and Buxton. The two first-named inves- 
tigators proved that these cysts do not degenerate in the fly's 
intestine and may be found there as long as any faecal matter 
remains. The direct passage of the faecal material through the 
alimentary canal of the insect takes but five minutes, and would 
seem to be of more importance in the dissemination of the 
disease than regurgitation of material through the proboscis. 

One thing is certain, that moisture is absolutely necessary to 
the vitality of the cyst ; if dried it immediately dies. There is 
little doubt, on epidemiological grounds, though unsupported 
by any direct evidence, that amoebic dysentery is spread by 
water infection, and it is probably due to the careful sterilization 
of the water supply in Egypt and Palestine that the amoebic 
dysentery rate was comparatively low. 

As in the bacillary disease the essential precautions consist 
of measures directed against the house-fly as well as careful 
supervision of the water supply. 



104 MEDICAL HISTORY OF THE WAR 

BALANTIDIAL AND OTHER FORMS OF DYSENTERY. 

The differential diagnosis of the dysenteries entails a know- 
ledge of all those conditions in which blood and mucus may 
appear in the stools. The following is a short resume of the 
conditions which may possibly be mistaken for the better- 
known forms of the disease. 

A blood-stained mucopurulent discharge may be passed in 
infestations with Schistosoma mansoni, S. hcematobium and 5. 
japonicum. Instances of the two former came under notice 
in troops infested with schistosomiasis in Egypt. Dysenteric 
symptoms are apt to supervene two to three months after 
infestation. The typical stools contain yellow or bile-stained 
mucus with clots or streaks of blood in which schistosome ova, 
generally lateral-spined, may be found under low power of the 
microscope. The presence of a high eosinophilia in the blood 
in a case with symptoms of subacute dysentery and, it may be, 
a previous history of pyrexia and urticaria, should make one 
suspect schistosomiasis. Amongst Egyptian troops and labour 
corps schistosomiasis accounted for 5 per cent, of all clinical 
dysenteries. But, of course, schistosomiasis may co-exist 
with either the bacillary or amoebic dysentery. Blood and 
mucus may also be passed in infestations of the intestinal 
canal with Ascaris lumbricoides or Ankylostoma duodenale, and 
also in Nigeria with a rare sclerostome of man known as 
(Esophagostomum apiostomum. 

Dysentery due to infection with a large infusorian known as 
Balantidium coli is a rare disease. The pathology and clinical 
symptoms resemble those of amoebic dysentery. It has been 
reported from the Philippines, Germany, France and Russia, 
mainly in those intimately associated with pigs, as this animal 
appears to be the reservoir of infection. This parasite has 
rarely been observed in cases from Gallipoli at Mudros, and once 
in Egypt, during the war ; but in neither of these instances was 
it associated with the clinical symptoms of dysentery. There 
is one record by Payan and Richet of an acute and fatal case 
occurring in a Serbian soldier in France. 

There is considerable doubt whether the protozoon Giardia 
(Lamblia) intestinalis is to be regarded as pathogenic. It is an 
inhabitant of the small intestine and may appear both as active 
forms and cysts in enormous numbers in the faeces. It is 
generally associated with diarrhoea, though occasionally bile- 
stained mucus may be present. It is believed by many 
investigators that when present in large numbers it can give 
rise to an explosive diarrhoea associated with abdominal dis- 
comfort, but except as a matter of medical interest it is of little 
importance from the military point of view. 



CLINICAL DYSENTERY 105 

With regard to malarial dysentery, a word of caution is 
necessary. Graham and Logan state that many cases of dysen- 
teric symptoms in association with malaria, especially of the 
subtertian type, are really due to a concomitant infection with 
the dysentery bacillus, but one should also note that intestinal 
haemorrhage associated with rigors, icterus and abdominal 
pain may occur in the course of a severe subtertian infection. 
In these cases the subtertian rings have been found in stained 
smears prepared from the stool. Much altered and even bright 
red blood may appear in the faeces and thus influence the 
medical 'officer on clinical grounds to disregard the malarial 
element. The prognosis in these cases is grave, and, directly a 
diagnosis is established by microscopical examination of the 
blood, quinine therapy should be instituted. 

Certain other conditions may give rise to blood and mucus in 
the stools. Such are non-specific colitis, both of the mem- 
branous and ulcerative varieties, tubercular ulceration of the 
bowel, syphilitic disease, and even simple polypus of the rectum. 
It is surprising how often in military practice blood from in- 
ternal or external piles, passed with the faeces, is mistaken 
for true dysentery. In such cases the blood is freshly passed, the 
faeces are generally formed and scybalous, and therefore no great 
difficulty should be experienced in making a correct diagnosis. 

Finally, it is possible that acute types of bacillary dysentery 
may be mistaken for Asiatic cholera, food poisoning, or infec- 
tions with Bacillus gaertner or aertrycke, in which conditions 
blood may be passed in the faeces, especially during the early 
stages of the illness. 

Under active service conditions, when the means of obtaining 
a laboratory diagnosis of such a complex subject as dysentery are 
difficult to procure, the following points may be taken as a 
guide in the routine management of cases of clinical dysentery, 
in order to ensure adequate treatment at the earliest possible 
moment. 

(1) A clinical dysentery, especially if acute and occurring 
suddenly, is probably of the bacillary type. The patient is 
therefore a source of danger to his fellows and should be isolated 
as soon as possible. Such a case should be given a full dose of 
anti-dysenteric serum without waiting for the pathological 
report. Whatever the type of case may be, the serum can do no 
harm, and, in the bacillary disease, there is ample evidence to 
show that any delay is unwarrantable, for it may entail 
irremediable damage to the intestinal canal. 

(2) Blood and mucus in the stools mean dysentery. The 
exudate should be reported upon by a competent pathologist at 
the earliest possible moment. 



106 



MEDICAL HISTORY OF THE WAR 



(3) A diagnosis of dysentery and the actual presence of 
blood and mucus must be legibly recorded, or, still better, 
stamped, upon the man's field medical card before evacuation 
and the appropriate treatment at once instituted. This, unless 
strong indications to the contrary are forthcoming, should be 
subsequently adhered to. In other words, a dysentery once 
diagnosed amoebic should be assured continuous emetine 
treatment, or, if bacillary, a continuance of saline aperients. 



Andrewes 

Bahr & Willmore 

Bahr & Young 
Bartlett 



BIBLIOGRAPHY. 
BACILLARY DYSENTERY. 

. . Dysentery Bacilli : The Differ- 
entiation of the True Dysen- 
tery Bacilli from Allied Species. 

. . Dysentery in the British Medi- 
terranean Expeditionary 
Force (a reply to G. B. 
Bartlett). 

. . War Experiences in Dysentery, 
1915-18. 

. . On Dysentery in the Mediter- 
ranean Expeditionary Force. 



Ranque, Etude bacteriologique d'une 
Senez, Coville & Paraf . epidemic de dysenterie bacil- 

laire. 

Boehncke, Hamburger Untersuchungen iiber Ruhrimpf- 
& Schelenz. stoffe in vivo und vitro. 

Boehncke & Elkeles Ruhrschutzimpfungen mit Dys- 
bakta. 

Boyd . . . . A case of Bacillary Dysentery 

in which Flexner-Y was re- 
covered from the Blood Stream 
during Life. 

Le diagnostic bacteriologique de 
la dysenterie bacillaire. 



Burnet &Legroux . 
Cowan & Miller 

Cowan & Mackie . 
Crouzon 



Delille, Paisseau, . 
& Lemaire. 



Dopter 



Dysentery. A clinical study. 



A note upon the mode of infec- 
tion in bacillary dysentery. 

La conjonctivite et le rhuma- 
tisme dysent6riques. 



Note sur une 6pid6mie de 
dysenterie bacillaire a 1'armee 
d'Orient. 



La Dysenterie Bacillaire dans 
les Armees en Campagne. 



Lancet, 1918. Vol. i, 
pp. 560-563. 

Quart. Jl. of Med. 

1918. Vol. xi., p. 
349. 

Jl. of R.A.M.C., 

1919. Vol. xxxii, 
pp. 268-275. 

Quart. Jl. Med., 
1916-1917. Vol. x, 
pp. 185-244. 
Bull. Acad. de M6d., 
1918. 3 e S. Vol. 
Ixxix, pp. 275-277. 
Berlin. Klin. 

Woch., 1918. Vol. 
lv, pp. 134-137. 
Munch. Med. Woch., 
1918. Vol. Ixv, 
pp. 785-787. 
Lancet, 1919. Vol. 
ii., p. 482. 



Bull. Inst. Past., 
1919. Vol. xvii, 
pp. 449-465. 

Jl. of R.A.M.C., 

1918. Vol. xxxi, 
pp. 217-228, 277- 
295 

Jl. of R.A.M.C., 

1919. Vol. xxxii, 
pp. 209-214. 

Bull, et Mem. Soc. 

Med. des H6pit. 

de Paris, 1916. 

3 e S. Vol. xl, pp. 

1926-1928. 
Bull, et M6m. Soc. 

Med. des H6pit. 

de Paris, 1916. 

3 S. Vol. xl, pp. 

1302-1308. 
Paris Med., 1915. 

Vol. xv, pp. 510- 

512. 



DYSENTERY 



107 



Dumas 



Dudgeon 



BIBLIOGRAPHY cont. 

Caracteres differentials des 
Bacilles observes au cours de 
la dysenteric bacillaire. 



. . The Dysenteries : Bacillary and 
Amoebic. 

Enright & Bahr . . On a pyaemia due to organisms 
of the Bacillus coli group 
occurring in Turkish soldiers. 

Fisher . . . . A short Description of Eight- 

Cases of Severe Collapse, 
which were regarded as the 
Choleraic Type of Bacillary 
Dysentery. 

Fletcher . . . . Preliminary agglutination in the 
Isolation of Typhoid and 
Dysentery Bacilli from the 
Excreta. 

Florand, Bezan9on & Sur une epid6mie de dysenteric 
Paraf. bacillaire a bacille de Shiga. 



Flu 



Experimenteele bijdrage tot de 
kennis van het bacillendragen 
bij de bacillaire dysenteric. 



Friedemann & Stein- Zur Aetiologie der Ruhr, 
bock. 

Ghon & Roman . . Ueber Befunde von Bacterium 
dysenteriae-Y im Blute und 
ihre Bedeutung. 

Gibson . . . . A new method of preparation of 

a vaccine against bacillary 
dysentery which abolishes 
severe local reactions. Also 
experiments with this vaccine 
on animals and men. 

Graham, G. . . . . Arthritis in Dysentery, its causa- 
tion, prognosis and treatment. 



Graham, D. . . . . Some Points in the Diagnosis 
and Treatment of Dysentery 
occurring in the British 
Salonika Force. 

Grussendorf . . . . Zur Behandlung der dysenteri- 
schen Leberabszesse. 

Gunson . . .-r Cardiac Symptoms following 
Dysentery among Soldiers. 

D'Hrelle . . . . Sur un bacille dysentrique 
atypique. 



Hollande & Fumey. 



Emploi de 1'ovalbuminate de 
soude et des papiers reactifs 
tournesoles sucres dans la 
differentiation des bacilles 
dysentriques ; gelification de 
1'alcali-albumine. 



C.R. Soc. Biol. 

1919. Vol.lxxxii, 

pp. 1346-1348, 

1363-1364. 
B.M.J., 1919. Vol. i, 

pp. 448-451. 
Lancet, 1918. Vol. 

ii, pp. 585-587. 

Jl. of R.A.M.C., 
1917. Vol.xxviii, 
pp. 97-104. 



Jl. of R.A.M.C.. 
1918. Vol. xxx, 
pp. 500-509. 

Bull, et Mem. Soc. 
M6d. des H6pit. de 
Paris, 1918. Vol. 
xlii,3 e S.pp.81-84. 

Geneesk. Tijdschr. 
v. Nederl.-Indie 
1918. Vol. Iviii, 
pp. 67-84. 

Deut. Med. Woch., 

1916. Vol. xlii, 
pp. 215-218. 

Wien. Klin. Woch., 
1915. Vol. xxviii, 
pp. 579-583, 620- 
624. 

Jl. of R.A.M.C. 

1917. Vol. xxviii, 
pp. 615-657. 



Proc. Roy. Soc. 

Med., 1919-1920. 

Vol. xiii, Med. Sect. 

pp. 23-42. 
Lancet, 1918. Vol. i. 

p. 51. 



Munch. Med. Woch., 
1916. Vol. Ixiii, 
pp. 1503-1505. 

Lancet, 1916. Vol. 
ii, pp. 146-147. 

Ann. Inst. Pasteur, 

1916. Vol. xxx, 
pp. 145-147. 

C.R. Soc. Biol., 

1917. Vol. Ixxx, 
pp. 835-839. 



108 



MEDICAL HISTORY OF THE WAR 



Inglis 



Jacobitz 



Ledingham 

fold. 
Ledingham 



& Pen- 



Manson-Bahr 



Manteufel 



Martin, Kellaway & 
Williams. 



Martin & Williams . . 



Martin, Kellaway & 
Williams 



Martin, Hartley & 

Williams. 
Maxwell & Kiep .. 



Medical Research 
Committee. 



BIBLIOGRAPHY cont. 
Bacillary Dysentery among 
British Troops in France, 
1918. 

Ueber Ruhrbacillen Agglutina- 
tion. 

Serological Tests in Dysentery 
Convalescents. 

Dysentery and enteric disease in 
Mesopotamia from the labora- 
tory standpoint. An analysis 
of laboratory data during the 
eighteen months ending De- 
cember 31st, 1918. 

The correlation of the Pathology 
and Bacteriology of Bacillary 
Dysentery. A Dissertation 
on some of the Laboratory 
Problems arising in connexion 
with this disease in the East- 
ern Theatres of War. 

The commoner complications of 
Bacillary Dysentery in 
Military Practice. 

Untersuchungen iiber die Bazil- 
lenruhr in Deutsch-Ostafrika. 



Notes on the Etiology of Dysen- 
tery ; (i) Types of Dysentery 
Bacilli, (ii) The Value of 
Agglutinins, (iii) Bacteriology 
of Stools. 

Types of Dysentery Bacilli 
isolated at No. 3 Australian 
General Hospital, Cairo, 
March August, 1916, with 
observations on the variability 
of the Mannite Fermenting 
Group. 

Epitome of the results of the 
Examination of the Stools of 
422 cases admitted to No. 3 
Australian General Hospital, 
Cairo, for Dysentery and 
Diarrhoea, March to August, 
1916. 

Agglutination in the Diagnosis 

of Dysentery. 
Notes on six cases of iritis and 

cyclitis occurring in dysenteric 

patients. 

Reports upon investigations in 
the United Kingdom of 
dysentery cases received from 
the Eastern Mediterranean. 
II. Report on 878 cases of 
bacillary enteritis. 



Med. Jl. Australia, 

1919. Vol. i, pp. 
313-314. 

Berlin. Klin. Woch., 
1916. Vol. liii, 
pp. 718-719. 

B.M.J., 1916. Vol. i, 
p. 47. 

Jl. of R.A.M.C., 

1920. Vol. xxxiv, 
pp 189-203. 306- 
320. 



Jl. of R.A.M.C., 
1919. Vol. xxxiii, 
pp. 117-138. 



B.M.J. 1920. Vol.i., 
p. 791. 

Zeitschr. f. Hyg. u. 

Infektionskr., 

1915. Vol. Ixxix, 

pp. 319-335. 
B.M.J. , 1917. Vol. 

i, pp. 479-480. 



Jl. Hygiene, 1917- 
Vol. xvi, pp. 257- 
268. 



Jl., of R.A.M.C. 
1918. Vol. xxx, 
p. 101-102. 



B.M.J., 1918. Vol. i, 

pp. 642-644. 
Brit. Jl. Ophth., 

1918. Vol. ii, 

p. 71-79. 

M.R.C. Special Re- 
port Series. No. 5, 
Lond. 1917. 



DYSENTERY 



109 



Medical Research 
Committee. 



Michaelis 

Moorhead 
Oppenheim , 



Payan & Richet fils 

Phear 
Pine 

Remlinger & Dumas 
Rist 

Roccavilla 

Rogers 


Schelenz 

Schiemann . 



BIBLIOGRAPHY cont. 

III. Report upon recovered cases 
of intestinal disease in the 
Royal Navy Hospital, Haslar, 
1915-1916. IV. Report upon 
combined clinical and bacter- 
iological studies of dysentery 
cases from the Mediterranean. 

A Contribution to the Study of 
Chronicity in Dysentery Car- 
riers. 

An Investigation of the Flexner- 
Y Group of Dysentery Bacilli. 

Ueber kombinierte Eiweiss- 
Saureagglutination, insbeson- 
dere zur Unterscheidung von 
Koli-und Ruhrbazillen. 

A Note on Dysenteric Arthritis 

L'insuffisance surrenale dans la 
dysenteric bacillaire et les 
ententes graves. 



Un cas de dysenteric balanti- 
dienne observee en France. 



Medical Experiences in Mace- 
donia and the Caucasus, 1920. 

Observations on East African 
Bacillary Dysentery. 

Insuffisance surrenale au cours 
de la dysenteric. 

Arthropathies et conjonctivites 
dysenteriques. 



Diaree ed enterocoliti dissen- 
teriformi in alcuni settori del 
nostro fronte. 

Sensitized Shiga and Flexner 
Vaccines in the Treatment of 
Chronic Bacillary Dysentery. 

Ergebnisse bei kombinierter 
Serum- Vakzinetherapie der 
Ruhr. 

Ueber Schwierigkeiten bei der 
serologischen Diagnose der 
Shiga-Kruse-Ruhr und iiber 
Modifikation der Tecknik der 
Agglutination. 



M.R.C. Special Re- 
port Series, No. 6, 
Lond. 1917. 



M.R.C. Special Re- 
port Series, No. 
29, Lond. 1919. 

M.R.C. Special Re- 
port Series No. 30, 
Lond. 1919. 

Deut. Med. Woch., 

1917. Vol. xliii, 
pp. 1506-1507. 

B.M.J., 1916. Vol. i, 

p. 483. 
Progres Med., 1915. 

No. 41. pp. 507- 

512. 
Bull, et Mem. Soc. 

Med. des H6pit, 

de Paris, 1915. 

3 e S. Vol. xxxi, 

pp. 1155-1168. 
Bull, et Mem. Soc. 

Med. des H6pit. de 

Paris, 1917. 3 e S. 

Vol.xli.pp.96-103. 
Proc. Roy. Soc.Med., 

1920. 
Jl. of Hygiene, 1917. 

Vol. xv, pp. 565- 

579. 
C.R. Soc. Biol., 1915. 

Vol. Ixxviii, pp. 

433-435. 
Bull, et Mem, Soc. 

Med. des H6pit. de 

Paris, 1916. 3 C S. 

Vol. xl, pp. 1762- 

1765. 
Riv. Crit. Clin. Med., 

1918. Vol. xix, 
p.p. 157-161, 169- 
175, 181-189. 

B.M.J., 1916. Vol. i, 
pp. 7-8. 

Deut. Med. Woch., 
1918. Vol. xliv, 
p. 1050. 

Berlin. Klin. Woch., 
1916. Vol. liii, 
pp. 1078-1080. 



110 



MEDICAL HISTORY OF THE WAR 



Schmitz 



BIBLIOGRAPHY cont. 

Ein neuer Typus aus der Gruppe 
der Ruhrbazillen als Erreger 
einer grosseren Epidemic. 



. . Abgrenzung desBazillusSchmitz 
gegenuber den Pseudo-dysen- 
teriestammen und Versuche 
iiber die Verwandtschaft der 
Rassen A bis H.untereinander. 
Seiff ert & Niedieck . . Schutzimpfung gegen Ruhr 



Singer 



Thomson & Hirst 



Tribondeau & Fichet 



Weinberger 



Ueber dysenterische Rheuma- 
toide. 

Reports from the Pathological 
Laboratories of No. - General 
Hospital, Alexandria. I. 
Bacillaemia due to Various 
Organisms. By Captain Thom- 
son and Captain Hirst. II. 
The Thermo-Precipitin Re- 
action as an Aid to the Rapid 
Diagnosis of Bacillary Dysen- 
tery. By Captain Hirst. 

Note sur les dysenteries des 
Dardanelles. 

Verhiitung und Behandlung der 
infektiosen (Bazillen) Dysen- 
teric. 



Zeitschr. f. Hyg. u. 

Infektionskr,1917. 

Vol. Ixxxiv, pp. 

449-516. 
Cent. f. Bakt. 1. Abt. 

Orig., 1918. Vol. 

Ixxxi, pp. 213-228. 



Munch. Med. Woch, 

1916. Vol. Ixiii, 

pp. 329-330. 
Wien. Med. Woch., 

1915. Vol. Ixv, 

pp. 318-322. 
Lancet, 1918. Vol. i, 

pp. 566-67. 



Whitehead & Kirk- The isolation of Dysentery 
patrick. Bacilli from the faeces. 

Willmore & Shearman On the Differential Diagnosis 
of the Dysenteries ; the Diag- 
nostic Value of the Cell- 
Exudate in the Stools of Acute 
Amoebic and Bacillary 
Dysentery. 

AMCEBIC DYSENTERY. 

The significance of Charcot- 
Leyden crystals in the faeces 
as an indication of Amoebic 
Colitis. 

Amoebic Abscess of the Brain : 
with Notes on a Case following 
Amoebic Abscess of the Liver. 

The Behaviour of Amoebic 
Dysentery in Lower Animals 
and its Bearing upon the 
Interpretation of the Clinical 
Symptoms of the Disease in 
Man. 

The Treatment of Amoebic 
Dysentery. 

Quelques notes sur les protozo- 
aires parasites intestinaux de 
l'homme et des animaux. 



Acton 



Armitage 



Baetjer & Sellards 



Bates 



Brug 



Ann. Inst. Pasteur, 

1916. Vol. xxx, 

pp. 357-362. 
Wien. Med. Woch., 

1914. Vol. Ixiv, 

pp. 2396-2401, 

2428. 
Lancet, 1918. Vol. ii, 

pp. 143-144. 
Lancet, 1918. Vol. ii, 

pp. 200-206. 



Indian Jl. Med. Res., 
1918. Vol. vi, 
pp. 157-161. 

Jl. Trop. Med. & 

Hyg., 1919. Vol. 

xxii, pp. 69-76. 
Johns Hopkins Hosp. 

Bull., 1914. Vol. 

xxv, pp. 237-241. 



Jl. Amer.Med.Assoc., 

1916. Vol. Ixvii, 

pp. 345-347 
Bull.Soc.Path.Exot., 

1919. Vol. xii, 

pp. 628-640. 



DYSENTERY 



111 



Buxton 

Candler 
Cameron 

Carter & Matthews 



Carter, Mackinnon, 
Matthews & Smith. 



Ciauri 

Cope 

Cropper & Row 



Dale 



Dale & Dobell 



Dobel] 



BIBLIOGRAPHY cont. 

The importance of the house-fly 
as a carrier of Entamceba 
histolytica. 

Abscess of the Liver among 
British Eastern Troops. 

A case of Liver Abscess 



The value of concentrating cysts 
of protozoal parasites in exam- 
ining the stools of dysenteric 
patients for pathogenic en- 
tamoebae. 

The Protozoal Findings in Nine 
Hundred and Ten Cases of 
Dysentery examined at the 
Liverpool School of Tropical 
Medicine from May to Septem- 
ber, 191 6 (First Report). 

Protozoological Investigation of 
Cases of Dysentery conducted 
at the Liverpool School of 
Tropical Medicine (Second 
Report). 

Dissenteria amebica 



The Surgical Aspects of Dysen- 
tery. 

A Method of Concentrating 
Entamceba Cysts in Stools. 



Treatment of Carriers of Amoe- 
bic Dysentery. 

The Treatment of Amoebic 
Dysentery Carriers. Note on 
the Use of the Double Iodide 
of Emetine and Bismuth. 

Experiments on the Therapeutics 
of Amoebic Dysentery. 



Incidence and Treatment of 
Entamceba histolytica Infection 
at Walton Hospital. 

Reports upon investigations in 
the United Kingdom of 
dysentery cases received from 
the Eastern Mediteranean. 
I. Amoebic dysentery and the 
protozoological investigation 
of cases and carriers. 

The Amoebae living in Man. A 
zoological monograph. 



B.M.J., 1920. Vol. i, 
pp. 142-144. 

Lancet, 1920. Vol. i. 
pp. 429-431. 

Med. Jl. Australia, 

1916. Vol. i, pp. 

432-434. 
Ann. Trop. Med. & 

Parasit. 1917-1918. 

Vol. xi, pp. 195- 

204. 

Ann. Trop. Med. 
Parasit. 1917. Vol. 
x, pp. 411-426. 



Ann. Trop. Med. & 
Parasit. 1917-1913, 
vol. xi, pp. 27-68. 



Giorn. Med. Milit., 
1917. Vol. Ixv, 
pp. 934-941. 

Oxford Publications, 
1920. 

Lancet, 1917. Vol. i, 

pp. 179-182. 
Proc. Roy. Soc. Med., 

1916-1917. Vol. x, 

Beck. Lab. Repts. 

pp. 1-12. 

Lancet, 1916. Vol. ii, 
pp. 183-184. 

Jl. of R.A.M.C.,1916. 
Vol. xxvii. pp. 
241-244. 

Jl. Pharmacol. & 
Exper. Therap., 
1917-1918. Vol.x, 
pp. 399-459. 

B.M.J., 1916. Vol.ii, 
pp. 612-616. 

M.R.C. Special 
Report Series, No. 
4, London, 1917. 



M.R.C. Reports, 
London, 1919. 



112 



MEDICAL HISTORY OF THE WAR 



Dobell & Jepps . . 



Dobell & Stevenson. 



Dobell, Gettings, 
Jepps & Stephens 



Dopter 
Faulds 

Fuchs & Bouchet . . 
Ghosh 

Imrie & Roche 

James 

Jepps & Meakins . . 

Job & Ernoul 

Kilgore 
Kuenen 
Leboeuf & Braun . 



BIBLIOGRAPHY cont. 

On the Three Common Intestinal 
Entamoebae of Man, and 
their Differential Diagnosis. 

A Study of the Diverse Races of 
Entamceba histolytica distin- 
guishable from one another by 
the Dimensions of their Cysts. 

A Note on the Duration of Infec- 
tions with Entamceba histoly- 
tica. 

A Study of 1,300 convalescent 
cases of Dysentery from Home 
Hospitals : with Special 
Reference to the incidence 
and Treatment of Amoebic 
Dysentery Carriers. 

Action de 1'emetine dans le 
Traitement des Abces Ami- 
biens du foie. 

Liver Abscess amongst our 
Soldiers. 

Une petite epidemic d'amibiase 

sur le front. 
The Treatment of Liver Abscess 

by Intra-Hepatic Injections of 

Emetine following Aspiration. 
Report on six cases of Amoeba 

histolytica Carriers treated 

with Emetine Bismuthous 

Iodide. 
A Study of the Entamoebae of 

Man in the Panama Canal 

Zone. 

Detection and Treatment with 
Emetine Bismuth Iodide of 
Amoebic Dysentery Carriers 
among cases of Irritable 
Heart. (Report to the Medical 
Research Committee). 

Un cas de dysenteric amibienne 
autochtone. 



Peripheral Neuritis following 
Emetin Treatment of Amoe- 
bic Dysentery. 

De Entamoeben van den Mensch 
en de Amoeben-Dysenterie. 



Resultats de I'examen micro- 
scopique de 436 selles. Fre- 
quence de 1'amibiase autoch- 
tone intestinale et h6patique. 



B.M.J., 1917. Vol. i, 
pp. 607-612. 

Parasitology, 1918. 
Vol. x, pp. 320-351. 



Trans. Soc. Trop. 
Med. & Hyg., 1918. 
Vol. xi, pp. 168-175. 
M.R.C. Special 

Report Series No. 

15, Lond., 1918. 



Paris Med., 1916. 

Vol. vi, pp. 243- 

253. 
Glasgow Med. Jl., 

1916. Vol. Ixxxvi, 
pp. 337-340. 

Presse Med., 1917. 

Vol. xxv. p. 455. 
Calcutta Med. Jl., 

1917. Jan., p. 205. 

Lancet, 1917. Vol. i, 
p. 17. 



Ann. Trop. Med. 

& Parasit., 1914. 

Vol. viii, pp. 133- 

320. 
B.M.J., 1917. Vol. ii, 

p. 645. 
Jl.of R.A.M.C..1917. 

Vol. xxix, pp. 704- 

712. 

Bull, et Mem. Soc. 

Med. des Hopit. 

de Paris, 1915, 

3S. Vol. xxxix, 

pp. 851-855. 
Boston Med. & 

Surg. JL, 1916. 

Vol. clxxv, pp. 

380-382. 
Geneesk. Tijdschr. 

v. Nederl.-Indie, 

1914. Vol. liv, 

pp. 235-318. 
Bull, et Mem. Soc. 

M6d. des H6pit. 

de Paris, 1916. 

3 e S. Vol. xl, pp. 

1602-1607. 






DYSENTERY 



113 



Lillie & Shepheard . . 



Labbe 
Low- 



Low & Dobell 

Love 

MacAdam & Keelan 



MacAdam 



MacGilchrist 



Manson - Bahr & 

Gregg. 
Matthews & Smith 



BIBLIOGRAPHY con/. 

A Report on the Treatment of 
Entamceba histolytica " Car- 
riers " with Emetine Bismuth 
Iodide, giving a Comparison 
between the Keratin-Coated 
Tabloids and Salol-Coated 
Pills. 

La frequence des dysenteries 
amibiennes meconnues. 

Amoebic Dysentery 



A Case of Amoebic Abscess of the 
Liver occurring Twenty Years 
after the Original Attack of 
Dysentery. 

Further Experiences with 
Emetine Bismuth Iodide in 
Amoebic Dysentery, Amoebic 
Hepatitis, and General Amce- 
biasis. 

A Series of Acute and Subacute 
Amoebic Dysentery Cases 
treated by Emetine Bismuth 
Iodide and other Drugs. 

Three cases of Entamceba his- 
tolytica Infection Treated with 
Emetine Bismuth Iodide. 

Amoebic Abscess of the Liver 

The Problem of the Amoebic 
Dysentery Carrier in India 
and Mesopotamia. An inves- 
tigation based on the proto- 
zoological findings in the stools 
of over 2,000 men, chiefly of 
the Mesopotamian Field 
Force. 

Entamceba histolytica Infections : 
Their prevalence among 
British Troops in India and 
Mesopotamia, with special ref- 
erence to the Question of 
" Clearing." 

Quinoidine : Its characters, 
composition, and lethality to 
Protozoa. (Cinchona Deriva- 
tives Inquiry. Fourth Com- 
munication.) 

The diagnosis of dysentery by 
the sigmoidoscope. 

The Spread and Incidence of 
Intestinal Protozoal Infec- 
tions in the Population of 
Great Britain : I. Civilians in 
the Liverpool Royal Infirm- 
ary. II. Army Recruits. III. 
Children. 



Jl. of R.A.M.C., 
1917. Vol. xxix, 
pp. 700-704. 



Bull. Acad. Med., 

1919. 3 C S. Vol. 

Ixxxi, pp. 550-552. 
Practitioner, 1916. 

Vol. xcvi, pp. 320- 

330. 
B.M.J., 1916. Vol. ii, 

pp. 867-868. 



Lancet, 1917. Vol. i, 
pp. 482-485. 



Trans. Soc. Trop. 

Med. & Hyg.. 

1918. Vol. xi, pp. 

155-167. 
Lancet, 1916. Vol. ii, 

pp. 319-321. 

B.M.J., 1918. Vol. i, 
pp. 696-697. 

Ind. Jl. Med. Res., 
1917-1918. Vol. v, 
pp. 239-272. 



Lancet, 1918. Vol. i, 
pp. 15-19. 



Indian Jl. Med. Res., 
1914-1915. Vol. ii, 
pp. 888-906. 



Lancet, 1921. Vol. i, 
pp. 1121-1125. 

Ann. Trop. Med. 
& Parasit., 1919, 
Vol. xii, pp. 349- 
359; 361-369. 



(2396) 



114 



MEDICAL HISTORY OF THE WAR 



Nixon 



BIBLIOGRAPHY -cont. 

Chaparro Amargosa in the Treat- 
ment of Amoebic Dysentery. 



Nobecourt & Gimbert Note sur quelques cas de dysen- 
teric amibienne autochtone 
observes dans une armee. 

Penfold, Woodcock & The Excystation of Entamceba 



Drew. 
Pyman & Wenyon . . 

Roche 

Savage & Young . . 

Sellards & Baetjer . . 
Shepheard & Lillie . . 

Smith & Matthews . . 
Smith 



Stout & Fenwick . . 
Wenyon 

Wenyon & O'Connor 



histolytica (letragena) as an 
Indication of the Vitality of 
the Cysts. 

The Action of Certain Emetine 
Derivatives on Amoebae. 



Intestinal protozoa in the Salo- 
nica War Area. 

Report on the Treatment of 59 
cases of Entamceba histolytica 
Infection ; with clinical re- 
marks. 

The Experimental Production of 
Amoebic Dysentery by Direct 
Inoculation into the Caecum. 

Persistent Carriers of Entamceba 
histolytica : Treatment with 
Chaparro Amargosa and Sima- 
ruba. 

Further records of the occur- 
rence of intestinal protozoa in 
non-dysenteric cases. 

Measurements of, and observa- 
tions upon, the Cysts of En- 
tamceba histolytica and of 
Entamceba coli. 

A Contribution to the Question 
of the Number of Races in the 
Species Entamceba histolytica. 

Cases of Acute Amoebic Dysen- 
tery in Asylum Patients never 
out of England. 

A Case of Amoebic Abscess of the 
Liver and Brain with no 
Previous History of Dysentery 

Observations on the Common 
Intestinal Protozoa of Man : 
Their Diagnosis and Patho- 
genicity. 

Human Intestinal Protozoa in 
the Near East. An Inquiry 
into some Problems affecting 
the Spread and Incidence of 
Intestinal Protozoal Infec- 
tions of British Troops and 
Natives in the Near East, with 
Special Reference to the 
Carrier Question, Diagnosis 
and Treatment of Amoebic 
Dysentery and an Account of 
Three New Human Intestinal 
Protozoa. 



Jl. Araer. Med. 

Assoc., 1916. Vol. 

Ixvi, p. 946. 
Bull, et Mem. Soc. 

Med. des Hopit. de 

Paris, 1918. Vol. 

xlii, 3 e S. pp. 57-60. 
B.M.J., 1916. Vol. 
i, pp. 714-715. 



Jl. Pharmacol. and 
Exper. Therap., 
1917-1918. Vol. 
x, pp. 237-241. 

Lancet, 1917. Vol. 
i, pp. 297-298. 

Jl. of R.A.M.C., 
1917. Vol. xxix, 
pp. 249-275. 

Bull. Johns Hopkins 
Hosp., 1914. Vol. 
xxv, pp. 323-328. 

Lancet, 1918. Vol. 
i, pp. 501-502. 



Ann. Trop. Med. & 
Parasit., 1917. 
Vol.xi, pp. 183-193. 

Ann. Trop. Med. 
& Parasit., 1918. 
Vol. xii, pp. 27-69. 

Ann. Trop. Med. & 

Parasit., 1919. 

Vol. xiii, pp. 1-16. 
Ann. Trop. Med. & 

Parasit., 1919. Vol. 

xiii, 
Lancet, 

p. 769. 



i, pp. 177-185. 
:et, 1918, Vol. i, 



Jl. of R.A.M.C., 
1915. Vol. xxv, 
pp. 600-630. 

London 1917: John 
Bale, Sons & 
Danielsson. 



DYSENTERY 



115 



Wenyon & O'Connor 



Woodcock 



BIBLIOGRAPHY cont. 

An Inquiry into some Problems 
Affecting the Spread and Inci- 
dence of Intestinal Protozoal 
Infections of British Troops 
and Natives in Egypt, with 
Special Reference to the Car- 
rier Question, Diagnosis and 
Treatment of Amoebic Dysen- 
tery, and an Account of Three 
New Human Intestinal Pro- 
tozoa. 

The Carriage of Cysts of Enta- 
mceba histolytica and other 
Intestinal Protozoa and Eggs 
of Parasitic Worms by House- 
Flies, with some notes on the 
Resistance of Cysts to Dis- 
infectants and Other Agents. 

Protozoological experiences dur- 
ing the summer and autumn 
of 1916. 

Note on the epidemiology of 
Amoebic Dysentery. 



Worster- Drought Amoebic Dysentery in a Man 
& Rosewarne. who had never left England. 

Mac- Persons who have never been out 
of Great Britain as Carriers of 
Entamaeba histolytica. 
The Presence of Entamceba 
histolytica and E. coli Cysts in 
People who have not been 
out of England. (With dis- 
cussion.) 
Amoebic Dysentery in England. 



Yorke, Carter, 

kinnon. Matthews 
& Smith. 
Yorke 



Lauzenberg 



Payan & Richetfils 



BALANTIDIAL DYSENTERY. 

Un cas de Balantidiose autoch- 
tone. Son traitement. 

Un cas de dysenteric balantidi- 
enne observed en France. 



Jl. of R.A.M.C, 
1917. Vol. xxviii, 
pp. 1-34, 151-187, 
346-370. 



Jl. of R.A.M.C., 
1917. Vol. xxviii, 
pp. 522-559. 



Jl. of R.A.M.C., 

1917. Vol. xxix, 
pp. 290-300. 

Jl. of R.A.M.C., 

1919. Vol. xxxii, 

pp. 231-235. 
B.M.J., 1916. Vol. 

i, pp. 715-716. 
Ann. Trop. Med. 

& Parasit., 1917. 

Vol. xi, pp. 87-90. 
Trans. Soc. Trop. 

Med. & Hyg., 

1918. Vol. xi, pp. 
291-296. 

B.M.J., 1919. Vol. 
i, pp. 451-454. 



Bull. Soc. Path. 

Exot. 1918. Vol. 

xi, pp. 558-559. 
Bull, et Mem. Soc. 

Med. des Hopit. 

de Paris, 1917. 

Vol. xli, 3S. pp. 

96-103. 



CHAPTER IV. 

CHOLERA. 

IN July 1914 cholera occurred in the Russian" provinces 
bordering on Galicia. The first cases in the Austro- 
Hungarian army operating in Eastern Galicia appeared on 
20th September, 1914, and by the end of 1914, 22,000 cases 
with 7,672 deaths had been reported ; by September 1915 the 
numbers had increased to 26,000 cases with 15,000 deaths. It is 
known that Austria employed certain divisions from Galicia to 
invade Serbia in 1914, and in all probability these troops were 
responsible for conveying the infection into Serbia, as a great 
epidemic broke out there in 1914. By September of that year 
12,000 cases had been reported in the Serbian army, with a daily 
proportion of fresh cases varying from two to three hundred. 

The German army co-operating with the Austro-Hungarian 
troops in Galicia is stated to have suffered severely from cholera, 
while the German troops operating against Russian Poland were 
also affected by the disease. The chief outbreaks in the German 
army were in December 1914 and August 1915, and it is 
recorded that 13 cases occurred among the German forces on 
the Western Front, 78 cases among German civilians, and 3,166 
cases among Russian prisoners of war between November 1914 
and November 1915. Although total figures for the German 
army are not given, ratios of 0-65 per 1,000 of strength in the 
field army, and 0-05 in the reserve army, have been published. 

In Turkey there was no record of any outbreak of cholera 
during the year 1915, but in the spring of 1916 many epidemics 
were reported from different areas. It has been stated that 
between May 1916 and 14th February, 1917, there were in 
Jerusalem and the surrounding villages 183 cases and 116 deaths, 
in Baghdad 179 cases and 76 deaths, in Mosul 130 cases and 51 
deaths, and in Aleppo 2,020 cases and 1,203 deaths. 

In Persia three cases occurred at Kazvin during November 
1915, and 10 cases and seven deaths at Kermanshah during 
July 1916. 

Although the British troops were operating in areas where 
cholera was endemic, and in contact with infected allies and 
enemies, they were affected by cholera only in Mesopotamia 
and Sinai, where 2,852 and 28 cases occurred respectively. 
Knowledge of the spread of the disease in the British armies 
during the war is derived from what took place in thes 
countries 

116 



CHOLERA 



117 




118 MEDICAL HISTORY OF THE WAR 

On 17th April, 1916, the British force operating on the Tigris 
for the relief of Kut, attacked and occupied the Turkish position 
at Bait Aiessa, and it was known that cholera had broken- out 
in the Turkish force operating in front of Kut. A glance at 
the map in Fig. 1 shows the position of the water creek 
which ran south-east from Bait Aiessa through the Turkish 
lines to the British trenches, and which afterwards became 
known as Cholera Creek on account of the infection it had 
bred. 

The water in this creek was polluted by faecal matter and 
corpses, and consequently when the British troops, suffering 
from fatigue, heat and thirst, drank its unsterilized water, they 
became infected. Cholera broke out in the 3rd Lahore Division 
on 25th April, and spread to the 7th Meerut and 13th British 
Divisions. Up to the middle of June, when the epidemic had 
practically subsided, the total number of cases admitted to 
hospital from the 3rd Lahore Division was 66, from the 7th 
Meerut Division 62, and from the 13th Division 249. 

Nomadic Arabs kept in close touch with the flanks of both 
forces, and, contracting the disease, they probably disseminated 
infection in other districts through their wanderings. 

At first no special field ambulance or casualty clearing station 
was detailed for cholera cases, nor were any preventive measures 
or schemes drawn up by headquarters, although in other 
theatres of war this had been done. All the field ambulances 
were crowded with sick and wounded, and officers commanding 
units experienced a shortage of both tents and personnel, so 
that the measures which could be adopted for segregating and 
isolating doubtful cases of cholera and contacts were limited. 
A certain number of doubtful cases were evacuated down stream 
by river boats, and there is no doubt that infection was carried 
in that way. 

The last considerable group of cases reported in the forward 
area occurred on the river steamer " P50.," when 33 cases from 
the 105th Maharatta Infantry were sent to hospital at Sheikh- 
Saad in mid-August. In September seven cases, and up to 
10th October four cases, were treated in the cholera hospital at 
Sheikh-Saad. The majority of these cases contracted the disease 
on river steamers coming down from the front area. The out- 
break on ' ' P50 ' ' was traced to the water supply. The drinking 
water was sterilized by means of steam from the engine and the 
tanks were filled from the river by a steam pump. The arrange- 
ments were not carried out satisfactorily, and the Indian per- 
sonnel of " C " and " D " Companies frequently drew water 
direct from the river below the latrines, which were situated 
about mid-ship. (See Fig. 2.) 



CHOLERA 



119 



In consequence of this outbreak, the question of the position 
of the cooking places was considered and investigated by the 
Deputy Director Inland Water Transport, and it was arranged 
that they should be placed forward instead of aft. 

There were 501 cases at Amara between 29th April and 1st 
December, 1916, and between 24th and 31st August, 1916, there 
was an acute epidemic in two of the hospitals stationed there. 
Thirty-five cases, with 14 deaths, were reported from No. 1 
British General Hospital, and 19 cases, with 10 deaths, from 



SKETCH OF 

RjVER STEAMER P5O 




Fig. 2. 

No. 23 British Stationary Hospital. In both hospitals infection 
was carried by the milk supply. The milk was sterilized before 
it was given io hospital patients, but unfortunately it often 
arrived late, and the sterilization was not always supervised. 

In Basrah, from April to November 1916, 673 cases of cholera 
were admitted to the hospitals and 246 cases died. The first 
cases were notified on 1st May, 1916, and the water supply was 
found to be the cause of the disease. At No. 9 and No. 10 
Indian General Hospitals there was a sharp epidemic in October. 
It was suggested that the milk had been infected, but it was 



120 MEDICAL HISTORY OF THE WAR 

discovered that only the men who were not confined to bed 
were attacked, and that those who were confined to bed and 
lived on a milk diet escaped. The infected men had drunk 
polluted water from a neighbouring creek in which bedpans 
had been washed by the hospital sweepers. 

Cases were reported in June 1916 from the 15th Indian 
Division stationed at Nasiriyeh on the Euphrates. Twenty- 
eight cases were admitted to hospital between June and Septem- 
ber and there were 19 deaths. There were 180 cases amongst 
the civilian population. Investigation showed that the out- 
break was due to infection which was water-borne, and that 
Arabs from the Tigris front had carried the germs of the disease 
to the villages situate upstream of Nasiriyeh. 

In the summer and autumn of 1917 a considerable number of 
cases of cholera was reported from Baghdad, Basrah and 
Nasiriyeh. When the British force captured Baghdad in March 
1917, the Turkish water pumps were taken over. These pumps 
delivered crude river water from seven different intakes into 
nine different pipe lines, which gave a limited and intermittent 
supply to every part of the city. It is interesting to record in 
connection with the Baghdad cases that, although automatic 
chlorinators were fixed to all the intakes of the water supply for 
Basrah early in 1917, it was not until April 1917 that one was 
taken to Baghdad, and they were not made use of there till 
November 1917, when the epidemic of cholera, which claimed 
General Maude as one of its victims, was shown to have sprung 
from the river. 

In 1918 cholera epidemics were reported among the Arabs, 
and the infection spread to the 13th, 14th and 15th Divisions, 
appearing also in Basrah and Baghdad. The number of cases 
reported between May and December 1918 was 69 in the 13th 
Division, 28 in the 14th Division, 5 in the 15th Division, 
141 in Basrah, 147 in Baghdad, and 1 in the Sheikh-Saad-Kut 
area. 

The occurrence of cases of cholera among the Turkish forces 
in Syria first became known to the Egyptian Expeditionary 
Force in July 1916, after the commencement of the British 
advance from the Suez Canal into Sinai. On August 4th, 1916, 
the Turkish attack, threatened since the middle of the preceding 
month, developed at Romani and Katia and continued during 
the next two days. The enemy were heavily defeated, and 
retreated, pursued by British troops. 

During the month of August the heat in the Sinai desert was 
very great, but every effort was made to provide a gallon of 
sterilized water per man per day, each mounted man being 
given two water bottles, although it was sometimes impossible 



CHOLERA 121 

during the fighting and pursuit to get the water camels out to 
the troops. 

Maintenance of water discipline was difficult in men exhausted 
by long working in the sand and heat of the desert, and after 
the capture of the oasis of Katia men of the 157th Brigade 
drank water from shallow wells which had been used by the 
Turks, without waiting to sterilize the water by means of soda 
bisulphate tabloids with which each man was provided. The 
enemy had just been driven from this oasis, leaving the sur- 
roundings of the wells and the whole area in a very foul condition. 
Certain men of the Anzac Mounted Division, during the pursuit 
of the Turks, also drank water from Turkish water barrels found 
in deserted oases. The first case of cholera occurred in a non- 
commissioned officer of the Anzac Mounted Division on 7th 
August, and subsequently 25 further cases were admitted to 
hospital at various dates up to and including 23rd August, 
after which date no more cases occurred. 

JEtiology. 

All recent evidence shows that the cause of cholera is infection 
with the cholera bacillus, which is taken into the body by the 
mouth by means of infected food or drink. The small outbreak 
which occurred in the Egyptian Expeditionary Force after the 
battle of Romani (Katia) in 1916 and the outbreaks in Mesopo- 
tamia were due to drinking infected water. 

The cholera bacillus has but feeble resisting powers outside 
the human body and soon dies if dried. If, on the other hand, 
it is kept moist it will live for a considerable time, as, for instance, 
on the surface of fruit or vegetables if not exposed to the sun ; 
and, as shown by Major Greig, I. M.S., it can exist in moist faeces 
for as long as seventeen days. The cholera bacillus soon dies 
in sterile water, but has been recovered from natural water 
within a period of 56 days. The cholera bacillus cannot as a 
rule be found in the faeces of patients for more than a few days 
10 days at the most after recovery from an attack, but 
occasionally patients have harboured the bacillus for a month 
or more. 

In recent years a considerable amount of research has been 
carried out as t6 the possibility of the disease being conveyed by 
means of cholera carriers. It has been found that during cholera 
epidemics the stools of healthy persons may contain true cholera 
bacilli, and that therefore the cholera carrier is an important 
factor in the spread of the disease. Examination of contacts 
is therefore essential during any epidemic of cholera, and the 
discovery and control of carriers is all-important. These facts 
were well recognized during the war, and both in Mesopotamia 



122 MEDICAL HISTORY OF THE WAR 

and Sinai the examination of cholera contacts was carried out 
as a preventive measure. 

The cholera bacillus may be isolated post mortem from the 
tissues such as the lungs and biliary passages, and may also be 
found in the liver, spleen, kidneys, and heart muscle and in 
large numbers in the mesenteric glands. The vibrio may be 
detected in the whole of the biliary tract from the gall bladder 
to the common bile duct. This last fact is of interest in con- 
nection with the question of carriers. 

Symptoms. 

The incubation period lasts from a few hours to two to six 
days. It is usually 24 to 48 hours. Observations, however, 
of cases during the war seemed to show that the incubation 
period might be prolonged in those who had been inoculated 
against the disease. 

It is usual to describe the clinical course and symptoms of a 
case of cholera under three headings, namely, the stage of 
evacuation, the stage of collapse, and the stage of reaction ; 
but it must be borne in mind that the three stages are not 
sharply divided but pass insensibly one into the other. 

The signs and symptoms of a typical acute attack of cholera 
in any of its three stages are well known and need not be fully 
described. Certain variations from the ordinary may, how- 
ever, be met with during an epidemic. 

Cholera sicca is an acute and almost invariably fatal form of 
the disease, but it is fortunately of infrequent occurrence. In 
it collapse takes place with little or no evacuation from the 
bowel, though the intestines may actually be distended with 
fluid. Sudden death may occur from cholera sicca, and such 
cases may present very great difficulties in diagnosis. 

In certain severe cases of ordinary cholera, even in those 
ultimately proving fatal, though diarrhoea is present and pros- 
tration marked, the stools may fail to show the typical rice- 
water appearance, and may resemble those met with in an 
ordinary attack of gastro-enteritis, and may even contain blood. 

The following complications and sequelae may occur during 
or after the stage of reaction in an attack of cholera : excessive 
febrile reaction, uraemia, pneumonia, dysenteric diarrhoea and 
rash. 

Prognosis. 

The mortality in different epidemics has varied considerably. 
An average mortality in former epidemics may be considered 
to have been 50 per cent., but with the modern treatment 
introduced by Sir L. Rogers the average mortality has been 
reduced below that figure. Young persons and old people have 



CHOLERA 123 

a high mortality, as have those also who suffer from kidney 
disease. Chronic alcoholism is very unfavourable. The mor- 
tality in the Sinai outbreak in 1916 was 25 per cent. ; in Meso- 
potamia during 1916 the mortality amongst all British and 
Indian cases occurring in the 3rd, 7th, 13th and 15th Divisions 
was 41 '4 per cent., and amongst cases in Amara it was 36-9 
per cent. In 524 Indian cases at Basrah in 1916 it was 33-7 
per cent. In the 13th Division (British) of 249 admissions, 102 
died, or 40-9 per cent. Finally, in 344 British and Indian cases 
admitted from 1st June, 1918, to December 1918, the mortality 
was 40 -55 percent. 

In the cases which recover permanent ill-effects are at the 
most very uncommon, and no disability giving any claim to 
pension or compensation should arise. 

Diagnosis. 

Diagnosis during an epidemic of cholera is' usually simple and 
should not present difficulty, but sporadic and atypical cases 
are less easy of recognition. In the East any sudden attack of 
severe diarrhoea and vomiting, particularly if attended with 
muscular cramps and prostration, should be regarded with 
suspicion, and the more so if it occurs during the cholera season, 
even though no previous cases have been reported. The signs 
on which the clinical diagnosis is usually based are the sudden 
onset, the character and copiousness of the stools and vomit, 
the prostration, the husky voice and the shrinking tissues. In 
mild cases the diagnosis may be impossible, or the disease not 
even suspected, without a bacteriological examination, as 
happened during the Sinai outbreak. Again, owing to active 
service conditions, cases may not be seen until the acute symp- 
toms have passed and a state of febrile reaction exists. Such 
cases are liable to be mistaken at first for fever of the enteric 
group, and the diagnosis is very difficult, as the cholera vibrio 
may not be found in the stools. One case of this nature was 
seen in Sinai in which cholera bacilli were only recovered post 
mortem from the gall bladder, five previous examinations by 
three skilled observers having failed to show the presence of 
the vibrio in the stools. In all suspected cases, therefore, the 
faeces should be examined bacteriologically for the detection of 
the cholera bacillus. Serum agglutination tests are helpful in 
the detection of cholera carriers, as convalescents, especially 
when the disease has been mild, may show a high agglutination 
titre. 

Certain diseases may be confounded with cholera, particularly 
when they have as symptoms or physical signs such affections as 
muscular cramps, cyanosis, shrinking of the tissues and so on. 



124 MEDICAL HISTORY OF THE WAR 

Ptomaine poisoning, meat poisoning of bacillary origin, 
malignant malaria, acute bacillary dysentery and acute gastro- 
enteritis (summer diarrhoea) in children, and poisoning with the 
irritant metals such as arsenic or antimony, may all produce 
symptoms having a resemblance to cholera. It is difficult to 
distinguish the premonitory diarrhoea of cholera from ordinary 
diarrhoea, and it is therefore of great importance during an 
epidemic of cholera to isolate all cases of diarrhoea if possible, 
or at any rate to make a bacteriological examination of the 
faeces. 

Treatment. 

In the treatment of premonitory diarrhoea all purgatives 
especially salines should be avoided. Rest in bed, warmth, 
and a suitable fluid diet are necessary. Astringents and 
bismuth salicylate are useful. Opium should not be given, as 
it may be harmful if the case should pass into the more serious 
form of cholera. 

The treatment, which is now recognized as the most 
efficacious and which is founded on sound principles, is that 
first introduced by Sir L. Rogers. This treatment when properly 
carried out has reduced the mortality from 50, 60 or even 80 
per cent, to 30 per cent. ; and in a recent large series of cases 
treated by Rogers the mortality was only 15 per cent. The 
principles on which Rogers' treatment is founded as laid down 
by himself are as follows. : 

(1) Whenever collapse occurs and the blood pressure falls 
to 70 mm. Hg., replace the fluids and salts lost from the body 
by hypertonic intravenous saline injections in sufficient quan- 
tity to raise the blood pressure to normal, adding alkalies to 
neutralize acidosis. 

(2) Watch and control the temperature in the reaction stage. 

(3) Continue to observe the blood pressure after the reaction, 
and maintain it at a level which ensures a free secretion of 
urine. 

The indications for the composition and the technique of the 
intravenous and rectal injections are described in the pamphlet 
included in the official War Office cholera outfit. One or two 
points of importance may be mentioned. 

During the stage of collapse in mild cases where the blood 
pressure is not below 70 mm. Hg. and the specific gravity of the 
blood is more or less normal (1,058 in Europeans, 1,055-6 in 
Indians), rectal injections of hypertonic solution combined with 
general treatment will suffice ; but a close watch must be kept 
on the blood pressure, and if it falls, recourse must be had to the 
intravenous injection applicable to the more severe cases. In 



CHOLERA 125 

the more severe cases the condition of the pulse affords the 
simplest indication for the necessity of intravenous injections, 
but it is much better to use the sphygmomanometer which is 
essential in the scientific treatment of cholera. If the blood 
pressure is found to be 70 mm. Hg. or lower, a hypertonic 
intravenous injection of three to six pints should be given. The 
specific gravity of the blood is another important guide to treat- 
ment, as if the specific gravity is 1060 or over and the blood 
pressure 70 mm. Hg. or less, a copious intravenous injection is 
required ; and further, if the specific gravity is over 1065, even 
if the blood pressure is over 70 mm., an injection should 
be given. 

Recent researches having shown the presence of acidosis in 
cholera, Rogers has modified the composition of his original 
hypertonic solution by the addition of sodium bicarbonate. It 
should be remembered that a bicarbonate solution is spoiled by 
boiling, and that the bicarbonate, sterilized by dry heat if 
necessary, should be added later to the sterilized water. 

The indications for the use of the original or modified 
saline solution may be briefly stated as follows. If a 
patient is admitted within the first day of the disease, 
and there is no marked suppression of urine, the ordinary hyper- 
tonic saline injection (sodium chloride, 120 grains ; calcium 
chloride, 4 grains ; sterilized water, 1 pint), should be given in 
the first instance. But in all cases requiring a second injection, 
as well as in patients only coming under treatment late in the 
disease or with a deficiency of urine, one pint of water containing 
60 grains sodium chloride -f- 160 grains sodium bicarbonate 
should first be injected, and then transfusion continued 
with the ordinary hypertonic solution. In mild cases, 
where only rectal injections are indicated, the combination 
of sodium chloride and sodium bicarbonate may also 
be used. 

In addition to the treatment by injections the administration 
of permanganate salts by pill (two grains potassium perman- 
ganate) and in solution (calcium permanganate three to six 
grains to the pint) should always be carried out, as detailed 
in the official pamphlet. If the patient cannot take the 
permanganate drink or refuses to take it in sufficient quantity, 
barley water may be given in sips, as larger amounts of fluid 
taken at one time are apt to excite vomiting. 

Rogers' treatment by means of hypertonic injections and the 
administration of permanganates is the standard treatment 
for cholera, but numerous other methods have been advocated 
from time to time, and one of the more recent for which success 
has been claimed is the so-called bolus alba. This consists of 



126 MEDICAL HISTORY OF THE WAR 

kaolin, that is, aluminium silicate powdered and free from gritty 
particles. It is given in water in a dose of 200 grammes (7 oz.) 
in 400 c.cs. (14 oz.) of water. If vomited, a second dose is 
given immediately in small sips. Atropine T Q gr. may be given 
hypodermically night and morning as a routine measure in 
addition to other treatment, and Rogers recommends that 
atropine should be given immediately on admission. 

If the treatment applied during the stages of evacuation and 
collapse is successful the diarrhoea and vomiting lessen or cease, 
the pulse returns, the body becomes warm, and the stage of 
reaction commences. The great danger during this stage is an 
excessive febrile reaction. It is well to take the rectal tempera- 
ture after an intravenous injection, and, if this is found to be 
raised, a pint of iced normal saline should be injected by the 
rectum, and treatment by cold sponging generally and cold 
applications to the head undertaken. This treatment should 
be continued or repeated if required. Diarrhcea may some- 
times occur during the stage of reaction, but unless excessive it 
should not be checked. 

Post-choleraic uraemia is one of the most serious complications 
of the disease, but the liability to its occurrence will be lessened 
if the alkaline sodium bicarbonate injection has been given. 
The alkaline rectal injections should be continued after the 
collapse stage in all cases of suppression of urine until two pints 
of urine are passed in the 24 hours, and the patient should be 
encouraged to drink as much water, or barley water, as possible. 
Intravenous injections of the alkaline saline need only be 
resorted to if the flow of urine is not brought about by these 
measures. Additional means of treatment are dry cupping 
over the loins, warm baths, if the patient's condition permits, 
and digitalin T n gr. injected hypodermically. 

General measures of treatment should include rest in bed 
even in mild cases, hot bottles to the feet and limbs, and massage 
to relieve the cramps. Adrenalin and pituitary extract given 
by injection have also been recommended. 

The diet should be only water, or barley water, during the 
acute stages. Great care should be exercised to avoid increasing 
the diet too suddenly. Whey, milk, farinaceous or Benger's food, 
and custards should be given at first. Soups and meat extracts 
should not be given until the kidneys are acting satisfactorily. 
The diet may then be gradually increased. Alcohol should not 
be given during the acute stage but is useful during 
convalescence. Tonics and change of air are usually necessary 
to complete recovery. 

In the treatment of cholera cases it is advisable, if possible, to 
have a separate room set apart for giving injections, with a 



CHOLERA 



127 



concrete or other impermeable floor, and as an emergency 
method the floor may be covered with tin, as was done in 
Mesopotamia. Certain medical units or portions of units should 
always be set apart for the treatment of cholera cases, and 
their location communicated to all concerned. These units 
should as far as possible be especially equipped for the 
purpose, and endeavour should be made to staff them with 
medical officers and subordinates with practical experience of 
the treatment of the disease. 

Prevention. 

With regard to preventive inoculation, there can be no doubt 
that inoculation with a cholera vaccine has an influence in 
protecting against the introduction of the disease, and it may 
also succeed in rendering it milder should it occur, although 
the following statistics, which were collected by Willcox in 
Mesopotamia, appear to show that the value of inoculation in 
reducing the case mortality is doubtful. 





Cases of 
Cholera. 


Deaths. 


Percentage. 


British 








Inoculated . . . . 


56 


20 


35-0 


Not Inoculated 


27 


18 


46-0 


Unknown . . 


54 


31 


57-4 


Indian 








Inoculated 


122 


36 


29-6 


Not Inoculated 


71 


22 


31-0 


Unknown 


246 


90 


36-6 



The following table shows the state of inoculation in all the 
cases which occurred in Sinai. 





Total No. 


Fully 
Protected.* 


Parti v 
Protected. 


Unknown. 


Cases 


28 


8 


16 


4 


Deaths 


7 


1 


2 


4 



*Fully Protected=2 injections of cholera vaccine within four months. 

No information is, however, available to show the degree of 
protection that had been obtained or the strength of the vaccine 
used. 



128 MEDICAL HISTORY OF THE WAR 

Unfortunately, the period of protection is comparatively short 
and marked immunity does not last for more than three months. 
It is highly advisable, nevertheless, for every person to be inocu- 
lated against cholera, if there is any possibility of the disease 
occurring. Still more is it necessary if the disease prevails in 
epidemic form, or if a visit has to be paid to an endemic area 
during the seasonal prevalence of the disease, or in war if it is 
known to be prevalent among enemy troops. Both in Mesopo- 
tamia and Egypt, where cholera occurred, prophylactic inocula- 
tion was carried out on a large scale and a high percentage of 
inoculation secured among both British and Indian troops. It 
was observed, however, during the war, that the vaccines which 
were used at first did not give a sufficiently high protection, so 
that in the later vaccines the dose of cholera bacilli was increased. 
The earlier vaccines contained 500 million cholera bacilli to the 
c.c. This strength was increased to 1,000 millions, to 4,000, 
then 5,000, and subsequently to 10,000 millions per c.c. which 
was given in two doses at intervals of seven to ten days, the 
first dose being -| c.c. and the second 1 c.c. 

Native followers, and wherever possible the civil population, 
should also be protected by inoculation. In stations or districts 
where cholera recurs yearly, it would be a wise precaution to 
cause the inhabitants to be inoculated annually, shortly before 
the probable time of the appearance of the disease. As the 
constitutional and local reactions following the injection of 
anti-cholera vaccine are generally slight, there ought to be no 
objection to this measure. 

During the war, in addition to the areas, Mesopotamia and 
Sinai, in which cholera actually occurred among the troops, 
anti-cholera inoculation was carried out on a large scale on the 
Salonika front, so that by the end of March 1915, in a large 
proportion of the units, 90 per cent, of officers and men were 
inoculated. 

The preventive measures adopted against cholera in France, 
Salonika, Mesopotamia and Sinai were briefly as follows. 

In France in 1915 comprehensive preventive preparations 
were made in view of the fact that cholera was reported to have 
broken out in the German army and might at any time be 
introduced into the British force. All units were asked to send 
in the names of officers and other personnel who had experience 
of cholera. Certain field ambulances and other units were 
detailed to organize small cholera sections, to be opened for the 
reception of cases at a moment's notice. Cholera equipment 
with a reserve of stores was sent out from England and held in 
readiness at the Base Depots of Medical Stores at Boulogne, 
Calais and Rouen for despatch to the medical units. 






CHOLERA 129 

The following simple pamphlet on preventive measures was 
printed and issued to the troops. 

"CHOLERA. 

1. The only way in which you can get cholera is by swallowing the germs. 
It is not " contagious " or " catching." 

2. When cholera germs are passed in the faeces or vomit of a man suffering 
from the disease they may get into water or on the food, which thus become 
infected. 

3. In the great majority of cases infection is caused by drinking infected 
water or swallowing infected food. 

4. The cholera germ is one which is very easily destroyed by heat, and any 
suspected water or food can be made perfectly safe by boiling or thorough 
cooking, especially if such food is kept protected from flies. 

5. There is very little danger if you remember the following things : 
Don't drink any unauthorized water or milk unless it has been boiled. 
Don't eat uncooked fruit or vegetables, or any food which has been 

exposed to flies. 
Don't drug yourself with opening medicines, which may make you more 

liable to an attack. 
Don't wait if you have a slight attack of diarrhoea, but report at once to 

the medical officer. 
Don't worry. If you think you have it, you are probably wrong and, if 

you prove to be right, worry lessens the excellent chance given by 

the prompt treatment you will receive." 

In Salonika, the D.M.S. of the British army was kept in- 
formed of the prevalence of cholera by the representatives of 
the International Commission of Hygiene. It was stated at 
one meeting in January 1916, that a type of enteritis resembling 
cholera was fairly common in the Salonika area, and in March 
true cholera was reported amongst 'the Serbians at Corfu, while 
a number of cases were reported to have occurred in the Bul- 
garian Army. Measures were at once taken to prevent the 
spread of cholera from the Serbians at Corfu, from captured 
Bulgarian prisoners of war, and from refugees from Asia Minor 
to the British force. The French established disinfection 
stations at Mikra Bay, and the Serbian Army was inoculated 
with cholera vaccine. 

During April and May 1916, the D.M.S. selected special 
medical units for the treatment of cholera cases in the 12th 
Corps area, the 16th Corps area, the Mounted Brigade Stavros 
area, the Base area and Lembet area. The units were equipped 
with cholera outfits and organized cholera compounds were 
formed inside barbed wire enclosures. Special incinerators, 
drinking water tanks, food safes, tub disinfectors and latrines 
and ablution places were erected, and detailed instructions 
issued regarding contacts, disinfection of quarters and other 
preventive measures. The pamphlet, which described in simple 
language what individuals should not do and which was first 
published in France, was issued to the troops. Certain field 
ambulances in the forward area were also equipped with cholera 

(2396) I 



130 MEDICAL HISTORY OF THE WAR 

outfits and organized small cholera units. A leaflet on the value 
of cholera inoculation was circulated, but, having due regard to 
the primary importance of protecting the troops against typhoid 
and paratyphoid, anti-cholera inoculation was only pressed 
after a T.A.B inoculation had been carried out. 

Prisoners of war were disinfected, isolated and examined by 
a medical officer daily for seven days. 

During June, July and September 1916, suspected cases of 
cholera were reported from Kuskus in the 5th Mountain Battery, 
the 81st and 83rd Field Ambulances, and in the 10th Devons. 
All these cases were examined for the cholera vibrio, but were 
found to be negative. 

Preventive measures were continued during 1917 and 1918 
and No. 7 Base Depot Medical Stores was ordered to keep in 
reserve from existing stock 20,000 doses of cholera vaccine, 
which were not to be issued for routine inoculation but kept for 
an emergency. Between May and August 1917, 190,000 
double doses of cholera vaccine were issued to medical units. 

In Mesopotamia when the cholera epidemic commenced the 
following special measures were ordered. 

Certain medical units were reserved for cholera cases. A 
large number of diarrhoea cases was examined and it was found 
that 33 per cent, of the cases which had been diagnosed 
" diarrhcea " were really cholera cases. These cases were 
admitted to special hospitals. 

Convalescents and contacts were collected in camps at 
Sheikh-Saad, Amara and Basrah. These camps were rapidly 
filled and it was necessary to consider what constituted a 
cholera contact. The following circular memorandum re- 
garding cholera was issued as a guide on 13th June, 1916. 

" (a) During the present cholera outbreak it has been shown that a high 
proportion of persons suffering from severe diarrhcea harbour cholera vibrios. 
Complete action to remove this ' carrier ' danger cannot be taken but the 
following partial action is suggested : 

(i) Every hospital should set apart a certain number of wards or tents in 
which all cases of diarrhcea should be treated apart from the general 
cases, and with separate latrine arrangements. 

(ii) In regiments and other units (when it is practicable to do so) men who 
have diarrhcea but are still able to do their duty should be accommo- 
dated separately from the rest of the regiment and should have 
separate latrine accommodation. 

" (b) It has been found that almost no case of cholera has occurred among the 
very large number of ' contacts ' segregated in accordance with the usual 
procedure. This justifies the modern view that segregation of contacts in 
separate contact camps is unnecessary. The action advised is that except in 
special circumstances only the direct or immediate ' contact ' of a convalescent 
should be removed to a contact camp. By the 'direct or immediate contact' 
is meant the one or two who were in attendance on the patient before he was 
seen by a medical officer. If the medical officer of a regiment considers it 
advisable, this procedure may be supplemented by such measures of segre- 



CHOLERA 131 

gallon of the associates of a cholera patient as may be possible under regi- 
mental arrangements. The period of segregation of contacts must not exceed 
seven days from the occurrence of the case. 

" (c) The procedure as regards cholera convalescents is that they are to be 
kept segregated for six weeks after the stools have become normal. At the end 
of that period, if they are otherwise fit, they are to be returned to duty, only 
those convalescents who are not fit after the six weeks' period of segregation 
being invalided to India." 

Infectious disease officers were appointed at the front, at 
Amara, at Ashar and at Basrah. Their duties were to inspect 
the infected units, to control the measures in the infected areas, 
to arrange for immediate notification of cases and their removal 
together with the contacts, to carry out disinfection and inocu- 
lation, and to supervise the water supply and conservancy. 
These officers had also to deal with the civil population, among 
whom the disease was prevalent. 

Eleven cholera outfits were dispatched from Egypt on 26th 
April. Twenty-eight were dispatched from London on 13th 
May, and twenty-six special water testing outfits for cholera 
were sent out at a later day. 

From 1st to 21st May, 1916, 150,000c.cs. anti-cholera vaccine 
were sent from India, and the prophylactic inoculation against 
cholera was commenced in all formations. Administrative 
medical officers were instructed to carry out anti-cholera 
inoculation in the following manner. J c.c. and 1 c.c. of anti- 
cholera vaccine were to be given at an interval of 10 days and 
re-inoculation carried out at intervals of three months during 
the subsequent cholera seasons. A record of these inoculations 
was entered in the soldier's pay book. It was arranged 
that India should supply 5,000 c.cs. of anti-cholera vaccine 
weekly. 

In Sinai very complete preparations were made in anticipation 
of the possible occurrence of the disease among British troops. 
These included anti-cholera inoculation on a large scale of all 
officers and men who had not been inoculated within three 
months, together with special arrangements for dealing with 
captured enemy forces. Intelligence officers gave special 
attention to information regarding sickness in enemy formations 
and areas, and information was obtained indicating the probable 
presence of cases of cholera among the Turkish troops at Katia 
and Bir-el-Abd in the Sinai desert. 

BIBLIOGRAPHY. 

Clemow . . . . Cholera in Turkey and adjoin- Lancet, 1920. 

ing countries since 1914. Vol. ii, p. 1215. 

Cox . . . . . . An Address on the Prevention Lancet, 1916. 

and Treatment of Cholera, Vol. ii, p. 3. 

delivered in Malta. 



132 



MEDICAL HISTORY OF THE WAR 



Davies 
Greig ... 

Johnston 

Mackie and Storer 

Rogers 

Roy 

Shorten 

Varian 

Epstein 



BIBLIOGRAPHY cont. 
A method of Cholera diagnosis. 



Recent Researches on the Eti- 
ology of Cholera. 

Agglutinins in the Blood of 
Cholera Cases. 

Some Bacteriological Phases of 
the Cholera Carrier Problem. 

Two Vibrio Species of the 
" Para-cholera " Group asso- 
ciated with a Cholera-like 
outbreak. 

Cholera and its Treatment . 



Cholera Prophylactic Vacci- 
nation. 

Observations on the Bio-Chem- 
istry of Post-Choleraic Urae- 
mia. 

Notes on Cholera Asiatica and 
its Early Treatment. 

Cholera in Austria 



Bolus alba therapy in Cholera. . 



Inoculation against Typhoid 
Fever and Cholera in the Ger- 
man Army. 



Jl. R.A.M.C., 1920. 
Vol. xxxv, No. 4, 
p. 329. 
Edin. Med. Jl., 1919. 

Vol. xxiii, No. 5, 

p. 4. 
Ind. Jl.ofMed. Res., 

1914-15. Vol. ii, 

p. 773. 
Philippine Jl. of Sc., 

1919. Vol. xiv, 

p. 459. 
Jl. R.A.M.C., 1918. 

Vol. xxxi, p. 161. 



Oxford Med. Publi- 
cations, Lond. 
1911. 

Ind. Med. Gaz., 1919. 
Vol. liv, pp. 209- 
404. 

Ind. Jl.ofMed. Res., 
1918. Vol. v, 
p. 570. 

Dublin Jl. of Med. 
Sc. 1919. Vol. 
cxlviii, p. 66. 

Wien. Med. Woch., 

1915. Vol. Ixv. 
p. 246. 

Brit. Med. Jl., 191 5. 
Vol. i p. 644. 
Munch. Med. Woch., 

1916. Vol. Ixiii, 
pp. 303, 441. 

Brit. Med. JL, 1916. 
Vol. ii, p. 192. 



CHAPTER V. 

TYPHUS FEVER. 

story of the dire results of typhus is written in the 
darkest pages of human history. True to its traditions 
typhus appeared, in the first six months of the war, 
in the Balkans and the Eastern war areas, and subsequently 
in nearly all the countries and areas in Europe affected by the 
war, with the notable exception of France, Belgium and Italy. 
Its scourges have exceeded those of any other epidemic 
disease during the war, and it has persisted in the Russian, 
Polish, and to a less extent in other Eastern War Areas, so that 
its prevention presents for solution the most difficult problem 
in epidemic disease which the war has left as its heritage. So 
widespread has been its extent, so severe its ravages, that even 
now accurate data about it are still wanting. 

The most reliable data were procured from the British 
Government's Sanitary Mission to Serbia. The Serbian 
Government appealed for help to the British Foreign Office on 
9th February, 1915, and six days later Colonel W. Hunter, 
A. M.S. (T.F.), the Senior Physician of the London Fever 
Hospital, with Lieutenant-Colonel G. E. F. Stammers, R.A.M.C., 
as sanitary officer, Captain W. W. C. Topley, R.A.M.C., as 
bacteriologist, and twenty-two lieutenants of the Royal Army 
Medical Corps, left for Serbia in charge of the unit, with 
instructions that the Mission was not to be employed in 
hospital clinical work, but should, after ascertaining the actual 
prevailing conditions and character of the epidemic, form some 
definite programme to prevent and check the epidemic in the 
Serbian armies and throughout the country. The Mission 
arrived at Nish on 4th March, 1915, when the epidemic was 
increasing by leaps and bounds. 

JEtiology. 

Till 1870, typhus was more or less endemic, and in some 
cases even prevalent in most of the countries of Europe. Since 
then and until the war broke out in 1914, it had become an 
almost unknown disease. The information obtained of its 
aetiology and lice-borne mode of infection during the war, 
exceeded that obtained during the whole previous history of the 
disease. Overcrowding in houses, malnutrition and squalor 
were well-known aetiological factors, but they are quite sub- 

133 



134 MEDICAL HISTORY OF THE WAR 

ordinate to the infection carried by lice from person to person, 
as first described by Nicolle in 1902. The infection is conveyed 
chiefly by bites, but experiments during the war proved the 
possibility of the transmission of typhus by the excrement of 
infected lice being rubbed into scratches or abrasions. Lice 
multiply rapidly, producing 70 to 80 eggs at a time ; the eggs 
reach maturity in about 17 days, so that a couple of lice in one 
month can give birth to more than a thousand. Lice cannot 
travel more than 100 metres, but within their radius they move 
about very freely. They live on human blood, and when deprived 
of it, die in two to five days. It suffices, therefore, to leave un- 
inhabited for two to three weeks a house which is infested with 
lice, in order to free it from any possibility of typhus infection. 
The proportion of lice which become infected is not known. 
The fife-cycle of the infection is five days' incubation in the 
louse and ten to twelve days' incubation in man. Until it was 
clearly ascertained that lice were the carriers, typhus had 
always been regarded as pre-eminently the disease of over- 
crowding, and the remedy was " let the crowds of inhabitants 
be scattered," the rule laid down by one of the chief observers 
during the great Irish famine of 1847. The role of over- 
crowding and its concomitant factors were subsequently made 
clear. They contribute to the spread of typhus by favouring 
the prevalence of lousiness, the number of infected lice, and 
the spread of such lice from person to person. 

Distribution. 

Up to the outbreak of the Serbian epidemic there was no 
previous experience in utilizing this knowledge to check the 
disease when in epidemic form. The only information on the 
point was obtained from Nicolle, who succeeded in reducing 
the number of cases in Tunis, where typhus was endemic, from 
836 cases in 1909 to 3 cases in 1914 by the disinfection 
of all infected personnel, clothing, bedding and rooms. 

The British troops, although operating in areas where the 
disease was endemic, and in contact with infected allies and 
enemy, suffered little from typhus, and our knowledge of 
the disease is principally derived from the work of Colonel 
Hunter's mission during the epidemic in Serbia. The infor- 
mation from other countries is necessarily scanty, only enabling 
approximate figures to be given, but it shows that the spread 
of the disease may be traced from Russia, Russian Poland, 
Austrian Galicia and Styria, and Turkey to the Balkans and 
Europe. 

There is no doubt that Russian prisoners conveyed typhus 
to Germany and Austria. The number of cases in Russia is 



TYPHUS FEVER 135 

unknown, and will doubtless never be known. It is estimated 
at ten million with two million deaths. The Russian territories 
and armies have, in fact, been the chief seat and source of 
the spread of the disease throughout the war. 

In Russian Poland the average annual number of cases prior to 
1914 was 1,887. The Germans overran this country in 1914 and 
are reported to have suffered difficulties from, and taken great 
precautions against, typhus. A severe epidemic occurred in the 
latter part of 1916 and again in November 1917, when 26,099 
persons were attacked by the disease in the Warsaw district. 
The mortality was very low, being only eight per cent. 
The total number of cases in Poland during the war has been 
estimated at 400,000 with a mortality of 10 per cent., but 
the figures are probably underestimated. 

Typhus is endemic in Turkey, and there was a widespread 
development of the disease in and around Constantinople and 
in all the provinces, especially in Palestine and Armenia. One 
epidemic among the soldiers of the Van population showed 
4,500 cases. Of this number 19 officers and 2,690 men died, 
a mortality of 50 per cent. 

In Austria, typhus, in addition to being endemic in certain 
areas, broke out in 1914 in a camp containing 9,000 Russian 
prisoners, and 300 cases were reported in less than a week. In 
January 1915, 1,500 cases, including 1,000 from Styria, were 
notified, and in the following month another outbreak occurred 
in a Russian prisoners' camp, followed by a severe epidemic in 
Przemysl, Galicia. 

The presence of typhus in Turkey and Austria was an im- 
portant factor in causing the 1914-1915 Serbian epidemic. The 
southern part of Serbia had been under the Turk for five 
hundred years, but, as the result of the Balkan War in 1913, 
it had come into the possession of the Serbs. In common with 
all areas governed by the Turk, this southern area was the 
endemic seat of typhus, and in 1913, 100 cases were reported in 
Belgrade. In Austria, the disease always remained endemic, 
especially in Galicia and Styria. The Austrians by employing 
troops from these areas spread the infection to other areas. 
The chief extension was caused by the Austrian invasion of 
Serbia in 1914. The Serbian army had been quite free from 
typhus, and when the Serbs retreated in November 1914 from 
Valyevo, a town near the Bosnian frontier, they left it free from 
typhus. On recapturing Valyevo and during the advance, 
they took about 40,000 prisoners and 3,000 sick and wounded. 
The Austrians had left many of their sick and wounded who 
were suffering from typhus in Valyevo, and many of their dead 
were left unburied in the cellars or only partially covered with 



136 MEDICAL HISTORY OF THE WAR 

a foot of soil. The prisoners were distributed over the country 
partly from lack of accommodation, and partly from need of 
their labour. The infected prisoners thus spread the disease 
broadcast through the Serbian troops to the civilian population. 
The great Serbian epidemic followed. It commenced in Decem- 
ber, gained head in January, and broke out over the whole 
country in greatest intensity during February and March 1915. 
Under more favourable circumstances, greater attempts might 
have been made to concentrate these prisoners and establish 
some measure of quarantine before dispersing them throughout 
the country, but the small and exhausted forces of the Serbians 
and the impoverished conditions of the country did not permit 
of these precautions being taken. The Serbs had neither 
accommodation nor food for idle prisoners in camp. They had 
not troops to guard the prisoners, and the need for their labour 
in the country was pressing. 

The outbreak was of the severest character and widest extent ; 
it raged through every town, village and hamlet in the land, 
finding conditions extremely favourable to its spread. By the 
end of December 1914, 100 cases were reported, and by the 
end of January 1915, 1,100 cases. Thereafter the course of 
the epidemic was fulminating, very imperfectly represented by 
the official figures of cases in hospitals, for the sufferers num- 
bered thousands and the hospitals were few and quite inadequate 
for their accommodation. On 28th February those in 
hospitals were over 3,000 and the mortality was 30 per cent. 
By 31st March the number had risen to 8,200 and a mortality 
of 60 per cent, was not unknown. These figures represent 
very imperfectly the widespread character of the epidemic 
among the civilian population in villages, where the proportion 
of sufferers was probably five to one of the military patients. 
Estimates of the total number of deaths caused by the epidemic 
range from 100,000 to 135,000, including two-thirds or more 
of the 40,000 Austrian prisoners. To the credit of the Serbian 
authorities, the very limited and utterly inadequate hospital 
accommodation was shared impartially by prisoners and their 
own soldiers. But the overcrowded and squalid conditions 
under which the prisoners lived, worked and slept greatly 
favoured the chance of infection, and led to a correspondingly 
greater prevalence of the disease among them. Observers 
working in such an epidemic realized something of the terrible 
fate which befell those who were stricken by this dread disease. 

In the case of Serbia the epidemic was immediately arrested 
by the preventive measures put in force on 16th March, 1915, 
eleven days after the arrival of the British Sanitary Mission. 
Its enquiry into the origin and subsequent distribution of the 



To face page 136. 



8500 




12 17 E2 27 I 



N'ew cases 



D 

Deaths 



12 17 122 33 123 129 1 122 174 2092041197 183 255 137 1 135 231 78 106 I Si 42 35 38 116 56 



73 I 72 
145 
49 



29 1 55 


252 1 296 


4-13 1 380 


392 


366 


184 


103 


84 


548 


793 


7J 


> 


2 


17 


i 2.0 


82 


222 


22 


2 


10 


8 

















TYPHUS FEVER 



137 



COURSE OF EPIDEMIC OF TYPHUS FEVER IN SEB.e>iAj9'/>, AND ITS 

RELATION TO PREVENTIVE MEASURES ADOPTED. 



SjDOC 



8,000 



7.000 



epoq 



5,000 



*,000 



3.000 



3000 



1,000 




CHART II. Number of cases of typhus in hospital in Serbia on dates 
specified, January 1 to June 9, 1915. 

March 4. Arrival of Mission in Serbia. June 10. Departure of Mission 
from Serbia, a, March 8. Barrel disinfector devised, b, March 13. Barrel 
disinfector made and tested, c, March 15. Suspension of railway traffic. 
d, March 22. Van disinfector devised ("Van 1"). e, April 5". Van 
disinfector ("Van 2") formed in Nish ; van bath devised. /, April 15. 
Resumption of railway traffic, g, April 19. English sanitary train (inocu- 
lation, disinfection and bath vans). h, April 25-30. Sudden check in 
fall of epidemic ten to fourteen days after the resumption of railway traffic. 



138 MEDICAL HISTORY OF THE WAR 

typhus epidemic showed that the army areas in the north were 
chiefly affected, 49 per cent, of the cases in hospital being in 
these areas, and only 28 per cent, in the southern civilian areas. 
The infection had thus been introduced specially into the armies 
and thence to the civilian areas. Accordingly two great pre- 
ventive measures, suspension of all railway traffic and stoppage 
of all leave from the army combined with delousing, were 
put in force on 16th March, 1915, and within ten to fourteen 
days (the incubation period of the disease) the number of patients 
in hospital reached its maximum. The number of new cases 
was reduced to one-half in two weeks, and one-fifth in four 
weeks. The number of daily admissions to the whole of the 
hospitals decreased from 1,500 cases on March 16th to 230 
cases on April 16th, and 100 by May 31st. The epidemic was 
so completely arrested in a month's time that by the middle 
of April movements of troops began again, and, although this 
caused a slight temporary increase in the number of cases 
admitted to hospital, the epidemic could be reported at an 
end by May 17th, and the British mission was consequently 
recalled on June 1st. 

If an epidemic can be said to have a useful purpose, this 
epidemic was probably useful in two ways. It gave the 
Serbians, exhausted as they were by their military efforts, 
complete military peace for nine months, since the fear of 
entering a country infected by typhus may have deterred the 
Austrians, Germans and Bulgarians from attack ; and it 
demonstrated the striking effect of preventive measures when 
applied simultaneously to the whole country. 

