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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 : 

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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. 

.   0 

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  •  0  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/0 

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 


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PQ     s 


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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  37ears.  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«- 


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Chart  I. 


36 


MEDICAL  HISTORY  OF  THE  WAR 


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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. 


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38 


MEDICAL  HISTORY  OF  THE  WAR 


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ENTERIC  GROUP  OF  FEVERS 


39 


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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 

0 

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 


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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 

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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  very»acute  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  1917—1918. 


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  37°C.  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  50°C.  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  twro  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. 
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Force  (a  reply  to  G.  B. 
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1915-18. 

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Ranque,  Etude    bacteriologique       d'une 
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laire. 

Boehncke,  Hamburger  Untersuchungen  iiber  Ruhrimpf- 
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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. 


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1302-1308. 
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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 
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on  animals  and  men. 

Graham,  G.  .  .  .  .  Arthritis  in  Dysentery,  its  causa- 
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Graham,  D.  . .  .  .  Some  Points  in  the  Diagnosis 
and  Treatment  of  Dysentery 
occurring  in  the  British 
Salonika  Force. 

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atypique. 


Hollande  &  Fumey. 


Emploi  de  1'ovalbuminate  de 
soude  et  des  papiers  reactifs 
tournesoles  sucres  dans  la 
differentiation  des  bacilles 
dysent£riques ;  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., 
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Bull,  et  Mem.  Soc. 
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Geneesk.  Tijdschr. 
v.  Nederl.-Indie 
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Deut.   Med.    Woch., 

1916.  Vol.    xlii, 
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Wien.  Klin.  Woch., 
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624. 

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Proc.      Roy.      Soc. 

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pp.  23-42. 
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p.  51. 


Munch.  Med.  Woch., 
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1916.  Vol.  xxx, 
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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. 

3e    S.    Vol.   xxxi, 

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

Med.  des  H6pit.  de 

Paris,  1917.    3e  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.   3C  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, 

3«S.    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. 

3eS.    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.       3CS.    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,  3eS.  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,  3«S.   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 


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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 

0     •     >, 

rt 

rt 

rt 

8> 

05 

w 

g 

o 

0 

o 

Q 

0 

Q 

3 

0 

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,  1915—13^  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    12—21 

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         3—12 

10 

380 

38 

200 

119 

59-0% 

March        13—22 

10 

390 

39 

124 



March       23  —  April  1 

10 

366 

36 

— 

88 

30-5% 

April            2—1  1 

10 

184 

18 



63 

32-0% 

April          12—21 

10 

103 

10 

— 

45 

17-4% 

April         22  —  May   1 
.May             2—12 

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  103°F. 
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 


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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 


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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 


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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 

0 

3             6            9\           0 

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, 

3e  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,   3e   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 


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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 


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INFLUENZA 


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MEDICAL  HISTORY   OF  THE  WAR 


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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. 


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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 

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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  0  •  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*2°C.).  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  5-5°C.  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  «0 

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      1/50th 

Strychnine  sulphate      . .          . .       grain      1/50th 

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 


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Bull,   et  Mem.   Soc. 

Med.  des  H6pit.  de 

Paris,  1919.     3e  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.     3e  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.     3e  S. 

Vol.  xliii,  pp.  581- 

583. 
Bull,   et  Mem.   Soc. 

Med.  des  H6pit.  de 

Paris,  1919.     3e  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.    3e  S. 

Vol.  xl,  pp.    1530- 

1545. 
Bull,   et  Mem.   Soc. 

Med.  des  Hopit.  de 

Paris,  1916.     3e  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. 

Epid£miologie  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.) 

T3HLEB°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 


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PHLEBOTOMUS   FEVER 


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352 


MEDICAL   HISTORY   OF  THE   WAR 


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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  60°C.  moist  heat  for  thirty 
minutes  and  is  fully  virulent  after  such  treatment,  but  is 
killed  by  a  temperature  of  70°C.  moist  heat  for  thirty  minutes. 
Obviously,  therefore,  a  temperature  of  55°C.  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  •  0 

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  (AsH3)  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  0  •  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  0  ;  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  0  ;  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. 