The subsequent incidence of typhus in Serbia is interesting. 
Apart from an article in the German press in 1916 by Doren- 
dorff , who gives his observations on a limited epidemic of typhus 
which had broken out among the troops operating in Serbia, 
no definite information is available concerning the regions 
occupied by the Austrians, Germans and Bulgarians from 
November 1915, to October 1918. It is known, however, that 
although the Serbian army in its retreat lost thousands and 
tens of thousands from exposure, diarrhoea and starvation, it 
had only a few deaths from typhus, owing to the use of the 
barrel disinfectors introduced into Serbia by the British 
Mission, and, in May 1916, arrived 150,000 strong in Salonika, 
developing only three or four cases of typhus on the voyage 
from Durazzo and Corfu to Salonika. 

Typhus from 1892 to the outbreak of the war was practically 
non-existent in Germany, but exact data from 1914 onward 
are not known. The Germans had difficulties in Poland iA 
1914, and early in 1915 reports were received that the diseas 



TYPHUS FEVER 139 

had broken out in prisoners' camps Hamburg, Wittenberg and 
Gardelegen. In Gardelegen there were 12,000, chiefly Russian 
and French prisoners, with 1,000 Belgian and 230 British. A 
historic report on this camp was published by Major P. C. T. 
Davy and Captain A. J. Brown of the R.A.M C. In the Witten- 
berg camp the epidemic raged for the first six months of 1915. 
There were between 250 and 300 cases among the British 
prisoners, of whom 60 died. The mortality amongst the 
French and Russians was very much higher. A full report 
was written by Major Priestly, Captains Vidal and Lauder, all 
of the R.A.M.C., and all prisoners of war. The conditions 
which existed in these camps form the most appalling reading 
connected with the history of typhus in prisoners' camps during 
the war. 

A certain number of cases was reported in Greece in 1914, 
but the Greek authorities, being alive to the necessity of pre- 
ventive measures, applied them with such success that only 
200 cases occurred in Salonika during the period of the Serbian 
epidemic. 

A mild epidemic broke out in Bucharest during the latter 
part of 1915 and early in 1916. From January to June 1917, 
a severe epidemic attended with a high mortality raged in 
Moldavia. 

With regard to the incidence of typhus in the British Armies, 
in Gallipoli there were no cases. In Salonika from 1916 to 1918 
there were no cases ; but subsequently in 1919 five cases 
occurred. During 1919 and 1920, 17 and 12 cases respectively 
were reported from the army of the Black Sea, with six deaths, 
a mortality of 27-6 per cent. In Egypt and Palestine there 
were 22 cases during 1916-1917, when the troops were for the 
most part in Egyptian territory, and 344 cases in 1918-1919 
when they conquered and occupied Palestine. The number of 
deaths was 80, or a mortality of 21 8 per cent. In Mesopotamia 
the infection spread to British troops from Turkish prisoners 
of war, Arabs and refugees ; during 1917 and 1918 there were 
385 cases amongst the Indian troops, with 149 cases amongst 
the British troops and 59 cases in 1919. The mortality was 
22-7 percent. 

In France and Italy there were only five cases. Preventive 
measures are responsible for the freedom from the disease 
testified by these figures, notwithstanding the prevalence of 
lice and the risk of infection from Egypt and Portugal. 

Typhus broke out in Oporto in March 1918, and from May 
to November 1,811 cases are stated to have occurred in 
Portugal, so that the risk of its introduction into the armies 
in France through the Portuguese contingent was very great. 



140 



MEDICAL HISTORY OF THE WAR 



Altogether the total number of typhus cases among the 
British forces in all war areas was 998, of which 221 were fatal. 
Their distribution is shown in the following table : 

Incidence of Typhus in British War Areas, 1916-1920. 





19 


16 


1 


17 


19 


18 


19 


19 


19 


20 




Total. 






. 


J3 


. 


.C 


in 


1 


8 


1 


S 


fl 


U) 


3 


>, 






rt 




rt 




rt 


8> 




05 




w 


g 






o 





o 


Q 





Q 


3 





9 

u 


s 




1 


oSrt 


France 


4 


_ 


1 


_ 


_ 






_ 


_ 




5 






Egypt 
Mesopotamia 


10 


2 


12 


4 


208 


51 


136 


23 


- 


- 


366 


80 


21'8% 


British 
Indian 


I 


: 


11 
8 


7 
4 


138 
377 


27 
85 


59 


12 


- 


:[ 


593 


135 


22-4% 


Army of Black Sea 


_ 


_ 










17 


2 


12 


4 


29 


6 


20-6% 


Salonika 


- 


- 


- 


- 


- 


- 


5 




- 


- 


5 


- 




Total Cases 


14 


2 


32 


15 


723 


163 


217 


37 


12 


4 


998 


221 


22-1% 



The chief incidence of the cases in Egypt and Palestine 
was between January and June, reaching its height in April, 
as is shown in the following table : 

Monthly Incidence of Typhus in British Troops in 
Egypt and Palestine, 1916-1919. 



Month. 


1916 


1917 


1918 


1919 


Total. 


January 










_ 


25 


16 


41 


February 











2 


21 


12 


35 


March 








1 


4 


43 


21 


69 


April 








4 


2 


47 


23 


76 


May .. 








2 


2 


37 


17 


58 


June . . 








1 


1 


19 


40 


61 


July .. 








1 


1 


7 


2 


11 


August 














2 





2 


September 














1 


3 


4 


October 














6 


2 


8 


November 























December 








1 











1 


Total 


10 


12 


208 


136 


366 



So far as is known there were no cases in the French, Belgian, 
and Italian armies, but 3,321 cases occurred in a camp for 
Austrian prisoners in Italy during 1919. 

Symptoms. 

The incubation period of the disease is from 10 to 12 days. 
Most observers consider it to be about 10 days ; Murchison 
fixed it in the majority of cases as not more than 12 days. 
These results were confirmed and strikingly demonstrated by 
the course of the Serbian epidemic, by the arrest of the disease 



TYPHUS FEVER 



141 



within fourteen days of the suspension of railway traffic on 
March 16th, and by its temporary recrudescence exactly 
fourteen days after the resumption of traffic on April 16th. 

CLimCflL CHflRT JJIEYYIHG EXfKT SiMlinRITY Of TYYO " 
TYPICflL OTttS OF TYPHUS ;-(fl) fROM THE LOtlDOh fEYER 
H05PITCL 1864 (W fROM THE JERftlflM EPIDEMIC 1915- 




CHART III. 

The clinical features of typhus are those of a severe toxic 
disease, affecting specially the brain and the heart. The 
course of the disease is very definite, extending from first to 



142 MEDICAL HISTORY OF THE WAR 

last over a period of two weeks, divided into four stages of 
approximately four days each : (a) the stage of invasion 
(three days) ; (b) the stage of advance (four days), com- 
mencing with the appearance of the rash and ending with 
prostration, sleeplessness, restlessness and delirium ; (c) the 
further stage of advance (five days), marked by increase of all 
the symptoms, especially of delirium and heart weakness, until 
on the twelfth day the patient is in a critical condition ; 
(d) the stage of crisis about the twelfth or fourteenth day, 
when the whole symptoms suddenly ameliorate by a sharp 
crisis or by rapid lysis, fall in temperature and return to 
normal pulse in the course of two or four days. The patient 
who, delirious and unconscious, has been at death's door on 
the twelfth day recovers so quickly that he may be able to 
get up by the sixteenth day and leave the hospital by the 
twentieth day, completely recovered though still weak. The 
course of the disease from first to last is represented on the 
preceding chart of two cases, one taken from the records of the 
London Fever Hospital, 1864, described by Murchison ; the 
other from the Serbian epidemic, 1915, described by Minkine. 
The close similarity between the two curves is remarkable, 
and extends to all features. A detailed comparison of the 
symptoms presented in cases in the Serbian epidemic with 
those classically described by Murchison in the 20,000 cases 
in the London Fever Hospital, 1848 to 1870, shows that the 
former were almost identical with those already known, 
differing, if at all, only in their severity, their greater number, 
and the distressing circumstances of their surroundings. 

Diagnosis 

The diagnosis presents little difficulty when typhus occurs 
in epidemic form, but it is otherwise when met with 
sporadically by those, and they include the great majority 
of medical officers, who have never seen a case before. The 
appearance of the rash on the fourth day distinguishes it from 
influenza, while the absence of rash from the face and neck 
and its discreet nature eliminate measles. Relapsing fever 
is unaccompanied by a rash and the spirillum can always be 
discovered in the blood on the third or fourth day. Typhoid 
and the paratyphoids are diagnosed by the isolation of the 
typhoid and paratyphoid organism. Cases of meningitis 
show intolerance to light and sun, whereas the typhus patient 
is indifferent to both. Difficulty in diagnosis is diminished 
by the use of the Weil-Felix agglutination test with the 
organism Proteus X. 



TYPHUS FEVER 



143 



Prognosis. 

The prognosis is always grave and is influenced by the 
nervous disposition of the patient. A strong healthy young 
officer, who from his previous knowledge dreads the disease, 
may succumb ; while the exhausted peasant soldier, worn 
out by over-exertion and under-feeding, recovers. This 
probably explains the high mortality amongst the Serbian 
doctors who were stricken down by typhus. Out of a total 
of 450, at least 360 were attacked and over 120 died. 
In an epidemic under the conditions of poverty, stress 
and misery, there is no disease except cholera and plague com- 
parable with it in danger to every patient attacked, or to 
the attendants who nurse them. When the disease is epidemic 
and virulent, the certainty is that nearly a third of the 
patients will die, and at the height of an epidemic the 
proportion may rise to one-half, as is shown in the following 
table : 

Figures from the largest Fever Hospital in Serbia 
(Kragujevatz), 1st January, 191513^ May, 1915. 















Mor- 


Date. 


No. of 
Days. 


Admis- 
sions. 


Average 
Daily. 


Com- 
pleted 
Cases. 


Deaths 


tality 
on Com- 
pleted 














Cases. 


January 1 11 


10 


34 


4 






_ 


January 1221 


10 


29 


3 











January 22 31 


10 


55 


5 


__ 


21 





February 1 10 


10 


252 


25 











Februarv 1 1 20 


10 


296 


29 











February 21 March 2 


10 


413 


41 


700 


185 


30-0% 


March 312 


10 


380 


38 


200 


119 


59-0% 


March 1322 


10 


390 


39 




124 





March 23 April 1 


10 


366 


36 





88 


30-5% 


April 21 1 


10 


184 


18 





63 


32-0% 


April 1221 


10 


103 


10 





45 


17-4% 


April 22 May 1 
.May 212 


10 
10 


73 
72 


7 
7 





23 
26 


14-4% 


Total 


130 


2,647 


20-1 


900 


694 


30-4% 



Treatment and Prevention. 

With regard to treatment, sera have been tried with 
indifferent success, and Murchison's dictum still remains 
true : "A patient with typhus is like a ship in a storm ; 
neither the physician nor the pilot can quell the storm, but 
by tact, knowledge, and able assistance they may save the 
ship." 



144 MEDICAL HISTORY OF THE WAR 

The measures of prevention are themselves simple in 
character, easily applied, and are directed against lice on 
clothes and persons ; but the difficulties in applying the 
delousing measures on the scale and with the frequency 
required, owing to the prevalence of lice in armies numbering 
millions, have been enormous and have taxed to the full 
the efforts and the medical resources of the armies concerned. 

The allied armies with the exception of the Russian were 
successful in combating the disease. The preventive measures 
adopted in Russia were either too limited or broke down. In 
Serbia the education of the people by means of pamphlets and 
appeals issued by the British mission within three days of 
its arrival, the isolation of cases, the segregation of contacts, 
the suspension of railway traffic both for the movement of 
troops and for civilians, the opening of bathing and delousing 
centres, the use of barrel disinfectors designed first by 
Lieut. -Col. Stammers, steam disinfecting railway vans, 
railway van douche baths first designed by Colonel Hunter, 
the formation of British sanitary disinfecting trains, and the 
cleansing of railway stations and rolling stock, proved suc- 
cessful. The most important of all these measures was the 
suspension of railway traffic amongst civilians. It was chiefly 
responsible for arresting the course of the epidemic in four 
weeks, and, on the restriction being rescinded, a sharp recrud- 
escence broke out and the admission rate to hospital increased 
three-fold and in some areas eight-fold. In connection with 
the prevention of typhus the experience of the British mission 
in Serbia may be summed up as follows : Prevent all move- 
ments of the infected population, and disinfest them in the 
areas in which they are found, and discard the rule to " Let 
the crowds of inhabitants be scattered," which in all previous 
great epidemics was laid down as the chief measure required. 

The above precautions were applied in France in connection 
with the Portuguese troops, when drafts were stopped and 
afterwards collected, detained in Portugal for 12 days and 
deloused in an area away from the centre of infection. On 
arrival in France special arrangements were made for the placing 
of the troops in quarantine for 11 days at the port of dis- 
embarkation, where they again underwent disinf estation before 
being sent to the front area. On the Eastern fronts these 
precautions combined with the bathing and delousing schemes 
in operation in all armies, assisted in procuring the immunity 
which the British troops enjoyed during the war. 

With regard to the precautions taken by the enemy forces, 
the arrangements made by Austria and Turkey do not seem 
to have been sufficient, and their armies became severely 



TYPHUS FEVER 145 

infected. In the case of Germany, the measures seem to have 
been a matter of meticulous preparation. They included 
delousing measures and the supply of appliances on an 
elaborate scale. In 1913, for example, 250 tons of sabadilla 
seeds were shipped from La Guaira to Germany ; and subse- 
quent instructions were issued by the German Imperial Board 
regarding the use of these seeds, the active principle of which 
is veratrine, as a parasiticide. No data of the results of the 
German preventive measures are as yet available, but con- 
sidering the dangers to which their armies were exposed, the 
measures were in all probability successful. Nevertheless, the 
amount of typhus in the German armies was considerable. 
Official information furnished up to the end of 1916 gave the 
number of deaths from typhus as 448. This represents an 
occurrence of approximately 4,000 cases, which probably ex- 
tended to all ranks and was prevalent in various camps. When 
the German armies advanced far into Russia during 1917 and 
1918, there is evidence that their measures were relatively 
successful, because during the period they were in charge of 
the Warsaw district, the incidence of typhus was held in 
check, becoming much more widespread after their departure. 
The important lesson gleaned from a study of typhus in 
this war is the necessity for providing simple methods of 
disinfection available for the smallest companies ; mobile dis- 
infecting plant, especially train disinfectors, which can always 
be in touch with the troops ; and a sufficient number of units 
adequately equipped for delousing in the field not only an 
army's own soldiers, but also enemy prisoners of war. As 
armies advance into a country where typhus is known to be 
endemic, such units, if used to advantage, will play a most 
important part in preventing the spread of the disease in 
epidemic form. 

BIBLIOGRAPHY. 

Balfour . . . . Typhus Fever, Lice, and the Lancet, 1915.Vol. i, 
War; a Suggestive Fact. p. 1311. 

Bruce Low . . . . The Epidemiology of Typhus 44th Report of the 
Exanthematicus in Recent Local Govern- 

Years. ment Board. 

1914-15. p. 28, 

Cantacuzene, Ciuca, Essais de serotherapie anti- Bull. Soc. de Path. 
Galasesco, Gerard. exanthematique. Exot., 1919. 

Vol. xii, pp. 367- 
372. 

Davy and Brown . . Clinical aspect of Typhus Fever. B.M.J., 1915. Vol. 
Observations on some 2,000 ii, p. 737. 

cases in a Prison Camp in 
Germany. 

(2396) K 



146 



MEDICAL HISTORY OF THE WAR 



Gerard 



Hirsch 
Hunter 



Mueller and Urizio. 
Murchison . . 
Newsholme . 



Priestly, Vidal 
and Lauder. 



Willcox 



BIBLIOGRAPHY cont. 

Les notions actuelles sur le 
typhus exanthematique. Etude 
des deux epidemics, (1916) 
epidemic serbe de Bizerte ; 
(1917) epidemic roumaine de 
Moldavie. Demonstration du 
role excitant du poux dans la 
transmission de la maladie. 

Handbook of Geographical and 
Historical Pathology. 

A Lecture on the Prevention and 
Arrest of Lice-borne Diseases 
by New Methods of Disinfec- 
tion. 

TheSerbian Epidemics of Typhus 
and Relapsing Fever in 1915. 



Sulla transmissione del der- 
motifo mediante le deiezioni 
dei pidocchi infetti. 

Typhus. 



Poverty and Disease as illus- 
trated by the course of Typhus 
Fever and Phthisis in Ireland. 

Report on the Typhus Epidemic 
at Wittenberg Camp. 



Typhus and Relapsing Fever in 
Mesopotamia and Northern 
Persia. 



Theses de Paris, 
1918-19. 



London, 1883-86. 

Lancet, 1918. Vol. 
ii, p. 347. 



Proc. Roy. Soc. 
of Med., 1919- 
20, Vol. xiii 
(Epidem.Sect.), 
pp. 29-158. 

Riforma Medical 
1919. Vol. xxxv, 
p. 734. 

Continued Fevers, 
3rd Edition, 
London, 1884. 

Proc. Roy. Soc. 
of Med., 1907-8. 
Vol. i (Epidem. 
Sect.), p. 1. 

Official Report by 
the Government 
Committee on 
the Treatment 
by the enemy of 
British Prison- 
ers of War, 1916. 

Proc. Roy. Soc of 
Med., 1919-20. 
Vol. xiii (Med. 
Sect.), pp. 59-81. 



CHAPTER VI. 



CEREBRO-SPINAL FEVER. 

/^EREBRO-SPINAL fever is an infection characterized by 
\^ meningitis and caused by the Diplococcus intracellularis 
of Weichselbaum. Since its recognition in 1805, the 
disease has occurred in epidemic waves of three or four years' 
duration, followed by periods of quiescence. Sporadic cases are 
'always present, and their numbers follow the same seasonal 
curve as that observed in the larger epidemics. Infants and 
recruits are peculiarly prone to the disease. In previous cam- 
paigns, with the exception of outbreaks in French garrisons 
during the Napoleonic Wars, and an epidemic in the Army of 
the Potomac in the American Civil War, the disease has been 
singularly absent. During the war of 1914-18, however, the 
disease was epidemic in a formidable manner amongst 
troops in the United Kingdom, while a concurrent epidemic 
raged amongst the civilian population, as is shown by the 
following tables : 





Troops in the 


Civilian Population. 






All Ages. 


Males 20-30. 








Mor- 






Mor- 






Mor- 


Year. 


Cases. 


Deaths. 


tality 


Cases. 


Deaths. 


tality 


Cases. 


Deaths. 


tality 








o/ 
/o 






% 






% 


1914.. 


46 


30 


65-2 


300 


206 


68-7 


9 


4 


44.4 


1915.. 


1,199 


587 


48-8 


2,343 


1,521 


64-9 


127 


80 


63-0 


1916.. 


967 


430 


44-5 


1,278 


838 


65-6 


45 


23 


51-1 


1917.. 


1,337 


593 


44-4 


1,385 


906 


65-4 


48 


31 


64-5 


1918.. 


689 


288 


41-8 


715 


484 


67-6 


12 


7 


58-3 


Total 


4,238 


1,928 


45-5 


6,021 


3,955 


65-6 


241 


145 


60-1 



Summary. 



Population. 


Cases. 


Deaths. 


Mortality Per 
Cent. 


. , 

Military 
Civilian 


4,238 
6,021 


1,928 
3,955 


45-5 
65-6 


Total 


10,259 


5,883 


57-4 



147 



148 MEDICAL HISTORY OF THE WAR 

The first military case occurred on September 19th, 1914, 
and somewhat later a serious outbreak took place amongst 
Canadian troops on Salisbury Plain, among whom cases had 
already appeared at Val Cartier Camp in Canada, while others 
had broken out on the voyage. From early in January 1915, 
the disease became epidemic. As usual, the infection could 
not be traced from case to case, but occurred in different units 
scattered throughout the country. 

In the British Expeditionary Force in France the disease 
first appeared in January 1915, and its incidence is shown 
by the following table : 



Year. 


Cases. 


Incidence 
per 1,000 
of strength. 


Deaths. 


Mortality 
Percentage. 


1915 


313 


55 






1916 


393 


33 


138 


35-1 


1917 


701 


43 


198 


28-2 


1918 


176 


11 


69 


39-2 



No serious outbreak occurred in any other theatre of war, 
but cases occurred in the Italian, Mesopotamian and 
Dardanelles forces, and also amongst the Indians and Arabs 
in Mesopotamia.* 

The seasonal incidence of the disease followed a definite 
curve, statistics showing that 77 per cent, of the cases in the 
United Kingdom occurred in the first six months of the year, 
though no month failed to produce at least one case. From 
January, the number of cases gradually increased until late 
March or early April, when a somewhat abrupt decline began. 
By the end of June only occasional cases occurred. The 
number of these decreased until December, when it began to 
rise again. 

^Etiology. 

Epidemics of cerebro-spinal fever have occurred in most 
countries in the world, so that climate cannot be claimed as 
playing any special part in engendering them. Weather 
conditions, on the other hand, have been accredited with exerting 
a definite influence on the spread of the disease, which is most 
rife in winter and early spring. Observations, however, instituted 

* A considerable outbreak occurred during 1916-1917 in transports with 
troops from Australia. From June 1916 to October 1917, 126 cases occurred 
on transports, the cases and their contacts being landed at Durban or Cape 
Town. This outbreak is of interest in that, owing to preventive measures 
employed, the disease did not spread either to the civilian population or to the 
garrison at the ports at which cases were landed. The measures adopted were 
segregation of contacts, naso-pharyngeal swabbing of non-contacts to ascertain 
the carrier rate, and the use of the sulphate of zinc spray in chambers. 






CEREBRO-SPINAL FEVER 149 

by Sir H. Rolleston at a naval base in 1915, upon northerly 
or easterly winds, a sudden fall in temperature, and the 
prevailing wind and average daily temperature contour, 
failed to show any conclusive relation between these weather 
conditions and case incidence. 

Fatigue has been claimed as one of the factors which favour 
outbreaks of the disease, but no conclusive evidence has been 
adduced to show that it exerts any more specific influence 
than other causes of lowered vitality. 

No direct relation between previous illness and infection 
has been established. The pandemic of influenza amongst 
troops in June and July, 1918, caused no rise in the incidence 
of cerebro-spinal fever. On the other hand, cases of cerebro- 
spinal fever complicated by influenza, or vice versa, are 
singularly fatal. 

Naso-pharyngeal catarrh has been claimed as a preliminary 
stage of cerebro-spinal fever. Sophian in America, Lundie, 
Thomas, Fleming and Maclagan working at Aldershot in 
1915, described a catarrhal stage as the first manifestation of 
the disease. Other observers, Sheffield Neave, Worster Drought 
and Kennedy, and the Advisory Committee of the Medical 
Research Committee have failed to substantiate this view, 
the report of the latter committee pointing out that the 
only relation is that both diseases occur in winter and early 
spring. On the other hand, Cleminson's observations 
show that 50 per cent, of chronic carriers have an 
excess of adenoid tissue, in whose folds it may be presumed 
the meningococcus finds a secure nidus. The fact that a 
chronic carrier can often be entirely cured by the operation 
of clearing the post-nasal space strengthens Cleminson's 
contention. Catarrh, therefore, although in no sense increas- 
ing the probability of any individual contracting the disease, 
may, if dependent on abnormal conditions of the mucous 
membrane, predispose him to become a carrier. Coughing 
and sneezing may, by increasing the range of his infectivity, 
tend to widen the spread of an epidemic. 

From the study of the recent epidemics, one causative factor 
stands out with startling distinctness, namely, overcrowding. 
In 1915, it wa at once recognized that wherever cubic space, 
either in huts or billets, fell below standard, cases began to 
occur. Captain Glover's work at a depot in 1917 gives an 
admirable picture of the mode in which epidemics arise from 
overcrowding. Glover found that the carrier rate with the 
peace standard of one yard between the beds rarely exceeded 
5 per cent. Mobilization standard of one foot four inches 
between the beds yielded a carrier rate of 10 per cent. At 



150 



MEDICAL HISTORY OF THE WAR 



one foot it rose to 20 per cent, and at less than nine inches 
28 to 30 per cent. When the carrier rate rose to 20 per cent, 
or over, cases began to occur. At this depot the carrier rate 
rose as high as 70 per cent. Spacing out produced a fall in the 
carrier rate, in a slower manner than the preliminary rise. 

The exciting cause of cerebro-spinal fever is infection of 
the meninges by the meningococcus. This is a gram negative 
organism whose habitat is the vault of the naso-pharynx. 
Dopter first differentiated this organism into two types, the 
meningococcus and the parameningococcus, and produced a 
specific serum for each. By the agglutination test controlled 
by the absorption test Gordon found that the meningococci of 
the epidemic during the war were divisible into four types, named 
I, II, III and IV. Of these I and III correspond to the menin- 
gococcus and II and IV to the para-meningococcus of Dopter. 

The following table indicates the relative frequency with 
which the types were found : 



Type .. 


I 


II 


III 


IV 


Specimens 


195 


218 


69 


36 


Percentage 


37-66 


44-05 


11-38 


6-94 



Infection spreads from throat to throat and in a small 
proportion of cases passes inwards from the naso-pharynx 
and ultimately infects the meninges. Opinions are divided 
as to whether the infection passes by direct extension through 
the cribriform plate or through the sphenoidal sinus, or is carried 
by the^ blood stream. The occurrence of both rapidly fatal 
and chronic cases of meningococcal septicaemia, in which the 
meninges are healthy, are strong arguments in favour of the 
latter view. Herrick obtained positive blood cultures in the 
early stages in a large proportion of cases ; other observers met 
with a contrary experience. Embleton and Peters found 
meningococci in the pus of the sphenoidal sinus in a large 
proportion of cases ; but Worster Drought and Kennedy failed 
to corroborate their observations. It has further been suggested 
that infection passes by direct extension through the dural 
sheaths of the olfactory nerves in the cribriform plate. On the 
whole the view that meningeal infection occurs through the 
blood stream is most widely held, but definite proof of the 
actual path is hitherto lacking. 

Morbid Anatomy. 

With regard to the morbid anatomy of the disease, in 
septic asmic cases the only appearances to be observed are a 
haemorrhagic rash and haemorrhages on the serous membranes. 



CEREBRO-SPINAL FEVER 151 

Fulminating cases exhibit intense congestion of the cerebral 
vessels with patches of pus lying in milky exudate. Acute 
cases dying somewhat later show large plaques of pus scattered 
over the vertex and covering the base of the brain. The cord 
is also covered with patches of pus which are most numerous 
in the dorsal and lumbar region. Microscopically, beyond 
superficial polymorphonuclear infiltration, there is little patho- 
logical change. In a type of chronic case, which usually dies 
about the third week, the brain and notably the cord are 
coated with thick shaggy pus, and there is but slight excess 
of fluid. Cases dying of hydrocephalus exhibit but slight 
signs of the original infection, pus having disappeared from 
the vertex and base, while the ventricles are distended with 
clear fluid. The obstruction will usually be found to be due 
to matting together of the areolar tissue of the roof of the 
fourth ventricle. In other cases the iter may be blocked, 
or adhesions between the spinal and parietal arachnoid may 
be the cause of obstruction. Changes in other organs are slight. 
The spleen is not enlarged, the liver and the kidneys show 
cloudy swelling. The lungs frequently show patches of 
broncho-pneumonia. The right heart is dilated and pericar- 
ditis may rarely be seen. Haemorrhages into the supra-renal 
capsules occur with comparative frequency. Death from 
large retro-peritoneal haemorrhages has been recorded in a 
few instances. 

Symptoms. 

The period of incubation for practical purposes may be 
regarded as from three to five days. Observations on men 
returning from leave to a unit hitherto uninfected, as well as 
observations on carriers who have developed the disease 
during observation, point to a short period of incubation. 

The symptoms of cerebro-spinal fever bear a two-fold 
aspect, those associated with an infective process, and others 
due to the evolution of nervous phenomena as the cerebro- 
spirial system becomes increasingly involved. In a small 
number of cases the latter class of symptoms may be entirely 
absent, a meningococcal septicaemia proving fatal while the 
meninges remain entirely unaffected. Some cases, on the 
other hand, In which a meningo-coccal infection is proved by 
positive blood cultures while meningeal symptoms are entirely 
absent, may run their entire course to complete recovery, 
exhibiting only the symptoms of continued fever, sometimes 
combined, with a rash or arthritis, or they may, after a long 
interval, ultimately develop meningitis. With these exceptions, 
however, cerebral symptoms develop soon after the clinical 
symptoms of fever. 



152 MEDICAL HISTORY OF THE WAR 

In the great majority of cases the onset is sudden and 
generally marked by a rigor, followed by a rise in temperature 
and marked anorexia. In other cases, the onset may be 
insidious, malaise and slight headache going on for some days 
until increased headache and the occurrence of vomiting 
rouse suspicions of the nature of the malady. In fulminating 
cases, and in some that recover, the patient passes almost at 
once into a condition of profound coma. The general aspect 
is characteristic. In the early stage, the patient presents a 
flushed face, with an aspect of suffering ; sometimes the 
expression is one of startled apprehension. As the disease 
progresses, this gives place to a dull heavy look recalling that 
of typhus. The patient usually lies curled up in bed or may 
rest face downwards supporting his head with his hands. 
Headache rapidly follows the initial rigor. This varies in 
its initial severity and in the rapidity of its exacerbation. 
As a rule, the whole head is affected ; pain may be more pro- 
nounced in the frontal or occipital region, but is never unilateral 
and is rarely influenced by drugs. The severity of the pain 
steadily increases, and may be of the most agonizing character. 
A slight degree of photophobia is usually present, but it is 
not so marked a symptom as in tubercular meningitis. With 
the exacerbation of the headache, vomiting shortly sets in. 
This is an almost constant symptom, but usually only lasts 
for about 24 hours. 

Delirium occurs in a large proportion of cases, the date 
of its onset varying from a few hours to five or six days. It 
varies from violent, almost maniacal excitement, to mere 
muttering, and in all its phases constant complaint is made 
of headache. In acute cases delirium leads on to stupor and 
this in turn passes into coma. 

The temperature usually rises to between 101 and 103F. 
after the preliminary rigor, and remains elevated during the 
course of the acute symptoms. The temperature curve affords 
no measure of the severity of the disease. The pulse, except 
in very acute cases, is somewhat slow in relation to the 
temperature. 

In about 50 per cent, of cases, a rash makes its appearance ; 
in fulminating cases, large purpuric spots appear on the body 
and also involve the face. In acute cases, a petechial rash 
appears which consists of small papules, varying in size from 
a pin's head to a peppercorn, and occurring principally on 
points of pressure, notably the trochanters, knees and elbows, 
malleoli and points of the shoulders (Plate I, Fig. 2). This 
rash is seen from the first to the third day, and is always 
evidence of profound toxaemia. The macular rash (Plate II), 



1 

05 



CD 



I 



OS 

uj 



OH 
I 



U- 



CL 
cn 

6 

cci 

CQ 
UJ 



U 




u 
en 



QQ 



UJ 
U 



CEREBRO-SPINAL FEVER 153 

which may be regarded as the specific rash of the fever, 
appears on about the fourth day and the distribution affects 
first the abdomen, then the thighs, the extensor surfaces of 
the forearm and legs, the back of the hands and the dorsum 
of the foot. The individual maculae vary in size from that 
of a millet seed to that of a No. 1 shot, and in colour from 
scarlet to purple. A transient erythematous rash may appear 
at any time during the disease (Plate I, Fig. 1). The larger 
purpuric spots may undergo ulceration, as pointed out by 
Elliott and Kaye, who refer to the lowered vitality engendered 
by cold in the trenches as favouring increased size in the 
purpuric patches and also a tendency to ulceration (Plate III). 
In from 30 to 40 per cent, of cases, herpes appears from 
the third to the sixth day, usually about the fourth. The 
vesicles are almost invariably facial or auricular in distribution, 
though other nerve areas such as the lumbar and sacral are 
occasion all v affected. 

Of symptoms more directly concerned with the nervous 
system, one of the earliest to manifest itself is retention of 
urine ; this occurs in about 50 per cent, of cases, and is not 
necessarily attended by mental hebetude. This symptom is 
of considerable diagnostic importance, as in no other febrile 
malady does retention occur at such an early stage. At 
later stages of the disease, notably in hydrocephalus, there 
may be incontinence both of urine and faeces. The febrile 
onset is often attended by general myalgic pains ; these in 
turn are succeeded by a varying degree of muscular rigidity. 
Rigidity and contraction of the muscles of the neck leading 
to retraction of the head form one of the most striking 
symptoms of the disease. This sign varies m the date of its 
appearance, but is usually present on the second or third day. 
It may, however, be delayed to the fifth or sixth. Few, other 
than fulminating cases, fail to show this sign at some period 
of their course. Another form of rigidity which is always 
manifested is the tonic contraction of the ham-strings which 
gives rise to Kernig's sign. This phenomenon is present in 
all except fulminating cases. It usually appears at the end 
of 18 hours, is fully established at the end of 24, and is of 
great diagnostic^ importance. As the disease progresses, other 
forms of rigidity make their appearance and should hydro- 
cephalus ensue both arms and legs may become rigid and flexed. 

The reflexes vary in different cases so that no diagnostic 
significance can be attached to them. The knee jerks may 
be absent in the acute stage ; the plantar reflex in some cases 
may show an extensor response. The abdominal reflexes 
are variable. 



154 MEDICAL HISTORY OF THE WAR 

Paresis of ocular muscles may be observed though less 
frequently than in tubercular meningitis, the sixth nerve 
being usually affected. Nystagmus and diplopia occur in a 
small number of cases. Of other cranial nerves, the facial 
and hypoglossal are in some instances affected. The palsy 
is of a transitory nature and passes off with convalescence. 
Hemiplegia occurs but rarely, being observed in but 12 
instances in 502 cases in the Royal Navy. Of the special 
senses, the eye and ear are affected. The pupils are usually 
dilated, and may be unequal. Conjunctivitis is fairly common, 
and iritis a rare complication. Panophthalmitis with conse- 
quent destruction of the eye-ball is rare. Optic neuritis is 
uncommon in comparison with its frequency in other septic 
forms of meningitis. Worster Drought and Kennedy found 
it five times in 80 cases ; Cooke and Foster twice in 40 cases. 
Deafness is the commonest abiding defect left by the disease. 
It occurred six times in 120 cases observed. It appears 
within the first week and is usually permanent. Otitis 
media is an uncommon complication. 

In acute cases rapid wasting occurs about the fourth or 
fifth day and continues while symptoms persist. In hydro- 
cephalic cases the marasmus reaches an extreme degree. 
Arthropathies, in which the synovial membrane rather than 
the cartilage or bone is for the most part involved, occur in 
a small percentage of cases. Rolleston found them in 4*8 per 
cent, of 502 cases in the Royal Navy. Such arthropathies 
must be distinguished from those incidental to serum sickness ; 
the joints are swollen and tender, and the meningococcus 
has been recovered from the effusion. The effusion is usually 
of short duration and rarely requires aspiration. Subsequent 
pain or stiffness is an uncommon event. 

Reference has already been made to the fact that naso- 
pharyngeal catarrh is in no sense an essential feature of the 
disease. Bronchitis is a complication in a certain proportion 
of cases and may be of the fetid type. Broncho-pneumonia, 
usually of pneumo-coccal origin, is a relatively common com- 
plication, especially in comatose cases. In some instances 
the meningococcus is the exciting cause. Lobar pneumonia 
is an uncommon complication. Pleurisy may occur, and in 
haemorrhagic cases, haemothorax. In acute fatal cases, un- 
dulant breathing of the cerebral type or Biot's breathing is 
a notable feature, and Cheyne-Stokes' breathing may be a 
terminal phenomenon. 

Slowness of the pulse in relation to the temperature is one 
of the most marked of the circulatory symptoms and may be 
regarded as due to vagus inhibition. In fulminating or acute 




C/) 

< 

OS 

OS 
< 



UJ 



u 

CO 



CQ 
UJ 



CEREBRO-SPINAL FEVER 155 

cases the pulse is rapid and feeble from the first. Pericarditis 
is an occasional complication and the meningococcus has been 
recovered from the lymph. Endocarditis is rare. It is 
remarkable what little impress a disease of such severity leaves 
on the circulatory system during convalesence. 

The alimentary canal suffers but slightly beyond the initial 
vomiting, which in some instances may be accompanied or 
replaced by diarrhoea, or even by mucous diarrhoea. Acute 
abdominal pain at the onset may tend to obscure the 
diagnosis. 

The blood shows a polymorphonuclear leucocytosis usually 
about 25,000 per c.mm., rarely as high as 50,000. 

Urinary changes are of slight importance. Haematuria may 
occur at the onset, even in cases without a haemorrhagic rash. 
Febrile albuminuria is not uncommon while glycosuria is a 
rare complication. True nephritis is rare. Owing to the 
frequency of retention or overflow incontinence, cystitis and 
pyelitis are not uncommon. Further experience has not 
confirmed Sophian's view of their meningococcal origin. As 
in all febrile affections, epididymitis and orchitis occasionally 
occur, and the meningococcus can be recovered by puncturing 
the affected organ. 

A study of a large number of cases reveals the fact that 
clinically the course of the disease runs in a variety of well- 
marked types. Primarily these may be differentiated into 
acute, in which either death occurs or the patient is on the 
way to convalesence in a fortnight, or chronic, in which the 
issue is doubtful for a longer period. Acute cases may be 
divided into fulminating cases, acute fatal cases, acute cases 
which recover, and abortive cases. 

Fulminating cases may be defined as those in which death 
occurs within 24 to 36 hours after onset. These cases fall 
into two categories ; of these the first is constituted by those 
comparatively rare instances in which death is due to 
meningococcal septicaemia, the meninges showing no patho- 
logical change, purpuric spots and the presence of the organism 
in the blood affording the only means of diagnosis. The 
second and far commoner form presents even at that early 
stage well marked purulent meningitis. The onset is of 
startling suddenness ; a man may fall down unconscious on 
parade or be seized with epileptiform convulsions or maniacal 
excitement. More commonly, however, he goes to bed in 
his usual health, and is found unconscious or even dead in 
the morning. Vomiting may occur before consciousness is 
lost. Within the first few hours, large purpuric spots, which 
may contain meningococci, make their appearance on the 



156 MEDICAL HISTORY OF THE WAR 

trunk, extremities and face. The temperature is usually but 
slightly raised or even sub-normal though hyperpyrexia may 
occur. The face is pale or cyanosed, the hands tremulous 
and bathed in sweat, the pulse rapid and feeble, often 
uncountable. The breathing is often undulant and dyspnoea 
a marked symptom, the patient beating the air in his struggles 
for breath. Kernig's sign is often absent and head retraction 
rarely has time to develop. The cerebro-spinal fluid usually 
contains an increase of polymorphonuclear cells. Menin- 
gococci may or may not be present, but can usually be recovered 
from the cerebral ventricles post mortem. Fulminating cases 
are comparatively infrequent ; two cases only occurred in 120 
consecutive cases under the care of Colonel Foster. Such 
cases are stated to occur more frequently in the earlier months 
of an epidemic, and this general impression is probably, in the 
main, correct. 

The acute fatal type may be defined as one in which death 
occurs within the first week from onset, usually within the first 
five days. Rolleston's figures show that of 86 deaths occurring 
in 225 naval cases in the third and fourth years of the war, 
40 to 44 per cent, occurred on or before the fifth day. It must 
further be remembered that these results were obtained when 
early diagnosis and prompt treatment had been brought to a 
high pitch. The striking clinical feature in these cases is that 
their course is uniformly downward, as though protective 
reactions were totally unable to develop. The onset is sudden 
and headache severe from the first. Vomiting comes on early, 
and is soon succeeded by delirium. A petechial rash makes 
its appearance on the first or second day, retention of urine 
about the same time. Head retraction develops at an early 
stage. The pulse is usually rapid, the breathing shallow and 
undulant, the face and extremities early become cyanotic. 
Delirium may be violent, is usually attended by extreme 
restlessness, and quickly lapses into coma. The cerebro-spinal 
fluid is usually obviously purulent, and contains in the smear 
large numbers of extra-cellular meningococci which grow readily 
on cultivation. 

The acute cases which recover present the symptoms described 
above though in a lesser degree. The onset is sudden, and 
headache severe ; vomiting occurs, usually during the first day. 
The second day may show not only no aggravation, but even 
an elusive improvement. With the onset of the third day, all 
the symptoms become accentuated, the delirium is often violent, 
and in many cases is succeeded by coma, retention of urine and 
inability to swallow. Dyspnoea, cyanosis and cerebral breath- 
ing, on the other hand, are not such marked features as in 




I 



* * 







X 

CO 

< 
as 

y 

5 



O, 

as 

UJ 



CO 

6 

as 
CQ 
uu 

as 

u 



CEREBRO-SPINAL FEVER 157 

the fatal cases. On the fourth day herpes may occur about 
the lips and a macular rash on the abdomen and extremities. 
The fundamental difference between the fatal acute cases and 
the acute cases which recover is that, in the latter, treatment 
begins at once to produce some improvement. During the fourth 
and fifth days there may be but little change except that 
the patient does not become obviously worse. From the 
fifth to seventh day improvement sometimes of the most 
dramatic character takes place. Once begun this usually 
continues with considerable rapidity, consciousness returns, 
and with it natural sleep ; the bladder resumes its functions, 
and head retraction disappears. Following this amelioration of 
symptoms, there may be fresh outbursts of fever accompanied 
by headache, vomiting and rigidity of the neck, due to the 
lighting up of fresh foci of infection, these recrudescences 
yielding in their turn to fresh administration of serum. 

During every epidemic, but notably towards its close, cases 
occur which are characterized by headache, vomiting, some 
rigidity as manifested by Kernig's sign, or slight stiffness of the 
neck. The cerebro-spinal fluid shows an increase of polymor- 
phonuclear leucocytes, and generally meningococci may be 
grown. In other instances, the fluid is sterile but the organism 
can be cultivated from the throat. In these cases recovery 
takes place in a few days. They are consequently described 
as abortive cases. 

The chronic types of the disease may be divided into 
suppurative, hydrocephalic, relapsing and recrudescent. 

In the suppurative type of case, as the disease progresses, the 
fluid obtained from the theca becomes increasingly thick and 
coagulated, until finally lumbar puncture yields only a few 
drops. This increasing density of the pus begins about the 
fourth or fifth day and continues in an augmented degree until 
death, which usually occurs in the third week. The patient 
wastes rapidly, the sphincters become affected, but instead of 
coma or violent delirium, the patient passes into a state of 
hebetude varied by periods of complete consciousness. This 
type of the disease is rare ; it occurred twice in Gaskell and 
Foster's 120 cases, is always fatal and neither the injection of 
serum nor washing out the theca with salines or citrate solution 
has any effect upon the density of the pus. The aberrant 
character of the exudation does not appear to depend on any 
specific difference in the infecting organism. Worster Drought 
and Kennedy found equal numbers of Types I and II infections. 

In discussing the acute fatal type of cases, it was shown that 
nearly half the mortality of the disease occurred within the 
first week. With the exception of death due to intercurrent 



158 MEDICAL HISTORY OF THE WAR 

cause, practically the other 50 per cent, of deaths are due to 
hydrocephalus. Pathologically, hydrocephalus arises from 
adhesions forming in the arachnoid membrane, which interfere 
with the circulation of the cerebro-spinal fluid, giving rise to a 
loculated meningitis, and, as a corollary, distension of all the 
spaces of the cerebro-spinal system above the obstruction. The 
latter is in the majority of cases due to matting together of the 
areolar tissue in the roof of the fourth ventricle, but sometimes 
to adhesions between the parietal and visceral arachnoid in the 
cord. 

It appears probable that adhesions form comparatively early 
and only begin to give rise to symptoms at a later date. In the 
acute fatal cases, adhesions are not as a rule observed, but in a 
case dying from intercurrent causes on the tenth day, the third 
and lateral ventricles were dilated. Again in a case trephined 
on the eighth day from onset, the roof of the fourth ventricle was 
densely adherent. A gush of fluid escaped from which the 
meningococcus was grown, while only 16 c.c. of sterile fluid had 
been obtained by lumbar puncture. This case is of interest as 
showing that complete occlusion may arise as early as the eighth 
day and further that about 16 c.c. may be taken to be the measure 
of the contents of the theca below the foramen of Magendie. 
However early the obstruction may be formed, the train of 
symptoms to which it gives rise does not develop until the 
second week. The acute symptoms have by then subsided, but 
agonizing headache continues. This is temporarily relieved by 
lumbar puncture. Towards the latter part of the second week 
more distinctive symptoms arise. The patient rapidly sinks 
into an adynamic state, with profuse sweating, incontinence of 
urine and faeces and a feeble pulse. Low muttering delirium, 
with a temperature of 100 to 101 and vomiting are present. 
Head retraction becomes more marked, and other forms of 
rigidity make their appearance, the legs and arms become 
flexed, and hyperaesthesia causes any movement to be attended 
by intense pain. Very rapid wasting takes place, and the patient 
passes into a semi-imbecile state in which he dies. Lumbar 
puncture yields a daily diminishing amount of progressively 
clearer fluid which is usually sterile, until only 10 to 15 c.c. are 
obtainable. In other cases the onset is more insidious. 
Usually the advent of these symptoms heralds a fatal result, 
but in a certain number the symptoms gradually pass off, the 
amount of cerebro-spinal fluid yielded by lumbar puncture 
increases day by day and complete convalescence results. It 
can only be conjectured that collateral sources of circulation 
are opened up until equilibrium is established. From the study 
of morbid anatomy and clinical symptoms presented by hydro- 



CEREBRO-SPINAL FEVER 159 

cephalus the practical point may be deduced, namely, that the 
anatomical disposition of the areolar tissue at the roof of the 
fourth ventricle renders this site peculiarly liable to adhesive 
inflammation and consequent blocking of the channels of 
circulation. As a rule of practice, therefore, every effort must 
be made to overcome the source of infection at the earliest date 
possible by the administration of serum ; and further when 
this has been accomplished, repeated lumbar puncture must be 
practised to ensure that there is no stagnation in the circulation 
of the cerebro-spinal fluid. 

In dealing with recrudescent or relapsing cases, the difficulty 
lies in the definition of what constitutes a true relapse. Recru- 
descences of fever and symptoms are common enough ; further, 
as Sophian has pointed out, a slight and unsuspected degree of 
hydrocephalus may produce an apparent relapse after a con- 
siderable interval of convalescence. Netter regards a true 
relapse as distinguished from a recrudescence by its occurring 
at least one month after all symptoms have disappeared. Even 
under these circumstances a relapse is presumably due to 
activity in a quiescent focus, since a second attack of cerebro- 
spinal fever is a very rare event. 

Recrudescences after apyrexial periods of five to ten days are 
far from uncommon, and may be regarded as due to activity 
of a focus in the choroid plexus, hitherto untouched by serum, 
or possibly fresh infection from the naso-pharynx. Clinically 
recrudescences are marked by a sudden rise in temperature, with 
headache and often vomiting ; on puncture, the meningococcus 
can usually be grown. The attack usually yields rapidly to 
serum treatment. Recrudescences may repeat themselves for 
a variable number of times ; up to six have been observed. The 
course of cerebro-spinal fever is a lengthy one. Although acute 
symptoms may have entirely subsided within ten days, the 
necessity for watchfulness as regards recrudescence, or the 
possible supervention of hydrocephalus, involves confinement 
to bed for a considerable period. Kernig's sign is the last 
symptom to disappear, and until this has been consistently 
absent for five days the danger of a recrudescence or latent 
hydrocephalus is not past. Convalescence is somewhat slow, 
as occasional headaches and pain in the back may interfere 
with exercise. 

Of the sequelae, those connected with the eye and ear are 
by far the most frequent and permanent. Deafness usually 
appears by the end of the second week ; in a few cases it passes 
off with convalescence, but as a rule the loss of hearing is com- 
plete and permanent. The labyrinth is the part affected, and 
the affection is generally bi-lateral though occasionally only 



160 MEDICAL HISTORY OF THE WAR 

one side is affected. Though the commonest form of abiding 
disability, the incidence of deafness is not large. Rolleston 
found it 26 times in 502 naval cases or 5 per cent , Foster 
in six out of 120 cases. Panophthalmitis with consequent 
destruction of the eye-ball and optic atrophy are the only 
permanent lesions affecting the eye. The number of cases of 
the former is small ; Rolleston gives 1-4 per cent. In 200 cases 
observed by Foster this complication occurred once. The 
affection is usually uni-lateral ; though both eyes may be 
affected, the right eye is more frequently affected than the left. 
Blindness from optic atrophy is extremely rare among adults, in 
contrast with its comparatively frequent occurrence in posterior 
basic meningitis of infants. Hemiplegia is an uncommon 
sequela, cases presenting this complication being frequently 
fatal. In most instances the lesion is organic, and to some 
extent permanent. Some cases present a staggering gait with 
exaggerated reflexes, volitional tremors and nystagmus. 
Recovery here again, though slow, is usually complete. 

Monoplegias with pain, wasting and loss of electrical 
reaction, as described by Netter, Horder and others, completely 
recover. Pain and stiffness of the back is a common complaint 
amongst convalescents. It has been attributed to repeated 
lumbar punctures, but may be observed in cases which have 
only received one puncture. Though perfectly well in other 
respects, these men are unable to bear their packs for some time, 
and this has been observed in soldiers who were candidates for 
commissions, when a motive for malingering was presumably 
absent. This disability entirely disappears in the course of 
two or three months. Headache is a residual symptom met 
with in a number of cases. It is recurrent often at considerable 
intervals, is relieved and often permanently cured by lumbar 
puncture, and is rarely permanent. Epilepsy, dating from an 
attack of cerebro-spinal fever, has been recorded. Mental 
changes of a permanent character practically do not exist ; as 
with all acute and painful diseases, a certain proportion of 
convalescents show symptoms of neurasthenia, marked by 
concentration upon their own symptoms and feelings. With 
outdoor life and exercise these symptoms entirely disappear. 
With regard to symptoms other than those associated with the 
central nervous system, it is remarkable how slight an impress 
a disease of such severity leaves upon the body at large. The 
heart muscle is entirely unaffected. Convalescents from this 
disease contrast markedly in this respect with those recovering 
from the enteric group. The kidneys are entirely unaffected ; 
anaemia, dyspepsia and disordered action of the bowels are of 
uncommon occurrence. 






CEREBRO-SPINAL FEVER 161 

Prognosis. 

With regard to prognosis, the signs and symptoms of the 
patient, his age, and the effect of treatment and the date at 
which it is begun, must be taken into consideration in each 
individual case. 

As regards individual signs, onset characterized by sudden 
lapse into coma is of grave significance, although a few cases 
recover. A purpuric rash appearing in the first 24 hours is 
a grave symptom. A petechial rash appearing on the first 
or second day is an unfavourable sign. Cyanosis, extreme 
dyspnoea, cerebral breathing, and a feeble- running pulse are of 
fatal augury. Extreme restlessness is a more unfavourable sign 
than either delirium or profound coma. The temperature 
forms no criterion of the probable course of the disease, except 
that a low temperature with an apoplectic form of onset is 
an unfavourable sign. In the later stages hydrocephalus is 
a grave complication, few cases recovering. Recrudescences, 
however numerous, are not dangerous except in so far as 
each burst of infection brings with it the danger of resulting 
hydrocephalus. 

As regards the age of the patient, the mortality rate is lowest 
according to Netter, at the fifteenth year ; it then rises slightly 
till the twentieth year. After full maturity is reached it falls 
during the decade 20 to 30. After 30 it rises abruptly, and 
continues to rise with each decade of life. In a patient over 30 
the outlook is always grave. 

As regards the effect of treatment, the most important point 
is the day on which treatment is begun. Flexner's early 
statistics demonstrated a marked difference in the results 
obtained when efficient serum treatment was begun at once, 
or when an interval of two or three days elapsed. Martin 
Flack's results in the London district bring out this point very 
clearly. 

The remote prognosis of cerebro-spinal fever has already 
been touched upon in treating of the sequelae of the disease. 
In dealing with troops, two administrative problems arise the 
length of hospital and convalescent treatment with the resulting 
period of invaliding, and the amount of permanent disability, 
which may give rise to a claim to pension. 

In dealing with the first of these questions the nature of the 
disease involves, in the majority of instances a prolonged stay 
in hospital. This may be further extended by the necessity 
tor swabbing until the naso-pharynx is free. Thus a case which 
yields rapidly to treatment is rarely fit for convalescent treat- 
ment under a period of 20 to 30 days. When recrudescences 
occur the period may extend to 50 or 60 days. Once convales- 

(2396) L 



162 MEDICAL HISTORY OF THE WAR 

cence is established the subsequent progress is rapid, so that 
many cases who are prolonged carriers are fit for duty by the 
time the naso-pharynx is free. 

The question next arises as to the incidence of a disability of 
such a nature as to give rise to a claim for pension. Two sources 
of information have been utilized the records of the Hitchin 
Convalescent Home and the records of the Ministry of Pensions. 
The Hitchin Convalescent Home was opened on May 5th, 1915, 
as a provision for all cases of tardy convalescence arising in 
military hospitals in the United Kingdom. This would also 
include cases of the same character evacuated from hospitals 
overseas. During the years 1915-16, 93 cases were admitted ; 
of these 89 returned to duty, two were invalided out, and two 
transferred to other hospitals. During the years 1917-18, 254 
cases were admitted. Of these 126 returned to duty, 25 were 
disposed of as chronic carriers, and the remainder" transferred 
to other hospitals. Thus even in chronic cases two-thirds of 
the patients are fit for duty. 

A further source of information is in the records of the 
Ministry of Pensions. Dr. H. W. Kaye has furnished reports of 
the Re-survey Boards, from 30th June to 1st November, 1919. 
During this period 254,374 men were examined and 22 cases 
claimed their invaliding disability as due to cerebro-spinal fever. 
It is probable that a certain number of other cases claimed 
disability on account of deafness, or the loss of an eye, or 
possibly rheumatism, and thus are not shown under this heading. 
In any case the fact remains that only this infinitesimal number 
of 22 men claimed disability on account of this disease. Of these 
22 cases, the documents of 13 show that 11 were graded A., 
while two were graded B. on enlistment. Of the 11 A. cases 
at their latest re-survey the disability adjudged in 10 was as 
follows : 

10 per cent, and less than 20 per cent. 1 

20 per cent 4 

30 per cent 1 

40 per cent 3 

70 per cent, (a case of complete deafness) 1 
Of the B. cases one partially deaf on enlistment was adjudged 
30 per cent. A second had been invalided out in 1901. At his 
last re-survey he presented tremor and wasting of left thigh and 
was adjudged 40 per cent, disability. The complaints of the 
men were, in the main, of pain and stiffness in the back, some- 
times accompanied by tenderness on pressure, in others vertigo 
with recurrent headache, and in a few instances tremors. Of 
these complaints pain and stiffness in the back is a common 
symptom, the duration of which varies markedly in different 



CEREBRO-SPINAL FEVER 163 

cases. In reporting on the condition of the convalescents at 
the Hitchin Home this condition was one of the commonest, 
and varied markedly in the time in which it disappeared, but 
in no case did it form a permanent disability. In estimating 
the disabling effects of this disease, it must be remembered that 
while certain organic lesions, as above described, occur in a 
small proportion of cases, a large proportion present functional 
nervous troubles, which under appropriate conditions, the 
avoidance of hospitalism being the most essential, entirely 
recover. Further, except where these organic lesions have 
occurred, the man's ultimate efficiency is in no wise lowered by 
an attack of the disease. Two of the first 30 cases seen in 1915 
early obtained commissions, a third, who ran a febrile course of 
50 days with no treatment other than a diagnostic lumbar 
puncture, was, on the testimony of his platoon commander, one 
of the best soldiers in the battalion. 

Diagnosis. 

In diagnosing a case of cerebro-spinal fever it must be clearly 
understood that the only reliable diagnosis in fulminating cases 
is derived from the bacteriological examination of the cerebro- 
spinal fluid or of the blood. Lumbar puncture should be per- 
formed at once in all cases in which a doubt exists. By using 
the fine needles made by Gentile of Paris a diagnostic puncture 
can be made almost painlessly. In acute cases and when serum 
is given, an anaesthetic should be used. Dickson and Halli- 
burton experimentally, and Flack clinically, have shown that 
anaesthesia markedly increases the flow of cerebro-spinal fluid, 
thus rendering the injection of serum in large quantities easier 
and safer. As a means of early diagnosis, and consequently 
efficient treatment, puncture must be performed before the 
clinical picture is in any sense complete. Both in England and 
France the tendency of medical officers was to wait for the 
appearance of distinctive symptoms, such as head retraction, 
before resorting to puncture, and thus to sacrifice valuable time. 
During the first 48 hours the symptoms may bear a general 
resemblance to those of any other acute infection ; the case may 
therefore remain undiagnosed because meningitis has not been 
thought of. Tt must be remembered that this disease is protean 
in its manifestations, the salient symptoms appearing more 
markedly in different systems in diverse cases, and varying 
notably in the time at which they become manifest. The 
points to which attention should be directed are the increasing 
severity of the headache, the possibility of eliciting Kernig's 
sign, and the most suspicious symptom of all, difficulty in 
micturition. The pressure at which the fluid flows is of slight 



164 MEDICAL HISTORY OF THE WAR 

diagnostic importance, and the appearance of the fluid itself 
unless obviously purulent is equivocal ; a clear fluid may be 
heavily infected. In some instances the fluid at the first 
puncture shows a yellowish pigmentation with a tendency to 
clot. This is Froin's syndrome, and is of grave prognostic 
significance. A yellowish colour at subsequent punctures is 
common enough and only due to bleeding at the previous 
puncture. 

The diseases from which a diagnosis has to be made are the 
acute specific fevers on the one hand, and other diseases of the 
central nervous system on the other. Of the acute specific 
fevers measles may cause difficulty, a macular rash being 
common to both, but the more severe headache and the presence 
of Kernig's sign distinguishes cerebro-spinal fever. Fevers 
of the enteric group differ in their gradual onset and in the 
absence of rigidity. Pneumonia in its early stages may be 
distinguished by the ratio of the pulse to the respiration, and 
the absence of Kernig's sign. In influenza Kernig's sign is 
absent and vomiting rare. Of diseases of the central nervous 
system, tubercular meningitis is the commonest cause of 
difficulty, but the slower onset, the more constant involvement 
of the cranial nerves, and the cell contents of the cerebro-spinal 
fluid, which in tubercular meningitis contains many lym- 
phocytes and few polymorphonuclear cells, will settle the 
diagnosis. Meningitis due to infection by other organisms 
will be differentiated by the bacteriological examination of the 
fluid. In abscess of the brain the headache is more localized 
and optic neuritis more common. The cephalic form of acute 
poliomyelitis can be differentiated by the negative findings 
in the cerebro-spinal fluid. Encephalitis lethargica can be 
recognized in the same way. In the course of many febrile 
affections a mimicry of meningeal symptoms occurs known 
as meningism. This condition can at once be recognized by 
the nature of the cerebro-spinal fluid. 

Treatment. 

With regard to treatment previous to the epidemic which 
occurred during the war, the researches of Flexner and Dopter 
had proved the efficacy of intrathecal injections of anti-menin- 
gococcal serum. On the outbreak of the disease amongst 
troops in 1914, serum treatment, however, yielded singularly 
disappointing results. Amongst the Canadians, there were 40 
cases with 26 deaths, a mortality of 65 per cent., while Rolleston 
stated that in the navy the mortality for serum-treated cases 
was 60 per cent. Further researches were undertaken, which 
eventually showed that the requisites for an efficient serum 



CEREBRO-SPINAL FEVER 165 

were that it should correspond in type with the infecting 
organism and that it should be standardized and of proved 
anti-endotoxic power. A serum known as the M.R.C. was 
finally evolved, which yielded remarkable results. The serum 
is more efficacious against Type I than against Type II. 
Gordon's final results with the M.R.C. serum in military cases 
were : 

Percentage 

Cases. Deaths. Mortality. 

249 .. 79 .. 31-72 

Of these cases 141 were treated with serum before the seventh 
day, of which 27 were fatal, a mortality of 19* 14 per cent. 

The technique of serum treatment is simple. Lumbar punc- 
ture should be performed, and as much fluid run off as possible. 
A quantity of serum less than that of the fluid evacuated 
should be injected by the gravity method. The initial dose 
should be 30 c.c., and in severe cases 60 c.c. ; if under an 
anaesthetic, these quantities can usually be injected without 
danger. For the first dose pooled serum of Types I and II 
should be employed until the type of infecting coccus can be 
ascertained. A practical point is that the naso-pharynx 
should be swabbed, growth from this source being more rapid 
than from cerebro-spinal fluid. Identification of type is thus 
hastened. When the type has been identified, the appropriate 
mono-type serum, if available, should be administered. After 
injection, the foot of the bed should be raised to encourage the 
flow of fluid towards the base of the brain. Injections of 30 
to 60 c.c. of serum should be repeated daily, according to the 
condition of the patient and the state of the cerebro-spinal 
fluid. Recrudescences should be treated by renewed serum 
treatment. It is of great importance that any recrudescence 
should be promptly recognized and dealt with. However 
slight the outburst, it always involves the possibility of sub- 
sequent hydrocephalus. Should more than ten days have 
elapsed since the last injection, the patient should be desensi- 
tized, either by the hypodermic injection of 1 c.c. four hours 
before treatment, or by Besredka's intravenous method. 
Should no serum be available, the drainage of the theca 
should be maintained by daily lumbar puncture, a method of 
treatment which yielded good results before efficient sera were 
available. When the pus is very thick, the theca should be 
washed out with normal saline or citrate solution. A con- 
siderable proportion of cases develop a serum rash often accom- 
panied by arthritic symptoms, manifestations seldom dangerous 
and alleviated by pituitrin. Herrick claims good results from 
intravenous injection of serum in early cases yielding positive 



166 MEDICAL HISTORY OF THE WAR 

blood cultures. Large doses, 200 to 400 c.c. in all, are given. 
Since the procedure is not without danger from anaphylactic 
shock, each patient should be tested for hyper-sensitiveness by 
an intracutaneous injection of I/ 10th c.c. of serum, which in 
sensitive cases produces a local reaction, characterized by 
redness, oedema and swelling, within 40 minutes. Netter and 
Sainton advocate the obviously safer course of intra-mus- 
cular injection. In any case, it must be remembered that 
the essential danger to life lies not so much in the blood 
condition as in the suppurative processes in the brain and 
cord, so that intrathecal medication must form the basis of 
all sound treatment. 

Injections either intra-muscular or intravenous of soamin or 
hexamine have yielded results far inferior to serum treatment. 
Vaccines have been employed, but without sufficient success to 
lead to their general adoption. In hydrocephalic cases, surgical 
measures have been attempted. These consist either in drain- 
ing the lateral ventricle after trephining, or trephining from the 
posterior fossa, raising the cerebellum and draining the fourth 
ventricle. These procedures have met with but slight success, 
but as the condition is otherwise hopeless, they give a chance of 
recovery. 

As regards general treatment, headache and restlessness 
are best controlled by morphia, which may be freely given. 
The diet should be nourishing, alcohol given in the acute stages, 
but withheld later. Maclagan and Cooke recommend the intra- 
muscular injections of liq. adrenalin in 10 mm. doses four-hourly 
in adynamic cases. In comatose cases the throat should be 
constantly swabbed out. 

On reviewing the results of the epidemic during the past 
five years, one fact stands out with startling clearness, that 
whereas the mortality among civilians remained substantially 
the same, the military death rate showed a marked and pro- 
gressive decline. The curves in Chart I demonstrate this fact. 

It may be argued that the higher civilian death rate is due to 
the greater mortality among infants, but the analysis made of 
the fatality of those from 20 to 30 years of age, and therefore 
physically comparable to the average soldier, negatives this 
view. The explanation is probably to be sought in the fact 
that military cases were all segregated into hospital centres, 
adequately equipped bacteriologically. Consequently no time 
was lost before efficient serum treatment was begun. 

Early in 1915 one or more centres were formed in each com- 
mand to which all suspected cases were sent for diagnostic 
lumbar puncture and bacteriological examination. These 
centres were formed for the most part in military hospitals and 



CEREBRO-SPINAL FEVER 



167 



territorial force general hospitals. A skilled bacteriologist was 
appointed 4 to the laboratory in each centre, while an adequate 
supply of serum was always available. Orders were issued that 
no diagnostic lumbar puncture on a suspected case should be 
performed outside these centres. Apart from better facilities 



o/ 

7* 


19W 


/g7 


1QJ6 


JQJ7 


/9/tf 














ou 
7O 












/ *- x 


^ 








__- 


6O 


^ 

\ 


^^ 
, 




...... 




5/7 




\ 


V 












^ 


""** 






- /zn 








** 




fU 

- 3O 










'N 


on 












&u 













Ci^/7/ans 
MiJ/tery 



2O-3O 



CHART I. Showing fatality of cerebro-spinal fever in the civil population 
of England and ^ales, and amongst troops in training in the United 
Kingdom respectively for 1914-1918. 

for treatment the extremely low vitality of the meningococcus 
rendered any attempts at culture other than those on the spot 
practically valueless. Further, the differentiation of the type 
of infecting organisms in order that the serum employed should 
be of like type, necessitated a special technique which was only 
available in such centres. Experience gained during the war 



168 MEDICAL HISTORY OF THE WAR 

has shown that even the gravest cases can be transported long- 
distances by car or rail without any serious detriment. More- 
over, the slight risk incurred in transport is infinitely less than 
that of foregoing efficient treatment from hesitation to move 
the patient. In France similar administrative measures were 
adopted, centres being formed in advanced areas as well as at 
the base, to which all suspected cases were sent. In these 
elaborate precautions may well be the cause of the difference 
between the civil and the military statistics. 

As regards the treatment of carriers, it may be stated that 
although sprays, notably chloramine T., have temporarily 
reduced the carrier rate, the most certain method of freeing 
the throat from infection is abundance of fresh air. 

Prevention. 

With regard to preventive measures, experience gained 
during the war has led to the accumulation of a mass of 
observations whence generalizations as to the spread of 
the disease could be formed. Military administration, more- 
over, enabled preventive measures to be rapidly put in 
force and efficiently carried out. The researches of Flack, 
Glover and others showed conclusively that the carrier 
rate of agglutinable meningococci bore a direct relation to 
season, the rate falling through the summer months and rising 
during the winter. Glover's observations in the London Dis- 
trict demonstrated the direct influence of overcrowding in 
increasing the carrier rate. Further, Glover proved that a 
decrease in overcrowding invariably led to a marked fall in the 
carrier rate. The corollary is that, as cerebro-spinal fever is 
largely caused by overcrowding, the first essential preventive 
measure is the strict observance of the hygienic rules already 
laid down. The provision of adequate lateral space in sleeping 
quarters is of primary importance, since the transference of 
infection by droplets from the upper respiratory passages is 
more likely to take place during sleep, owing not only to longer 
period of exposure but also to greater propinquity. In the 
event of the disease becoming prevalent in a unit in the field, it 
is advisable to bivouac these men out in fields, rather than to 
crowd them into out-buildings and billets. Chart II., drawn 
by Glover, immediately demonstrates the nature of the precau- 
tions to be observed.* 

With regard to carriers, the development of cerebro-spinal 
fever in a carrier is a very rare event. Flack and others have 
recorded cases. But carriers transmit the disease to others 

* From Medical Research Committee's Report, No. 50, page 139. 






CEREBRO-SPINAL FEVER 

by droplets from the upper respiratory passages. In this 
regard may be quoted Fildes' observations on the development 
of cerebro-spinal fever in a number of new recruits in the navy, 
in whom swabs from the naso-pharynx had proved negative 
on enlistment. Similar results have been recorded by other 
observers. 

The danger from carriers is particularly evident in the 
number of cases reported by Reece, Glover and others, in 
which a soldier carrying the meningococcus has infected his 
family while on leave. On the occurrence of a case the imme- 
diate contacts should be swabbed and carriers segregated from 
the others. 

Where overcrowding is unavoidable, as during mobilization, 
and where there is reason to suspect a high proportion of carriers 
among a particular body of troops, an attempt should be made 
to reduce the spread of infection among these men by the 
general use of some mild disinfectant. Various methods 



\Fee1- (Scafe +J 7 


2 


3 


Jnches 369 





3 6 9\ 


3690 


MM I 


\ 


\ iii; 


\ (Ml 


Beds /ess than 3 "apart. 
Carr,er Rate =30% or more 






i 

: 
: 

j 


Beds /ess than one foot apart'. 
Carrier Rate ~ 20% or more 


' 4* apart ( The usual distance in 
.".ten sfondard strictly observed) f?afe*3-l& 


Bees 2 '6 'apart (as m spacing out Calerham) Carrier Rate ** ut 


ia-'er 5% 


Beds 3 feet apart. Carrier Rate - under 2% 





CHART II. Relation of distance between edges of beds to carrier rate. 
Army plank beds 2 feet wide in ordinary barrack-rooms and huts under 
war conditions. 

are available for this purpose, such as gargling the throat 
and washing out the nose with a solution of 1 in 5,000 pot. 
permang. in normal saline, the solution being warmed before use. 
But where large numbers of men have to be dealt with, a 
trial should be made of inhaling rooms, the air of which is 
charged with some finely divided disinfectant, the atomizer 
being worked by steam or compressed air. The men are 
treated in batches, according to available space, remaining in 
the chamber from five to ten minutes, during which time they 
inhale vigorously through the nose. This treatment should be 
carried on daily and has the advantage of not interfering with 
training. The disinfectants used in these chambers are either 
chloramine T. or sulphate of zinc. Of these chloramine T. was 



170 



MEDICAL HISTORY OF THE WAR 



first used, but although the most active disinfectant in practice 
it was not well borne. In the later stages of the war zinc 
sulphate was used with satisfactory results. The strength of 
solution used was 2 per cent, in normal saline. Two forms of 
apparatus can be employed for this purpose : 

(a) A small portable spray, operated by steam generated 

by burning methylated spirit, called a Levick spray. 
Two instruments are necessary, one in operation 
while the other is being filled. One Levick spray 
charges the atmosphere of 1,000 cubic feet air 
space, which suffices for the treatment of 20 men 
at a time. 

(b) For larger inhaling rooms a special jet devised by 

Lieut. -Colonel T. G. M. Hine was found to give 
satisfactory results. This jet is operated by steam 
under pressure generated from a boiler outside, or 
compressed air when available may be employed. 

In employing these mechanical methods, it must always be 
borne in mind that abundance of fresh air is the most rapid 
method of freeing the throats of carriers from infection. 

It must be remembered also that every patient who has the 
disease is a carrier, and the mental hebetude or delirium which 
so frequently marks the disease increases the danger of infection 
from naso-pharyngeal discharges. Therefore all such patients 
should be strictly isolated and early diagnosis is of the first 
importance. 



BIBLIOGRAPHY. 

Adami . . . . War Story of the C.A.M.C. 

Anderson, McNee, Cases of Meningococcus Septi- 

Brown, Renshaw, cemia. 

McDonnell & Gray. 
Attlee . . . . Cerebro-Spinal Fever, notes on 

92 consecutive cases. 
Bourke, Abrahams Some clinical observations on 

& Rowland. Cerebro-spinal Fever. 



Brown 

Cleminson 
Compton 



Culpin 



Cerebro-spinal Meningitis. 



Xaso-pharyngeal conditions on 
meningococcus carriers. 

(1) Report on Cerebro-spinal 
Meningitis in the Dorset Mili- 
tary Area, March and July, 
1915. 

(2) Cerebro-spinal Fever in rela- 
tion to age susceptibility. 

The diagnosis of Abortive Cere- 
bro-spinal Meningitis. 



London, 1919, p. 68. 
Jl. of R.A.M.C., 

1917, Vol. xxix, 
p. 463. 

Lancet, 1918, Vol. i, 

p. 602. 
Jl. of R.A.M.C., 

1915, Vol. xxv, 
p. 633. 

Jl. of R.A.M.C., 

1916, Vol. xxvii. 
p. 744. 

B.M.J., 1918.. Vol. ii, 

p. 51. 
Jl. of R.A.M.C., 

1915, Vol. xxv, 

p. 546. 

Jl. of R.A.M.C., 

1918, Vol. xxxi, 
p. 241. 

B.M.J., 1916, Vol. i. 
p. 307. 






CEREBRO-SPINAL FEVER 



171 



1 X>pter 



Klliott & Kaye 
Kmbleton 



BIBLIOGRAPHY cont. 

. . (1) fitude de quelques germes 
isolesdu Rhinopharynx voisins 
du Meningococque. (Para- 
Meningococques.) 

(2) Diagnose et Traitement de 
la M6ningite Cerebro-spinale. 

(3) La Serotherapie anti-Menin- 
gococcique. 

. . A note on Purpura in Meningo- 
coccal Infection. 

.. Sphenoidal Empyema and 
Cerebro-spinal Fever. 



ibleton & Peters (1) Cerebro-spinal Fever and the 
Sphenoidal Sinus. 

(2) Cerebro-spinal Fever and the 

Sphenoidal Sinus, 
rley & Stewart . . Cerebro-spinal Fever. 



& Baker . . Cerebro-spinal Fever in the 
Navy at Portsmouth, 1916- 
1917. 

1 ) Bacteriological studies in the 
Pathology and Preventive 
Control of Cerebro-spinal 
Fever among the forces 
during 1915-1916. 
(2) Report on Cerebro-spinal 
Fever in the London District, 
December, 1915 to July, 1916. 
jr . . Mode of Infection, Means of 

Prevention and Specific Treat- 
ment of Epidemic Meningitis. 

. . Cerebro-spinal Fever Diagnosis 

and Treatment. 

& Gaskell . . Cerebro-spinal Fever 
skell . . . . Report from the Cerebro-spinal 

Fever laboratory, Cambridge. 

. . (1) Cases of Cerebro-spinal 
Fever definitely traceable to 
infection by a particular 
carrier. 

(2) "Spacing out " in the Preven- 
tion of Military Epidemics of 
Cerebro-spinal Fever. 

(3) Military overcrowding and 
the Meningococcus Carrier 
Rate. 

(4) The Cerebro-spinal Fever 
epidemic of 1917, at " X " 
Depot. 



Compt. Rend, de 
Soc. de Biol, 1909, 
1909, Vol. Ixvii, 
p. 74. 

Paris, 1918. 



Annales de 1'Insti- 

tut Pasteur, 1910, 

Vol. xxiv, p. 96. 
Quart. Jl. Med., 

1916-1917, Vol. x, 

p. 3jl. 
Proc. Roy. Soc. 

Med., 1919-1920. 

Vol. xiii. Path, 

Sec., p. 67. 
Jl. of R.A.M.C., 

1915, Vol. xxiv, 
p. 468. 

Lancet, 1915, Vol. i, 
p. 1078. 

Commonwealth of 
Australia Publica- 
tions, Melbourne, 

1916, No. 9. 
M.R.C. Report, 

No. 17, London, 
1918. 

M.R.C. Special 
Report Series 
No. 3, London, 
1917. 

Jl. of R.A.M.C., 

1917, Vol. xxviii, 
p. 113. 

Rockefeller Institu- 
tion for Medical 
Research, New 
York, 1917. 

B.M.J., 1915, Vol. i, 
p. 543. 

Cambridge, 1916. 

Jl. of R.A.M.C., 
1915, Vol. xxv, 
p. 286. 

Lancet, 1918, Vol. ii, 
p. 422. 



B.M.J., 1918, Vol. ii, 
p. 509. 



M.R.C., 
1918. 



London, 



Jl. of R.A.M.C.. 
1918, Vol. xxx, 
p. 23. 



172 



MEDICAL HISTORY OF THE WAR 



Gordon 
Gullan 
Hanes 
Herrick 



Hobhouse 

Horder 
Ker 

Lundie, Thomas, 

Fleming & Mac- 
lagan. 

Maclagan & Cooke. 



MacKarell 
Muir 

Nash 
Neave 

Netter 



Netter & Debre 
Osier 

Reece . . 



BIBLIOGRAPHY cont. 
Cerebro-spinal Fever. 



Clinical notes on Epidemic Cere- 
bro-spinal Meningitis with 
observations on treatment. 

The spinal fluid syndromes of 
Nonne and Froin and their 
diagnostic significance. 

(1) The intravenous serum treat- 
ment of Epidemic Cerebro- 
spinal Meningitis. 

(2) Early diagnosis and intra- 
venous serum treatment of 
epidemic Cerebro-spinal Men- 
ingitis. 

The Diagnosis of Cerebro-spinal 
Fever. 

Cerebro-spinal Fever. 

Serum sickness in Cerebro-spinal 
Meningitis. 

Cerebro-spinal Meningitis diag- 
nosis and prophylaxis. Its 
recognition and treatment. 

(1) The fulminating type of 
Cerebro-spinal Fever, patho- 
logy and cause of death. 

(2) Fulminating Cerebro-spinal 
Fever, prognosis and treatment 

Malignant endocarditis as a com- 
plication of Cerebro-spinal 
Fever. 

On the presence of meningococci 
in the skin petechiae in Cere- 
bro-spinal Fever. 

Cerebro-spinal Fever in connec- 
tion with the War. 

Notes on 73 cases of Cerebro- 
spinal Fever. 

Rechutes Tardives dans la Men- 
ingite Cerebro- Spin ale. 



La Meningite Cerebro-Spinale. 
Cerebro-spinal Fever in camps 
and barracks. 

(1) Anthrax simulating Cerebro- 
spinal Fever. 

(2) Notes on the prevalence of 
Cerebro-spinal Fever among 
the civil population of Eng- 
land and Wales during the last 
four months of 1914 and first 
six months of the year 1915, to- 
gether with a short account of 
the appearance of the disease 
and its distribution among 
troops in the British Isles, 
during the same period, and of 
the military administrative 
measures adopted to deal with 
the prevalence of the disease. 



M.R.C. Special 
Report Series No. 
50, London, 1920. 

B.M.J., 1915. Vol.i. 
p. 756. 

Amer. Jl. Med. 

Scien, 1916, vol. 

clii, p. 66. 
Arch, of Int. Med., 

1918, Vol. xxi, 

p. 541. 
Jl.~ Amer. Med. 

Ass., 1918. Vol. 

Ixxi, p. 612. 

B.M.J., 1915. Vol. i. 

p. 419. 

London, 1915. 
Lancet, 1917. Vol. ii, 

p. 822 
B.M.J., 1915. Vol. i, 

pp. 466, 493, 628, 

836. 
B.M.J., 1916. Vol. ii, 

p. 869. 

JUofR.A.M.C., 1917. 

Vol. xxix, p. 228. 
Jl.ofR.A.M.C.,1915. 

Vol. xxv, p. 353. 

JLofR.A.M.C.,1919. 
Vol. xxxiii, p. 404. 

Lancet, 1917. Vol. i, 

p. 968. 
Lancet, 1917. Vol. i, 

p. 219. 
Bull, et M6m, Soc. 

Med. des H6p.. 

Paris, 1918.Vol.xlii, 

3 e serie. p. 527. 
Paris, 1911. 
B.M.J., 1915. Vol. i, 

p. 189. 
Lancet, 1917. Vol. i, 

p. 406. 
Jl.ofR.A.M.C.,1915. 

Vol. xxiv, p. 555. 



CEREBRO-SPINAL FEVER 



173 



Rollcston 



ton 

Scott 

Sophian 

Symmers 

Symonds 
Weakely 

Wilson, Puree 

& Darling. 

Worster-Drought 



Worster-Drought 
Kennedy. 



BIBLIOGRAPHY cow*. 

(3) Cerebro-spinal Fever. 



(1) The Treatment of Cerebro- 
spinal Fever in the Royal 
Navy. 

(2) Cases of Cerebro-spinal 
Fever in the Royal Navy, 1st 
August, 1916, to 31st July, 
1917. 

(3) Lumleian Lectures on Cere- 
bro-spinal Fever. 

(4) Serum Disease after intra- 
thecal injections of serum. 

(5) Cases of Cerebro-spinal 
Fever in the Royal Navy, 1st 
August, 1915, to 31st July, 
1916. 

Epilepsie Consecutive a la M6n- 
ingite Cer6bro-Spinale. 



Meningitis with absence of cere- 
bral symptoms. 

Epidemic Cerebro-spinal Menin- 
gitis. 

Case of fulminating Cerebro- 
spinal Fever without Meningi- 
tis. 

The pre-meningitic rash of Cere- 
bro-spinal Fever. 

Metastatic endophthalmitis in a 
case of Cerebro-spinal Menin- 
gitis. 

Certain points observed with re- 
gard to Cerebro-spinal Fever 
in the Belfast District. 

(1) Observations on the Treat- 
ment of Cerebro-spinal Fever. 

(2) The nervous sequels of 
Cerebro-spinal Fever. 

(1) The relation of the type of 
coccus to the type of disease 
in meningococcal Meningitis. 

(2) Cerebro-spinal Fever. 



Report of the 
Medical Officer 
Local Govern- 
ment Board, 
1917-18, 1918-19. 

Lancet, 1915. Vol.ii, 
... 909. 

Lancet, 1918. Vol. i, 
p. 87. 



B.M.J., 1919. Vol. i, 
pp. 406, 536, 573. 

Lancet, 1917. Vol. ii, 
p. 821. 

Lancet, 1917. Vol. i. 
p. 54. 



Bull, et M6m, Soc. 

Med. des H6p.. 

Paris, 1918. 

Vol. xlii, 3 e serie 

p. 368. 
Jl.ofRj\.M.C.,1916. 

Vol. xxvi, p. 394. 
London, 1913. 

B.M.J.. 1917. Vol. ii, 
p. 789. 

Lancet, 1917. Vol. ii, 

p. 86. 

B.M.J., 1916. Vol. i, 
p. 47. 

B.M. J., 1916. Vol. ii, 
p. 900. 

B.M. J., 1916. Vol. ii, 

p. 689. 
Lancet, 1918. Vol. ii, 

p. 39. 
B.M.J., 1917. Vol. i, 

p. 261. 

London, 1919. 



CHAPTER VII. 

INFLUENZA. 

ORDINARY influenza was never absent from the various 
army commands in the United Kingdom during the war. 
In 1916 there had been 36,072 admissions and in 1917, 28,980 
admissions, the incidence in those years tending to be rather 
higher in the winter than in the summer. In 1918 the figures 
were about normal, until in June there was suddenly a great 
increase, as shown in the following table : 



Month. 


Admissions. 


Month. 


Admissions. 


January, 1918 


3,158 


January, 1919 


4,547 


February 


2,356 


February 


13,752 


March 


3,483 


March 


7,709 


April 


2,306 


April 


2,954 


May 


4,737 


May ,, .. 


1,017 


June 


31,138 


June 


416 


July 


25,480 


July . . 


381 


August 


3,358 


August 


281 


September 


2,738 


September ,, 


365 


October 


30,097 






November 


23,021 






December 


6,910 







In France the disease began by a few local outbreaks in the 
First and Second Armies in April and May 1918. It appeared 
both in Rouen and Wimereux in April. At the end of May it 
reappeared with great violence in the Second Army, spread 
apparently a little later in the First and Third, and in the 
Fourth Army from about the end of June. 

The numbers affected were very great. The Second Army 
admitted to its casualty clearing stations 1,921 cases during the 
weekending 12th June, and 3,851 cases during the week ending 
19th June. From 25th June the rate fell rapidly and by the 
middle of August it had sunk to 50 daily. The First Army 
admitted 36,473 cases to its casualty clearing stations between 
18th May and 2nd July. The Fourth Army admitted to 
casualty clearing stations during the week ending 1st July 
2,705 cases, and 3,480 cases during the week ending Sthjuly. 

This epidemic died down in August, though perhaps it did 
not wholly disappear. At the end of September the disease 
began to spread again. 

174 



INFLUENZA 



175 



On 5th October 1918, the disease was made notifiable in the 
British Armies in France, and the numbers for the succeeding 
weeks during 1918-19 were as follows : 



Week ending 


Admis- 
sions. 


Deaths. 


Week ending 


Admis- 

MODS. 


Deaths. 


Oct. 12th 


1,776 





Dec. 28th 


2,579 


73 


Oct. 19th 


3,080 


2 


Jan. 4th 


2,768 


34 


Oct. 26th 


9,280 


314 


Jan. llth 


2,195 


32 


Nov. 2nd 


13,203 


701 


Jan. 18th 


1,888 


33 


Nov. 9th 


11,877 


878 


Jan. 25th 1,563 


40 


Nov. 16th 


7,389 


689 


Feb. 1st 2,354 


69 


Nov. 23rd 


8,008 


546 


Feb. 8th 


3,074 


104 


Nov. 30th 


8,206 


526 


Feb. 15th 


4,011 


144 


Dec. 7th 


7,087 


412 


Feb. 22nd 


5,768 


212 


Dec. 14th 


6,033 


213 


Mar. 1st 


3,502 


200 


Dec. 21st 


3,919 


121 


Mar. 8th 


2,714 


140 



The acme of incidence was in the week ending 2nd November, 
1918 ; the acme of mortality was, as might be expected, a week 
later. But a curious difference is found at the end of January, 
when the mortality began to rise before the incidence. The 
fatality cannot be calculated weekly, as the cases dying in any 
given week are largely composed of cases admitted before that 
week began. On the total it is almost 5 per cent, of the cases 
admitted, 112,274 admissions to 5,483 deaths. 

The same curve with three waves, in June and November 
1918, and February 1919, was reproduced in the figures for 
the civil populations of Copenhagen and London, and for 
the troops in the United Kingdom. 

The disease was world-wide, and its course seemed to be from 
west to east. It prevailed in America in 1917. In 1918 the 
first European epidemic on a large scale took place in Spain in 
May. It invaded France, Italy and Germany, and weakened 
the effective strength not only of the Allied but of the German 
Armies as well. It was rife in Macedonia and Egypt. It 
caused great mortality in India, and in the late summer was 
very severe in South Africa, where monkeys and baboons are 
said to have died of it. 

In Mesopotamia, 100 cases of a three-day fever were reported 
at the end of J<me in a batch of men returning from leave in 
India. The fever so closely resembled sand-fly fever, which was 
prevalent, that for several weeks medical officers could not be 
persuaded that the new disease was anything else. By the 
middle of July it had spread up to the front and was evidently 
very contagious. On 6th August, orders were issued to return 
the new epidemic as influenza. No accurate figures are avail- 



176 MEDICAL HISTORY OF THE WAR 

able for July, but in August and September 1918 there were 
admitted to hospital a total of 8,026 cases, of whom 3,337 were 
British and 4,689 Indians. These figures, however, give little 
idea of the extent of the epidemic, as the majority of cases 
were treated in unit lines. It caused a great increase in the 
admission rate and it swelled the death rate, though it had 
little or no effect in increasing wastage by invaliding. In 
October its severity was increasing, and it reached its acme in 
the second week of October. During the last quarter of the 
year there were 16,961 admissions to hospitals, equal to 41 
per 1,000 of strength, the British showing a higher admission 
rate, 79 per 1,000, than the Indians, 28 per 1,000, but the 
Indian admission rate and case mortality for pneumonia 
were much higher than the British. The mortality for 
influenza, allowing for many deaths recorded as pneumonia, 
was reckoned at 6' 5 per cent, of cases in this quarter of the 
year. Thereafter the numbers fell gradually until in April 
1919 they became negligible. TJiere was no such re- 
crudescence of the epidemic in the first quarter of 1919 as 
occurred in England and France. 

It was noted in England, Germany and elsewhere that mor- 
tality was specially great between the ages of 25 and 40. 

The disease was extremely infectious. In an army school, 
320 strong, 90 men, and in a labour company 520 strong, 140 
men, were found ill at one visit. A brigade of artillery lost a 
third of its strength in 48 hours, and in a brigade ammunition 
column on one day only 15 out of 145 men were fit for duty. 

Symptoms amongst Troops in the United Kingdom. 

The epidemic in England may be subdivided into two parts, 
both acute and widespread, but quite distinct in clinical type 
and mortality, namely : 

(1) The acute and very widespread " three-day fever " 

epidemic of June- July, 1918, with very few 
fatalities. 

(2) The severe " pneumonic " type of the winter of 1918- 

1919, with a considerable mortality from pulmonary 
complications. 

During the summer epidemic the first case of influenza would 
occur in the midst of perfect health in a circumscribed com- 
munity, such as a barracks or a school, and within the next 
few hours -or days a large proportion, occasionally even every 
single individual of that community, would be stricken with the 
same type of febrile illness. The patient would be seized 
rapidly, or almost suddenly, with a sense of such prostration as 



INFLUENZA 177 

to be utterly unable to carry on ; he would be obliged to lie 
down where he was, or crawl with difficulty back to bed, so that 
barrack rooms which the day before had been full of bustle and 
life would now be converted wholesale into one great sick room. 
The hospitals were, within a day or two, so overfull that 
fresh admissions were impossible and the remainder of the sick 
had to be nursed and treated where they were. 

The men's temperatures were raised to varying heights, 
generally about 103 or 104 F. ; the pulse rates were less 
raised in proportion ; the tongue was coated, the face flushed, 
and the eyelids a little drooped as though the patient were but 
half awake. There was often huskiness of the voice, the throat 
was sore, and there was some frothy expectoration from 
the pharynx and larynx. There was some reddening of the 
fauces and pharynx, and in some cases the tonsils, besides being 
reddened, looked swollen and enlarged, and there might be 
tenderness on either side of the upper part of the neck below 
and behind the angle of the jaw, suggesting that the lymphatic 
glands here were inflamed too, though palpable glandular en- 
largement was not as a rule found. Headache, made worse by 
a change of posture or by the effort of coughing, was prevalent. 

Thus lassitude and general aching, with fever, a coated tongue, 
loss of appetite, soreness of the throat, huskiness of the voice, 
and headache were the main symptoms. 

Most patients slept well and asked simply for water and 
cooling drinks. The temperature in many was already coming 
down to normal at the end of the second day, and in most it had 
become normal at the end of the third day, and remained so 
thereafter. The patient by this time was feeling almost himself 
again, asking for food, wishing to get up, and complaining of 
little more than some remains of soreness of the throat and 
perhaps some huskiness of voice. Convalescence was rapid 
and the great majority of the patients were fit for their ordinary 
work again by the end of the week. 

There was practically no mortality. 

There was no albuminuria ; no special tendency to infection 
of the accessory nasal sinuses ; indeed no tendency to any 
particular complication at all. Hundreds of cases ran very 
much the same course, and " three-day influenza " was the 
popular name generally given to the disease. 

Contrasted with this extensive and acute but non-fatal out- 
break of the summer of 1918, the world-wide " plague " of 
influenza of the following autumn and winter, with its millions 
of deaths, presented very different clinical characters. Those 
who had experienced the minor epidemics of " purulent 
bronchitis with heliotrope cyanosis and fatal ending" that 

(2396) M 



178 MEDICAL HISTORY OF THE WAR 

had occurred here and there in military camps in America, 
England and France during 1916 and 1917, had already 
become familiar with some of the worst features, especially the 
dreaded blueness of what was probably the same malady 
under a different name ; but now it was a question of seeing 
hundreds of cases in districts in which the fatal " purulent 
bronchitis " had affected but a few. 

Nevertheless, it is important to emphasize the fact that these 
fatal " pneumonic " cases constituted but a minority of the 
whole. There were far more cases of ordinary typical benign 
influenza than there were of " influenza! pneumonia." 
Broadly speaking, out of 1,000 individuals stricken by the 
disease fully 800 had no more than an ordinary attack of un- 
complicated " influenza," a little more severe perhaps than 
the " three-day fever " of June 1918, but not any worse than 
simple influenza as it may occur at any other time. In the 
remaining 200, " pneumonic " symptoms were added to those 
of simple influenza, and of these about 80 died. The most 
ominous symptom was the heliotrope cyanosis. It developed 
in less than half of the pulmonary cases, but once it became 
definite the prognosis was so bad that out of every 100 " blue " 
cases about 95 died. 

Even the mildest case had to be regarded as potentially 
grave ; no matter how benign the illness might appear to be at 
first, the pulmonary complications and cyanosis might 
set in without any notice at all. A patient might have 
been ill a day or two with mild influenza and seem to be progress- 
ing well ; in an hour or two the whole picture might change, and 
twenty-four hours later the patient might be dead. During the 
epidemic itself, therefore, every case had to be regarded as in 
grave danger. It is only on looking back that the two great 
classes 800 out of every 1,000 mild and ordinary ; 200 out of 
every 1,000 severe, pulmonary, grave emerge clearly into 
view. 

In these latter, although the pulmonary complications were 
spoken of as " pneumonia," the one thing they hardly ever 
showed was ordinary croupous lobar pneumonia in the recog- 
nized sense of the term. Although the occurrence of dullness, 
bronchial breathing, bronchophony, pectoriloquy and crackling 
rales over the greater part or whole of one lobe was frequent 
enough to make those who saw no autopsies believe that there 
was real lobar pneumonia present, yet it was only in exceptional 
cases that croupous lobar pneumonia was found post-mortem. 
The " pneumonia " was an acute infective pulmonary 
inflammation in which such consolidation as resulted was 
due, not to croupous lobar pneumonia of the classical sort, 









INFLUENZA 179 

but to a conglomeration of changes which included bronchitis 
and peribronchitis, coagulative oedema, haemorrhage, collapse, 
broncho-pneumonia, abscess formation and compression by 
pleuritic effusion, totally different from anything ordinarily 
seen in the post-mortem room. Hence, in speaking of these 
cases as " pneumonic," it must be emphasized that the pul- 
monary inflammations implied were those peculiar to the 
epidemic, and not just croupous lobar pneumonia complicating 
influenza. 

The " pneumonic " complications would develop at any 
period of the influenzal attack. In most cases the patient had 
been ill for a day or two with ordinary simple influenza, not 
necessarily more severe than that of his neighbours, when there 
was a rapid or sudden change for the worse, and the picture 
changed to that of severe disease of the lungs. The effects of 
the pulmonary changes were often so fulminating that death 
might ensue in 24, 36 or 48 hours, in such a way as to suggest 
that it was due not to the lung lesions themselves but rather 
to a generalised and very virulent microbic toxaemia, or actual 
septicaemia. 

On the other hand there was often no preliminary " influen- 
zal " period at all, the patient being attacked from the start in 
such a way that ordinary lobar pneumonia of virulent or even 
ultra-virulent type would have been the most likely diagnosis, 
if the case had occurred singly and not in such an epidemic. 

Again, the pulmonary complications were often later in their 
development, yet equally fatal. The patient might have had 
no symptoms other than those of ordinary influenza for nearly 
a week ; his temperature might be falling steadily, or might 
have become normal, so that danger might be regarded as past, 
and yet the " pneumonic " complications might set in and carry 
off a man who seemed almost convalescent. 

Less often, and yet not infrequently, the patient might be 
apparently quite convalescent from " influenza," ready to be 
discharged from hospital, and yet go down with " pneumonic " 
symptoms and die. 

All types were seen in abundance the initial, the early, the 
later, and the latest. 

At whatever s.tage the pulmonary complications set in the 
patient generally began to complain of pain in some part of his 
chest. In practically every case there was also cough, not 
always severe, but sometimes in itself distressing, short, dry 
and hacking to begin with, looser and associated with frothy, 
blood-stained or purulent sputum within a few hours, or on the 
following day. Towards the end of a severe case coughing and 
expectoration would be entirely absent from sheer weakness of 



180 MEDICAL HISTORY OF THE WAR 

the sufferer and inability to cough at all. The rate of breathing 
became accelerated out of all proportion to the physical signs ; 
in the worst cases the respiration rate would rise to 40, 50, or 
even 60 to the minute, and yet without any particular evidence 
of respiratory distress. Orthopncea was exceptional, and 
although the patients were breathing so rapidly they seldom, if 
ever, complained of actual difficulty ; it was rather a polypncea 
or tachypnoea, than a true dyspnoea. The condition of the 
skin was not constant ; it might be hot, dry, and pungent as in 
ordinary lobar pneumonia ; quite as often the whole of the 
patient's body and limbs would be covered with profuse perspi- 
ration, the latter often resulting in sudamina and miliaria. A 
rigor might occur at the onset of the pulmonary complication, 
but more often there was nothing in the way of a definite rigor 
to attract notice, though the temperature, already raised, might 
rise higher. 

The pulse rate, though raised, was seldom unduly rapid, and 
it was a remarkable feature of a great majority of the cases that 
the condition of the pulse remained good almost to the very last, 
failing only in articulo mortis. 

The physical signs varied widely, and as a general rule were 
remarkable by their paucity. There might be a few scattered 
rhonchi over the front of the chest and over the upper part of 
the back, with a few rales lower down, or there might be little 
more than deficient vesicular murmur at one or other base. 
Again there might be a patch or two of consonating rales, or even 
definite bronchial breathing over a considerable area of a lower 
lobe, and yet later, on the same day, these signs might disappear 
entirely. Pleural friction, most often at the back or in the 
axilla, was heard in a large number of cases. The extent, 
however, of the physical signs bore little relation to the degree of 
illness of the patient, or to his cyanosis. A man might be of 
heliotrope colour with hardly any lung signs, or he might have 
signs of consolidation of both lower lobes and not be blue at all. 
Subcutaneous emphysema of the chest wall was occasionally 
seen, and was of bad omen. On the other hand, not a single case 
of spontaneous pneumothorax was observed. 

Herpes facialis occurred, sometimes in a very severe form. 
Herpes of the pinnae was several times seen. A localized 
purpuric eruption on the legs was sometimes found, and in two 
cases this was followed by haemorrhagic bull as with oedema, 
which subsequently ulcerated. Both these patients died. 
Erythematous areas were occasionally seen. 

Epistaxis was strikingly common at the onset. Haemoptysis 
was also common. Haematemesis was many times observed, 
sometimes no doubt from swallowed blood, but occasionally 



.lly 



0) 

~^ 

JS2 

OH 




C ""O .~ m 

~ c -o 

it ill 

"=3 T & 5 

g ^ & J 
.2 * "^ 

* 'Z *- * S 
D o o Q. 

5 o S a 

g -2 oo j 

8 - . -T3 
^ -. -g) g- 

- -s 'i 2 -S 



frJI-i 



J! 1 :> 

c oc 







lliJ 

B 8 i 



I-M 



11 j 

5 .2 a " 
2 j .n .2 

1 ' 1 -s 

11 = 

" -5 -a'B 




J H * 

o 





S 



* c -is 

/5 " 

S .< 1 -6 

i: o "~~ .S v. 

J -S =2 



H - 



S SJ 



co " O, 

i :^ 

i -c f i 

CO ~- l^ 



INFLUENZA 181 

without doubt originating in the stomach itself. The prognosis 
was not necessarily bad. 

The facies, at first flushed and red, with a peculiar drooping 
of the eyelids giving a weary look, shown in Plate IV, Fig. I, 
might remain purely red throughout, but in a large number of 
the cases affected by the pulmonary complications the red tint 
rapidly changed to one of progressive cyanosis, such as is 
depicted in the plates (Plate IV, Figs. 2 and 3). When 
this heliotrope cyanosis appeared the prognosis was altered 
so completely that a fatal ending was regarded as almost 
inevitable. A small percentage of cases recovered, even 
after the cyanosis had developed, but the great majority 
succumbed, and it was among cases of this type that 
the great mortality of the epidemic occurred. There were, 
of course, cases which died without the cyanosis being pro- 
nounced, but in going round a large ward one could, without 
examining the patients at all beyond looking at their coun- 
tenances, pick out those who were going to die with almost 
uniform certainty by reason of their colour alone. The cyanotic 
tint might be definite in a patient who was complaining little,was 
taking his liquid nourishment well, intelligently interested in his 
surroundings, answering questions promptly and clearly, and in 
fact without any indication, except his colour, that by the next 
day or the day after he would almost certainly be dead. 

The drawings reproduced in Plate IV were taken from rather 
extreme cases, and very often the degree of fatal heliotrope 
cyanosis fell a long way short of that depicted. Whatever 
the degree of cyanosis, however, it rendered the prognosis bad. 

In some the cyanosis might be well marked before the 
patient had been ill twenty-four hours, and death occurred in 
some instances within this time. In others the duration might 
be forty-eight hours. In others again, the lividity came on 
more gradually and the patient might remain alive for three, 
four, or five days, or even for a week, breathing 50 or 60 to the 
minute, not unconscious, not subjectively distressed, though 
objectively a dreadful picture ; but in over 90 per cent, of all 
the cases in which the cyanosis developed the course was 
progressively downhill towards death, the latter being preceded 
in many instances by delirium of a low type, associated 
with unconsciousness, though in some, on the other hand, 
consciousness was retained almost, if not quite, to the very last. 

For a long time the nature and causation of this peculiar 
heliotrope cyanosis was obscure. It was certainly not due to 
cardiac or circulatory failure, for the condition of the heart and 
pulse remained strikingly good. At one time it was thought 
that there might be some peculiar chemical change in the blood 

(-2396) M 



182 



MEDICAL HISTORY OF THE WAR 



leading to the formation of methaemoglobin, or even sulph- 
haemoglobin, but repeated spectroscopic examination showed 
no abnormal blood pigment to be present. Microscopical 
sections of the lungs, however, in which coagulative exudation 
both into the alveoli and into the interstitial tissues was often 
a very pronounced feature, showed that this albuminous exudate 
quite different from that seen in ordinary pneumonic cases 
was the probable cause of the cyanosis. The appearances in 
some lung sections were very similar to those of the profuse 
exudate that results from gassing, and layers of this albuminous 
fluid coming between the inspired air and the blood capillaries 
would necessarily interfere with the absorption of oxygen by 
the latter, and cause an extreme degree of anoxaemia. This 
was the generally accepted explanation of the condition. 

The temperature was very variable. The ten charts indicate 
this. Five are from cases which recovered and five from 
cases which died. Sometimes the temperature dropped rapidly 
with speedy recovery, as in Chart I ; but Chart VI shows that 
the temperature may seem to be falling comfortably by lysis 
and yet the patient may die. Chart II shows termination of the 
illness by crisis with recovery ; Chart VII a similar sudden fall of 
the temperature followed by death ; Chart III a fall by lysis 



INflUEriiA 




CHART I. 




CHART II. 



INFLUENZA 



183 




CHART III. 





d^bu'KlTjia. 






ii (|.;^.;M 


V, 





=E 











asc 




M * 


i : ' -- : 








: ' Sffi 


r 
















ws* 


Ste 






: -: : i-: j 










-: ) 


p 


















-> i -. 


; j 




! ' ! ' 






































A - 













































. ! - : 1 '. j 






























I . 


- 




-:![!-;!/ 


fflEJ 






.' I 






















1 


/ 




J^ ! : \L 


BH 




































T : --\-\- 


SB 


| K 


fe 
























*~i 




* 




-..i ! : Tiy .: 


. 4 







i 
























K 


^ : 







* 




















,,,; 










n * 




IS 


~TfT 















































CHART IV. 




CHART V. 





Mi: 



w^- 



CHART VI. 



184 



MEDICAL HISTORY OF THE WAR 





t 


^ 


L.I^. 




V. 2, 






MF 


Uf 


S]LC 


-p 


<c\ 


n c 


K\- 


S 


TT 


ctU 


v.\ 




T) 


AT^, 


lot- 

Wi- 
ll*- 

09- 

X~* 

08* - 

nj~ J 

*~r ', 




- 


















- : k 
































/ 




















































" 




























; 


































f 














































^ 


% 


/V 


i 


, 




* 


i 






































5 












/ 


i 


^ 








































' 












[ 












































- 










































































































| :" 










^ 





















































































































CHART VII. 




CHART VIII. 







m 



CHART IX. 




CHART X. 



INFLUENZA 185 

prolonged by irregular persistence for several days, ending in 
recovery ; Chart IX a fall by lysis in a severe case that seemed to 
be doing well, with subsequent rapid rise and death. Chart X 
shows a rapid fall on the third day of the disease as though the 
patient had terminated his illness by crisis, but the pyrexia 
rose again by steps to a second maximum about the tenth day, 
when a second apparent crisis occurred, and yet the illness 
continued, pyrexia recurring after the second apparent crisis and 
terminating in death. While all varieties occurred, definite 
termination by crisis and recovery, as shown in Chart II, was 
very rare indeed. On the whole the temperature chart was of 
little use for prognosis. 

The respiration rate was a much more helpful guide than 
was the pyrexia. The rapidity of breathing in the fatal cases 
was even greater than that in ordinary lobar pneumonia. 
Rates that were nearer 40 than 30 to the minute were very 
common, but in the worst cases the rapidity of breathing was 
generally over 40 and often 50 or even 60 to the minute, and 
this sometimes before the fatal cyanosis became evident. 

The sputum was very variable. Some cases had hardly any 
sputum at all. Sometimes there was nothing but pure froth ; 
again there might be froth only with some bouts of coughing, 
and nummular pellets of muco-pus at other times in the same 
patient ; or the sputum might be glairy and mucoid, or stringy, 
or simply purulent. Again it might be tinged with blood 
streaks, or pure clotted blood might be coughed up separately, 
or there might be liquid red blood expectorated in a way 
recalling a moderate haemoptysis from phthisis. Or the more 
purulent type of sputum might be tinged red or brown with 
altered blood, or it might be definitely glairy rusty sputum like 
that of ordinary lobar pneumonia. No conclusion could be 
drawn from the appearances of the latter as to what degree of 
the malady the patient had. 

No ulceration of the stomach was found in fatal cases, but 
acute congestion was common. Bleeding per rectum was rare. 
A number of cases of spontaneous rupture of one or both recti 
abdominis muscles was met with, and in a still larger number 
this muscle was found at autopsy to be in a haemorrhagic 
necrotic state, such as precedes rupture. Almost invariably 
this lesion had affected only that part of the muscle which is 
below the umbilicus. 

Delirium and coma occurred in bad cases, but more striking 
was the number of cases in which they were entirely absent. 
Big, strong men, cyanotic, breathing 30 to the minute and 
obviously dying, would be fully conscious and would talk 
rationally, not realizing their danger in the least, to within 



186 MEDICAL HISTORY OF THE WAR 

half an hour of death. Subsultus tendinum was marked in 
many cases and was usually of bad prognosis. 

Acute meningitis due to one of the infecting organisms found 
in other organs, B. influenza, diplo-, strepto-, or pneumococcus, 
occurred in a small number of cases. Acute otitis media with 
otorrhoea was rare, though temporary deafness and pain 
suggesting this condition were not uncommon. Of special im- 
portance in relation to the local pain behind the eyes frequently 
noted during the attack, and perhaps to the headaches which 
in some patients persist long after the acute illness, is the 
condition of the ethmoidal and sphenoidal sinuses described 
under the heading of morbid anatomy. 

Albuminuria was common, and since in a total of over 100 
autopsies there was no instance in which the kidneys were not 
definitely inflamed, the inference is that some at least of the 
albuminuric cases which survived had some degree of nephritis 
also. The number of cases in which permanent lesion has 
resulted is not yet known. 

Jaundice was uncommon. Its degree and type were similar 
to those of the ordinary catarrhal form. 

Unilateral or bilateral parotitis was not uncommon. It was 
exceptional for suppuration to occur. 

Panophthalmitis was seen twice. 

Pericarditis was occasionally reported. Endocarditis was not 
observed during the epidemic, nor was it seen at any autopsy, 
but it is noteworthy that throughout the year 1919 it was 
common to meet with cases of the chronic type of infective 
endocarditis whose origin was obscure. 

Symptoms amongst Troops in the Field. 

The incubation period lasted from two to four days according 
to various observers. 

In the summer epidemic the onset was in most cases sudden. 
In a small minority it began gradually and reached its height 
within six hours. Rigors occurred in many cases. The initial 
symptoms were headache, pains in the back and limbs, and a 
feeling of weakness. In a report by Major Scarisbrick on 
440 cases, the following relative frequency in the sites of pain 
was noted : 

Pains in the head occurred in 73 per cent, 
back 45 

eyes 43 

limb muscles ,, 41 
knees 32 

hips 22 

ankles and shoulders rarely. 



INFLUENZA 187 

Pains in the head and eyes, and pains in the back and muscles 
of the limbs were associated respectively. The pains were of 
a severe aching character. That in the head was referred 
usually to the frontal sinuses, that in the eyes to the back of 
the globe. 

These initial symptoms lasted as a rule for two or three days ; 
the temperature commonly reached its height on the first, but 
sometimes on the second day. The highest level was usually 
between 102 and 103 F., but 105 has been noticed. In some 
cases the temperature never rose above 100. It usually fell 
by lysis, but in a small minority a fall of three or four degrees 
was completed in twenty-four hours. In the First Army's 
Report of 18th June, the disease was called " three days' fever," 
and it was stated that the great majority of the patients were 
fit for duty in a week. But a week or two later it was 
found that many cases remained febrile till the sixth day. The 
pulse was rapid during the first two days, though it seldom 
reached 120, but was usually between 70 and 80 by the fourth 
day. At first there were hardly any other symptoms. On 
12th June, Colonel Soltau, the consulting physician of the 
Second Army, reported : 

' There has been a remarkable absence of physical signs. In 
no case has the spleen been enlarged, nor has there been any 
rash. Rarely has anything abnormal been heard in the lungs, 
nor has there been any increase above the usual in the number 
of cases of broncho-pneumonia under treatment." 

But a fortnight later he found that there had been an increase 
both in incidence and virulence, and mentioned the prevalence 
of pharyngitis with a tendency to spread down the respiratory 
tract. 

Several symptoms of less importance were noticed. In some 
cases a rash was observed, usually of a mixed urticarial and 
erythematous character, principally seen on the neck, the 
shoulders, the wrists and the dorsum of the feet. This was 
noted also in Italy by Morelli, and in Germany. Labial herpes 
was sometimes seen, and became more common as pulmonary 
complications increased. Conjunctivitis and coryza were re- 
ported by several medical officers. Enlargement of the spleen 
was found occasionally during life, and has been reported post- 
mortem. The tongue, except for a clear marginal zone, was 
usually covered with a slight fur. This was grey or white, 
according to its degree, but the yellow or brown fur common 
in trench fever seems to have been rare. Anorexia was common. 
Loss of taste and loss of smell were observed. Vomiting was 
common in the first day or two, diarrhoea less frequent. At 
the commencement of the epidemic in May, several localized 



188 MEDICAL HISTORY OF THE WAR 

outbreaks were ushered in by vomiting and tenesmus in a 
majority of the cases. 

Colonel W. E. Hume and Captain Todd at No. 42 Casualty 
Clearing Station noted the following relative incidence of 
symptoms : 

Headache and general muscular 

pain 76 per cent. 



pain . . . . . . . . /t> 

Shivering or definite rigors . . 41 

Suffused eyes . . . . . . 78 

Pharyngitis 100 

Furred tongue . . . . . . 100 

Constipation 52 

Spleen palpable 14 



In the earlier stages of the epidemic recovery was remarkably 
rapid, and convalescence was established without any sequelae. 
The mental depression often associated in previous epidemics 
with a post-influenzal state was very rarely seen. 

Towards the end of June 1918, however, the disease gradually 
became rather more severe. A short relapse of fever and 
symptoms about the seventh day began to occur and grew more 
frequent. Bronchitis, broncho-pneumonia, and lobar pneumonia 
began to appear. The two former were severe and prolonged, 
with a high irregular temperature, a rapid pulse, dyspnoea and 
cyanosis. The sputum was often of the green nummular variety. 
The few cases which resembled lobar pneumonia showed a more 
regular fever, but frequently terminated by lysis. Many cases 
proved fatal. 

Pleurisy and pleura! effusion occasionally occurred, and in 
one or two cases an inter-lobar empyema was found in which 
the B. influenza was the only infection. 

A very few cases of pericarditis and suppurative otitis were 
noticed, but the chief complications after the pulmonary were 
albuminuria and nephritis. In some of the cases of nephritis, 
according to Symonds, a profoundly toxic condition super- 
vened, with which were associated a dry, black tongue, 
pronounced mental symptoms, and a grey lividity of the face. 

A rare complication was meningitis both of brain and cord, 
in which the B. influenza was found. In a few cases presenting 
similar symptoms, the cerebro-spinal fluid was found to be 
considerably increased, but to be sterile. 

This wave of the epidemic died down at the end of July 1918. 

The autumn epidemic which began at the end of September 
of the same year differed from that of the summer, chiefly in 
the increased proportion of pulmonary cases. Purulent 
bronchitis, broncho-pneumonia and acute pneumonia of the 



INFLUENZA 189 

lobar type were all present. The temperature charts varied 
much. Some, and these were the most favourable, showed 
a high and level pyrexia falling by crisis as in pneumonia. 
Others with a similar high level fell by lysis. In others the 
temperature though high was irregular from the first. The 
two latter classes varied much in the duration of the primary 
fever. It sometimes fell at the end of a week, in other cases it 
persisted for three weeks or more. Some remained febrile for 
even six weeks. But the worst feature was the tendency 
to relapse. The fever would fall to normal and remain so 
for some days, and then, without any external cause, would 
rise again to its former height. A patient might recover from 
two such bouts and die in the third. 

It was often possible at the time of the relapse to discover 
that a fresh part of the lung had been invaded, or that consoli- 
dation had taken place in a part where formerly only rales had 
been heard. But in other cases it was impossible to obtain 
any physical explanation of the recurrence of fever. 

Even when the temperature fell and remained low, the lungs 
remained affected for a long time. The patient appeared to 
have no power to absorb the exudation or to recover his normal 
condition. It seemed that the infecting microbes had overcome 
his power to resist them. Many men died several days after 
their fever had subsided, and in nearly all it took many weeks 
before the lungs were free from signs of disease. 

In many cases the patient was admitted in a state of cyanosis, 
which was not accounted for by the physical examination of the 
lungs. In some cases death occurred within the first few days, 
and while cases were described in which the post-mortem appear- 
ances showed little amiss, most of them showed extreme con- 
gestion, with a large amount of oedema fluid in the tubes and 
in the parenchyma. It may be said in general that the cyanosis 
was such as is hardly ever seen in ordinary hospital practice. 
Entering a ward, one might see six or eight of these cyanotic 
cases, some heliotrope, as it has been well called, others really 
purple, yet not appearing as much distressed in their breathing 
as might be expected from their colour. The opinion was 
expressed by some that such cases never recover. This was 
not true, yet no doubt on the whole it was a most 
unfavourable sign. 

The explanation of this cyanosis was not easy. There was 
not in these cases such failure of the circulation as would account 
for it. In some instances the same may be truly said of the 
state of the lungs. The condition of congestion with oedema 
seen in others recalled phosgene poisoning, in which cyanosis 
is common. 



190 MEDICAL HISTORY OF THE WAR 

The sputum was sometimes mucous, often purulent and 
nummular, often rusty. Not infrequently there was haemop- 
tysis like that of phthisis. Sometimes, on the other hand, there 
was little or no sputum. 

The pulse in these cases was usually rapid for many days, and 
in some remained rapid after convalescence. The tongue, 
which in the early epidemic was almost always moist, became 
in bad cases dry and brown like the tongue of typhoid. Such 
patients fed badly, but many who fed well died. Indeed, one 
was struck by the fact that many died who almost up to the 
last ate well, slept well, and were in full command of their 
senses. Some, however, became restless and delirious, and 
closely resembled typhoid patients. 

Pleurisy and empyema were not uncommon. Pleurisy with 
haemorrhagic effusion was often seen. 

Nephritis was a common complication. It occurred in a large 
number of the cases with pulmonary symptoms. The urine 
contained blood or albumin, sometimes in large amount ; the 
patient complained of pain in the back and for a time passed 
little urine. But there was little of the oedema which was a 
marked feature of the primary war nephritis. It was some- 
times difficult to tell which the case really was. For instance, 
an officer was admitted for nephritis. He had blood and albumin 
in very large quantity in the urine, but he had no oedema, and 
he had considerable fever and marked signs in the lungs. 
Although his illness had not begun acutely, it seemed probable 
that it was influenza, and the opinion was given that the urine 
would soon become normal. It did so, but a fortnight later he 
again passed blood and again rapidly recovered. A similar 
attack occurred after exposure to severe cold two months later. 
The diagnosis lay between ordinary war nephritis with 
bronchitis, the febrile haematuria that was often seen in 
France, and influenza. 

There was a marked tendency to haemorrhage. Haemoptysis 
has already been mentioned. Epistaxis was a common feature. 
Colonel Pasteur, the consulting physician of the Third Army, 
saw no less than 30 cases of haemorrhage into the sheath 
of the rectus abdominis, and in cases reported by others 
this was found so large as in one instance to bulge into 
the abdominal cavity, and in another to rupture the sheath. 
A purpuric condition of the feet sometimes leading to the 
formation of blebs was also noticed. Haemorrhages in the 
pleura and pericardium were frequently found post-mortem. 

Jaundice had been seen on the American transport " Nestor " 
in September, but was infrequent in France until the beginning 
of 1919, when it became much more common. It occurred at 



INFLUENZA 191 

all stages of the disease and was not of bad prognosis. In cases 
examined there was no obstruction in the ducts of the liver. 
The gastro-intestinal symptoms which in some countries were 
so marked as to differentiate a special type of the disease were 
not prominent amongst the British troops. 

The white blood cells did not in uncomplicated cases present 
any significant variation in France. Leucopenia was found in 
27 out of 100 German cases. 

Pathology. 

Although expert bacteriologists in various countries, who 
were thoroughly familiar with the appearance of Pfeiffer's 
bacillus and the technique necessary to demonstrate its 
presence, examined numerous cases in the first few months, 
they isolated bacilli in so small a percentage of cases that 
even those who recognised most fully that this latest pandemic 
reproduced in all essential particulars that of the early 
nineties, came to the conclusion that Pfeiffer's bacillus could 
at the most be regarded as associated with, but not as the 
essential and specific organism of influenza. And for a time 
its death-knell appeared to have been tolled when, one after 
another, Nicolle and Lebailly in Tunis, Gibson, Bowman 
and Connor at Abbeville, and Rose Bradford, Wilson and 
Bashford at Etaples, reported results which appeared to 
demonstrate the presence of a filterable virus capable of 
reproducing the disease in monkeys and the lower animals. 

But as 1918 progressed, and as the different army laboratories 
became more expert in the technique necessary for the recog- 
nition of Pfeiffer's bacillus, steadily more and more observers 
reported the presence of this organism. More particularly, the 
bacillus was reported to be constantly isolated when " choco- 
late " medium was used that is agar to which, when hot and 
just under the boiling point, blood or washed blood corpuscles 
are added, a medium so favourable to the growth of Pfeiffer's 
bacillus that within 24 hours large, easily recognisable colonies 
show themselves and when swabs were secured from the upper 
air passages, or cultures made from the sputum in the early, 
as distinct from the late, stages of the disease. 

Subsequently grave doubt was thrown upon the technique 
employed by those who reported the presence of a filterable 
virus. The criticism, it is true, did not explain away the 
statements of those who claimed that, employing the filtra 
from acute and typical cases of the disease, they had reproduced 
in monkeys what are admitted to be the characteristic lung 
lesions of the disease, namely haemorrhages and oedema, and 
patchy peribronchial infiltration. 



192 MEDICAL HISTORY OF THE WAR 

Thus at the end of the war there was no consensus of 
opinion regarding the bacteriology of the disease. Each 
of the following views had its upholders : 

1. That Pfeiffer's bacillus is the essential causative agent, the 
other organisms found in great numbers in the pneumonic lung 
of the fatal cases, streptococci haemolytic and non-haemolytic, 
pneumococci of the various types, staphylococci and gram- 
negative cocci being secondary invaders varying in their 
incidence in different regions. 

2. That Pfeiffer's bacillus is not the essential causative agent, 
but either : 

(a) That like the streptococci and pneumococci Pfeiffer's 

bacillus is, during periods of epidemic influenza, so 
frequently to be found in the throats of those not 
affected with influenza, that even the fact of its 
being present in 100 per cent, of influenza patients 
would not prove it to be specific. Or 

(b) That the disease is due to the symbiotic or combined 

action of several organisms of which the B. 
influenza may be one, and streptococci or pneu- 
mococci most commonly the others. Or 

(c) That the essential cause is a filterable virus which in 

pneumonic and fatal cases most often paves the way 
for the growth in the respiratory passages of 
Pfeiffer's bacillus, and of sundry species of cocci. 

While during 1919 small epidemics have occurred here and 
there, they have been of diminished virulence, with great 
reduction in mortality, so that, as in 1893, little opportunity 
has been afforded to any one individual to deal with an 
adequate amount of suitable material. Any predilection for 
one or other of these views must, therefore, be taken as the 
expression of an individual opinion and not as the commonly 
received view of bacteriologists in general. 

There is the evidence brought forward by careful observers 
that the blood serum of influenza patients possesses a definite 
though slowly manifested power of agglutinating Pfeiffer's 
bacillus, which at the end of the first week rises from 1 in 50 to 
1 in 80 according to various observers, the blood of normal 
individuals not agglutinating the bacilli in dilutions greater 
than 1 in 20. It is true that, as one observer points out, this 
reaction might show itself were the bacillus a secondary 
invader, true also that with complement fixation and absorption 
tests the results are irregular, indicating the existence of a 
great number of strains. 



INFLUENZA 193 

As regards the first objection, it is not an objection proper, 
only an alternative explanation. As regards the second, the 
same is true regarding B. dy sentence, yet this does not prevent 
one from regarding dysentery as a disease induced by various 
strains of the bacillus. One must however admit that the 
variation shown in Valentine and Cooper's New York results is 
extreme. 

In the second place, there is the evidence afforded by vac- 
cination, employing as vaccine B. influenza alone. Here the 
results at first appear to be very conflicting, but evidently 
everything depends on the mode of preparation of the vaccine. 
As pointed out by Duval and Harris, to kill off the bacilli by 
heat, after the method employed by Wright and Leishman in 
the preparation of typhoid vaccine, is futile. Even so low a 
temperature as 56 C. renders cultures practically worthless as 
an antigen. Trier esol and phenol derivatives also are not to be 
considered. Even 0.25 per cent, tricresol has a deleterious 
effect. Chloroform rapidly kills the bacteria without 
apparently having any harmful effect 

Properly prepared with chloroform, the pure B. influenza 
vaccine was found by Duval and Harris to confer protection for 
from ten weeks to three months. Of 3,072 persons vaccinated, 
2,608 with three injections, 346 with two, and 118 with one, 3-3 
per cent, developed influenza, whereas among 866 unvaccinated 
controls the incidence was 41.6. Not one of the vaccinated 
developed pneumonia, whereas among the controls refusing 
vaccination there were 41 cases. Duval calls attention to the 
severity of the reaction induced by his vaccine. Constitutional 
effects following the administration were noted in 90 per cent 
of those inoculated, and in 30 per cent, they were severe and 
simulated in symptom complex the early toxaemia of true 
influenzal infection : lassitude, severe frontal and occipital 
headache, neuralgic pains over the body, not infrequently 
ushered in by chills and nausea, and followed by a temperature 
of 101 to 102. 

And thirdly there are the observations upon the existence 
and actions of an endo-toxin by Huntoon and Hannum. These 
observers were unable to demonstrate the existence of a soluble 
toxin or ecto-toxin, but by growing 10 strains of the bacillus, 
drying the growths in vacuo and grinding them up with salt 
they were able to extract what apparently is an endo-toxin of 
which 0-25 c.c. was fatal to white mice, whereas similar salt 
extracts of meningococci, streptococci, and pneumococci were 
not fatal in four times the amount. The lesions induced by 
the bacillary extracts particularly involved the lungs, producing 
congestion with haemorrhages. 



194 MEDICAL HISTORY OF THE WAR 

The latest strong evidence in favour of regarding Pfeiffer's 
bacillus as the specific organism of the disease comes from the 
army medical laboratory at Washington, where Major Blake 
and Captain Cecil, starting from the assumption that the 
pathogenicity and virulence of the B. influenza is rapidly 
lost in artificial media, preceded to raise the virulence by 
rapid successive passage through eleven white mice followed 
by thirteen monkeys. Intraperitoneal inoculations were given, 
and fluid was drawn from the peritoneal cavity from eight to 
ten hours after injection, that is, at a time when the bacteria 
were still actively growing in the cavity. The first and second 
cultures were employed for inoculation. The strain employed 
had been obtained six weeks previously from a child with 
influenza and pneumonia and at first had no virulence for white 
mice. After the eleventh passage, 0-01 c.c of a 16-hour blood- 
broth culture injected intraperitoneally killed a white mouse in 
48 hours. 

Twenty-two monkeys were next employed, some used for 
intraperitoneal injections and passage, the rest for infection 
through the respiratory passages, in part by swabbing or 
instillation through the mouth and nose, in part by direct 
intratracheal injection just below the larynx. Major Blake 
and Captain Cecil conclude that the disease initiated in 
monkeys by inoculation with these cultures of Pfeiffer's bacillus 
of exalted virulence appears to be identical with influenza in 
man ; that when injected into the trachea the cultures produced 
in monkeys a tracheo-bronchitis and broncho-pneumonia, the 
pathology of which appears to be essentially identical with 
that which has been ascribed to pure influenza bacillus 
infection of the lungs in man ; so that it seems reasonable to 
infer that B. influenza is the specific cause of influenza. (Fig. 1 .) 

The question arises as to how these observations can be 
co-ordinated in the first place with those of the capable 
observers who have reproduced the lung condition by 
employing the filtrate from fluids obtained from influenza 
patients, but have failed to obtain cultures of B. influenza 
from the affected organs, or again with those observations 
of first-class observers employing the best methods, who, 
in localised epidemics which clinically were of the same 
disease, reported that 100 per cent, of the cases examined 
failed to afford influenza bacillus either by culture or by 
microscopic examination of the discharges or the lung tissue. 

There is one possibility that cannot be passed over, namely, 
that Cecil and Blake employed mixed cultures of the influenza 
bacillus and an almost invisible virus. Another, that those 
who have failed to obtain the influenza bacillus from cases 



Plate III. 







A. Monkey Lung (Group I, No. 4) showing inflammatory exudate in alveoli 
and bronchiole (mucous membrane iutact) (x700). 




B. Monkey Lung (Group I, No. 6) showing margin of inflammatory exudate 
(left), clear lung (right) (x500). 



INFLUENZA 195 

which clinically were apparently identical, studied mainly 
old-established cases in which pneumonia had developed at a 
period when the influenza bacillus had been over-grown and 
destroyed by secondary invaders. These are points which 
have yet to be decided. It is worthy of note how frequently 
Cecil and Blake found the disease self-limited in the monkey, 
bacilli disappearing after the fourth or fifth day. In the mean- 
time, however, one is impressed with the fact that the lesion 
common to mild and to severe and complicated cases is an acute 
congestion and inflammation of the trachea ; that the one 
member of the characteristic group of minute bacilli of what is 
termed the influenza group, pathogenic in man, is the Bordet- 
Gengou bacillus of whooping cough, and that this also 
particularly affects and involves the epithelial lining of the 
trachea, as has been convincingly demonstrated by Mallory 
and his pupils. 

It is true that the argument from analogy is dangerous, yet 
an arrest of the proper educent action of the ciliated epithelium 
of the trachea and bronchi, either by actual destruction and 
exfoliation of the epithelium, or, as in whooping-cough, by 
massive growth of the bacilli on the surface and between the 
cilia, affords the most satisfactory explanation of the frequent 
secondary infection of the lungs by organisms from the mouth 
and throat, with the development of forms of pneumonia 
varying according to the micro-organism which gains eventual 
dominance. 

On the question of immunity it has hitherto been widely 
believed that a previous attack of influenza predisposes rather 
than protects. There have, however, been no accurate statistics, 
nor are there any on a sufficient scale now. A few reports from 
schools have shown a little evidence that those affected by the 
summer epidemic escaped that of the autumn. An analysis 
of the statistics of the war may throw some light upon the 
question. At present the only evidence worth considering is 
that provided by the preventive inoculation carried out in the 
army. 

Morbid Anatomy. 

The morbid anatomy of the disease presented a variety of 
pathological changes in the organs of the body. Autopsies 
were made in France during June and July 1918, by 
Captain Shore upon 30 cases in which the clinical diagnosis 
was " influenza." They illustrate the gross pathological 
changes met with and the frequency with which they occurred 
in the summer epidemic there. The patients were not all 
previously healthy for in seven cases, 23-3 per cent., obsolete 



196 MEDICAL HISTORY OF THE WAR 

tuberculosis, pulmonary or glandular, was found. In a pre- 
vious series of 1,500 consecutive autopsies the total incidence 
of tuberculosis was 9-6 per cent. Two patients had chronic 
nephritis and one unilateral hydronephrosis. Old pleuritic 
adhesions were present in 12 cases. With these exceptions, 
the patients were apparently previously healthy. None were 
suffering from wounds. The most striking lesions were those 
in the lungs and heart. 

In one form or another pneumonia was present in every case. 
The majority had broncho-pneumonia, which had a distinct 
tendency to become confluent, and to show a condition closely 
resembling the early grey stage of lobar pneumonia. Un- 
doubted lobar pneumonia was only once found. In five cases 
the pneumonic areas were small and shotty when felt between 
the fingers, closely resembling miliary tuberculosis. On 
microscopic section the small patches were found to consist of 
consolidated lung, generally with fibrinous exudate, surrounding 
inflamed bronchioles. The name " bronchiolitis " was applied 
to the condition, but " miliary pneumonia " seemed more 
descriptive. No bacteriological investigations were made of 
these cases, so it is not possible to say if they differ from the 
more usual form of broncho-pneumonia in that respect. In 
two cases the process passed on from confluent broncho- 
pneumonia to abscess formation. Marked emphysema occurred 
in two cases, involving chiefly the anterior border of the lungs. 
In five there was an excessive amount of collapse, chiefly along 
the vertebral border of the lung. Two of these cases showed a 
small amount of pleura! fluid, but in the other three the pleura 
was dry. Subpleural and interstitial haemorrhages were seen in 
eighteen cases but only as small localized areas. Purulent 
bronchitis was present in fourteen cases. 

Twenty-four cases showed recent pleurisy ; fourteen of 
these were dry, but in ten a varying amount of purulent or 
sero- purulent fluid was found, never more than a pint and gener- 
ally only a few ounces. In fifteen cases the bronchial or tracheal 
glands were markedly enlarged and inflamed. In a few cases 
more distant glands, such as the retroperitoneal and even 
inguinal, were affected. 

One of the most striking features of the morbid anatomy of 
these cases was the constant occurrence of dilatation of the 
heart, accompanied by nearly as constant myocardial changes. 
Twenty-nine out of thirty cases showed marked dilatation of 
the heart, chiefly of the right side but very commonly of the 
left side as well, and twenty-one cases showed myocarditis 
demonstrable to the naked eye. The latter took the form of a 
general pallor and softness of the myocardium, with mottling 



INFLUENZA 197 

and frequently subpericardial and subendocardial haemorrhages 
similar to those seen beneath the pleura. These were not in- 
frequently noticed on the interventricular septum, and on the 
papillary muscles. Endocarditis of the mitral valve was found 
in two cases. The vegetations were small and numerous, and 
obviously recent ; in one case there was a fair amount of recent 
thrombus adherent to the vegetations. In practically all cases 
the right side of the heart was distended with the yellow 
" agonal " or " chicken fat " clot found so constantly in 
pneumonia. Pericarditis was not found. 

In most cases the spleen was a little enlarged. The largest 
weighed 15 oz., the smallest 4 oz., and the average weight of 
the series was 1\ oz. The spleen was generally pale and soft, and 
showed a marked enlargement of the Malpighian corpuscles. 
In a few cases it was congested. No infarcts were found. 

The liver did not present any striking features. In most 
cases it was pale and inclined to show early fatty changes. 
Some few cases showed chronic or relatively chronic congestion, 
presenting a " nutmeg " appearance. In three cases a mild 
degree of jaundice was present, but there were no signs of 
biliary obstruction. 

Apart from the two cases already mentioned as having 
chronic nephritis, ten cases showed a marked degree of " toxic 
nephritis." Sections were made of only two of these, but 
they showed no glomerular change, only cloudy swelling and 
a little fatty change in the tubules. In these ten cases the 
kidneys were flabby, pale and a little swollen. The capsule 
was easily removable without tearing the surface. Stellate 
veins were prominent on the surface. There appeared no 
divergence from the normal proportions of cortex, medulla, 
and intrapelvic fat. Their average weight was 12J ozs. the 
pair, the average for the series being 12 ozs. In one case the 
kidney had a " flea-bitten " appearance, and on section 
showed, as well as the condition described, hyaline thrombosis 
of the afferent glomerular vessels. The glomeruli appeared 
to be practically all affected, which would account for the 
sudden and complete suppression of urine, without previous 
haematuria, which led to the patient's death. This was one 
of the cases which showed abscess formation in the lung. 

Cerebral abscess was found in one case, in which purulent 
bronchitis but no particular bronchiectasis was present. 
Meningitis was not found. 

Reports of 46 additional autopsies were contributed from 
various other pathologists in France. The predominating 
lesion was purulent bronchitis in 12, broncho-pneumonia in 
29, and lobar pneumonia in five of the cases. In all but two 

(2396) N 



198 MEDICAL HISTORY OF THE WAR 

cases the respiratory passages contained purulent exudate. 
In the two exceptions consolidation was of lobar type and 
confined to one lobe. In the cases with purulent bronchitis 
there appears to have been little or no consolidation. The 
commonest condition described is one of purulent bronchitis 
with broncho-pneumonia often associated with fibrinous 
exudate upon the pleural surface. The lungs are described 
as greatly congested and as exuding blood-stained watery 
fluid from the cut surface. The extent of the broncho- 
pneumonic areas varied from numerous areas a few millimetres 
in diameter, surrounded by regions in which haemorrhage had 
occurred, to confluent broncho-pneumonia involving the 
greater portion of a lobe. Sections of the lungs showed the 
same irregular patches of consolidation with alveoli filled with 
leucocytic exudate or blood and often interspersed with emphy- 
sematous portions. The surrounding vessels were greatly 
distended, and the mucous membrane of the bronchioles 
swollen and disintegrating. Pneumococci were seen in the 
alveoli amidst the leucocytes, and sometimes in immense 
numbers, but in only a few instances were bacilli resembling 
Pfeiffer's bacillus recorded. 

Cultures were made from the broncho-pneumonic areas in 
53 instances. Pneumococci were invariably recovered, and 
in 40 cases bacilli resembling B. influenza also. Similar 
bacilli have been isolated from the meninges in cases dying 
with meningitis and, along with pneumococci, from the 
fibrino-purulent pleural effusion. 

The only lesions in other organs recorded were congestion 
of the kidneys with small haemorrhages in the pelvis of the 
kidney. In one instance small haemorrhages in the white 
matter of the brain were observed. 

Autopsies made in England during the summer and winter 
confirmed these observations and amplified them in the 
following directions. 

In 22 consecutive cases the results of examination of the 
cranial sinuses were as follows : One case was normal, in 21 
cases the lining membrane was congested, in 6 there was 
definite yellow pus, in 15 turbid fluid yielding in every case 
the same micro-organisms as were found in the lungs. To the 
naked eye the ethmoidal sinuses were less affected than 
the sphenoidal, and the frontal least of all, but there was little 
difference in the results of culture. 

The lesions found in the lungs included acute congestion, 
giving a more or less dark red colour to the whole lung ; diffuse 
haemorrhage producing still darker red, often almost black-red 
areas in the already deep-red lung, varying in size from miliary 



Plate V. 




WHOLE LUNG IN A CASE OF INFLUENZAL PNEUMONIA. 



INFLUENZA 199 

to massive, and scattered at random throughout the lungs ; 
hsemorrhagic infarcts similar in colour to diffuse intrapul- 
monary haemorrhages, but differing from the latter in their 
pyramidal shape ; broncho-pneumonia, sometimes recognizable 
only on careful search, sometimes widely disseminated, and 
occasionally confluent ; miliary abscesses, often aggregated 
together in little focalized groups of from three or four to a 
score or more, similar to those seen in the midst of septic 
infarcts due to infected emboli ; croupous pneumonia, met 
with very rarely indeed ; purulent bronchiolitis, with thick 
pus expressible from the bronchioles seen in the cut lung ; 
collapse, sometimes superficial only, sometimes associated 
with multiple areas of broncho-pneumonia, sometimes massive ; 
passive oedema of the bases ; active oedema with extensive 
albuminous exudate into all parts of the lungs, not definable 
by the naked eye, but shown to be extreme in many histological 
sections, a peculiar and apparently highly important feature 
of these cases ; and interstitial emphysema, often widespread 
throughout the lung tissue. 

It is worthy of note that here and there a case occurred with 
the same clinical picture as the rest and yet with lungs so little 
altered to the naked eye that one might easily have passed 
them as almost normal. Microscopically there would be 
bronchiolitis, peribronchiolitis and diffused inflammatory 
albuminous exudate, both interstitial and infra-alveolar, yet 
without any discernible broncho-pneumonia, and no obvious 
consolidation anywhere. No part of any lobe, larger than 
a minute fragment, would sink in water, and yet the clinical 
picture of the case was indistinguishable from that in which 
extensive broncho-pneumonia would be found at autopsy. 
In short, though broncho-pneumonia was usually found 
in little or greater degree, it was only part, but not an 
essential part, of a much more complex mixture of lesions. 

Microscopically the lung lesions were found to be just as 
protean as the macroscopic appearances would suggest. The 
most remarkable were the " Gruyere cheese " changes, which 
were common and entirely unlike what is met with in any 
ordinary form of pneumonia. The condition has been illus- 
trated in the special report series* of the Medical Research 
Committee, and it is not very dissimilar to the initial results 
of the action of acute irritant gases on the lungs (Plate V). 
All through the section of the lung filling the alveoli in 
some places, distending the interalveolar walls or the 
peri-bronchial connective tissue in others, or blocking the 

* No. 36. 



200 MEDICAL HISTORY OF THE WAR 

bronchioles, or infiltrating all parts of the section simul- 
taneously there was a hyaline or homogeneous material, 
staining faintly pink with eosin, but containing few cells, 
resulting apparently from the rapid outpouring of an 
albuminous, non-cellular, coagulable exudate which in the 
process of fixation of the tissues becomes converted into 
what looks like hyaline material. (Fig. 2.) 

Amid this are seen outlines of normal alveoli in some places, 
alveoli whose walls are disintegrating in other places, and, in 
yet others, spaces which are not alveolar at all, round or ovoid 
holes of varying sizes without any defined walls, but reminiscent 
of the air holes which characterize a Gruyere cheese. Some 
of these may be the result of breaking down of interalveolar 
walls so that two, three or more original alveoli have been 
thrown together into one larger one. Some, on the other 
hand, appear to be gas-bubbles microscopic interstitial 
emphysema in the albuminous intrapulmonary exudate. 
Similar non-cellular exudate is seen after acute gas poisoning. 
It seems likely that it is this acute inflammatory oedema of 
the lung tissue which, preventing inspired air from gaining 
access to the intra-capillary blood, accounts for the anoxaemia 
and heliotrope cyanosis of the worst cases. 

The lesions found in the lungs may be summed up as con- 
sisting of bronchitis, usually of the severe purulent type ; 
haemorrhagic oedema, especially in cases rapidly fatal ; and 
inflammation and consolidation of the parenchyma, which may 
be miliary or lobular, sometimes so confluent as to involve 
large areas, but is rarely true lobar consolidation. Micro- 
scopically the characteristic change is that of vacuolation 
with fibrinous exudation. 

The thyroid gland was uniformly enlarged in nearly every 
case, a phenomenon which attracted attention, though its 
causation was not obvious. The gland was sometimes quite 
three times the average size, and the isthmus was swelled 
as well as the lateral lobes, much in the same way that it is 
in Graves' disease. The swollen gland was firm and uniform in 
consistence, generally of its ordinary dull-red colour, and micro- 
scopically it did not show evidence of being acutely infected. 
The condition seemed to be one of simple uniform swelling of the 
gland secondary to the acute toxaemia of the general disease. 

The alimentary canal seldom presented microscopic evidence 
of infection ; but a group of cases was observed in which 
the colon was in a state of extensive and acute ulcerative colitis, 
with destruction of the mucosa similar in type and degree 
to that which results from acute dysentery. 

Important investigations into the pathology of epidemics 



Plate IV. 






. "; 

7; , v 

'>.' 









/ 

. V 



** . 



\; 

f 









A. Human Lun^, area of oedematous pneumonia, showing alveoli filled with 
albuminous exudate. Leucocytic reaction not marked. (x700). 




B. Human Lung, area of multiple abscess formation, showing total destruction 
of bronchial mucous membrane with rupture and solution of the surrounding 
alveolar walls. (x700). 



INFLUENZA 201 

of pneumonia, which occurred in the army concentration 
camps in America during 1918, have some bearing on the 
epidemics of influenza. A full account of the work has 
been written by MacCallum in a monograph of the Rocke- 
feller Institute and in other papers. 

MacCallum points out that, during the period referred to, 
examples of the classical type of lobar pneumonia, ending 
by crisis, were met with in the usual numbers to be expected 
under camp conditions and at the season of the year in which 
they occurred. There arose, however, in addition, outbreaks 
of pneumonia of a very different character, which appeared 
to follow in the train of other epidemics of some predisposing 
disease of which measles and epidemic influenza were the 
chief. It is in its ultimate application to the epidemics of 
influenza that the work of the American pathologist requires 
particular attention. During the winter and spring 1917-18 
there were extensive epidemics of measles in the American 
camps, complicated by a very fatal pneumonia shown to be 
due to the invasion of the lungs by a haemolytic strepto- 
coccus. During the great epidemic wave of influenza in the 
latter part of 1918 similar pneumonic complications were 
observed, and in these the secondary infecting organisms 
were observed to be the haemolytic streptococcus, the 
bacillus of Pfeiffer, and Staphylococcus aureus. MacCallum 
showed clearly that there were important differences in the 
pathological pictures of these various pneumonias, and that 
they depended on a variety of factors, such as the nature 
of the predisposing or primary disease ; the organism which 
secondarily invades the lungs ; the virulence of the organismal 
strains ; and the resistance of the infected person. 

Though it is possible to describe typical appearances as 
brought about by a single variety of invading organism, such 
a clean picture is not commonly met with. The various 
secondary invaders may all be present, or they may invade 
the lungs one after the other, and each produce additional 
effects. It is, however, common for one or other of the 
organisms to multiply quickly, and assume a predominant 
role in the pathology. Subsequently another organism may 
multiply, and add to, or even completely cover up, the lesions 
produced at the earlier stage. All these changes increase 
greatly the difficulty of elucidating the pathology of different 
aetiological types of the disease. It should be mentioned that 
MacCallum assumes that in the present state of knowledge 
neither of the main predisposing diseases, measles and epidemic 
influenza, can be considered as caused by bacteria, but that 
they must be ascribed to a virus of unknown nature. 



202 MEDICAL HISTORY OF THE WAR 

The first epidemic of pneumonia investigated by MacCallum 
occurred during a great outbreak of measles in a Texas camp 
in February 1918. In this epidemic the main secondary 
invader which brought about the pneumonia was clearly shown 
to be a hsemolytic streptococcus. So obvious did this become 
that ultimately the prophylactic measure was adopted of 
segregating all cases of early measles in which the haemolytic 
streptococcus could be obtained in the throat. This was 
followed by excellent results in diminishing the pneumonia 
incidence in other cases of measles. 

A later epidemic in another camp occurred without the 
co-existence of measles at all, from the bulk of which again 
the haemolytic streptococcus was obtained. In this epidemic 
the streptococcus was apparently virulent enough to set up 
pneumonia without the usual primary predisposing disease 
coming into play. 

The characteristic lesion of all these cases may be 
summarized as being that of an interstitial broncho-pneumonia 
of an unusual type. Macroscopically the cut surface of the 
lung showed branched grey projecting foci of consolidation, 
surrounded by areas of oedema, haemorrhage and collapse. 
The essential feature of the lesion on histological examination 
was the rapid infiltration of the walls of the alveoli and 
bronchioles with wandering cells, followed by new formation 
of connective tissue in these situations, so that the walls of 
the alveoli become greatly thickened. The streptococci were 
present in the lesion in relatively small numbers, and were 
confined practically to the bronchi and lymphatic channels 
of the lung. This is in great contrast to the findings in lobar 
or lobular pneumonia, where the main lesion consists in 
exudation of fibrin and leucocytes into the alveolar spaces, and 
where myriads of pneumococci or other organisms are to be 
seen in the alveolar exudate. The peculiar acute inflammatory 
change in the alveolar walls, with cellular infiltration followed 
by fibrosis, appears then to be a particular pathological change 
characteristic of the disease caused by the haemolytic strep- 
tococcus after measles. 

The appearances varied somewhat according to the stage at 
which death occurred. In cases where death supervened within 
a few days of the onset, no actual areas of consolidation were 
seen on the cut surface of the lung. All the bronchi were 
intensely reddened, and their walls were swollen. Micro- 
scopically such a lung showed in the bronchi an accumulation 
of leucocytes containing streptococci. The damage extended 
beyond the bronchi only into the closely adjacent alveolar 
walls, which were thickened by oedema and infiltrated by 



INFLUENZA 203 

mononuclear wandering cells. If the illness had lasted more 
than a week, the post mortem changes were far more advanced. 
There was then generally pleural exudate, thin, watery and 
turbid, often with a greenish brown sediment, and swarming 
with streptococci. The lung surrounded by the fluid exudate 
was collapsed, airless and flabby, but contained obvious 
palpable areas of consolidation. In section, the lung surface 
showed nodules of consolidation which projected above the 
cut surface and were surrounded by areas of haemorrhage and 
oedema. Each bronchus contained thick pus. The infection 
was essentially confined, in the first place, to the interstitial 
tissues either of the wall of the bronchioles or of the alveoli, 
and the organisms showed a tendency to pass from these areas 
to the surface of the lungs by the lymphatic drainage channels, 
which in consequence might be distended with such large 
collections of pus as to resemble a choked bronchus. 
Microscopically the same interstitial changes were predominant, 
but further advanced. The interlobular septa were greatly 
thickened, and the alveolar walls were thick both from 
infiltration with wandering cells and from the formation of 
new connective tissue, which was well vascularized. The 
alveolar spaces might contain at this stage dense plugs of 
fibrin, mixed with catarrhal cells from the alveolar walls, but 
leucocytes and red corpuscles were scanty. 

In certain cases the familiar lesion of lobular pneumonia 
was also present in other parts of the lungs, the alveoli being 
filled with exudate of fibrin and leucocytes containing in the 
meshes very abundant streptococci. This change MacCallum 
regarded as evidence of lowered resistance on the part of the 
host, so that there was no restriction to the invasion and multi- 
plication of the streptococci. The alveoli became filled with 
organisms in contrast to the course of events in the interstitial 
pneumonia where the organisms were " imprisoned in the bronchi, 
and carried to the pleura only by migration along the lymphatics. ' ' 

In these epidemics MacCallum found that all the cases 
could be divided pathologically into the following types : 

(1) Lobar pneumonias caused by the pneumococcus. 

(2) Pneumonias caused by the haemolytic streptococcus, 

either pure interstitial broncho-pneumonias, or 
interstitial pneumonia added to lobular pneumonia, 
or rarely lobular pneumonia without any of the 
changes in the framework of the lung. 

MacCallum's subsequent work refers to the pneumonias 
met with during the great influenza epidemic in the autumn 
of 1918. He again affirms that the nature of the primary 



204 MEDICAL HISTORY OF THE WAR 

disease is unknown, but that it lowers the powers of resistance 
to a degree scarcely paralleled in any other disease. 

In this epidemic the secondary pneumonia was brought about 
by invasion of the lungs with many kinds of bacteria, including 
the various types of the pneumococcus, the staphylococci, and 
the bacillus of Pfeiffer, invading singly or all together. 

The type of pneumonia was here again found to be quite 
different in different epidemic areas in America, according to 
the predominant secondary invading organism. 

In the cases where the various types of pneumococci were 
identified as the predominating organism, the consolidation 
was seen to be at first lobular, but soon these solid areas 
coalesced until the greater part of a lobe might be solid and 
airless. The bronchi in these cases were not red, but pale. 
Microscopically the aveoli were found filled with a light fibrinous 
reticulum, entangling red corpuscles, leucocytes and desqua- 
mated endothelial calls. This exudate contained as a rule 
abundant pneumococci, and in fact the lesion was very little 
different from a typical early lobar pneumonia. 

In the cases where the haemolytic streptococcus was the 
chief secondary invader, the appearances in the lungs corre- 
sponded to those described in the earlier epidemic as character- 
istic of the invasion of tissues in cases with lowered resistance. 
None of the typical interstitial connective tissue changes were 
present, but there were large areas of lobular consolidation 
packed everywhere with streptococci, and often undergoing 
rapid necrosis. In these cases again intense inflammatory 
redness of the trachea and bronchi was evident. 

The few cases in which the staphylococcus appeared to 
predominate were too scanty in number to give absolute 
conclusions, but in one the lesion was similar to that induced 
by the pneumococcus. 

In the cases in which Pfeiffer's bacillus was present in 
abundance the changes found resembled very closely those 
described as acute interstitial pneumonia caused by the strep- 
tococcus after measles infection. There was again the same 
thickening of the alveolar walls with round-celled infiltration 
and newly formed connective tissue, while the small bacilli 
were practically confined to the bronchi and did not invade the 
alveoli. It was evident from the lesion that the tissues here 
were stoutly resisting the invasion of the bacilli. 

MacCallum concludes one of his papers by saying that stress 
must be laid on the epidemic character of the secondary invasion 
of the lungs in all the outbreaks. In one camp all the pneumonic 
cases might show a pneumococcal type of lesion, in others 
almost every case might be due to Pfeiffer's bacillus. In this 



INFLUENZA 205 

way Pfeiffer's bacillus might carry conviction to some people as 
the true cause of epidemic influenza, whereas it might be almost 
absent in other areas where pneumococci and haemolytic 
streptococci were the opportune secondary invaders. This all 
leads him to the reiterated conclusion that we are still quite 
ignorant of the cause of epidemic influenza. 

Acute interstitial pneumonia was recognized microscopically 
in France by Dunn and McNee in December 1916, in individual 
cases of "broncho-pneumonia" before the influenza epidemic. 
The general observations of MacCallum and Cole in 1918 were 
fully confirmed during the epidemic by Tytler, Janes and 
Dobbin in work at Boulogne ; in these latter cases staphylo- 
cocci were frequently present among the secondary infecting 
organisms, and staphylococci were especially prominent in a 
group from Malta, recorded by Captain Patrick. 

Diagnosis. 

With regard to diagnosis, influenza has to be distinguished 
from the onset of any other acute fever. In the case of the 
zymotics the subsequent course and the rash proper to each 
form the main points of diagnosis. Trench fever can sometimes 
only be distinguished by its relapsing character as the rash 
may be inconspicuous. Severe influenza may closely resemble 
typhoid fever ; in this case the diagnosis turns upon the 
presence of the signs of the latter disease. Some regard a 
relatively slow pulse as characteristic of severe influenza, but 
this may occur in typhoid also, and is not universal in cases 
of influenza. Malaria may resemble influenza. The history 
and the presence of the malarial parasite will usually provide 
grounds for diagnosis. 

Prognosis. 

The prognosis of the disease is indicated in the descriptions 
of its symptoms and progress. Inquiries made seem to show 
that the epidemic has not produced any large number of 
those mental sequelae which have been noticed on previous 
occasions. There is some suspicion that a rather chronic form 
of infective endocarditis may be the consequence of an attack 
of influenza. Also it is said there are some cases of fibrosis of 
the bases of the lung resulting from the epidemic. It is 
suggested above that the kidneys may be left affected. Such 
cases are not, however, numerous. 

Treatment. 

The treatment of influenza is both preventive and curative. 
Segregation was attempted in France On 23rd June, 1918, a 



206 MEDICAL HISTORY OF THE WAR 

committee appointed to investigate the outbreak reported to 
the D.G.M.S. as follows : 

"1. The contagion of this disease appears to be air-borne, although its 
exact nature has not yet been ascertained. The main principle to be followed, 
therefore, is to spread troops as widely as possible, avoiding the crowding of 
men in tents, billets, messrooms, etc. 

"2. Whenever the military situation permits, it is advisable that troops 
should sleep in individual blanket-shelters in the open air. 

"3. As the infection appears to be spread by the movement of infected 
individuals, drafts arriving at reinforcement depots from England or the 
bases should as far as possible be accommodated in separate lines for a period 
of four days. Individual shelters should be insisted on, in order to avoid the 
necessity for quarantine if any cases arise. 

"4. In medical units arrangements should be made for the separation of 
these cases from other patients. 

"5. In billets where infection has occurred all blankets and kits should 
be taken out and aired, and the usual precautions taken so far as circumstances 
permit." 

Later a further segregation was made by separating cases of 
broncho-pneumonia from the remainder. 

In most influenza wards the nurses and orderlies wore masks. 
The incidence of infection among them was on the whole 
surprisingly small, but it can hardly be attributed to the masks, 
which were carelessly used, for it was small too even in those 
wards where masks were not worn. 

In Mesopotamia, where the disease was recognized, its 
incidence was so great that the hospitals were overtaxed. In 
the 15th Indian Division regiments were ordered to form their 
own hospitals and detain cases. Tents were set aside, latrines 
made, personnel detailed for nursing, water and cooking 
arranged, and drugs and comforts supplied. For prophylactic 
purposes games were stopped and units were paraded twice 
daily when every man gargled his throat and inserted in 
each nostril some menthol and camphor ointment. 

Preventive inoculation was employed to some extent. Eyre 
and Lowe in England had some time before inoculated a body 
of New Zealand troops with a mixed vaccine against respiratory 
diseases. These troops during the following six months showed 
as compared with unvaccinated New Zealand troops a rate of 
respiratory disease lower in the proportion of 12 vaccinated to 
73 unvaccinated of those attacked. A War Office conference 
reported in favour of a prophylactic vaccine containing : 
B. influenzae . . 60 millions } 
Pneumococci . . 200 ,, r in 1 c.cm. 
Streptococci . . 80 ,, J 

the first dose to be J c.cm., the second, to be given 10 days later, 
1 c.cm. But both dosage and composition were criticized by 
Matthews and Wynn, Eyre and Lowe again reported favour- 
ably on their results during the autumn epidemic. 






INFLUENZA 207 

In the autumn epidemic in France it was considered inad- 
visable to use the prophylactic vaccine upon the combatant 
troops, as it was impossible to be sure that men were not already 
infected, and there was some evidence that a negative phase 
was produced which might in that case be dangerous, but at 
Boulogne a test on a small scale was made on the base personnel 
with equivocal results. 

Prophylactic vaccine did not arrive in Mesopotamia till April, 
by which time the epidemic had so far died down that no 
satisfactory trial of its use could be made. 

Leishman's statistics, published in 1920, show a much lower 
rate of incidence among those previously inoculated with this 
vaccine. Further, among 221 inoculated patients who caught 
influenza only two died, whereas among 2,059 non-inoculated 
patients 98 died. The numbers included in his returns are 
approximately 60,000. There are one or two anomalous returns, 
and there are one or two which appear unreliable. Expert 
statisticians also claim that the circumstances of infection 
diminish to a certain extent the difference between the rates. 
Yet a balance of evidence is left in favour of inoculation as a 
means of preventing the disease, and the low death rate of 
the inoculated affords considerable evidence of the creation 
of temporary immunity. 

It was, however, considered advisable to increase the propor- 
tion of B. influenza and the vaccine eventually issued by the 
War Office contained : 

B. influenzse . . 400 millions "j 
Pneumococci . . 200 V in 1 c.cm. 
Streptococci . . 80 ,, J 
the first dose in | c.cm., and the second, 1 c.cm., as before.* 

* Extreme measures of protection against the pandemic of influenza in 
1918 were taken on board the Japanese cruiser " Nukata," which was in 
Simon's Bay and Table Bay during the progress of a very severe and fatal 
outbreak in the Cape Peninsula during the latter part of the year. The 
personnel of the ship entirely escaped infection. The preventive measures 
included stoppage of shore leave or of visitors from shore, the wearing of masks 
by men necessarily sent on duty on shore, disinfection of everything taken 
on board and inoculation with anti-influenza vaccine. Vegetables from the 
shore were washed and exposed to sunshine ; bread was exposed to heat in 
kitchen ovens, meat and fish were exposed to air and the covers on them 
changed on the pier at Cape Town ; newspapers and letters were sprayed 
with formalin and dried in the sun ; men returning from shore duty gargled 
with 1 in 1,000 solution of perchloride of mercury and cleansed their clothing 
and boots with a 3 per cent, solution of carbolic acid on the pier before returning 
to the ship. They were given formalin tabloids to use on shore and instructed 
to avoid crowds. The men on board gargled with salt after every meal and with 
perchloride of mercury solution before turning in. Temperatures were taken 
every day and men with signs of inflammation of the naso-pharyngeal passage 
searched for and isolated. All table dishes were boiled after use and at the 
height of the epidemic on shore no provisions from shore were allowed on board. 
(See Vol. I. General History of the Medical Services, p. 319.) 



208 MEDICAL HISTORY OF THE WAR 

Preventive inoculation with mixed vaccines has been tested 
in New York, on 6,000 persons by Jordan and Sharp, and on 
over 4,500 by Park, with doubtful result. The dose of influenza 
bacilli was 500 and 1,000 millions in their respective vaccines. 

With regard to curative measures alike in France and in 
England treatment was mainly symptomatic. There were not 
wanting, however, advocates of specific remedies. 

Turner advised 20 grain doses of salicin every hour, and 
stated that out of 2,500 cases thus treated he had lost 
none, and had never seen bronchitis or pneumonia develop. In 
France the cases came in too late to give this method a trial, 
and there has been no corroboration of his statements on a large 
scale in England. Quinine and the salicylates were of little 
use. Corrosive sublimate and colloidal arsenic or silver, the 
former recommended by Ferrarini in 1 cgm. doses, the latter by 
Capitan, as intravenous injections, were each praised by some 
officers, whose reports were controverted by others. Large 
doses of alcohol were ineffective. Oil of camphor and musk 
were advocated as restoratives. The usual expectorants 
were given. Cyanosis was temporarily relieved by oxygen 
inhalation through the Haldane apparatus. Oxygen was of 
about as much value as it is in cases of ordinary lobar pneumonia 
and, whereas in gas poisoning it undoubtedly saved life and 
that frequently, in influenza it at the most sometimes prolonged 
it. Venesection is never permissible. 

Treatment by the serum of convalescents advocated by 
Benj afield and Hohlweg was not tried in France. Its efficacy 
depends upon the degree of immunity conferred, which is yet 
uncertain; but further trial is very desirable, for clinical evidence, 
though difficult to estimate, is in such a case the final test. 
Curative vaccine treatment was not employed in France, and 
was not found of value by those who tried it in England. 

The points of main importance are that a patient with 
influenza should be sent to bed at once, and should not be 
sent long journeys if these can be avoided ; yet even when 
these precautions were taken and the best possible conditions 
secured throughout, experience showed that the attack might 
be very severe. 

At Aldershot the overcrowding was so great that the most 
hopeless cases were placed under shelter in the open air, to make 
room in the wards for those whose chances seemed more favour- 
able. It was found, to the surprise of the physicians, that an 
unexpectedly large number of these apparently hopeless cases 
recovered, though it was winter time. This accidental obser- 
vation may be of great importance, and the open-air method 
should certainly be tested again. 



INFLUENZA 



209 



Empyema was uncommon in France, and is not even men- 
tioned in the account of the disease in England, but it seems to 
have been more frequent in the American army. It should be 
borne in mind, and, when found, should be treated first by 
aspiration, and, if it collect a second time, by resection. 



Abrahams, Hallows 
& French 

Burnford 



Capitan 
Eyre & Lowe 
Ferrarini 

Fildes, Baker & 

Thompson 
Fleming 

Foster & Cookson . . 
Friedemann 



Gibson, Bowman & 
Connor 

Gotch & Whitting- 

ham 
Hohlweg 



Huntoon &Hannum 



Jordan & Sharp 

Leishman . . 
MacCallum 



BIBLIOGRAPHY. 

A further Investigation into 
Infl uenzo-pneumococcal 
Septicaemia. 

On Influenza with special refer- 
ence to Pneumonia. 



Traitement de la grippe grave 
par 1'arsenic et 1'argent col- 
loidaux purs. 

Prophylactic Vaccinations 
against Catarrhal Affections 
of the Respiratory Tract. 

Cura dell' influenza colle in- 
jezioni endo venose di subli- 
mate corrosive . 

On the Pathology of the present 
Epidemic. 

On some simply prepared Cul- 
ture Media for B. Influenzee. 

On a small localized Epidemic 
of Influenza. 

Ueber Serum-therapie der 
Grippe-pneumonic. 

A filtrable virus as the cause of 
the early stage of the present 
Epidemic of Influenza. 

On the Influenzal Epidemic of 
1918. 

Zur Behandlung von Grippe- 
kranken mit Rekonvaleszen- 
tenserum. 

The Role of Bacillus Influenza 
in Clinical Influenza 



Effect of vaccination against 
influenza, etc. 

Results of Protective Inoculation 

against Influenza. 
Pathology of the Pneumonia 

following Influenza. 

Pathology of Epidemic Pneu- 
monia in Camps and Canton- 
ments in 1918. 



Lancet, 1919. Vol.i, 
p. I. 

Proc. Roy. Soc. Med. 

1918-1 9 19. Vol. xii, 

Med. Sect. p. 49. 
Lancet, 1919 Vol i, 

p. 794. 
Bull. Acad. de M6d. 

Paris, 1918. 3 S6r. 

Vol. Ixxx. p. 388. 
Lancet, 1918. Vol. ii, 

p. 484. 1919. Vol.i, 

p. 553. 
Riforma Med., 1918. 

Vol. xxxiv. p. 893. 

Lancet, 1918. Vol. ii, 

p. 697. 
Lancet, 1919. Vol. i, 

p. 158. 
Lancet, 1918. Vol. ii, 

p. 588. 
Deut. Med Woch., 

1918. Vol. xliv, 

p. 1293. 
Brit. Med. Jour., 

1918. Vol. ii, p. 

645. 
Brit. Med. Jour., 

1918. Vol. ii. p. 82. 
Miinch. Med. Woch., 

1918. Vol. Ixv, 

p.' 1247. 
Proc. New York 

Path. Soc., 1919. 

March 12. 
Jour, of Immuno- 
logy 1919. Vol. iv, 

p. 167. 
Jour. Infect. Dis. 

1921. Vol. xxviii, 

p. 357. 
Lancet, 1920. Vol. i, 

p. 366. 
Jour, of Amer. Med. 

Ass., 1919. 

Vol. Ixxii, p. 720. 
Med. Rec., 1919. 

Monographs of the 

Rockefeller Insti- 
tute for Med. Res., 

New York, 1919. 



210 



MEDICAL HISTORY OF THE WAR 



MacCallum 

Matthews 
Morelli 

Nash 

Nicolle & Le Bailly 

Patrick 

von Sholly & Park 

Smith 

Symonds 

Whittingham & Sims 

Wilson 

Wirgman 

Wynn 

Yamanouchi & 

others. 
Miscellaneous 

Reports. 



BIBLIOGRAPHY cont. 

The Pathology of the Pneumonia 
in the United States Army 
Camps during the winter of 
1917-1918. 

Influenza, a Preventive Inocu- 
lation. 

Osservazioni cliniche ed epi- 
demiologiche sopra 1'epidemia 
della influenza estiva. 

The Age Incidence of the pre- 
vailing Epidemic of Influenza. 

Quelques notions experimentales 
sur le virus de la grippe. 



Note on Staphylococcus aureus 
Septicaemia as a Complication 
of Influenza in an Epidemic in 
Malta. 

Report on the prophylactic vac- 
cination of 1,536 persons 
against acute respiratory 
diseases 1919-20. 

Cases of Influenza in the Wool- 
wich district. 

Nephritis in relation to Influenza 

Bacteriology and Pathology of 

Influenza. 
Post-Influenzal Haemoptysis . . 

An Influenza Outbreak 

Influenza, and Preventive Inocu- 
lation. 
The Infecting Agent in Influenza 

Influenza Committee of the Ad- 
visory Board, Report to 
D.G.M.S. in France. 

War Office Conference 

Memo. Royal Coll. of Physi- 
cians. 

Memo. Med. Research Com- 
mittee. 



London County Council Report 
by Medical Officer (Hamer). 

Discussion at Joint Meeting of 
sections of Medicine, Preven- 
tive Medicine, and Pathology, 
Brit. Med. Assoc. 

Discussion 



Lancet, 1918. Vol. ii, 

p. 602. 

Policlinicall., Rome, 
1918. Vol. xxv, 
Soz. Prat. p. 926. 
Brit. Med. Jour., 
1918, Vol. ii, 
p. 686. 

Comptes Rendus de 
1'Acad. des Sciences 
1918. Vol. clxvii, 
p. 607. 

Lancet, 1919. Vol. i, 
p. 137. 



Jour, of Immunology 
1921. Vol. vi, 
p. 103. 

Lancet, 1919. Vol. i, 

p. 421. 
Lancet, 1918. Vol. ii, 

p. 664. 
Lancet, 1918. Vol. ii, 

p. 865. 
Lancet, 1919. Vol. i, 

p. 137. 
Lancet, 1919. Vol. i, 

p. 357. 
Lancet, 1918. Vol. ii, 

pp. 642, 874. 
Lancet, 1919. Vol. i, 

p. 971. 
Brit. Med. Jour., 

1918. Vol. ii, p. 505. 

Lancet, 1918. Vol. ii, 

p. 565. 
Brit. Med. Jour., 

1918. Vol. ii.p. 546. 
Lancet, 1918. Vol. ii. 

p. 717. 
Med. Res. Com., 

Special Report, 

No. 36. Lond., 

1920. 
1919. 

Brit. Med. Jour., 

1919. Vol. i, p. 488. 



Proc. Roy. Soc. of 
Med., 1919. Vol. xii, 
p.l. 



INFLUENZA 



211 



Miscellaneous 
Reports. 



King, Barty 



BIBLIOGRAPHY cont. 

War Office Daily Review of 
Foreign Press, Med. Supple- 
ment. 

Influenza 



Studies of Influenza in Hospitals 
of the British Armies in 
France, 1918. 

Studies in Influenza and its 
Pulmonary Complications. 



Lond., 1918 & 1919. 



Medical Science 
Abstracts and 
Reviews, 1919-20. 
Vol.i, pp. 38, 141. 

Med. Res. Com., 
Special Report 
Series No. 36, 
Lond., 1919. 

London, 1922, 
Churchill. 



CHAPTER VIII. 

PURULENT BRONCHITIS AND BRONCHO-PNEUMONIA. 

DURING the campaign in France and Flanders respiratory 
affections were common, and at certain periods the num- 
bers affected were large, more especially during the cold 
and wet seasons. These maladies were of the usual and well- 
known types, such as bronchitis, pleurisy and varieties of 
pneumonia, and they do not call for special notice. They 
varied in their severity and character and in their incidence 
amongst the troops, derived as they were from different parts 
of the world and often of different races. Such affections were 
prevalent from time to time during the earlier years before the 
occurrence of the pandemic of influenza in 1918, and in some 
years, notably in the winter of 1916, they assumed considerable 
proportions. In 1918, however, they occurred in very large 
numbers in association with the severe epidemic of influenza 
prevalent in the autumn of that year. 

Bronchitis was one of the diseases that occurred, as might 
be expected, in different degrees of severity and in varying 
numbers in different years, and it also presented varying forms, 
sometimes catarrhal, sometimes muco-purulent and not un- 
commonly frankly purulent. Such varieties are well known 
and universally recognised. But, in addition to these, another 
and remarkable form of the disease was seen from time to time 
in isolated instances, and, in certain years, in considerable 
numbers. It is this variety of bronchitis to which the term 
acute purulent bronchitis is given. The outstanding features 
of the malady are the remarkable and peculiar sputum, the 
high fever and prolonged course of the disease and in a certain 
proportion of cases tachycardia. Other striking features such 
as cyanosis, and the patient's mental state, although also of 
much clinical interest, are phenomena that are by no means 
unusual in other severe forms of bronchitis, especially when 
acute, and hence although they are prominent features of puru- 
lent bronchitis, they are not so special as the sputum and the 
prolonged and high pyrexia. 

In France, although sporadic cases were seen from time to 
time throughout the campaign, the bulk of them occurred in 
the winters of 1914 and 1916, while very few were seen in the 
winters of 1915 and 1917. In the autumn and winter of 1914 
the weather was cold and very wet and the troops suffered 

212 



PURULENT BRONCHITIS 213 

considerably from exposure. The winter of 1916 was also 
severe ; the malady was then more prevalent but the number of 
men serving was much greater than in 1914. The remarkable 
feature is rather the fact that so few cases occurred in 1915. 
In addition to the cases occurring in healthy men, purulent 
bronchitis was not an uncommon complication in the wounded, 
and many cases were seen as complications of chest wounds, 
especially where the wounded men had not been picked up 
until the lapse of some time. Hence it seems that exposure 
was a factor of importance in the causation of the disease. It 
is of interest that although the bacillus of Pfeiffer was the organ- 
ism most constantly found in the sputum, the disease occurred 
in the years 1914 and 1916, when there was no epidemic of 
influenza in the armies. 

The disease attacked strong, healthy men, and although most 
cases occurred in the more mature men, some were seen in 
quite young soldiers, and the disease was by no means one 
which chiefly affected the older men. This was more especially 
seen in 1914 and 1916, when the aetiological problem was not 
complicated by the presence of the influenza epidemic. The 
1914 cases occurred in the men of the old army, and the 1916 
in the men of the new armies, and both these categories were 
exceptionally vigorous and strong men. The influence of cold 
and exposure in causing the development of this more virulent 
type of bronchitis was very evident among men who came from 
India to Flanders during the winter of 1914-15, and naturally 
felt the climatic conditions more severely than did the relatively 
acclimatized troops from home. Certain British battalions, 
which were recalled from India and arrived for service in France 
in December, suffered severely from the disease. Indian 
troops serving in Flanders were similarly affected. 