**  VSflLtit1**  ^^  *  ** 

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  vx*"   '.«         .  /^  • 

•-• 


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. 


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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. 


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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. 

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Post-mortem,    pale 
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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 


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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. 
3eS.  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.  3eS. 

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 
Ict£rigene. 

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  Spiroch£te  de 
I'lct6re  H6morragique  par  les 
Methodes  de  Loffler  et  de  Van 
Ermengen  ;  Presence  de  Cils. 

Sur  les  Propriet6s  Agglutinantes 
et  Immunisantes  du  S£rum 
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.  3e. 

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,  apparently  as  a  result  of  several  months'  hospital  diet. 
Scurvy  amongst  British  troops  in  Russia  in  1919  may  there- 
fore be  regarded  as  practically  non-existent,  but  the  reason 
for  the  absence  of  this  disease  is  undoubtedly  due  to  the  careful 
prophylactic  measures  taken  in  the  light  of  recent  knowledge 
on  the  subject. 

In  February  1919  scurvy  was  first  diagnosed  amongst 
Russian  prisoners,  and  later  a  large  number  of  severe  cases 
occurred.  Captain  A.  J.  Stevenson,  who  investigated  this 
outbreak,  attributed  the  cause  to  vitamine  deficiency  in  the 
prison  dietary  and  to  over-cooking  of  the  food. 

The  average  period  between  the  commencement  of  the  prison 
diet  and  the  development  of  symptoms  was  somewhat  over 
four  and  a  half  months,  but  in  many  cases  which  had 
associated  diseases  the  prescorbutic  period  was  less  than  three 
months,  and  some  cases,  suffering  from  such  diseases  as  typhus 
or  enteric  group  disease,  developed  scurvy  in  conjunction  with 
these  diseases. 

A  large  number  of  cases  was  also  reported  from  Murmansk 
amongst  the  civil  population  in  March  1919,  and  measures 
were  taken  by  the  British  military  authorities  to  deal  with 
them  as  far  as  possible. 

Scurvy  occurred  only  to  a  slight  extent  amongst  native 
carriers  and  porters  attached  to  the  force  in  East  Africa. 
Very  few  cases  appear  to  have  occurred  amongst  the  troops. 
In  this  connection  the  following  extract  from  a  report  to  the 
War  Office  by  Surgeon-General  Pike  and  Lieut. -Colonel 
Andrew  Balfour,  who  had  been  specially  appointed  to  report 
on  medical  conditions  during  the  East  African  campaign,  is 
of  special  interest : — 

"  During  our  tour  of  inspection  only  one  case  of  genuine 
scurvy  was  seen,  and  such  evidence  as  is  available  does  not 
point  to  there  having  been  anything  like  an  outbreak  of  the 
disease.  Indeed,  it  would  seem  to  have  been  uncommon  even 
in  the  case  of  Indian  troops.  This  is  somewhat  remarkable, 
considering  the  shortages  in  food  and  the  lack  of  anti-scorbutic 
substances  in  the  Indian  dietary.  Doubtless  cases  have  been 
missed  or  not  reported,  but,  even  so,  it  is  strange  that  in  the 
non-meat-eating  units  at  least  scurvy  did  not  make  its  appear- 


SCURVY  413 

ance  to  any  extent.  The  disease  has  occurred  to  a  slight 
extent  amongst  the  carriers.  The  officer  commanding  Native 
Detail  Hospital,  Dar-es-Salaam,  informed  us  that  he  had  seen 
cases  amongst  porters  coming  from  the  Rufiji  line  at  a  time 
of  great  privation  and  suffering,  and  it  is  possible  that  there 
were  others  of  which  we  have  no  record,  for  scurvy  is  not  a 
disease  familiar  to  many  medical  officers  serving  in  this  country. 

"  A  full  and  careful  inquiry  into  the  matter  would  be  both 
interesting  and  instructive,  but  would  occupy  much  time 
and  would  have  to  be  carried  out  as  a  special  research.  The 
fact  that  there  has  usually  been  a  fresh  meat  ration  available 
probably  accounts  for  the  absence  of  scurvy  amongst  white 
troops.  An  inspection  of  some  Indian  troops  for  the  presence 
of  pyorrhoea  did  not  indicate  that  this  condition  was  common 
amongst  them." 

On  5th  June,  1917,  unexplained  ecchymoses  were  observed 
amongst  the  German  prisoners  of  war  on  the  island  of  Raasay 
in  Scotland,  and  on  6th  July,  1917,  the  diagnosis  of  scurvy 
was  established.  On  22nd  August,  1917,  Professor  Leonard 
Hill*  visited  the  Prisoners  of  War  Camp  and  made  a  thorough 
investigation  of  the  cause  of  the  outbreak.  It  appeared 
that  on  24th  April,  1917,  a  somewhat  restricted  ration 
scale  was  introduced  from  which  potatoes  were  excluded. 
From  this  date  also  the  purchase  of  food  by  the  prisoners  was 
forbidden  owing  to  the  food  shortage  throughout  the  country. 
Previously  the  men  had  been  in  the  habit  of  buying  from 
local  sources  bacon,  which  they  ate  raw,  and  also  other  articles 
of  food  were  purchased  with  the  money  earned  by  their  work, 
and  the  rations  thereby  supplemented.  The  onset  of  symp- 
toms of  scurvy  occurred  about  seven  weeks  after  the  restriction 
of  the  rations,  and  most  of  the  prisoners  affected  were  those 
doing  work  in  the  mines  which  was  of  a  somewhat  heavy 
character.  The  examination  of  the  diet  scales  showed  that, 
as  regards  protein,  fat  and  carbohydrates  value,  and  also  as 
regards  vitamine  content  and  calorie  value,  there  was  an 
adequate  allowance.  The  figures  corresponded  to  those  for 
the  ration  scales  of  English  civil  prisons,  and  were  equal  to 
those  of  the  German  army  ration  1916-1917.  The  values 
were  higher  than  those  of  German  munition  workers  and  of 
some  hostels  and  canteens  of  munition  workers  in  this  country. 
Professor  Hill  consequently  attributed  the  occurrence  of  scurvy 
in  the  camp  not  to  a  deficiency  of  the  rations,  but  to  the  method 
of  cooking  them,  which  consisted  in  stewing  the  meat  and 

*  Director  of  the  Department  of  Applied   Physiology,  Medical  Research 
'Committee. 


414  MEDICAL   HISTORY   OF  THE  WAR 

vegetables  at  about  100°  C.  for  the  long  period  of  five  hours, 
whereby  the  special  vit amines  would  be  destroyed.  An 
additional  allowance  of  potatoes  and  cabbage  was  made  to 
the  ration  scales,  and  precautions  were  taken  against  prolonged 
cooking,  following  which  the  outbreak  of  scurvy,  which  had 
not  been  severe  in  type,  very  rapidly  cleared  up. 

During  the  war  a  few  cases  of  scurvy  occurred  amongst 
the  civil  population  in  England  and  Scotland  in  1917,  in 
certain  of  the  large  centres  of  population  such  as  Manchester, 
Newcastle  and  Glasgow,  owing  probably  to  a  temporary 
shortage  of  fresh  vegetables,  especially  potatoes,  in  addition 
to  the  restricted  ration  of  fresh  meat. 

The  attention  paid  to  the  increased  production  of  potatoes 
throughout  the  country  was  followed  by  a  disappearance  of 
scurvy. 

JEtiology. 

It  has  been  conclusively  proved  that  the  essential  cause 
of  scurvy  is  the  continued  absence,  over  a  long  period,  of  an 
accessory  food  substance  or  vitamine  in  food  consumed. 

The  former  theories  that  scurvy  was  primarily  due  to  a 
deficiency  of  potassium  salts,  or  to  an  acid  intoxication,  or 
to  toxic  materials  in  the  foods  as  the  result  of  decomposition, 
or  to  a  specific  bacterial  infection  must,  in  the  light  of  recent 
knowledge,  be  abandoned. 