Hospital returns never made a reliable differentiation between 
purulent bronchitis and other respiratory diseases, but the 
following figures for 1914 and 1915 from the Meerut Stationary 
Hospital, at Boulogne, serve to illustrate the frequency of 
these maladies amongst Indians : 

Total admissions .. .. .. .. 20,107 

Respiratory diseases . . . . . . 2,485 

Deaths from latter .. :. .. 84 

These cases included 233 returned as pneumonia, with 58 
deaths ; and in many the pneumonias were in reality cases 
of purulent bronchitis. 

The incidence of similar types of disease amongst troops in 
the United Kingdom was first brought to notice early in 1916, 
when Major Abrahams and Colonel French observed at the 

(2396) O 



214 MEDICAL HISTORY OF THE WAR 

Connaught Hospital, Aldershot, that certain cases admitted 
as " pneumonia " differed very materially from any ordinary 
cases of lobar pneumonia in the paucity of their physical 
signs, their atypical pyrexia and course, their peculiar 
cyanosis, their abundant expectoration of almost pure pus 
often 10 ounces a day or more their high mortality and the 
atypical character of the autopsy findings. Bacteriological 
investigation carried out by Eyre showed that these cases 
were examples of a double infection of the respiratory 
passages either influenzo-pneumococcal or influenzo-strepto- 
coccal. These results were published in the Lancet, and agreed 
in almost every respect with those of similar researches carried 
out independently in France by Hammond, Rolland and Shore. 
Previous to 1917 the cases were for the most part 
returned under the comprehensive heading of " pneumonia " ; 
but, after they were differentiated from ordinary " pneumonia " 
and began to be recognized as distinct under the name 
" purulent bronchitis, " cases were returned from nearly 
every command, with minor epidemics in some, such as Alder- 
shot, and larger outbreaks in others, notably at Oswestry, and 
amongst the New Zealand troops in the Southern Command in 
the neighbourhood of Salisbury. 

Etiology. 

In 18 out of 20 cases examined in France by Rolland in the 
winter of 1916, the Bacillus influenza was found to be present, 
and in a considerable portion of the cases a pneumococcus was 
also detected ; less frequently a streptococcus, and Diplococcus 
catarrhalis were found in association with Pfeiffer's bacillus. 
In ten cases the B. influenza was the predominating organism, 
and in three no other organism could be seen in the films pre- 
pared from the sputum. It seems from these results, and also 
from similar work of other observers, that the organism most 
constantly found in the sputum of these cases was the B. 
influenza, but that the pneumococcus was frequently also 
present especially in the cases where Pfeiffer's bacillus was 
abundant. Pfeiffer's bacillus was constantly present in 
various infections of the respiratory tract throughout the 
campaign, and naso-pharyngeal swabs from men who were being 
examined because they had been in contact with cases of cerebro- 
spinal meningitis, frequently showed its presence in perfectly 
healthy individuals. It is reasonable to assume that specially 
debilitating influences of cold and exposure might weaken an 
individual so that Pfeiffer's bacillus had the opportunity to 
develop rapidly and, probably in symbiosis with pneumococci 






PURULENT BRONCHITIS 215 

or other organisms, to produce this novel picture of acute 
suppurative bronchitis without broncho-pneumonic extension. 
The essential point in connection with the bacteriology of 
the Aldershot cases was that the infection was shown to be 
a double one, a combined attack by influenza bacilli 
and by pneumococci. The influenza bacilli were found mostly 
early in the malady, the pneumococci prevailed later, and 
Eyre's conclusion was that the acute beginning and the 
infectiveness of the disease were both due to influenza bacilli, 
pneumococci thereafter continuing the attack and causing 
the purulent bronchitis itself and death from a greater or lesser 
degree of pneumococcal septicaemia. Practically all the cases 
in the Aldershot Command that were investigated in this way 
proved to be influenzo-pneumococcal, but precisely similar 
cases, especially amongst the New Zealand troops in the 
Salisbury district, proved on investigation to have a form of 
streptococcus as the organism associated with the influenza 
bacillus and not the pneumococcus, so that, whereas the 
Aldershot cases were influenzo-pneumococcal, other cases 
were influenzo-streptococcal, and the general impression was 
that there was no intrinsic reason why yet other organisms 
might not sometimes be associated with the primary influenza 
infection in causing the severe purulent bronchitis syndrome. 
In other words, the bacteriology of purulent bronchitis is not 
apparently constant. The influenza bacillus seems to be an 
important factor in its epidemiology, but another micro- 
organism, associated with the influenza bacillus, plays an 
important part in the severity of the illness, the combination 
being in some epidemics influenzo-pneumococcal, in others 
influenzo-streptococcal, with a presumption that yet other 
micro-organisms might be found if further epidemics could 
be investigated. 

Morbid Anatomy. 

The lungs on post-mortem examination were large and bulky, 
owing to the presence of much emphysema, but the most 
characteristic lesion was the presence of thick greenish-yellow 
pus in all the small bronchi and bronchioles, so that on a section 
of the lung a large number of greenish-yellow points of varying 
size were seen scattered over the surface of the section wherever 
a bronchus was cut across. The pus was thick and completely 
filled the lumen of the smaller bronchi and bronchioles, so that 
these were obstructed and contained no air. The mucous mem- 
brane of the larger bronchi was congested, and the pus here 
might be discoloured from admixture with blood. The lung 
contained many areas of collapse, small in size and scattered in 



216 MEDICAL HISTORY OF THE WAR 

distribution, usually best marked in the lower lobes and towards 
their posterior borders. No case of massive collapse as a result 
of purulent bronchitis was observed by Bradford, although 
some instances of purulent bronchitis were seen as a complication 
of cases of primary collapse in gunshot wounds of the chest. 

(Edema of the lungs, together with much congestion, was 
frequently present. In at least half the cases that terminated 
fatally the bronchitic lesions described above were found without 
any broncho-pneumonia, but in a considerable number of cases 
small areas of broncho-pneumonia forming nodules, in the centre 
of which the affected bronchiole could be seen, were also present. 
Exceptionally these broncho-pneumonic areas were of larger 
size and by their coalescence considerable areas of consolidation 
might be produced. 

The bronchial glands were frequently enlarged and pinkish 
in colour, and in some instances the lymphatic glands generally 
were enlarged. Pleurisy was frequently present but was usually 
slight, a small amount of lymph being found on the pleura and 
occasionally a few ounces of clear fluid in the pleural cavity. 
Empyema was rare. The heart usually showed signs of dila- 
tation especially on the right side, and the muscular substance 
was pale and soft. The signs of dilatation were most evident in 
cases where marked cyanosis had been present during life. The 
kidneys in approximately half the cases showed evidence of 
change, in that the cortex was pale and swollen and the texture 
flabby. The renal epithelium was found on microscopic exami- 
nation to have undergone degenerative changes, and frequently 
desquamation of the epithelium, much congestion and some 
round cell infiltration were also present, changes similar to those 
found in acute nephritis. 

The spleen, the liver, and sometimes the kidneys, showed 
generally signs of engorgement, and fatty changes were not 
infrequent in the liver. 

There was nothing constant about the morbid anatomy of 
the fatal cases amongst troops in the United Kingdom, except 
the amount of pus exuding from nearly all the bronchioles 
when the cut lungs were squeezed. In those cases that had 
survived a number of days there was generally a con- 
siderable amount of diffuse broncho-pneumonia with interstitial 
haemorrhage as well ; and acute pleurisy, generally without 
effusion, was frequently present in addition. But amongst the 
considerable number seen there were several in which, in spite 
of careful search, no macroscopic evidence could be found of 
any broncho-pneumonia at all, though the clinical course- 
beyond perhaps being rather more acute than the remainder- 
was otherwise similar to those in which broncho-pneumonia 



PURULENT BRONCHITIS 



217 



was present. In such cases the histological examination of the 
lung showed remarkable inflammation not only in, but around 
the smaller bronchioles, a pronounced and extensive bronchitis 
with peribronchitis, as shown in the following illustration. 




FIG. 1. Section of lung tissue, under low power of microscope, showing 
the alveoli to be hardly affected at all, while the bronchiole is filled with cells 
and debris, and its wall and the immediately surrounding parts are 
characteristically infiltrated with small round cells. 

Symptoms of Cases in France and Flanders. 

There was some variety in the clinical picture of the malady 
in different cases. Some were not only acute in onset, but 
might be more appropriately described as fulminating, owing 
to the very rapid development of severe and often fatal lesions. 
Others were more gradual both in their origin and in their 
subsequent development. 

In the acute type the onset and early symptoms present some 
analogy to those seen at the onset of acute pneumonia. Thus 
the onset of illness is sudden and accompanied by high fever, 
cough and expectoration that may be tinged with blood. 
Although these symptoms resemble those of pneumonia, there 
are really certain differences. Thus the pyrexia is not usually 
as high in purulent bronchitis as in pneumonia, and there is not 
usually the definite rigor that is characteristic of pneumonia. 
Local pain in the chest is also not common although there may 
be much discomfort and sense of oppression. The sputum is 
not rusty ; if blood is present it occurs as streaks of blood in 

(2396) 0* 



218 



MEDICAL HISTORY OF THE WAR 



the sputum, and this rapidly becomes frankly purulent and of 
a peculiar greenish hue. Cough and oppression are very promi- 
nent features, and the dyspnoea soon becomes urgent and is 
accompanied by cyanosis. This cyanosis develops with great 
rapidity, and in some of the most severe cases it may take only 
a few hours for it to become one of the most marked features 
of the illness. In many cases the patient is of a pale leaden 
hue, in others the cyanosis is of the usual livid colour. Quite 
early in the course of the malady the pulse rate is rapid, and 
quite out of proportion to the pyrexia present. These acute 
cases may terminate fatally on the fifth day of illness, and in 
the most severe forms even earlier. Active delirium and 
excitement such as are seen in pneumonia do not occur ; 
the patient is more apt to be lethargic, although mild 
delirium may be present. 

In the less acute cases the disease runs a very remarkable 
clinical course. The onset is more gradual, the symptoms of 
cough and dyspnoea less urgent, although there may be and 
usually is much fever. The temperature probably reaches 
103 F., but it is not sustained and there are daily remissions 
leading to the production of a chart that presents considerable 
resemblance to that of a case of tuberculosis or even of enteric 
fever. In these chronic cases the pulse rarely rises to 120, and 
it may even be somewhat slow in relation to the temperature. 
This pyrexia may persist for six or even more weeks, reaching 
perhaps 102 F., or even 103 F. every day. The pyrexia is 
accompanied with much sweating and very considerable wast- 
ing, so that in many cases there is a resemblance to phthisis, 
and sometimes it may not be easy to determine apart from 
sputum examination whether tuberculosis is present or not. 

Some cases also have a remittent pyrexia, with two, three, 
or perhaps more bouts of high fever each lasting several days, 
separated by intervals of comparatively low temperature. 



*. 



CHART I. A less acute case, showing the prolonged, rather swinging 
temperature and the fall by lysis without diminution of pulse-rate just before 
death. Bacillus influenzce isolated. 



PURULENT BRONCHITIS 219 

The fever may terminate by a critical fall even as late as the 
third week of illness, more usually it subsides gradually by 
lysis, but death may nevertheless occur several days after the 
temperature has reached and remained at the normal 
level. 

The sputum is remarkable in several respects. In the first 
place it is very abundant. A patient will expectorate from six 
to ten ounces in less than twenty-four hours, and soon after the 
onset the sputum consists of nummulated non-aerated masses, 
each one discrete, roughly the size of a shilling and remaining 
discrete in the sputum cup. They are of a peculiar greenish 
or greenish-yellow colour, not offensive, and very occasionally 
streaked with blood ; this is very rare except at the onset and 
the amount of blood is always small. The character of the 
sputum and the very large quantities expectorated suggest at 
first the sputum common in phthisis and in bronchiectasis ; 
but it differs in that it is uniformly homogeneous and purulent, 
there is no separation into layers, and no expectoration of mucus 
and muco-catarrhal matter, in fact no liquid expectoration at 
all, only these nummulated masses. This peculiar sputum is 
one of the main clinical features of the disease. 

Cough is frequent and at the onset painful and distressing ; 
for a short time there may be but little expectoration, and it is 
at this period that the sputum is apt to contain streaks of 
blood. When the sputum has assumed its typical purulent and 
nummular character, the cough, although necessarily very fre- 
quent, is often not painful, and the sputum is expelled easily. 
In the very acute and fulminating cases the cough is often 
ineffectual, the sputum more scanty, and this is one of the 
factors in the grave nature of these cases. 

The pulse rate is rapid and frequently over 120 even in 
cases that recover, and, as mentioned above, this tachycardia 
is one of the main clinical features of the disease. The volume 
and the tension of the pulse are often good notwithstanding the 
rapid rate. In severe and unfavourable cases the tachycardia 
is still more marked. 

Dyspnoea and cyanosis are also prominent symptoms ; the 
rate of respiration in all cases except the slightest is considerably 
increased, and a respiratory rate of 30 to 40 per minute is not 
unusual when the fever is not higher than 102 F. to 103 F. 
The dyspnoea causes considerable distress, and in the more 
severe forms, anxiety ; but in the most severe cases where 
mental dullness or torpor is present, dyspnoea may reach a high 
degree without apparently causing much discomfort. The 
cyanosis is very marked and very persistent ; it is always a 
sign of bad omen and the pallid form is the more serious. In 



220 MEDICAL HISTORY OF THE WAR 

the acute and fulminating forms, the cyanosis is most marked 
and such cases are of the utmost gravity. 

The physical signs are usually well marked, although they 
are not so prominent a feature of the illness as is the case in 
pneumonia, and the significance of some of the signs, more 
especially the importance of the presence of areas in which the 
breath sounds are weak, may be overlooked unless due care is 
taken. In the earlier stages of the disease, rales and crepita- 
tions, fine in character and perhaps rather limitedin distribution, 
are the most marked signs, but together with these the breath 
sounds are weak and distant, and areas may be found of 
varying size where they are almost inaudible. The rales are 
especially fine in character. These signs are most marked in the 
lower axillary region, and posteriorly between the angle of the 
scapula and the vertebral column. They may become more or 
less rapidly generalized, but attention should be especially 
directed to weakness of the breath sounds, without the presence 
of any marked impairment of the percussion resonance or any 
great alteration in the character of the breath sounds. In cases 
where broncho-pneumonia is also present, the usual tubular 
breathing and other physical signs of this condition may be 
made out. The weakness of the breath sounds is doubtless 
dependent upon the presence of areas of collapse, but these are 
not generally sufficiently large to cause dullness on percussion, 
although the resonance may be somewhat diminished. The 
complete occlusion of the finer bronchioles by the purulent 
exudate is the probable reason for the absence of tubular 
breathing over the areas of collapse. 

A pleuritic rub in the axillary region may sometimes be heard, 
but often the presence of pleurisy is not detected clinically 
owing to the presence of abundant rales masking the pleura! 
friction . 

In cases characterized by the presence of cyanotic lividity the 
usual signs of over-distension of the right heart may be detected, 
such as epigastric pulsation, fullness and pulsation of the veins 
of the neck, and increase in the area of cardiac dullness to the 
right of the sternum. 

In many cases, even apart from cyanosis, considerable albu- 
minuria is present and not uncommonly nephritis of a severe 
type, with not only considerable quantities of albumin in the 
urine, but also blood. The nephritis, even when severe, is not 
accompanied by dropsy, but its presence adds greatly to the 
gravity of the case. 

The course of the malady varies ; in the acute cases it is 
measured by days, and in the most severe death may occur on 
the fifth day, or earlier still in cases of the fulminating type 



PURULENT BRONCHITIS 221 

associated with much cyanosis. In the less acute cases the 
illness lasts many weeks and the high fever may persist for from 
three to six weeks, or in some cases even longer. In such cases 
even when recovery ultimately takes place there is great 
prostration and much wasting. 

A remarkable feature of the illness is that death may occur 
after the subsidence of the fever both in the cases where this 
occurs by crisis and also where lysis is seen, and the fatal event 
may not take place until the lapse of two or three days after the 
return of the temperature to the normal level. Death in these 
cases is dependent upon one or other of the forms of asphyxia, 
the result of the blocking of the bronchioles by the purulent 
exudation. 

Symptoms of Cases in the United Kingdom. 
The characters of a typical case were briefly as follows. The 
onset was usually acute, the man falling sick with what he 
would regard generally as a " feverish cold in the head " and 
with little about him to suggest that he was suffering from more 
than acute " coryza " or " febricula." Many such cases would 
recover quickly and not pass on to the next phase ; some would 
not even report sick that day at all ; but those cases that were 
going to be serious and there was no means of distinguishing 
these from others had a temperature of 101 F. or 102 F. 
the next day, felt ill, began to have a cough and were sent to 
hospital. The cough was dry at first but within a very short 
time phlegm began to come up, and by the third or fourth day 
the sputum attracted particular notice by reason of its large 
amount. Simultaneously the respiration rate rose to 28, 30, 35, 
40, 45 or even 50 to the minute. So rapid and shallow was the 
breathing in these cases that ordinary lobar pneumonia was 
at once suspected, and it would have been difficult to persuade 
those who had not attended post-mortem examinations in such 
cases that the condition was not really lobar pneumonia. 
The physical signs found were the same as those found in 
France and as in France were remarkable for their atypical 
character. Death might occur without any consolidation at 
all, and during life the physician was struck by the paucity of 
abnormal lung signs, although the case was one of obviously severe 
pulmonary infection. The pulse might be accelerated no more 
than was to be expected from the temperature often indeed less 
so and the heart's action might remain good almost to the end. 
The three most striking clinical features at first were the 
abundance and character of the pus-expectoration, the relative 
fewness of physical signs, and the rapidity of the respiration 
rate. A little later in the disease a fourth point attracted 



222 MEDICAL HISTORY OF THE WAR 

notice, namely a peculiar dusky cyanosis of the face, lips, ears 
and finger nails, which was always a grave omen. Over half 
the cases died when once this cyanosis had become obvious. It 
depended upon the man's natural ruddiness or otherwise what 
his actual colour became ; a sallow man would look dusky- 
ashen in his forehead, cheeks and nose, but his lips and ears and 
nails would have the pale bluey-purple hue ; whilst a naturally 
high-coloured man would change from red to a more and more 
purple or blue-purple hue which might be obvious from the 
other end of the ward. It was the cyanotic look, not the 
actual colour, which portended the fatal issue.* The pulse 
remained good ; the cyanosis was not due to heart failure, and 
it was not benefited by venesection ; it seemed to result from 
anoxaemia, oxygen being unable to gain access to the capillaries 
by reason of the abundance of purulent secretion in the tubes. 
Recovery at this stage might occur, but by the time the 
cyanosis had become at all pronounced the prognosis was 
extremely bad, although the number of days the patient sur- 
vived in spite of it was sometimes surprising. 

By this time the dyspnoea had often become very marked, 
respiration consisting of short shallow movements, which in bad 
cases amounted almost to gasps reminiscent of the effects of gas 
poisoning. In less severe cases dyspnoea might be in abeyance 
when the patient lay quite still, yet the slightest effort, such as 
turning to one side for examination of the back, might send the 
respiration rate up at once from 30 to 50 or over, this rate not 
falling to the lower figure again for quite a long while afterwards. 
The patients were consequently best left undisturbed. 

The character of the sputum pus in abundance would 
remain the same for days, though sometimes it would be blood- 
stained or pure blood might be coughed up independently of 
the pus. Rusty sputum was exceptional. In the later stages 
of the illness areas of impaired note or actual dullness might be 
found, particularly at the bases, associated with bronchial 
breathing and crepitant rales. These might be due to progres- 
sion of the purulent bronchitis into hypostatic pneumonia or 
into actual broncho-pneumonia ; or they might be the result of 
massive collapse secondary to the bronchitis and obstruction of 
the bronchioles by thick pus ; or, again, as the result of pleurisy. 
This last was not uncommon and not infrequently caused an 
exudate of a pint or more of thin turbid fluid, which more 
often than not cleared up after simple aspiration. An actual 
empyema followed only in exceptional cases. 

Defervescence was usually by lysis rather than by crisis, 

* The plates at page 181 illustrate this condition. 



PURULENT BRONCHITIS 



223 



and convalescence slow. Troublesome cough and persistent, 
though diminished, expectoration might last for weeks, and 
recrudescence of the mischief, possibly with a fatal termination, 
after all had seemed to be going well, might occur even several 
weeks after the primary attack. Many patients, on the con- 
trary, made a complete recovery in a fortnight or three weeks. 

The following chart is typical of the longer cases : 

The patient was a mechanic in the Royal Air Force, age 35 ; service four 
months. He was admitted to hospital on April 4th, 1917, with a history of 
having been out of sorts with a cold and bronchial cough for ten days 
previously. On admission his temperature was 103 F. ; pulse-rate, 112; 
respiration-rate 36. Abundant blood-stained purulent sputum. The 
accompanying temperature chart indicates the course of the disease. The 
man was seriously ill with purulent bronchitis for ten days ; improved 
considerably for a short time ; then relapsed for a week, becoming seriously 
ill again, but ultimately recovering completely. Throughout the whole time 
he was in hospital he was coughing up abundant thick yellow pus, which, at 
first bloodstained, was latterly yellow and free from visible blood. No tubercle 
bacilli were found. The treatment was mainly by the use of antiseptic 
inhalations. 

The bacteriological findings were as follows. The sputum showed the 
presence of B. influenza, pneumococcus, and Micrococcus catarrhalis. 



CHART II. 




10. 26.102. 6. /O.2. &M.2- 6\M.2. 6.K&2. 6 V.2J&/0. 2. 



2 6./C2.& K3.2. 6.K>. 2.6. >O.2\6IO J. 6.M.2. f. Q 




22 



26 



27 

>.^6.K^2.A\Al',At l iAya^6.JC^2.6^O.2\&x(2.6.\M}.2\&n 



. V.Z AM 2. & f0.2t&Xi 



105 
104.' 
103' 
102* 
1OI* 
100* 



? 



\ 



S/ 



at 




S? 



f 



224 



MEDICAL HISTORY OF THE WAR 



APRIL 


8 


29 


30 


MAY 1 


2 


3 


+ 


jr 


6 


7 


a 


HOU8S 


2.6. 


a.j\s/a 


\2--6. 


/0.2, 


6.10. 


2.6. 


/a 2 


6./0. 


2.6. 


/(a.? 


6.10. 


Z 


/#..? 


tf./a 


2.6. 


10.2 


6XR 


1.6. 


/O.Z 


tf./a 


ztf 


/<ai 


&.IL 


2.6. 


J>OL 


6.4 


2.6. 


/OL2 


6.KI. 


2.6. 


/a ^6jo. 


103* 
102* 

ir 

100* 
99' 
































































































































P 




































































v 




































































\ 


ft 

2 


\t 


A 
L 


jfc 




/S 


A 

W 


25 




f 






i ^t 










/ ' 




























98* 

97 














-W 








W*- 






^ 




\S 


ss* 


s_ 


~*r 


k~ 


^ 


/ 




^ 


i^ 


?* 


"^ 


^ 


































































V 












PULSE. 
KE3P. 


/& 


120 

at 


/2i) 

Off 


B 

w 


.'-'j 
1 ex 


12 


too 


//6' 
112 


/<X> 
//* 


{ 


/sf 
//2 


^ 


^2 


ni? 
//'5 


//^ 
/jf 


Si 


'X) 
/OS 


i> 
JM 


JH 


B 

,?? 


j5 

^ 


9 

g 


7 I 

gff f2 


?3 


so 




loo 












48 


+0 

to 


ft 

32 


9 

32 


fO 


44 


30 


3O 
32 


r^ 
<J? 


.?? 


^* 

' 23 


48 
28 


jtf 


>3 


X 

2S 


'24 




^? 


& 
24- 

































Complications other than the supervention of broncho- 
pneumonia or pleural effusion were quite uncommon. The 
gastro-intestinal tract seemed to escape, except for thick 
febrile coating of the tongue ; the latter in severe cases was apt 
to become dry, brown and cracked, from the effects perhaps of 
rapid breathing through the mouth. This dry cracked tongue 
was an unfavourable symptom. There was not the same 
tendency to nephritis that the 1918-19 epidemic of influenzo- 
pneumonia produced. Mental symptoms delirium or Coma 
were not more pronounced than was to be expected in any 
febrile illness of severity. Sore throats of mild degree were 
complained of in the early stages, but all other symptoms in 
the cases were quite overshadowed by the four characteristic 
phenomena already described. 

Prognosis. 

With regard to prognosis, the malady is a very serious one 
and the mortality is very high, especially in the acute type. 
It is difficult to give figures since these would vary with the type 
of case included under the term purulent bronchitis. Many 
cases were seen where the fever was not very high ; the sputum, 
although purulent and nummulated, was not very abundant, 
and the general illness was slight. Such cases were not un- 
common in wounded men, and frequently subsided with simple 
treatment. If the more severe cases are alone considered 
where the symptoms were urgent, the sputum copious and the 
fever high, it is probable that the mortality was generally as 
high as 30 per cent, and often much higher. Cases with marked 
cyanosis did not often recover, and this was true both of the livid 
and the pallid type, but the prognosis was undoubtedly graver 
in the latter than in the former. Increasing tachycardia 
was also a very unfavourable sign, and also the presence of 
broncho-pneumonia or nephritis. Bodily vigour and youth 



PURULENT BRONCHITIS 225 

did not increase the chances of recovery as much as might be 
expected, and some striking instances were seen where recovery 
took place in men of relatively poor physique. Age and habits 
influenced the course of the disease in a manner similar to that 
seen in pneumonia. In the cases where recovery took place 
the convalescence was slow and prolonged, but neither relapses 
nor any permanent ill effects, such as emphysema, were observed 
by Bradford. 

Diagnosis. 

The main difficulties in diagnosis are the distinction of the 
malady from pneumonia in the earlier stages of its progress, 
and later the liability to confound it with tuberculosis and 
sometimes with enteric fever. In some instances it may be diffi- 
cult to distinguish between purulent bronchitis complicated 
with nephritis and a primary nephritis complicated with 
broncho-pneumonia. The suddenness of onset and the severity 
of the respiratory symptoms lead to the confusion with 
pneumonia, and the long-continued fever of irregular type 
causes the superficial resemblance to enteric fever and tuber- 
culosis, especially as some cases of enteric fever have not only 
pulmonary symptoms but sometimes definite pulmonary signs. 
The abundant sputum and the marked emaciation also are 
responsible for the confusion with tuberculosis. Examination 
of the sputum for the bacillus of tubercle will usually enable 
the differentiation to be made. The essential features in 
the malady are the remarkable sputum, the pyrexia, the 
tachycardia, and the cyanosis. 

Treatment. 

With regard to treatment, it is not surprising, seeing the 
nature of the lesion in the small bronchioles, that the treatment 
is not very satisfactory. No line of treatment was discovered 
which seemed to modify the course of the disease, once it got 
hold of the patient. The most important point is to try 
and render the expectoration of the sputum easier to the patient 
and thus spare his strength. For this purpose a warm moist 
atmosphere is essential, and a steam tent and hot inhalations 
are the most serviceable means of securing this. Eucalyptus or 
Friar's balsam may be added to the hot steam inhalations with 
benefit. Small doses of potassium or sodium iodide are also 
useful, and tartar emetic in small doses is also of value in the 
early acute stage. In cases with livid cyanosis venesection is 
sometimes beneficial, and from ten to twenty ounces should be 
withdrawn. Oxygen inhalation is also of use, and care should 



226 MEDICAL HISTORY OF THE WAR 

be taken to warm the oxygen. Although there is much differ- 
ence of opinion as to the use of digitalis in inflammatory lung 
disease, it is of considerable value in purulent bronchitis. 
Adrenalin may also sometimes be given with advantage. 
Moderately free purgation especially with concentrated saline 
purgatives should also be employed. No special precautions 
were taken in France to isolate these cases from other patients 
in the hospital wards, and during the winters of 1914 and 1916 
there was no evidence to suggest that the disease required to 
be regarded as contagious. The occurrence of many cases in 
any particular unit or formation at the front showed that under 
exhausting conditions of cold and wet the disease affected 
many men, but removal from such conditions was all that seemed 
necessary to prevent the infection from extending. 

In the United Kingdom, however, a different opinion pre- 
vailed. In view of the facts that when one case developed in 
a barrack-room others were apt to follow, and that influenza 
bacilli were found constantly in the sputum in the earlier 
cases, the need for the isolation of the earliest cases and 
disinfection of the abode in which they occurred, in order 
to prevent the infection spreading to healthy contacts, 
was strongly emphasized. The question of prophylactic 
inoculation of troops in a district in which purulent bronchitis 
has begun to appear has been considered in the chapter 
on " Influenza." The treatment of patients suffering from 
influenzal pneumonia is equally applicable to the prophylaxis 
and treatment of purulent bronchitis. 

BIBLIOGRAPHY. 

Abrahams, Hallows, Purulent Bronchitis, its Influen- Lancet, 1917. Vol. ii, 
Eyre & French zal and Pneumococcal Bacter- p. 377. 

iology. 
Eyre & Lowe .. Prophylactic Vaccinations Lancet, 1918. Vol. ii, 

against Catarrhal Affections p. 484. 

of the Respiratory Tract. 

Hammond, Rolland Purulent Bronchitis A Study Lancet, 1917. Vol. ii, 
& Shore of Cases occurring amongst p. 41. 

British Troops at a Base in 

France. 



CHAPTER IX. 

MALARIA. 
AETIOLOGY, INCIDENCE AND DISTRIBUTION. 

OF all diseases responsible for casualties during the war 
malaria probably holds first place. To realise this fully 
one has only to look at the figures for admissions for malaria 
for the three years 1916, 1917 and 1918. In Macedonia they 
reached the total of about 160,000 ; in Egypt, about 35,000 ; 
in East Africa 107,000 between June 3rd, 1916 and October 
27th, 1917; and in Mesopotamia about 20,000. Other 
places, such as the Cameroons, German South-West Africa, 
France, and even England itself, contributed to the total, 
but the numbers are insignificant in comparison with these 
figures. 

MACEDONIA. 

The British Army arrived at Salonika at the end of 1915, 
after the malaria season was well over. From this point of 
view a better season could not have been selected, as it gave 
time for settling down and making a malarial reconnaissance 
of the country. 

Macedonia is a country with a hot summer and cold winter, 
the extremes being fairly great. The maximum summer tem- 
perature in August for the past ten years has been about 
90 F., the minimum at the same season being about 70 F. 
The coldest period is in January and February with a maximum 
of about 52 F. and a minimum of about 38 F These tem- 
peratures are based on the mean daily temperatures, maximum 
and minimum, for ten years, but they do not represent the 
actual extremes in various parts of the country. There is a 
wet season, commencing in the autumn and extending through 
the winter, and a dry summer which is broken by heavy 
thunderstorms and great downpours of rain. All these factors 
are important in that they affect the behaviour of the 
mosquitoes which carry malaria. 

Cardamatis has drawn attention to the fact that malaria is 
much worse in Greece after a very wet winter and spring, since 
this condition favours the development of mosquitoes. During 
the winter much snow falls, especially in the hills, and there 
are sharp frosts. 

The country itself may be described as a continuous series 
of hills and valleys. In the area occupied by the British there 

227 



228 



MEDICAL HISTORY OF THE WAR 



were two large rivers, the Struma and the Vardar, and several 
lakes. The Struma river with the lakes of Tachinos and 
Butkova, Lake Doiran, the Vardar river with the lakes of 
Ardzan and Amatova, and the Lakes Langaza and Besik, form 
a rough circle in low-lying land. This series of rivers and 
lakes represents the line which was occupied with such fatal 
results in the middle of 1916. Surrounding this circle and also 
within it is elevated country which itself is a complicated 
system of hills and gullies and innumerable streams. This 




Map illustrating the area occupied by the British Army in Macedonia, to 
show the circle of lakes described in the text. The figures are heights in 
metres. 

difference between the low-lying circle and the hilly country 
corresponded with the distribution of the two chief anopheles 
responsible for the Macedonian malaria. 

The Struma valley with the lakes of Tachinos and Butkova 
is about 60 miles in length with a breadth of 5 to 10 miles, 
representing about 400 square miles of fairly flat country. It 
receives water from all the hills north and south of it and, as 
in many places it is actually below the level of the Struma, a 
most intensive breeding ground for mosquitoes is produced. 






MALARIA 229 

Marshes occur everywhere, especially about the mouth of the 
Struma and the two lakes. Many of the streams running 
down from the hills never reach the main river but are lost in 
marshes. The Struma valley is very fertile and in spring and 
early summer presents a glorious picture of green, broken up 
by acres of wild flowers of every colour and of fruit trees in 
bloom. As the summer advances the scene is completely 
changed as on many areas between the marshes the grass is 
entirely dried up. The valley of the Vardar, with the two 
lakes beside it, is of a similar nature and consists of low-lying 
country intersected by streams and broken up by marshes ; 
the same may be said of the Langaza valley. 

The hill country, the most important section of which from 
the British point of view was that within the low-lying circle 
of lakes, consisted, as already noted, of hills and gullies. In 
most places there were no trees, but in spring the hills were 
covered with green, though the grass quickly dried, leaving a 
brown, burnt-up country. The gulh'es, however, retained their 
vegetation of grass, bushes and even trees, because of the 
countless perennial springs found all over the land. Every 
gully had in summer its trickle of water, which became a 
rushing stream or torrent in winter or after the sudden 
thunderstorms of the hot season of the year. The streams 
arose in springs at elevations up to three or four thousand 
feet above sea level. The source was often built in as a 
fountain by the inhabitants. The overflow would trickle away 
amongst the stones, flow through stretches of grass or rushes 
and be completely hidden from view, pass through a rocky 
channel or disappear in dense brushwood. On every side the 
stream thus formed was receiving tributaries and increasing in 
size. Frequently in sandy, permeable soil it would disappear 
below the ground and be found again lower down the gully. 
Passing across a stretch of comparatively level ground it would 
form small marshes or would fall over a ledge into a rocky pool. 
Eventually reaching the valley it would open into the river or 
be lost in a marsh. During the summer much of the water 
dried up and the streams would completely vanish lower 
down or be represented by isolated pools, but higher up the 
springs were still present and nearly every gully retained its 
trickle of water and grass-grown pools. 

Hilly country of this nature existed south of Lakes Langaza 
and Besik and to the east of Salonika, and it was here on the 
high Hortiak plateau that sites were chosen for summer 
hospitals. 

West of the Vardar river in the area occupied by the French, 
Serbs and Italians, the country was largely of a hilly nature, 



230 MEDICAL HISTORY OF THE WAR 

though low valley areas also existed. Directly west of Salonika 
was the delta of the Galiko and Vardar rivers, a large tract of 
flat country cut up by streams and extensive marshes. 

In order properly to comprehend the malaria problem 
of Macedonia it is necessary therefore to recognize the two 
types of country, the low-lying marsh, river and lake districts 
along the circle of lakes and in the Vardar delta, and the high, 
hilly country around and within the circle. 

When the expeditionary force arrived in Salonika the troops 
were distributed over the hills south of Langaza Lake and about 
Salonika itself and also on the hills east of the Galiko river 
as far as Kukus. Troops were also stationed west of 
Salonika along the Monastir road. The possibility of 
the occurrence of malaria, especially in this latter area, was 
recognized, and early in 1916 steps were taken to deal 
with the area from a mosquito-breeding point of view. At 
this time it was evident that malaria was to be expected in the 
marshy country, but the whole system of the countless hill 
streams proved to be a more prolific source of mosquito 
production than was anticipated. Had the troops remained 
in the positions just indicated there would have been un- 
doubtedly a good deal of malaria, but nothing to be compared 
with what actually occurred after the move forwards in the 
middle of June, just at the time when the worst malaria season 
of the year was commencing. Up to the time of the advance 
there had been about 150 cases of malaria, and of these 90 
occurred in June, so that malaria was even then beginning to 
occur. 

At the end of June 1916, the troops moved forwards to the 
Struma and eventually occupied, in a line running east and 
west, the whole valley from the mouth of the river to Lake 
Butkova, thence to the south of Lake Doiran and then over 
the hills to the Vardar at a point north of Smol. West of this 
the line was occupied by the French. It was recognized that 
this was a highly malarial zone from the earliest period of the 
British occupation: but it was not anticipated that troops 
would move beyond the perimeter of defences of Salonika, and 
anti-malarial measures were consequently confined at first to 
the latter area. 

The effects of the advance are clearly shown by the monthly 
admissions for malaria for one division from June to October 
inclusive, the successive monthly figures being 4, 1300, 2500, 
1600 and 1100. In all there were over 30,000 cases of malaria 
during the year 1916. From the same line, and behind it in 
1917, there were over 70,000 admissions, and in 1918 about 
60,000. For the period 1st November, 1915, to 31st October, 



MALARIA 231 

1918, the admissions per 1,000 of strength worked out as 
follows : 

1st November, 1915 to 30th April, 1916 . . 0-24 

1st November, 1916 to 30th April, 1917 . . 56-83 

1st November, 1917 to 30th April, 1918 . . 162-75 

1st May, 1916 to 31st October, 1916 . . 237-28 

1st May, 1917 to 31st October, 1917 . . 277-85 

1st May, 1918 to 31st October, 1918 . . 253-82 

The admissions to hospital which the above figures represent 
indicate only a part of the incidence, for many cases were 
treated in field ambulances or in the units without the men being 
admitted to hospital. Consequently, it is almost impossible 
to form an accurate estimate of the extent to which the army 
became infected with malaria. During the influenza epidemic 
of 1918, 83 per cent, of a series of over 100 autopsies per- 
formed by Captain Taylor on men who had died of influenzal 
broncho-pneumonia showed definite malarial pigment in 
the spleen without there being active malaria. This figure 
therefore would probably not be too high an indication of the 
percentage of the army which actually became infected with 
malaria in Macedonia. 

The anopheline mosquitoes of Macedonia are five in 
number : A . maculipennis, A . superpictus, A . bifurcatus, 
A. sinensis (pseudopictus) and A. algeriensis. A. maculipennis 
was universal, but occurred in greatest numbers in the 
low-lying districts described above. It was the prevalent 
anopheline of the Struma valley, the Vardar valley, the lakes 
and the Vardar and Galiko deltas west of Salonika. On the 
other hand A . superpictus was essentially a hill stream mosquito 
and could be found breeding in any of the streams from their 
source 3,000 or 4,000 feet above the sea right down to where 
they broke on to the plains. A. maculipennis would be 
found on the edges of the lakes and in every marsh, however 
large or small, in the borrow pits, the holes left by horses' 
hoofs, in tin cans and in fact in any collection of water 
occurring in the valley. A. superpictus bred in the streams, 
not in the actual current though they could be taken there, 
but in every little pool or backwater, in the tiny bays behind 
stones or in the sand, in the small collections of water formed 
by seepage and in every place where clean and especially alga- 
growing water appeared. In the streams frogs and water- 
boatmen abounded and the mosquito larvae lived with these 
in perfect harmony. In the lower reaches fish were often pre- 
sent but none of these natural enemies of larvae seemed able to 
cope with the intensive mosquito breeding. In the valleys also 

(2396) P 



232 MEDICAL HISTORY OF THE WAR 

the same association of mosquito larvae and their natural 
enemies was constantly observed. During the summer the 
whole of the low-lying districts were breeding A. maculipennis, 
and the hill country A . superpictus. 

A. bifurcatus was not a very important mosquito in Mace- 
donia. Its larvae could frequently be found in the partially 
closed receptacles of the built-in fountains in the hills, but it 
was also found breeding in the streams and in the valleys in 
small numbers. A. sinensis was rarely encountered except 
in certain localities. It was quite common, however, near the 
marshy south end of Lake Ardzan and around Butkova. It 
was taken in other marshy districts, but in small numbers. 
A . algeriensis was taken only once, when its larvae were collected 
from a fountain in the hills along the upper part of the Seres 
road. 

Though it has been pointed out that A. maculipennis is a 
valley, and A. superpictus a hill mosquito, this demarcation 
was subject to exceptions. There was a certain amount of 
overlapping. A. maculipennis was sometimes found breeding 
high up, especially where a stream passed across a compara- 
tively level tract and in its course produced marshes and pools 
resembling those in the valley, while A. superpictus would 
also be taken in the valley. It must have happened that many 
larvae of the latter species were washed down the streams into 
the valley, especially after the summer thunderstorms. But that 
the main distribution is correct the following figures will show. 

In 1918 Captain Cummins, R.A.M.C., collected during July, 
August and September at No. 60 General Hospital on the 
high Hortiak plateau 9,402 anophelines. Of these 9,291 were 
A. superpictus and 111 A. maculipennis. Of 2,910 anophe- 
lines collected for dissection at Lahanah village 2,000 feet 
above sea-level, 2,831 were A. superpictus and 79 A. maculi- 
pennis. Of 50 anophelines taken casually at Dragos in the 
Struma valley in July, August and September 1918, all were 
A. maculipennis. On November 25th, 1918, collections were 
made at Sakavca in the Struma valley and at Lahanah in 
the hills. In the former place about 60 A. maculipennis 
were taken in one building, while at the latter the same number 
of A. superpictus was collected. It would be possible 
to multiply these illustrations, but the above serve to 
show clearly the relative distribution of the two important 
Macedonian anopheles. 

It is quite clear that the greatest amount of malaria occurred 
in the valleys where A. maculipennis was the chief carrier. 
Quite apart from any difference that might exist in the carrying 
power of the two mosquitoes this is what might have been 



MALARIA 233 

expected. The temperature in the valleys is higher than in 
the hills, and consequently the mosquito season is longer. In 
the Struma valley the breeding season extended from May 
to November, while in the hills it was from July to October. 
In the valley on warm days in winter mosquitoes would usually 
attack in the open so that in the valley there was a much 
longer breeding season. By the time that breeding had 
commenced in the hills the valley had had a two months' 
start and was infested with anophelines. These mosquitoes 
had also been infecting themselves with malaria in 1916 from 
the natives and in subsequent years from the troops so 
that large numbers of infected mosquitoes existed in the 
valley by the time that the hill mosquito was beginning to 
spread the disease. Thus A. superpictus in the hills would 
never be able to overtake either in actual numbers or in 
intensity of infection the A. maculipennis of the valleys. 
It is for this reason that the greatest amount of malaria 
originated in the valleys. 

It has been suggested that there was possibly a difference 
in the carrying powers of A. superpictus and A. maculipennis 
and that the former, appearing later than the latter, 
might be especially responsible for the late outbreak of 
malignant tertian malaria. A similar statement was made in 
reports on the malaria of Palestine. Wenyon conducted 
experiments to test these various theories. It was shown 
that both A. superpictus and A. maculipennis could very 
readily be infected with P. falciparum and that they become 
infected to the same extent. With P. vivax again both became 
infected, but A. maculipennis a little more readily than A. 
superpictus. It was quite clear that any explanation of the 
late appearance of malignant tertian malaria, or the more 
intense malaria of the valleys, which was based on any supposed 
difference in the infectiveness of the two mosquitoes, was not 
sound. The mosquitoes appeared to be equally dangerous, 
but the valleys were the worst places because the mosquitoes 
were more numerous there and probably more highly infected. 

Furthermore, there was no special association of malignant 
tertian cases with A. superpictus. The greatest number came 
from the valleys, where A. maculipennis was the chief vector, 
but they also occurred in A. superpictus areas such as the 
Hortiak plateau. The same can be said of the severest cerebral 
types of malignant malaria so that there is no evidence whatever 
to justify the association of one mosquito with one particular 
type of malaria. The late appearance of A. superpictus and 
of P. falciparum is merely a coincidence dependent on two 
entirely different factors. 



234 MEDICAL HISTORY OF THE WAR 

It has been stated that malaria was prevalent to the greatest 
extent in the valleys, and this is proved by the sudden outbreak 
which occurred when the troops occupied the Struma valley. 
All along the front line occupied by the troops and in 
the more backward area along Lake Ardzan malaria was 
particularly rife. The very worst places were Karasuli at 
the south end of Lake Ardzan and Causica at the north end, 
the south side of Lake Doiran, where two long borrow pits 
made in the construction of the railway embankment had 
developed into extensive marshy breeding ground, Dova Tepe, 
the district about Butkova Lake, and the mouth of the Struma. 
These places were notoriously dangerous, but the whole front 
line was very much of this nature, except the short section 
between Doiran Lake and the Vardar river. 

That the hill country, the chief breeding place of A. super- 
pictus, was also malarious is well illustrated by the figures 
for malaria admissions amongst the personnel of some of the 
hospitals in these situations. The Hortiak plateau, 2,000 feet 
above the sea, was a beautiful spot which on account of its 
lower summer temperature was selected as a site for summer 
tented hospitals. The prevalent mosquito was A . superpictus 
which was found in numbers in all the hospitals in spite of 
very energetic anti-mosquito work on the streams. There the 
61st General Hospital in 1917 had 49 cases of malaria 
amongst its personnel and 5 amongst the sisters. The 49th 
General Hospital lost from its personnel each month from 
June to December, 1, 2, 26, 39, 13, 5, and 2 men respectively 
from malaria. In August 14 sisters, in September 15, in 
October 6, and in December 2, went down with the disease. 

Here then in an elevated area, where the anopheline was 
almost entirely A. superpictus, malaria was quite common. 
At the 37th General Hospital stationed at the foot of hills at 
Vertikop, about 80 kilometres west of Salonika, the malaria 
incidence was higher. The mosquitoes here were both A. 
maculipennis from the plain and A. superpictus from the hills. 
In 1917 amongst the personnel there were 45 primary cases, 
and 69 amongst men who had previously had the disease. 
In 1918 the figures were 55 and 94, giving totals of 114 and 
149 for the two years. There were 23 primary and 6 secondary 
cases amongst the sisters. 

Various theories have been put forward to explain the 
early appearance of P. vivax of benign tertian malaria, and the 
late appearance of P. falciparum. Temperature conditions 
more favourable to P. falciparum in the late summer have 
been suggested, but experiments show that the difference in 
temperature required for the development of the two species 






MALARIA 235 

is really very slight. Roubaud has offered as an explanation 
the more rapid development of P. vivax in mosquitoes. This 
difference in the rate of development is corroborated by 
Wenyon's experiments, but is hardly sufficient to account for 
the difference in the time of appearance of the malaria parasites. 
A more simple explanation suggests itself. It is well known, 
and the war has produced much confirmation of this, that 
benign tertian infections in man are very persistent and relapses 
are common. An infection, once acquired, tends to persist for 
several years in spite of treatment. P. falciparum infections, 
though more severe at the time, disappear more rapidly, either 
as a result of a natural resistance or the greater specificity of 
quinine for this type of malaria, and an infection rarely tends to 
carry over into the succeeding year. Thousands of cases of 
malaria diagnosed as malignant tertian in Macedonia have on 
return to England and France shown relapses not of malignant 
tertian, but of a benign tertian infection, which must have 
co-existed at the time the diagnosis was made. The advocates 
of the theory which claims that the malarial parasites belong 
to one species and that the differences merely indicate seasonal 
or other variations in form have made use of this fact to support 
their arguments. 

In a series of examinations made under the direction of 
Colonel Dudgeon in Macedonia in the winter of 1916-17, to 
discover the extent of infection of men in the Struma valley, 
the following figures resulted. In one series 977 men examined 
showed 216 P. vivax infections, 24 P. falciparum, and 1 
P. malaria. A second series of 828 gave 222 P. vivax, 9 
P. falciparum and 1 P. malarice, while a third and later 
series of 1,031 men gave 251 P. vivax, no P. falciparum, and 
no P. malarice. Those men were not actually suffering from 
malaria at the time, but the figures show clearly not only the 
extent of the carriers amongst the men, but also the tendency 
for the P. falciparum infection to disappear during the 
winter. 

After the commencement of the malaria season each year 
a large proportion of the benign tertian cases will be relapses 
or superimposed infections, while, the majority of the malignant 
tertian cases will be definite primary infections. Thus at the 
commencement of the malaria season there will be a much 
larger number of carriers of P. vivax than of P. falciparum, 
and a larger number of mosquitoes will become infected with 
the former than with the latter. The first great influx of 
cases will be benign tertian. Isolated cases of malignant tertian 
malaria will also occur, and there is a record of an undoubtedly 
primary case from the Struma valley as early as May. 



236 



MEDICAL HISTORY OF THE WAR 



When once acquired, malignant tertian malaria is more 
severe and in a shorter time produces a greater number of 
gametocytes than benign tertian. There will, therefore, be a 
tendency for malignant tertian to overtake the benign tertian 
because mosquitoes will more readily become infected in the 
cases containing the greater number of gametocytes. Further- 
more, experiments, mentioned below, have shown some 
indication that the gametocytes of P. vivax are more easily 
rendered non-infective to mosquitoes by means of quinine 
than those of P. falciparum. 

Mention has just been made of the fact that benign tertian 

malaria occurs earlier in the year than malignant tertian. 

Very large numbers of blood film examinations were made in 

JQOOO 



9000 
80OO 
7000 
6000 
5OOO 
4000 
3OOO 
200O 
1000 



















/ 


\ 
























/ 


\) 


\ 
















/ 
/ 


\ 
v 




1 


A 


\ 














8 " 


/ 

/ 


\ 
\ 


/ 


1 


i \ 


3 












^ 


^ ^ 




i 


X 
X 


\ 




E 


\ 








1 
/ 

1 








I 




t 




\ 


\ 








1 
1 

1 








/ 


A 


r 




\ 


\ 






s 

/ 


/ 

/ 


^\ 


^ 






? 


/ 

a 


V 

/ / \ 




\\ 








/ 










z 


/I 












>. 

V 










^ 


/X 

s 













Feb. Mar flp. May June July flug. Sep. Oct. Wot/ Dec 

Estimated number of malignant tertian and benign tertian 
admissions in the Macedonia Expeditionary Force 1917 and 1918. 
Curve, based on approximately 40,000 positive blood film examina- 
tions as collected from the army laboratories by Colonel Dudgeon. 

the various army laboratories. The tabulated results of 
about 40,000 positive films for 1917 and 1918 show that 
towards the end of the year about half the blood films 
show Plasmodium vivax and the other half P. falciparum. 
After this period there is a fall in the proportion of the 
latter and a rise in the former till, during the period March to 



MALARIA 237 

May, when mosquitoes are just becoming active, well over 
98 per cent, of the positive films show P. vivax. The first 
influx of fresh cases begins in June to July, and these are 
mostly benign tertian. The malignant tertian cases do not 
appear in great numbers till August. If the positive blood 
film examination of P. vivax and P. falciparum is taken to 
represent the proportion of the two types of malaria in all 
cases admitted to hospital, the monthly admissions for benign 
tertian and malignant tertian malarias can be estimated. The 
results are illustrated on the chart on page 236. It will be 
seen that during the whole year there was a greater number 
of benign tertian cases, reaching a maximum in August. The 
malignant tertian cases reached a maximum one month later, 
but this maximum was lower than that of benign tertian cases. 
The figures obtained by the armies of the Allies agreed with 
those of the British. The infection of mosquitoes with malaria of 
course depends upon the presence of infected individuals. The 
early incidence of P. vivax compared with the late appearance 
of P. falciparum has already been explained as due to the 
greater number of carriers of P. vivax at the early part of the 
mosquito-breeding season. The mosquitoes which first infected 
the troops undoubtedly acquired their infection from the 
native inhabitants, who were largely infected with malaria. 
When the army advanced to the Struma line the natives were 
still present in the villages in the valley and the troops became 
infected from them. The villages were then evacuated, but 
at the next malaria season so many of the troops were 
carriers that the native was no longer required as a reservoir 
for the parasites. 

The incidence of malaria depends on two factors : the 
number of anophelines and the percentage of these infected. 
There are no figures showing the percentage of infected 
mosquitoes in the Struma valley. In 1917, 175 anophelines 
(A . maculipennis and A . sinensis) collected from hospital tents 
at Karasuli near Lake Ardzan, a very unhealthy spot, were 
examined. Not a single infected mosquito was found amongst 
them. Isolated instances of infection were found amongst 
anophelines (^4. maculipennis) collected in the Struma valley, 
but the numbers dissected were too small to allow of any 
deductions. 

French writers state that in certain localities, especially 
around hospitals for malaria patients, nearly every mosquito 
was infected, but such a condition was never found by 
Wenyon, who consequently doubts the accuracy of the French 
observations. 

Dissections on a large scale were made at Lahanah village, 



238 MEDICAL HISTORY OF THE WAR 

2,000 feet above the sea. This village was selected because 
it was accessible, and the natives were known to be highly 
infected. Thus in October 1917, in films made from eight 
children P. falciparum was found in three, P. vivax in one, and 
P. malar ice in one. In June 1918, in films from 52 children 
attending school, P. falciparum was found in five, P. vivax 
in 15, and P. malaria in three, double infections of the two 
first-named parasites in two and ring forms only in four. 
Fifty-five per cent, were found infected on a single film 
examination. In November 1918, a similar result was 
obtained with 49 per cent, infected. 

Lahanah was thus a suitable place to test the infectivity of 
mosquitoes. In all, 2,831 A. superpictus and 79 A. maculi- 
pennis were dissected through the summer and winter of 1918. 
The results showed that the highest percentage of infections 
occurred at the height of the malaria season, for on September 
2nd, of 125 A. superpictus examined seven were infected, while 
on August 6th, of seven A . maculipennis one was infected. 

Taking the figures in four monthly periods the percentages 
of infected anophelines were as follows : 

November 1917 to February 1918 5 per cent. 

March 1918 to June 1918 - . . 0'3 

July 1918 to October 1918 . . 1-5 

November 1918 0-2 

It was perhaps surprising that in such a heavily infected 
village a higher infection rate was not obtained. A great 
deal evidently depends on the opportunity the anopheles have 
of obtaining infected blood. Thus on September 2nd, 1918, 
a batch of 42 A. superpictus taken from one barn gave six 
positive results a percentage of 14. It is highly probable 
that some infected child had been sleeping in this barn. The 
result further illustrates the danger of calculating percentages 
of infected mosquitoes unless large numbers are examined. 

In the light of these results it is difficult to understand 
the high percentage of infected mosquitoes found in Italy 
at Taranto, which was not nearly so malarious as Lahanah 
village in Macedonia. 

The earliest date on which an infected mosquito was 
detected was on May llth, when an A. maculipennis taken 
at Dragos in the Struma valley was found to have oocysts 
in the stomach. It is, however, almost certainly the case 
that infections in the Struma took place much earlier than this. 

Macedonia being a country with a hot summer and a cold 
winter, there is a definite period of hibernation of anopheles. 
The conditions vary with the elevation and as already explained 



MALARIA 239 

there is a longer season of mosquito activity in the Struma 
valley than in the hills. As the cold weather approaches, 
in October in the hills, and November in the valley, great 
numbers of large, fat, hibernating females appear and take up 
their winter quarters. The favourite place of hibernation is 
in the barns of occupied villages. The Macedonian village 
house has two storeys, the lower one used as barns or stables 
and the upper, approached by an outside stair, as a living 
quarter. The barns and stables are dark, have dirty 
cobweb-covered beams and rafters and thus make an ideal 
hibernation retreat for mosquitoes. In those places the 
anopheles can be found in thousands in the winter A. 
maculipennis in the valleys and A . superpictus in the hills. 

On dissection of these mosquitoes during the winter, it was 
noted that at the early part of the season they were loaded 
with fat and had immature ovaries ; as the season became 
warmer towards the summer the fat was reduced and the 
ovaries developed till they were finally mature. Artificial 
incubation of these mosquitoes during the winter produced 
the same result. As no hibernating males were found amongst 
many thousands collected, it was evident that impregnation 
had taken place before hibernation. 

A particular feature of the hibernation was that in many 
cases it was only partial. In the barns during the winter, 
cattle, buffaloes and donkeys were frequently housed and these 
animals acted as veritable stoves, warming up the atmosphere 
to such an extent that the mosquitoes were rarely completely 
so moribund as they were in empty barns. A varying per- 
centage of all anophelines collected from such barns was found 
to contain fresh blood, even on the coldest days, showing 
that they had taken an opportunity of feeding on the animals. 
They were indeed seen in the act of doing so. In the Struma 
valley, and even sometimes in the hills on warm days in the 
middle of winter, anophelines would sally forth from their 
hibernation quarters and actually attack man in the open. 
A number of A. maculipennis and A. sinensis were taken on 
the night of March 1st, .1918, in the neighbourhood of Butkova, 
where they were attacking men very energetically. Of 78 
A. superpictus taken in Lahanah barns on December 18th, 
1917, 14^had blood in the stomach ; on January 21st, 1918, 
of 98 collected 38 had recently fed, and on January 23rd, of 
49 fifteen had fed, while on February 9th, of 61 thirty-six had 
blood in the stomach. The term hibernation as applied to 
anopheles in Macedonia is thus only relative. 

It therefore appears that in Macedonia, at any rate in the 
warmer valleys, mosquito nets should be used from April to 



240 MEDICAL HISTORY OF THE WAR 

November, if infection is to be avoided. Even at Lahanah, 
a mosquito with sporozoites in the salivary glands was taken 
on llth November, 1918. 

Larvae of anopheles may survive the winter. This is 
especially true of A. bifurcatus, which bred in the wells. Its 
larvae could be found there all through the cold weather, and 
hatching took place as soon as the conditions became favourable 
in the spring. In Palestine, further south, this mosquito 
would pupate and hatch all through the winter, but in Mace- 
donia no evidence of this was obtained. 

Larvae of A. maculipennis were found to withstand freezing. 
They could be frozen in a solid block of ice for 24 hours or 
more and be still living when the ice was melted, but though 
possibly this mosquito and A . superpictus might thus be able 
to survive the winter in the larval state, the hibernation of the 
adult female is undoubtedly the method by which these mos- 
quitoes tide over the cold weather. No observations were made 
on the hibernation of A . sinensis though, as already stated, it 
was found biting in the open at Butkova as early as 1st March. 

The series of dissections carried out at Lahanah of hiber- 
nating mosquitoes revealed an interesting fact. All through 
the cold weather mosquitoes with partially developed pre- 
sporozoite cysts were discovered. These cysts had a perfectly 
normal appearance and the question at once arose as to whether 
it would be possible for such cysts to continue their development 
if temperature conditions became more favourable. 

A series of experiments was instituted to test this point. 
Batches of mosquitoes were fed on crescent cases and incu- 
bated for about a week. Some of the mosquitoes were dissected 
and the size and condition of the cysts noted. The remaining 
anopheles were then exposed to the ordinary indoor winter 
temperature (9-6 C. 18*2C.). By dissecting specimens 
at intervals it was noted that the cysts had remained 
without further degeneration. After three weeks a further 
incubation was found to bring about complete development 
of the cysts. It was thus demonstrated that development 
could be completely arrested and then continued, so that 
carriage of malaria through the winter by mosquitoes them- 
selves becomes a possibility. Before finally deciding the point, 
however, it will be necessary to discover if development could 
be arrested for longer periods, such as three months. 

When after such partial development mosquitoes were 
placed in the ice chest (9 C. 12 C.) for a week it was found 
that degeneration of the cysts took place, as evidenced by 
shrinking of the contents and crinkling of the cysts. Exposure 
to a temperature of 5-5C. in the ice chest for a period of 



MALARIA 241 

12 hours did not cause any degeneration. It thus appears 
that in nature a short exposure to cold, as, for example, a very 
cold night, would not cause the cysts to degenerate. 

A difference between P. vivax and P. falciparum seemed to 
occur in respect of the effects of quinine on the gametocytes. 
In one A. maculipennis and 12 A. superpictus fed throughout 
the experiment on cases infected with P. vivax taking quinine 
there were no infections, while of five A. maculipennis and 
15 A. superpictus fed at least once on a case not taking 
quinine there were eight infections. 

With P. falciparum, however, of 40 A. maculipennis and 
37 A. superpictus fed on cases taking quinine 30 of the former 
and 26 of the latter were infected. It appeared that the 
quinine had a greater effect on the gametocytes of P. vivax 
than on those of P. falciparum in rendering them non-infective 
to the mosquitoes. 

The experiments are not conclusive, for it generally happens 
that the P. falciparum cases selected for experiment harbour 
more gametocytes than the P. vivax cases. In fact, P. 
falciparum as a general rule develops gametocytes in greater 
numbers than P. vivax. 

If this action of quinine is a fact then it seems that a regular 
administration of quinine during the winter to an infected 
population would do more to rid it of P. vivax than of P. 
falciparum. On the other hand, P. falciparum infections 
respond to quinine more readily than those of P. vivax. 

Many statements have been made as to the peculiar severity 
of the malaria in Macedonia, and some have even sought 
to discover some special feature in the malaria parasites them- 
selves to account for this. It is true that in 1916 the mortality 
was fairly high for malaria (1-01 per cent.), but it must not 
be forgotten that the great outbreak came as suddenly and 
unexpectedly as a Macedonian summer thunderstorm, and 
that the arrangements for dealing with such a large number 
of sick were at first inadequate. The roads along which the 
patients were brought to the base were at the time in a very 
bad condition, and it is only surprising that the mortality was 
not greater. In 1917 and 1918, with greatly improved con- 
ditions of transport and treatment, the most important of 
which was the wonderfully constructed Seres road, the mor- 
tality was much lower ('37 and -31 per cent.), though the 
malaria to which the troops were exposed was the same. The 
number of cerebral cases of malaria was not really great when 
compared with the large number of P. falciparum infections. 
It seems extremely improbable that the proportion of serious 
cases was any higher in Macedonia during 1917 and 1918 



242 MEDICAL HISTORY OF THE WAR 

than amongst any group of individuals living in any other 
area where malignant tertian malaria occurs. The feature of 
the malaria of Macedonia, therefore, which made it so serious 
was the very large number of cases and not the greater pro- 
portion of severe cases amongst them. They were numerous, 
of course, but only because the total number of cases was 
so overwhelmingly great. 

The hardships of war added to the severity, but even these 
did not produce as high a mortality rate as frequently occurs 
on a much smaller scale in other parts of the world. 

It was frequently noted that any sudden change in the 
habits of the troops which necessitated great expenditure 
of energy or exposure to hardship caused the malaria infection 
of many to become active, though before this they had estab- 
lished some sort of balance between the parasites and them- 
selves. Sudden exertion or exposure broke down this balance 
and relapses occurred. 

A careful examination of the malaria parasites themselves 
did not reveal any peculiarities. They were identical in every 
way with those which had previously been studied in other 
countries. The intensity of the infections in the severe 
cerebral cases, with the capillaries of the brain and other 
organs blocked with infected cells, and the enormous numbers 
of parasites sometimes seen in smears of the spleen, have been 
noted on many occasions in cases dying of cerebral malaria 
in other countries. 

Macedonia is probably the worst malaria country in Europe, 
but there are many parts of the world equally bad, which 
would have produced the same disastrous results if an army 
of susceptible individuals like that of the expeditionary force 
in Macedonia had been campaigning there. 

Natives undoubtedly formed the original reservoir from 
which the troops acquired malaria in 1916, but, as already 
stated, in subsequent malaria seasons the troops were 
infected to such an extent that they formed their own sources 
of infection for the mosquitoes. Among the troops P. vivax 
and P. falciparum were the common forms of the malaria 
parasite. P. malaria was so rare as to be a curiosity. It 
was at first thought that the isolated cases of this infection 
were in men who had probably acquired it in some other 
country, but this was afterwards found not to be the case. 

The malaria rate amongst the natives was very high and 
spleen indices taken amongst the children gave figures varying 
from two to nearly 100 according to locality. Blood films taken 
from children in Lahanah village gave a high percentage of 
infections, as already noted. After the armistice a series of films 



, 



MALARIA 243 

was made from children in villages in the valley of the Strumica, 
a river in Bulgaria flowing into the Struma just north of the 
Rupel Pass. The percentage of infections for six villages varied 
from 1 1 to 52, and as only a single film was examined in each 
case it is evident that the infections must have been very high 
in some of them. 

An interesting point in connexion with the examinations 
of the native children was the frequency of Plasmodium 
malaria. In one village in the Strumica valley nineteen films 
gave eleven positive results, and six of these showed the parasite 
of quartan malaria. This is all the more remarkable when the 
rarity of this particular parasite amongst the British cases is 
remembered. Two experiments to infect anopheles with 
P. malar ice failed to produce any positive result. 

In 1916 anti-mosquito measures were commenced in the 
area west of Salonika along the Monastir road. In 1917 the 
work was greatly extended and included practically the whole 
of the area occupied by the British. In 1918 more still was done 
with gangs of native labour added to those of the troops and 
every known device for combating the breeding of mosquitoes 
was in practice. The extent of the work carried out in 1918 
was enormous and it is difficult to see how more could have been 
done under the actual conditions. The area involved was 
many hundred square miles of country, all of it, whether on 
account of the streams on the hills or the marshes in the valleys, 
affording facilities for mosquito breeding. The troops were 
scattered over the country and in very many cases it was only 
possible to deal with a limited area round each camp. Beyond 
the area, usually a half-mile limit, breeding still continued, 
and much of the work was wasted because of mosquitoes which 
travelled in from without. 

The range of flight of the mosquito, especially when it can 
be done in stages, is not half a mile but often two or three 
miles or even more. The absence of a population near a breed- 
ing ground encourages the mosquito to travel long distances 
to find a host upon whom it can feed. The result is that the 
camps, though surrounded by a cleared area of half a mile, 
even if this area was properly maintained, became the centre 
of attraction for mosquitoes breeding all over the country. 
In the valleys the conditions were worse than in the hills, for 
so much breeding ground existed immediately beyond the 
British lines that the partial treatment of what was within 
it was of little avail. 

In dealing with the hill streams two difficulties had to be 
encountered. During the summer the streams were constantly 
shrinking and many of them actually dried up, but in process 



244 MEDICAL HISTORY OF THE WAR 

of so doing the conditions were constantly changing so that 
new pools and breeding places were continually forming. 
A careful watch had to be kept and the stream could 
be controlled only by weekly inspections. The second 
difficulty was the occurrence of the summer thunderstorms 
which would in a few minutes convert a tiny trickle into a 
roaring torrent capable of washing away men or animals. 
The work of weeks would in this way be destroyed in a few 
minutes. 

If anti-mosquito measures are a complete success the ano- 
pheles will disappear from the area. If they are still present 
it proves either that the work is not sufficient, not properly 
carried out, or that it does not extend far enough. 

Many statements were made about the diminution in mos- 
quito density as a result of the measures adopted, but there 
are no actual figures of mosquito density for several years 
wherewith results can be controlled. However, observations 
were made in areas where a great amount of anti-mosquito 
work was done. On the Hortiak plateau, for example, during 
the two months 23rd July to 24th September, 1918, over 
9,000 anopheles were collected from the hospital marquees 
of No. 60 General Hospital. These mosquitoes can only 
have been a small percentage of those actually in and about 
the camp. The other hospitals on the plateau were similarly 
situated. Consequently, in spite of the energetic measures, 
the area was heavily infested with anopheles. Unless there- 
fore the mosquitoes could have been reduced to a very much 
greater extent than was the case, little hope of reducing the 
malaria could have been entertained. For when the mosquitoes 
are very numerous a reduction by 50 per cent, does not mean 
a 50 per cent, reduction in the chances of infection, as it 
matters little whether a man is attacked by 10 or 5 infected 
anopheles. In either case the chances of infection are prac- 
tically certain. 

In another area, Guvezne, where energetic measures were 
carried out, a similar state of affairs existed. The tents of a 
casualty clearing station there in September were simply 
swarming with A. superpictus and half an hour's collection 
by two people yielded several hundred mosquitoes. 

Near Lahanah a casualty clearing station moved out one 
day and its site was occupied by a field ambulance the next. 
Very careful work had been carried out in all the streams 
for a half-mile radius, yet the first morning after the field 
ambulance marquees had been erected over 700 anopheles 
were taken from 7 marquees. 



MALARIA 245 

Similar conditions existed everywhere though it was 
frequently reported that no mosquitoes were present. The 
discovery of anopheles in tents and buildings is not so simple 
a matter as many imagine. A mere glance round might 
reveal nothing, yet on careful search under flaps and in corners 
or amongst hanging clothes anopheles would be found hiding. 
These insects disappear during the day into any dark retreat 
and it is for this reason that erroneous impressions of their 
absence constantly arose. Powers of observation also vary 
considerably amongst individuals, for in rooms with mosquitoes 
actually flying about the windows at the time some observers 
have failed to notice them. Impressions as to their presence 
or absence or their relative numbers have therefore often been 
found to be of no value whatever, even when the information 
has been given by those who might have been expected to 
know something of the habits of mosquitoes. 

For these reasons it is very difficult to estimate the value 
of the anti-mosquito measures in Macedonia. The area was 
so vast that it was an impossible task to exterminate the mos- 
quito in a short time, and probably no one imagined that more 
than a partial success could be attained. It is questionable 
therefore whether the measures employed reduced the mosquito 
incidence to such an extent as to justify the amount 
of labour expended. In the areas mentioned above it would 
seem that this was not the case, and yet these areas were 
comparatively easy to deal with when contrasted with the 
extensive valley regions of the Struma and Vardar. In certain 
districts such as the plains about Janes, in the hill section of 
the front line between Lake Doiran and the Vardar and possibly 
in the Dudular area west of Salonika on the Monastir road, 
some good may have resulted, but in most places the 
mosquito incidence was still so high that infections can have 
been only very slightly reduced. 

In 1918 a light form of mosquito-proof hut, consisting of 
wood, canvas and gauze, was put up on a large scale even near 
the front line. In these huts the men had their meals or sat in 
the evenings before retiring for the night. It is reasonable to 
suppose that, if it had been possible to supply every unit with 
a sufficient number of these huts before the malaria season 
started, a very appreciable degree of protection would have 
resulted. 

A very satisfactory type of bivouac mosquito net was designed 
in 1918 as the result of previous experiences. The faults were 
that there was only one net for two men and that there were not 
enough nets to enable damaged ones to be replaced at once. 
A net for each man with a sufficient number in store in each 



246 MEDICAL HISTORY OF THE WAR 

unit for immediate replacement of damaged nets would have 
been an advantage. 

There were many other protective measures and they all had 
their uses, but it would seem that a properly carried out 
campaign of protection against the mosquito would have reduced 
the incidence of malaria more than the unavoidably imperfect 
and partial anti-larval work carried out in Macedonia. 

ARMY OF THE BLACK SEA. 

After the armistice the British Expeditionary Force in 
Macedonia moved eastward where it became the Army of the 
Black Sea and occupied various positions around Constantinople, 
the Black Sea, the Caucasus and as far as the Trans-Caspian 
regions. 

Naturally many relapses occurred amongst the former 
Macedonian troops but most of the cases were sent to England 
as soon as possible. The improvement in the general condition, 
however, was very marked, there being only 7,480 cases of 
malaria for the whole of 1919. 

Constantinople itself was a veritable health resort after 
Macedonia. There was practically no malaria in the town and 
very little round about. A. maculipennis was prevalent in the 
valley of the " Sweet Waters of Europe " but very little primary 
malaria resulted. In the hills north and west of Constantinople 
there appears to have been some primary malaria due to A. 
superpictus, and again on the Asiatic side along the Baghdad 
railway some cases of primary malaria occurred, probably due 
to the same mosquito. At a small port on the Asiatic side of 
the Bosphorus near the Black Sea a small outbreak of benign 
tertian malaria occurred amongst the troops holding a fort. 

Batoum, at the Black Sea end of the Trans-Caucasian 
railway, was highly malarious. The town itself was on a level 
stretch of land surrounded by hills. There was a heavy rainfall, 
the driest month of the year being reputed to yield three inches. 
The result was that vegetation was abundant and there were 
endless facilities for mosquito breeding. A . maculipennis was 
the commonest mosquito breeding in the marshes and pools. 
A. superpictus was rarely taken in the hills behind. The 
malaria was undoubtedly due to the A. maculipennis breeding 
about the town. 

The railway from Batoum to Baku ran through .highly 
malarious country. Tiflis itself was practically free though the 
surrounding country was heavily infested with anopheles, 
especially along the Tiflis-Baku section of the line. At practically 
every station high towers had been erected so that the station 
staff could sleep at nights above the low-flying mosquitoes. 



MALARIA 247 

The need of these was evident, for an examination of the station 
buildings, especially the latrines, showed them to be heavily 
infested with A. maculipennis. In one latrine many hundreds 
of these mosquitoes were found sheltering from the light of day. 
A . sinensis also occurred but was seen in much smaller numbers, 
while the miles of plain through which the railway passed were 
teeming with the ferocious Ochlerotatus dorsalis (0. caspius) 
which boarded the trains even when in motion and attacked 
the passengers with intense voracity. 

An experience of 305 N.G.O.'s and men of the Royal Warwick- 
shire Regiment who were sent to a post south of this line is of 
interest. They chose as a camp a site on the banks of a small 
stream at Varda. In a fortnight's time cases of malaria 
occurred and, as these increased in number, the whole unit 
was quickly removed to a healthy site on the hills above Tiflis. 
Here practically every man who had not already malaria 
quickly succumbed. In all, 303 of the 305 were known to have 
gone down with the disease. This is a good illustration of 
what may happen when exposure takes place without any 
protection. Prophylactic quinine was not taken, nor, it is 
believed, were nets used, and the sick rate from malaria in the 
few weeks the troops were stationed at this spot was practically 
100 per cent. a rate which was considerably higher than in any 
of the worst spots in Macedonia, where prophylactic quinine may 
still have protected some individuals from infection or 
prevented relapses though it failed to protect the majority.* 

Another highly malarious spot was Petrovsk on the Caspian 
Sea, the headquarters of the Royal Flying Corps. Here 
A. maculipennis abounded and many cases of malaria, both 
malignant tertian and benign tertian, occurred. 

The whole of the plains in this country are highly malarious, 
but the hills are relatively free and, as it was possible to select 
the sites for camps during the British occupation, unnecessary 
exposure did not take place, except in the case of incidents 
such as that noted above. The malaria situation had been 
considered by the Russian Government and schemes of im- 
proving the country had been drawn up before the war. 
Literature in Russian had been published, maps constructed 
and leaflets and placards for propaganda purposes prepared. 
The outbreak of war, however, had frustrated these schemes. 

PALESTINE AND EGYPT. 

Malaria became of great importance after the active operations 
in Palestine had commenced in 1917-18. In 1916 there were 

* Wenyon states that on several occasions when prophylactic quinine was 
stopped the incidence of malaria immediately increased. 

(2396) Q 



248 MEDICAL HISTORY OF THE WAR 

scarcely more than 1,000 cases reported from Egypt. In 1917, 
during the latter part of which the operations against Palestine 
had commenced, there were 8,480 cases, while in 1918 there 
were over 28,000. In 1919, after the operations were over the 
number f eU to about 6,400. 

The malaria of 1916 occurred chiefly in the Canal Zone, the 
Fayoum (Senussi campaign), and the Western Oasis (Dakkla). 
In the Canal Zone the most abundant anopheles were Cellia 
pharoensis, the commonest anopheline of northern Egypt, 
A. turkhudi, and A. mauritianus. Both the former were 
shown by Manson-Bahr to be carriers of malaria. In the 
Fayoum Cellia pharoensis was the carrier. 

In the Western Oasis an outbreak of malaria occurred ten 
days after the arrival of troops at the end of December, 1916. 
In this instance the vector appears to have been A . turkhudi. 

The expedition against Gaza in 1917 did not produce much 
malaria, but after the successful operations of November, 1917, 
and the movement forward of the troops, it was evident that a 
highly malarious country had been occupied and the conditions 
were completely changed. The line occupied by the troops at 
the end of 1917 consisted of three distinct sectors : the seaboard 
line from a point a little north of Jaffa to the hills, the line over 
the hills in the direction of Jericho, and the Jordan valley line 
north of the Dead Sea. As regards the mosquitoes and the 
malaria incidence these three sectors differed considerably. 

The temperature conditions in the three sectors were not the 
same. The mean daily temperatures were highest in July and 
August, being just over 78 F. at Bir Salem in the coastal 
plain with a minimum of about 67 F. At Jerusalem the 
corresponding temperatures were 73 and 61 F. and in the 
Jordan valley 87 and 75 F. It will be evident therefore that 
the temperature of the coastal sector was 5 to 6 degrees higher 
than at Jerusalem, while in the Jordan valley it was higher than 
on the coastal plain. If 60 F. is taken as the temperature 
below which mosquitoes will not breed, then in the Jordan 
valley they would have commenced in March, on the coastal 
plain in April and in the hills in May, It will be seen that 
this was a little earlier than in Macedonia, as was to be 
expected in a country so much further south. 

The British line crossed the coastal plain, the hills and the 
Jordan valley roughly at right angles and in this respect it 
differed from the line in Salonika which ran along the whole 
length of the Struma valley from the sea to Lake Butkova. 
The Palestine line was roughly 60 miles in length with 
10 miles of this on the coastal plain, about 40 on the hills 
and 10 in the Jordan valley. As the hills were relatively 






MALARIA 249 

free from malaria it is thus apparent that the exposure 
to infection, other things being equal, was much less than 
in Salonika.. 

The coastal area consisted of sand dunes parallel to the sea 
and within them a marshy plain, through which ran the river 
Auja with its numerous tributaries. On the eastern side were 
the hills, down the valleys of which streams ran to the plain. 
The hill country did not, however, have the very extensive 
stream system found in Macedonia and in consequence anopheles 
were very much less numerous. Furthermore, the drying up 
of these streams during the summer was greater than in 
Macedonia and there was not the same danger from sudden 
thunderstorms. In the Jordan valley there were the river 
itself and its tributaries with marshes along their course and 
hill streams running into the valley. 

A feature of Palestine was the system of wells. These were 
found everywhere, especially in the villages of both the coastal 
plain area and the hills, and they were taken advantage of by 
the anophelines to a much greater extent than in Macedonia, 
where the wells and built-in fountains in the hills were not such 
sources of danger as the streams themselves. The worst areas 
from the malaria point of view were the two marshes, the 
Burak Leil about half-a-mile long by some 200 yards 
broad, and the Baharet Katurieh about one mile long and a 
third of a mile broad, in the coastal plain. In addition, in this 
area was the river Auja from its source near the foot hills to the 
sea. It had numerous tributaries and one of these formed 
another marsh, the Tel Abu Zeitun. The two main marshes, 
however, had been drained and anti-mosquito measures had 
been taken along the greater part of the river system. 

There was therefore in this sector nothing comparable to the 
Struma valley with its large lakes and extensive marshes, such 
as those surrounding Lakes Tachinos and Butkova, which were 
breeding millions of mosquitoes. The river Auja presented 
greater difficulties but the length to be dealt with, including its 
tributaries and marshes, was short compared with the river 
Struma and its tributaries. The Auja river was attacked with 
great energy and most of the water-ways cleared, so that in 
this sector practically all the breeding places up to the outpost 
lines were under control. The wells also were rendered harm- 
less by regular oiling. 

Here then was an area which, though it involved a great 
expenditure of labour, held out some prospect of success in the 
prevention of mosquitoes. There was, however, this drawback, 
that no anti-mosquito work was done on the enemy's front, 
and consequently there was always danger of invasion by mos- 



250 MEDICAL HISTORY OF THE WAR 

quitoes from that quarter. It is probable that invasion of this 
kind took place but perhaps not to a great extent, for the 
mosquitoes would probably find sufficient attraction in the 
Turkish army to prevent them wandering far afield ; but in 
some cases oiling of pools was carried out right up to the Turkish 
wire. 

In the Judaean hill sector there were the streams and the wells. 
The streams ran on the one hand to the coastal plain and on the 
other into the Jordan valley. The hills and gullies of Palestine 
were, however, much drier than those of Macedonia. A far 
greater number dried up completely in the summer so that, 
though some of them were perennial, their limited number 
made it possible to clear them. The real danger in the hills came 
from the wells, but as every one of these could be discovered 
and recorded they could be rendered innocuous by systematic 
oiling. 

In the Jordan valley conditions again changed ; there were 
wells to be dealt with and again the river system with its 
consequent marshes. The line was a short one, barely 10 miles 
in length. It was the worst sector and the most difficult to 
control. There were extensive breeding grounds at Musal- 
labah and other places beyond the British lines, and every night, 
helped by the prevailing wind, mosquitoes invaded the lines 
and caused a very high incidence of malaria. The conditions 
in the Jordan valley may be said to have resembled those of 
the Struma valley. 

The important malarial mosquitoes were A. bifurcatus, A. 
superpictus (palestinensis) and A. maculipennis. The first was 
the well mosquito. Its larvae and pupae occurred in wells all 
through the winter and hatching took place on warm days. 
This was true not only of the wells in the valleys but also of 
those in the hills. In Macedonia this mosquito was not of 
great importance, though there also its chief breeding place was 
the wells. There also the larvae survived the winter but the 
more rigorous winter climate of Macedonia rendered them less 
active than in Palestine. A. maculipennis was the common 
mosquito of the coastal area and along the Jordan valley. Its 
breeding habits in the marshes were the same as in Macedonia. 
A. superpictus was also observed in the valleys but it was 
chiefly found breeding in the clear water near springs and in 
rivulets. It was also the mosquito of the streams in the Judaean 
hills ; so that, as in Macedonia, A. superpictus may be said to 
be the hill stream mosquito and A. maculipennis the mosquito 
of the valley. 

Another mosquito was the A. sinensis (pseudopictus) , which 
was found in marshes and sluggish water in the coastal sector, 



MALARIA 251 

and had habits similar to those of the same species found in 
Macedonia. 

A mosquito not occurring in Macedonia but seen in Palestine 
was A . turkhudi, which was found in some of the rivers of the 
Jordan valley. A. algeriensis was also observed occasionally. 

As regards the incidence of malaria an attempt was made to 
estimate the number of primary cases amongst the three corps 
holding the front line. Altogether some 8,500 primary cases 
occurred between April 1st and October 1st, 1918. This gives 
a ratio of just over 5 per cent, of the strength. The rate was 
highest, about 8 per cent., in the Desert Mounted corps in 
the Jordan Valley. It was 6 or 7 per cent, in the 21st Corps 
in the coastal region and only 1 per cent, in the 20th Corps 
holding the hill area. This is what might have been 
expected from the mosquito distribution in the three sectors. 

The 7th Division, occupying a position near the Baharet 
Katurieh, had a high incidence of malaria. From June to 
September the cases of primary malaria were 2,060, or 11-4 per 
cent, of the average strength. They were exposed to A . maculi- 
pennis, many of which are stated to have come from the Turkish 
lines. The 3rd and 54th Divisions occupied the Auja river 
area. Amongst them 1,800 cases of malaria occurred, or 10 
per cent, of the average strength. 

In the Jordan valley the Desert Mounted Corps changed 
very much in composition during the summer but the incidence 
curve of malaria showed a steady rise from May with a maximum 
in July. There then followed a fall, which was attributed to 
the anti-malaria measures. In other words, it was thought 
that the reduction in the number of mosquitos was causing 
fewer infections. Yet a rise in the curve from 7th to 10th 
August and on 7th September was explained by the fact that 
new units joined the corps and within the first two or three 
weeks of their stay in the valley had a large number of cases. 
This incident was against the supposition that the anti- 
mosquito measures had been responsible for the fall in malaria 
amongst the non-infected men already there. It must be 
remembered, however, that the incidence rate of malaria is 
highest at the commencement of the occupation of a malarial 
area and gradually diminishes, quite apart from any reduced 
exposure to infection. Amongst a large body of new arrivals the 
initial malaria rate will gradually fall, owing either to the weeding 
out of the most susceptible, to an acquired immunity, or to the 
establishment of a balance between the host and the parasite. 

Very instructive curves of the incidence of benign tertian 
and malignant tertian malaria have been made from the results 
of the laboratory diagnosis of the coastal and Jordan valley 



252 MEDICAL HISTORY OF THE WAR 

sectors. In the Jordan area there was a rise in the number of 
benign tertian films from May to a maximum at the middle of 
June. There was then a fairly steady fall to the end of the year. 
The malignant tertian cases rose more slowly and more 
irregularly to a lower maximum in the second week in August. 
There was then a fall for one week, a rise to a point a little 
lower than the maximum the next, and then a still greater fall 
followed by a steady rise during the latter part of August and 
September. 