The  antiscorbutic  vitamine  is  contained  in  a  number  of 
fresh  foods — in  largest  amount  in  oranges,  lemons,  tomatoes 
and  fresh  green  vegetables,  in  considerable  amount  in  roots 
and  tubers  such  as  onions,  swedes,  turnips,  potatoes,  and 
in  small  quantities  in  fresh  meat  and  milk.  The  vitamine  is 
thermolabile  and  is  destroyed  by  prolonged  heating  such  as 
stewing.  Boiling  for  a  short  period  is  less  destructive  than 
prolonged  heating  at  a  slightly  lower  temperature  such  as 
occurs  in  stewing.  It  is  also  rapidly  destroyed  by  alkalies 
such  as  carbonate  of  soda,  which  should  not  be  used  in  the 
cooking  of  vegetables.  Desiccation  causes  destruction  of  the 
antiscorbutic  vitamine  so  that  it  is  absent  from  dried  food 
stuffs. 

Cabbage  cooked  for  one  hour  at  temperature  ranging  from 
80°  to  100°  C.  loses  about  90  per  cent,  of  its  original  anti- 
scorbutic value.  Heating  in  water  for  sixty  minutes  at  60°  C. 
or  for  twenty  minutes  at  90°  to  100°  C.  causes  similarly  a 
loss  of  about  80  per  cent. 

Freezing  reduces  the  amount  of  antiscorbutic  vitamine  so 
that  frozen  meat  contains  less  than  fresh  meat. 

The  history  of  scurvy  in  Mesopotamia  furnishes  a  good 
example  of  the  effect  of  a  dietary  deficient  in  antiscorbutic 


SCURVY 


415 


vitamine.  Up  to  4th  July,  1916,  the  rations  of  the  troops 
in  Mesopotamia  were  the  field  service  rations  given  in  Tables 
I  and  II  of  "  War  Establishments,  India,"  1916. 

TABLE  I. 


Field  Ration  of  British  Troops. 


Bread 
Fresh  meat 
Bacon 
Potatoes  . . 
Tea 


1  Ib. 
1  Ib. 
3  oz. 
1  Ib. 
1  oz. 


Sugar 
Salt 
Pepper 
Fuel 


Chocolate 
or  Bread 

Lime  Juice 
or  Sugar 

Rum 


Extras, 


1  oz. 
4oz. 
|oz. 
*oz. 
4oz. 


2Joz. 
ioz. 

7&OZ 

3  Ib. 


TABLE  II. 

Field  Ration  of  Indian  Troops  and  followers. 


Atta  . . 
Fresh  meat 
Dhall* 
Ghi    . . 
Gur    .  . 
Potatoes 
Tea    . 


Atta  . . 
Ghi  or  Gur 


Hlb. 
4oz. 

Ginger 
Chillies 

4  oz. 

Turmeric 

2oz. 

Garlic 

1  oz. 

Salt    .. 

2oz. 

Fuel  .  . 

ioz, 

Extras. 

£lb.  Rum 

1  oz.  Lime  Juice  and  sugar 


oz. 


ioz. 
ioz. 
Hlb. 


. .     2  oz. 
|  oz.of  each. 


It  is  seen  from  these  ration  scales  that  the  ration  of  the 
British  soldier  was  protective  against  scurvy,  while  the 
Indian  ration  was  very  greatly  deficient  in  antiscorbutic 
vitamine,  the  only  substances  containing  this  being  potatoes 
2  oz.,  and  fresh  meat  4  oz. 

As  mentioned  above,  owing  to  difficulties  of  transport, 
even  these  two  items  were  commonly  absent  from  the  ration 
actually  issued  to  Indian  troops  at  the  front.  The  result  was 
a  great  outbreak  of  scurvy  in  1916,  which  began  to  subside 
in  November  1916,  as  a  result  of  the  improved  rationing  of 
the  troops. 