The final advance of the British in Palestine commenced on 
21st September, 1918, when the troops went forward over the 
old Turkish lines, but any increase in infections resulting 
from an advance into untreated mosquito-breeding country 
would not be evident for at least a fortnight later, so that the 
rise in malignant tertian incidence up to 5th October may be 
taken as due to infections acquired while the troops were still 
in the original area. It is necessary to deal with this aspect 
of the question for there is a tendency in reports to assume 
that up to the time of the advance there had been a steady 
fall in the malaria rate, and that, but for the advance into 
untreated areas, the malaria rate would have continued to fall. 
In the Jordan valley area at any rate there was evidence that 
the malignant tertian outbreak which would be expected in 
the autumn had just commenced before the advance, and 
was running concurrently with it. During the advance, 
however, the figures undoubtedly rose considerably higher 
than they would have done if the troops had remained 
stationary in their original lines. This was probably due both 
to the increased hardships associated with the advance and 
to the impossibility of employing the methods of protection to 
which the troops had become accustomed while they were 
stationary. It is not suggested that the anti-breeding 
measures carried out in the Jordan valley were not responsible 
for a reduction in the malaria, but that in spite of these, and 
in spite of the protection given by nets and other means, 
there would still have been an autumn rise in malignant tertian 
malaria. In this case the curves would correspond closely 
with those of Macedonia where the benign tertian infections 
began to fall while the malignant tertian infections rose to 
their maximum in October. In Macedonia the troops were 
stationary and the incidence could be observed without the 
complications of a sudden advance. 

The corresponding curve of the coastal area, however, appears 
to illustrate the effect of the advance more conclusively, for 
there was a definite and striking rise in the malignant tertian 
rate exactly a fortnight after the advance commenced. There 



MALARIA 253 

was a similar but less marked benign tertian rise which com- 
menced a week later. Here then there seems more reason 
for assuming that the rise was due to the advance, but it is 
impossible to state that no rise would have taken place even 
if the troops had remained stationary. In a report on 
malaria conditions in Palestine, Syria and Cilicia in September 
1919, by Lieut.-Golonels E. C. Hodgson and R .C. Watts, I.M.S., 
and Lieut. P. Barraud, a curve showing the incidence of 
primary malaria in 1919 is given. It shows the usual marked 
rise in malaria in September and October and is the kind of 
curve which would probably have resulted if no advance 
had originally taken place and the troops had remained in the 
Jaffa- Jericho line through the autumn of 1918. This curve 
conforms very closely with the incidence of malaria in 
Macedonia. 

In Palestine no systematic collection of mosquitoes on a large 
scale was undertaken, and only a few accurate scientific obser- 
vations of their habits are recorded. These refer specially to 
the presence of mosquito larvae. 

In 1919 the relative incidence of malaria in the areas occupied 
by the British, taking the incidence in Cilicia, the worst district, 
as 100, is as follows : 

Cilicia 100 

Syria (not including Lebanon) .. .. 31 

Palestine 23-0 

Suez Canal Area . . . . . . . . 3-6 

Egypt 2.6 

Observations were made in Palestine on the temperature 
conditions favouring the development of mosquitoes. It was 
found that eggs of anopheles have seldom been laid in a season 
when the temperature exceeded 70 F., while a temperature 
below 60 F. retarded their development. A temperature 
between these levels was the optimum not only for the laying, 
but also for the hatching of the eggs and the further develop- 
ment of the larvae. It was further noted that the adult 
anopheline is a moist insect and in consequence of evaporation 
through its tracheal system its temperature is not necessarily 
that of the surrounding air. Differences in the relative 
humidity of the atmosphere had marked effects on the adult 
mosquitoes. In a dry atmosphere, provided there is food and 
water, the mosquito will tolerate a high temperature, whereas 
a humid atmosphere is unfavourable. 

EAST AFRICA 

Whereas the conditions favouring the spread of malaria in 
Macedonia and Palestine closely resemble one another except 



254 MEDICAL HISTORY OF THE WAR 

that in the latter the temperature is higher and the extent of 
summer drying of the hill streams greater, in the East Africa 
campaign very different conditions existed, and another group 
of anophelines came into play. In the earlier period of the 
campaign there was a considerable amount of malaria, but the 
greatest incidence occurred after Dar-es-Salaam became the 
base. Although the problem of dealing with malaria pre- 
sented itself in connection with the occupation of other 
coastal towns and up country, where, however, little could 
be done beyond the use of protective measures against the 
bites of mosquitoes, Dar-es-Salaam was probably the most 
malarious locality within the area of operations and the danger 
of its incidence existed throughout the whole year. The town 
lay to the north of an inlet from the sea and into it ran the 
Gerasini Creek, where the most extensive mosquito breeding 
grounds existed. Breeding grounds also existed in the town 
itself and north of it ; in fact the whole area was dotted over 
with marshes and pools which produced mosquitoes throughout 
the whole year. The conditions of a hot summer followed by 
a cold winter, which are characteristic of Macedonia and 
Palestine, no longer obtained, so that there was no winter 
cessation of infections. 

It was unfortunate that such a place should have been the 
base of operations, for new troops arriving were constantly 
infected before they went up country, where the danger from 
mosquitoes was considerably less. And it was likewise un- 
fortunate that no proper survey of the town was made 
immediately after the occupation in September 1916, with 
a view to selection of the most mosquito-free sites for camps. 
An area north of the inlet and bordering the sea was decidedly 
less infested with mosquitoes than the sites actually chosen 
for the concentration and other camps. 

The mosquito nets used during the early part of the cam- 
paign were almost useless and, though a good deal of screening 
of buildings had been done by the Germans before the British 
occupation, so little was the value of this appreciated that 
much of it was destroyed by the British troops in order to 
obtain better ventilation. 

Whatever was the cause, avoidable or not, the incidence 
of malaria amongst the troops was very high, for during the 
period 3rd June, 1916, to 27th October, 1917, the admissions 
for malaria were 3,036 officers and 104,666 men. 

There was a mortality of 10 .amongst the officers and 639 
amongst the men. Malaria was responsible for 57-4 per cent, 
of the total admissions for sickness. Between 6th January, 
1917 and 24th November, 1917, there were over 21,000 cases 



MALARIA 255 

of malaria amongst the carriers, and other native formations 
suffered to a similar extent. 

The mosquitoes chiefly responsible for malaria were the 
well-known African carriers A. costalis and A. funestus. 
A. mauritianus was also present, but is a doubtful carrier, 
while A. squamosus was of a very minor importance.* 
The breeding of these mosquitoes continued throughout the 
year, though possibly it was somewhat diminished during the 
dry weather. This limitation, however, must have been 
very slight, for in February, before the rains had com- 
menced and at the end of the dry season, several hundreds of 
anophelines were collected in the vicinity of one of the camps. 

There is no information of any value on the relative incidence 
of malignant tertian and benign tertian malaria during the 
campaign in East Africa. 

Kilwa Kivinji and Kilwa Kisiwani, on the coast south of 
Dar-es-Salaam, and Tanga to the north were also highly 
malarious places. Inland the features of the country were 
a system of hills and valleys. The high land was relatively 
free from malaria. The valleys were hotbeds of the disease. 

Anti-malaria work was not taken up seriously till the later 
phases of the military operations, and when it was commenced 
the troops had already been infected to a large extent. Malaria, 
in fact, practically ran riot in the early stages of the campaign, 
before adequate arrangements had been made for the pro- 
tection of new arrivals from the moment they disembarked. 
Had such arrangements been possible the incidence of malaria 
in this campaign would undoubtedly have been materially less. 

THE CAMEROONS. 

Of the specific diseases malaria was the most important in 
the operations against the Cameroons. There were about 
3,000 European troops in the various columns, and of the 
admissions at the Duala Base Hospital there were 613 for 
malaria during the 17 months of the campaign. This figure, 
however, represented only a fraction of the total malaria 
amongst the Europeans, for many did not come into hospital 
during the campaign, j 

MESOPOTAMIA. 

Malaria in Mesopotamia was not such a serious disease as 
in these other theatres of war. The admissions for the three 
years 1917, 1918 and 1919 were 6,723, 10,331 and 5,261 
respectively. The great bulk of infections took place in the 

* Dr. Mansfield Aders, of Zanzibar, has made a very useful mosquito survey 
of the country. 

f See p. 306, Vol. 1, General History of the Medical Services. 



256 MEDICAL HISTORY OF THE WAR 

district between Basra and Kurna, but many infections 
occurred during the expedition into North Persia in 1918. 

The climate of Mesopotamia resembled that of Macedonia 
and Palestine in having a wet winter season and a dry summer. 
The winter, however, was not so cold and the summer was 
hotter. While mosquito breeding almost entirely ceased in 
winter, there was evidence that winter infection took place 
on a small scale. Thus of 232 cases admitted to a British 
general hospital during the period November to January, 
1916-1917, 108 were recorded as primary infections, although 
mosquito breeding at this time was in abeyance. 

The country is flat. In and around Basra, Kurna and other 
towns there are the palm tree plantations irrigated by channels 
from the Tigris or Shatt-el-Arab. The latter is tidal so that 
the creeks are filled and emptied at each tide, and it is probably 
on this account that mosquitoes were not more prevalent. 
Similar conditions existed at Nasiriyeh on the Euphrates. 
Apart from the rivers and the channels the country occupied 
by the expeditionary force was quite dry in the summer. 

There was little malaria along the Tigris north of Kurna 
and the marshy stretch of river above Kurna, but the disease 
again appeared along the Diala river towards the Persian 
frontier. Mosquito breeding took place chiefly in pools formed 
along the channels. Many of the channels were full of water- 
plants which acted as dams. 

Mesopotamia malarial surveys were carried out by Major 
Christophers, I.M.S. He found six species of anopheles : 
A. pulcherrimus, A. stephensi, A. sinensis, A. lukisi, A. nursei 
(A. superpictus) , and A. maculipennis. The first is not an 
intense carrier though it was present sometimes in large 
numbers. A. sinensis is a marsh breeder, and it was seen in 
swarms in the marshy districts along the Euphrates between 
Kurna and Nasiriyeh. Fortunately, this district was unoccu- 
pied by troops save for a few isolated posts. It was not found 
to any extent in Basra or Kurna itself nor higher up the river. 
A . lukisi and A . nursei were only rarely seen and this is true also 
of A. maculipennis. The most dangerous mosquito was A. 
stephensi, a well-known carrier, and malaria was prevalent 
wherever it occurred. 

As regards the race incidence of malaria the susceptibility 
of the British was greater than that of the Indian troops. The 
former had approximately the same number of cases as the 
latter, though they were only one- third the strength. The 
usual types of malaria were found, but, as in Macedonia and 
Palestine, only an occasional quartan parasite was seen. In 
October 1917, the percentage of malignant tertian cases was 



MALARIA 257 

56-7 for the Basra area. There was then a steady fall till 
April 1918, when only 16-9 per cent, were malignant tertian. 
The figure remained at about this level, with slight rises and 
falls, till August, after which there was a steady rise to 28-5 
per cent, in January 1919. 

For the Baghdad area in October 1917, the percentage 
for malignant tertian cases was 14-8, in November 29-2, and 
then it oscillated between 24-4 and 8-0 till July. After this 
there was a steady rise till in December it reached 56-4 with 
a fall in January to 38-2.* The marked rise in the Baghdad 
curve at the end of 1918 was due to the arrival of patients 
who had been evacuated from North Persia. Generally 
speaking, there was a rise in the proportion of malignant 
tertian cases towards the end of the year, but this was not 
nearly so marked as in Macedonia and Palestine. 

Major Mackie, I. M.S., found Anopheles nursei in the area 
occupied by the Persian Force and by dissection proved it to 
be a carrier of malaria. A . nursei, however, is the same as the 
well-known carrier A. superpictus of Italy, Macedonia, Palestine, 
(A. palestinensis) and the Caucasus. 

ITALY. 

The malaria problem in Italy presented itself in the front- 
line area, at Taranto and also to a certain extent on the lines 
of communication, which were established for reinforcements 
to and evacuations from the Eastern Mediterranean and other 
theatres of war in the east by way of Taranto, in order to 
avoid sea transport. 

In the front line there was very little malaria amongst 
British troops, though the Italian Army on the lower Piave 
front suffered heavily. From December 1917 to December 
1918, inclusive, the British, with an average strength of about 
78,000, had only 35 primary cases of malaria and 51 relapses. 
They were part of the 6th Italian Army which occupied the 
comparatively healthy Asiago plateau. The French troops 
in the same army had 73 primary and 140 relapse cases, 
and the Italians 150 and 331 respectively. In the mid Piave 
area the 8th Italian Army had 563 primary and 269 relapse 
cases, while on the lower Piave the 33rd Italian Army had 
4,443 primary and 1,318 relapse cases. 

On the lines of communication through Italy to Taranto, 
anopheles invaded the trains at many of the stopping places 
and infections took place there. There is no record of the 

* These figures were compiled by Lieut. -Col. Ledingham, consulting 
bacteriologist to the Mesopotamian Force, and represent the results of 
the positive blood film examinations in the army laboratories. 



258 MEDICAL HISTORY OF THE WAR 

extent of this, but it was noticed that anopheles were con- 
stantly brought to the Taranto camp by the trains. Attempts 
were made to regulate the stopping places so that the worst 
malaria areas could be passed through quickly, but the irregu- 
larities of the railway service rendered this impossible. The 
question of mosquito-proofing the trains was considered but 
was found to be impracticable. 

At Taranto the troops exposed to infection, apart from 
those passing through the camp, numbered about 1,573 in 
1917. Amongst these were 220 primary cases, of which 28 
were evacuated to England and 6 died. The infection rate 
was 14 per cent. A labour detachment of 101 men arrived 
at the camp on 21st May, 1917, and by 15th November, 32 
had been admitted to hospital with malaria. Later, four 
others contracted the infection, giving a malaria rate of 35 
per cent. Another labour detachment of 96 men arrived 
on 17th September, and by the end of the year five had malaria, 
and by the following March four more. The sanitary section 
at Taranto received a draft of 31 men, only 25 of whom 
remained in the camp area. By the end of December six had 
gone down with malaria. 

Troops, on their way to Salonika and Egypt, remained in 
the Taranto camp for a variable number of days before 
embarkation, and very soon complaints were received at 
Taranto that malaria infections were taking place amongst 
the men who had been there. As regards the prevalence 
of mosquitoes in the camp there are few records for 
1917, but between 19th and 31st October, the entomologist, 
Sergeant Hargreaves, collected from 11 tents near the centre 
of the camp a daily average of three anophelines. Early in 
1918 systematic collections were made in two areas. One was 
the camp area itself, and every hut, house or tent in this area 
was searched every day. The second area was outside the 
camp, and a series of eight houses was selected near the limit 
of the anti-mosquito operations. Daily collections were made. 
The first week of this work yielded 53 anophelines in the camp 
and 531 in the outer area. The numbers fell steadily till 
towards the end of April, and during May none were taken 
in the camp and very few outside. This fall was apparently 
due to the destruction of the hibernating mosquitoes before 
breeding had commenced. During May the anopheles leave 
their winter quarters to seek water on which to deposit their 
eggs. June showed a rise in the number collected, but the 
weekly number in the camp did not exceed 18, and in the 
outer area 110. During August and September there was a 
fall in the numbers, but at the end of September again a rise, 



MALARIA 



259 



so that for the two weeks ending 30th September and 7th 
October,23 and 20 anopheles were taken in the camp and about 40 
in the outer area. The numbers then fell to the end of the year. 

The collections were continued during 1919 but the large 
numbers found at the beginning of 1918 ceased to appear. 
There was a steady fall until, during the summer, practically no 
anopheles were found in the camp, although a small number 
were collected in June and a larger number in September. 
It is important to note in this connection that the 
anopheles were being transported to the camp by the trains 
and nearly all the anopheles caught were in the huts and tents 
near the place where the trains stopped. 

It was evident therefore that the anti-mosquito measures 
adopted in 1918 and 1919 practically kept the camp free from 
anopheles in 1919 and that the few which were found had been 
brought in by the trains. So free did the camp become that 
prophylactic quinine and the use of mosquito nets were discon- 
tinued. Amongst a personnel of over 1,000 in 1919 there were 
only nine possible camp infections, and it was probable that 
infection had been contracted elsewhere. 

The mosquito breeding places were of the usual type ; there were 
marshes, drains, pools and wells, and all of these were dealt with 
energetically by the well-known methods of mosquito destruction. 

The prevalent mosquito was A. maculipennis which came 
chiefly from the ditches and marshes to the south and east of 
the camp, while A. bifurcatus was found to the west, where 
breeding places in the shape of troughs and wells occurred. 
A . superpictus was taken only once and was probably imported. 

A number of dissections of anopheles was carried out in 1918 
and 1919 with the following results : 





Stomachs. 


Salivary Glands. 


Source. 
















Exam. 


Infect. 


o/ 
/o- 


Exam. 


Infect. 


o/ 
/o- 


1918. 














Camp 


122 


19 


15-0 


119 


3 


2-0 


House 14 


97 


3 


3-0 


73 


1 


1-25 


Salina Grande 


163 


8 


5-0 


150 


4 


2-6 


House 31 


53 


4 


7-5 


44 


1 


2-0 


House 26 and Italian Anti- 


514 


40 


8-0 


519 


3 


5 


Aircraft Station. 














1919. 














Camp 


269 


22 


8-1 


272 








Train 


103 


16 


15-5 


110 


5 


4-5 


House 26 


299 


30 


10-0 


285 


2 


0-7 


Other Houses 


268 


18 


6-7 


292 


"~" 


* 



260 MEDICAL HISTORY OF THE WAR 

These figures are interesting in that they show a high degree 
of infection. It is difficult to explain this in the light of 
Wenyon's observations in Macedonia where at Lahanah village, 
which was known to be very malarious, a dissection of 2,910 
anopheles yielded a very much lower incidence of infection. 

The anti-malarial problem was much simpler in Taranto* 
than in Macedonia. The breeding places within the radius of 
the camp were limited and could be dealt with easily. In 
Macedonia on the other hand the breeding places were so 
extensive that it was impossible to deal with them all and the 
mosquitoes still persisted in such numbers that malaria could 
not be reduced to any great extent. Though the incidence of 
malaria was high in Taranto in 1917, the number of anopheles 
probably never reached more than a fraction of the numbers 
in such places as the Hortiak plateau in Macedonia, even after 
active measures for mosquito destruction had been carried out. 
Taranto and Macedonia may be regarded as two extremes. In 
the former anti-mosquito measures dispensed with the neces- 
sity of protective measures against the bites of mosquitoes, 
whereas in the latter protective measures had to take the 
place of mosquito destruction. Palestine, at least the line 
occupied before the advance on 21st September, 1918, 
occupied an intermediate position between these two extremes. 

LIST OF MOSQUITOES 
COLLECTED AND IDENTIFIED IN THE VARIOUS WAR AREAS 

DURING 1914-1918. 
MACEDONIA : 

Anopheles maculipennis, Mg. 

Anopheles maculipennis, Mg., var. 

Anopheles bifurcatus, L. 

Anopheles plumbeus, Steph. 

Anopheles hyrcanus, Pall, and var. pseudop ictus, Grassi. 

Anopheles algeriensis, Theo. 

Anopheles superpictus, Grassi. 

Stegomyia fasciata, F. 

Ochlerotatus caspius, Pall. 

Ochlerotatus pulchritarsis, Rond. 

Ochlerotatus lepidonotus, Edw. 

Ochlerotatus rusticus, Rossi. 

Ochlerotatus detritus, Hal. 

Ochlerotatus vexans, Mg. 

F inlay a geniculata, Oliv. 

Finlaya echinus, Edw. 

Taeniorhynchus richiardii, Fie. 

Theobaldia (Allotheobaldia) longiareolata, Macq. 

Theobaldia annulala, Schrk. 

Theobaldia (Culicella) fumipennis, Steph. 

Theobaldia (Culicella} morsitans, Theo. 

* The work at Taranto is described in two reports by Colonel J. C. Robertson 
one for 1918 and the other for 1919. The report for 1918 appears in full in 
the Journal of the Royal Army Medical Corps for May 1920. 



MALARIA 261 

MOSQUITOES cont. 



MACEDONIA cont. 

Culex pipiens, L. 
Culex hortensis. Fie. 
Culex mimeticus, No6. 
Culex apicalis, Adams. 
Culex modestus, Fie. 
Culex tipuliformis, Theo. 
Culex univittatus, Theo. 
Uranotaenia unguiculata, Edw. 

PALESTINE : 

Anopheles maculipennis , Mg., var. 
Anopheles bifurcatus, L. 
Anopheles superpictus, Grassi. 
Anopheles culicifacies Giles var. sergenti, Theo. 
Anopheles multicolor, Camb. 
Anopheles pharoensis, Theo. 
Anopheles hyrcanus, Pall. 
Anopheles mauritianus, Grandpr6. 
Anopheles algeriensis, Theo. 
Stegomyia fasciata, F. 
Ochlerotatus caspius, Pall. 
Ochlerotatus detritus, Hal. 
Ochlerotatus mariae, Serg. 

Theobaldia (Allotheobaldia} longiareolata, Macq. 
Theobaldia annulata, Schrk. and var. subochrea, Edw. 
Theobaldia (culicella) morsitans, Theo. 
Taeniorhynchus richiardii, Fie. 
Uranotaenia unguiculata, Edw. 
Culex pipiens, L. 
Culex hortensis, Fie. 
Culex mimeticus, Noe. 
Culex tipuliformis, Theo. 
Culex univittatus, Theo. 
Culex laticinctus, Edw. 

MESOPOTAMIA : 

Anopheles stephensi, Listen. 

Anopheles pulcherrimus, Theo. 

Anopheles hyrcanus, Pall. 

Anopheles algeriensis, Theo. 

Anopheles superpictus, Grassi. 

Anopheles maculipennis, Mg., var. 

Stegomyia fasciata, Mg. 

Ochlerotatus caspius, Pall. 

Theobaldia (Allotheobaldia} longiareolata, Macq. 

Culex modestus, Fie. 

Culex tritaeniorhynchus, Giles. 

Culex fatigans, Wied. 

Culex tipuliformis, Theo. 

Culex pipiens, L. 

NORTH WEST PERSIA : 

Anopheles superpictus, Grassi. 
Anopheles maculipennis, Mg. 
Ochlerotatus caspius, Pall. 
Ochlerotatus vexans, Mg. 
Culex pipiens, L. 
Culex tipuliformis, Theo. 



262 MEDICAL HISTORY OF THE WAR 

MOSQUITOES cont. 
NORTH RUSSIA: 

Anopheles maculipennis, Mg. 
Thcobaldia arctica, Edw. 
Ochlerotatus lutescens, F. 
Ochlerotatus alpinus, L. 
Ochlerotatus, sp. 

ITALY : 

Anopheles maculipennis, Mg. 

Anopheles bifurcatus, L. 

Anopheles algeriensis, Theo. 

Ochlerotatus caspius, Pall. 

Ochlerotatus caspius, Pall. var. hargreavesi, Edw. 

Ochlerotatus detritus, Hal. 

Ochlerotatus vexans, Mg. 

Ochlerotatus rusticus, Rossi. 

Ochlerotatus nemorosus, Mg. 

Ochlerotatus pulchritarsis, Rond. 

Theobaldia annulata, Schrk. 

Theobaldia (Allotheobaldid) longiareolata, Macq. 

Culex hortensis, Fie. 

Culex pipiens, L. 

Culex univittatus, Theo. 

Uranotaenia unguiculata, Edw. 

TANGANYIKA TERRITORY : 

Anopheles costalis, Lw. 

Anopheles funestus, Giles. 

Anopheles mauritianus, Grandpre. 

Anopheles squamosus, Theo. 

Anopheles maculipalpis, Giles. 

Skusea pembaensis, Theo. 

Stegomyia fasciata, F. 

Culex fatigans, Wied. 

Culex watti, Edw. 

Culex sitiens, Wied. 

Culex aurantapex, Edw. 

Culex bitaeniorhynchus, Giles. 

Culex duttoni, Theo. 

Culex consimilis, Newst. 

Culex tigripes, Grp. 

Eretmopodites chrysogaster, Graham. 

Megarhinus (Toxorhynchites] brevipalpis, Theo. 



BIBLIOGRAPHY. 

Austen . . . . Anti-mosquito measures in Pal- Trans. Soc. Trop. 
esti ne duri ng the campaigns of Med . & Hyg .1919- 
1917-1918, 20. Vol. xiii, pp. 

47-60. 

Cardamatis.. .. Le paludisme en Macedoine .. LaMalariologia,1919. 

Anno xii, Ser. 1. 
Nos. 4-5. 

Delmege .. .. Some practical notes on the pre- Jl. of Trop. Med. & 
vention of mosquito breeding Hyg. 1919. Vol. 

xxii, p. 181. 
Manson-Bahr . . Experiences of Malaria in the Lancet, 1920. Vol. i, 

Egyptian ExpeditionaryForce pp. 79-85. 
Niclot,Bour,Monier- Le paludisme 
Vinard& Buget 



Robertson 
Roubaud 



Sewell & Macgregor 



Woodcock . 






Gaskell & Millar 



MALARIA 

BIBLIOGRAPHY cont. 

On the anti-malaria campaign 
at Taranto during 1918 

Recherches sur la transmission 
dupaludismepar les anopheles 
fran9ais de regions non- 
palustres 

An anti-malaria campaign in 
Palestine. An account of the 
preventive measures under- 
taken in the 21st Corps Area 
in 1918. 

Notes and Comments upon my 
Malaria experiences while with 
the Egyptian Expeditionary 
Force, 1916-1918 

Travaux et resultats de la Mis- 
sion Antipaludique a 1'Armee 
d' Orient 

Studies on malignant malaria 
in Macedonia 



263 



Jl.ofR.A.M.C. 1920. 

Vol.xxxiv, p. 444. 
Annales de 1'Institut 

Pasteur, 191 8. Vol. 

xxxii, p. 430. 

Jl.ofR.A.M.C. 1920. 
Vol.xxxiv, pp. 85- 
100, 204-218. 



Jl.ofR.A.M.C. 1920. 
Vol. xxxiv, p. 385. 



Bull.Soc.Path.Exot., 

1918. Vol. ii, p. 

456. 
Quart. Jl. of Med. 

1919-20. Vol.xiii. 

pp. 381-426. 



(2396> 



w 



CHAPTER X. 

MALARIA (continued) . 

PATHOLOGY, SYMPTOMS, DIAGNOSIS AND TREATMENT. 

ITH regard to the pathology of malaria, the interest has 



mainly centred round the subtertian infection. The 
suddenness with which death may occur has been much 
commented upon. It is recorded by Dudgeon that out of the 
number of fatal cases in Salonika, 57 per cent, died within two 
days of admission to hospital. Many died of acute heart failure. 
Out of 50 post-mortem examinations in this disease in Palestine, 
10 died from right heart failure, an equal number with cerebral 
complications, 7 with haemolytic icterus, 3 from hyperpyrexia, 
while 13 were complicated by pneumonia and the remaining 
7 by co-existing infections, such as bacillary and amoebic 
dysentery. 

Malaria-stricken patients were specially liable to contract 
other virulent infections, and of these the chief appears to have 
been influenzal broncho-pneumonia. This was a specially fatal 
complication, and it is recorded that out of 797 deaths from 
malignant malaria in Palestine and Syria towards the end of 
1918, no less than 62-5 per cent, were due to the influenzal 
broncho-pneumonia then sweeping through the country. This 
complication was not commonly noted before the middle of 
October 1918. 

As an explanation of the sudden fatalities in uncomplicated 
subtertian malaria, Dudgeon and Clarke have described a fine, 
fatty degeneration of the heart muscle akin to that of a diph- 
theritic toxaemia. The adrenal glands showed congestion and 
loss of characteristic lipoids, together with thrombosis and 
necrosis of the cortex. 

In the spleen, extreme congestion and excessive phagocytosis 
of red blood cells were always observed and necrosis of the pulp 
tissue, especially of the Malpighian corpuscles, was also noted. 

The liver and kidneys also showed focal necroses and 
deposition of pigment in large clumps, and, according to 
Wenyon's observations, these appearances are associated in 
the former organ with a corresponding increase in the 
production of bilirubin. 

The brain in fatal coma showed extensive thrombosis, 
especially of the vessels in the white matter, degeneration of 
nerve cells and blockage of the capillaries with parasites. 

264 



MALARIA 265 

In certain cases of coma energetically treated with quinine 
during life, no parasites were found in the brain capillaries, 
but a considerable oedema of the brain substance and an 
increase in the cerebro-spinal fluid were noted, possibly due to 
the action upon and absorption by the cerebral substance of a 
circulating malaria toxin. So often was death noted in cases 
completely cinchonised, in which no parasites could be found 
after death in any of the tissues or bone-marrow, that the 
existence of a malarial toxaemia, as opposed to the hitherto 
accepted theory of a mechanical obstruction of the capillaries 
by the sporulating subtertian parasite, must be considered as a 
possible cause of death. 

In the intestines of algid or abdominal cases, congestion, 
petechial haemorrhages and scattered necroses of the mucosa 
have been noted. 

Great variation in the size of the spleen and in the number 
of contained parasites has been noted in these fatal cases. The 
spleen is generally engorged and contains a dark and diffluent 
pulp ; the capsule is stretched and shiny and the whole organ 
may weigh two pounds or more ; lymphoid flakes and evidences 
of perisplenitis may be present. On the other hand, fatal cases 
have been seen with only a slight enlargement of the spleen, 
with a firm dark red pulp, a few contained parasites and 
scattered pigment. The toxicity of these parasites in different 
individuals must therefore vary considerably. Spontaneous 
rupture of the engorged spleen with sudden death was noted in 
Mesopotamia, Macedonia and Palestine ; this may have been 
due to infarction or to rupture of the capsule. 

Symptoms. 

The cases which occurred during the war presented little 
that was new in the clinical aspects of benign tertian malaria. 
Primary infections especially were for the most part typical, 
with a rapid rise of pyrexia, rigors and an equafiy rapid fall. 
Higher degrees of pyrexia (temp. 105- 106 F.) were almost 
invariably recorded than in the subtertian form. There is 
scarcely any other epidemic pyrexia, with the exception of 
sand-fly fever, with which this infection may, from a clinical 
point of view, be confused. 

Observations upon the remarkable periodicity which the 
benign infection exhibits tended to show that the attacks were 
more liable to occur in the earlier hours of the day. 

Tertian periodic pyrexias were found to be due to one genera^ 
tion, quotidian pyrexias to two generations of the parasite. 
Severe and alarming symptoms, and even coma, were observed 



266 MEDICAL HISTORY OF THE WAR 

in benign tertian cases, especially in Macedonia, but gener- 
ally, when they occurred, they were caused by a double infection 
with the subtertian parasite. 

Quartan infections occurred so rarely amongst British troops 
as to preclude any extensive observations being made ; usually 
unsuspected on clinical grounds, they were recognised quite 
accidentally by microscopic examination. 

The pleomorphism which subtertian infections may exhibit 
and the many medical and surgical conditions they may 
simulate, has attracted a considerable amount of attention. 
It is not surprising that many medical officers new to the 
tropics failed to recognise the true nature of the disease ; the 
wonder is rather that mistakes in diagnosis were so few. 

There is considerable danger, wherever malaria is prevalent, 
of a tendency to make a diagnosis of malaria too readily in 
doubtful cases. Thus Phear records that such diverse condi- 
tions as cerebral abscess, meningitis, hepatic abscess, peritonitis 
from different causes, and even suppurative peritonitis, were 
found at autopsy in cases which were suspected of being purely 
malarial in nature. It should be emphasised that, wherever a 
blood film diagnosis of malaria will not fully explain the clinical 
picture, other possible causes of the illness should be carefully 
considered and assistance sought in a leucocyte count. 

On the other hand, in the absence of laboratory diagnosis 
or where such facilities are not fully used, malignant malaria 
provides many pitfalls for the unwary owing to the diversity of 
symptoms which it may exhibit. The tendency is for the 
clinician, after a fatality has once occurred, to disregard clinical 
symptoms altogether and to trust too much to the laboratory 
for diagnosis. 

Malignant tertian fever, which is caused by the subtertian 
parasite, in general may be extremely mild, fairly severe, or 
in a small percentage of cases fulminating in character. Many 
dramatic deaths were recorded. The suddenness with which 
death might take place had to be seen to be realized ; men have 
fallen out and died while on the march, and in several instances 
the fatal illness lasted only a few hours. 

Compared with the benign infections, malignant malaria was 
less sudden in its onset ; more usually it was insidious, and the 
pyrexia might not be so marked or subject to such sudden 
intermissions. For the first five days of a primary infection, 
a gradual steppage rise of a remittent pyrexia resembling that 
of enteric was quite commonly observed. Rigors might be 
entirely absent. There might be no subjective symptoms, save 
headache and an aching in the bones. On the other hand it is 
known that parasites may be present in the peripheral blood 



MALARIA 267 

in quite considerable numbers without any history of malaise 
or fever at all. Such cases were recorded from Macedonia and 
from the Jordan valley. 

The number of parasites in the peripheral blood did not ap- 
pear as a general rule to bear any relation to the severity of the 
clinical symptoms. This is probably due to the method of 
sporulation in the capillaries of the internal organs. Coma and 
death occurred in cases which showed but scanty rings in the 
peripheral blood, and conversely patients were seen who had 
a very heavy blood infection with but few concomitant 
symptoms. 

The double crisis of temperature which this disease exhibits 
in its' typical form was not always discernible and should, there- 
fore, not be too much relied upon in diagnosis. 

The subtertian parasite produces symptoms by mechanical 
blockage or by toxaemia. In the first method sporulation in 
some particular organ causes a blood stasis or partial thrombosis, 
and may give rise to all kinds of local symptoms ; in the second 
there are general symptoms due to a diffuse toxaemia. 

During the war it was realised that splenomegaly is 
not an integral part of a malarial infection. It is only 
after repeated infections and relapses that the spleen be- 
comes large enough to be palpated. It was remarked that 
in only a small percentage of cases, microscopically diagnosed, 
was the spleen at all palpable. Too great weight should not 
be given to percussion of the splenic area as a means of ascer- 
taining enlargement of the organ ; on the other hand, there 
was usually a considerable degree of pain and tenderness over 
the splenic area during the attack of fever. 

The clinical types of subtertian malaria may be classified and 
described according to the organs upon which fhe stress of 
infection fell. 

Psychical disturbances due to toxaemia, or cerebral irritation 
produced by the subtertian parasite take the form of delirium, 
acute mania, or delusional insanity, with a tendency to suicide. 
The mental state and muscular inco-ordination closely 
resemble that produced by alcohol ; there were several 
instances of men being arrested as either drunk or mentally 
deranged, and even sent down from the firing line under guard, 
who were found to be suffering from a malarial infection. 

Haemorrhages into the motor area produce monoplegia or 
diplegia or, if into the internal capsule, complete hemiplegia*; 
pontine lesions with crossed paralysis have been recorded. The 
effects of these lesions were sometimes permanent. The hyper- 
pyrexia associated with cerebral disturbance closely resembled 
that of heat stroke. Unilateral epileptiform convulsions 



268 MEDICAL HISTORY OF THE WAR 

produced by cerebral irritation simulated those of a Jacksonian 
epilepsy, and in these cases the parasites might be very scanty 
in the peripheral blood. Spinal pains combined with cerebral 
symptoms, head retraction and rigidity of neck muscles might 
arouse the suspicion of a cerebro-spinal meningitis. 

Cases with profuse vomiting, or even actual haematemesis 
were noted. Where the pain was very severe, intestinal ob- 
struction might be suspected, or the patient might present the 
picture of acute haemorrhagic pancreatitis. 

Malignant malaria sometimes resembled certain surgical con- 
ditions ; pain over the liver or gall bladder, with fever, was quite 
commonly mistaken for cholecystitis. Appendicular pain might 
closely simulate surgical appendicitis, and it is recorded that in 
Salonika, and elsewhere, this mistake not infrequently occurred. 
The pain in such cases might be strictly localized to McBurney's 
point, and therefore in doubtful cases the surgeon should exclude 
malaria by means of a blood examination and a leucocyte count. 

Enteritis of varying degrees of severity was commonly 
observed in subtertian infections and might focus the attention 
of the clinician entirely on the alimentary tract. The throm- 
bosis and the toxaemia might produce petechiae and haemorr- 
hages, which, if they were into the intestinal canal, might 
cause symptoms resembling those of dysentery. 

Algid cases with subnormal temperatures and collapse were 
commonly observed ; if associated with vomiting, profuse and 
watery diarrhoea, they simulated cholera. 

Several authorities, including Falconer and Anderson, believe 
that a purely malarial infection can produce symptoms and 
physical signs of bronchitis, pulmonary congestion and consoli- 
dation. Most clinicians noted the frequency of pulmonary 
complications with subtertian infections, but the majority 
regarded actual consolidation as being due to a secondary in- 
fection with the pneumococcus. Whether pleurisy or pleuritic 
adhesions can be produced by the same means is open to doubt. 
Generally speaking, a splenic pain, due to distension of the 
organ by malaria, is referred to the pleura and may thus give 
rise to pain in this region. 

Cases with joint effusions closely resembling acute rheumatism 
were recorded ; the bone pains accompanying the pyrexia 
might suggest rheumatism, or more commonly a tentative 
diagnosis of influenza; it was remarkable how frequently 
this mistake occurred. 

The pyrexia of subtertian malaria is apt to be regarded at 
first as one of the commoner pyrexias. The remittent tem- 
perature, especially during the first week, simulated that of 
enterica ; and the clinical differentiation from relapsing fever, 






MALARIA 269 

especially the North African type, might be impossible on 
clinical grounds alone. 

Haemorrhages occurred into the skin in acute subtertian cases 
and sometimes produced lesions similar to those of purpura 
haemorrhagica, typhus, or even measles, and occasionally led 
to mistakes in diagnosis. 

General oedema with ascites due to subtertian malaria with- 
out albuminuria was occasionally seen both in Salonika 
and in Palestine. A general oedema of the face and extremities, 
yielding to quinine, occurred among the German prisoners from 
Palestine. Certain cases closely resembled acute nephritis, the 
urine containing blood and renal epithelial cells. Occasionally 
lumbar pain was associated with haematuria in an uncomplicated 
subtertian infection. 

A high remittent temperature with icterus is known as the 
bilious remittent form of subtertian malaria. The haemolytic 
icterus thus produced may be very striking and resemble that 
of yellow fever ; it is often associated with a profuse bilious 
vomit. The tendency was to mistake this form for obstructive 
jaundice with pyrexia, or for the malignant jaundice of Spiro- 
ch&tosis icterohcemorrhagica. The lesson to be learnt from this 
is that repeated blood examinations should be made in every 
case of jaundice occurring in malarial districts. 

The disturbance in cardiac rhythm might be mistaken for 
disordered action of the heart. The vasomotor changes, 
such as arterial spasm, were sometimes important. Thus gan- 
grene of the feet due to this cause was observed in Salonika. 

The most important sequelae were cachexia and anaemia. 
The debility produced might be considerable and the anaemia 
might reach a high degree. The haemoglobin might be 
reduced to one-half or even one- third and the cells to 1,000,000 
or less. Splenomegaly was nearly always present. A very great 
degree of anaemia with general anasarca was noted especially 
amongst Turkish prisoners from Arabia who were very heavily 
infected with malaria. The debility and anaemia following 
a primary infection may rapidly produce a cachectic condition 
especially in young soldiers. This condition has been referred 
to by James under the designation of acute primary cachexia. 

Post-malarial anaemia was generally of the pernicious type 
with poikilocytes, megaloblasts, and even myelocytes ; in fact 
it might resemble pernicious anaemia or leucocythaemia very 
closely indeed, but the extreme changes in the white cells which 
occur in the latter disease were never seen. In other cases 
there was an aplastic anaemia with little or no attempt at red 
cell regeneration. 



270 MEDICAL HISTORY OF THE WAR 

A large proportion of cases of disordered cardiac action with 
unduly sensitive exercise response was attributable to malaria ; 
this is possibly due to the specific action of malarial toxins upon 
the myocardium. 

In addition to cases of peripheral or central lesions, the 
influence of subtertian malaria as a contributory factor in 
functional disorders of the brain was generally recognized in 
Salonika. The commonest type of psychosis following malaria 
was some form of mental confusion or depression, which 
fortunately was not permanent. In a few instances a peculiar 
mental disorder with obliteration of all sense of time and space, 
known as Korsakoff's syndrome, supervened. There was no 
evidence that a true malarial neuritis exists. 

Finally, the tendency of subtertian infections to develop 
blackwater fever, especially during the winter season, must 
always be borne in mind. The relationship between these two 
conditions is very close, and Parsons and Forbes from clinical 
observations in Salonika show that a transient haemoglobinuria 
takes place quite commonly in an otherwise uncomplicated 
subtertian infection. 

Both the subtertian and the benign forms of malaria are liable 
to be complicated by other diseases. The most frequent of 
these in the war was some form of dysentery, most usually of 
the bacillary type. When co-existing with a primary subtertian 
attack the prognosis was grave. Many pulmonary infections 
were prone to supervene ; sometimes it was a lobar pneumonia, 
and the extent and virulence of influenzal broncho-pneumonia 
as a cause of death has already been noted. Malaria was 
especially prone to co-exist with and complicate an abscess of the 
liver. Its liability to occur in association with enteric has long 
been recognized. 

It was pointed out during the war that malaria subjects were 
prone to develop a pulmonary tuberculosis or that latent 
tubercular infections might become active during the course of 
the disease. 

Diagnosis. 

The clinical forms of subtertian malaria and the diseases 
which it might simulate may be summarized as follows : 

Type of Subtertian Malaria. Diseases simulated. 

Cerebral forms. 

Comatose . . . . . . . . Coma of various kinds, especially 

alcoholic or traumatic. 

Coma with hyperpyrexia . . . . Sunstroke or heatstroke. 

Maniacal or delirious with suicidal Lunacy or mania ; acute typhus. 

tendency. 

Epileptiform ... . . . . . . Jacksonian epilepsy. 

Cerebro-spinal . . . . . . Cerebro-spinal meningitis. 



MALARIA 



271 



Abdominal forms. 
Malarial enteritis with haemorrhage 
Algid with subnormal temperature 

and collapse. 
Obstructive 



Acute dysentery. 
Cholera or paracholera. 

Appendicitis, cholecystitis, acute pan- 
creatitis, intestinal obstruction. 



Pulmonary forms. 
Bronchitic 
Pneumonic 
Pleuritic 



Broncho-pneumonia. 

Pneumonia. 

Pleurisy. 



Types of average severity. 
Influenzal or rheumatic, with 

pyrexia and joint pains. 
Enteric-like 



Influenza ; acute rheumatism. 

Enterica, sand-fly fever, trench fever, 
relapsing fever, and hepatic abscess. 



Cutaneous forms. . 
Cases with multiple petechiae 



. . Typhus, purpura or measles. 



Nephritic forms with oedema. 
Cases with albumen and cells in Acute nephritis. 

urine. 
General oedema without albumen Cardiac failure or war oedema. 

and sometimes ascites. 



Icteric forms. 

Bilious remittent type with bilious 
vomit and hsemolytic icterus. 



Weil's disease, yellow fever, obstructive 
jaundice. 



Sequela. 
Cachexia and anaemia 

Blackwater fever 

Neurasthenia and mental confusion 



Pernicious anaemia, leucocythaemia, 
pulmonary tuberculosis, debility. 

Quinine haemoglobinuria and paroxys- 
mal haemoglobinuria. 

Insanity. 



The experiences of the war disclosed little new with regard 
to the microscopic diagnosis of malaria. The mechanism 
ought to be near at hand ; a microscope, and a pathologist 
skilled in its use, ought to be an integral part of a field 
ambulance in a malaria-stricken country. The clinical 
symptoms of malaria being of so protean a character, clinical 
diagnosis must always be supplemented by that of the micro- 
scope. Special malaria diagnosis units, consisting of one officer 
and two men with the necessary transport and light equipment 
with two microscopes and essential stains, proved to be the 
most satisfactory means of dealing with this aspect of the 
subject in Palestine. Being extremely mobile and independent, 
such a unit could be moved to any part of the field of operations 
and attached to a field ambulance wherever its services were 



272 MEDICAL HISTORY OF THE WAR 

most required. It is essential that both the officers and men 
should be specially trained in the microscopic diagnosis of 
malaria. 

For rapid work and satisfactory results, provided an ample 
supply of neutral distilled water is obtainable, no stain has 
yet been found to surpass Leishman's. The adoption of the 
thick film method is said to have resulted in East and 
South Africa in improving the accuracy of diagnosis by 
50 per cent. 

It undoubtedly has the advantage of showing up the parasites, 
especially crescents, in the peripheral blood, but against this 
a considerable amount of difficulty is at first experienced 
in recognizing the stage and the species of the parasite 
owing to the distortion which takes place during dehaemo- 
globinization. The technique is the same as that detailed for 
the detection of spirochaetes in African relapsing fever.* 

The thick-film method also has the advantage of showing up 
spirochaetes of relapsing fever, if these are present. 

Failures with Leishman's stain are generally due to over- 
fixation with the raw stain or over-action in its diluted state. 
Probably half a minute is quite sufficient for fixation with the 
raw stain and two and a half minutes when subsequently diluted 
with three times its amount of distilled water. 

In differentiation of the two forms of parasite, too much 
reliance should not be placed on the presence of Schiiffner's 
dots in benign tertian malaria ; they are often absent in the 
early stages of infection. Much more attention should be paid 
to the character of the ring and the enlargement of the infected 
corpuscle. 

Whatever method of making films is adopted, the thick or 
the thin film, or a combination of both, it is advisable in a 
suspicious case that at least three films of the patient's blood 
be examined on three separate occasions before a diagnosis of 
malaria is definitely negatived. One should remember that a 
severe clinical subtertian infection may be associated with 
scanty parasites in the peripheral blood. 

On no account, if it can be avoided, should the microscopic 
diagnosis of malaria be relegated entirely to casualty clearing 
stations and base hospitals ; the nearer it is carried out to the 
seat of actual operations the better. 

Attempts have been made to improve diagnosis by a com- 
plement deviation method in the latent phases of malaria, and 
experiments in this direction have been made by Thomson, 
using antigens prepared both from splenic extracts and artificial 

* See Chapter XIV, p. 339. 



MALARIA 273 

blood cultures of the parasites dissolved in dilute caustic soda. 
The results have hitherto been somewhat indefinite. 

As regards the rise of mononuclear leucocytes which super- 
venes after a malaria attack, although abundant confirmation 
has been forthcoming of a rise above 15 per cent, immediately 
following the pyrexia, the value of this method in ascertaining 
a latent infection, as, for instance, in pensionable men, is being 
seriously discredited as a means of arriving at a diagnosis. It 
has been shown by Thomson that the mononuclear rise varies 
inversely with the temperature ; when the temperature is rising 
the number of mononuclears in the peripheral blood is falling, 
and when the temperature falls the mononuclears increase. 

During the height of the paroxysm there is a leucopenia of 
2,000 leucocytes per c.mm., followed by a post-malarial 
leucocytosis. 

Treatment. 

During the war unparalleled opportunities presented them- 
selves for testing various forms of treatment of malaria. Con- 
tinuous observations were possible upon large numbers of 
disciplined men, and the results obtained were minutely 
recorded, especially in Salonika and in the United Kingdom. 
Little, however, that is new in the treatment of malaria has 
been ascertained. The whole treatment may still be summed up 
in the one word quinine. But from the maze of literature 
upon this subject one indisputable fact emerges ; namely, that 
quinine is by no means the specific drug it was formerly 
supposed to be. It is not to be inferred that belief is waning 
in its curative powers, but there are serious doubts in many 
minds of its power of preventing relapses, more especially in 
benign infections. 

As quinine is the only drug that acts efficiently upon the 
malaria parasite, its administration, should be begun directly 
a diagnosis is obtained, quite irrespective of the stage of the 
attack or of the degree of pyrexia ; but in order that the full 
benefit may be obtained, it is essential that the drug should be 
absorbed by the stomach and intestines. Should there be any 
intestinal stasis, should digestion be in any way disarranged, 
or the intestinal mucosa become covered with mucus, absorption 
of quinine will only be partial. 

A preliminary purge of calomel (grains 3-5) or of blue pill 
(4 grains), followed by a saline aperient, should invariably 
precede the administration of the quinine. The drug should 
always be given in dilute solution and in a mixture which will 
render the taste less unpleasant. Syrup of orange (drachm 1) 
will disguise the taste to a certain extent. This is said to be 



274 MEDICAL HISTORY OF THE WAR 

also the case if glycerine is added to the mixture, or if the 
quinine is dissolved in milk. In military practice, if tabloids 
have to be substituted for a mixture, chewing of a piece of 
bread to a great extent removes the unpleasant taste. 

Wherever possible, quinine should be given by the mouth, as 
experience showed that it is as quickly absorbed by the ali- 
mentary as by any other route. In the acute stage of the 
disease, where a tendency to nausea and vomiting exists, all 
diet, even milk, should be withheld, but the patient should be 
encouraged to drink freely of water and especially hot decoction 
of lemon. This is made from four slices of lemon, including the 
peel, with a teaspoonful of sugar to 8 ozs. of water. It assists 
the absorption of the drug. 

The dosage of quinine should not be less than 30 grains, or 
exceed 45 in the twenty-four hours. The most soluble salts 
should always be .used wherever possible. Of these the bi- 
hydrochloride is the most soluble, the hydrochloride most 
nearly approximates it, while the sulphate is the least soluble. 
For ordinary purposes the hydrochloride is to be preferred ; it 
should be given in 10-grain doses, dissolved in 2 ozs. of water, 
three times a day, at four-hourly intervals, and it is undoubtedly 
more quickly absorbed by an empty stomach. Most authori- 
ties are agreed that heroic doses of 80 to 100 grains in twenty- 
four hours were not more effectual than the smaller ones. If 
the sulphate or bi-sulphate is used, a certain amount of acid 
must be added in order to dissolve the drug completely ; 
the proportion being 2 minims of dilute sulphuric acid to 
every 10 grains of quinine. The patient should be put to bed, 
at any rate for the first week, as rest is essential. 

In benign tertian and subtertian infections of average severity 
it is advisable to continue the full dosage of quinine for some 
considerable time, at any rate for 21 days, in order to prevent 
a relapse ; and the experience gained during the war showed 
that it was advisable to continue it, in 10-grain doses, every 
day for the subsequent three months. Symptoms of cinchonism 
may develop, but unless severe and continued, are not serious. 
For the tinnitus so produced the quinine should be dissolved 
in hydrobromic acid, or one of the bromides should be pre- 
scribed as in the following prescription : 

Hydrochloride of quinine . . . . grains 10 

Dilute hydrobromic acid . . . . minims 30 

Syrup of orange . . . . . . drachm 1 

Water . . . . . . . . to half an oz. 

If vomiting is troublesome, a teaspoonful of bicarbonate of 
soda in warm water should be given at the same time, and if 



MALARIA 275 

rejected, the dose of quinine should be repeated; if very severe, 
the stomach should be washed out with small doses of tincture 
of iodine (30 minims to the pint) and counter-irritation applied 
to the epigastrium. Wherever possible there appears to be a 
distinct advantage in giving quinine in small doses of 5 grains 
each, six times during the day. 

Other measures are of course necessary. During the cold 
stage, hot water bottles must be applied ; during the hot stage, 
it may be necessary to sponge the patient frequently with warm 
water in order to reduce the pyrexia, and to give copious draughts 
of lemonade to assist perspiration. Diaphoresis may be pro- 
moted by prescribing the following mixture : 

Solution of acetate of ammonia . . drachms 2 
Spirit of nitrous ether . . . . minims 30 
Camphor water . . . . . . to half an oz. 

For the headache, caffeine, aspirin or phenacetin (10 grains) 
may be used. 

A large tender spleen may often incite vomiting, and the 
pain, which may become severe, becomes less apparent after 
the application of a mustard plaster or of a hot fomentation, 
the patient being instructed to lie on the left side. 

During the second week of treatment quinine is better borne 
when given in an effervescing form, as in the following pre- 
scription : 

Quinine hydrochloride . . . . grains 10 
Citric acid 20 

mixed together in powder form and taken with the following 
mixture : 

Carbonate of ammonia . . . . grains 20 

Carbonate of potash 20 

Water to half an oz. 

In men who bear quinine badly it is better tolerated if given 
with small doses of opium, as in the preparation known as 
Warburg's tincture, which contains aloes, opium (1 in 4,000), 
rhubarb, camphor and a number of other herbs, in doses of 1 oz. 
every four hours continued for four or five days. 

In the management of a malaria case the clinician should be 
guided by frequent microscopic blood examinations, and more 
especially is this necessary should any untoward symptoms 
occur after the primary pyrexial period is passed. 

In the care and after-treatment of a malaria case it is essential 
that due consideration should be given to the question of food, 
clothing and avoidance of over-exertion. Soldiers should be 
hardened by graduated exercise while in convalescent camps 



276 MEDICAL HISTORY OF THE WAR 

especially set aside for the purpose, a practice which obtained 
recognition during the war. Convalescence should last at least 
three weeks. The administration of quinine should by no 
means be neglected, and a daily parade for this purpose should 
be held at an appointed hour. 

In order to counteract the anaemia produced by malaria, 
and in order, in the opinion of many, to aid in the absorption 
of quinine, arsenic should be given from the onset, either in 
the form of liquor arsenicalis (minims 5) thrice daily, or in 
the form of a mixture combined with iron as in the following 
prescription : 

Acid solution of arsenic . . . . minims 3 

Ferrous sulphate grains 2 

Dilute hydrochloric acid . . . . minims 3 

Water . . to half an oz. 

In military practice it is more convenient to prescribe the 
iron and arsenic together in pill form, which should be given 
twice daily. Strychnine may be added as in the following 
prescription : 

Iron hypophosphite . . . . grains 2 

Arsenious acid . . . . . . grain 1 / 50 th 

Strychnine sulphate . . . . grain 1 / 50 th 

Saccharine grain Viooth 

As regards the treatment of the two main forms of malaria 
the following general statements may be made. 

In benign tertian infections the individual attack is easily 
dealt with, the asexual parasites normally disappearing from 
the blood in four days, but the patient is liable to parasitic 
and clinical relapses for a long period and complete eradication 
of the parasite from the system is very difficult. The same 
rules hold good for the quartan infections which were 
occasionally found during the war. 

In subtertian infections, the individual attack is consider- 
ably more resistant to quinine, the asexual parasite remaining 
in the blood for four days on the average, the longest period 
noted being thirteen days. The patient will be cured in a 
large number of cases in the first treatment, if it is con- 
scientiously carried out, and especially if followed by the 
administration of quinine for the prevention of relapses, 
the liability to relapse being much less than in the benign 
tertian. But, further, the thorough treatment of subtertian 
or malignant infections is more important than that of the 
benign form, owing to the alarming clinical manifestations 
which may supervene. 

Should the number of parasites present in the peripheral 



MALARIA 277 

blood be great, the patient mentally confused, the tongue 
unduly furred, hyperpyrexia supervene, the spleen and liver be 
enlarged and tender or vomiting be excessive, should in fact 
any unfavourable symptoms manifest themselves* in spite of 
oral treatment with quinine, recourse must be had to other 
methods of quinine administration, and of these the intra- 
muscular route has been the one most practised. 

With regard to the advantages and disadvantages of this 
method, the observations of Dudgeon and Manson-Bahr at 
numerous autopsies showed, what had long been recognized, 
that quinine is undoubtedly a tissue poison and that it 
probably causes a slight degree of muscle necrosis in every 
case, but if given wisely or in not too concentrated a form 
and at definite intervals no real danger is likely to ensue. 
On the other hand in a patient unduly debilitated and wasted, 
whose powers of resistance are small, a more extensive tissue 
necrosis is liable to occur than in a normal individual ; further- 
more, Fairley and Dew have shown that haematogenous septic 
infections are likely to ensue in these individuals owing to 
the absence of any leucoblastic response in the bone marrow, 
and such an infection will set alight any necrotic patch in the 
muscular tissue. Manson-Bahr's experiences corroborated this 
observation. Great caution should therefore be observed in 
injecting quinine in debilitated subjects. 

In some cases a considerable fibromyositis may occur from 
injections of quinine involving the sciatic nerve with consequent 
paralysis of the corresponding leg. This and more severe 
consequences, such as supervention of general sepsis, gas 
gangrene, extensive haemorrhages into the tissues through 
implication of a large vessel, spreading oedema and widespread 
tissue necrosis leading to abscess, have all been recorded as 
the result of too vigorous treatment by intramuscular injec- 
tions, but it is doubtful whether these unfortunate occurrences 
outweigh the undoubted clinical improvement which has 
followed the adoption of this method. 

Every care must be taken to maintain asepsis in the opera- 
tion, and due consideration must be paid to the anatomical 
structures of the part chosen for injection. 

The site of injection is preferably the muscles of the buttocks 
on the line of, and a hand's breadth posterior to, the great 
trochanter ; a stout needle should be used and the injection 

* Mental or other grave symptoms coining on suddenly in the course of a 
benign tertian infection have usually been due to a co-existing infection 
with the subtertian parasite, which, owing to the peculiar method of 
sporulation in the capillaries of the internal organs, may have been at first 
overlooked on microscopical examination. 



278 MEDICAL HISTORY OF THE WAR 

made deep into the gluteal muscles, but on no account should 
the quinine solution impinge upon the ilium, and care must 
be taken to avoid the course of any important nerve. The effect 
of the injection and its absorption may be increased by massage. 

The salt of quinine employed for the purpose should be the 
most soluble the bi-hydrochloride, in the proportion of 6 grains 
to the c.c. of distilled water. It is ' best to give two 
injections daily for three consecutive days, supplementing 
them if possible by quinine administered orally. Some clinical 
workers, such as Phear in Macedonia, advise 40 grains in the 
24 hours till all alarming symptoms have disappeared. 
Experience at autopsy has shown that, even with the more 
moderate doses recommended above, a complete disappearance 
of the asexual parasites from the blood and internal organs 
takes place subsequent to the injection of 36 grains. 

This method obtained a considerable degree of approval 
from clinicians especially in Salonika. It has, however, its 
limitations and it is open to abuse, the chief of which is the 
tendency to continue intramuscular injections repeatedly, in 
the circumscribed area, when all indications for their adminis- 
tration, as judged by microscopic blood examination, have 
disappeared. It is useless to continue to inject quinine after 
all parasites have disappeared from the circulation. In certain 
cases of benign tertian infection where oral quinine is ineffective 
in reducing the temperature, a few intramuscular injections 
have been followed by good results. One point, the impor- 
tance of which is apt to be overlooked, is that routine intra- 
muscular injection of quinine in all serious cases of sub tertian 
malaria ensures its retention and absorption at the earliest 
possible moment and therefore may prevent pernicious 
symptoms supervening. Quinine thus administered un- 
doubtedly saved many lives, and further it probably increased 
the chances of effecting a permanent cure of the disease. 

The intravenous method of quinine administration is 
advocated in severe cases of cerebral malaria with coma or 
convulsions, or where such complications are threatening ; 
it may also be used in the algid and choleraic forms. 

The injection should be made into the median basilic or 
cephalic vein at the bend of the elbow, with a 10 c.c. syringe 
provided with a sharp needle. It is advantageous to make 
the vessels prominent by constriction with a rubber tube or an 
elastic bandage. On entry into the vein the piston should be 
slightly withdrawn so as to allow some blood to flow back into 
the barrel ; it is then safe to proceed with the injection, which 
should be made slowly, three minutes at least being taken over 
the operation. 



MALARIA 279 

The best concentration of quinine would appear to be 10 
grains of the bi-hydrochloride dissolved in 10 c.c. of normal 
saline. Sometimes it is necessary to repeat the injection, and 
in Salonika in exceptional cases as many as 60 grains were 
given in the twenty-four hours by this method. As a rule, 
however, smaller doses sufficed. In an apparently hopeless 
case it is probably better to supplement intravenous by intra- 
muscular injections. Apparently there is no object in unduly 
diluting the quinine, for, in the opinion of many, this greatly 
increases the consequent reaction. 

As regards the dangers of intravenous administration of 
quinine, alarming symptoms of reaction and even sudden 
death may ensue in pernicious subtertian cases, presenting 
cardiac or pulmonary distress. In such cases it is better to 
proceed by the intramuscular route. Finally, there is evidence 
that a coma which persists after the disappearance of parasites 
from the peripheral blood may be due to increased intra-thecal 
pressure, and, for this, repeated lumbar puncture and with- 
drawal of cerebro-spinal fluid has been practised with advantage. 

Kerr and Turnbull after extensive observation concluded 
that intravenous injection of large doses of bi-hydrochloride of 
quinine in benign tertian infections caused not only a rapid 
improvement in the patient's general condition but also 
prevented further relapses. Unfortunately, further experience 
has not confirmed these apparently favourable results. 
Quinine injection by the rectum was employed at times during 
the war, but by no means obtained universal approbation. 
It is given in doses of 10 to 40 grains dissolved in 10 to 20 
ounces of saline. The method proved of value as a means of 
temporarily supplementing the amount of quinine introduced 
by other channels. 

Subcutaneous injection of quinine was practised in Mace- 
donia by the French, and was to a certain extent employed in 
East Africa. The hydrochloride of quinine was used by the 
French in combination with urethane in doses of 7 grains of 
the former with 2 grains of the latter. Sloughing of the skin 
was occasionally observed, and possibly the method possessed 
no advantage over the intramuscular route, besides being much 
more tedious. 

In addition to intramuscular and intravenous methods of 
administering quinine for the treatment of pernicious symptoms 
of subtertian malaria, attempts may be made to lessen the 
malarial toxaemia by abstraction of a considerable amount 
of venous blood, one pint or more, and the injection of a 
corresponding quantity of normal saline ; but this is a method 
which requires further investigation. 

(2396) S 



280 MEDICAL HISTORY OF THE WAR 

Though quinine given in moderate doses has a distinct 
influence upon the gametocytes of benign tertian malaria, it 
acts less strikingly upon the crescent forms of the sub tertian. 
In full doses of 30 grains of quinine a day it was shown that 
these forms take a period of three weeks or more to disappear 
from the peripheral blood. Therefore, in such cases full doses 
of quinine should be given for at least that period. 

Malarial cachec tics, with anaemia and large spleen, emaciation 
and a low form of pyrexia, require to be treated with full doses 
of iron, arsenic and quinine ; added to which attention must be 
paid to diet, rest and other general treatment. 

When there is a high degree of anaemia, such as was observed 
in malaria-saturated subjects in Salonika, medicinal treatment 
is of little use. In these cases splenectomy has been advocated, 
though not practised to such an extent as to enable a correct 
judgment to be found of its value. Although great improve- 
ment was reported by some surgeons, it hardly seemed a justifi- 
able procedure. It certainly did not prevent subsequent 
relapses. Blood transfusion was performed with apparent 
success in Salonika ; in two cases recorded 18 to 24 ounces 
were introduced by direct transfusion. The immediate effect 
was very striking, being followed by a leucocytosis and a 
gradual regeneration of the red cells. As far as experience has 
gone at present the transfusion has to be repeated two or more 
times at fortnightly intervals. 

According to the researches of Nierenstein approximately 
one-tenth of the total amount of the quinine is excreted by 
the urine. The method of administration did not make any 
appreciable difference in this rate of excretion of quinine. 
Quinine appeared in the urine 5 minutes after administration 
and could be detected for the next 70 hours. The drug is 
for the most part excreted unchanged, and reaches a maximum 
concentration of 7 to 11 grains of quinine base per litre of urine. 
In blackwater fever a new disintegration product of quinine, 
showing haemolytic properties and called haemoquinic acid, 
was obtained. 

The tests for presence of quinine in the urine are best made 
by the Mayer-Tanret method, by dissolving 1 35 grammes of 
mercuric chloride in 75 c.c. of water with 5 grammes of iodide 
of potash in 20 c.c. of water in a 100 c.c. flask ; the mercuric 
solution should be poured into the iodide solution under 
agitation. When added to urine containing quinine it produces 
a turbidity even in a solution of 1 in 300,000. 

As regards other preparations of quinine which have been 
tested, such as euquinine, colloidal quinine, ethyl quitenine 
hydrochloride, quinoidin, quinidine, hydroquinine, chinidin, 



MALARIA 281 

hydrochinidin, cinchonin, hydrocinchonin, chinethylin and 
chinopropylin, none have been found so far to exert a 
greater influence on malaria than the salts already mentioned, 
though recent work by Acton throws some fresh light on this 
point. He brings forward evidence to show that the laevorota- 
tory alkaloids, quinine and hydroquinine, have a specific 
action on the subtertian parasite, whilst the dextrorotatory 
alkaloid quinidine is more powerful in its action than is quinine 
on the benign tertian parasite ; cinchonidine behaves very 
similarly. Both these isomerides are much less toxic to man 
than quinine. 

At one time there appeared to be grounds for believing 
that arsenical preparations such as galyl, kharsivan and 
neoarsenobillon in -3 to -6 grammes intravenously had a specific 
action in the pernicious forms of subtertian malaria. Un- 
doubtedly they possess certain parasite-destroying powers, 
but extended experience has been disappointing. They are 
of value in stimulating the blood-forming organs, and are 
consequently of use in combating the severer forms of anaemia 
and cachexia which follow both forms of malaria. 

Quinine Poisoning. 

Quinine in moderate doses usually produces a buzzing 
in the ears, accompanied by slight deafness ; large doses are 
not infrequently followed by temporary loss of hearing, but 
there is little evidence that it can produce permanent deafness. 

Contraction of the field of vision, or quinine amblyopia, is a 
severe complication which may occasionally lead to total blind- 
ness, as in twelve cases which were reported from Salonika in 
1917. This complication is generally the result of intense 
quinine poisoning with large amounts of the drug ; it seldom 
occurs after therapeutic doses. It is surprising that it was not 
more frequent when the very large amounts of quinine, which 
were occasionally given, are taken into account. For instance, 
Alport advised 80 grains of quinine bi-hydrochloride daily in 
the first week of a subtertian fever, and cites 26 cases treated 
for 72 days with average daily doses of 35 grains, the maximum 
quantity taken during the period being 3,560 grains. Phear 
cites a case of quinine blindness following a severe cerebral 
malaria after the administration of 160 grains of quinine by the 
intravenous and intramuscular routes. There was another 
similar case with permanent blindness following the adminis- 
tration of 135 grains in three days. 

A study of all the reported cases of quinine blindness collected 
by Elliott reveals the most startling variations in the amount 
of the drug required to produce pathological phenomena in 



282 MEDICAL HISTORY OF THE WAR 

different patients. The cases of total blindness have generally 
followed heroic doses administered within twenty-four hours. 
When more gradually administered a progressive failure of 
sight may be the first symptom of quinine poisoning, without 
any cerebral disturbance. After massive doses, on the other 
hand, the onset is sudden, and is noted on waking up from a 
comatose sleep, a condition which in itself is known to be caused 
by quinine. 

The duration of blindness may vary ; usually it begins to pass 
off from fourteen to twenty-four hours after stopping treatment, 
but it is doubtful whether complete restoration of the vision 
ever occurs. A contraction of the visual field is the most con- 
stant sign. Usually the pupil becomes fixed and dilated. 
Fundus changes consist of a pallor of the discs, extreme con- 
traction of the veins and arteries of the retina, with a cherry-red 
spot at the macula and retinal oedema. The red spot at the 
macula is not so vivid as in embolism ; this is explained by 
the constriction of the choroidal vessels, which therefore do not 
show up so brightly. 

Other symptoms are mental confusion and it may be coma. 
It is necessary that the clinician should be aware of these 
complications and be on his guard not to attribute them to the 
action of the malaria parasite and so disregard the action of 
quinine. 

There is no evidence that a moderate anti-relapse treatment 
causes any permanent injury to the visual acuity of the 
majority. The investigations of Jamieson and Lindsay on 
cinchonized patients showed that long-continued treatment with 
quinine had the effect of slightly contracting the field of vision. 
Their observations tended to show, however, that no one need 
be deterred from giving moderate doses of 30 to 45 grains of 
quinine a day. The extensive use of quinine during the war 
brought into prominence the fact, previously well known, that 
certain persons are peculiarly sensitive to it. In many cases 
this is shown by the development of ear or eye symptoms after 
moderately small doses. A special form of idiosyncrasy is a 
tendency to develop amblyopia sometimes after 2 or 3 grains 
of quinine. Considering the very large amount of quinine 
given serious effects of the administration of this drug were 
fortunately very rare in Macedonia. Skin rashes of various 
kinds, erythema, scarlatiniform rashes, urticaria and less 
commonly purpura have been recorded. They are generally 
accompanied by rise of temperature. Violet-coloured maculae 
on the chest and abdomen in malaria subjects have been 
attributed to the action of quinine. Two serious cases of 
exfoliative dermatitis have been recorded by Phear. 



MALARIA 283 

A transient haemoglobinuria with a rapid development of a 
marked anaemia, supervening upon the administration of 
quinine, has been reported in certain cases, and except for the 
absence of pyrexia such cases are apt to simulate blackwater 
fever. 

Treatment of Malarial Invalids. 

The points which have to be considered in connection with 
the invaliding of men suffering from chronic malaria came into 
prominence in 1917, when the evacuation of invalids from 
Salonika by hospital ships had to be abandoned in consequence 
of submarine warfare. At first these cases were retained in 
Salonika and by December 1917, some 15,000 had accumulated 
there, and a scheme was introduced of transferring them at the 
rate of 1,000 monthly to England through Italy and France, by 
the line of communication established between Taranto and the 
Channel ports. 

The scheme effected an extensive reduction in the number of 
carriers and removed from the expeditionary force a population 
which did little but circulate between hospitals and convalescent 
depots with an occasional day or two of light duty. It would 
have been difficult to justify the retention of these chronic cases 
with a military force operating in a country where malaria is 
endemic. The diminished physical fitness, the lack of energy 
and initiative, the state of indifference and even apathy which 
accompany chronic malaria, are well-recognized conditions. 
They seldom improve so long as the patient remains in the 
infected area. Especially is this the case under the conditions 
of active service. Apart from individual considerations the 
retention of men suffering from chronic malaria forms a danger 
to the community. It is an elementary principle of prevention 
that an army operating in a malarial area should avoid the 
proximity of native villages with their population of gametocyte 
carriers, and it seems illogical to retain in much closer contact 
with the troops large numbers of individuals equally infective. 

While it was found impossible to lay down any hard and fast 
rules, the following conditions were accepted in Macedonia as 
indicating the types of cases for whom invaliding was 
necessary : 

(a) Cases in which the attack had seriously endangered 

life, including all cerebral cases and the other more 
serious pernicious forms of malaria. 

(b) Cases in which internal organs had been severely 

affected, such as suprarenal cases with pigmenta- 
tion, thyroid cases with exophthalmos, cases with 
nephritis, jaundice or pneumonic symptoms. 



284 MEDICAL HISTORY OF THE WAR 

(c) Cases of malaria in association with debilitating or 

organic diseases, such as pulmonary tuberculosis, 
even if latent, gastric or duodenal conditions hinder- 
ing absorption of quinine and chronic bronchitis. 

(d) Resistant cases, relapsing while under adequate 

quinine treatment, or showing frequent recurrences 
with short apyretic intervals, especially those cases 
showing a continual persistent slight evening pyrexia. 

(e) Cases followed by serious sequelae, persisting in spite 

of treatment, such as marked anaemia, debility, 
splenomegaly, nerve lesions, mental changes, and 
psychoses. 

(/) Cases with much cardiac disturbance persisting after 
an adequate period of regulated exercise, " effort 
syndrome," or marked tachycardia. 

(g) Cases of blackwater fever or haemoglobinuria. 

(h) Cases of definite quinine intolerance. 

The general appearance of a patient was always a valuable 
guide. Age might be of importance, a positive decision being 
given more readily in patients under 23 or over 40 years of age. 
And as a counsel of perfection it would have been desirable 
to invalid from Macedonia every case of malignant tertian 
malaria. 

In order to estimate the average duration of invalidism, 
the following table, comprising a series of 3,000 cases of 
malaria, has been compiled by the Medical Research Council 
from the admission and discharge books of military hospitals 
in France, Salonika, Mesopotamia, Egypt and West Africa 
during the years 1915 to 1918. It shows the number of days 
during which patients were under treatment for malaria in the 
different theatres of war. 



Force from which 
derived. 


No. of 

cases. 


Total No. of days 
under Treatment. 


Average No. of 
days under Treat- 
ment. 


France 
Salonika 
Mesopotamia 

Egypt 

West Africa 


1,050 
600 
600 
550 
200 


24,475 
24,810 
10,685 
10,993 
1,898 


23-3 
41-3 
17-8 
19-9 
9-5 


Total 


3,000 


72,861 


24-3 



Anti-relapse treatment has probably claimed more attention 
than any other problem in malaria during the war, as indeed 
the necessity of rendering such large numbers of malaria- 



MALARIA 285 

stricken troops once more fit for active service demanded. 
From large numbers of experiments made under the guidance 
of Sir Ronald Ross in London, Oxford and Aldershot, as well 
as in Salonika, it appeared that a subject who has been 
saturated with quinine over a period of weeks or months is 
less resistant to the disease when he leaves off taking it than 
one who has not been dosed in this manner. This is probably 
due to the debilitating effect of the drug. In Salonika the best 
results were obtained, and the fewest number of relapses re- 
corded, by administering 30 grs. of quinine on each of two 
consecutive days in each week, a method which has been 
described as the " week-end " system. By this means the 
number of relapse cases was diminished from 78 to 32 per cent. 

Attempts to sterilize the patient by short intensive, or longer 
and more moderate, cinchonization have not met with success. 
Of the two methods the latter appears to have been the more 
efficacious. The cases invalided to the United Kingdom and 
treated at Aldershot were given two intramuscular injections 
of 15 grs. each and 30 grs. by the mouth for three days, followed 
by 40 grs. by the mouth for three weeks. In Salonika one 
intensive experiment of two intramuscular injections of 20 grs. 
combined with oral doses of 20 grs. for 12 consecutive days was 
found to have no advantage over the more moderate doses. 

General experience has resulted in the administering of 
60 grs. weekly, until the malarial subject has been free from 
malaria for 60 days. This method reduces the relapses of 
benign tertian infections to ten per cent, of cases per month. 
It is best given in doses of ten grains daily for six days. 

In order to render malaria-infected battalions fit for 
active service, special measures were instituted in France when 
twenty-two battalions of infantry arrived in rapid succession 
during the months of June and July 1918 from Salonika, and 75 
to 85 per cent, of the personnel in these battalions were found 
infected with the malaria parasite. Within a few days of arrival 
in France 273 men of one battalion, for example, were admitted 
to hospital suffering from malaria, and had the battalion then 
been ordered to a forward area at least 50 per cent, would have 
had to be retained at the base. It was evident that these 
troops were unfit for arduous duties at the front, and it was 
consequently decided to form camps for their treatment. They 
were formed into two divisions and the following treatment 
was carried out : 

(1) Feeding. The diet was liberal and supplemented by 
bottled stout, which could be ordered by the medical 
officers for any men whom they considered it would 
benefit. 



286 MEDICAL HISTORY OF THE WAR 

(2) Administration of Quinine. 15 grains of sulphate 

or hydrochloride of quinine in solution were given 
daily for 14 successive days. Afterwards for a 
period of two months 10 grains were given every day 
for six days a week, Sundays being excepted. The 
quinine was given at a definite hour daily either at 
1 1 a.m. or 2 p.m. Aperients were given as a matter 
of routine twice or thrice a week. If a man suffered 
from a relapse he was admitted into a medical unit, 
and on his discharge the daily dose of quinine was 
again commenced. While in the medical unit, he 
received 10 grains of quinine in solution (hydro- 
chloride or sulphate) every four hours, until 40 grains 
were given in the twenty-four hours. This was con- 
tinued for five days. When the patient was free from 
fever for two days he was discharged to his unit. 
During the relapse treatment he received an ounce 
of mistura alba every morning, before any 
quinine was given, and his diet consisted of milk, 
bovril, beef-tea, arrowroot, rice ; but tea was 
excluded. Men who had undergone 28 days' 
treatment without a relapse were allowed to pro- 
ceed to England on leave. They were given a 
supply of quinine tabloids sufficient for 14 days' 
treatment with definite instructions to take 10 
grains a day. They were also given a post-card, 
already addressed to their battalion headquarters, 
in order to let the unit know should they be 
admitted to hospital while on leave. No officer 
or man who had been in a malaria district was 
allowed to escape the daily dose of quinine. 

(3) Work. Only four hours' work was allowed during 

the first stage of quinine administration. Physical 
exercises, squad drill, instruction in signalling, 
Lewis gun and recreational exercises, were con- 
sidered suitable work. As the treatment progressed, 
the daily number of hours for work was increased, 
and trials were instituted to see what amount of 
work the men could stand without developing a 
relapse. Route marches, commencing with a dis- 
tance of five miles without packs, increased to 
8 miles, 10 miles and up to 14 miles without packs, 
were instituted for this purpose. Medical officers 
took part in these marches and reported 
amongst other details on the number of 
men falling out, the causes in each instance of 



MALARIA 287 

falling out, and the number of relapses on the day 
of the route march or following days. When a 
series of route marches without packs was completed, 
a series of marches, commencing with light packs and 
working up to full packs, was begun. As a supreme 
test the troops underwent a 14-mile route march, 
with field operations, and a night in the open 
without blankets. 

(4) Recreation. The men were marched to the sea, 

allowed to remain in the water for 10 to 
15 minutes, and then marched back to ' camp. 
Inter-regimental football matches, regimental sports 
and concerts were the order of the day. Passes 
were given freely to enable the men to visit 
the neighbouring towns, where beer was plentiful. 
The regimental canteens also stocked ample 
supplies of French beer, which was a good 
diuretic and tonic, contained little alcohol, and was 
considered better for malarial subjects, who 
were taking quinine, than boiled tea of which the 
chief constituent was tannin. 

(5) Improving the moral of the men. Medical officers were 

instructed to impress upon the men both in con- 
versation and in lectures that malaria was a disease 
of no importance when quinine was obtainable 
and when they were removed from the infected 
zone. How malaria was caused, the method of 
transmission, and the fact that it was not an 
incurable disease if they followed the line of 
treatment laid down, was also explained to the 
men. Every effort was made to remove any feeling 
of despondency. 

This course of treatment was only possible by the sympathy 
and co-operation of the medical officers in charge of regiments, 
the general officers commanding the divisions, the battalion 
and company commanders, and the senior N.C.O.'s. 

The results were excellent, as the average duration of treat- 
ment was ten weeks, and the two divisions were put in the 
forward area within three months of the commencement of 
treatment. At a later period reports received from the 
administrative medical officers of the divisions showed a 
complete absence of anything like a malarial relapse, and the 
divisions, when in the field, proved as efficient in a military 
sense as divisions of battalions which had never been exposed 
to malarial infection. 



288 



MEDICAL HISTORY OF THE WAR 



The results obtained in a comparatively malaria-free country 
like France are not, however, likely to be obtained by similar 
measures carried out in a malaria-infested country such as 
Macedonia. 



Abrami & Senevet 



Acton 

Armand-Delille, Pais- 
seau & Lemaire. 



Armand-Delille 
Austen 

Alport 

Bass & Johns 

Bahr .. . 

Bruce-Porter 

Cardamatis 

Carnot 



Chambelland 



Cowan & Strong 



BIBLIOGRAPHY. 

Pathogenic de Faeces palustre. 
La crise hemoclasique initiale. 



Pathogenic de 1'acces palustre. 
La crise hemoclasique. Causes 
et consequences. 



Researches on the Treatment 
of Benign Tertian Fever. 

Notes sur quelques cas de palu- 
disme primaire observes en 
Macedoine. 



Considerations relatives a la 
conception uniciste des Hem- 
atozoaires des fievres tierces 
b6nigne et maligne. 

Anti-mosquito measures in Pal- 
estine during the campaigns of 
1917-1918. 

The treatment of Malaria 



A method of Concentrating 
Malaria Plasmodia for diag- 
nostic and other purposes. 

The transmission of Malaria by 

Egyptian Anopheles. 
The Treatment of Malaria 

Mode d'action de la quinine sur 
les diverses formes d'hema- 
tozoaires ; traitement pro- 
phylactique et curatif le plus 
emcace du Paludisme. 

Les Bilieuses paludeennes 



Sur le mecanisme de la dispar- 
ition des schizontes dans le 
sang peripherique au cours 
des acces de paludisme. 

Culture de I'Hematozoaire du 
paludisme 

The treatment of Malaria 



Bull, et Mem. Soc. 

Med. des H6pit. de 

Paris, 1919. 3 e S. 

Vol. xliii, pp. 530- 

536. 
Bull, et Mem. Soc. 

M6d. des H6pit. de 

Paris, 1919. 3* S. 

Vol. xliii, pp. 537- 

544. 
Lancet, 1920. Vol. 

i, pp. 1257-1261. 
Bull, et Mem. Soc. 

Med. des Hopit. de 

Paris, 1916. 3 e S. 

Vol. xl, pp. 281- 

289. 
C.R. Acad. Sciences, 

1919. Vol. clxviii, 

pp. 419-421. 

Trans. Soc. Trop. 

Med. &Hyg.,1919- 

20. Vol. xiii, pp. 

47-60. 
Jl.of R.A.M.C.,1919. 

Vol. xxxii, pp. 352- 

360. 

Amer. Jl. Trop. Dis. 
& Prevent. Med., 

1915. Vol. iii, pp. 

298-303. 
Jl.ofR.A.M.C.,1918. 

Vol. xxx, p. 525. 
Lancet, 1919. Vol. ii, 

p. 1169. 
Bull. Soc. Path. 

Exot., 1918. Vol. 

xi, pp. 648-662. 



Paris Med., 1917. 

Vol. vii, pp. 169- 

176. 
C.R. Soc. Biol., 

1917. Vol. Ixxx, 

pp. 575-578. 

Presse Med., 1919. 
Vol. xxvii, pp. 783- 

784. 
Quart. Jl. of Med., 

1919-1920. Vol. 

xiii, pp. 1-24. 



MALARIA 



289 



Davis 

Dennys 

Dudgeon & Clarke 



Dudgeon 
Duerck 

Dunley-Owen 
Elliott 
Fairley & Dew 



Falconer & Ander- 
son. 



Falconer 



Fox 
Fraser 

Forrester 

Garin, Sarrouy & 
Pouget. 

Graham 

Gunson & others . 



BIBLIOGRAPHY cont. 

Ocular Complications of Malaria 
and the Toxic Effect of Quin- 
ine upon the Eye. 

Iron and Arsenic as a cure for, 
and a Prophylactic against 
Malaria. 

On the Cultivation of the Malar- 
ial Parasite in vitro. 

A contribution to the micro- 
scopic histology of Malaria, 
as occurring in the Salonika 
Force in 1916, and a compari- 
son of these findings with cer- 
tain clinical phemomena. 

On the Effects of Injection of 
Quinine into the tissues of 
Man and animals. 

Ueber die bei Malaria perniciosa 
comatosa auftretenden Ver- 
anderungen des Zentralnerven- 
sy stems. 

Notes on Malaria 



Quinine amblyopia 



The causes of death from Mal- 
aria in Palestine A study in 
cellular Pathology. 

Clinical types of Subtertian 
Malaria, as seen in Salonika 
in September, October and 
November 1916. 

Notes on the Treatment of Sub- 
tertian Cerebral Malaria with 
Quinine and Galyl. 

The pulmonary Manifestations 
in Malaria. 

The pulmonary Manifestations 
in Malaria, 1920. 

Intramuscular Injections of 
Quinine Bi-hydrochloride in 
Simple Tertian Malaria. 

A note on the Treatment of Re- 
current Malaria and Malarial 
Relapses. 

Malaria and Insanity. 

Les syndromes surrenaux frustes 
dans le paludisme secondaire. 

Prophylactic Use of Quinine in 
Malaria. 

The treatment of severe relaps- 
ing cases of Malaria. 



Southern Med. Jl., 

1916. Vol. ix, pp. 

769-773. 
Ind. Med. Gaz., 

1916. Vol. li, pp. 

242-246. 
Lancet, 1917. Vol. 

i, pp. 530-531. 
Lancet, 1917. Vol. 

ii, pp. 153-156. 



Jl. of Hyg., 1919- 

1920. Vol. xviii, 

pp. 317-336. 
Arch. f. Schiffs-u. 

Trop. Hyg., 1917. 

Vol. xxi, pp. 117- 

132. 
S. African Med. Rec., 

1918. Vol. xvi, 

pp. 136-138. 
Amer. Jl. Ophth., 

1918. Series 3. 

Vol. i, pp. 547-560. 
Trans. Soc. Trop. 

Med. & Hyg., 1919- 

1920. Vol. xiii, 

pp. 121-125. 
Jl.of R.A.M.C.,1918. 

Vol. xxx, pp. 215- 

226. 

Jl.of R.A.M.C.,1918. 

Vol. xxxi, pp. 83- 

89. 
Quart. Jl. of Med., 

1919-1920. Vol. 

xiii, pp. 25-34. 
Jl.ofR.A.M.C.,1920. 

Vol. xxxiv, pp. 

131-140. 
Lancet, 1917. Vol. 

ii, pp. 909-910. 



Lancet, 1919. 
ii, p. 1134. 



Vol. 



Vol. 



Lancet, 1920. 

i, pp. 16-17. 
Progres M6d., 1917. 

Vol. xxxii, pp. 324- 

326. 
B.M.J., 1919. Vol. 

i, p. 626. 
Lancet, 1918. Vol. 

i, p. 866. 