*  Dhall  is  the  name  given  to  the  dried  whole  or  split  edible  seed  of  several 
varieties  of  Leguminosae  occurring  in  India.  It  has  formed  part  of  the  ration 
for  Indian  troops  and  is  liked  by  them.  It  is  equivalent  to  small  dry  lentils. 


416 


MEDICAL   HISTORY   OF   THE   WAR 


British  troops  were  immune  from  scurvy  in  Mesopotamia, 
the  few  isolated  cases  which  occurred  among  them  being  due 
to  a  restriction  of  dietary  made  necessary  by  some  other 
disease  occurring  in  the  individual  patient. 

The  importance  of  an  addition  of  antiscorbutic  articles  to 
the  Indian  ration  was  fully  realised  by  the  director  of  medical 
services,  who  strongly  represented  the  necessity  of  an  improve- 
ment as  regards  protection  against  scurvy.  On  July  4th, 
1916,  new  ration  scales  were  consequently  sanctioned  in  which 
the  addition  was  made  to  the  Indian  ration  of  the  antiscor- 
butics, fresh  fruit  2  oz.,  and  as  extras,  fresh  fruit  4  oz., 
fresh  vegetables  4  oz.,  fresh  meat  2  oz.,  tamarind  2  oz. 

The  revised  field  ration  of  Indian  troops  then  consisted  of 
the  following  articles  : — 


Atta  . .  l£lb.         Condensed  milk 

Fresh  meat  4  oz.          Tea    . . 

Dhall .  .  4  oz.  Ginger 

Ghi    . .  2  oz.          Chillies 

Gur    .  .  2  oz.  Turmeric 

Potatoes  2  oz.          Garlic 

Fresh  fruit  2  oz.  Salt    . . 

Tobacco  (weekly)  2  oz.  Fuel  . . 

Matches  (boxes,  weekly)  2 

(Substitutes  same  as  for  British  troops.) 

Extras. 


2oz. 

1-  OZ. 

oz. 
oz. 
oz. 
-k  oz. 
oz. 


Atta 

Ghi  1  oz.  or  Gur 

Fresh  meat'  . . 
Fresh  vegetables 


£lb.  Fresh  fruit    ..          ..  . .  4  oz. 

2  oz.  Tamarind     . .          . .  . .  2  oz. 

2  oz.  Rum    (25    per   cent,  under 

4  oz.  proof)     . .          . .  2  fl.  oz. 


In  August  1916  the  Medical  Advisory  Committee  appointed 
by  the  War  Office  visited  Mesopotamia.  The  occurrence  of 
scurvy  in  the  force  received  special  attention  and  investigation, 
and  on  31st  October,  1916,  the  ration  scales  were  further 
improved.  The  rations  for  Indian  troops  then  became  :— 


Daily. 

Atta  or  Rice  ...... 

Fresh  meat   .  .          .  . 

Gur     (when     fresh     meat 

not  obtainable)  .  . 

Dhall  ...... 

Gur    .  .          .  .          .  .          .  . 

Ghi     ........ 

Potatoes  or  fresh  vegetables 
Dried    vegetables     (when 

fresh  not  available)     .  . 
Fresh  fruit    .  .          .  .          .  . 

Tinned  fruit  2  oz.  or  dried 

fruit  1  oz.  (when  fresh 

fruit  not  available.) 
Tea    ........ 


6  oz. 

2  oz. 
4oz. 
2  oz. 
2  oz. 
6  oz. 

2  oz. 
2  oz. 


oz. 


Milk,  tinned ..          ..          ..  2  oz. 

Condiments  (ginger,  chillies, 

garlic,  turmeric)  . .  f  oz. 

Salt    . .          . .          .  .          .  .  J  oz. 

Tamarind  or  cocum             . .  2  oz. 

Fuel  (wood) 2  Ib. 

Thrice  weekly. 

Ghi  (Mondays,  Wednesdays, 

Fridays)    .  .          . .          . .      2  oz. 

Lime   juice    (Tuesdays, 
Thursdays  and  Saturdays, 
not  in  winter)        .  .          . .      \  fl.  oz. 

Weekly. 

Tobacco  (Sundays) .  .          . .     2  oz. 
or    cigarettes   No.  41    or 
sweets        .  .          . .  4  oz. 