290 



MEDICAL HISTORY OF THE WAR 



Harford 

von Heinrich 

Holmes a Court 
James 



Jamieson & Lindsay 
Job & Hirtzmann . . 



Leighton & Moeller 
Loewenstein 

MacGilchrist 



Manson-Bahr 
Mayne 

Miller 
Murray 



BIBLIOGRAPHY cont. 
Quinine as a Prophylactic 



Mischinfektion und Latenz- 
erscheinungen der Malaria. 

Sub-Tertian Malaria. A report 
of Thirty-Five cases. 

The intravenous administration 
of quinine bi-hydrochloride in 
malaria and a remark upon 
the form of the parasite re- 
sponsible for true relapses. 

Malaria at Home and Abroad . 



Remarks on Treatment of Mal- 
aria in England. 

The effects of long continued 
dosage with quinine on the 
visual apparatus. 

Paludisme et infections ty- 
phoides. 



Paludisme et diarrhee . . 



A case of Spontaneous Rupture 
of the Malarial Spleen. 

Ueber die Wirkung des Chinins 
auf die Halbmond-formen der 
Malaria. 

The relative Therapeutic Value 
in Malaria of the Cinchona 
Alkaloids Quinine, Cinchonine, 
Quinidine, Cinchonidine and 
Quinoidine, and the Two De- 
rivatives Hydro-Quinine and 
Ethyl Hydro Cupreine. (Cin- 
chona Derivatives Inquiry, 
Fifth Communication.) 

Experiences of Malaria in the 
Egyptian Expeditionary Force. 

The Thick Blood Film Method 
for Malaria Diagnosis Appli- 
cable to Present Field Condi- 
tions. 

The treatment of Chronic Re- 
lapsing Malaria with Salvar- 
san Substitutes. 

Notes, chiefly clinical, on the 
treatment of Malaria. 



Trans. Soc. Trop. 

Med. &Hyg.,1916- 

17. Vol. x, pp. 43- 

44. 
Wien. Klin. Woch., 

1917. Vol. xxx, 

pp. 1317-1320. 
Med. Jl. Aust.,1918. 

Vol. i, pp. 63-66. 
Jl.ofR.A.M.C.,1917. 

Vol. xxix, pp. 

317-322. 



Publication by 

Messrs. John Bale, 
Sons & Danielsson, 
Ltd., 1920. 

Lancet, 1919. Vol. 
ii, pp. 1016-1018. 

Jl.ofR.A.M.C.,1919. 
Vol. xxxii, p. 295. 

Bull, et M6m. Soc. 

Med. des H6pit. de 

Paris, 1919. 3 e S. 

Vol. xliii, pp. 581- 

583. 
Bull, et Mem. Soc. 

Med. des H6pit. de 

Paris, 1919. 3 e S. 

Vol. xliii, pp. 629- 

633. 
Jl. Amer. Med. 

Assoc., 1916. Vol. 

Ixvi, pp. 737-738. 
Ztsche. f. Hyg. u. 

Infektionskr.,1917 

Vol. Ixxxiv, pp. 

317-322. 
Ind. Jl. Med. Res., 

1915-1916. Vol. 

iii, pp. 1-89. 



Lancet, 1920. Vol. i, 

pp. 79-85. 
Pub. Health Rep., 

1919. Vol. xxxiv, 

pp. 837-842. 

Jl.ofR.A.M.C.,1919. 
Vol. xxxii, pp. 483- 
486. 

War Office Publica- 
tion, 31st Dec., 
1918. 



MALARIA 



291 



Miihlens 

Neumann 

Newell 
Nierenstein 



Oesterlin 



Paisseau & Lemaire 



Patrick 

Pringle 
Pepin 



Phear 
Plehn 



Parsons & Forbes 



BIBLIOGRAPHY cont. 

Bericht iiber eine Malaria Ex- 
pedition nach Jerusalem. 



Zur Salvarsanbehandlung der 
Malaria. 

Prophylactic use of Quinine in 
Malaria. 

Quitinine A disintegration pro- 
duct of quinine found in the 
urine. 

Report on the excretion of quin- 
ine in the urine. 

Erfahrungen iiber den mechan- 
ischen Schutz gegen Malaria. 



Erfahrungen in einem Malaria 
Ambulatorium in Durazzo. 



Acces pernicieux palustres et 
surrenalites aigues. 



Syndromes h^morragiques dans 
le paludisme primaire. 



, De 1'insuffisance surrenale dans 
le paludisme. 

Experiences with Intravenous 
Injections of Quinine and An- 
timony in the Treatment of 
Malaria. 

Quinine in Malaria Prophylaxis. 

Quinine et Paludisme, Elimin- 
ation de la quinine par 1'urine, 
quelques dosages precis, possi- 
bilite de determiner la meil- 
leure forme d'administration 
de la quinine dans le palu- 
disme. 

The treatment of Malaria in 
Macedonia. 

Ueber Malaria , 



Mazedonische Malaria oder Mal- 
aria der Chiningewohnten. 

Haemoglobinuria (Blackwater 
Fever). Observations on a 
transient form occurring 
amongst the troops in Mace- 
donia. 



Centralbl. f. Bakt. 

I. Abt.Orig., 1913. 

Vol. Ixix, pp. 41- 

85. 
Deut. Med. Woch., 

1919. Vol. xlv, 

pp. 767-768. 
B.M.J., 1919. Vol. i, 

p. 626. 
Jl.of R.A.M.C.,1919. 

Vol. xxxii, pp.2 18- 

219. 
W.O. Observations 

on Malaria, Dec. 

1919, pp. 4-79. 
Arch. f. Schiffs u. 

Trop-Hyg., 1919. 

Vol. xxiii, pp. 49- 

57. 
Arch. f. Schiffs u. 

Trop-Hyg., 1919. 

Vol. xxiii, pp. 68- 

72. 
Bull, et M6m. Soc. 

Med. des Hopit. de 

Paris, 1916. 3 e S. 

Vol. xl, pp. 1530- 

1545. 
Bull, et Mem. Soc. 

Med. des Hopit. de 

Paris, 1916. 3 e S. 

Vol. xl, pp. 1672- 

1685. 
Presse Med., 1916. 

Vol. xxiv, pp. 545- 

547. 
Jl.of R.A.M.C.,1919. 

Vol. xxxii, pp. 407- 

429. 

Ind. Med. Gaz.,1918. 

Vol. liii, p. 258. 
Presse Med., 1918' 

Vol. xxvi, pp. 492- 

493. 



Lancet, 1920. Vol. i, 

pp. 195-196. 
Berlin. Klin. Woch., 

1917. Vol. liv, pp. 
431-435. 

Deut. Med. Woch., 

1918. Vol. xliv, 
pp. 1296-1298, 

Lancet, 1918. Vol. ii, 
pp. 317-819. 



292 



MEDICAL HISTORY OF THE WAR 



Rawnsley . . 
Rogers 
Ross. . 



Ross & James 
Ross 

Salm 
Stein 



Stephens, Yorke, 
Blacklock, Macfie 
& Cooper. 

Stephens, Yorke, 
Blacklock, Macfie 
Cooper & Carter. 

Stephens, Yorke, 
Blacklock & 
Macfie. 

Stephens, Yorke, 
Blacklock, Macfie 
& O'Farrell. 



Stephens 

Sternberg 
Thomson, J. D. 



BIBLIOGRAPHY cont. 
Prophylaxis of Malaria . . 



Quinine Prophylaxis in Malaria. 



Report on the Treatment of Mal- 
aria (Abstract of 2,460 cases. 
War Office investigations). 
(Additional remarks.) 

War Experiences of Malaria 

The care and treatment of cases 
of Malaria. 

Suggestions for the care of Mal- 
aria patients. 

Observations on Malaria by 
Medical Officers of the Army 
and others. 

Een geval van Malariapsychose. 



Malariaparasiten und Neosal- 
varsan. 

Malariaparasiten und Neosal- 
varsan. 

Studies in the Treatment of Mal- 
aria. 



Studies in the Treatment of Mal- 
aria. 



Studies in the Treatment of Mal- 
aria. 



Studies in the Treatment of Mal- 
aria. 



A Factor hitherto over-looked 
in the Estimation of the Cura- 
tive Value of a Treatment of 
Malaria. Result of an Investi- 
gation carried out at the 
Liverpool School of Tropical 
Medicine. 

Zur Bakteriologie und Aetiologie 
der Ruhr. 

Notes on Malaria 



Jl.ofR.A.M.C.,1918, 

Vol. xxxi, pp. 60, 

272. 
Ind. Med. Gaz.,1918. 

Vol. liii, pp. 249- 

252. 
Ind. Med. Gaz.,1918. 

Vol. liii, pp. 241- 

249, 292-293. 

B.M.J., 1919. Vol. i, 
p. 558. 

Lancet, 1919. Vol. i, 
pp. 780-781. 

H.M. Stat. Office, 
1919. 

War Office Publica- 
tion, 1919. 

Geneesk Tijdschr. 

Ned. Ind., 1915. 

Vol. Iv, pp. 466- 

473. 
Wien. Klin. Woch., 

1916. Vol. xxix, 
pp. 1071-1072. 

Wien. Klin. Woch., 

1917. Vol. xxx, 
pp. 436-438. 

Ann. Trop. Med. & 

Parasit.,1917. Vol. 

xi, pp. 91-111, 

113-126. 
Ann. Trop. Med. & 

Parasit., 1918- 

1919. Vol. xi, pp. 
283-307. 

Ann. Trop. Med. & 
Parasit., 1919- 

1920. Vol.xiii,pp. 
97-99, 101-108. 

Ann. Trop. Med. & 

Parasit., 1919- 

1920. Vol.xiii, pp. 

117-118 119-124, 

125-131. 
Trans. Soc. Trop. 

Med. &Hyg.,1918. 

Vol. xi, pp. 297- 

303. 



Wien. Klin. Woch., 
1916. Vol. xxix, 
pp. 1257-1262. 

Jl.ofR.A.M.C.,1917. 
Vol. xxix, pp. 379- 
411. 



MALARIA 



293 



Thomson, J. D. 



Thomson, D. 



Thomson, J. G. 



Turner 



Treadgold 

Ward 
White, R. O. 

White, M 

Wiltshire 



Willcox 



Woodcock . . 



Buchanan & others 



BIBLIOGRAPHY cont. 

Quinine in Malaria. Its Limita- 
tions and Possibilities. 



Diagnosis and Treatment of 
Malaria Fever. 



Preliminary Note on the Com- 
plement Deviation in Cases of 
Malaria. A New Aid to Diag- 
nosis. 

Complement Deviation in Mal- 
aria and the Question of the 
Influence of Malaria on the 
Wasserman Reaction. 

Spontaneous Rupture of the 
Spleen. With an Account of 
a Case due to Malaria and One 
of Necrotic Infarct with In- 
traperitoneal Haemorrhage 
simulating Spontaneous Rup- 
ture. 

The prophylactic use of quinine 
in Malaria, with special refer- 
ence to experiences in Mace- 
donia. 

A Criticism of the Memorandum 
on Malaria. 

A note on some cases of Intes- 
tinal Malaria. 



Malaria from the Surgeon's 
Standpoint. 

The Value of Intramuscular 
Injection of Quinine in the 
Treatment of Macedonian Mal- 
aria and some Conjectures 
concerning Quinine Therapy 
in General. 

The Treatment of Malaria 



Notes and comments upon my 
Malaria experiences while with 
the Egyptian Expeditionary 
Force, 1916-1918. 

Reports and Papers on Malaria 
contracted in England in 1917 



Trans. Soc. Trop. 

Med.& Hyg., 1918. 

Vol. xi, pp. 226- 

231. 
Jl.ofR.A.M.C.,1917. 

Vols. xxviii, pp. 

658-688, and xxix, 

pp. 1-37. 
B.M.J., 1918. Vol.ii, 

pp. 628-629. 



Trans. Soc. Trop. 

Med. & Hyg., 1919- 

1920. Vol. xiii, pp. 

18-20. 
Lancet, 1917. Vol. i, 

pp. 799-801. 



B.M.J., 1918. Vol. i, 
pp. 525-529. 



Lancet, 1919. Vol. ii, 

pp. 126-127. 
Report of the Accra 

Laboratory, 1915. 

London, 1916, 

J. & A. Churchill, 

pp. 47-48. 
Lancet, 1919. Vol. ii, 

pp. 154-156. 
Jl.ofR.A.M.C.,1919. 

Vol. xxxiii, pp. 

251-261. 



Lancet, 1919. Vol.ii, 
pp. 1105-1106. 

B.M.J., 1919. Vol.ii, 
pp. 796-797. 

Jl.ofR.A.M.C.,1920. 
Vol. xxxiv, p. 385. 



Reports to the Local 
Government 
Board on Public 
Health and Medi- 
cal Subjects (New 
Series No. 119), 
1918. London: 
H.M. Stationery 

. Office. 



CHAPTER XI. 

BLACKWATER FEVER. 

"OLACKWATER Fever, also known as haemoglobinuric fever, 
JD melanuric fever, haematuric fever and endemic haemoglo- 
binuria, is an acute disease, commonly starting with 
a severe rigor, and characterized by pyrexia, bilious vomiting, 
jaundice, haemoglobinuria and frequently diminution or even 
suppression of urine. 

Before the war the chief places in the world where black- 
water fever occurred were West Africa, Assam, certain 
parts of India, East Africa and the Solomon Islands, and to a 
lesser degree Demerara, the southern parts of Europe and 
the southern states of America. 

During the war, owing to the aggregation of large numbers 
of troops in some of these centres of the disease, to the 
hardships of campaigning, the great prevalence of malaria, and 
the exposure of considerable bodies of unacclimatized men to 
unusual climatic conditions, blackwater fever took a con- 
siderable toll of men on service. More especially was this 
the case in East Africa and Macedonia. 

In the former, although no exact figures of the incidence of 
the disease are as yet available, many hundreds of cases of the 
disease among the troops were noted. The disease principally 
attacked the white soldiers, though Chinese labourers employed 
towards the end of the campaign seemed especially liable to 
attack. There is no record of the disease having occurred 
amongst the black African troops employed. Taute states that 
amongst the German troops in East Africa from the beginning 
of the war to the end of June 1917, of all cases which died 
other than from wounds, 64-2 per cent, were from blackwater 
fever. No case of the disease was ever seen by him in a native. 

With regard to Macedonia more complete figures are avail- 
able. Phear states that during the year ending October 1918 
136 cases of blackwater fever were reported amongst the British 
troops in the Salonika command. Of these cases 36 died, giving 
a case mortality of 26*5 per cent. 

With reference to the seasonal incidence in Macedonia, he 
shows that 116 out of the total of 136 cases were reported during 
the months of December to April 1917-18 inclusive, and that the 
incidence reached its maximum in February, in which month 
32 cases were reported. During the summer months, i.e., from 

294 



BLACKWATER FEVER 295 

June to September, no case of the disease was reported until 
September when nine cases occurred. He is unable to account 
for this prevalence of the disease in the cold months of the 
year, but seeing that in other parts of the world the onset of 
an attack is frequently determined by a previous chill it may 
be that during the cold period of the year, when chills are readily 
contracted, one would expect a greater prevalence of the disease. 
In the preceding year, 1916-1917, only 18 cases occurred. 

Arkwright and Lepper also give particulars of 16 cases of the 
disease observed by them in Malta, all of these cases being in 
soldiers transferred there from Salonika, who developed the 
disease whilst in Malta during the years 1916-17. Of these 
sixteen cases four ended fatally. 

The British were not the only troops attacked by the 
disease. Thus Armand-Delille records its occurrence in 1916 
amongst the troops forming the French Army of the East and 
states that the mortality was 30 per cent. 

Enemy troops were also attacked. Wiener describes four cases 
that came under his notice in Albania. Seyfarth gives clinical 
details of 11 cases of the disease in Bulgaria, of whom 8 were 
Bulgarians, 2 Russians and 1 Turk. In a further contribution 
he states that blackwater fever is common in South Eastern 
Bulgaria, in the coastal region of South Western Bulgaria, 
in and around Salonika and in Greece. 

In theatres of war other than Macedonia and East Africa, 
cases of blackwater fever appear to have been rare. 
Thus Mackie, writing on diseases of Mesopotamia in 1919, 
makes no mention of the disease, and several medical officers 
who served in that area stated that they never saw a case 
there. In Palestine also the disease appears to have occurred 
but rarely, at any rate in the earlier part of the campaign, 
though a certain number of cases were noted after the fighting 
in the Jordan valley. 

There is no record of blackwater fever occurring in the short 
campaign in Togoland. During the operations in the 
Cameroons seven cases with five deaths were recorded 
amongst admissions to the base hospital at Duala.* No 
information is available as to its occurrence amongst the 
Australian and New Zealand troops employed in expeditions 
to certain of the South Pacific Islands. 

^Etiology. 

The causation of the disease is unknown. Various theories 
have from time to time been put forward to explain the 

* See App. F, Table III. General History of the Medical Services, 
Vol. I. 

(2396) T 



296 MEDICAL HISTORY OF THE WAR 

production of the disease. Amongst these the principal 
are : 

(1) That it is due in some way to malaria. 

(2) That it is caused by a specific parasite at present 

unknown. 

(3) That it is a manifestation of quinine poisoning. 

(4) That it is due to malarial anaphylaxis. 

The general trend of opinion expressed by workers in the 
various theatres of war seems to be that the disease is the result 
in some way of previous malaria, the onset frequently being 
precipitated by some other factor, such as chill, fatigue or the 
administration of quinine. 

It is generally agreed by most observers that the disease is 
almost invariably associated with previous and commonly oft- 
repeated attacks of sub-tertian malaria, though in very rare 
instances cases have been recorded in which the patient had 
not previously suffered from sub-tertian malaria but from one 
of the other varieties of malaria. Thus Stephens records such 
a case in which the disease followed infection with quartan 
malaria. 

Wiener also records four cases of which three suffered from 
benign tertian malaria, whilst the fourth was infected with the 
parasites of both benign tertian and sub-tertian. 

The relation of the administration of quinine to the pro- 
duction of blackwater fever has been widely discussed. That 
quinine in itself can produce true blackwater fever is 
generally discredited, but that quinine can in certain cases 
act as the determining factor in precipitating an attack of 
blackwater fever in a patient, the subject of much previous 
malaria, is undoubted. Quinine in such cases seems to act 
merely as the " firing charge/' much as cold, chill or fatigue 
may act. 

The theory that the disease is a malarial anaphylaxis has a 
few advocates and those chiefly of the continental school of 
thought. Widal and Ascoti were the original exponents of this 
view, and Porak appears to agree with them, but their views 
have not met with a great amount of support from British 
authorities. 

Morbid Anatomy. 

In post-mortem examination of a fatal case of black- 
water fever the most notable changes are found in the 
kidney, spleen and liver. Microscopically the kidneys are fre- 
quently somewhat congested and may be darker in colour than 
normal. On microscopic investigation it will be found that the 
tubules are extensively blocked with casts consisting of an 



BLACKWATER FEVER 297 

amorphous-like material, frequently containing granules of 
" malarial " pigment, but with only an occasional red blood 
cell. The straight tubules especially show these changes. In 
the great majority of cases the renal epithelium shows very 
little change ; occasionally there may be cloudy swelling 
or even fatty degeneration of the cells, but this is unusual. 
The cells by suitable treatment will be found to contain 
yellow pigment and also granules containing iron in organic 
combination (haemosiderin). 

The liver is sometimes large and congested and shows evi- 
dence of marked blood destruction in the deposition of yellow 
pigment and haemosiderin in the parenchymatous cells. 
Melanin may also be present. The gall bladder is usually full 
of very dark inspissated bile. The spleen also is congested and 
shows similar evidence of blood destruction and deposition of 
melanin. All the tissues are more or less jaundiced and the 
heart is commonly somewhat pale and its walls flabby. 

Symptoms. 

The onset of the disease is sudden and generally accompanied 
by a severe rigor, the temperature rapidly rising to 103 F. or 
104 F. Pain of a dull aching character is commonly com- 
plained of over the liver area, over the loins or the bladder. 

The patient has an urgent desire to micturate and passes a 
considerable quantity of almost black urine. In mild cases the 
urine may be of a dark brown colour rather than black. Fre- 
quency of micturition continues, but in the absence of suitable 
treatment the amount passed at each act of micturition tends 
to get less and less till perhaps only a tablespoonful is passed 
at a time or complete suppression may set in. 

Within a few hours of the onset of the haemoglobinuria 
jaundice will occur, first noticed in the eyes and gradually 
deepening and involving the whole body. The jaundice is not 
of the light lemon colour associated with ordinary catarrhal 
jaundice, but the colour is darker and more bronzed. 

Vomiting usually sets in within some eight or ten hours of 
the onset of the disease. It may be almost continuous or, if 
early and efficacious treatment is adopted, only occasional. The 
vomit is bilious. The spleen is moderately enlarged. 

The temperature is commonly of a remittent character but 
falls to normal rapidly when, in a favourable case, the urine 
begins to clear. 

The patient rapidly becomes exhausted and violent palpita- 
tion may ensue on the slightest exertion. The pulse becomes 
rapid, compressible and of low tension. 



298 MEDICAL HISTORY OF THE WAR 

In a case of moderate severity the temperature remains high 
for some 36 to 48 hours whilst the passage of the black or very 
dark urine continues. Thereafter the patient's skin becomes 
moist, sweating increases, the temperature falls and the urine 
begins to clear, the colour with each successive micturition 
becoming lighter and lighter until within about 8 to 12 hours 
after the clearing process has begun the urine will assume its 
normal appearance. With the complete clearing of the urine 
sweating stops, the temperature is down to normal or even below 
it, and the patient, beyond the extreme prostration, feels fairly 
comfortable. The jaundice, with the clearing of the urine, 
lessens and usually has completely disappeared within a day or 
two after the urine has become normal in appearance. 

Such is a brief outline of a moderately severe case. In more 
severe cases the urine may fail to clear for some four to five days, 
or after the urine has cleared and the temperature has returned 
to normal the fever may again occur accompanied by a re- 
crudescence of the haemoglobinuria and the repetition of all the 
accompanying symptoms. On the other hand, the urine may 
show no signs of clearing, the amount passed may become less 
and less until complete suppression occurs, vomiting becomes 
continuous, hiccough, a very bad sign, is persistent and the 
patient dies. If suppression continues for two or three days, 
death almost certainly ensues, though recovery from such a 
condition has on rare occasions been recorded. 

Taute records a remarkable case in which complete anuria 
persisted for five days. Then the patient evacuated some 500 c.c. 
of bloody urine. Complete suppression then recurred for eight 
days, when the patient died. 

It is fairly common in most cases of the disease for the tem- 
perature to rise a degree or two after the urine has cleared. 
This is not accompanied by a return of the blackwater and 
seems to be due to the efforts of the body in absorbing and 
assimilating some of the products of the haemolysis. 

With the defervescence of this secondary fever convalescence 
sets in and is generally fairly rapid, though on account of the 
severe anaemia it is necessary to keep the patient very quiet 
and lying down for some two weeks or so. 

Examination of the blood at the onset of the attack fre- 
quently reveals the presence of malarial parasites therein, 
though commonly in scanty numbers. These are usually of the 
sub-tertian variety, though occasionally benign tertian or even 
quartan may be found. With the full establishment of the 
attack, parasites usually disappear even without any quinine 
being administered. This is probably due to the destruction 
of the corpuscles containing the parasites by the acute 



BLACKWATER FEVER 299 

haemolytic process. Possibly such corpuscles are more 
vulnerable to the haemolytic process than those not containing 
parasites. 

Examination of the blood some hours after the attack of 
blackwater has commenced will reveal very grave changes. It 
will be seen that an extensive and massive haemolysis has taken 
place, resulting in a very large diminution in the total number 
of red cells in the blood and a great reduction in the haemo- 
globin. Instead of a normal 5,000,000 red cells per c.mm., the 
number will probably be reduced to 2,500,000, and with the 
progress of the disease this figure may fall to 1,000,000 or even 
less. The haemoglobin is correspondingly diminished. No 
marked reduction in the number of white cells appears to take 
place, but a differential count reveals a relative increase in the 
proportion of the large mononuclears. 

If a sample of the typical black urine of an ordinarily severe 
case of the disease be examined it will be found on standing to 
separate into two layers, an upper clear black portion and a 
lower somewhat brownish-black layer consisting of a sediment. 
Examination of this sediment shows it to consist largely of a 
granular material, together with renal casts of a somewhat 
amorphous character, detached epithelium and possibly a very 
occasional red blood corpuscle. 

The urine is highly albuminous and if heated an almost 
solid brownish-black coagulum is produced. The albumen in 
the urine will persist for several days in gradually diminishing 
quantity, even after the urine has become clear and of normal 
appearance. 

Spectroscopic examination of an ordinary blackwater urine 
shows the absorption bands of oxy-haemoglobin, but in mild 
cases, in which the urine is only dark brown, methaemoglobin 
alone may be present. Such a mild attack may, however, be 
followed by a serious relapse and the passage of black urine. 

The amount of dilution necessary to render any sample of 
blackwater urine transparent is a rough guide to the severity 
of the attack. Thus, if only an equal quantity of water is 
necessary, the attack is a mild one, whilst if two, three, four or 
more times the amount of water is necessary, such amounts 
point to progressively more severe forms of the disease. It 
may be difficult in the very mild forms of the disease in which 
only methaemoglobin is present to distinguish between such a 
urine and a urine darkened by bile pigment. Shaking of 
such a urine gives valuable information. If the colour is due 
to bile the froth will be of a yellowish-green colour, if to 
methaemoglobin of a rose-red colour. 

Complications of the disease are not common. Several 



300 MEDICAL HISTORY OF THE WAR 

observers have recorded the passage of haemoglobin or blood 
per anum, but the condition seems to be a rare one. 

Vinson records one case of blackwater fever complicated 
with cerebral malaria, the blood showing sub-tertian parasites. 
This patient recovered. 

Newham also had a similar case under his care in the East 
African campaign. A patient developed a typical severe 
attack of blackwater fever with quantities of sub-tertian 
parasites in his blood. Within six hours of the onset of the 
blackwater he became comatose. Vigorous administrations of 
quinine banished the coma in about 12 hours from its onset, but 
the blackwater persisted and the patient died the following day. 

Newham has also seen one case in which typical blackwater 
fever was followed by a definite attack of enteric fever. 

Sequelae of blackwater fever are rare. There is always a 
certain amount of exhaustion and anaemia after the attack, 
and complete recovery may be somewhat protracted. Some 
authorities have noted nephritis as a rare sequel. 

Patients who have once had an attack of the disease are 
thereby rendered more prone to subsequent attacks, and 
instances are on record in which patients have successfully 
passed through as many as ten or more attacks. The mortality 
seems to vary considerably, being very high in some series 
of cases and very low in others. Thus Plehn gives a mortality 
of only 4 per cent, in a series of cases seen by him, whilst other 
workers have recorded figures as high as 50 per cent. 

During the war, although definite figures are not yet 
available, probably a percentage of 25 to 30 represents the 
mortality rate amongst British soldiers suffering from the 
disease. The figure under service conditions will probably 
be higher than under civil conditions owing to the exposure, 
great fatigue, repeated malarial attacks, and in many cases to 
the difficulty of treating such cases in unsatisfactory surround- 
ings incidental to active service. 

It is a well-recognised fact that where the necessity for 
moving a patient suffering from blackwater fever arises, such 
removal, especially after the disease has lasted ten hours, 
tends greatly to lessen his chance of recovery. 

Prognosis. 

During the course of the disease signs which are of bad 
omen are particularly persistent vomiting, persistent hiccough, 
marked diminution in the volume of the urine passed, per- 
sistence of the black urine after the third day, clouded mind 
and great restlessness, persistent high temperature and 
suppression of urine. 



BLAGKWATER FEVER 301 

Diagnosis. 

The diagnosis of the disease presents few difficulties. The 
sudden onset of copious haemoglobinuria together with a 
severe rigor and rapid rise of temperature presents a picture 
that is not simulated by any other disease. Haemoglobinuria 
may occur in a few other conditions, such as paroxysmal haemo- 
globinuria and Raynaud's disease and after taking certain 
drugs, but the differentiation of these should present no 
difficulties. Difficulty may arise in very mild cases in which 
methaemoglobin only is passed, but the spectroscope should 
remove any doubts. 

Treatment. 

In the treatment of the disease absolute rest in bed and good 
nursing are imperative. The patient must be kept flat on 
his back and on no account allowed to sit up, and this measure 
should be enforced for at least a fortnight after the urine 
has cleared and the patient is apparently recovering, since 
during that period there is a grave risk of sudden fatal syncope 
consequent on the severe anaemia. If it can possibly be 
avoided it is better not to move a blackwater patient from 
the place where he was taken ill, and if removal is absolutely 
necessary it should be for as short a distance as possible and be 
carried out in the first few hours folio wing the onset of the disease. 

Drugs in general seem of very little material benefit in this 
disease. The great essential is to keep the kidneys well flushed 
and so to dilute the albuminous material excreted through 
these organs that coagulation with the formation of casts 
and blocking of the tubules may be prevented. The best 
flushing material is undoubtedly water. It may be 
administered in several forms and in several ways. During 
the early stage of the disease, when vomiting has not 
occurred, or is only occasional, water is best administered 
by the mouth, four ounces being given every hour with 
instructions that it should be sipped at intervals and not all 
swallowed at one time. The water may be given in the form 
of soda water, barley water, milk and soda, or any other form 
in which it is acceptable. Should vomiting become so frequent 
that the stomach cannot retain the water, recourse must be 
had to some other form of administration. Perhaps the best 
method is to introduce into the rectum every hour six ounces 
of normal saline, suitably warmed. If care be taken to 
introduce it slowly and a larger bulk than six ounces is not 
administered at one time irritation of the lower bowel is not 
produced and repeated injections can be given Other 
methods of introducing water into the system are by means 



302 MEDICAL HISTORY OF THE WAR 

of subcutaneous or intravenous injections of saline, one to 
two pints being injected on each occasion. 

In whatever way fluid is supplied care should be taken to 
measure accurately the amounts of urine passed, as by so 
doing any diminution in the output of urine is soon detected 
and measures can be taken to increase the intake of fluids. 
Generally speaking, an excretion at the rate of about four 
ounces per hour should be aimed at. 

Stimulating diuretics should not be employed as there is 
a danger of over-stimulation of the kidneys and failure of 
excretion. The administration of fluids should be continued 
until the urine is quite clear. 

The patient should be kept warm and guarded from chills, 
and he is best kept in blankets which should be changed as 
often as marked sweating occurs. Tepid sponging after 
sweating is very grateful to the patient. 

The advisability of administering quinine in blackwater 
fever, in view of its known action as a common precipitating 
agent of the disease, has aroused marked diversity of opinion. 
Some authorities recommend its use whilst others never 
employ it. Perhaps the safest course to adopt is to administer 
quinine in small doses if malarial parasites are found by the 
ordinary or the thick film method to be present in the blood, 
otherwise to withhold it. The blood should be examined by 
both thick and thin film methods, as parasites are often scanty 
and easily overlooked. 

Burkitt has shown that in this disease there is a well-marked 
acidosis, and to combat this some authorities have recourse 
to intravenous injection of a one per cent, solution of sodium 
carbonate. Others employ Hearsey's mixture (solution of 
perchlor. of mercury m. 30, bicarbonate of soda gr. 10, water 
to one ounce) . An ounce of this is administered by the mouth 
every three hours till the urine clears. It is doubtful whether 
these drugs have much influence on the course of the disease, 
but the employment of Hearsey's mixture seems to control 
somewhat the tendency to vomit. The vomiting may be 
relieved also by sinapisms to the pit of the stomach, sucking 
of ice, or by a small dose of morphia hypodermically. 
Hiccough is best controlled by blistering the left side of the 
neck over the course of the pneumogastric nerve. 

Food is best withheld in the early part of the attack, but 
as soon as the stomach can tolerate it fluid diet in the form 
of milk, albumen water, Benger's food, may be administered. 
In some cases resort to rectal feeding may be necessary. 
Stimulants may be necessary, and in such cases champagne, 
preferably iced, is recommended. 



BLACKWATER FEVER 303 

Many drugs have been recommended from time to time as 
having distinctly beneficial results in this disease. Several 
have recommended and used salvarsan in one or other of its 
various forms, but a study of their results does not appear 
to show that cases so treated do any better than those treated 
on the lines recommended above. In the case of most other 
drugs the number of cases treated is commonly so small that 
no conclusive opinion as to their merits is warranted. 

During convalescence, good easily digested food should be 
given, the bowels kept acting freely, and iron and arsenic 
administered as tonics. 

In view of the liability to recurrence it is advisable that all 
patients on recovery should be evacuated from the infected 
area to a non-malarial country. 

It cannot be too strongly emphasised that mild cases of 
the disease, those in which methaemoglobin only is being 
passed, must be treated with the same scrupulous care as the 
more severe cases with passage of black urine. Any neglect 
in such cases may lead to what in the first instance was a 
mild attack developing into one of a fulminating and fatal type. 

Seeing that the cause of blackwater fever is unknown it 
is impossible to lay down exact rules as to the definite pre- 
ventive measures necessary. 

In view of the undoubted close association between malaria, 
especially sub-tertian, and blackwater fever, measures directed 
against malarial infection would seem to offer the best chance 
of success. It has been shown in various parts of the world 
that by successful application of methods designed to limit 
infection with malaria, the incidence of blackwater fever has 
fallen concurrently with a marked reduction in the malarial 
incidence. All prophylactic measures adopted for malaria 
would therefore seem to be indicated in the case of blackwater 
fever. Where prophylactic measures include the taking 
of quinine, it is important that prophylactic doses of quinine 
should be taken regularly, as many authorities hold that 
irregular administration of prophylactic quinine is apt to 
precipitate blackwater fever. 

BIBLIOGRAPHY. 

Arkwright & Lepper A series of 16 cases of blackwater Trans. Soc. Trop. 
fever occurring in the Eastern Med. & Hyg., 1917- 
Mediterranean. 1918. Vol. ii, 

pp. 127-148. 

Armand- Delille, Note sur les caracteres de la Trop. Dis. Bull., 
Paisseau, Lemaire. bilieuse haemoglobinurique 1918. Vol. ii, p. 40. 
observee chez les paludeens 
de 1'armee d'Orient. 

Burkitt .. .. Blackwater fever .. .. Lancet, 1915. Vol. ii, 

pp. 1138-1140. 



304 



MEDICAL HISTORY OF THE WAR 



Castellan! & Chalmers 
Connal 

Daniels 
David 

Lalor 
Lopez 
Mackie 

Manson 
Phear 

Porak 
Roux 
Seyfarth . . 



Schiiffner 
Taute 

Vinson 
Wright 
Wiener 



BIBLIOGRAPHY cont. 
Manual of Tropical Medicine . . 

Report of the Medical Research 
Institute (Lagos) for the year 
1916 

Tropical Medicine and Hygiene. 

Sur 1'Etiologie et la prophylaxie 
de la fievre bilieuse haemo- 
globinurique. 

Investigation of Malaria in the 
district of Katha. 

Research on the Pathology and 
Treatment of Bilious Haemo- 
globinuric Fever. 

Diseases in Mesopotamia 



Tropical Diseases 

Notes on Blackwater fever in 
Macedonia. 

Bilieuse haemoglobinurique 
paludeenne et autoanaphyl- 
axie. 

Traitement de la fievre bilieuse 
haemoglobinurique. 

Blackwater fever in the Balkan 
Peninsula. 

Blackwater fever in South-East 
Bulgaria. 

Finding of a Spirochaeta in a 
disease with clinical symptoms 
of Blackwater fever. 

Aerztliches aus dem Kriege in 
Ostafrika 1914-1918. 



Contribution a 1'Etude de la 
Malaria. 

Notes on the Treatment of 
Blackwater fever. 

Einige Falle von Schwarzwasser- 
fieber. 

Memoranda on Medical Diseases 
in the Tropical and Sub-tropi- 
cal War Areas. 

Blackwater fever in Tropical 
African Dependencies. 



3rd edition. Lond. 

1919. 
Trop. Dis. Bull., 

1919. Vol. xiii, 

p. 297. 
2nd edition. Lond- 

1913-1917. 
Bull. Soc. Path. 
Exot., 1914. 

Vol. vii, pp. 509- 

512. 
Trop. Dis. Bull. 

1914. Vol. iv, 

p. 295. 
Trop. Dis. Bull. 

1918. Vol. xii, 
p. 360. 

Bristol Med. Chir. 

Journ., 1919. 

Vol. xxxvi, p. 118. 

6th edition. Lond. 

1917. 

Jl. ofR.A.M.C.,1920. 
Vol. xxxiv, 
pp. 1-14. 
Trop. Dis. Bull., 

1919. Vol. xiii, 
p. 299. 

Trop. Dis. Bull., 

1919. Vol. xiii, 

p. 302. 
Trop. Dis. Bull., 

1919. Vol. xiii, 

p. 298. 
Trop. Dis. Bull., 

1918. Vol. xii, 
p. 355. 

Trop. Dis.. Bull., 

1919. Vol. xiii, 
p. 300. 

Archiv. fur Schiffs- 

und Tropenhy- 

giene, 1919. 

Vol. xxiii, pp. 523- 

554. 
Trop. Dis. Bull., 

1914. Vol.iv,p.96. 
Trop. Dis. Bull., 

1918. Vol. ii, p. 41. 
Trop. Dis. Bull., 

1918. Vol. ii, p. 42. 
Lond. 1919. War 

Office Publication. 

Government Report 
for 1913. 



CHAPTER XII. 

TRYPANOSOMIASIS (SLEEPING SICKNESS). 

n^RYPANOSOMIASIS is an African disease due to the 
-L invasion of the body by a specific parasite (trypano- 
soma) ; it is characterized by a long-continued irregular 
fever, adenitis, a rash, rapid action of the heart, enlargement 
of the spleen, and, unless efficiently treated, terminates 
fatally by involvement of the central nervous system and the 
production of what is known as " sleeping sickness." 

Seeing that the disease is confined to Africa, instances in 
British troops in the war were only found amongst men 
engaged in one of the African campaigns. 

The incidence of the disease amongst the British was 
fortunately slight. So far as is known, only one case, in a 
naval rating, occurred in the Cameroons campaign. In the 
East African campaign some 20 cases in all were discovered. 
Of these five were Europeans, the rest being natives. Amongst 
the German Forces Taute records 23 cases, of which only one 
was in a European. This case died with a sharp attack of 
haemoglobinuria. No mention is made of the fate of the 
22 native cases. 

Of the 20 cases amongst the British in East Africa the 
histories of 18 are given by Newham. The other two cases 
were in natives. One was an East African native whose 
previous history it was impossible to obtain, whilst the other 
was a West African native soldier. In the latter, trypanosomes 
were discovered in the course of ordinary routine blood 
examinations, but he had no symptoms pointing to trypanoso- 
miasis. From the fact that the parasites were quickly 
banished from the peripheral circulation with a few doses of 
atoxyl it is probable that they were of a low form of virulence 
and that this individual contracted his infection in West Africa 
and not in East Africa. 

Mtiology. 

The causative organism of the disease is the trypanosoma. 
Although no distinctive morphological differences can be 
made out in the organisms causing the disease in various 
parts of Africa, it is generally held, in view of the varying 
virulence of the parasites and the differences in the clinical 
picture displayed by cases in which the infection was con- 

305 



306 MEDICAL HISTORY OF THE WAR 

tracted in different parts of Africa, that probably there are 
several strains of the organism. Generally speaking, four types 
of cases can be distinguished, according to the degree of 
virulence : 

(1) Those in which the infection is contracted in the 

Belgian Congo, the French Congo and the Southern 
Sudan. 

(2) Those in which the infection is contracted in West 

Africa. 

(3) Those in which the infection is contracted in Uganda. 

(4) Those in which the infection is contracted in Rhodesia, 

Nyasaland, Tanganyika Territory and Portuguese 
East Africa. 

These four groups vary considerably in the virulence of the 
disease, the Congo variety being the mildest, whilst the others 
show an increasing virulence up to the Rhodesian variety which 
is the most virulent of all. The first three are due to infection 
with trypanosoma gambiense, while authorities make a separate 
species of the Rhodesian trypanosoma under the name of 
T. rhodesiense. 

The insect vector of the parasite is the tsetse fly. Different 
species of the fly can subserve this function in different parts 
of Africa. The best known and most widely distributed 
species which is an efficient host of the parasite is glossina 
palpalis, though in Rhodesia and in German and Portuguese 
East Africa, in places known to be affected with the disease, this 
species is unknown, and glossina morsitans appears to be the 
most important carrier. The parasite met with in German 
and Portuguese Africa undoubtedly belongs to the Rhodesian 
type. 

The particular areas in these two colonies where the disease 
occurs have not yet been fully defined. In the former country 
the disease is known to exist in the northern part around the 
shores of Lake Victoria Nyanza, in the west on the shores of 
Lake Tanganyika, and in the south at several points along the 
River Rovuma, which forms the boundary between German 
East Africa and the Portuguese territory. It is of interest to 
note that in the campaign in East Africa it was not until 
the troops on both sides reached the River Rovuma, at the 
end of 1917, that cases of the disease began to occur. 

In the case of Portuguese East Africa even less is known 
as to the foci of the disease. In the course of military opera- 
tions in that country a long line of communications was opened 
up from Port Amelia on the coast towards Lake Nyasa, running 



TRYPANOSOMIASIS 307 

almost due west from Port Amelia. At a point about 12 miles 
from the coast, and extending westward for about 10 miles 
therefrom, was a well-marked fly belt, and it was from that 
area that most of the cases of the disease in British troops 
appeared to derive their infection. One patient, however, a 
European officer, seemed to have contracted the infection 
further south in Portuguese territory, probably in the 
neighbourhood of the Lugenda river. 

In these areas of infection glossina pallidipes and glossina 
morsitans were met with, the former being much the more 
common. G. palpalis was never encountered. 

Morbid Anatomy. 

In post-mortem examination of a case dying from sleeping 
sickness infection, no very gross macroscopic changes are to 
be seen. The spleen is usually enlarged, somewhat soft and 
congested, and the other abdominal organs may show a con- 
dition of general congestion. On examining the brain the 
pia mater is frequently somewhat dull looking, and may have 
a slightly obscured appearance like fine ground glass. Fre- 
quently it is more or less adherent to the brain substance, 
tearing the latter when attempts are made to strip it off. The 
convolutions of the brain may be slightly flatter than usual, 
and the cerebro-spinal fluid in excess of normal. 

In the spinal cord no gross changes are observable. The 
fluid is increased in amount, and trypanosomes will usually 
be detected on centrifugalization. 

Microscopically, sections of the brain and spinal cord show 
a great aggregation of small round cells surrounding the smaller 
blood vessels and situated between the vesseFand its sheath. 

Symptoms. 

It is obviously very difficult to arrive! at a correct 
estimate of the period of incubation. It has been noted by 
Manson that in a number of cases of the disease under his 
care the patients would frequently refer to some particular 
bite of a tsetse fly occurring shortly before the onset of the 
disease, which bite had been much more painful and its effects 
more lasting than they had ever experienced before. It has 
been suggested that such a bite may be the infective one and, 
if so, it would appear that the period of incubation varies 
between 5 and 21 days. Doubtless the incubation period may 
vary with the particular type of trypanosome introduced. 
In East Africa, of the Europeans who contracted the disease, 
two gave a very clear history of a particular tsetse bite which 
was extremely painful and occurred a short time before they 



308 



MEDICAL HISTORY OF THE WAR 



were taken ill. In the one case a period of only five days 
elapsed between the bite and the onset of the symptoms ; in 
the other 14 days. With such a virulent parasite as the 
Rhodesian trypanosome, the organism concerned in these cases, 
it may well be that the incubation period is shorter than in 
infection with the less virulent strains, and this seems to be 
borne out by animal inoculation experiments. 

The chief symptoms of the disease are fever, erythema, 
local oedema, enlargement of the spleen, adenitis, and rapid 
action of the heart. The disease commonly starts with an 
attack of fever, usually ascribed by the patient to malaria 
and treated by quinine with no alleviation. At the onset of 
the disease there are great variations in the appearance of the 
temperature chart and it cannot be said that any particular 
type of chart is diagnostic. In the majority of cases fever 
comes on suddenly, the temperature rising to perhaps 103 F. 
or more, but rigor is rarely seen. The fever generally remains 
high with occasional remissions for a week or two and then 
tends to come down gradually. 




Chart I. 



TRYPANOSOMIASIS 



309 




Chart II. 



In other cases the fever may be definitely intermittent from 
the start, the evening temperature being always the higher. 
After about a fortnight or so what may be described as a 
" low " form of fever is established in which, although the 
temperature may not rise above 99-4 F., or thereabouts, a 
diurnal variation of fairly wide range is to be observed, due 
to the temperature falling well below normal in the apyrexial 
periods. 

Exacerbations of the fever occur from time to time, and 
such are characterized by an increase in the number of parasites 
in the blood. (See Charts I. and II.). 

The erythema associated with trypanosomiasis is most 
frequently seen in the early stages of the disease, but the 
appearance may be delayed for several weeks, and in certain 
cases for several months. This rash is a fugitive, patchy and 
usually annular erythema occurring most commonly on the 
chest, back and face, and less often on the limbs. The rings 
are usually of large size, occasionally complete, but more 
frequently interrupted at some point in their circumference, 



310 MEDICAL HISTORY OF THE WAR 

and the area of the skin enclosed within the ring sometimes 
shows discoloration resembling that seen in old braises. The 
rash is extremely difficult to detect in natives, and the descrip- 
tion given of it is based on cases in Europeans. 

Local oedema is chiefly confined to the face and may affect 
one side, or be limited to the eyelids and those portions of the 
cheek just below the eyes. 

Enlargement of the spleen is usually of a moderate degree, 
but in exceptional cases may be very marked, the organ 
extending to or even below the navel. The most commonly 
affected glands are the cervical, and especially the posterior 
cervical. They are enlarged, often markedly so, soft and as a 
rule not particularly tender. This enlargement of the glands 
is usually an early and fairly constant symptom in the disease. 
But although adenitis at some stage or other is a well-marked 
symptom in most cases of trypanosomiasis, it is by no means 
commonly present in the victims of Rhodesian trypanosomiasis. 
Many observers have commented upon the infrequency with 
which the symptom is met with in this type of the disease, 
and of the 20 cases in the East African campaign which 
came under Newham's notice only two showed this symptom 
and then not in a well-marked degree. 

The pulse rate is commonly somewhat increased, and is 
readily accelerated by slight exertion, such as getting out of 
bed or walking across the room. 

There is progressive muscular weakness so that the patient 
very readily becomes tired, some loss of flesh, and often a 
considerable degree of anaemia. 

Other symptoms may be met with, but are not common. 
A form of hyper sesthesia known as " Kerandel's symptom " 
may exist, i.e., if a patient strikes a limb against a hard object 
acute pain may be experienced out of all proportion to the 
strength of the blow and this production of pain is slightly 
delayed. 

Iritis, keratitis, or retinal changes may occur and the first 
is occasionally one of the early symptoms. Keratitis, 
if it occurs, usually comes on later in the course of the disease. 
Optic atrophy may occur, but is in all cases probably due to 
over dosage with arsenic given for the cure of the disease. 

Orchitis is a somewhat rare occurrence in trypanosomiasis, 
but occurs early and appears to be more common in infections 
with the Rhodesian variety of the parasite than with others. 

Periostitis of the tibiae has been noted in a few cases as 
occurring in the early stages of the disease. 

The disease is usually prolonged, but in some cases, death 
supervenes early as a result of the virulence of the affection 



TRYPANOSOMIASIS 31 1 

or from some intercurrent affection, such as pneumonia, to 
which trypanosome infected patients seem particularly 
vulnerable and in whom it runs a very rapid and fatal course. 

On the other hand in a case not treated, or only inefficiently 
treated, the case may drag on for months or even one or two 
years and then end fatally with the symptoms of sleeping 
sickness. Such symptoms, marking the involvement of the 
central nervous system, are frequently ushered in by a slowly 
progressing weakness and the development of a fine tremor of 
the tongue and hands, Mental symptoms in the form of a 
rapidly developing coma, a series of epileptiform convulsions 
or the progressing lethargic condition known as sleeping 
sickness soon become manifest and the patient passes away. 

In Europeans the commonest ending is in a series of epilepti- 
form convulsions coming on suddenly and rarely lasting over 
24 hours, when death occurs. 

In cases that recover, beyond a particular liability to 
pneumonia conditions and possibly some eye trouble due to 
over-dosage with arsenic, there are no sequelae of the disease. 

Prognosis. 

The prognosis is undoubtedly serious and has to be based 
on various factors. Firstly, the place where the patient was 
infected is an important point to be taken into account in 
forming an opinion, for, as has been stated, the specific organism 
seems to vary greatly in its virulence in different parts of Africa. 
If the patient has had the misfortune to become infected with 
the Rhodesian type of the organism the outlook is almost 
hopeless. So far only one case of the Rhodesian type is believed 
to have been cured. In cases other than the Rhodesian type the 
prospect is rather more hopeful, provided the patient can be 
removed from the infected area in the early stage of the disease 
and placed under thorough treatment. 

The age of the patient undoubtedly has a bearing on the 
prognosis. It is only the younger patients who seem to tolerate 
well and in sufficient dosage the powerful drugs necessary to 
control the disease. As a rule patients beyond 30 years of age 
stand treatment poorly, and consequently have much less 
chance of recovery. Natives generally stand the treatment 
well, but are very apt to get tired of the prolonged medication 
necessary and commonly run away. 

In the present stage of our knowledge it is difficult to 
determine when a patient is definitely cured. If he 
remains free from parasites in the blood for a period of a year 
and at the same time has had no fever or other sign of the 
disease he is in all probability cured, but it is advisable to 

(2396) U 



312 MEDICAL HISTORY OF THE WAR 

prolong the treatment for a further year to be sure. Generally 
speaking, if, after a period of several months' freedom from 
parasites and symptoms, the treatment has been relaxed and 
parasites have then reappeared in the blood, the outlook is poor. 

Diagnosis. 

With regard to diagnosis, chronic irregular fever not relieved 
by quinine and associated with adenitis erythernatous rash, 
and rapid heart, in a patient in Africa or who has recently 
resided there, should suggest the possibility of trypanosomiasis. 

The actual diagnosis is determined by the finding of the causa- 
tive organism. This is often scanty in the peripheral blood, and 
many preparations should be systematically examined before 
a negative diagnosis is made. The employment of the thick 
film method is usually of great assistance in the search for the 
parasite. 

When failure to detect the parasites in the peripheral blood 
occurs it is sometimes possible to find them in the enlarged 
glands. The gland is punctured with a fine needle attached 
to a syringe and a little of the gland juice aspirated. This is 
blown out on to a slide, and spread out like a blood film and 
stained. 

Failing discovery of the parasite by blood or lymph examina- 
tions, recourse must be had to animal inoculation, 10 to 20 c.c. 
of blood drawn from a vein being used for that purpose. The 
best experimental animal is a monkey, and if the inoculated 
blood contains parasites the animal should usually show them 
in fair numbers in its peripheral blood in two to three weeks. 

Treatment. 

Treatment, to be successful, should be commenced as early 
in the disease as possible. Once the patient has passed into the 
terminal or sleeping-sickness stage treatment of any kind is 
hopeless. A multiplicity of drugs have been employed for the 
treatment of this disease in man, but only two appear to be 
of any real value, namely, arsenic and antimony. 

In some infections the disease seems to be well controlled 
and even cured by the use of arsenic only, whereas in other 
cases arsenic in doses short of producing serious arsenical 
poisoning appears to be quite ineffective. Especially is this 
so in the Rhodesian type of the disease. In the vast majority 
of cases a favourable result is to be anticipated only by the use 
of both arsenic and antimony. Of the various preparations of 
arsenic the most successful is atoxyl. This, at the onset of 
the treatment, should be administered thrice weekly in doses 
of 2J-3 grs. Later, when the disease is well under control, 



TRYPANOSOMIASIS ^ 313 

it may be found advisable to give it only twice weekly. Care 
should be taken to look out for any signs of intolerance of the 
drug in the shape of colic, cramps, or pains in the eyes, but 
as a rule with the dosage advised no ill effects are to be 
anticipated. Large doses, such as have been recommended by 
some authorities, are distinctly dangerous and liable to produce 
optic atrophy with total and permanent blindness. The drug 
is best administered by the intramuscular method deep into 
the gluteal muscles. 

Antimony is used mainly in the form of tartar emetic. 
This is administered well diluted and by the intravenous 
method. An ordinary funnel, rubber tubing and hollow needle 
as used for salvarsan injections are employed. Some 
two to three ounces of normal saline are first in- 
troduced to make sure that everything is working well 
and that the needle is well in the vein. Then the appropriate 
dose of tartar emetic dissolved in two ounces of normal saline 
is introduced in the same way and followed by a further two 
to three ounces of normal saline to wash out the last dregs of 
the tartar emetic solution in the apparatus. 

Certain points in the administration need attention. Care 
must be taken to see that none of the tartar emetic solution is 
allowed to escape into the tissues around the vein as a painful 
necrosis is set up if such an accident occurs. The tartar emetic 
solution and the normal saline are best made up with freshly 
distilled water, and all solutions must be carefully sterilized 
and administered at blood heat. 

The reaction of the patients to such injections varies greatly. 
Usually, towards the completion of the injection, an attack of 
spasmodic coughing comes on, but passes off in ten minutes or 
so and is of little consequence. The temperature rises to a 
varying degree and is frequently accompanied by a rigor which 
may be very severe. The patient commonly complains of some 
headache. In most cases the temperature falls to normal again 
in three to four hours and the patient feels comparatively well. 
Other symptoms which may be complained of are tightness 
across the chest, and abdominal colic usually of a mild type, 
sometimes accompanied by two or three evacuations of the 
bowel. Vomiting rarely takes place. 

With regard to the dosage of the drug it is best to start with 
a small dose, say, J gr., and to increase it by \ gr. at each 
injection, until a maximum of 2J grs. is being administered. 
It is found that it is impossible for some patients to take as 
large a dose as 2 grs., owing to the very severe reaction 
produced. Such cases usually do badly and it would appear 
that the dose of 2J grs. is the minimum which, if administered 



314 MEDICAL HISTORY OF THE WAR 

over a sufficient length of time, is likely to bring about a satis- 
factory result. The tartar emetic injections are given twice 
weekly. 

Another method of administering antimony is to give anti- 
mony oxide in the form of subcutaneous injections of Martin- 
dale's Injectio Antimonii Oxidi. This may be given in one, 
two or three drachm doses every day. The administration is 
painless. The amount of antimony in the preparation is small, 
but appears to have a definitely beneficial effect on the disease, 
and is useful for supplementing other treatment. 

The patient is best kept in bed during the early part of the 
illness and until treatment has succeeded in more or less 
controlling the fever and symptoms. 

In a case that is doing well under intravenous antimony, it 
will usually be found that when no parasites are dis- 
covered in the blood, and the fever and other symptoms have 
abated, the reaction to the administration of the antimony 
becomes less and less until at the most it produces only a little 
discomfort in the shape of headache and possibly a rise of one 
degree in the temperature. 

Natives appear to stand antimony much better than Euro- 
peans, and in the former repeated doses of 3, and in a few cases 
3J grs., have frequently been administered without the 
slightest untoward results or the causation of any particular 
discomfort to the patient. 

The best results are undoubtedly produced by the combined 
atoxyl and antimony treatment, an intramuscular injection of 
atoxyl being given every Monday, Wednesday and Friday, and 
an intravenous injection of tartar emetic on the Thursday in 
each week, but it cannot be too strongly emphasized that, in 
the present state of our knowledge, treatment must be continued 
for a long time after all signs and symptoms of the disease 
have disappeared. In order to be on the safe side treatment 
extending over a period of two years from the time of the final 
disappearance of the parasite from the blood is possibly neces- 
sary before a case can confidently be proclaimed cured. 

In view of the great liability to pneumonic affections to which 
these patients seem prone, care should be taken to instruct them 
to avoid the crowded buildings of theatres, cinemas and other 
places where they may be exposed to impure atmospheres. 

General prophylactic measures against the disease, which 
consist in some cases of the removal of the entire population of 
certain areas, and the destruction of wild game over widely 
extended districts, are too varied and too extensive to be con- 
sidered in connection with war. Personal prophylaxis consists 
in protecting oneself against the bites of tsetse flies. This can 



TRYPANOSOMIASIS 



315 



be accomplished by the use of veils to protect the head and 
neck, gloves to protect the hands, and the use of trousers and 
breeches, rather than shorts, so as to afford protection to the 
knees. 

In the absence of gloves, some one or other of the fly repellant 
mixtures so much in vogue may be used to smear on the hands 
and arms. Bamber oil is probably one of the best of these, but 
must be frequently renewed to be effective. 

White clothing is advisable as less likely to attract the fly 
than darker materials. Although the flies mainly bite by day, 
it has been shown that they will feed on moonlight nights, and, 
therefore, measures of protection should not be dispensed with 
even after sundown in a tsetse-infested neighbourhood. 



Bassett Smith & 
Mangham. 

Bassett Smith 



Castellani & Chal- 
mers. 
Daniels 

Daniels & Newham 



Manson 
Newham 

Taute 



BIBLIOGRAPHY. 

Forms of Fever in the West 
African Expeditionary Force. 

A case of Trypanosomiasis, etc. 



A case of Trypanosomiasis, etc. 

Manual of Tropical Medicine. 
Tropical Medicine and Hygiene. 

A case of Trypanosoma rhode- 
siense infection which re- 
covered. 

Tropical Diseases 

Trypanosomiasis in the East 
African campaign. 

Aertzliches aus dem Kriege in 
Ostafrika 1914-1918. 



Memoranda on Medical Diseases 
in the Tropical and Sub- 
tropical War areas. 



Jl. of R.N. Med. Ser., 

1916. Vol. ii, 

pp. 454-463. 
Jl. of Trop. Med. 

and Hyg., 1918. 

Vol. xxi, pp. 

93-94. 
Jl. of R.N. Med. Ser., 

1918. Vol. iv, 

p. 323. 
3rd Edition. Lond., 

1919. 
2nd Edition. Lond., 

1917-1919. 
Lancet, 1919. Vol.ii, 

pp. 829-830. 

6th Edition. Lond., 

1917. 
Jl. of R.A.M.C., 1919 

Vol. xxxiii, pp. 

299-311. 
Archiv fur Schiffs- 

und Tropenhy- 

giene, 1919. Vol. 

xxiii. pp. 523-554. 
Lond., 1919. War 

Office Publication. 



CHAPTER XIII. 

RELAPSING FEVER (SPIROCH^TOSIS) . 

OPIROCILETOSIS represents a group of acute, febrile, 
O communicable diseases occurring in temperate, sub- 
tropical and tropical countries, and characterized by sudden 
onset, elevation of temperature for 24 hours or several days, 
rapid defervescence, and relapses occurring at fairly regular 
intervals of time and varying in number and severity. 

So far as the war areas are concerned two distinct types must 
be recognized : (a) the relapsing fever of Europe, Palestine, 
Egypt, Persia and Mesopotamia, the infection of which was 
conveyed by lice, with the possible exception of cases in Pales- 
tine and North Persia, where the tick Argas persicus may have 
been a vector ; (b) East African relapsing fever, where the 
infection is carried by the tick Ornithodoros moubata. The 
latter type is described separately in the chapter on East 
African tick fever, and the following account is concerned 
only with the relapsing fever of European and Asiatic theatres 
of war, and Egypt. 

The war records show that the infection of relapsing fever, 
caused by lice, was not infrequently transported from place to 
place. Thus in 1917-18 cases were reported amongst hidian 
troops and Labour Corps at Marseilles, and in all probability 
the source of infection was Egypt. In September, 1917, a case 
was reported from France in one of the Chinese labourers who 
had reached Europe by way of Canada. Again there is evidence 
that the disease was introduced into Mesopotamia by the 
Egyptian Labour Corps, and possibly infection was also derived 
from India. 

Mackie states that severe relapsing fever infections were 
brought down from Upper Mesopotamia by the Turks and that 
a milder outbreak at Basra was due to infection carried by a 
British regiment just arrived from Port Said. The Turkish 
troops in Mesopotamia suffered heavily throughout the whole 
period of the war. 

^Etiology. 

Ledingham has directed attention to the relation of the 
disease in 1917-18 to the meteorological conditions peculiar to 
Mesopotamia and the effect of the latter on the prevalence and 

316 



To face page 317. 



A ,, 

a n t 




JOOO 



500 



12 17 22 27 I 6 II 16 21 26 3 8 13 |)8 23 28 2 7 12^17 22 127 2 J7 12 JI7 22 27 I 

Jan. fet>. March c April f h /J/^k L June en 

2179 1361 1435 939 1126 724 658 611 415 312- 

a-Arr/^/ofAf/ss/on f~ Resumption of Railway Traffi'c 

b Programme of Prevention ^-Increase of Cases in Hospital 10 days after f. 
c ^-Suspension of Railway Traffic K*A Second increase IO days after h. 

&.* Arrest in No: of Cases in L-A Third increase 10 days after k.due to evac.of F?Ambu/. 

Hospital IO ofays after c. m^M/ss/'on left Serbia. 



RELAPSING FEVER 317 

activity of lice. It started from small beginnings in the last 
quarter of the year 1917, and attained its greatest prevalence 
in April 1918, falling thereafter abruptly to minimal or zero 
figures in the hot season. Indian troops were chiefly attacked. 
After April, conditions became increasingly unfavourable for 
the louse, the very high temperature with rapidly diminishing 
humidity being inimical to breeding, whilst the . hot 
weather led to shedding of superfluous clothing and to 
excessive sweating, thus depriving the louse of comfortable 
shelter. 

Very serious epidemics occurred in Serbia. That of 1915 has 
been fully dealt with from the epidemiological standpoint by 
Hunter. The chief points to which he directs attention are 
sufficiently indicated in Chart I. 

Climatic conditions such as cold and wet, which drive men 
indoors and may, under certain conditions, lead to overcrowding, 
undoubtedly predispose to relapsing fever. Verminous soldiers, 
huddling together for the sake of warmth, fall victims if infected 
lice are present to transmit the disease. The lice-borne forms 
are not influenced by soil or race but if A . persicus is regarded 
as a vector the sandy soil in which this tick loves to harbour 
must be considered in this connexion. In former times re- 
lapsing fever was known as famine fever, and it is amongst 
starved and debilitated populations that the disease assumes its 
most virulent form and spreads with the greatest rapidity. A 
good example is seen in the case of Serbia. Exposure and 
fatigue doubtless also act as predisposing causes. 

In the case of white troops close association with natives, 
such as those composing the Egyptian Labour Corps, or in- 
habiting infected villages favours the dissemination of the fever. 
Cases are likely to occur when men have to be transported in 
crowded trains and vessels and indeed under all conditions 
which render lice numerous and active. 

If there are forms of the disease due to the fowl tick, sleeping 
in places infested by these vermin predisposes to infection. 
Certain caves, rock tombs and masonry buildings in Palestine 
may, therefore, be cited as sources of infection. The ticks are 
also often found in native wooden bedsteads. The work 
of Ed. Sergent and Foley in Algeria clearly shows that 
A. persicus plays no part in the case of the North African 
disease. In Persia a species of Ornithodoros is more likely 
to be a vector than A. persicus to judge from the pre-war 
work of Dschunkowsky. 

The exciting cause is a Spironema, and hitherto it has been 
customary to describe different species in different countries. 
The European form of relapsing fever is attributed to Sp. 

(2396) I* 



318 MEDICAL HISTORY OF THE WAR 

recurrentis (Fig. 1), the North African form to Sp. berbera, 
the Mesopotamian variety to Sp. carter i. It has .been suggested 
that the cases seen in Palestine and North Persia, Miana 
disease, may be due to special strains, but nothing definite is 
known regarding this. 

According to Macfie and Yorke there is no morphological 
distinction between the different spirochaetes. Certain strains 
can, however, be separated by agglutination tests with their 
specific sera. 

Lice are the vectors, both the body louse and the head louse 
being carriers. It is also possible that the crab louse may be 
a carrier. Until recently it was believed that infection is not 
conveyed by the bites of lice, but from their excreta or from 




Fig. I. Sp. recurrentis in human 
blood, (x about 1,000.) 

the crushing of the insect on the skin or mucosa, the virus 
entering through abrasions, but a few experiments by Rocha- 
Lima point to the possibility of infection being transmitted 
by the bites of lice. Infective material may be carried by 
the fingers to the nose or eye. It should be noted that the 
spirochaete has been proved capable of passing through intact 
mucous membrane and the unbroken skin. Infection by these 
routes is, however, quite exceptional. 

Infection may possibly be hereditary in the louse but the 
evidence is conflicting. That furnished by Ed. Sergent and 
Foley regarding the North African spirochaetosis is in favour 
of this being the case. 

Some have incriminated bed-bugs as vectors, but it is very 
doubtful if they play any part in the transmission of the disease. 
Recent experimental work by Wiese negatives this supposition. 



RELAPSING FEVER 319 

Morbid Anatomy. 

In relapsing fever the spleen and liver are enlarged, the former 
being congested and often exhibiting infarcts, the latter showing 
cloudy swelling and sometimes fatty infiltration. Hypos tatic 
pulmonary congestion is common. The kidneys are enlarged 
and congested, there are often signs of gastritis, and parenchy- 
matous degeneration of the cardiac muscle has been noted in 
severe cases. In fatal cases there is usually evidence of j aundice 
and the bone-marrow is hyperaemic. The blood displays, as a 
rule, a marked polymorphonuclear leucocytosis. 

Symptoms. 

Apparently the incubation period may vary from a few hours 
to a fortnight, but, in the European form at any rate, it is 
usually 5 to 10 days. 

The onset is very characteristic. It is remarkably sudden. 
The patient is taken with a chill or definite rigor, he feels giddy 
an important symptom he develops a bad frontal headache, 
pain in the back, joints and limbs, and he may, and often does, 
vomit. Implication of the calf muscles, which are often very 
tender, causes a difficulty in walking. Occasionally convulsions 
herald the attack. A feeling of heat follows. The temperature 
shoots up to 104 or 106 "(Chart II), and the pulse grows 
rapid, running at 110 or 120. The patient becomes seriously 
ill, and is quickly prostrated and often delirious. His tongue 
is moist but coated with a white or yellowish fur. It is to be 
noted that, in centra-distinction to what is met with in typhus, 
the tongue continues moist throughout the illness save in very 
grave infections. There is constipation, the skin is usually dry 
and jaundice may appear, though it is of ten a mere conjunctival 
tinge. Thirst, restlessness and vomiting, it may be of blood, 
complete the picture, but in a minority of cases there is an 
evanescent rash, either rose spots like those of typhoid or a 
reddish mottling. Haemorrhagic forms of the disease sometimes 
occur. Liver and spleen enlarge. The urine is scanty and high 
coloured. The appetite is poor but occasionally a voracious 
hunger is developed. 

The patient may pass into a toxaemic state with tympanites 
and hiccough and eventually die, but usually, after an elevated 
temperature for five or six days, the first crisis takes place, and is 
accompanied by profuse sweating and sometimes by diarrhoea. 
The fall of temperature, often to subnormal, is both marked and 
sudden. There may be a descent of 10 F. in 24 hours. The 
change in the patient's condition is remarkable. His appetite 
returns and after a day or two he may feel so well that 



320 



MEDICAL HISTORY OF THE WAR 



he is keen to get out of bed. In debilitated patients, however, 
the fall of temperature may be accompanied by serious 
collapse. 

After a week or so of apyrexia the first relapse occurs. Once 
again the temperature swings up and all the symptoms of the 




0? 

A 

U 

1 

'& 

H 



first stage are repeated, sometimes in a minor degree. Sweating, 
however, is usually more in evidence and the amount of urine 
passed is increased. The temperature remains elevated for three 
or four days and then a second crisis occurs. The patient may 



RELAPSING FEVER 321 

thereafter become convalescent or he may have a second and 
even a third or fourth relapse, but this is rare in the European 
form of relapsing fever. 

The implication of the calf muscles has been mentioned, and 
Kuelz, who saw much of the disease in German soldiers, in 
Turks on the Persian front, and in Rumanians in Macedonia, 
Serbia and the Dobrudja, describes the resulting gait as follows : 
' The patient moves slowly and heavily with steps which seem 
to cleave to the ground .... he is insecure and seeks for 
support .... it is as if the trunk were too heavy for the legs." 
This author also states that ambulatory relapsing fever never 
occurs. Von Hcesslin regards haemorrhages as characteristic, 
and says they occur usually just before or during the crisis and 
are most commonly from the nose. All his patients complained 
of loss of taste. 

Yacoub records, in an Egyptian outbreak, four cases in which 
dysenteric symptoms formed the outstanding feature and this 
has been noted in other epidemics during the war. In one case 
which proved fatal no intestinal ulceration was found. 

Some observers have laid stress on the presence of psychical 
symptoms, such as mental confusion accompanied by delirium, 
but in many cases acute delirium is absent, at least in the 
North African form, according to Parrot. Cutaneous oedema 
has been mentioned by several writers, but apparently does 
not occur in well-fed patients. It is evidence of a deficient 
dietary and lack of vit amines. 

Castellani, recording his experiences in Serbia, directs atten- 
tion to two skin features, the so-called cutis marmorata and flush- 
ing of the face, which he says were very frequent. Occasionally 
he noted a very fine rash composed of minute, roundish, delicate 
pinkish, or red roseola spots on the chest, abdomen and trunk. 

Dudgeon, in Macedonia, found spirochaetes in the urine of 
27 out of 89 cases, which were specially examined for their 
presence, and he believes these were Sp. recurrentis, as they 
occurred along with albumin, red cells and casts, and it was 
noticeable that under treatment with kharsivan the condition 
of the urine improved. 

As regards the blood, the view has hitherto been held that 
spirochaetes are found in the peripheral circulation only during 
the fever periods. It is, however, possible that the introduction 
of the dark field and thick film methods may lead to a modifi- 
cation of this belief and that a few spirochaetes may occasionally 
be found in the apyretic intervals, as indeed is the case in African 
tick fever. Wiener, who studied the disease in Albania in 
1916-17, occasionally found spirochaetes in the fever-free in- 
tervals, especially in poorly-nourished prisoners. 



322 MEDICAL HISTORY OF THE WAR 

The polymorphonuclear leucocytosis already mentioned is 
associated with the febrile paroxysms. It is most marked about 
the critical period, but does not persist long after the crisis. It 
is important from a diagnostic standpoint. Boyd states that 
in the Palestine form there was a marked increase of large 
mononuclears, but, as Stitt has pointed out, this may possibly 
be connected with malaria or amoebiasis. According to 
Sterling-Okuniewski the arterial blood pressure is not altered. 

Boyd separates the Egyptian from the Palestine type of re- 
lapsing fever, partly on account of the above-mentioned blood 
picture and partly because the spirochaetes which were numerous 
in the Egyptian disease were scanty in the Palestine cases. 
Further, in the latter, the period of pyrexia was short. 
Mackenzie has also noted the scantiness of the spirochaetes and 
the short duration of the pyrexial attack. As regards the latter, 
he says that it usually lasted from 15 to 24 hours and was 
represented on the temperature chart by a very characteristic 
spike. Another point on which he lays stress is the irregularity 
of the relapse, varying from seven to ten days. 

Treves does not agree with Mackenzie's conclusions. Many 
of his Egyptian cases showed the characteristics which 
Mackenzie looks upon as being peculiar to the Palestine form. 

In protracted cases convalescence is slow, but as a rule it is 
fairly rapid and recovery is complete. 

Jaundice, severe diarrhoea, epistaxis, haematemesis and 
haematuria, parotitis, herpes labialis, nephritis, pneumonia, 
meningeal irritation and ophthalmia may be mentioned as 
complications of the disease. Tausig and Jurinac have re- 
corded a case of spontaneous rupture of the spleen in relapsing 
fever, while Rudelle found various surgical complications in a 
Rumanian epidemic during the winter of 1916-7. He mentions 
cellulitis, glandular complications, myositis, osteo-periosteal and 
articular trouble and implication of the special sense organs 
such as otitis, palpebral abscess, and laryngitis. 

Prognosis. 

Epidemics vary greatly in intensity. In time of war amongst 
starved and debilitated communities relapsing fever tends to 
be a serious disease and the mortality, usually slight, may be 
very considerable. 

Save under the conditions just mentioned prognosis is, 
generally speaking, good both as regards life and subsequent 
health. Marked jaundice is a bad sign. Death, when it occurs, 
is the result of toxaemia, collapse or some complication. As a 
rule, in untreated or improperly treated cases there is a certain 
amount of temporary debility, but it is rarely necessary to 






RELAPSING FEVER 323 

evacuate a convalescent. Provided he can be well fed and 
looked after, the period of invalidity, after all attacks have 
ceased, need not exceed a fortnight or three weeks. A great 
deal depends on prompt diagnosis, and early and appropriate 
treatment, as the disease can be cut short by suitable remedies. 
A certain immunity is acquired after one or several attacks, 
and it may last for some weeks or months, but is not absolute. 
Agglutinating and germicidal substances have been demon- 
strated in the blood of infected animals. Phear says that when 
visiting hospitals in Southern Russia, Northern Persia, and the 
Caucasus, he found that no treatment was considered necessary, 
all the patients getting well without it. This, he thinks, pointed 
to a relative immunity in those peoples among whom the disease 
was endemic. 

Diagnosis. 

Although in typical cases with several relapses a diagnosis 
can usually be made from the temperature chart, generally 
speaking the disease can only be diagnosed with certainty by 
the discovery of the specific organism in the blood. Whenever 
a microscope is available the diagnosis should be made at the 
time of the first attack. Under conditions obtaining in the 
field this is best done by the thick-drop method, described in 
the next chapter. The dark field method, when avail- 
able, is of great service, and Coles has introduced a 
modification of it which consists in examining in a dry state 
a film containing spirochaetes, stained in the usual way with 
Giemsa or Irishman's stain, with dark-ground illumination, 
using a dry lens of medium power. No mounting medium of 
any kind is employed. He considers the method simple and 
exceedingly valuable. Vital staining with toluidin blue solution 
0-05 per cent, is useful. It is advisable to centrifugalize the 
urine of suspected cases and stain the deposit by the Levaditi 
silver method. It must, however, be remembered that spiro- 
chaetes other than those of relapsing fever have been found in 
the urine in various maladies and also in healthy people. 

During the apyrexial periods when no spirochsetes can be 
found in the blood and incases where spirochaetes are very scanty 
and difficult to demonstrate, the diagnosis may be aided by 
Lowenthal's method if a case showing spirochaetes is available. 
From the latter a drop of blood containing spirochaetes is mixed 
with a drop of blood from the suspected case, sealed under a 
cover slip and incubated at 37 C. for half an hour. If the case 
is not relapsing fever most of the spirochaetes remain motile, 
but if it is a case of relapsing fever and due to the same strain 
of spirochsete as the case furnishing the test drop the organisms 



324 MEDICAL HISTORY OF THE WAR 

will be found motionless and clumped. A control should always 
be made, the time limit being two and a half hours. For 
diagnosis during the apyrexial period, Aravantinos advocates 
splenic puncture, which he considers to be perfectly safe. 

At the outset, relapsing fever may be mistaken for typhoid, 
typhus, trench fever, phlebotomus fever or cerebro-spinal fever 
but, in typical cases at least, the peculiar course of the tem- 
perature is characteristic. It should be noted that during an 
outbreak at Salonika previous to the war, stiffness of the neck 
and hypersesthesia were prominent symptoms, the condition 
closely resembling cerebro-spinal fever. 

Relapsing fever sometimes simulates plague and the two 
diseases may co-exist. This is also true of relapsing fever and 
typhus. Kirkovic and Alexieff have given an account of such 
combined infections, as have Martini and Miihlens. The pains 
of relapsing fever may cause it to be mistaken for acute rheu- 
matism, but, as Von Hcesslin has pointed out, the absence of 
inflammation, the predominance or exclusive localization of the 
pain in the bones, the dry skin, the enlarged spleen and the 
failure of salicylates are distinguishing features. 

Relapsing fever is also apt to be confounded with malaria, 
more especially in its later stages when a remittent or inter- 
mittent curve may be seen. In such cases the microscope must 
decide. It should be remembered that malarial attacks may 
follow relapsing fever and thereby simulate spirochaetal relapses. 
In relapsing fever the febrile attack, unlike that of malaria, is 
apt to occur towards evening, while the size of the spleen varies 
somewhat, the enlargement being most marked during the 
pyrexia. Malaria and relapsing fever are not infrequently 
found co-existing in the same patient. 

Treatment. 

With regard to treatment, nursing, diet and general hygienic 
measures are required, as in typhus fever. After the crisis the 
patient is often ravenously hungry, and, if so, it is important 
to regulate his diet carefully, as injudicious feeding is apt 
to bring on bad diarrhoea and even dysenteric symptoms. 
Happily there is a specific which kills the parasite and cuts 
the disease short. This is salvarsan (kharsivan), which, as 
soon as the diagnosis is made, should be administered 
intravenously in a minimum dose of 6 grains. In the Egyptian 
form of relapsing fever, 9-grain doses were often found necessary 
and were as a rule well tolerated. Even if albuminuria is 
present this line of treatment is not contra-indicated. If 
relapse occurs the injection should be repeated. Sometimes it 
produces a temporary but short aggravation of the symptoms 



RELAPSING FEVER 325 

but its action is rapid and certain. According to Boyd, khar- 
sivan was not as effective in the relapsing fever of Palestine. 
He thinks this may have been due to the shortness of the 
pyrexial period, which made it difficult to administer the drug 
while the spirochaetes were present in the peripheral circulation. 
There is, however, a possibility that the strain was more re- 
sistant. Mackenzie states that salvarsan intravenously always 
cured the condition. In Mesopotamia, Willcox found that 
doses larger than 0-3 grm. were inadvisable owing to the risk 
of hyperpyrexia. In a limited number of cases, Boyd found 
that alarming symptoms followed the administration of khar- 
sivan in as small a dose as 0-3 grm., and, therefore, in a disease 
seldom if ever fatal to Europeans, he questions the advisability 
of administering the larger dose of 0-6 grm. which was fre- 
quently given. In all probability, however, the ill effects were 
due to idiosyncracy or faulty technique, and from a military 
point of view it is certainly undesirable to withhold a specific 
treatment which is generally harmless and prevents a period 
of debility and incapacity. Ludyl or galyl may be used if 
salvarsan is not available. They are quite efficient in doses of 
from 4 to 7 grains. Foley and Vialatte report favourably on 
the use of neosalvarsan intravenously in North African re- 
lapsing fever. They gave doses of 0-05 to 0- 1 grm. per kilo, of 
body weight. 

Arrhenal (sodium methyl arsenate), according to Dumitresco- 
Mante, is also effective, but has to be given in much larger 
doses, namely 45 grains in 10 c.c. of distilled water. It has the 
advantage of being non- toxic. Like the other drugs it is 
administered intravenously . Wiener, however, found it useless . 

Arsalyt (dimethylamino-tetramino-arsenobenzol) in half- 
gramme doses has been recommended both by Miihlens and 
Kostoff in the European form. Portocalis treated French cases 
at Salonika with serum collected during the first apyretic in- 
terval, and with cyanide of mercury intravenously, but the 
results were not encouraging. 

Castellani, from his experience in the Balkans, advocates 
a combined therapy with salvarsan and tartar emetic. He 
finds that the latter prevents relapses and he usually gives it 
intravenously in 2 per cent, solution. 

According to Daniel, iodosalyl, which consists of metallic 
iodine and salol in olive oil, when administered intramuscularly, 
is very effective. He records a hundred per cent, of cures 
within a month. 

In debilitated persons, camphor, ammonia, digitalis or 
strophanthus, and stimulants are indicated. Sometimes the 
back and limb pains demand the exhibition of opium. If 



326 



MEDICAL HISTORY OF THE WAR 



hiccough is troublesome and does not yield to the usual remedies, 
blistering over the line of the vagus on the left side of the neck 
may be tried. 

The disease being lice-borne, preventive measures are the 
same as those for the prevention of typhus fever. But it must 
be remembered that the spirochaete has been found in the sweat 
and in the tears, and that it has proved capable of passing 
through intact mucous membranes and the unbroken skin. 
A case is on record where the disease was acquired from infected 
blood accidentally squirted upon the face. Dudgeon has 
drawn attention to the necessity of disinfecting the urine, as 
it may apparently contain the specific organism, and he enjoins 
the need of care in the transport of samples of urine in hospital. 

If certain forms of the disease are proved to be tick-borne, 
measures very similar to those detailed under East African 
relapsing fever will have to be adopted. 



Aravantinos 

Boyd 

Castellan! 

Coles 
Daniel 

Dschunkowsky 

Dudgeon 

Dumitresco-Mante. . 
Foley &Vialatte .. 

Hunter 

Kirkovic & Alexieff 



BIBLIOGRAPHY. 

Le role de la rate dans la fievre 
recurrente. 

Experiences of a Consulting Phy- 
sician on Duty on the Pales- 
tine Lines of Communication. 

Notes on Tropical Diseases met 
with in the Balkanic and Adri- 
atic Zones. 

An easy method of detecting 5. 
pallida and other spirochaetes. 

L'iode en therapeutique tropicale 
specialement contre la try- 
panosomiase. 

Das Riickfallfieber in Persien. . 



Examination of the Urine in 
cases of Relapsing Fever 
occurring in Macedonia. 

Injections intraveineuses d'ar- 
rhenal dans la fievre recurrente 

Traitement de la fievre recur- 
rente Nord-Africaine par le 
Neosalvarsan et 1'Olarsol. 

The Serbian Epidemics of Ty- 
phus and Relapsing Fever in 
1915 ; their Origin, Course, 
and Preventive Measures em- 
ployed for their Arrest. 

Ueber kombinierteErkrankungen 
an Fleck-und Ruckfallfieber. 



Annales de 1'Institut 

Pasteur, 191 9. Vol. 

xxxiii, p. 425. 
Ed. Med. Jl., 1919. 

N.S. Vol. xxii, p. 

276. 

Jl. of Trop. Med. & 

Hyg., 1917. Vol. 

xx, p. 170. 
B.M.J., 1915. Vol.ii, 

p. 777. 
PresseMedicale.1919. 

Vol. xxvii, p. 492. 

Deutsche Medizini- 
s che W och en- 
schrift, 1913. Vol. 
xxxix, p. 419. 

Lancet, 1917. Vol. ii, 
p. 823. 

PresseMedicale,1918. 

Vol. xxvi, p. 155. 
Bulletin de la Soci- 

ete de Pathologic 

Exotique, 1914. 

Vol. vii, p. 569. 
Proc. Roy. Soc. of 

Med., 1919-20. 

Vol. xiii, Epid. 

Sect. p. 29. 

Archiv fiir Schiffs- 
und Tropenhygi- 
ene, 1918. Vol. 
xxii, p. 289. 



RELAPSING FEVER 



327 



Kostoff 

Kuelz 

Ledingham 

Macfie & Yorke 

Mackenzie . . 
Mackie 

Martini 
Miihlens 



Parrot 
Phear 

Portocalis . . 
Rocha-Lima 

Rudelle 
Sergent & Foley 



BIBLIOGRAPHY cont. 

Arsalytbehandlung beim Riick- 
fallfieber. 



Beitrage zur Pathologic und 
Therapie des Riickfallfiebers. 



Bacteriology of Typhus and Re- 
lapsing Fever in Mesopotamia 
and Northern Persia. (Under 
heading : Royal Society of 
Medicine.) 

The Relapsing Fever Spiro- 
chaetes. 

Ticks and Relapsing Fever 
Disease in Mesopotamia 



Mischinfektion mit Riickfall-und 
Fleckfieber. 



Bemerkungen zu Martini : 
" Mischinfektion mit Riickfall- 
fieber und Flecktyphus." 

Arsalytbehandlung, besonders 
beim Ruckfallfieber. 



Du delire et des reactions psycho- 
motrices dans la fievre recur- 
rente algerienne. 

Bacteriology of Typhus and Re- 
lapsing Fever in Mesopotamia 
and Northern Persia. (Under 
heading : Royal Society of 
Medicine.) 

Le traitement de la fievre recur- 
rente. 



Die Uebertragung des Riickfall- 
fiebers und des Fleckfiebers. 
Bemerkungen zu Rickettsia- 
frage. 



Recherches sur la fievre recur- 
rente et son mode de trans- 
mission, dans une epidemic 
algerienne. 

Epidmiologie de la fievre r6- 
currente. 



Deutsche Medizin- 
ische Wochen- 
schrift, 1917. Vol. 
xliii, p. 1168. 

Archiv fur Schiffs- 
und Tropenhygi- 
ene,1917. Vol xxi, 
p. 181. 

Lancet, 1920. Vol. i, 
p. 379. 



Ann. of Trop. Med. & 
Parasit, 1917. Vol. 

xi, p. 81. 
B.M.J., 1920. Vol. i, 
p. 200. 

The Brist. Med. Chir. 