Matches  (boxes)        .  .          . .     2 


SCURVY  417 

The  Indian  .ration  now  contained  as  protection  against 
scurvy  : — 

Potatoes  or  fresh  vegetables,  such  as  onions  . .  6  oz. 

Fresh  fruit  2  oz. 

Fresh  meat  6  oz. 

Tamarind  or  Cocum        . .         . .         . .         . .  2  oz. 

Lime  juice  (three  times  a  week)  . .          . .  |  oz. 

This  ration  proved  satisfactory,  but  the  great  difficulty  up 
to  March  1917  was  its  conveyance  to  the  troops. 

During  the  latter  part  of  1916,  owing  to  the  high  incidence 
of  scurvy  amongst  the  Indian  troops,  it  was  ordered  that  when 
there  was  a  shortage  of  vegetables  and  fruit  they  should  have 
the  first  call  on  the  issues  available. 

Towards  the  end  of  1916  the  transport  was  much  improved 
and  the  refrigerator  barges  which  arrived  with  cold  storage 
chambers  for  fresh  meat  were  of  great  value.  Also  special 
crates  were  devised  for  the  conveyance  of  fresh  vegetables 
and  fruit  up  river,  so  that  as  little  damage  as  possible  occurred 
in  transit. 

After  the  occupation  of  Baghdad,  local  supplies  of  fresh 
vegetables  and  fruit  and  meat  were  obtainable  in  abundance 
for  troops  in  the  front  area,  and  from  this  time  scurvy  almost 
disappeared  from  the  force.  The  few  cases  that  afterwards 
occurred  were  amongst  Indian  troops  in  distant  places  in  the 
desert  where  there  was,  for  some  special  reason,  difficulty  of 
transport  of  vegetables  and  fruit. 

Baghdad  and  the  area  around  it  was  a  fertile  source  of 
supply  of  vegetables  and  fruit  of  fine,  quality,  which  were 
grown  in  abundance  in  irrigated  areas  by  the  native  population. 
The  following  fruit  and  vegetables  were  obtainable : — 

Vegetables. 

A. — Summer  planting    commencing       B. — Winter  planting      commencing 

from  the  month  of  February.                  from  the  month  of  September. 

Onions.                       Tomatoes.  Cabbage.  Turnips. 

French  beans.           Cucumber.  Beans.  Radish. 

Haricot  beans.          Pumpkin.  Spinach.  Cauliflower. 

Brinjals.                     Melons.  Beetroot.  Lettuce. 

Lady's  finger.            Water  melons.  Carrots.  Purslane. 

Fresh  Fruits. 

A. — Fruit  produced  during  the  sum-  B. — Fruit  produced  during  the  winter 

mer  locally.  locally. 

Apricots.  Figs.  Oranges.  Limes. 

Apples.  Dates.  Tangerine  oranges.  Quince. 

Peaches.  Pears.  Sour  oranges.  Pomegranates. 

Plums.  Mulberries.  Lemons.  Citron. 

Grapes. 

It  will  be  seen  that  many  of  them  are  rich  in  antiscorbutic 
vitamine. 

(2396)  B  B 


418 


MEDICAL   HISTORY  OF  THE  WAR 


A  difficulty  with  which  the  military  authorities  had  to 
contend  in  protecting  troops  from  scurvy  was  the  danger  of 
intestinal  infection  from  the  eating  of  raw  vegetables  or  fruit. 
This  was  particularly  the  case  in  Mesopotamia  where  dysentery, 
enteric  group  disease  and  cholera  always  had  to  be  reckoned 
with.  Orders  were  issued  that  vegetables  or  fruits  with  an 
outer  skin  or  rind  should  be  washed  in  chlorinated  water 
before  consumption,  but  green  vegetables,  such  as  lettuce, 
were  to  be  cooked  rapidly,  as  the  risk  of  infection  from 
imperfect  washing  was  so  great. 