Jl., 1919. Vol. 

xxxii, p. 118. 
Archiv fur Schiffs- 

und Tropenhygi- 

ene,1917. Vol. xxi, 

p. 398. 

Archiv fur Schiffs- 
und Tropenhygi- 
ene, 1918. Vol. 
xxii, p. 153. 

Deutsche Medizin- 
ische Wochen- 
schrift, 1917. Vol. 
xliii, p. 1167. 

Bulletin de la Soci6t6 
de Pathologic Ex- 
otique, 1917. Vol. 
x, p. 692. 

Lancet, 1920. Vol. i, 
p. 381. 



Comptes Rendus de 
la Soci6te de Bio- 
logic, 1918. Vol. 
Ixxxi, p. 273. 

Deutsche Medizin- 
ische Wochen- 
schrift, 1919. Vol. 
xlv, p. 732. 

Theses de Paris, 
1917-18. 

Annales de 1'Institut 
Pasteur, 1910. Vol. 
xxiv, p. 337. 

Malaria, 1916. Vol. 
vii, p. 1. 



328 



MEDICAL HISTORY OF THE WAR 



BIBLIOGRAPHY cont. 

Sterling-Okuniewski. Der Blutdruck im Verlaufe von 
Riickfallfieber. 



Tausig & Jurinac . . Ueber einen Fall von Milzruptur 
bei Febris recurrens. 



Treves . . . . Ticks and Relapsing Fever . . 
Von Hoesslin Zur Klinik des Riickfallfiebers 



Wiener . . . . Atypische Rekurrensfalle 



Wiese . . . . Zur Uebertragung des Riickfall- 

fiebers. 



Willcox . . . . Typhus and Relapsing Fever in 

the East. 
Yacoub . . . . Spirochaetal dysentery and post- 

spirochaetal paralysis during 

an epidemic of Relapsing 

Fever. 



Deutsche Medizin- 
ische Wocnen- 
schrift, 1918. Vol. 
xliv, p. 265. 

Wiener Klinische 
Wochenschrift, 
1917. Vol. xxx, 
p. 1651. 

B.M.J., 1920. Vol. i, 
p. 235. 

Miinchener Medizin- 
ische Wochen- 
schrift, 1917. Vol. 
Ixiv, pp. 1065, 
1106. 

Archiv fiir Schiffs- 
und Tropenhygi- 
ene, 1917. Vol. xxi, 
p. 237. 

Deutsche Medizin- 
ische Wochen- 
schrift, 1918. Vol. 
xliv, p. 60. 

B.M.J., 1920. Vol. i, 
p. 222. 

Practitioner, 1917. 
Vol. xcix, p. 487. 



CHAPTER XIV. 

EAST AFRICAN RELAPSING OR TICK FEVER. 

TICK fever is a relapsing fever caused by the spirochaete, 
Spironema duttoni, which is transmitted from the sick 
to the healthy by the tick Ornilhodoros moubata. It is com- 
monly known as Central African relapsing fever or African 
tick fever and occurs over a wide area of the more tropical 
parts of Africa reaching from the Atlantic to the Indian Ocean, 
the northern limit on the west being the French Congo and 
on the east Uganda ; the southern limit on the west Angola, 
and on the east the Zambesi Valley. There is no definite 
evidence that the form met with on the West Coast is distinct 
from the East African type. 

The disease was very prevalent in German East Africa, 
especially in places like Dar-es-Salaam and Morogoro where 
large numbers of black troops and carriers congregated and 
where the conditions were favourable for its spread. It was 
also apt to be acquired along the main roads and caravan 
routes utilized for military operations. It occurred also in 
British and Portuguese East Africa but statistics regarding 
it are very unreliable as it was constantly confused with malaria 
and the great majority of medical officers were not familiar 
with it. 

Manson and Thornton have given a valuable account of 
the disease as seen in the Carrier Depot Hospital, Dar-es- 
Salaam. It is founded on observations made upon 1,500 cases 
during the latter part of 1917 and up to October 1918. Euro- 
peans, being less exposed to infection, did not suffer nearly 
as much as natives. Of the latter many different races were 
present and they may be grouped as West African, Central 
East African, Baganda (inhabitants of Uganda) and Coastal 
East African. A considerable proportion of West Africans 
in the Dar-es-Salaam area contracted the disease and in their 
case the infection resembled that in Europeans. Manson and 
Thornton argue that this lack of immunity indicates that the 
West Coast relapsing fever is different from the East Coast 
type. It should, however, be noted that the West Coast 
natives were Nigerians, Mendies, Hausas, Timinies and natives 
of Sierra Leone, who came from regions where African tick 
fever is unknown, for there is no record of its occurrence even 

329 

(2396) X 



330 MEDICAL HISTORY OF THE WAR 

so far south as the Cameroons, in which territory some of the 
West Coast troops had previously operated. In Central East 
African natives the disease, as was to be expected, appeared, 
generally speaking, in a somewhat modified or less severe form. 
In some cases the symptoms were slight probably on account 
of an immunity acquired from recent attacks. Cases amongst 
the Baganda were rare and not severe, perhaps owing to the 
long-standing prevalence of the disease in Uganda. The 
Coast Boys exhibited a marked tolerance due almost certainly 
to the immunity resulting from infection in early childhood. 

The Belgian experience of the disease is related by Rodhain, 
who states and his statement is confirmed by Van Hoof- 
that many of the Congolese soldiers were not immune and hence 
infections were numerous in Rhodesia and the districts east 
of Katanga. They became so frequent on the invasion of 
German East Africa that during the offensive of 1916 relapsing 
fever was one of the chief causes of sickness and mortality 
amongst the Belgian troops and accounted for one-sixth of 
the deaths. The principal centres of infection were Kigali, 
Bieramulo (Ussuwi), Saint-Michael, Shangugu, Kitega and 
Usumbara. On the high plateaux the disease was particularly 
severe. This was possibly due to a specially virulent type of 
infection but the large number of infective bites and the adverse 
conditions due to war and climate also played a part. 

During the offensive of 1917 relapsing fever was quite a 
secondary cause of disease and death, as the black soldiers 
had learned to fear the tick and to appreciate the value of 
preventive measures. 

Van Hoof states that infection is less severe when acquired in 
early life. 

According to Taute, though many cases of the disease were 
seen amongst the German forces, it never became so prevalent 
as to be a real source of danger to the troops. The cases were 
frequently very severe and obstinate, many natives dying of 
collapse. 

Mtiology. 

The predisposing causes of the disease are intimately con- 
nected with the distribution and habits of the insect vector, 
which is the tick, Ornithodoros moubata. Thus the soil which 
suits the tick is also that associated with the disease. The 
same is true of climate but, in addition, adverse climatic 
conditions such as are encountered in tropical Africa predispose 
to infection, as do exposure, poor or deficient dietary, and 
fatigue. So far as race is concerned the question appears 
to be chiefly one of acquired immunity and hence is more 



AFRICAN RELAPSING FEVER 331 

individual than racial though, as noted above, certain races, 
owing to very general infection in childhood, are less predisposed 
to the disease than others. 

The insect vector, 0. moubata, is one of the Argasidae. It 
is a blind tick, the general appearance of which is shown in 
Figs. 1 and IA. The colour of the living tick is greenish brown 




Fig. 1. 0. moubata, dorsal aspect (magnified). Fig. IA. 0. moubata, ventral aspect. 

and, like all the Argasidae, it is devoid of a shield or scutum but 
is covered by a leathery integument. This integument is dotted 
over with close-set granules and exhibits several grooves both 
on the dorsal and ventral aspects. In gorged females these 
disappear. Unfed adults are about 4/10th of an inch in length, 
but a gorged female may be well over half an inch long and 
be very nearly of an equal breadth. The fecundated female 
after a meal of blood lays, in batches, from 50 to 100 (Manson 
and Thornton say 100 to 300) nearly spherical, glistening, 
golden-yellow eggs, the number in each batch varying. The 
eggs, which are agglutinated into masses, are laid in the soil or in 
other hiding places. They hatch in about 20 days and as the 
hexapod larval stage is practically suppressed it is an eight-legged 
nymph which emerges from the egg-shell and the larval skin. 

0. moubata probably lives for several years and can survive 
unfed for long periods. It is very resistant to heat and ger- 
micides. It exists in native huts and in rest-houses which 
natives may have occupied. It may also be found under the 
shade of trees when the soil is dry. It is commonest along trade, 
travel and caravan routes. During the day it hides in the loose 
sand of the floors of native houses and in cracks and crannies 
in these floors and in the walls. Manson and Thornton failed 
to find the ticks in the thatched roofs of bandas in Dar-es- 
Salaam, but they have been described elsewhere as harbouring 
in thatched roofs. They are commonly found about the bases 
of the vertical wooden roof supports, especially when the latter 

(2396) -X* 



332 MEDICAL HISTORY OF THE WAR 

are poles set in the ground, for round these poles the earth 
becomes somewhat loose. They are rarely, if ever, found 
at a greater depth than six inches. Occasionally they shelter 
in cracks in native wooden bedsteads. It is important to note 
that they may be carried long distances in packs and blankets. 
Both male and female ticks are blood-suckers and they sally 
forth on the blood quest at night. They feed both on man 
and animals, and as the feeding process is a slow one it can be 
fully carried out only when the victim is asleep. The bite is 
painful, may leave a tingling sensation behind it and is some- 
times followed by a local infl ammatory reaction, 

Infection takes place as the result of the tick's infected 
faeces contaminating the tick-bite. One tick can infect. 

The exciting cause is Spironema duttoni, a blood spirochaete. 
Its appearance is shown in Figs. 2 and 3, which are re- 
produced from drawings by Manson and Thornton. According 
to recent work by Macfie and Yorke, it does not differ 
morphologically from the other blood spirochaetes which cause 
relapsing fever. 

Morbid Anatomy. 

With regard to the morbid anatomy of tick fever, attention 
may be directed to the changes in the heart found in cases 
dying from hyperpyrexia and indicating an acute toxaemia, 
there being slight dilatation and a pale, flabby and friable 
muscle exhibiting cloudy swelling and in certain cases fatty 
change. The liver in fatal cases shows acute toxic hepatitis 
and there is marked jaundice, the tissues being bile-stained. 
There seems to be little change in the spleen, save in 
fulminating cases, where it may become very soft and pulpy. 
Van Hoof records a great increase in the size of the organ 
in such cases. Some degree of splenomegaly is usually 
present in cases dying in the acute stage. The bone-marrow 
is hyper aemic. The kidneys may show cloudy swelling or may 
be almost unaffected, as in Manson and Thornton's cases. 

Symptoms. 

The symptoms, generally speaking, resemble those of the 
European form of relapsing fever, but there are certain 
differences, and the careful clinical observations of Manson and 
Thornton have added materially to our knowledge of the 
disease as seen during the war. 

The incubation period is usually given as from two to twelve 
days and in many cases it would seem to be somewhere between 
two and seven days, shorter than is usually supposed. 

The symptoms vary according to the gravity of the disease 
for the latter may be a mild febrile complaint, a moderately 






AFRICAN RELAPSING FEVER 



333 



severe fever, a grave and serious pyrexia or a fulminating and 
rapidly fatal toxaemia. The early symptoms are lassitude, 
headache and vague pains. 

The patient is usually irritable and dislikes being disturbed 




FIG. 2. Showing an infection of moderate severity. 




FIG. 3. Showing masses of spirilla as met with in 
rare fulminating cases. 

The cephalalgia is frontal, of a neuralgic nature and often very 
severe. There may be vomiting and giddiness at this stage. 
The pains are of a rheumatic type and occur chiefly in the shins 
and ankles. Initial rigors were rare in the East African cases 



334 



MEDICAL HISTORY OF THE WAR 



but a feeling of coldness in the hands and feet and a goose-skin 
sensation over the surface of the trunk were not infrequent. 
The course of the disease resembles generally that of European 



5! 




relapsing fever, but the initial pyrexia is usually shorter and 
may terminate within three days. The rise is sudden, reaches 



AFRICAN RELAPSING FEVER 



335 



102 to 106 F., and occurs for the most part in the latter half 
of the day. At first the frontal headache is severe but it 
passes off. Pains in the bloodshot eyes are rather characteristic 
but are not mentioned by Manson and Thornton. The course 
of the temperature is well shown in the accompanying charts. 
As a rule spirochaetes are found in the peripheral blood 
chiefly when the temperature is at its maximum or when 
it is on the rise. This, however, is not invariably the case, 
for Chart I shows that they may be present during the 
apyrexiaJ period, though usually only at a certain stage, that 
is to say, within 12 hours of the onset of the next relapse. 
There can be little doubt that the use of the thick-film 
method and dark field observations will alter existing ideas 
as regards the persistence of spironemata in the peripheral 
blood. The observations of Manson and Thornton, based 
on the thick-film method, show that the organisms are much 
more numerous during the first attack than in relapses, indeed 
in the final relapse it may be very difficult to detect them ; that 




CHART II. Saddle-back type of temperature chart. 

their number is greatest during the first few hours of the rise of 
temperature ; and that they may be demonstrated in the blood 
some hours before the temperature actually rises. Contrary to 
general experience Manson and Thornton were frequently unable 
to find them during the 24 hours preceding the crisis or, if 
they were demonstrable, they were few in number. They 
were able to estimate the approximate numbers present and 
it would appear that in the first attack the average is about 
10,000 per cubic millimetre but variations of from 500 to 50,000 
were noted Very rarely there was a huge infection, the para- 
sites equalling the red cells in number and in such cases 
being apparently of a special type, very long, thinner than 
usual and showing no tendency to looping. 

When the temperature is not spiked but remains elevated 
and at a fairly constant level for a few days there is produced a 
saddle-back form of chart (Chart II), which is regarded as being 



336 



MEDICAL HISTORY OF THE WAR 



an almost certain indication of the presence of bronchitis. 
In uncomplicated cases the temperature remains elevated for 
about a couple of days arid then drops to sub-normal suddenly, 
usually at night. A slight pre-critical rise is sometimes in 
evidence. Profuse sweating accompanies the crisis and, in the 
case of Europeans, collapse often occurs. Manson and Thornton 
found collapse very uncommon in natives but Taute records it, 
as already mentioned. Distressing symptoms abate, the patient 
falls asleep and wakes refreshed and hungry. 

During the attack the patient is very uncomfortable, has no 
appetite, has a furred tongue, an evil-smelling and foul mouth, 
and passes scanty and high-coloured urine which may contain 
a trace of albumin but there is no record of spirochaetes being 
found in it. Diarrhoea is not infrequent and there may be 
dysenteric symptoms. 

The apyretic intervals vary greatly in length. The first 
relapse appears as a rule about ten days after the initial attack 
but the period may be much shorter or much longer. It is 



flAYS of DISEASE 
F* 
05 



- 



CHART III. Typical chart of untreated case of African relapsing fever. 
Note nine febrile attacks and regular ten-day intervals. 

usually less severe than the first attack but resembles it in its 
symptomatology. Sometimes the temperature is higher than 
at the onset, but its course is usually shorter and a sudden crisis 
brings it to normal or subnormal in a few hours. 

A second relapse ensues after a varying interval but is less 
severe, and this is true of all the succeeding attacks, which 
may number as many as eleven, though the average would 
appear to be five. In cases which are untreated the tendency 
for each succeeding relapse to be less severe than its predecessor 
is evident and the last attack may be so slight as almost to 
pass unnoticed. As stated, the intervals between relapses vary 
in length but they are usually somewhere in the neighbourhood 
of ten days. Reford and Duke, however, record a remarkable 
European case in the Mwanza district, immediately south of 
Victoria Nyanza, in which 46 days of apyrexia intervened 



AFRICAN RELAPSING FEVER 



337 



between the second and third relapses and 25 days between 
the third and fourth. During the greater part of these apyretic 
periods the patient was perfectly well and going about his 
duties. Apparently there was no question of fresh infection. 
In untreated cases the intervals between relapses tend to be 
shorter as the disease progresses. (Chart III.) 

As regards the involvement of different organs it should be 
noted that bronchitis is common and often severe and that 
Manson and Thornton recognize a pseudo-pneumonic condition 
(Chart IV) of a remarkable nature, inasmuch as there is a sudden 
and complete clearing up of the physical signs at the time when 
consolidation may be expected to occur. Occasionally spiro- 
chaetes are found in the sputum, but it is doubtful if these are 
Sp. duttoni. Save in toxaemic cases there is nothing special 
to note in the condition of the heart. The liver is always 
affected in some measure, the change being in the nature of an 




CHART IV. Pseudo-pneumonic type of temperature. 

acute hepatitis. Jaundice is often present. The spleen is not 
markedly involved in uncomplicated cases. There is fre- 
quently slight splenomegaly and some tenderness over the 
splenic area. The kidneys do not appear to be affected. The 
blood, according to Manson and Thornton, shows no marked 
change as regards the total leucocyte and differential leucocyte 
count except in cases with high temperature and bronchial 
symptoms. These show a leucocytosis with increase of poly- 
morphs to 75 or 80 per cent. On the other hand, Van Hoof 
states that there is usually an increase of basophiles, young 
neutrophiles and large mononuclears, and that neutrophile 
myelocytes and metamyelocytes are present. Polymorphs and 
small lymphocytes are diminished in number. The occurrence 
of fulminating cases has been mentioned. In these the blood 
swarms with spirochaetes and there is an intense toxaemia 
causing myocarditis and grave cardiac and nervous symptoms. 



338 MEDICAL HISTORY OF THE WAR 

Complications are most common in Europeans, in whom 
the nervous system is specially apt to suffer. Generally 
speaking, the complications are simple conjunctivitis and other 
eye affections such as amaurosis, with signs of retinitis, iritis 
and irido-cyclitis, very severe headaches resembling those of 
syphilis and yielding to mercury and arsenic, meningism, 
paresis of the legs, usually spastic, attacks of dysenteriform 
enteritis and, most important of all, myocarditis. 

Manson and Thornton devote special attention to the nerve 
lesions seen in their cases. These occurred late in the course 
of the disease and were looked upon rather as sequelae than as 
complications. They were of a transient nature, suggested 
the action of a toxin and fell into two groups : those showing 
gross central nervous lesions, such as aphasia, complete 
facial paralysis and hemiplegia ; and those showing involve- 
ment of one or more cranial and spinal nerves, especially, 
perhaps, the third, fourth and sixth. Sometimes mixed 
cases occurred. 

Prognosis, 

The prognosis varies according to the severity of the infection 
and is also influenced by questions of race, immunity and 
facilities for nursing and treatment. Fulminant cases are fatal 
in a very short time. Slight cases in natives end in speedy and 
complete recovery. The more severe forms, both in natives 
and Europeans, though usually non-fatal, are very debilitating 
and may result in permanent damage to the heart. 

Europeans, in the great majority of cases, must be invalided 
for a time after a sharp attack of tick fever, and will not, as a 
rule, recover full health and strength until they have had a 
thorough change and a course of tonic treatment. They should 
therefore be evacuated from the infected area. Natives 
require tonics and good food. Claims for pension may arise 
as a result of the nerve lesions or of permanent damage to the 
heart owing to myocarditis. It should be noted that Taute 
thinks that acquired immunity lasts only a short time, and 
records two cases of severe re-infection after periods of eight 
and nine weeks respectively. 

Diagnosis. 

Diagnosis can only be made with certainty by finding the 
spirochaetes in the blood. Failing dark-field scrutiny the thick- 
drop method should always be employed. The procedure 
followed by Manson and Thornton, which, indeed, was in 



AFRICAN RELAPSING FEVER 339 

general use both for relapsing fever and malaria throughout 
the East African war area, is as follows : 

A fair-sized drop of blood is taken on the slide and spread to about the 
size of a shilling. It is allowed to dry for at least one hour before staining, 
and must be carefully protected from dust during this time. Stain with the 
following mixture, seeing that the whole slide is covered with stain : 

Solution 1. Azur II, 1/1,000 in neutral distilled water. 

Solution 2. Eosin, 1/16,666. This latter is best kept as a stock 1 per cent, 
solution, of which three cubic centimetres are added to 500 cubic centimetres 
neutral distilled water. For use, mix one cubic centimetre Solution 1 with nine 
cubic centimetres Solution 2. This final mixture should be made up fresh 
daily. 

This watery stain both dehaemoglobinizes and stains the film at the same time, 
all that remains being the stained leucocytes and any parasites that may be 
present lying free in the homogeneous debris of the red corpuscles. After 
staining for thirty minutes, flood the stain off rapidly with distilled water, and 
allow it to dry protected from dust. 

It is highly important that the distilled water in the above be strictly neu- 
tral ; to determine this Tribondeau's haematoxylin test was always employed. 
two drops of a saturated alcoholic solution of haematoxylin in a test 
tube half filled with water to be tested ; in neutral water, the purple colour of 
the haematoxylin will develop in between two and four minutes ; should the 
water be alkaline, colour is seen at once ; if acid, it is delayed. The addition 
of 1 per cent, acid or alkali is then made until on further testing the colour 
appears in the prescribed time. 

The disease was most usually confounded with malaria, which 
can be definitely excluded only by blood examination, at 
least in the earlier stages. The course of the temperature 
serves as a guide in differentiating the two diseases, and the 
spleen is more frequently involved in malaria. Malaria and 
relapsing fever often occur together, and Manson and Thornton 
describe two types of cases resulting from such double infection : 
an irregular type, in which attacks of the two diseases bear no 
relationship to one another, and a regular type, in which 
malarial rises of temperature are seen only during the spiro- 
chaetal relapse or follow immediately upon it. Naturally the 
former produces a puzzling form of temperature chart. 

Cerebro-spinal fever and plague are other diseases which 
may have to be differentiated from tick fever. The importance 
of early and repeated blood examination cannot be too strongly 
insisted upon. 

A point in diagnosis, not of the disease itself but in relation 
to it, is the technique for examining a tick to see if it is infected. 
This is simply done by pulling off one of its legs and examin- 
ing microscopically the drop of fluid which exudes from the 
stump. 

Treatment. 

With regard to treatment, general measures and good nursing 
are of great importance in sharp attacks and in severe cases, 
for the patient suffers much discomfort, and his condition can 
be greatly alleviated by skilled and careful attention. 



340 



MEDICAL HISTORY OF THE WAR 



As regards the specific treatment, opinions vary and many 
different drugs have been tried. Probably the most reliable 
conclusions are those of Manson and Thornton, who carried out 
a series of careful tests and had ample material at their com- 
mand. They recommend as a means of cure the administra- 
tion of salvarsan or one of its substitutes. Of these, 
novarsenobillon 0-9 gramme gave the most satisfactory 
results in their hands. It should be given on the first attack 
of fever, and, failing this, on rise of temperature on the first 
relapse. It should always be administered on the rise of 
temperature, and never in the apyrexial period. Should a 
further relapse occur, the dose should be repeated as 
before on the rise of temperature. (See Charts V.-X.). 

Whatever preparation be employed it is best given in con- 
centrated form in 10 c.c. distilled water, administered with a 
10 c.c. syringe. The solution must be kept at body tempera- 
ture and injected at this heat, otherwise rigors are certain to 
follow its injection. 

Van Hoof, while agreeing that salvarsan and its substitutes 
can cut short the disease when given early at the first febrile 
attack, states that in the later stages arsenical treatment can 
only relieve some of the symptoms and will not cure the 
disease. In his opinion recourse must then be had to mercury, 
and he recommends salicylate of mercury in 'doses of from 
1 to 2 eg. daily, injected as an aqueous solution, to which is 
added a little ammonium benzoate and some drops of ammonia. 
Manson and Thornton, however, found the native very sus- 
ceptible to the action of mercury and were unable to confirm 
Van Hoof's statement as to the efficacy of the drug. De 
Ruddere recommends " satoxyl " in the early stages. It 
consists of atoxyl 10 grammes, perchloride of mercury 0'3 
gramme, iodide of potassium 2*5 grammes, distilled water 
100 grammes. Of this 3 to 4 c.c. are given twice weekly by 
intravenous injection. It seems to mitigate symptoms, but 
is not so useful as salvarsan. 

Preventive measures must be directed against the insect 
vector. The European usually gets infected when on the march 
and it is essential for him to avoid sleeping in native huts or 
in rest-houses which natives have occupied. He should never 
camp on sites previously used by natives, for these may harbour 
the ticks, which are able to remain without food for long periods. 
Native bedsteads of wood, with string or hide, are dangerous. 
If used, their legs should be smoothed to prevent ticks from 
climbing up them. It is best to employ a hammock. Sleeping 
on the ground favours infection. A mosquito net is useful 
as it prevents the access of ticks during the night, and it is 



AFRICAN RELAPSING FEVER 



341 



9 20 21 22 23 24 25 26 27 28 23 30 31 32 33 



CHART V. Treatment with salvarsanized serum showing failure; but 
success of novarsenobillon on subsequent relapse. 




CHART VI. '-Shows effect of treatment of first attack by neosalvarsan. 




CHART VII. First attack treated with novarsenobillon; no relapses 
occurred. 
(2396) X* 



342 



MEDICAL HISTORY OF THE WAR 



r' 

I OS* 
104," 
103 
102 
101 
100 
9 9 
98 
97' 




26 27 28 29 30 31 33 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 




105 
I 04 
103 
102 
10 1 
IOC- 
go" 
98 
97 



CHART VIII. Treatment novarsenobillon in first apyrexial period, showing 
recurrence, but success of further novarsenobillon at subsequent relapse. 



3 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 : 




34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 68 59 60 61 62 63 64 65 



98" 
97 



y v 



CHART IX. Treatment novarsenobillon in first apyrexial period, showing 
failure ; also failure of further novarsenobillon given at subsequent relapse. 



AFRICAN RELAPSING FEVER 



343 







CHART X. Treatment novarsenobillon, 0'9 gramme at second 
spasm of temperature. 

advisable to employ a night-light, as it keeps them away. In 
districts known to be heavily tick-infested, blankets should 
be carefully inspected before beds are made up, and it is also 
well to institute periodical inspections of porters' packs. 

Bandas should be constructed in such a way as to lessen the 
chances of tick infestation. For example, the reed walls of huts 
and bandas should be so constructed as to leave a space of eight 
or ten inches between the ground and the bottom of the walls. 
Mud and rubble buildings are to be avoided. Floors should 
always be raised six or eight inches and, if not of cement, 
hammered hard and kept clean. An excellent floor can be 
prepared from ant-heap earth and cow-dung, according to 
Manson and Thornton. The former is hammered hard on the 
selected site to a depth of at least four inches and allowed to 
set. Thereafter a top dressing of cow-dung in a liquid con- 
dition is smeared over the whole surface to a depth of half 
an inch. The surface is treated once a week with the watery 
solution of cow-dung to keep it in good order. The ticks 
were found to have a great antipathy to cow-dung, and a floor 
of this kind presents a hard, even surface which does not 



344 



MEDICAL HISTORY OF THE WAR 



smell and is easily kept clean. A trench with perpendicular 
sides, surrounding a hut or banda, and filled with wood ash, is 
useful in keeping wandering ticks away. 

In lines and camps, temporary buildings, which have become 
infested, are best burned down. The ground can be fired as it 
stands or the floor dug up to a depth of several inches, removed 
and pitted or treated with fire, care being taken that ticks do 
not migrate during the process. Recourse may be had to 
firing with the Lucal Comet Heater, or one of the other types 
of apparatus in which petroleum gasified under pressure is 
employed. Intense heat is generated, when it is passed over 
surfaces by means of long flexible tubes. 

In permanent buildings fumigation with pyrethrum powder 
is indicated. 

BIBLIOGRAPHY. 



De Ruddere 



Macfie & Yorke 



La fievre recurrente spirillaire et 
son traitement aux troupes de 
1'Est Africain Allemand. 

The Relapsing Fever Spiro- 
chaetes. 



Manson & Thornton East African Relapsing Fever. . 



Reford & Duke 
Rodhain 

Taute 

Van Hoof , 



A case of Spirillum Fever in 
(German) East Africa. 

Observations medicales recueillies 
parmi les troupes coloniales 
beiges pendant leur campagne 
en Afrique Orientale, 1914- 
1917. 

Aerztliches aus dem Kriege in 
Ostafrika, 1914-1918. 



Note preliminaire sur la fievre 
recurrente parmi les troupes 
beiges dans 1'Est Africain Alle- 
mand. 



Archives Medicales 

Beiges, 1917. Vol. 

Ixx, p. 710. 
Ann. of Trop. Med. & 

Parasit. 1917. 

Vol. xi, p. 81. 
Jl. of R.A.M.C. 1919. 

Vol. xxxiii. pp. 97 

& 193. 
Jl. of R.A.M.C. 1919. 

Vol. xxxii, p. 78. 
Bulletin de la Societe 

de Pathologic Ex- 

otique, 1919. Vol. 

xii, p. 139. 

Archiv fur Schiffs- 
und Tropenhygi- 
ene, 1919. Vol. 
xxiii, p. 523. 

Bulletin de la So- 
ciete de Pathologie 
Exotique, 1917. 
Vol. x, p. 786. 



CHAPTER XV. 

PHLEBOTOMUS FEVER. (PAPPATACI, SANDFLY OR THREE-DAY 

FEVER.) 

T3 HLEB TOMUS fever is a non-fatal, acute, specific 
JL fever of short duration, caused in all probability by an 
ultramicroscopic organism of which the vector is a species 
of sandfly or phlebotomus. 

It has a wide geographical distribution but, so far as the 
war areas are concerned, was reported from the Dardanelles, 
where it was especially troublesome amongst the French 
troops at Cape Helles during the summer of 1915, from 
the JEgean Islands, from Macedonia, Egypt and Palestine, 
and from Mesopotamia. So far as Macedonia is concerned 
the presence of sandflies was reported in the town of Salonika 
early in June 1916, and a few doubtful cases of the fever 
occurred during the month. In July a sharp epidemic broke 
out amongst the men of two mechanical transport companies 
camped on the Lembet Road. They had landed from Egypt 
four days previously. Phlebotomus flies were found in the 
Greek artillery barracks which they were occupying. In 
August of the same year the personnel of one of the field 
ambulances of the 22nd Division on the Doiran Front was 
attacked, and the fly vectors were found breeding amongst 
the stonework of old Turkish fountains in the vicinity. The 
disease was also encountered in the Struma Valley, and indeed 
by 1918 the whole of the Macedonian war area had been 
infected, the conditions at Janes and Gugunchi being especially 
bad. 

^Etiology. 

With our present knowledge any factor favouring the propa- 
gation of the sandfly must be considered as a predisposing 
cause of phlebotomus fever. The disease is one of sub-tropical 
and tropical climates, and its range probably corresponds to 
that of the sandfly. It may, however, be said that the fever 
is most common in countries which during some part of the 
year are very hot and dry. Thus in sub- tropical regions it 
occurs chiefly during the summer and early autumn. The 
influence of soil is only apparent in so far as the latter supplies 
suitable breeding places for the fly. Cotton-soil constitutes a 
favouring condition owing to the way it cracks, as sandflies 
often oviposit in the crevices. During the war the earthen 

345 



346 MEDICAL HISTORY OF THE WAR 

parapets and sides of trenches and the walls and roofs of 
dug-outs, which were usually fissured, provided numerous 
nurseries, while crevices in caves, the interiors of rubble and 
stone walls, heaps of damp stones, bricks and tiles, the masonry 
walls of wells, old cellars, cess-pools and privies are also 
frequently utilized by the female phlebotomus for purposes 
of egg-laying. A certain amount of moisture is essential for 
the development of the larvae. 

Conditions aiding the transportation of the insect may 
possibly be considered as predisposing to the disease ; hence 
it is well to note that the small flies may be blown considerable 
distances by the wind, and it has been shown that they may 
be carried in timber and other cargo from place to place by 
sea-going vessels, a matter of some importance in time of war, 
when hospital huts, cooking sheds, and wooden latrines are 
often being transported. 

Little is known as regards the influence of race, but new- 
comers to an infected centre are specially prone to attack. 
War experience has shown that exposure to the sun is un- 
doubtedly a predisposing cause, and the same is probably true 
as regards fatigue. It should be noted that Brack in Turkey 
recorded a short, febrile, epidemic illness amongst horses at the 
time of a phlebotomus fever outbreak. The first men attacked 
were those on stable guard. 

The actual exciting cause is not known, but is almost certainly 
an ultramicroscopic organism. At any rate the work of Doerr, 
confirmed by Birt, Kilroy and others, points to the presence in 
the blood of a virus which can pass through the candle of a 
Pasteur Chamberland filter F, the pores of which are so fine that 
it arrests Micrococcus melitensis. Phlebotomus fever is so like 
dengue fever, and dengue in some respects so closely resembles 
yellow fever that it is possible all three diseases are due to 
spirochaetes. If so, some special form of the parasite must 
be present in the blood of patients suffering from phlebotomus 
fever, as no spirochaete can be demonstrated by any of the 
ordinary methods of examination.* The virus is infective up 
to the end of the second day of the fever, and can be transmitted 
by sandflies to persons outside the infected area. A monkey 
has also been infected in this way. The fly does not become 
infective immediately after feeding on a fever case, but only 

*Couvy, in Bull. Soc. Path. Exot., 13th April, 1921, says that at Beyrout a 
spirochaete was found in the blood during the incubation period of dengue in 
five or six cases, but not during the pyrexial period or after defervescence. 
As French writers, however, not infrequently use the term " dengue " for both 
dengue and phlebotomus fever, it is not quite definite which disease is 
referred to. 






PHLEBOTOMUS FEVER 347 

after the lapse of about a week, so that the virus must pass 
through some developmental cycle in the insect vector. 
Chalmers and O'Farrell succeeded in transmitting the disease 
to a monkey by the intravenous injection of infected human 
blood. Doerr thinks that the fly may transmit the infection 
to its larva, but absolute proof of hereditary transmission 
is lacking. 

In the absence of definite knowledge as regards the causal 
organism the fly vector (Fig. 1) may be considered as an 
exciting cause. It is a moth midge or owl midge belonging 
to the family Psychodidse, genus Phlebotomus, of which there 
are various species. P. papatasii is the only one definitely 
known to be a carrier of infection and was widely distributed 
during the war. It was found in Malta, the Dardanelles area, 
the ^Egean Islands, Macedonia, Egypt, Palestine and Mesopo- 
tamia. Legendre, in the early part of July 1916, at Vignacourt 




FIG. 1. Phlebotomus papatasii and larva (magnified). 

near the Somme, found a packet of eggs attached to a fragment 
of floating manure. From these P. papatasii was bred out, 
the insect being identified by Roubaud. It has also been 
found near Paris. It is possible that other species may act 
as vectors, such as P. minutus, which occurs in Malta, Mace- 
donia and Palestine, at Aden and in Mesopotamia, and P. 
perniciosus, known to exist in Malta and Macedonia and 
recorded by Sarrailhe from the Dardanelles. 

The fly is exceedingly minute, its tiny, hairy body, minus 
its legs and wings, being about a quarter the size of the head 
of an ordinary pin. Including wings and legs the insect occupies 
an area about equal to the size of a pin's head. It is 
therefore able to pass through the meshes of an ordinary 
mosquito net containing 16 to 18 holes to the linear inch. The 
sandfly is very delicate and of slender shape, except when 
gorged with blood. It has a yellowish, greyish or brownish 



348 



MEDICAL HISTORY OF THE WAR 



colour. The somewhat narrow, leaf-shaped wings are large 
in proportion to the body, and the thin, scaled legs are of great 
length. Wings, body and antennae are densely coated with 
short hairs, and when the fly is resting the wings project 
upwards from the thorax. The proboscis is as long as 
the head and the tips of the piercing lancets may project 
beyond the labium. The eyes are large and conspicuous. 
Sandflies dislike sunlight, but are attracted by artificial light. 
It is probable that they rarely traverse more than 50 yards 
or so in their silent flight and they do not fly high. During 
the day the flies shelter in the breeding places already 
mentioned and in hollow trees. They can also be found 
harbouring in the dark corners of rooms, bathrooms and 
latrines. The females feed chiefly at night, principally at 
twilight and at dawn, and are most voracious. There 
is no definite proof that the males suck blood. The parts 
chiefly attacked are the wrist and ankles and the flies will 
crawl under the bedclothes to get at the latter. They can 
easily bite through thin socks or light cotton and linen clothing. 
A single fly may make many punctures. After several 
suctions it tends to become sluggish. One fly can infect. An 
attack by many flies effectually prevents sleep, for the bites 
are painful and give rise to great local irritation. The bitten 
part may become much swollen and occasionally vesicles 
resembling those of chicken-pox may result from the punctures. 
In the absence of human blood sandflies will feed on animals 
and more especially on geckos and lizards. 

P. papatasii is known to lay about 40 eggs at a time. These 
hatch into larvae in from 4 to 14 days according to the pre- 
vailing air temperature. The larva is readily recognized by 
the long bristles, two in the young, four in the full-grown, 
which spring from a pair of tubercles on the last abdominal 
segment. The larvae pupate in from 2 to 14 days, and the 
pupal stage lasts from 8 to 28 days. Roughly speaking, the 
complete life-cycle from egg to imago averages a month in hot 
weather and two months in cold. According to Birt, the 
winter months are passed in the larval or pupal condition. 
Graham, however, writing of Chitral, believes that the fly 
tides over this period in the egg stage. 

As the disease is scarcely ever fatal, and then only from some 
complication, nothing is known regarding its morbid anatomy. 

Symptoms. 

With regard to symptoms, the usual incubation period is from 
four to seven days, but according to Brack may extend to 10 
days. The onset is usually sudden, the attack commencing 



PHLEBOTOMUS FEVER 349 

with a feeling of chilliness and malaise. There may be rigors, 
but these are never so severe as those of malaria. Giddiness, 
very severe frontal headache, pain at the back of the eyes, 
accentuated by pressure on the globes and the least movement 
of the head, pains in the back and head like those of influenza 
and general stiffness of the muscles soon prostrate the patient, 
who becomes drowsy, irritable if roused, but suffers from 
insomnia. The face is very flushed and may look swollen. 
According to Castellani this flushing may persist for from 8 
to 15 days after the febrile attack and fades away very slowly. 
The conjunctivas are injected so that the appearance resembles 
that sometimes seen in mastiffs or blood-hounds, hence the 
original name of the " dog disease." This eye condition, 
however, is by no means invariably present. Not infrequently 
a red line traverses the sclera, running from the cornea to the 
outer or inner angle of the eye. As a rule the lachrymation 
and catarrh seen in influenza are absent, but there may be a 
dry cough and a little bronchitis with some muco-purulent 
expectoration. Anorexia with pain or discomfort in the pit 
of the stomach is a feature, and constipation is the rule, though 
diarrhoea sometimes occurs, as does also vomiting. Amongst 
cases seen in Turkey, Brack observed some with dysenteric 
stools, cases of painful micturition, and mania. The 
tongue, clean at the tip and edges, is coated elsewhere by 
a thin white or brown fur. The fauces and palate are often 
congested and may exhibit small vesicles. The soft palate 
may present a stippled appearance due to the presence of 
small hyperaemic roundish spots. These do not extend to 
the mucous membrane of the hard palate. They are not 
pathognomonic of phlebotomus fever, as they may occur in 
relapsing fever and typhus. Epistaxis is not infrequent at 
a late stage in the illness. The skin is generally dry and even 
harsh, but may be moist. Indeed Hartley, describing an 
outbreak amongst Yeomanry in Mid-Egypt in 1917, states 
that sweating was profuse, and this has also been noted else- 
where. Apart from the face flush, which may involve the 
neck and upper part of the chest, there are no rashes, but these 
may be simulated by the numerous bites of the sandflies 
which, possibly as the result of scratching and irritation, may 
assume the appearance of a severe skin lesion, even resembling 
scabies. Castellani describes a delicate subcuticular mottling 
of the skin of the chest and abdomen the so-called cutis 
marmorata which seems not infrequently to be present. 

The rise of temperature is rapid. By the evening of the 
first day's fever a temperature of 101 to 103 is reached. 
It seems to be highest in those who have been working in the 



350 



MEDICAL HISTORY OF THE WAR 



sun. It remains elevated for about 24 hours and then begins 
to fall, descending gradually on the third and fourth days 
(Charts I-IV). In certain epidemics, however, and notably one 
in Macedonia, described by Delmege and Staddon, the fever 
in most cases terminated by crisis, the fall to normal or sub- 
normal being very sharp (Chart V). Castellani, speaking of 
cases in the Balkans, says that those lasting two to three 
days or less terminate by crisis, while those with more prolonged 
pyrexia end by lysis. An after-rise of temperature is by no 
means uncommon in some outbreaks (Charts VI and VII). 




CHART I 



~elr~5f 
SHSIAJI 


/. 


5 


3. 


b. 


$ 


6 


^. 


M' f 

eutAU 


F< W 


M.I 


M t 


M. 


M.6 


M.E 


M. 


m.c 


c 1 


\ol 














; 




105 
















. 44* 



















4(f 




















tos 

102 


: i 


ft 












. air 




:- 


r 


V 








! 




100 




i 


M 










. stf 


M 











5 




j 














^4 






. 3/ 


Oft* 












J^* 


' 




















aeC 


96 














' 




M 
PVLSC 


\ 


;& 


\6* 
6& 


^ 


^ 


\^i 
^V\ 


s 


tt/U* 



CHART II 



PHLEBOTOMUS FEVER 



351 



CAY or 
OJSCASE 


2 


3 


t+ 


# 


6 


^ 


8 


z^/jy a' 
0/5EA*k 


F 


ME 


M.e 


ME 


M.E 


M.E 


M.E 


)4. 


f* 


K>7* 













: 


I 


C 




IO6 


















105' 
















-Al' 




















fO4 































' 




-4O 


IO3 


*M 
















fO2* 


'^ 














-39 


101 


1 




















* 














inrf 




\ 













-S8 


ft" 









ft 


















* 


M^ 


"L 


0. 


-S7 


96* 












ifr 






97 



















96 
















-6* 



CHART III. 



F . 

107 
IO 
105* 
104* 
103' 

102 
101* 

99 
93 
97 
_3$_ 



4tf 



- 38* 



- Stf 



CHART IV. 



352 



MEDICAL HISTORY OF THE WAR 



103 
102 
101 
100 
99 
98 
97 




CHART V. 



103 
102 
101 
100 
99 
98 
97 



V 



r 



CHART VI. 




flMJPM 



;m|win|pn 



CHART VII. 



The pulse rate throughout is comparatively slow, and in 
the later stages the pulse itself may be weak. The blood 
picture is rather typical, and presents a leucopenia with a 
relative decrease in the polymorphs. There is some increase 



PHLEBOTOMUS FEVER 353 

in the large and small mononuclears. The eosinophiles 
diminish during the fever, but increase after it. The liver and 
spleen are not enlarged. 

Recovery appears to be the invariable rule, and most cases 
of phlebotomus fever recover speedily and completely, so that 
invaliding need merely be of a temporary nature. In a certain 
proportion of cases, however, convalescence may be protracted 
and characterized by mental depression, loss of memory, 
lethargy, bone pains, neuritis, insomnia and dyspepsia. 
Phlebitis has been noted as a complication. General disability 
appears never to be permanent. 

Opinions differ as regards acquired immunity. It was 
formerly thought that a high degree was developed, but reports 
of re-infection during the war were not lacking, more especially 
perhaps in Macedonian cases. Secondary attacks are milder 
than the primary ones. Re-infections must, of course, be dis- 
tinguished from relapses which may possibly occur. Brack 
is emphatic as to there being no acquired immunity, but 
Adelmann, speaking of German cases in the Dardanelles, 
states that one attack almost always gave immunity to the 
soldiers. 

Diagnosis. 

There is no certain method of diagnosis, but in places where 
sandflies are present phlebotomus fever may be suspected in 
cases of acute fever occurring during the hot season and 
characterized by sudden onset, short duration, face flush, 
headache, injected eyes, rheumatoid pains and absence of 
splenomegaly. The disease must be distinguished from 
dengue, paratyphoid, abortive enteric fever, malaria, influenza, 
undulant fever, typhus, heat stroke and minor septic conditions. 

Phlebotomus fever and dengue were at one time considered 
to be the same disease, and some still adhere to this view. 
The chief protagonists of this theory are Sarrailhe and Megaw. 
The former deals with the diseases as seen in the Mediterranean 
war area, and indeed speaks of a " Mediterranean Dengue " 
which, however, would appear to be merely a special form 
of phlebotomus fever exhibiting an eruption like that of 
dengue. Megaw draws attention to the great similarity of 
the two fevers in India. He states that he would subscribe 
to the following statement as regards phlebotomus fever: 

" It is a disease which is either one of the modifications of dengue or is closely 
related to dengue. Those who consider it to be different from dengue say that 
it can be distinguished by the absence of a rash and by the absence of a secon- 
dary rise of temperature, though it must be admitted that in many outbreaks 
of undoubted dengue numbers of the cases show neither rash nor secondary 
fever. There is also a possibility that dengue is conveyed by a mosquito, 
while sandfly fever is conveyed by a phlebotomus." 



354 MEDICAL HISTORY OF THE WAR 

Since this was written the infection of dengue has been defin- 
itely shown to be transmitted by a mosquito, Stegomyia fasciata, 
and, although there is no doubt that clinically dengue and phle- 
botomus fever are very much alike, it would appear advisable to 
regard them as distinct diseases. Seventy per cent, of cases of 
dengue show the characteristic rashes while in some varieties 
of dengue the temperature curve differs from that of sandfly 
fever. The conjunctival congestion seen in the latter is also 
rather characteristic. Castellani states that in 30 to 70 per 
cent, of cases of dengue the superficial lymphatic glands, 
especially those of the neck, are enlarged. This is occasionally 
seen in pappataci fever. It is conceivable that the virus 
of both diseases is similar, but is modified according as it 
passes through the phlebotomus or the mosquito. 

The absence of splenomegaly serves to distinguish sandfly 
fever from paratyphoid, and the sudden onset is against 
enteric. Malaria may be distinguished by the severity of 
the rigor, the splenic enlargement and the presence of parasites 
in the blood. In influenza, catarrh is usually more pronounced, 
the pulse is quicker, and there is a leucocytosis and some 
decrease in the lymphocytes. Weinberg mentions as points 
of distinction the extremely rapid onset and quick rise to its 
maximum of phlebotomus fever, the intensity of the con- 
stitutional symptoms almost immediately prostrating the 
patient, the greater severity of the pains affecting particularly 
the ocular muscles, the greater injection of the conjunctiva 
and the rarity of involvement of the respiratory tract. He 
also draws attention to the evidence of the puncture marks 
of sandflies and their presence in great abundance in the 
locality. In Mediterranean fever the diagnosis is confirmed 
by the agglutination test or by blood cultures, while in typhus 
there is no leucopenia. In heat-stroke the temperature is 
higher and the nervous symptoms more pronounced. Lumbar 
puncture will show the cerebro-spinal fluid to be under increased 
tension. 

Treatment. 

The following table, compiled by the Medical Research 
Council from admission and discharge books, comprises a series 
of 2,000 cases treated in military hospitals in Mesopotamia 
and Salonika in 1916, 1917 and 1918. It shows the number 
of days the patients were under treatment for sandfly fever 
in those theatres of war. 



PHLEBOTOMUS FEVER 355 

Duration of Treatment in cases of Sandfly Fever. 



Force from which derived. 


No. of cases. 


Total number of 
days under treat- 
ment. 


Average number 
of days under 
treatment. 


Salonika 
Mesopotamia 


120 
1,880 


1,873 
21,995 


15-6 
11-7 


Total 


2,000 


23,868 


11-9 



There is little doubt that the most valuable drug is 
opium, especially if given early. Its efficiency was shown in 
Mesopotamia and has been demonstrated in India and the 
Sudan. A full dose (30 drops) of liquid extract of opium 
administered at the outset will be found to afford great relief. 
Failing this, the tincture may be given, also in a full dose. 
Aspirin and the salicylates in fairly large doses often afford 
comfort, and pyramidon has been found to assuage pain. 
Myalgia is benefited by the application of hot sandbags. 
Tonics are indicated during convalescence. Quinine is useless 
and may aggravate the symptoms. It is advisable to apply 
tincture of iodine to sandfly bites. It allays irritation and 
lessens the risks of sepsis. 

With regard to preventive measures, cases treated in infected 
areas in hospital should be kept under fine-mesh nets during 
the first forty-eight hours of fever to prevent the risk of others 
becoming infected. A sandfly net should have a mesh of 
twenty-two holes to the linear inch. Unless the material of 
which it is composed is very fine such a net is oppressive in 
a hot climate. Sandfly nets were, however, used with marked 
success in Macedonia, were not found too hot and, apart 
from the prevention of infection, enabled the men to sleep 
in comfort. Those living in infected areas, and especially new- 
comers, should use fine-mesh nets if at all possible. It is 
important to see that there are no flies inside the net before 
using it at night. They should be looked for in the angles 
formed by the top and sides of the net. 

It has been stated that sandflies do not fly high, and 
Higgins, who records an outbreak of the fever from an island 
in the Eastern Mediterranean, found that moving men from 
the ground floor of a building to a lobby on the first floor 
was a very effective preventive measure. 

Repellents smeared on the skin may be tried. Of these 
the vermijelli preparation containing some oil of citronella is 
one of the most useful. Hewlett strongly recommends oil 



356 MEDICAL HISTORY OF THE WAR 

of cassia, a good formula being oil of cassia, one part ; brown 
oil of camphor, two parts ; vaseline, lanoline or salad oil, 
4-5 parts. Eucalyptus oil alone or combined with the oils of 
anise and turpentine may be employed, a suitable prescription 
being : 

Ol. anisi "^ 

Ol. eucalypti >aa Tl\iii 

Ol. terebinth J 

Lanolini 5i. 

M. ft. ung. 

,A lump of camphor may be taken to bed, as the flies dislike 
its odour. Tobacco smoke keeps them away to some extent, 
and electric fans, especially if depending from the ceiling, 
are excellent deterrents. Lights in tents and bedrooms at 
night attract the flies. In the case of billets and houses 
generally, heavy furniture should stand well out from the walls, 
as the insects are apt to hide behind cupboards and sideboards. 

Frequent cleaning, dusting and removal of hangings help 
to get rid of them, as do whitewashing and free ventilation. 

When it can be managed camps should be placed on high- 
lying sites exposed to the wind and should be well away and up- 
wind from horse-lines. Breeding places in the neighbourhood 
of drinking-water fountains should be avoided after dark. 

The following general measures should also be adopted. 
Where possible, ruined walls, masonry, heaps of rubble and 
stones, and old damp latrines, which harbour the larvae, should 
be removed. When this cannot be done all crevices should 
be filled up by pointing the walls, if of stone or brick, or 
plastering them smoothly if of mud, as, for example, in the 
case of trenches and dug-outs. Where such breeding places 
are limited it may be possible to make advantageous use of 
some form of flame as, for example, a powerful painter's 
lamp or the Lucal Comet Heater. Rat-holes and ant-holes 
should be stopped. Vegetation about these places should be 
cleared away and kept down. Cracks in the ground, and 
especially in black cotton soil, should be filled up, or, if this 
is impossible, treated with kerosene oil. Cultivation and 
systematic watering prevent cracks from re-forming. 

Measures should also be taken to capture the flies. For 
this purpose biscuit boxes blackened on the inside and placed 
in dark corners of the room are useful. Austen recommends 
that sheets of " tangle-foot " with lights in front of them 
should be affixed to the walls. These sheets should be slightly 
warmed before use. Fumigation with sulphur may be employed 
and spraying with 1 per cent, formalin has been recommended. 



PHLEBOTOMUS FEVER 



357 



Adelmann 

Birt 
Brack 

Castellan! 

Delmege & Staddon 

Graham 

Hartley 

Higgins 

Legendre 

Megaw 
Sarrailhe 

Weinberg 



BIBLIOGRAPHY. 

Beitrag zur Kenntnis des Pap- 
patacifiebers 



Phlebotomus Fever 

Pappatacimiicken und Pappa- 
tacierkrankungen 



Notes on Tropical Diseases met 
with in the Balkanic and Adri- 
atic Zones 

Clinical Notes on Phlebotomus 
Fever 

Sand-fly Fever in Chitral (N. 
India) 

Notes on an Outbreak of Phle- 
botomus Fever 

Note on Cases of Phlebotomus 
Fever at an Island in the 
Eastern Mediterranean. 

Sur 1'existence dans La Somme 
du Phlebotomus papatasii. 
Scop. 

Sandfly Fever and its Relation- 
ship to Dengue 
Dengue et Fievre de trois jours 



Pappatacifieber und Influenza. 



Archiv fur Schiffs- 

u n d Tropenhy- 

giene, 1919. Vol. 

xxiii, p. 81. 
B.M.J. 1915. Vol. ii, 

p. 168. 
Archiv fur Schiffs- 

und Tropenhy- 

giene, 1917. Vol. 

xxi, p. 381. 
Jl. of Trop. Med. & 

Hyg. 1917. Vol. xx, 

p. 170. 
B.M.J. 1918. Vol i, 

p. 396. 
B.M.J. 1915. Vol. ii, 

p. 169. 
Jl. of R.A.M.C. 1918. 

Vol.xxxi, p. 317. 
B.M.J. 1916. Vol. i, 
p. 166. 

Comptes Rendus de 
la Societe de Bio- 
logic, 1916. Vol. 
Ixxix, p. 25. 

Ind.Med. Gaz. 1919. 
Vol. liv, p. 241. 

Bulletin de la So- 
ciete de Pathologic 
Exotique, 1916. 
Vol. ix, p. 778. 

Archiv fur Schiffs- 
und Tropenhy- 
giene, 1919. Vol. 
xxiii, p. 331. 



CHAPTER XVI. 

TRENCH FEVER. 

npRENCH fever is an infectious disease characterized by 
J_ febrile periods which tend to recur at regular intervals, 
by local pains, by an erythematous rash, and by enlarge- 
ment of the spleen. 

It was first noticed in the British troops in Flanders by 
Graham in the summer of 1915, in Salonika by Hurst in the 
latter part of the same year, in French troops in France in 
1916, and about the same time in Italy. It occurred in 
the German and Austrian Armies, but most of the accounts 
given of it there, under the names of " Wolhynian fever," 
" five days' fever," " Polish, Russian intermittent, or 
Meuse fever," and " His- Werner disease," evidently confuse 
it with other diseases, and are not of great value as clinical 
records. It has also been termed "shin fever," " gaiter-pain 
fever," and " trench shin." It differs from any disease known 
to medicine before the war. Allusions to a quintan fever by 
ancient and mediaeval writers are too vague for identification. 

The name " trench fever " was first used by Hunt and 
Rankin. McNee, Renshaw and Brunt were the first to prove 
its infectious character by injection of a patient's blood into 
the vein of a healthy man. The clinical features of the disease 
were studied, and the louse was early suspected to be the 
vehicle, but nothing was certainly known until in 1917 the 
Medical Investigation Committee commenced work in France, 
and the War Office Trench Fever Committee in England. The 
American Research Committee co-operated with the former 
and carried out the experimental part of the work done in 
France, and regular communication was kept up between the 
groups of workers. 

The disease was recognized in Flanders, France, Macedonia 
and Italy and in the German and Austrian Armies. It is not 
therefore much affected by climate or soil. All Europeans and 
races originally European are subject to it. It was in no army 
so carefully studied as in the British, but as it is easily confused 
with other diseases the statistical returns give no exact idea 
of its prevalence even in the British, still less in other armies. 
Age has apparently no influence. In France patients were of 
all ages up to 43, and in England volunteers of 70 seemed as 
susceptible as younger men. There was no effect traceable 

358 



TRENCH FEVER 359 

to food or drink. It was rightly named trench fever, for it 
originated in the front area, and for a long time was hardly 
noticed to arise at the base. Hospital officers, nurses and 
orderlies caught it, and later when officers and other ranks 
were sent from the front to army schools they brought the 
infection into the back areas. 

It is impossible to give with any accuracy the rate of inci- 
dence among the troops. The name trench fever was not 
sanctioned until 1917, and the fever was not made notifiable 
till 1918, by which time it was much less common. In July 1918, 
Colonel Soltau reported that for the preceding 12 months the 
total admissions for all forms of sickness into the clearing 
stations of the Second Army were 106,247, of which 

15,392 cases were diagnosed as pyrexia of uncertain origin. 
5,244 , , trench fever. 



4,755 

635 

2,535 

2,587 



, myalgia. 

, rheumatism. 

, debility. 

, cardiac (nearly all disordered action of 



the heart). 

Those who could fully examine the cases received as 
pyrexia of uncertain origin were satisfied that the bulk of 
them and many also of myalgia and rheumatism were really 
trench fever. Without pretending to exactness, experience 
justifies the statement that 15,000 to 20,000 of the 26,026 cases 
diagnosed as P.U.O., trench fever, myalgia or rheumatism, were 
probably cases of trench fever. This is confirmed by the 
accurate observations in four base hospitals at Boulogne 
by Lewis, Thursfield, Jex-Blake, and Foster, who received 
1,241 cases labelled pyrexia of uncertain origin, trench fever, 
or myalgia, and found that 822 or 66 per cent, were true 
trench fever. The 26,026 cases above mentioned would 
with the same ratio produce 17,350 cases of trench fever 
which would thus form 16 per cent, of the total sickness. 
In addition trench fever was probably responsible for a 
considerable number of the 5,000 chronic cases. The 
importance of the disease may be gathered from the following 
estimates. The average evacuation for sickness, as distinct 
from the result of wounds, from armies to base in France was 
0-6 per cent, of the strength weekly. During the worst year 
of trench fever, 1917, the percentage figure for this disease, 
at, say, 15 per cent, of 0-6 per cent., would be somewhere 
about -09 per cent. ; that is an army of 1,000,000 would lose 
in a year by evacuation to the base at least 45,000 casualties 
from trench fever. Of these casualties, as is shown below, 
80 per cent, would lose on the average 60 days in hospitals 
or depots, and at least three months in all off duty ; and of 



360 MEDICAL HISTORY OF THE WAR 

the remaining 9,000 more than 2,000 would be incapacitated for 
a period of over six months. There were no deaths, but the 
total loss of man-power resulting from this apparently new 
disease was a very heavy drain on the army. 

Mtiology. 

When first recognized clinically in the spring of 1915, the 
disease, from its general symptomatology, was suspected to 
belong to the enteric group of fevers, possibly modified by 
preventive inoculation. Much of the early work on aetiology 
was therefore directed to proving or disproving this theory, 
until evidence that the disease was a separate and complete 
entity was gradually collected. All cultures from the blood, 
stools and urine were negative, while the fact that B. para- 
typhosus A and B had not then been introduced into the 
preventive vaccine made the agglutination reactions simple 
in their interpretation. The experimental work of McNee, 
Renshaw and Brunt, showing that the blood was infective, 
was strongly against the enteric theory, and the proof 
was finally completed by the work of the American Com- 
mittee. 

Since the early experimental work demonstrated that the 
virus circulated in the peripheral blood, long search was made 
in blood films for a parasite, either intra or extra-corpuscular, 
without result. These examinations of films, moreover, did 
not reveal anything of diagnostic or prognostic significance 
for the clinical pathology of the disease. Later work has all 
tended to show that the virus circulating in the blood belongs 
to the " filter-passing " group, and is therefore ultra-micro- 
scopic. Observations on the possible nature of the virus con- 
tained in the excreta of infected lice are dealt with below. It 
has also been shown that the virus circulates free in the plasma 
during the illness. 

The body louse was early suspected to be the means of 
transmission of the infection, and complete proof that this 
is the case has been afforded by the experiments of the British 
and American Committees. Both committees are agreed 
that the blood of an infected man, and the faeces of an infected 
louse, can be used to infect a new host, while the American 
workers have also shown that in some cases the urinary 
sediment and sputum may contain the virus. There is a 
point of difference in the findings of the two committees 
which merits attention. Whereas the American Committee 
hold that the disease can be transferred from man to man 
by the simple bite of the louse, the British Committee believe 
that the mere bite is insufficient, that the virus is only present 



TRENCH FEVER 361 

in the faeces of the infected insect, and that a bite, scratch, or 
abrasion of any kind, is of equal importance as a point 
of entrance of the infection when .contaminated with in- 
fected lice excreta. On this latter view Byam has brought 
forward evidence to show that a louse must have bitten a 
case of trench fever five to eight days previously before its 
faeces become actively infective. 

In work on the faeces of infected lice, Arkwright has fully 
confirmed the observations of da Rocha Lima on the almost 
invariable presence of so-called " Rickettsia bodies " in the 
excreta of insects which have fed on patients suffering from 
trench fever. These bodies, originally found by Ricketts 
(1909) in the tick which transmits the disease known as Rocky 
Mountain spotted fever, and later by Ricketts and Wilder 
in the excreta from lice on cases of typhus fever, are of very 
small size. The following criteria are given by Arkwright, 
Bacot and Duncan for their recognition : 

(1) Minute size smaller than M. melitensis or B. influenza 

.usually about 0-3 x 0-3 or 0-3 x 0-5mm. 

(2) Irregularity in shape round, oval, diplococcal, or 

bacillary with stained poles. 

(3) Occurrence in very large numbers, or even in masses, 

especially in flakes of solid material in the excreta. 

(4) Well-stained appearance when coloured by Giemsa's 

stain, the colour being purple like that of the 
nucleus of a leucocyte. 

These bodies appear to be in some way closely connected 
with the virus, but their exact relationship to the aetiology 
of trench fever is so far uncertain. 

The remaining points of importance in the aetiology of 
the disease which have been clearly established concern the 
powers of resistance of the virus and the period of infectivity 
of cases of trench fever to lice, and therefore to other men. 

It was established by the American Committee that the 
virus " resists a temperature of 60C. moist heat for thirty 
minutes and is fully virulent after such treatment, but is 
killed by a temperature of 70C. moist heat for thirty minutes. 
Obviously, therefore, a temperature of 55C. for thirty minutes, 
which destroys the louse (Pediculus humanus) and its ova, 
does not suffice to destroy the virus of trench fever which 
may be present on the underclothing of trench fever patients." 

With regard to the period of infectivity of sufferers from 
trench fever, Byam has published observations on chronic 
cases which show that the virus may still be present in the 
blood for a very long time after the onset. He gives two 



362 MEDICAL HISTORY OF THE WAR 

instances in which lice were infected and transmitted the 
disease to a new host by feeding on chronic cases who had 
been first taken ill nine and fifteen months previously and had 
subsequently remained in hospital in England. 

No fatal case of the disease is known to have occurred. 
Observations on morbid changes produced in the tissues by 
the virus are therefore not available. 

The experiments of the War Office Committee and of the 
American Medical Research Committee show that when 
conveyed by intravenous injection of infected blood or plasma, 
or by inoculation of the faeces of infected lice on to the scarified 
skin, the period of incubation is as a rule from five to nine 
days, but when transmitted by the living louse the incubation 
period is from fourteen to over thirty days when estimated 
from the time the lice are placed upon the subject. 

Symptoms. 

Prodromal symptoms are rare, and are confined to slight 
headache or malaise. The onset is usually rapid or even 
sudden, but in a few cases more gradual. There is shivering 
or chilliness, and the temperature rises rapidly. At the 
same time there is in all cases severe headache, and in 
many sudden weakness or dizziness. Vomiting occurs in 
about a third of the cases on the first day ; anorexia is universal. 

A common history is that the patient was awaked in the 
night by violent headache, and in the morning was unfit for 
duty, or that at some time in the day he was seized with pain 
in the head and fell down as if in a faint. 

On admission the patient is prostrated, looks ill and is 
lethargic. He complains of pain in the forehead and in the back, 
movement of the eyes is painful and there is slight nystagmus 
on looking outwards. Within a day or two the characteristic 
rash usually appears, the spleen is felt below the ribs, and 
there are pains in the limbs. The tongue is coated on the 
dorsum with a brown or yellow fur, but clean on the tip and 
edges. The throat is sometimes congested and a dry cough 
then occurs. 

The rash consists of small rosy spots, which are usually 
round, but sometimes of irregular outline, are effaced by 
pressure, and are level with the surface of the skin. They 
come out, like the spots of enteric, in successive crops, and, 
like them, occur chiefly on the chest and abdomen. They 
have once or twice been found on the back. But they differ 
from enteric spots in that they are rather redder than the 
typical pink enteric spot, have a more indefinite margin, and 



TRENCH FEVER 363 

do not project. They last from twelve to thirty hours, whereas 
the enteric spot lasts two or three days. Their number may 
vary from a single spot to many hundreds. 

The rash occurs as a rule with fever, and, when the case 
is of a regular type and relapses can be distinguished, the spots 
usually appear a few hours before the fever. In a small 
minority of instances spots are seen on afebrile days. 

The rash has been seen on the first day, and as late as the 
thirty-fourth. 

The pains vary greatly in situation, duration, character 
and intensity. There is no pain that can be considered dis- 
tinctive. Their persistence, sometimes for weeks, is, however, 
peculiar to trench fever. The commonest sites of pain at the 
onset are the head, back and legs. The most constant of 
all pains is frontal headache. This is practically invariable 
at the onset, and is often very persistent. Headache is felt in 
the morning, sometimes for weeks after other pains have 
disappeared. Pain in the head is sometimes substituted for 
the word headache by the patient, and probably represents 
a different kind of pain. It is sometimes felt in other parts of 
the head than the forehead. 

Occasionally pain and stiffness in the nape of the neck 
occur at the onset simulating cerebro-spinal fever. In a few 
cases this pain has been so severe that the diagnosis was 
uncertain until lumbar puncture was performed. 

Pain in the chest is not infrequent. It is sometimes felt 
on one side alone, either in the upper or the lower half. In 
the latter case the left hypochondrium is a far more frequent 
site than the right, and the pain is connected with enlargement 
of the spleen. Occasionally it is felt round the lower ribs on 
both sides. 

Some cases have complained of pain in the right iliac fossa 
very suggestive of appendicitis. The distinction is usually not 
difficult to recognize. The iliac pain in trench fever is felt when 
the skin is even lightly touched, and is not increased by deeper 
pressure. There is not the rigidity characteristic of appendicitis, 
and there is no tumour to be felt. 

Pain in the back, of an aching kind, sometimes referred to 
the flanks rather than the loins, is the most common of all 
pains except headache. It lasts almost as long as headache, 
coming and going for many weeks. 

The lower limbs are far more commonly painful than the 
upper. In order of frequency the shins and thighs are the 
most often attacked, next the knees and calf-muscles, and then 
the hips and ankles. Now and again the instep or the sole 
of the foot is the seat of pain. Shin pains are about as 



364 



MEDICAL HISTORY OF THE WAR 



frequent as backache and occur in about two-thirds of the 
cases. 

The arms are much less frequent sites of pain. Almost 
every part of them has, however, been attacked shoulders, 
upper arms, elbows, forearms, and wrists in the series of 
cases observed. 

The pains are referred to different structures. The shin 
pains are referred to the bones themselves, sometimes to 
definite parts such as the central part of the bone, or the 
posterior surface. 

Pains in the calves, in the thighs, and in the upper arms 
are referred to the muscles in those situations, and sometimes 
to particular muscles such as the deltoid or biceps. Pains 



K 23 4 5 67 8 9 10 11 1213 14 15 16 17 18 19 20 21 2223 242526 




CHART I. Patient aged 19. Regular form of pulse-rate (light line) rising 
and falling with temperature (heavy line). 

round the knees are referred to places outside the joint. They 
are not felt to be within the joint itself. Muscles to which 
pain is referred, such as the calves or the thigh muscles, are 
usually tender when squeezed, and there is tenderness round 
the outside of the knee-joint, especially, it has seemed, at the 
site of tendinous attachments. 

These pains interchange. They will be felt one day in the 
shin bones, another day in the calves, and a third day in the 
back. There is no division to be made between cases with 
bone pains and cases with muscle pains. Nor is there any 
variety of the disease that can be called shin fever. 






TRENCH FEVER 



365 



There is occasionally superficial tenderness of the skin, in 
ill-defined areas, and occasionally the site of tenderness is 
in areas of the trunk corresponding to the zone supplied by 
one or perhaps two of the dorsal or lumbar nerves. 

The character of the pain varies. It is sometimes aching, 
sometimes boring, and sometimes shooting, in the same patient. 
The boring pain is commonly in the shins, but these may also 
ache. Shooting pains are generally felt in the length of the 
limb. 

The intensity of the pain varies also. Many patients are 
kept awake by it, as it is commonly worse at night. A very 
few patients have no severe pain. Pains usually disappear 
in a fortnight, but in some cases last much longer. 

The fever reaches its highest point, 102 or 103 F. on the 



46 47 48 49 50 51 52 53 54 55 56 57 




CHART II. 

first, or sometimes on the second day, but from this its course 
is extremely variable. In some cases it follows the typically 
relapsing form which first drew attention to the disease. 

In such cases the peaks of the chart occur usually at intervals 
of five, or less commonly four, six, even up to eight days. 
There is a tendency for the highest point to become lower and 
for the interval to increase as the disease progresses. As 
many as seven relapses have been seen. 

In other cases the relapsing character is less distinct, and 
in some the fever is quite irregular and may last thus almost 
six weeks, or after beginning by one or two relapses may later 
become irregular and continuous. 



366 MEDICAL HISTORY OF THE WAR 

Even when the temperature is not above 99 F. it is common 
for the daily variation to be much greater than the normal. 
There is often a difference of two degrees between the morning 
and evening level for many days together, as in Chart II. 

The American experiments showed that these types do not 
breed true, that any type may in the next generation produce 
any other, and that trench fever includes them all. 

In the early stage the pulse commonly varies with the 
temperature, as shown in Chart I, rising to over 100 at the acme 
and falling to normal in the interval. Sometimes a rise in the 
pulse-rate may be the only evidence on the chart of a relapse. 
At a later stage, while in a few cases rates below 60 are seen, 
it is more common for the pulse to become rapid. Sometimes 
tachycardia develops gradually, in other cases, as in Chart II, 
suddenly with palpitation and even dyspnoea. This is more 
common if patients get up early, but occurs also while they 
are in bed. It was not seen in the American volunteers who 
were carefully selected and had not undergone arduous duty. 

With tachycardia the heart's apex beat sometimes shifts 
outwards even to an inch outside the nipple line, and a 
systolic bruit may be heard for a few days. Praecordial pain 
has been noticed, but there is no evidence that endocarditis 
ever develops. The systolic blood-pressure shows a slight 
tendency to rise as the disease progresses. 

Some have reported that the febrile stages are marked by 
polymorphonuclear leucocytosis, and the afebrile periods by 
an increase of the mononuclears. But Perkins and Urwick, 
who made daily counts in many acute cases, showed that 
polymorphs, mononuclears and lymphocytes all tended to 
increase in the febrile periods, while the period of convalescence 
was marked by a gradual rise in lymphocytes. A rise in poly- 
morphs has been found to occur during the few days preceding 
the onset. 

The symptoms connected with the eyes are pain, made 
worse on movement, and referred to the back of the eyeball, 
conjunctivitis or " pink eye/' and nystagmus on looking 
outwards, which is probably due to muscular weakness. 

The spleen is usually in 85 per cent, of the experimental 
cases palpable at some period of the disease. In about a 
third of the cases it is felt on the first day, but in some not 
until much later. The condition may persist for as long as 
five weeks, but usually disappears in a fortnight. It may 
reappear again, showing that the organ probably remains 
enlarged in the interval though not enough to be palpable. 

There is no special affection of the gastro-intestinal system. 
The appetite returns after the first few days. Occasionally 



TRENCH FEVER 367 

the original symptoms recur in the relapse. A slight tem- 
porary albuminuria is sometimes found as in other fevers, 
but no cases of true nephritis were noticed. 

In some patients in the early stage a few rales may be heard. 
Otherwise the lungs are not affected. 

It has become evident that in a large proportion of the 
cases of trench fever invalided home there is a tendency to 
advance through a subacute towards a chronic condition, 
with symptoms of disordered action of the heart, and also in 
some cases neurasthenia. 

The symptoms met with may be summarised as follows, in 
the order of their importance : (1) Exhaustion ; (2) giddiness 
and fainting ; (3) headache ; (4) breathlessness on exertion ; 
(5) pain; (6) irritability; (7) lassitude; (8) sweating; (9) 
coldness of the extremities ; (10) palpitation and cardiac 
irregularity; (11) fever. 

Physical activity is not a necessary factor in the causation 
of disordered action of the heart, as many cases develop the 
condition while lying in bed. Tachycardia, however, is usually 
of vasomotor type, the " sleeping pulse rate " approaching 
normal, as pointed out by Harris. 

In the later subacute stage or transitional stage of the 
disease the patient presents a well-defined clinical picture. 
Throbbing headache is complained of, the face is flushed, 
the pupils dilated, the skin warm, profuse sweating occurs on 
slight exertion, marked tremor is present. Sometimes constant 
nausea is felt and fainting frequently occurs. When the 
chronic stage, or stage of disordered action of the heart has 
been established this extreme instability of the nervous 
system is less well marked. The patient no longer tends to 
swing from states of excitement to states of collapse. Another 
and different clinical picture is met with, corresponding to 
the entity which has acquired the title of " neurasthenia," 
qualified by some with the words " of vasomotor type." No 
matter what name may be given to it, it will be found that there 
occur brisk reflexes, coldness and blueness of the extremities, 
irritability of temper, inability to fix attention for long periods, 
and exhaustion after sustained effort far in excess of that 
evoked by the same effort in healthy men. 

Breathlessness on exertion, palpitation, praecordial pain 
and giddiness are features of both subacute and chronic 
conditions. 

The temperature in these chronic cases varies considerably ; 
definite fever waves lasting from a few hours to several days 
occur at irregular intervals, which frequently are to be 
measured in months. Most cases show an increased daily 



368 MEDICAL HISTORY OF THE WAR 

range of temperature, and this is probably the most character- 
istic condition, the morning reading being definitely subnormal, 
the evening rise barely reaching fever height, but the daily 
swing frequently exceeding two degrees Fahrenheit. 

Invaliding. 

It is important, but at the same time it is difficult, to give 
an accurate estimate of the period for which trench fever 
incapacitates. When the disease first appeared it was 
customary to look upon it as a slight affair, but it was soon 
evident that in some cases it was much more serious. 

The best unselected groups of cases from which such an 
estimate can be formed are those cases which were under 
special observation by the committee in No. 12 Stationary 
Hospital at St. Pol ; the experimental cases of the American 
Research Committee; and a series of 822 cases specially 
observed for this purpose in 1918 at Boulogne. 

The St. Pol cases numbered 348. All were admitted in the 
acute stage, many on the first day. When possible such cases 
were retained for several weeks. At times pressure on beds 
compelled evacuation. 

181 = 52 per cent, were discharged to duty; 96 within six weeks, and 
85 later than six weeks owing in 44 cases to disordered action 
of the heart, in 14 to continuance of fever or pain. 

167 = 48 per cent, were evacuated to England ; 73 owing to want of 
room, and 94 later than the fifth week for symptoms, namely, 
66 for disordered action of the heart, 25 for continuance of 
fever or pain. 

The Americans give no statement of the length of their 
cases but, having had some cases of relapse after long intervals, 
conclude " that long periods of latency may exist, and that 
with our present methods of observation we have no certain 
means of telling when the patient has completely recovered." 
Their cases were, as above mentioned, remarkable for the 
absence of disordered action of the heart. 

At Boulogne, out of 822 cases which were carefully observed 
for the special purposes of determining the resulting incapacity 
and invalidism 

684 = 83*2 per cent, were discharged to duty in an average of 60 days. 
92 = 11 '5 per cent, were evacuated to England, including 21 for 

disordered action of the heart, 37 for continuance of fever 

and 28 for debility. 
46 = 5-2 per cent were sent to a medical board to be reduced in 

category partly, at any rate, for other causes than trench fever. 

Of the 92 cases sent home 70 per cent, were traced one year 
later. This was done partly by scrutiny of hospital case 
sheets, but chiefly and in every case by a return filled in by 
the patient himself, who would naturally emphasize any 
persistent disability. 



TRENCH FEVER 369 

It was found that 12 per cent, were quite fit. The rest all 
complained of weakness, loss of weight, and of various pains. 
The symptoms of disordered action of the heart were not 
prominent in the replies made by the men. Out of the total, 
56 per cent, had not been regarded as eligible for any pension. 
The detailed figures were : 

Recurrent fever . . None in 42 per cent. ; slight in 36 per cent. ; 

more severe in 1 1 per cent. ; not ascertained 

in 1 1 per cent. 
Pensions granted . . None in 56 per cent. ; for disordered action of 

the heart in 19 per cent. ; for debility in 

13 per cent. ; for myalgia in 6 per cent. ; 

cause not stated in 6 per cent. 

The grade of discharge from the army was found to be of no 
comparative value owing to the various classifications employed. 
Serious disability, requiring evacuation to England, therefore, 
had developed in 11-5 per cent, of the total of 822 cases, and 
5 per cent, were still pensionable invalids after the expiration 
of one year. 

Similar cases reached the special trench fever wards at 
Hampstead, and a careful analysis of their after-histories 
was made by By am and his co-workers. 

Over 1,100 trench fever cases were studied, and their disposal 
on discharge from hospital was as follows : 

To duty . . . . . . . . . . 5 9 per cent. 

To lower category . . . . . . 5 

To command dep6t . . . . . . 9 3 

To convalescent hospital .. . . 72*4 

To civil life as permanently unfit for 

military duty . . . . . . . . 7 2 

The average duration of disability on day of discharge from 
Hampstead hospital was 4*5 months. 

Of the above cases 402 were reported on with regard to 
disordered action of the heart, with the following results : 

D.A.H. due to all causes 155 = 38 -5 per cent. 

D.A.H. due to causes other than trench 

fever .. .. .. .. 44=10-9 

D.A.H. due to trench fever with onset of 

D.A.H. before admission to Hampstead 69=17'1 ,, 
D.A.H. due to trench fever with onset of 

D.A.H. after admission to Hampstead. 42=10'4 . 
, Average day of disease on which D.A.H. 

was first recorded in cases developing 27 '3 

D.A.H. in Hampstead Hospital 
Extremes of onset of D.A.H 15th-62nd day. 

Febrile relapses were found to occur in all types of cases 
invalided to England, 8 per cent, showing a definite febrile 
relapse with temperature of 102 F., or more after an afebrile 
period varying from two to five months, during which time 
the temperature had not exceeded 99*4 F. 



370 



MEDICAL HISTORY OF THE WAR 



The statement has been made that all but a very small 
percentage of trench fever patients made a good, complete 
and rapid recovery. While this is true of about 85 per cent, 
in the acute disease, as has been stated above, it does not in 
any sense apply to the chronic disease, as is abundantly proved 
by these figures, and By am states that " the average of de- 
finitely known disability, lasting for over six months, cannot 
be reduced to anything less than 37 per cent, of the chronic 
cases, or considerably more than 5 per cent, of all the infected." 
In the year 1920 there were about 6,000 pensioners who 
attributed their disability to trench fever, and a very small 
proportion, less than 5 per cent., of the cases of disordered 
action of the heart were attributed to the same cause. 

The following table is based on a series of 2,000 cases of 
trench fever treated in military hospitals in France and 
Salonika over the period 1915-1918, and shows the number of 
days patients suffering from trench fever were retained under 
treatment in those theatres of war. The information has been 
compiled by the Medical Research Council from index cards 
and admission and discharge books. 

No. of Days under Treatment in a Series of Cases of Trench Fever. 



Force from which derived. 


Number 
of Cases. 


Total average 
of Days under 
treatment. 


Average Number 
of Days under 
treatment. 


France 
Salonika 


1,944 

56 


155,463 
1,169 


80 
20-9 



Prognosis. 

With regard to prognosis, trench fever is practically a non- 
fatal disease, but may result in prolonged ill-health in from 
10 to 20 per cent, of all those affected. 

During the war some cases were observed where evidence 
of a persistent infection lasted for three or four years, and in 
the present state of knowledge it is impossible to tell the 
ultimate fate of such sufferers. Certain it is, however, that 
field service conditions were not alone responsible for the 
prolonged disability, as similar symptoms were occasionally 
observed to follow experimental infections in the best hygienic 
surroundings. 

Age, in its reaction to the demands of modern warfare, 
produces a man so diminished in recuperative capacity that 
when infected he is less able to throw off the disease than the 



TRENCH FEVER 371 

younger man. Men of thirty-five years and over, when in- 
fected in the field, usually required six months or more to 
complete recovery. 

A bad past medical history is of the greatest significance. 
The analysis of a group of 236 chronic cases showed that 18-2 
per cent, were physically unfit when they contracted the disease. 
The man who gives a history of former attacks of trench fever 
is particularly prone to pass into the chronic stage. 

The earlier the patient gets to bed after the onset of the 
attack, the more likely is he to make an early and complete 
recovery. In the chronic stage a steady gain in weight 
constitutes the most reliable guide to a favourable prognosis. A 
constantly declining weight curve is an unfavourable indication. 

Diagnosis. 

With regard to diagnosis, as has been noted above, acute pain 
is felt by some patients in the right iliac region. This has led 
occasionally to a diagnosis of appendicitis and even to operation. 
The points of distinction have been mentioned already. 

Attention has also been drawn to the fact that cases of 
trench fever occasionally have pain and stiffness in the neck 
so severe as to simulate cerebro-spinal fever, and that the 
distinction must be made by lumbar puncture. 

The diagnosis from influenza is much more difficult. At the 
onset the two may be practically indistinguishable,* but the 
characteristic rash, the relapsing form, and in a typical case 
the rather peculiar pains of trench fever will generally render 
the diagnosis easy within a week. Before influenza became 
epidemic the diagnosis of trench fever was frequent and 
unhesitating. After influenza appeared trench fever was a 
rare cause of admission and every indistinct fever with pain 
was called influenza. It can hardly be doubted that the two 
often were, and often will be, confused. 

Treatment. 

With regard to treatment, no remedy has been found that 
will cure the disease. Quinine, arsenic, salvarsan, perchloride 
of mercury, antimony and colloidal silver were tried in France 
and in England, but without satisfactory results. As is usual in 
such cases good effects were reported but were not corroborated. 
Opium in the form of Dover's powder or morphia may be used 
in case of severe pain, especially if sleep is disturbed. 

Experience shows that, in order to return men to duty as 
soon as possible, the surest course is to treat the disease seriously, 
to admit the patient to hospital at the earliest possible date, 

* See Influenza, p. 205. 

(2396) Z 



372 



MEDICAL HISTORY OF THE WAR 



to keep him in bed for twenty-one days at least, and for a 
week after he has shown any symptoms, and to watch care- 
fully the effect of getting up upon the circulation. The 
Boulogne observers conclude as follows : 

" The best general means are probably much the same as 
those which were used with such admirable results in France 
in 1918 for the treatment of relapsing malaria cases from the 
Mediterranean namely, to take the patient away from hospital 
environment and slowly to restore his general resistance by 
food, fresh air, and light exercise until the infection is overcome. 
Few cases required prolonged rest in hospital, and the majority 
can be returned soon and successfully to full duty. Such a 
view of their normal disposal is obviously governed only by 
a consideration of the invalidism of the casualties who have 
already gone sick. It is not concerned with the other aspect 
of the question, as to whether an early return of such casualties 
to the lice-infested areas at the front may not be a disadvantage 
because it may re-introduce possible sources of infection to other 
healthy troops." 

The preventive treatment consists in freeing the men as 
far as possible from lice. 

It is remarkable that there has been no spread of the fever 
in the United Kingdom since demobilization. The louse does 
not transmit the poison to its offspring, and the degree of 
lousiness of the civil population is not to be compared with that 
of the army. The close contact of a patient infested with lice, 
which is a necessary condition of infection, is therefore seldom 
present in the United Kingdom. 

BIBLIOGRAPHY. 
The Association of Rickettsia 

Bodies in Lice with Trench 

Fever 
Trench Fever 



Arkwright, Bacot & 
others 



B.MJ. 1918. Vol. ii, 
p. 307. 



Byam & others 



Byam 
Coombes 

Crean & Barton 
Davies & Weldon 
Dimond 
Drummond 
Graham 
Grieveson . . 



Trench Fever 

Trench Fever in Mesopotamia . . 

109 Cases of Trench Fever . I 

Preliminary Contribution to 

Trench Fever 
Trench Fever 

Trench Fever 

On a Relapsing Febrile Illness 

of unknown origin 
On Trench Fever 



Soc. rop. 

Med. & Hyg. 1918, 

Vol. xi, p. 237, 
B.M.J., 1918. Vol. 

i, p. 591. 
London, 1919. 
Lancet, 1917. Vol. i, 

p. 183. 
Jl. of R.A.M.C. 1918. 

Vol. xxx, p. 320. 
Jl. of R.A.M.C. 1918. 

Vol. xxx, p. 92. 
Lancet, 191 7.* Vol. ii, 

p. 382. 
Quart. Jl. Med. 1918. 

Vol. xi, p. 363. 
Lancet, 1915. Vol. ii, 

p. 703. 
Lancet, 1917. Vol. ii, 

p. 84. 



TRENCH FEVER 



373 



Henry 

Hiss 

Hughes 

Hunt & Rankin 

Hunt & McNee 

Hurst 



Jungmann & Kuc- 
zynski 

Lewis, Thursfield, 
Jex-Blake & Foster 
Lloyd 

McNee, Renshaw & 
Brunt 



Muir.. 