The  Mesopotamia  campaign  gave  additional  proof  that 
fresh  meat  has  important  antiscorbutic  value.  During  1916, 
when  the  troops  at  the  front,  both  British  and  Indian,  were 
unable  to  get  fresh  vegetables  or  fruit  for  long  periods,  the 
only  protection  that  the  British  had  over  the  Indians  was 
the  fresh  meat  allowance  of  1  Ib.  daily.  Usually  two  or 
three  issues  were  obtained  from  local  supplies  of  Arab  sheep  ; 


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CHART  I. — Showing  admission  rate  to  hospital  per  mille  of  Indian  strength. 
Upper  curve  =  1917.     Lower  curve  =  1918. 

on  other  days  tinned  beef  was  issued.  The  Indian  troops 
usually  had  only  one  or  two  rations  of  6  oz.  a  week.  On 
other  days,  owing  to  their  caste  prejudices,  tinned  meat  could 
not  be  issued. 

Further  evidence  of  the  value  of  fresh  meat  was  obtained 
by  investigations  carried  out  by  Major  Marjoribanks,  I.M.S., 
on  Indian  patients  suffering  from  scurvy,  in  1916,  at  Nos.  9 
and  10  Indian  General  Hospitals.  Two  parallel  groups  of 
scurvy  were  treated  on  identical  lines  as  regards  diet,  except 
that  one  group  was  given  a  daily  ration  of  fresh  meat  juice, 
with  the  result  that  they  improved  much  more  rapidly  than 
the  other  patients. 

The  climatic  condition  of  Mesopotamia  and  the  risk  of 
parasitic  infection  prohibited  the  general  use  of  raw  meat 
juice  in  the  treatment  and  prophylaxis  of  scurvy,  but  in  the 
treatment  of  cases  of  scurvy  in  hospital  the  beneficial  effect 
of  a  liberal  allowance  of  fresh  meat  was  very  striking. 


SCURVY  419 

The  ration  lime  juice  up  to  the  end  of  1916  had  no  anti- 
scorbutic value,  and  produced  no  beneficial  effect  on  patients 
suffering  from  scurvy.  It  usually  arrived  in  Mesopotamia 
after  a  long  journey  overseas,  and  was  probably  six  months 
or  more  old  before  issue.  In  August  1916,  on  Colonel 
Willcox's  suggestion,  fresh  lime  juice  was  prepared  in  India 
from  fresh  limes,  a  small  quantity  of  alcohol  (5  per  cent.)  and 
salicylic  acid  (2  grains  to  the  pint)  being  added  as  a  pre- 
servative. This  was  sent  to  Mesopotamia  in  special  casks, 
with  the  date  of  preparation  marked  on  it,  and  gave  better 
results  as  regards  antiscorbutic  properties  ;  it  was  used  in  the 
treatment  of  patients  suffering  from  scurvy  as  well  as  for  issue 
to  troops. 

Lime  juice  as  a  prophylactic  against  scurvy  is  of  uncertain 
value,  since  it  is  difficult  to  ensure  its  delivery  to  an  army  in 
the  field  within  three  months  of  its  preparation,  and  after  that 
time  much  of  its  antiscorbutic  value  is  lost.  Undoubtedly 
when  fresh  it  has  important  antiscorbutic  properties,  as  was 
demonstrated  on  many  occasions  in  patients  suffering  from 
scurvy.  After  the  occupation  of  Baghdad,  lime  juice  was 
prepared  from  limes  and  bitter  oranges  obtained  locally ; 
preservative  was  added  as  above  described.  It  was  issued 
to  the  troops  with  as  little  delay  as  possible.  Lemon  juice  is, 
however,  of  superior  value  to  lime  juice  as  an  antiscorbutic, 
according  to  the  recent  investigations  by  Miss  Chick  and 
Miss  Hume. 