Pappenheimer & 

others 
Perkins & Urwick. . 

Plesch 



Strethill Wright . . 
Strisower 

Strong 

Sundell & Nankivell 
Tate & McLeod . . 
\Verner 

Werner & Benzler . . 



BIBLIOGRAPHY cant. 

The " haemogregarene " of 

Trench Fever 
Ueber eine neue periodische 

Fiebererkrankung 
Trench Fever 

Intermittent Fever of Obscure 

Origin 
Further observations on Trench 

Fever 
Trench Fever 



Medical Diseases of the War . . 
Zur Klinik und Aetiologie der 
Febris Wolhynica 

Invalidism caused by Trench 

Fever 
Sub-acute Trench Fever 

Trench Fever 



Pyrexia or Trench Fever 
Etiology of Trench Fever 

The Haematology of Trench 

Fever 
Febris periodica (Sog. Fiinftage- 

fieber) 



Notes on Trench Fever 

Experimentelle u. Klinische Bei- 
trage zur Febris Quintana 

Trench Fever. Report of Com- 
mission of the Medical Re- 
search Committee of the 
American Red Cross 

Trench Fever 

Trench Fever 

Zur Geschichte der Febris Quin- 
tana 

Zur Aetiologie und Klinik der 
Febris Quintana 

Medical Investigation Commit- 
tee in France 

War Office Committee on Trench 
Fever 



B.M.J. 1917. Vol. ii, 

p. 739. 
Berl. Klin. Woch., 

1916.Vol.liii,p.738. 
Jl. of R.A.M.C. 1917. 

Vol. xxviii, p. 596. 
Lancet, 1915. Vol. ii, 

p. 1133. 
Quart. Jl. Med. 1915- 

1916,Vol.ix,p.442. 
Jl. of R.A.M.C. 1917, 

Vol. xxviii, p. 207. 
Lancet, 1916. Vol. 

ii, p. 671. 

Edit.2. London, 1918 
Deut. Med. Woch. 

1917. Vol. xliii, 
p. 359. 

Lancet, 1919. Vol. i, 

p. 1060. 
Lancet, 1919. Vol. i, 

p. 791. 
Jl. of R.A.M.C. 1916, 

Vol. xxvi, p. 490. 
B.M.J. 1916. Vol. i, 

p. 225. 
B.M.J. 1916. Vol. ii, 

p. 641. 
B.M.J. 1917. Vol. ii, 

pp. 474, 568. 
Quart. Jl. Med. 1917- 

1918,Vol.xi ) p.374. 
Samml. Klin. Vor. 

trage N.F. Leipz. 

1918 ; Nr. 745-6, 
Inn. Med. Nr. 

251-2. 
B.M.J. 1916. Vol. ii, 

p. 136. 
Munch. Med. Woch., 

1918. Vol. Ixv, 
p. 476. 

London, 1918. 



Lancet, 1918. Vol. i, 

p. 399 
Lancet, 1918. Vol. i, 

p. 603. 
Munch. Med. Woch. 

1917. Vol. Ixiv, 

p. 133. 
Munch. Med. Woch. 

1917. Vol. Ixiv, 

p. 695. 
B.M.J. 1918. Vol. i, 

pp. 9 1,296. Vol.ii, 

p. 120. 
Jl. ofR.AiM.C. 1918. 

Vol. xxx, p. 351. 



CHAPTER XVII. 

JAUNDICE. 

JAUNDICE is not a disease in itself ; it is a symptom that 
may appear in many different diseases, but it proves that 
such disease has directly or indirectly affected that par- 
ticular function of the liver which deals with the excretion of 
bile-pigment. 

Jaundice was seen under many conditions of disease during 
the war. Some of these, such as that associated with poisoning 
during the manufacture of trinitrotoluene, or in the use of a 
particular varnish containing tetrachlorethane for aeroplane 
wings, were relatively new to medical experience. Spirochaetal 
jaundice had been seen before under the name of Weil's disease ; 
but its pathological cause was only discovered early in the war 
by workers in Japan, and their conclusions revealed what 
therefore became practically a new infectious malady, though 
fortunately it never produced any serious amount of inefficiency. 

Apart from the cases of poisoning by T.N.T. amongst 
civilians, which was soon eradicated when its nature had been 
determined, the most serious loss of man power to the army 
by invaliding on account of diseases associated with jaundice 
was due to the extensive epidemics of campaign jaundice seen 
in Gallipoli, Egypt and Mesopotamia. The exact nature of 
this epidemic infection was never ascertained, though it ap- 
peared to follow upon intestinal and blood infection by some 
organisms of the coli-dysentery group. Similar outbreaks had 
occurred in previous wars, for example, during the South 
African War and in the American War of 1862, when certain 
camp areas showed a particularly heavy incidence. 

The general trend of pathological work in the last few years 
has been to emphasize the view that jaundice in most diseases 
is the result of direct damage to the liver. In the gravest 
examples of such disease the liver cells are found to be necrotic, 
and the liver may be in the condition spoken of as acute yellow 
atrophy. Even in these cases, however, there are irregularly 
scattered areas of less severe cell destruction, where bile pigment 
continues to be formed, but cannot escape down the bile 
capillaries and so finds its way into the blood stream. To 
use the term " obstructive jaundice " for such forms, where 
no distension of the larger bile ducts can be discovered, is to 
stretch a classification unduly. It is better to confine the 

374 



JAUNDICE 375 

term to those forms of disease in which the liver cells are 
at first normal and the jaundice arises simply because the 
efflux of bile is directly blocked somewhere in the main ducts. 

An intermediate group of diseases has been repeatedly 
described in which the destruction of liver cells is less manifest, 
but inflammation of the finer bile ducts leads to their blockage 
by inspissated bile. These are generally spoken of under the 
heading of " obstructive cholangitis," and the tendency has 
been to classify them with the true forms of obstructive jaun- 
dice. It is better, however, to assimilate them to the group 
of toxic hepatitis, realizing that the injuries causing inflam- 
mation of the bile ducts may often pass deeper into the 
parenchyma of the organ and damage the liver cells, just as in 
the lungs bronchitis may readily pass into broncho-pneumonia. 

The value of recognizing that jaundice is in most diseases 
caused by hepatitis, whether this be from poisons or from an 
immediate infection by organisms, is that it enables one to rise 
to a wider view of each intoxication or infection as probably 
affecting other organs, for example, the kidney with albuminuria 
and the spleen with enlargement. Thus in spirochaetal j aundice 
the liver is infected and jaundice appears, while the hepatic 
cells may show all conditions ranging from no microscopic 
change up to extreme necrosis and dissociation. But it is easy 
to conceive how a blood infection by these spirochaetes may 
cause inflammatory disease of other organs without the appear- 
ance of jaundice, and such forms of this spirochaetosis did as a 
matter of fact occur. It is interesting to note the frequency 
with which spirochaetal blood infections may be associated with 
jaundice from hepatitis, as in spirochaetosis ictero-haemorrhagica, 
in relapsing fever, in yellow fever, and often in syphilis. 

The various maladies in which jaundice was seen to occur 
during the war are recapitulated in the following list, with 
brief remarks, except for certain groups that are dealt with 
separately in detail. 

A. Jaundice due to excessive destruction of red blood cor- 
puscles and consequent overloading of the liver with derivatives 
of haemoglobin. The stools usually show a full dark or yellowish 
.colour. This form of jaundice is found in : 

(1) Blackwater fever, and in ordinary malaria, where it was 

seen occasionally but was not of ominous prognosis. 

(2) Poisoning by arsine (AsH 3 ) fumes. The arsenic sub- 

stances employed in gas warfare did not cause 
haemolysis and jaundice ; but some cases of arsine 
poisoning were met with in the navy, where the 
gas had been generated from the use of impure 
chemicals for accumulator batteries in submarines. 



376 MEDICAL HISTORY OF THE WAR 

(3) Some gas gangrene and some streptococcal infections 
causing rapid anaemia, and, with this, light jaundice 
was occasionally observed as an index of the grave 
nature of the infection. It is doubtful whether such 
jaundice should be ascribed to the haemolysis or to 
a direct damage of the liver. 

B. Obstructive jaundice caused by blockage of the main bile 
ducts while the liver cells are at first normal and healthy. The 
stools are finally a chalky white. 

Occasional examples due to gall-stones or tumours were of 
course seen, but none of the ordinary diseases with jaundice that 
occurred during the war could be fairly placed in this group. 

C. Jaundice associated with hepatitis, this being either a 
direct inflammation or necrosis of liver cells, or a cholangitis 
with obstruction of the finer bile ducts. The stools may range 
from normal to a greyish-white colour. The two forms are 
frequently mingled, so that it is hard to draw a line between 
them except in the histological examination of any individual 
case. Even when an infection reached the liver by ascending 
the bile passages from the intestine it none the less caused some 
hepatitis as well as cholangitis, and the hepatitis and similar 
inflammatory changes in other organs of the body were the 
really serious factors in the disease, while the jaundice was only 
a colour smeared over the essential details of the clinical picture. 
Portal obstruction and ascites were seen to develop in a few of 
the chronic cases of some of these maladies, but there has been 
no satisfactory evidence that any of them were particularly 
liable to be followed by a slowly progressive hepatic cirrhosis. 

Jaundice of this nature may be classified as follows : 

1. Spirochaetosis ictero-haemorrhagica (Weil's Disease). The 
closely allied disease, yellow fever, did not appear among the 
British troops. 

2. Epidemic catarrhal j aundice. C. J. Martin has argued with 
great weight of evidence that this infection should be regarded 
as one of a generalized character, like that in spirochaetal 
jaundice, with the possibility of hepatitis, albuminuria, and 
splenic enlargement occurring in it. 

3. Simple catarrhal jaundice. These sporadic cases of mild 
jaundice were frequent in military just as in civil experience. 
They appeared to be infective, and sometimes lightly contagious. 
Their relationship to epidemic jaundice is uncertain. 

4. In typhoid and paratyphoid fevers. Jaundice was rare in 
dysentery. 

5. In influenza and lobar pneumonia. Jaundice was not 
often seen in France as a concomitant or sequela of influenza 






JAUNDICE 377 

until January 1919, It was, however, reported in the 
transport " Nestor," bringing troops from America, as early 
as September 1918. During the wave of influenza that 
began in January 1919 it became much more common. 
It occurred at any stage of the fever, sometimes in the first 
few days, sometimes not until convalescence was advanced. 
In the latter case it has been ascribed to the increase in diet, 
but there seems to be no good ground for this suggestion, and 
probably, like that which occurred earlier in the disease, 
it was due to the influenza virus or organisms associated with 
that infection. It had the appearance of an ordinary catarrhal 
jaundice, was not attended with any severe symptoms, and did 
not in any way affect the prognosis. 

Such cases were few compared to the number of cases of 
influenza, and there was seldom an opportunity of making an 
examination of the organs. In one case which died deeply 
jaundiced in the first week of the fever, with severe pulmonary 
lesions, the bile passages outside the liver and the duodenum 
itself showed no abnormal appearances. 

The occasional occurrence of jaundice in lobar pneumonia had 
been observed before the war and was seen during it, perhaps 
more frequently in pneumonia of the right lung. 

6. In relapsing fever. This complication of a blood infection 
by Obermeier's spirochaete was not uncommon. Captain 
Nicholson observed jaundice in 64 per cent, of two hundred 
and forty-one cases in hospital at Baghdad, but the incidence 
was usually much lower than this. White as well as coloured 
troops were affected. The jaundice occurred early and was 
sometimes deep, but it did not affect the prognosis, for there 
was neither anaemia with it nor severe degeneration of the 
hepatic cells. 

7. In salvarsan poisoning. Syphilis itself, in either the 
secondary or tertiary stages, may be associated with moderate 
jaundice. But examples were seen of very severe or fatal 
jaundice, with intense destruction of the liver, which were 
directly caused by salvarsan treatment. The symptoms might 
appear at the end of a course of treatment, or even some weeks 
subsequently. 

8. In trinitrotoluene poisoning. From the handling of this 
high explosive the substance is absorbed through the skin, and 
in susceptible persons may cause extreme destruction of the 
liver. In the twelve months of August 1916 to 1917 there 
were 238 cases of this toxic jaundice among munition workers 
in England, with 75 deaths. 

9. Poisoning by tetrachlorethane from the use of aeroplane 
varnish. In this case the poison was absorbed through the 



378 MEDICAL HISTORY OF THE WAR 

lungs. The histological injuries, with associated degeneration 
in the heart and kidney, were similar to those with T.N.T., 
and in chronic cases there was considerable cirrhosis of liver. 

Delayed chloroform poisoning was sometimes observed to 
cause a similar toxic jaundice. 

10. Intestinal worms, such as ascaris, were occasionally the 
cause of a secondary jaundice. 

Of these the spirochaetal type, the epidemic catarrhal of 
campaigns and the jaundice associated with the enteric 
group of fevers were distinct forms of jaundice which 
occurred during the war, and call for detailed description. 

SPIROCH^ETOSIS ICTEROH^EMORRHAGICA. 

Spirochaetal jaundice or spirochaetosis ictero-haemorrhagica is 
caused by a micro-organism identified in November 1914 by 
two Japanese workers, Inada and Ido, and named by them 
Spirochata ictero-hcemorrhagice. They showed the presence 
of this spirochaete in the liver of a guinea-pig which had been 
inoculated with the blood of patients suffering from a form of 
infectious jaundice, and they also obtained the organism from 
the blood and urine of the patients themselves. By the courtesy 
of Dr. Flexner of the Rockefeller Institute, an early account of 
their results was forwarded to the Medical Research Committee 
and reached France in February 1916. In the summer and 
autumn of 1915 the attention of medical officers in France had 
been arrested by the occurrence of severe cases of iaundice in 
which there were high fever, haemorrhages, enlargement of the 
liver, and a tendency to febrile relapses, the features of which 
conformed neither clinically nor bacteriologically to those of 
typhoid fever. In the autumn of 1915 cases of this kind were 
collected for purposes of closer study, and in April and May 
1916, when the Japanese investigation became known, the 
Spirochceta ictero-hamorrhagice was shown to be the cause of 
the disease in these military patients. 

The disease occurred in the French and German as well as 
in the British armies on the Western front. It seems probable 
from Martin's account that it also occurred in Gallipoli, though 
he had not there facilities for animal experiments. 

JEtiology. 

Japanese workers were the first to point out that this 
spirochaete is found in the kidneys and urine of rats. They 
were able to show the presence of S. ictero-hczmorrhagice in 
38 per cent, of the field rats coming from areas in which jaundice 
was epidemic, and they suggested that the infection might be 
conveyed by the rat's urine, directly or indirectly. Noguchi 



SPIROCILETAL JAUNDICE 



379 



has shown that American wild rats contain this organism in 
their kidneys ; Coles found it in nine out of a hundred rats 
investigated in England ; and Stokes showed that six out 
of fifteen rats caught in the areas in Flanders, in which 
jaundice was endemic, contained in their kidneys a spirochaete 
capable of producing the disease in the guinea-pig. Rats act, 
then, as reservoirs for the infective agent. 

It is easy to see how the infective urine of rats can convey 
the disease by fouling the water and food in the trenches. 
Nearly all the cases on the Western front occurred in men who 
were, or had lately been in the trenches ; and the disease was 
shown to be more prevalent in wet than in dry trenches. 

The rats do not appear themselves to suffer from the presence 
of the spirochaete. At the Wellcome Bureau of Scientific 
Research, no obvious changes were found in the kidneys or in 
other organs of infected rats. 




FIG. 1. Spiroch&ta ictero-hcemorrhagia. (Pettit.) 

As the result of later investigations on the parasite of ictero- 
haemorrhagic jaundice, Noguchi found no differential features 
between the Japanese, European and American strains. 
He has shown that, both morphologically and in its resistance 
to destruction by a 10 per cent, solution of saponin, it is unlike 
all previously described spirochaetes. For this reason he prefers 
to place it in a separate genus under the name Lepiospira 
icterohcemorrhagice. 

The infecting spirochaete varies in length from 4/x to 25 ,M, 
the average being 8// to 9/u ; its thickness is estimated by the 
Japanese workers at 25^. The ends are sharp, pointed and 
often hooked. Terminal flagella of varying length and ending 

(2396) Z^ 



380 MEDICAL HISTORY OF THE WAR 

in circular knobs have been described, but their significance 
is unknown. 

This organism shows irregular undulations, usually composed 
of two or three large, or four or five smaller, waves. 







FIG. 2. Spirochcsta ictero-hamorrhagicB in blood of guinea-pig 
experimentally injected. (Bedson.) 

Now and then forms are seen in which the waves are more 
numerous and regular, like those of Treponema pallidum. 
Other variations in shape are sometimes seen ; round or oblong 
granules, three or four in number, may appear within some of 
the spirochaetes. The organism may be grown in various media, 
liquid and solid blood agar and gelatine, human serum, diluted 
ox serum and ascitic fluid. The optimum temperature is about 
27 C., but growth occurs at temperatures between 22 C. and 
32 C. The growth is at its height about the tenth day in 
primary culture, and from the fourth to the sixth day in sub- 
sequent subcultures ; by the end of three weeks the culture is 
usually dead. The presence of contamination hinders or des- 
troys growth. This spirochaete has, in general, strong vitality ; 
it will remain active in tap water exposed to wintry weather 
for many days ; yet sometimes it will suddenly die out iinder 
good conditions for no apparent reason. 

The antiserum for spirochaetal jaundice, first prepared by 
Martin and Pettit, contains a specific agglutinin in addition to 



SPIROCILETAL JAUNDICE 381 

spirochaeticidal immune bodies. The serum of convalescents 
possesses also the power of clumping the spirochaetes ; this 
agglutination thus provides an additional diagnostic test. The 
agglutinating power of the serum of convalescents may rise to 
a titre of 1 in 500 or 600, whilst normal serum and the serum of 
syphilitic patients are without effect on S. ictero-hcemonhagice. 
Attempts to reproduce the disease in animals have shown 
that the guinea-pig is extremely susceptible, but the mouse, 
rat, rabbit and monkey are also prone to the disease. The 
guinea-pig can be infected by intraperitoneal injection of the 
patient's blood or urine, but where blood is used it must be 
taken early in the disease. The disease in the guinea-pig 
incubates for from six to thirteen days, a week being a usual 
period ; it is characterized by jaundice, haemorrhages (those in 
the lungs being especially characteristic), conjunctival con- 
gestion, albuminuria and pyrexia. It is nearly always fatal. 
Jaundice appears when the temperature has reached its 
maximum (103 to 106 F.), and the animal then becomes more 
acutely ill. Twenty-four hours later there is a fall of tempera- 
ture to subnormal, followed usually by collapse and death. 
Spirochaetes appear in the blood with the onset of fever, and in 
the urine soon afterwards ; they are plentiful, too, in the liver, 
kidneys, and suprarenals. 

Symptoms. 

The following clinical description of spirochaetal jaundice is 
drawn in the main from the study of cases occurring among 
soldiers in France and Flanders. The patients were almost 
invariably attacked by the disease either in the trenches or 
immediately after having left them. 

The period of incubation is not constant ; its limits have not 
been determined, though they are probably six to twelve days. 

In a case of accidental laboratory infection, recorded by 
Martin and Pettit, the term of incubation was fixed between 
six and eight days. 

The onset is more often sudden than gradual ; early symptoms 
are shivering, headache and body pains, great prostration, 
vomiting and diarrhoea. The temperature rises quickly to 
102 F. or higher. During the next three or four days the 
conjunctivae become injected, and herpes (often haemorrhagic) 
appears on the lips in some 40 per cent, of the patients. 
Bleeding, while uncommon in mild, is usual in severe cases ; 
it may come from the nose, lungs, stomach or intestine, or it 
may take the form of a purpuric rash. Early in the illness 
slight haemoptysis is a valuable diagnostic sign. Haemorrhage 
generally precedes jaundice in order of appearance. 



382 MEDICAL HISTORY OF THE WAR 

The jaundice appears, as a rule, on the fourth or fifth day of 
illness, but it may be as early as the second or as late as the 
seventh day ; it reaches its height about the tenth or twelfth 
day. Sometimes it is intense and the skin has the greenish 
hue seen in complete obstruction of the common bile duct. 
Constipation is pronounced ; the stools may be clay coloured, 
but are more often light brown. Tenderness in the upper 
abdomen is usual ; the tongue is furred, dry and brown, and 
in severe cases there are sordes on the lips. The liver is fre- 
quently enlarged as much as two or three fingers' breadth below 
the costal margin, but the spleen is seldom palpable. The 
lymphatic glands in the axillae and groins are sometimes 
enlarged and shotty. 

In severe cases signs of bronchitis are usual ; the respiration 
rate may rise to 30 or even higher, and when death is impending 
the range and character of the breathing may be modified as 
they are in cases of uraemia and diabetic coma. The pulse is 
slow in proportion to the pyrexia, a rate of 75-85 being quite 
usual. 

The early weakness and prostration are characteristic of this 
disease. Frontal headache and aching behind the eyeballs 
cause much distress at first, but diminish as the days pass. 
Dawson and Hume found vomiting a symptom in 60 per cent, 
of cases and Ryle in 76 per cent. The muscular pains last 
longer and are at times intense. The patients complained of 
feeling as if they had been beaten and the muscles were tender 
on pressure. Twitchings and convulsions may precede or 
accompany the coma of fatal cases. The urine contains bile 
in abundance, which may persist for four or five weeks. Albu- 
mlnuria is usually present and urinary casts, hyaline, epithelial 
and granular, are common. French authors lay stress on the 
evidences of renal insufficiency. Ryle found acetone to be 
present in 16-3 per cent, of his cases. 

The course of the illness varies with the severity of the attack. 
In an acute case irregular pyrexia persists for ten days to a 
fortnight, and falls by lysis. Sometimes there is a secondary 
rise of fever about the beginning of the third week, but without 
exacerbation of symptoms or increase of jaundice. The tem- 
perature may fall about the tenth day, when the jaundice 
reaches its height ; or it may fall earlier, while the jaundice is 
still deepening. Convalescence is slow, but recovery is usually 
complete. 

Not all cases of this disease conform to the foregoing 
picture ; many are like the following, mild and less defined in 
their manifestations, and therefore more difficult of detection. 



SPIROCILETAL JAUNDICE 



383 




CHART I. CASE 1. 

Case 1. Aged 38. Onset sudden, with vomiting. Day 3: dark urine. 
Day 4 : drowsy ; ill ; reported sick. Day 7 : brown tongue ; jaundice 
_|_ _|_ epigastric tenderness. Liver + two fingers; spleen 0. Urine 
albumin, bile, casts. Stools contained some bile. Blood R.B.C. 5,200,000 ; 
W.B.C. 13,000. Days 7 to 18 : toxic ; jaundice -f + Day 19 : gall-bladder 
drained (operation). Day 22: jaundice less; condition improved. 
Day 32 : convalescent.. 



Day ofDis. 



100' 



99' 



87' 
false- 
Rc.sp 



P 



CHART II. CASE 2. 

Case 2.* Sudden onset ; pains head and body ; vomiting. Day 6 : 
suffusion of conjunctivas, slight jaundice ; liver ; spleen 0. Day 9 : 
jaundice + -f drowsy. Day 10 : condition improving, W.B.C. 8,500. 
Day 12 : typical spirochaetes found in urine. 

Jaundice is a usual though not invariable feature of this 
disease. Cases 3 and 4 illustrate the variety in which it is 
absent. 



Compare with this enteric jaundice, page 401. Charb VIII. 



(2396) 



384 



MEDICAL HISTORY OF THE WAR 




CHART III. CASE 3. 

3. Onset sudden ; feverish ; generalized pains ; lassitude + 
giddiness. Day 3 : cough ; herpes labialis. Day 4 : spirochaetes in blood ; 
pains continue. Day 10: patient improving. Day 14 : typical spirochaetes 
in urine. 

Case 4. Sudden onset ; headache ; body pains ; photophobia ; vomiting. 

5 : 

aemorrhages. 
relapse of fever and pains. 



T. 104-2 ; patient very ill. Days 2 to 5 : conjunctival suffusion ; herpes 
labialis ; vomiting + no haemorrhages. Day 14 : convalescence. Day 20 : 



Inoculated guinea-pig developed jaundice. Spirochaetes in patient's urine 
until the end of the ninth week. 

In some cases nephritis is a prominent feature. 




106 
105 
104 
103 
102 
101 
100 
99 



97 



CHART IV. CASE 5. 

Case 5. Onset and early days; body pains; mild headache; transient 
oedema. Urine albumin and blood. Day 10 : looked ill. Urine 
albumin, blood and casts. Day 11 : fever. Urine as before. Day 15: 
jaundice faint. Day 17 : jaundice deep. Urine ; blood ; albumin trace. 
Days 17 to 30 : weak ; wasted ; drowsy ; cholaemic. Picture resembled 
spirochaetosis. Slow recovery. Bacteriological data ; enteric negative. 
Typical spirochaetes in urine on three occasions. 



SPIROCILETAL JAUNDICE 

In the following cases the result was fatal :- 



385 



Case 6. Onset : vomiting ; pains in leg ; fever. Day 3 : haematemesis 
( pint). Day 4 : ill ; drowsy. Day 7 : jaundice rapidly + + Day 10 : 
jaundice -f + + ; abdominal distension ; slight cough ; bloody sputum ; 
liver -f- 3 fingers ; spleen 0. Urine bile + albumin + no casts. Stools, 
clay. R.B.C. 3,000,000. W.B.C. 20,000. Day 14 : drowsy ; weak. 
Day 20 : temperature normal ; jaundice less. Days 22 to 29 : drowsiness 
+ + picture of diabetic coma ; jaundice diminishing ; general clonic con- 
vulsions on 27th day ; death in coma. 

Case 7. Onset acute ; pains ; repeated vomiting ; very ill ; vomiting 
continued until 14th day. Jaundice appeared 5th day. Liver -f 2 fingers ; 
spleen 0. Urine albumin trace ; casts + + Stools almost clay-coloured. 
Blood W.B.C. 22,500. Drowsy throughout; died on 14th day from 
toxaemia. 



102 e 



100' 



CHART V. CASE 8. 

Case 8. Onset : head and body pains, weakness, chilliness. Tempera- 
ture 102. Days 2 and 3: repeated vomiting. Day 3: herpes labialis; 
jaundice. Day 4 : temperature normal ; jaundice markedly increased ; 
liver and spleen not palpable ; patient much worse. Day 5 : haemate- 
mesis ; albumin + + epithelial and erythrocytic casts, no spirochaetes ; 
dry brown tongue ; tonic convulsions ; general condition grave. Day 6 
and onwards : epistaxis, haematemesis, melaena, purpura. Guinea-pig in- 
oculated seventh day : negative. Day 12 : death from toxaemia and 
anaemia. Urine contained characteristic spirochaetes. 



Clinical Pathology. 

Apart from the finding of the spirochaete, examination of the 
peripheral blood reveals certain abnormalities. 

In severe cases there is slight anaemia, the average red cell 
count being 4 to 4| million per c.mm., and the haemoglobin is 
reduced to 80 or 90 per cent. Some cases become very anaemic. 
There is invariably a leucocytosis, amounting in some cases to 
25,000 per c.mm. This may, however, be absent or slight 
in the early stages, according to Stokes. The differential 
count shows a relative increase of the polymorphonuclear 
leucocytes to 75-80 per cent. The fragility of the red 



386 MEDICAL HISTORY OF THE WAR 

corpuscles is either normal or slightly diminished. No ab- 
normal red cells have ever been detected. From this it may 
be concluded that the jaundice is not of haemolytic origin. 

In man the blood infection is brief and relatively light, and 
the spirochaete is difficult to find in blood films or cultures. 
After the fifth day of disease, recovery of the organism is rare, 
but intraperitoneal inoculation of a guinea-pig may yield a 
positive result up to the seventh, eighth or ninth day. Later 
than that the result is always negative. 

Reproduction of the disease in the guinea-pig by injection of 
the patient's blood or urine is beyond doubt the most satis- 
factory and convincing diagnostic test we at present possess. 
Since, however, the blood is infective only in the early stages of 
the disease, while the infectivity of the urine varies much, this 
method of diagnosis as a practical measure has its limitations. 

Leptospira ictero-hcemorrhagice, as shown by the Japanese, is 
eliminated chiefly by way of the kidney. From the ninth day 
onwards it can be demonstrated microscopically in the urine. 
At first it appears in small numbers only, the number gradually 
increasing to a maximum about the thirteenth to the fifteenth 
day of the disease, to diminish again and finally disappear from 
the urine in the fifth or early in the sixth week of illness. It 
does not suffice to examine the urine on one occasion only ; 
several examinations at intervals of two or three days may be 
necessary before the organism is found. 

Spirochaetes may be present in the urethral meatus of healthy 
persons. It is necessary, therefore, to eliminate this source of 
error by washing the glands and meatus, and then catching the 
middle portion of the urine in a sterile flask. They are never 
excreted from the kidney in health. Spirochaetes have, how- 
ever, been found in a few cases of pyrexia of uncertain origin, 
and in relapsing fever. The final test depends upon the effect 
of inoculation upon the guinea-pig, which is immune to any 
except the Spirochceta ictero-hcemonhagia , but, if that form is 
injected, reproduces the characteristic signs of the disease. 



Morbid Anatomy. 



In two of the above fatal cases the mucous membrane of 
the duodenum was very cedematous and congested, its colour 
resembling a dark-blue plum. The ampulla of Vater was 
swollen and congested, and around it there was a raised area 
of red and injected mucous membrane. A lesser degree of 
congestion and oedema was seen in the first three feet of the 
jejunum and in the stomach, but the rest of the intestines were 
unaffected. Enlarged lymph glands were seen at the edge of 









SPIROCtLETAL JAUNDICE 387 

the lesser omentum and about the bile ducts. The last portions 
of the common bile and pancreatic ducts, when laid open, were 
of normal appearance except the termination in the ampulla of 
Vater, which was swollen, congested and blue. That no 
inflammation of the duodenum occurs in this disease is borne 
out by the results of duodenal intubation ; the withdrawn 
duodenal contents have been shown to contain polymorpho- 
nuclear leucocytes and large mononuclear cells clearly the 










FIG. SA. Section of liver from a case of spircchaetal jaundice. 

products of local inflammation. It would seem to be clear, 
therefore, that in some instances the spirochaetal infection 
localizes in the duodenum ; whereas in others the duodenum is 
normal in appearance and the chief changes are found in the 
liver and less often in the kidneys. 

Of five post-mortems studied by Dawson and Hume, two had 
a duodenal change, while the bile ducts, the pancreatic duct and 

(2396) Z* 



388 MEDICAL HISTORY OF THE WAR 

livers showed no change ; one had duodenal change and slight 
liver changes ; ^one showed no morbid appearances in either 
duodenum or liver ; one showed no duodenal changes but 
marked disorganization of the liver. 

The changes in the liver are not uniform. To the naked eye 
they are often slight or insignificant, the pattern and texture 
appearing normal, though some discoloration due to bile stasis 
is not uncommon. On microscopical examination the appear- 
ances vary (Figs. SA, SB). The cells of the lobule may be 
natural in size, shape and arrangement, and apart from evidence 
of biliary stasis the only abnormality may be the presence of 
collections of cells in the portal areas, such as occurs in many 
other diseases. 







** VSflLtit 1 ** ^^ * ** 

i^Vta 



FIG. SB. Part of same section more highly magnified. The liver 
cells and their arrangement appear normal. Biliary stasis is evident. 

In other cases definite changes are found on microscopic 
section. There is some loss of lobular pattern, the cells 
show undue variation in size and shape, and here and there 
the nuclei are large or multiple, and a few mitotic figures and 
vacuolation of the cytoplasm can be observed (Fig. 4). Or, 
again, these changes just described may be more advanced, 
dissociation of cells may be pronounced, and the cells in 
the centre of the lobules show granular degeneration (Fig. 5). 
These changes suggest the effect of damage not great enough 
to cause extensive necrosis, but sufficient to stimulate cell 
growth. They somewhat resemble what is seen in subacute 
yellow atrophy. 






SPIROCILETAL JAUNDICE 



389 




FIG. 4. Section of liver from Case 8, showing slight changes. 


















o 



' -0 



FIG. 5. Section of liver from a case of spirochaetal jaundice, 
showing dislocation of cells and marked degenerative changes. 



390 



MEDICAL HISTORY OF THE WAR 



In very acute cases of short duration (Fig. 6) advanced changes 
have been found in the liver, both naked-eye and microscopic. 
In such rapidly fatal infections the organ is diminished in 
size, with a wrinkled capsule, the section reveals loss of lobuiar 
pattern and numerous yellow areas of necrosis. Here complete 
destruction of liver cells may be seen, the framework of inter- 
stitial tissue only being left. Hart and other German workers 
bear out these earlier observations in the British army. 

It would thus appear that the disease falls with varying force 
on the liver, the changes showing gradations between the 
slightest deviation from normal structure and an extreme 
degree of destruction indistinguishable from acute yellow 
atrophy. Hart describes the subsequent 'anatomical changes 




FIG. 6. Section of liver from a case of spirochaetal jaundice showing 
extreme degrees of change. 

which followed disorganization of the liver in a case which lived 
three months. The liver had an irregular surface, lobuiar 
structure was lost, only islands of liver tissue remained, and there 
was an extensive nbro-nuclear infiltration round these islands 
in other words cirrhosis had supervened on acute atrophy. 
The changes in the kidneys likewise vary, though not so much 
as those in the liver. The appearances (Figs. 7 and 8) may be 
merely those of cloudy swelling ; there may be infiltration with 
polymorphonuclear leucocytes between and within the renal 
tubules ; or there may be in addition haemorrhages in the 
glomeruli causing disruption of cells ; the protoplasm of the 



SPIROCHyETAL JAUNDICE 



391 



tubular epithelium may stain badly, have a granular appearance 
and show vacuolation in short, the changes may approach 
those of necrosis 




FIG. 7. Section of kidney from a ca se of spirochaetal jaundice showing cloudy 
swelling as well as inter- and mtra-tubular polymorphonuclear infiltration. 




.\ * ^V v x*" '. . /^ 

- 




FIG. 



S. Section of kidney from a case of spirochsetal jaundice showing 
marked degenerative changes in the parenchyma. 



392 MEDICAL HISTORY OF THE WAR 

The spleen and pancreas show no departure from the normal. 
Peritoneal, subpleural, and sub-pericardial haemorrhages are 
often seen. Even more common are haemorrhages within the sub- 
stance of the lung, sometimes reaching the size and consistency 
of the haemorrhagic infarcts met with in mitral stenosis. In no 
other organ of the body has anything worthy of note been found. 

In the case illustrated in Plate VI the patient died on the 
eleventh day, having spat up glutinous dark red blood 
continually for thirty-six hours. 

The upper lobe of the lung shows the staining of jaundice 
and scattered small sub-pleural haemorrhages. The lower lobe 
has been sliced open in order to reveal the distribution of the 
haemorrhage throughout the substance of the lung. This 
appearance is very similar to that produced in guinea-pigs 
experimentally by the injection of blood containing the spiro- 
chaetes, which has been compared by the Japanese workers, 
who discovered the nature of the illness, to the mottled wings 
of a butterfly. 

The pathological appearances, like the clinical manifestations, 
indicate that the brunt of this infection does not always fall 
on the same organs. When inflammation and swelling of the 
duodenum and papilla of Vater occur, without any change in 
the liver beyond bile stasis, the jaundice is clearly due to 
obstruction at the outlet of the common bile duct. When, on 
the other hand, as is more common, there is disorganization 
of the lobules, with damage to the cells and intrahepatic 
ducts, the jaundice must be due to derangement of secretion 
within the liver. In the absence of definite changes in the 
liver and of duodenal inflammation there is no jaundice. 

Diagnosis. 

A comparison between acute yellow atrophy and spirochae- 
tosis icterohaemorrhagica is worthy of attention. On the 
pathological side two of the illustrations manifest a striking 
resemblance to acute and subacute yellow atrophy. On the 
clinical side acute yellow atrophy, though usually running a 
rapid course, may extend to fourteen or more days' illness. Again, 
in the wards the clinical picture has often been that of acute 
atrophy, and yet there have been no characteristic changes in the 
liver after death. Such cases are described as " icterus gravis," 
thus avoiding the difficulty in diagnosis. Further, Rolleston 
records a case of acute yellow atrophy without jaundice. 

Onset sudden, with pain and slight haematemesis. On second and third 
days haematemesis, and on following three days melaena. On second day liver 
dullness was diminished. The temperature was usually between 99 and 100 F. 
No jaundice. The patient became progressively weaker and drowsy, and died 
on the eighteenth day. Post mortem the liver showed acute yellow atrophy. 




u 

o 



X 

6 

& 

UJ 

u 



UJ 

u 



U 

o 



o 

LL) 

U 
< 

O 



o 

D 

H 
O 

5 



SPIROCILETAL JAUNDICE 393 

Spirochaetosis ictero-haemorrhagica may therefore be regarded 
as a disease in which certain symptoms and lesions can be 
referred to a definite known cause, and acute yellow atrophy 
as a provisional term denoting a condition in which the same 
symptoms and lesions occur but the cause is unknown. 

The spirochaete can sometimes be found in the peripheral 
blood stream of patients suffering from the disease. Injection 
of infected human blood into the peritoneal cavity of the 
guinea-pig will, after an incubation of about a week, produce a 
characteristic fatal illness in that animal, in whose tissues the 
spirochsetes are present in large numbers. The spirochaete has 
occasionally been isolated in pure culture from the blood, and 
the guinea-pig inoculated from such culture contracts the disease. 
The disease has been produced in man by accidental inoculation 
from an infected guinea-pig. After the first fortnight of the 
disease the spirochaete may be found in the patient's urine, and 
in the third week of the disease the patient's serum agglutinates 
the spirochaete. 

At the commencement of the illness there may be difficulty 
in diagnosis from the fact that the early symptoms may be 
limited to those common to this and other diseases such as 
influenza, enteric fever, trench fever or cerebro-spinal meningitis. 
The complete clinical picture with jaundice is not present until 
the fourth or fifth day. The occurrence of haemorrhages will 
certainly suggest Spirochaetosis ; the same will be true, though 
in less degree, of conjunctival suffusion and herpes. Both of 
these may also occur in trench fever, though the herpes in the 
latter is not haemorrhagic. 

The guinea-pig test should be carried out the moment that 
suspicion arises, for the blood of the patient suffering from 
Spirochaetosis is only infective during the earlier stages of the 
disease. After the fifth day the chances of a positive result 
diminish, and after the eighth day are few. Since the average 
day of appearance of jaundice is the fourth or fifth, it is easy to 
see that the opportunity of inoculating a guinea-pig in time 
may easily slip. Though, therefore, this diagnostic test is 
conclusive, it has in practice its limitations. In mild cases 
and non- jaundiced cases these limitations are even greater, for 
in the former the infectivity of the patient's blood is of more 
brief duration, and in the latter the manifestations suggesting 
the presence of this disease will often be too late in 
appearing. 

During the second week of the illness the differentiation of 
the enteric group will be assisted by the fact that the reaction 
of the patient to atropine ( 1 / 30 gr. hypodermically) is normal, 
whereas in enteric the acceleration of the pulse is often absent. 



394 MEDICAL HISTORY OF THE WAR 

A study of the clinical manifestations of the enteric group of 
diseases during the war will show how closely they can 
resemble spirochaetosis in its earlier stages. The onset of 
paratyphoid fever was often sudden, there were head and body 
pains, vomiting was sometimes an early feature, the abdomen 
was commonly flat and the spleen was frequently not palpable. 
The occurrence of stupor, haemorrhage and jaundice would 
enable a diagnosis to be made. 

Between spirochaetosis and trench fever in their earlier stages 
clinical differentiation is often impossible. 

After the ninth day, if the disease is spirochaetosis, spiro- 
chaetes appear in the urine, reach their maximum about the 
fifteenth day and disappear at the end of four or five weeks. 
Jaundice in typhoid or paratyphoid fever does not usually 
appear before the end of the second week, that is, a week later 
than in spirochaetosis. Cases of enteric fever do, however, 
occasionally occur in which jaundice appears early, and the 
resemblance in the manifestations of the two diseases is then 
very close. Blackwater fever and bilious remittent fever may 
both of them be mistaken for spirochaetosis. Yellow fever also 
closely resembles it. 

Prognosis. 

The Japanese found the mortality of the disease to be 30 per 
cent. In Europe it has certainly been much less. Stokes and 
his colleagues observed 100 cases of which six died. Dawson 
and Hume observed 78 cases of which five died. McNee 
estimates the mortality as not over four per cent. Death usually 
occurs from the severity of the disease within the first fortnight, 
but has occurred at twenty-one days from nephritis, at twenty- 
eight days, cause not stated, and after three months when 
extreme atrophy and cirrhosis of the liver were found. The 
suspicion arises that the foundations of chronic disease of the 
liver or kidneys may be laid in some patients who recover from 
the spirochaetosis, but as yet there is no definite knowledge on 
this point. 

Treatment. 

The Japanese prepared an antitoxic serum, but found little 
advantage from its use. Pettit and Martin prepared a curative 
serum from the horse which they found effective in the case 
of guinea-pigs. This has since been confirmed by Noguchi. 
Its use in man is doubtful. Renaux and Wilmaers reported in 
favour of it, and Bassett-Smith recommended that it should 






EPIDEMIC JAUNDICE 395 

be supplied to the naval forces in France, but Gamier found 
no benefit from its use in thirteen cases. Stokes showed that 
guinea-pigs infected from rats could be cured from the serum of 
a convalescent human patient. 

EPIDEMIC CATARRHAL JAUNDICE. 

Under the titles epidemic catarrhal jaundice of campaigns, 
epidemic jaundice of campaigns, and camp jaundice, is 
included a form of jaundice usually slight in degree in 
which the constitutional symptoms are mild. It has the 
features of an infection, either a blood infection which 
has localized in the duodenum, for example, or less often per- 
haps an infective gastritis which has extended to the duodenum. 
The usual symptoms are malaise, transient fever, headache, 
anorexia, nausea, abdominal discomfort, with jaundice super- 
vening later. In France and Flanders these cases of jaundice 
only occurred singly or in small groups, and not in epidemics as 
they did in the Eastern theatres of war. 

Epidemic catarrhal jaundice broke out in certain camps in 
Alexandria in July 1915, and thereafter spread rapidly to 
Gallipoli, Mudros, Salonika, and ultimately to Mesopotamia. 
Gunson and Gunn described the group of cases occurring at 
Alexandria among British troops during the summer of that 
year. Early in 1916 Willcox published an account of epidemic 
jaundice in the Dardanelles. This paper was supplemented by 
C. J. Martin's article on the pathology and aetiology of the 
outbreak and by the bacteriological reports of Archibald, 
Hadfield, Logan and Campbell, working at the Mudros labora- 
tories. 

It was so prevalent as to be an important cause of 
invaliding. Thus in Helles between 15th October and 
November 1915, out of a total of 2,062 sick cases, 385 or 18 
per cent, were cases of jaundice. The number of cases of 
jaundice in Helles from 5th September to 6th November 
was 2,195. 

Out of a total of 22,810 sick evacuated from Suvla from 
8th August to 7th November, 676 or three per cent, were cases 
of jaundice ; and a large number were treated in the field 
ambulances. Between 12th August and 1st December the 
number of cases in the three field ambulances of the 53rd 
Division in Suvla was 456 as compared with 612 cases of 
" pyrexia " and 4,026 cases of dysentery and diarrhoea. 
Its rate of incidence and relation to the above-mentioned 
conditions are shown in the following tables. 



396 



MEDICAL HISTORY OF THE WAR 



Number of cases of Dysentery and Diarrhoea, Pyrexia and 
Jaundice evacuated from Suvla Bay. 





Diarrhoea 






Week ending 


and 
Dysentery. 


Pyrexia. 


Jaundice. 


August 15, 1915 






161 


5 




22 






339 


16 





29 






913 


101 


8 


Sept. 5 






840 


58 


4 


12 






827 


147 


7 


19 






1080 


189 


17 


26 






1037 


178 


17 


Oct 3 






1144 


309 


38 


10 






971 


242 


52 


17 






790 


154 


123 


24 






922 


206 


109 


31 






875 


251 


169 


Nov. 7 






621 


282 


132 


Total 


10,520 


2,138 


676 



Incidence of Dysentery and Diarrhoea, Pyrexia and Jaundice, 
in 53rd Division, Suvla Bay. 





Diarrhoea 






Week ending 


and 


Pyrexia. 


Jaundice. 




Dysentery. 






August 19, 1915 






441 


1 




26 






354 


2 


5 


Sept. 2 






544 


14 


1 


9 








326 


47 





16 








256 


60 


, 


23 








237 


,58 


2 


30 








224 


48 





Oct. 7 








229 


48 


3 


14 








201 


62 


10 


21 








292 


66 


20 


28 








206 


35 


51 


Nov. 4 








172 


37 


70 


11 






t 


154 


57 


72 


18 








225 


32 


61 


25 






t 


120 


24 


103 


Dec. 1 











45 


21 


58 


Total 


4,026 


612 


456 



Between 24th September and 31st October the number of 
cases admitted into the field ambulances of the 13th Division 
at Suvla was 74 ; in November it rose to 287 and then fell to 92 
by 19th December when Suvla was evacuated a total of 453 



EPIDEMIC JAUNDICE 397 

cases. Similar rates of incidence occurred in every unit on the 
Gallipoli Peninsula. 

On evacuation of the Peninsula in December 1915, jaundice 
from Suvla Bay was brought back to Egypt by the 53rd 
Division, but it rapidly died out by the end of January 1916. 

It was carried by the 10th Division from Suvla Bay to Salonika 
in November 1915, and prevailed in that division during the 
intensely wet weather in December, high up on the Bulgarian 
mountains. Cases of jaundice there constituted a third or 
more of the total sick admitted into hospitals in December 
1915. It then died out and did not reappear. 

The 13th Division which had also been badly affected -in 
Suvla Bay returned to Egypt for the first three months of 1916, 
and afterwards went to Mesopotamia carrying the infection with 
it, for a sharp outbreak of 555 cases occurred in this division 
in June 1916. The incidence fell rapidly during July and 
August. 

The usual history in any battalion affected commenced with 
one or two isolated cases ; then there was an interval of about 
three or four weeks with an occasional case ; then a large 
number of cases for three weeks ; and finally an occasional 
case for a few more weeks. 

JEtiology. 

The epidemic character of the disease in the Dardanelles and 
Mesopotamia was beyond doubt. There were numerous in- 
stances of a large proportion of the cases occurring in one unit. 
In general, infection appeared to be due to a common cause, 
though cases occurred in which it appeared to be conveyed from 
person to person. There was close association between the 
incidence of epidemic jaundice and that of the dysentery and 
enterocolitis groups of affections. The charts of the two groups 
showed that the jaundice curve reached its summit about three 
weeks after the dysentery curve. Moreover, a recent history 
of diarrhoea was not uncommon in the jaundice cases. On 
the other hand, no jaundice occurred in Gallipoli till early in 
August, although dysentery and diarrhoea were very prevalent 
from June onwards. 

Bacteriological investigation of epidemic catarrhal jaundice 
was carried on with great persistence by many observers. Cases 
here and there were found in which an organism of the enteric 
group, typhosus or paratyphosus, was present. Spirochastal 
infection as a cause was definitely excluded in those cases which 
were studied after the recognition of spirochastosis ictero- 
haemorrhagica. Blood and urine cultures yielded no results. 
Mackie found an organism of B. coli communis type during life 

(2396) AA 



398 MEDICAL HISTORY OF THE WAR 

on two occasions once from liver puncture and once from the 
urine. 

In one case where duodenal intubation was tried, Martin and 
Hurst, in Mudros, obtained a bacillus of the faecalis alkaligenes 
group in six out of eight cases, and in three out of four control 
cases. 

The typhoid-coli group of organisms produces many varieties 
of infection, the clinical manifestations of which are only very 
imperfectly determined. In the war there were infections 
whose symptoms did not conform to atypical paratyphoid fever. 

The facts point to this epidemic catarrhal jaundice being 
due to an infection which is localized in the upper part of the 
alimentary tract, but the actual organism is unknown. 

Observation suggests that the incubation period of the 
infection is at least two weeks, and according to Hunter in most 
cases even more. The uniformity in its mode of incidence and 
its subsequent spread is of importance in connection with the 
question of its aetiology, namely, whether it is only an incidental 
complication of other known infections, e.g., typhoid, para- 
typhoid, or dysentery, or on the other hand an infection sui 
generis. Taken as a whole the facts speak for the specificity of 
the infection. 

Symptoms. 

The clinical picture appears to have been fairly constant. 
The illness was, as a rule, ushered in with headache, general 
malaise, loss of appetite, fever, nausea, and sometimes vomiting, 
with discomfort and tenderness over the upper abdomen. The 
abdominal symptoms would sometimes precede the onset of 
pyrexia. Constipation was as common as diarrhoea. The 
tongue was usually furred but in some cases remained clean. 

Jaundice appeared on the third or fourth day of illness, 
sometimes with the decline of pyrexia ; it reached its height 
about the tenth day and then gradually faded. It varied 
much, however, in intensity and duration ; when severe it 
was liable to last several weeks, but it seldom ran parallel 
with the malaise. The jaundice was sometimes associated 
with swelling and tenderness of the liver and less often of 
the gall-bladder, and with enlargement of the spleen (Chart VI). 

In Mesopotamia, Willcox frequently observed that about the 
third or fourth day precordial dullness increased on the right 
side. This increase lasted only for four or five days and then 
subsided. During the fever the pulse quickened to 80 or 90, 
but in some cases it was noticed that it was only 50 when 
jaundice commenced. The urine contained bile, and slight 
albuminuria was not unusual. The stools were clay-coloured. 
Persistent pain in the back and legs was a feature of some cases. 






EPIDEMIC JAUNDICE 399 

There was a liability to relapses of four or five days' duration. 
Many patients suffered from persistent weakness accompanied 
often by a marked loss of weight. Convalescence lasted two 
or three months. 





M 


u 


M 


tr 


ii 


29 


3D 


sfr 


rf- 


3 


1 


f 


6 


,-fr 


I0i 
102 
101 


T 






a 




-^ 


IE. 






L 


.1.. 


,..u,_. 


" J 




J 




























j 




























100 




\ * 


1 
























99 




- 


h 




* 
























V 


j\ 


/ 


\ 
















^ 


97 








J 


3 




S^ 


A 


j 


V 


^* 


V 







96 










y 








v 













CHART VI. Epidemic Catarrhal Jaundice. 

Jaundice appeared on 24th September. On 26th September liver and spleen 
enlarged and right heart dilated (Willcox). 

Generally speaking, infective catarrhal jaundice, both in the 
sporadic and epidemic forms, was a mild though somewhat 
exhausting illness. Here and there, however, more severe 
infections occurred, and sometimes what appeared to be a typi- 
cally mild case passed on to icterus gravis and ended fatally. 
During the jaundice stage acute toxic symptoms developed and 
death ensued two or three days after their onset. 



V= Vomited. 

D = Delirious. 

C = Coma. 
Post-mortem, pale 
yellow atrophy. 



TSHf> 

IQ3 
108 
107 
/06 
105 
10* 
103 
102 
101 

100 

99 

98 
97 


3?Jl *B 


?9 


V 


1( 




? 


> 


1 




M [f 


& 


3 


ai 


M r 


HJI 


lie 


1|C 




































































































V 


D 


D 


c 












































































2 


-^ 1 


A 




K 






f 








* { 


/\ 


f 


^ 




/ 










\t 


V 


V 


\r 


I 




WistM 


7Q 


*1 


71 


8< 


?B 


n 


80 


Z'O 



CHART VII. Epidemic Catarrhal Jaundice with Icterus Gravis. 
Jaundice before Admission. 

The grave symptoms usually supervened about ten days 
after the first appearance of the jaundice, though in one case 
they developed as early as two days, and in another as late as 
twenty-nine days. There was no foreboding of these grave 
developments in such cases. The following case illustrates this 
occurrence (Chart VII). 



400 MEDICAL HISTORY OF THE WAR 

Patient taken ill 24th December, 1917, with slight fever and usual symptoms 
of epidemic catarrhal jaundice. On 28th December, temperature normal, 
liver enlarged and tender, spleen palpable and slightly tender, tongue furred, 
constipated, definitely jaundiced, urine bile-stained, mental condition normal. 
Several attacks of vomiting, with no blood, occurred during the next three days. 

2nd January, 1918 : Vomit contained streaks of blood and was bile-stained. 
Jaundice now deep. Very restless and maniacal during last night and this 
morning. 

3rd January, 1918 : Vomit as on previous day. Epistaxis in morning, 
liver dulness much diminished, being only two inches vertically ; knee jerks 
increased. Very restless and noisy. 

4th January, 1918 : Patient became comatose in morning, urine contained 
albumen, bile, and a few red corpuscles, no spirochaetes found in urine or blood. 

5 p.m. Cheyne Stokes breathing, extensor plantar reflex. 

10 p.m. Temperature suddenly rose to 109, death occurring at 10.30. 

Post-mortem Examination. Liver 39 ozs. stained yellow. Spleen enlarged 
and soft, kidneys yellowish. Small haemorrhages in pleura, pericardium, 
omentum, mesentery, and lungs. Wall of stomach and duodenum con- 
tained petechiae and contents were blood-stained. 

Microscopical examination and animal experiments for spirochaetes of liver, 
kidney, and spleen were negative. Liver showed almost complete destruction 
of hepatic cells in blocks, only isolated islets of cells remained, in parts total 
necrosis of all but trabecular tissue. Kidney, extensive degeneration of tubu- 
lar cells. Pancreas, early but definite cell necrosis, with shrinkage and loss of 
outline of the cells that remain, in some places great reduction in number of 
-cells. 

The following case is an example of a more severe infection 
from the outset. 

Onset was gradual with chilliness, fever, weakness, anorexia, abdominal pain 
and vomiting. On the fourth day, patient declared sick, and the temperature 
was 108. On the fifth day the temperature was normal and j aundice appeared . 
The upper half of the abdomen was tender and the spleen could be felt for 1 \ 
inches below the costal margin. The jaundice rapidly became deep, but, 
though apathetic, the patient never was in a toxic condition. The urine con- 
tained bile and a trace of albumin. 

On the ninth day the jaundice was slightly less. On the tenth day there 
was a return of fever and the spleen remained palpable, but there was no 
deepening of the icterus. The temperature did not finally settle till the 
eighteenth day ; the jaundice and the enlargement of the spleen had dis- 
appeared on the twentieth day, and by that time convalescence was established, 
The atropin test was made twice on the sixth day, when there was an 
escape of 20 (60-80), and on the fifteenth day, when there was an escape of 
16 (66-82). 

Agglutinations were tested three times on the ninth, fourteenth and nine- 
teenth days. They were negative to paratyphoid A and B, and typhoid 
remained constant at 1 in 215. The patient had been inoculated against 
typhoid only two years previously. 

A blood culture was made during a relapse of fever, and two cultures from 
urine and two from fasces were negative to the enteric group. On two occa- 
sions the urine was thoroughly searched for spirochaetes, but with negative 
results. 

The fasting stomach and duodenum were intubated. Cultures from the 
gastric contents were negative, while those from the duodenum contents 
showed a growth of a gram negative coccobacillus. The characters of this bacil- 
lus were tested by putting it through broth, gelatine, agar, litmus milk, litmus 
whey, peptone, and the sugars. Litmus milk and whey became alkaline in 
twenty-four hours without clot formation in the former. The sugars were not 
acted upon, with the exception of glucose, from which acid without gas was 
formed after forty-eight hours' incubation. 

This coliform organism was the sole positive result from the investigations. 
It was not agglutinated by the patient's own serum. 



ENTERIC JAUNDICE 



401 



JAUNDICE IN THE ENTERIC GROUP OF FEVERS. 

Jaundice is an uncommon though interesting feature of 
enteric fever. During the first two and a half years of the war 
its incidence among cases of enteric in the British armies in 
France and Flanders was 1*38 per cent., and amongst cases 
occurring at the Dardanelles and in Mesopotamia, according to 
Willcox, as much as 5 per cent. The jaundice may occur 
early in the illness, that is, before the tenth day, or during the 
later stages ; it may present every grade from faint to deep 
pigmentation. If severe, the icterus will make the patient 
more drowsy and toxic, otherwise it seems to have little effect 
on the course of the illness and its appearance in the later weeks 



10 II 12 13 14 15 16 17 18 19 20 21 




CHART VIIJ. 

is not necessarily associated with either return of fever or 
exacerbation of symptoms. Of the early symptoms, headache 
is the most constant, and vomiting is common. In a series of 
26 cases the following were the manifestations with their relative 
frequency : headache 19, vomiting 12, abdominal pains 8, 
back and leg pains 8, diarrhoea 5, shivering 2, extreme lassitude 
2, epistaxis 1. Spots were present in four cases, and the spleen 
was palpable in four cases, but the relative infrequency of these 
two manifestations, as also of abdominal distension, was charac- 
teristic of the clinical picture of enteric fever in France and 
Flanders throughout the war. When the jaundice occurred 
early its onset was more often sudden, whereas when it occurred 
at a later stage a gradual onset was more usual. 



(2396) 



AA* 



402 



MEDICAL HISTORY OF THE WAR 



When jaundice occurs early in a febrile illness, the possibility 
of one of the enteric groups being the underlying cause may 
easily escape notice, and this is especially the case if the fever 
is of short duration, or moderate in degree, as is illustrated by 
the following case of infection by B. typhosus '(Chart VIII). 

There was a sudden onset with extreme lassitude and headache, which 
forced the patient to bed within a few hours. On the second day there were 
pains in the head, legs and across the abdomen, and the temperature was 104. 
On the fifth day there was repeated vomiting, and icterus, which had shown itself 
on the previous day, had become definite. By the sixth day the jaundice was 
marked, though the temperature had fallen and the pulse-rate was 88 ; the 
abdomen was flat, but tender in its upper half ; the spleen was not enlarged, 
but the liver extended three fingers' breadth below the costal margin ; no 
herpes ; the glands were shotty ; the patient was apathetic and drowsy. The 
next day the apathy continued and there was vomiting. On the eighth day 
the white cells were 23,800 per c.mm., the red cells 4,800,000 and the 
haemoglobin was 80 per cent. Films showed the red cells to be normal. On 




CHART IX. 

the tenth day there was still apathy, the tongue was dry in the centre and 
furred at the side, the spleen was enlarged to percussion, but not palpable ; 
the urine had a specific gravity of 1,01 1, was acid, contained bile and numerous 
hyaline and granular casts, a few red blood cells, but no albumin. The casts 
had disappeared two days later and a trace of albumin had appeared. 

On the fifteenth day the patient's condition had improved ; the jaundice, 
though still marked, was diminishing ; the spleen, however, had become dis- 
tinctly palpable. Blood pressure was 118 systolic and 58 diastolic. In 
spite of a slight rise of temperature on the seventeenth day the patient's 
condition steadily improved, and the jaundice faded. 

On the tenth day after the injection of ^ grain of atropin, the maximum 
acceleration of the heart was only six beats (70 to 76) in 50 minutes. On the 
sixteenth day the same dose of atropin produced an escape of twenty-four 
beats (68 to 92) in half an hour. The difference in these two observations 
illustrates what Captain Harris has pointed out that the locking of the heart 



ENTERIC JAUNDICE 



403 



under atropin in the enteric group may be limited to a few days, the favourite 
period being about the tenth day. 

Bacteriological cultures from the blood, stool and urine were negative. 
Agglutinations on the eighth day showed a big rise in typhoid, viz., 1 in 2,500, 
rising after delay to 1 in 3,675. On the sixteenth day the agglutinations had 
fallen to 1 in 2,822. Paratyphoid A and B were negative to 1 in 5. The patient 
had been inoculated against typhoid about a year previously but not against 
paratyphoid. 

Investigation was made for spirochaetosis ; a guinea-pig was injected with 
the patient's blood on the sixth day, but with negative results ; the urine was 
examined twice for spirochaetes, the last time on the seventeenth day, and 
with negative results. 

This is a case of interest, for it might easily have been mis- 
taken for either spirochaetal or catarrhal jaundice. The acute 
onset, lassitude and pains, the jaundice developing as the tem- 
perature fell, the shotty glands, could justly have pointed to 
spirochaetosis ; and if the atropin test had not been applied 
till the sixteenth day, the escape of the heart might have been 
an argument against enteric fever. On the other hand, the 
very brief period of fever, the flat abdomen, and the absence 



^ j- g y ^ ^ jQ jl |5 J3 |4 I*- ic |^r jo | 



^FSI 



^ 



v y 



CHART X. 

of splenic enlargement in the early part of the illness might 
well have led to a diagnosis of catarrhal jaundice. 

Chart IX represents the chart of a case of infection by paratyphosus B. 
Here again the onset was sudden, the patient being seized with pains in the 
legs, which were so bad that he was unable to stand. Later he vomited. At 
the onset of the illness the temperature reached 104. On the third day 
jaundice appeared in the conjunctivas and rapidly spread all over the body. 
On the eighth day the temperature was 101 '2 and the pulse rate 96 ; the 
patient was deeply jaundiced and drowsy and complained of a general aching 
The liver extended three fingers' breadth below the ribs ; the spleen could not 
be fe.lt, but the splenic region was very tender. 

On the twelfth day the temperature rose further, and the patient became 
worse. On this day the atropin test was applied, and after the injection of 
3^ grain the heart only quickened four beats, from 100 to 104. He was more 
drowsy ; there were bronchitic rales throughout both lungs and the pulse was 
markedly dicrotic. He remained very ill for three weeks, during which he 
passed through a serious relapse, associated at its commencement with an 
increase in the jaundice. 

About the twenty-first day the jaundice began to diminish and the symp- 
toms to improve, and at the end of five weeks of illness convalescence was 
established. 

Chart X represents the chart from a case of paratyphoid A in which the 
jaundice appeared on the sixth day. Paratyphoid A was recovered from the 
stools. 



404 MEDICAL HISTORY OF THE WAR 

Such cases indicate the importance of being on one's guard 
lest catarrhal jaundice is not in reality disguising enteric fever. 

When jaundice occurs late in a case of enteric fever there is 
seldom any added difficulty of diagnosis owing to its presence. 
The jaundice appears without special symptoms, though, ex- 
ceptionally, these are suggestive of cholecystitis. Thus, in a 
case of paratyphoid B, during the fourth week, there were three 
rigors, jaundice appeared, and the region of the gall bladder 
became tender. Bacillus paratyphosus B was found in a stool, 
and the agglutination curve pointed to that organism. 

Pathology. 

The cause of the jaundice in these cases would seem to be 
some obstruction in the biliary tract. The symptoms are not 
usually severe or lasting enough for there to be any involvement 
of the smaller ducts within the liver, and are best explained by 
swelling of the papilla of Vater as part of a duodenal inflam- 
mation due to the localization of the infection in the duodenum. 
The localization of typhoid and paratyphoid infections, though 
showing a strong selectiveness for the ileum and colon, does not 
limit itself always to that part of the intestine, and the lesions 
may rarely be found not in the intestine at all, but in some 
other organ for example, abscess of the spleen. 

In a case which occurred in the Dardanelles, jaundice de- 
veloped on the third day and death occurred on the ninth day. 
The duodenum was found to be of a velvety appearance and 
the walls of the common bile duct and hepatic ducts showed 
acute inflammation. Paratyphosus B was recovered from the 
bile in the gall bladder. This was clearly an ascending 
inflammation from the duodenum. 

On the other hand, Brule argues that the classical explanation 
of the origin of jaundice namely, that there is a mechanical 
obstruction of the larger or smaller bile ducts, or of both is 
not wholly satisfactory in the light of modern investigations. 
He seeks to prove that in view of the infective origin of most 
cases of jaundice, excluding those caused by gross obstructions 
of bile ducts, the biliary retention must be due to a hepatitis 
rather than to angiocholitis, and that the derangement of 
secretion must occur in the liver cells themselves. His work as 
a whole throws some new light on the problems of hepatic 
disease. Holding that injury of the secretory cells of the liver 
is the usual cause of jaundice, he believes that jaundice caused 
by obstruction of the bile ducts is relatively uncommon. 

Jaundice associated with pylephlebitis may very rarely be 
caused by infection due to one of the enteric group of organisms, 
and one such case occurred in France. 



Archibald, Hadfield, 
Logan & Campbell 



Bassett-Smith 
Bietzke 

Brute 
Carpi 

Chambers . . 
Coles 



Cockayne 
Costa & Trosier 



Cristau 

Dawson & Hume . 



Dawson, Hume & 

Bedson 
Dawson . . % . 

Fiessinger 



Fraenkel 

Frugoni & Cannata 

Gamier & Reilly . . 



JAUNDICE 

BIBLIOGRAPHY. 

Reports of the M. & H. Labora- 
tories dealing with the diseases 
affecting the troops in the 
Dardanelles. 

A short laboratory study of 
Spivochcsta ictero-hcemorrhagics. 

Ueber die pathologische Anato- 
mie der anstechenden Gelb- 
sucht. 

Recherches re'centes sur les 
icteres. 

Osservazioni sulla spirochetosi 
itterogena. 

An outbreak of infectious Jaun- 
dice. 
Rat-Bite Fever 

A note on the occurrence of 

Spirochata HcBmovrhagics in 

the common rat in England. 
Catarrhal Jaundice, Sporadic & 

Epidemic (with full historical 

bibliography) . 
Mort du Lapin et Survie du 

Cobaye dans la Spiroche'tosa 

Icterohe'niorragique Exp6ri- 

mentale. 
Reactions Cytologiques et Chim- 

Iques du Liquide Cephalora- 

chidien dans la Spiroch6tosa 

Ict6roh6morragique. 
De la Dilatation Cardiaque Aigue 

dans la Spirochetosa Ict6ro- 

h^morragique. 
Note sur la Spiroch6tose a 

Lorient. 

Jaundice of Infective Origin . . 



Infective Jaundice (Spirochae- 

tosis Ictero-hasmorrhagica) . 
An Address on Spirochaetosis 

Ictero-haemorrhagica . 
A propos des Spirochetes du 

M6at et de 1'Urine de 1'Homme 

Normal. 
Icterus Infectiosus 



Ittero epidemico al campo da 
bacillo paratifo B. 

L'Ictere Infectieux a Spirochetes 



La Recherche du Spirochete 
Icte"rigene dans 1'Urine de 
l'Homme et du Cobaye. 



405 



Jl. of R.A.M.C.,1916, 
Vol. xxvi, p. 695. 



Parasitology, 1918- 
19. Vol.xi, p. 198. 

Berl. Klin. Woch., 
1916. Vol. liii, p. 
188. 

1919. 

Policlinico (Rome), 
1917. Vol. xxiv, 
Sez Prat., p. 949. 
Jl.ofR.A.M.C., 1917. 

Vol. xxix, p. 108. 
B.M.J., 1918. Vol. i, 

p. 275. 

Lancet, 1918. Vol. 
i, p. 468. 

Quart. Jl. of Med., 

1912-13. Vol. vi. 

p. 1. 
Compt. Rend, de la 

Soc. de Biol., 1917. 

Vol. Ixxx, p. 27. 

Ibid. 191 7. Vol. Ixxx, 
p. 29. 



Bull. Soc. M6d. des 
Hdp. de Paris, 1917. 
3 e S. Vol. xli, p. 638. 
Compt. Rend, de la 

Soc. de Biol., 1917. 

Vol. Ixxx, p. 778. 
Quart. Jl. of Med., 

1916-1917. Vol. x, 

p. 90. 
B.M.J., 1917. Vol. ii, 

p. 345. 
Lancet, 1918. Vol. i, 

p 503. 
Compt. Rend, de la 

Soc.de Biol., 1918. 

Vol. Ixxi, p. 38. 
Munch. Med. Woch., 

1917. Vol. Ixiv, p. 

846. 

La Sperimentale, 
Florence, 1916. Vol. 
Ixx. p. 25. 
Soc. M6d. des H6pit. 

de Paris, 1916. 3 e S. 

Vol. xl, p. 2249. 
Compt. Rend, de la 

Soc. de Biol, 1917. 

Vol. Ixxx, p. 38. 



406 



MEDICAL HISTORY OF THE WAR 



Garner & Reilly 



Gamier 
Gray 

Gunson & Gunn 
Gwyn & Ower 
Hart 

HartiU 
Hiibener& Reiter. 



Hurst 



Inada, Ido, Hoki, 
Kaneko & Ito. 

Ito & Matsuzaki . . 

Inada, Ido, Hoki, Ito 
& Wani. 

Kartulis 



McNee 
Martin 

Martin & Pettit 



BIBLIOGRAPHY cont. 

Action de la Bile sur la Virulence 

. de Spiroch&ta iclerohtsmor- 
thagicB. 

La Recherche des Substances 
Immunisantes chez les Con- 
valescents de Spirochetose 
Ictrigene. 

La Spirochetose Icterigene 

Le D6terminisme des Lesions 
H6patiques dans la Spiroche- 
tose Icterigene chez VHomme. 

La Transmission au Cobaye de 
1'Ictere Infectieux Primitif. 

Outbreak resembling Epidemic 
Catarrhal Jaundice in Eng- 
land. 

An Epidemic of Jaundice occur- 
ring at Alexandria. 

Infective Jaundice (Spirochae- 
tosis icterohaemorrhagica) . 

Ueber die Beziehungen des 
Ikterus Infektiosus. 

Epidemic Catarrhal Jaundice in 

England. 
Beitrage zur ^tiologie der 

weilischen Krankheit. 

Zur jEtiologie der weilischen 
Krankheit. 

Die .rfEtiologie der weilischen 

Krankheit. 
Epidemic Jaundice 



The ^Etiology, Mode of Infection 

and Specific Therapy of Weil's 

Disease. 
The Pure Cultivation of 

S. icterohamorrhagia . 
Intravenous Serotherapy of 

Weil's Disease. 

Contribution to Discussion on 
Cases of Jaundice in the Mili- 
tary Hospital at Alexandria. 

Spirochaetal Jaundice : Morbid 
Anatomy and Mechanism of 
Production of the Icterus. 

Concerning the Pathology and 
^Etiology of the Infectious 
Jaundice common at the Dar- 
denelles, 1915. 

Preparations Microscopiques et 
Pieces Anatomiques rela- 
tives a la Spirochetose Ictero- 
h6morragique. 



Ibid. 1917. Vol.lxxx, 
p. 41. 

Ibid. 1917. Vol.lxxx, 
p. 101. 



Paris M6d., 1917. 

Vol. xix, p. 176. 
Compt. Rend, de la 

Soc. de Biol., 1917. 

Vol. Ixxx, p. 733. 
Compt. Rend, de la 

Soc. de Biol., 1916. 

Vol. Ixxix, p. 928. 
Lancet, 1918. Vol. i, 

p. 503. 

Lancet, 1915. Vol. ii, 

p. 1294. 
Lancet, 1916. Vol. ii, 

pp. 518, 720. 
Munch. Med. Woch., 

1917, Vol. Ixiv, 

p. 1598. 
Lancet, 1918. Vol. i, 

p. 586. 
Deut. Med. Woch.. 

1915. Vol. xli, 
p. 1275. 

Deut. Med. Woch., 

1916. Vol. xlii, 
pp. 1, 131. 

Zeit. fur Hyg., 1916. 

Vol. Ixxxi, p. 171. 
Medical Diseases of 

the War, 1918. 

Chap, vi, p. 104. 
Jl. of Exper. Med., 

1916. Vol. xxiii, 

p. 377. 
Ibid. 19 16. Vol. xxiii, 

p. 557. 
Cbrr. f. Schweiz. 

Aertze,Basel,1917. 

xlvii, p. 65. 
B.M.J., 1916. Vol. i, 

p. 320. 

Jl. Path. Bact., 
1919-1920. Vol. 
xxiii, p. 342. 

B.M.J., 1917. Vol. i, 
p. 445. 



Compt. Rend, de la 
Soc. de Biol.,1916. 
Vol. Ixxix, p. 659. 



Martin & Pettit 



Martin, Pettit, & 
Vaudremer. 



Manine, Cristau & 
Plazy. 

Medical Research 
Committee. 



Monti 

Moreschi 

Moreschi & Carpi . . 

Nankivell & Sundell 

Patterson 
Pettit 

Plique 

Rimmer 
Ryle 



JAUNDICE 

BIBLIOGRAPHY cont. 

La Spiroch6tose Icterohemorr- 

agique. 
Trois Cas de Spirochetose Ict6ro- 

h6morragique en France. 

La Spirochetose Ict6roh6mor- 
ragique en France. 

A propos des Lesions Histolo- 
giques qui surviennent chez 
l'Homme au Cours de la Spiro- 
chetose Ict6roh6morragique. 

Presence du S. icterohcsmorrhagiea 
chez le Surmulot de I'lnt6- 
rieur. 

Coloration du Spirochte de 
I'lct6re H6morragique par les 
Methodes de Loffler et de Van 
Ermengen ; Presence de Cils. 

Sur les Propriet6s Agglutinantes 
et Immunisantes du Srum 
Sanguin chez les sujets 
atteints de Spirochetose 
Icterohemorragiqiae . 

La Spirochetose Icterohemor- 
ragique a Lorient. 

The Causation and Prevention 
of Tri-Nitro-Toluene (T.N.T.) 
Poisoning. 

T.N.T. Poisoning, and the Fate 
of T.N.T. in the Animal Body. 

Spirochetosi nei topi ed ittero 
epidemico. 



Appunti Epidemiologichi sulla 
Spirochetosi Itterogena. 

Osservazioni Cliniche e Speri- 
mentali sopra una Forma 
d' Ittero Infettivo Epidemico 
nelle Truppe Combattanti. 

On the Presence of a Spirochaete 
in the Urine of Cases of Trench 
Fever. 

Spirochaetes occurring in the 
Urine of Cases of P.U.O. 

Sur un Spirochete observ6 chez 
des Malades a l'H6pital Mari- 
time de Lorient. 

Traitement et Prophylaxis de la 
Spirochetose Icterohemor- 
ragique. 

A Case of Spirochaetosis Ictero- 
haemorrhagica. 

Spirochaetosis Icterohaemor- 
rhagica : A Clinical Analysis 
of Fifty-five Cases. 



407 



Bull. M6d., 1916. 

Vol. xxx, p. 558. 

Bull, de 1'Acad. de 

Med., 1916. Vol. 

Ixxvi, p. 247. 
LaPresseMed.,1916 

Vol. xxiv, p. 569 
Compt. Rend, de la 

Soc. deBiol.,1917. 

Vol. Ixxx, p. 640. 

Ibid. 1917. Vol. Ixxx, 
p. 574. 

Compt. Rend, de la 
Soc. de Biol.,1916. 
Vol. Ixxix, p. 1053. 

76^.1917. Vol. Ixxx, 
p. 949. 



Compt. Rend, de la 

Soc. deBiol.,1917. 

Vol. Ixxx, p. 531. 
Special Report 

Series. No. 11, 

Lond. 1917. p. 43. 
SpecialReport Series, 

No. 58, Lond., 

1921. p. 15. 
Policlinico (Rome) 

1917. (Sez. Pra- 

tica). Vol. xxiv, 

p. 962. 
Policlinico (Sez. Pra- 

tica), 1917. Vol. 

xxiv, p. 265. 
Policlinico (Sez. Pra~ 

tica), 1917. Vol. 

xxiv, p. 955. 

(quoted). 
Lancet, 1917. Vol. 

ii, p 672. 

B.M.J., 1917. Vol. ii, 

p. 418. 
Compt. Rend, de la 

Soc.deBiol., 1917. 

Vol. Ixxx, p. 774. 
Jl. de Med. et de 

Chirur., 1917. Vol. 

Ixxxviii, p. 514. 
B.M.J., 1917. Vol. i, 

p. 453. 
Quart. Jl. of Med., 

1920-21. Vol. xiv, 

p. 139. 



408 



MEDICAL HISTORY OF THE WAR 



Sarrailhe' & Clunet 

Stoddard 
Stokes & Ryle 

Stokes, Ryle & 
Tytler. 

Tooth & Pringle . . 
Uhlenhuth &Fromme 



Willcox 



Wilmaers & Renaux 



BIBLIOGRAPHY cont. 

La " Jaunisse des camps " et 
1'epidemie de paratyphoide 
des Dardanelles. 



The Occurrence of Spirochaetes 
in the Urine. 

A Note on Weil's Disease 
as it has occurred in the Army 
in Flanders. 

Weil's Disease (Spirochaetosis 
Ictero-haemorrhagica) in the 
British Army in Flanders. 

Jaundice among the British 
troops in North Italy. 

Experimentelle Untersuchungen 
iiber die sogenannte weilischen 
Krankheit. 

Weitere experimentelle Unter- 
suchungen iiber die soge- 
nannte weilischen Krankheit. 

Experimentelle Grand! agen fur 
eine specifische Behandlung 
der weilischen Krankheit. 

Zur ^Etiologie der sogenannte 
weilischen Krankheit. 

The Epidemic Jaundice of 
Campaigns. 

Lettsomian Lectures on Jaun- 
dice, with special reference to 
types occurring during the 
War. 

Quarante-sept cas de Spiro- 
che"tose Icterohemorragique. 



Jaundice due to Ascarides 



Bull, et Mem. de la 

Soc. M6d. des H6p. 

de Paris, 1916. 3 e . 

S. Vol. xl, pp. 

45 & 563. 
B.M.J., 1917. Vol. ii, 

p. 416. 
Ibid. 1916. Vol. ii, 

p. 413. 

Lancet, 1917. Vol. i, 
p. 142. 

Ibid. 1919. Vol. ii, 

p. 248. 
Med. Klinik.( Vienna) 

1915. Vol. xi, 
p. 1202. 

Ibid. 1915. Vol. xi, 
p. 1264. 

Ibid. 1915. Vol. xi, 
p. 1375. 

Berl. Klin. Woch., 

1916. Vol. liii, 
p. 269. 

B.M.J., 1916. Vol. i, 

p. 297. 
B.M.J., 1919. Vol. i, 

pp. 565, 605, 639, 

671, 706. 

Archives M6d. Bei- 
ges, 1917. 4*S. 
Vol. Ixx, pp. 115, 
207. 

Lancet, 1921. Vol. i, 
p. 86. 



CHAPTER XVIII. 

SCURVY. 

SCURVY is defined as a disorder of metabolism due to 
deficiency of a certain accessory food factor or vitamine 
present in fresh food such as vegetables, fruits and meat. 
It is characterized by great debility, anaemia, special changes 
in the gums and a tendency to haemorrhage. The history of 
scurvy during the war and the knowledge gained from a 
practical study of the disease in the various epidemics which 
occurred, together with the recent experimental study of the 
effect of diets which produce scurvy in animals, place it with 
certainty in the group of deficiency diseases. 

By far the greatest incidence of scurvy during the war 
occurred in Mesopotamia, where, in 1916, a very severe epi- 
demic occurred amongst the Indian troops. During the years 
1916, 1917 and 1918 the following number of admissions and 
deaths were recorded amongst them : 





Admissions. 


Deaths. 


1916. July 1st to December 31st 


11,455 


24 


1917. Jan. 1st to December 31st 


2,199 


6 


1918. Jan. 1st to November 30th 


825 


2 



A very large number of cases occurred in the first half of 
1916, but statistics of these are not available. 
The great incidence of scurvy is explained by three factors : 

(1) The ration scales of Indian troops which were in force 
until July 4th, 1916. 

(2) The system of rationing Indian troops in stations in 
India prior to 1917. Under this system the Indian soldier 
received a money allowance in lieu of rations, and he bought 
his food from the bunniah or food contractor of his unit. There 
was thus no guarantee that he consumed the equivalent of a 
service ration. As a consequence of this system a consider- 
able percentage of Indian troops arriving in Mesopotamia 
from India were anaemic, debilitated and suffering from 
pyorrhoea. With men in this condition the latent period for 
scurvy would be short were dietetic deficiencies imposed upon 
them. 

(3) The military situation in Mesopotamia up to March 
1917. 

409 



410 MEDICAL HISTORY OF THE WAR 

Until the occupation of Baghdad, on llth March, 1917, the 
troops in the fighting area were stationed in districts far from 
centres of native population, and local supplies of fresh vege- 
tables or fruit were unobtainable. At Basrah and Amara a 
certain amount of fresh vegetables and fruit was grown, but 
not in sufficient quantity to supply troops in the fighting area. 
It is interesting to note, however, that in Indian troops 
stationed at Basrah and Amara the scurvy incidence was 
very much less than amongst troops at the front, since 
antiscorbutic foods were available for them to some extent 
from native sources. 

Added to the absence of adequate local supplies of suitable 
foods there was great difficulty of transport. Between 
28th September, 1915, when the force had advanced to.Kut, 
and 23rd February, 1917, the front area of operations was 
some 300 miles by river from Basrah. During this period all 
supplies had to be sent by river transport, and owing to the 
intense heat during the summer months it was impossible to 
convey fresh vegetables and fruit to troops in the front area, 
since supplies of these articles, when sent, invariably arrived 
in a damaged condition and unfit for human consumption. 
There was not then available special river transport, such 
as refrigerating barges, for the conveyance of these perishable 
articles, so that there was a great deficiency, indeed almost 
a complete absence, of the food stuffs rich in anti- 
scorbutic vitamine in the rations issued to troops in the front 
area. 

As a consequence of this the experiment was perforce made 
of feeding a large number of troops on a dietary greatly 
deficient in the accessory food factor necessary for the pre- 
vention of scurvy. The result was a great outbreak of scurvy 
amongst the Indian troops, while British troops escaped. 
The explanation of the freedom of the British troops from 
scurvy is to be found in the much more liberal allowance 
of fresh meat which was obtainable from local sources. Certain 
classes of Indian troops, partly from their caste objection 
to meat and partly from inadequacy of supplies, obtained 
very little fresh meat during this period. Cases also occurred 
during the siege of Kut, when the besieged were in straits for 
food. Minor outbreaks occurred later, especially amongst 
labour detachments and Hindu non-meat eaters. In most 
cases they were attributed to insufficient disciplinary action 
being taken to ensure that the men consumed sufficient anti- 
scorbutic elements in their rations. Strict supervision was 
maintained by the medical services, and these minor outbreaks 
and their causes were at once brought to notice. 



SCURVY 411 

A number of cases of severe scurvy also occurred during 
the Dardanelles Campaign at Mudros amongst Indian soldiers 
who had been serving on the Gallipoli peninsula, and were 
attached to Indian Mountain Batteries operating there. The 
aetiological conditions were similar to those of Mesopotamia. 
A few cases were also seen in Turkish prisoners arriving at 
Mudros who had been captured at Gallipoli. 

In March 1915 three cases of scurvy in Indians were 
admitted to hospital in Marseilles ; two of them had been 
in France over five months, the third had arrived only a 
month previously. During April 1915 seven further cases 
were reported amongst Indian troops in the Marseilles area. 
All of them, except one, had been in France over six months, 
and no particular camp was affected, nor could any common 
factor be discovered. The daily dietary for Indian troops 
contained, as antiscorbutics, four ounces of fresh meat and 
two ounces of potatoes, and it seemed probable that the few 
cases affected had not consumed their full ration of meat 
and potatoes, and had not supplemented their rations by 
the purchase of fresh vegetables. 

In April 1915 a few cases of scurvy were reported amongst 
Indian troops in the Indian Corps attached to the 1st Army 
in France. The Director of Medical Services of the army 
then issued an order warning medical officers of the import- 
ance of early recognition of cases, and advising as regards 
dietetic prophylactic measures. No further cases were 
reported. 

In June 1918 special attention was paid to the occurrence 
of scurvy amongst the South African Native Labour Corps 
Contingent serving in France. A few cases had been reported 
as early as October 1917, but it was not until May 1918, that 
the cases occurred in sufficient number to attract attention. 
In May 1918, out of a strength of 6,795, 121 cases of scurvy 
were admitted to hospital and a slightly larger number in June 
1918. A special investigation was made by the Adviser in 
Pathology and the A.D.M.S. (Sanitation), as a result of which 
it was concluded that overcooking of the food and conse- 
quent destruction of the antiscorbutic principles was pro- 
bably the chief cause. It was also suggested that the flour 
meal supplied, which was different from the native meal to 
which the men had been accustomed, was a factor, but there 
was no proof of this. The dietetic measures adopted resulted 
in the speedy disappearance of scurvy amongst the contingent. 
In August 1915 twelve cases in British troops were reported from 
No. 24 Field Ambulance, 8th Division, as suffering from scor- 
butic symptoms. These were of a mild type and did not show 



412 MEDICAL HISTORY OF THE WAR 

the characteristic gum changes. Night blindness was a symp- 
tom in 10 of these cases, and some had ecchymoses. The 
symptoms of scurvy were somewhat indefinite, and other cases 
were not reported. 

Only four cases occurred amongst the British troops in 
North Russia in 1919. Three of them were admitted to 
hospital suffering from other diseases and developed symptoms 
of scurvy, appa