In  a  paper  of  historical  interest  by  Miss  Alice  Henderson 
Smith  it  is  stated  that  "  lime  juice  "  was  introduced  as  a  ration 
for  the  British  Navy  in  1804,  but  that  up  to  1875  lemon  juice 
was  in  fact  issued  under  this  name.  Since  1875  the  "  lime 
juice  "  supplied  has  been  the  true  lime  juice  from  the  West 
Indies,  and  would  therefore  be  much  inferior  in  antiscorbutic 
value  to  lemon  juice.  On  this  point  control  experiments  were 
made  on  selected  cases  of  scurvy  in  Northern  Russia  in  1919, 
by  Captain  A.  J.  Stevenson,  who  found  that  the  addition  of 
4  oz.  of  lemon  juice  freshly  prepared  from  fresh  lemons  gave 
markedly  beneficial  results. 

The  antiscorbutic  value  of  the  Indian  dried  fruits,  tamarind, 
cocum  and  mango  has  recently  been  experimentally  investi- 
gated by  Chick,  Hume  and  Skelton.  From  the  results  of  their 
experiments  on  guinea  pigs  it  was  found  that  all  of  these  had 
a  definite  but  small  antiscorbutic  value,  greatly  inferior  to 
raw  cabbage,  swedes,  germinated  pulses,  orange  or  lemon 
juice,  but  equal  or  superior  to  that  of  carrot,  beetroot,  cooked 
potato,  or  raw  meat  juice.  Tamarind  was  taken  by  the 
Indian  troops  either  as  a  chutney  with  stewed  meat,  or  as 


420  MEDICAL  HISTORY   OF  THE   WAR 

an  infusion  with  sugar,  when  it  formed  a  palatable  acid  drink. 
Cocum  is  a  sort  of  dried  plum,  which  appeared  to  have  no 
antiscorbutic  value  on  man. 

The  discovery  of  the  value  of  germinated  lentils  (dhall) 
as  an  antiscorbutic  gives  to  forces  in  the  field,  where  no  fresh 
vegetables  or  fruit  are  available,  a  very  valuable  antiscorbutic 
prophylactic.  Unfortunately,  during  the  trying  periods  of 
1915  and  1916  in  Mesopotamia,  when  antiscorbutics  were  not 
available  for  the  troops  at  the  front,  this  was  not  known. 
After  May  1917  germinated  dhall  was  used  in  outlying  districts 
in  Mesopotamia  as  a  ration  when  fresh  vegetables  or  fruit 
could  not  be  supplied.  It  was  used  also  in  hospitals  for  the 
treatment  of  scurvy,  but  it  had  no  advantage  over  the  use 
of  fresh  fruit  and  vegetables,  and  was  less  palatable.  The 
great  value  of  germinated  dhall  is  that  it  can  be  used  as  a 
good  substitute  for  fresh  fruit  and  vegetables  when  these  are 
not  available  ;  it  is  not  meant  to  take  their  place.  Peas  or 
lentils  should  be  neither  milled  nor  decorticated.  They  should 
be  steeped  in  water  at  50°  or  60°  F.  for  twenty-four  hours, 
or  at  90°  F.  for  twelve  hours.  The  water  should  then  be 
drawn  off  and  the  seed  should  be  left  in  the  air,  but  kept 
moist  by  covering  with  wet  sacking  for  twenty-four  to 
forty-eight  hours,  when  they  will  have  visibly  begun  to 
sprout.  An  important  precaution  in  the  use  of  germinated 
lentils  is  the  avoidance  of  over-cooking ;  the  period  of 
cooking  should  not  exceed  thirty  minutes.* 

In  Northern  Russia,  Captain  A.  J.  Stevenson,  in  a  series 
of  controlled  experiments  on  scurvy  cases,  showed  very  good 
results  with  an  addition  to  the  dietary  of  8  oz.  daily  of  ger- 
minated peas  cooked  for  half  an  hour ;  the  improvement 
corresponded  to  that  obtained  with  4  oz.  of  fresh  lemon  juice. 
Germinated  beans  gave  slightly  inferior  results.  Germinated 
peas  and  beans  formed  part  of  the  ration  of  the  British  troops 
in  Northern  Russia  in  the  winter  season  1918-1919,  when 
fresh  foods  were  unobtainable,  and  this  no  doubt  explains 
their  immunity  from  scurvy  during  that  period. 

Fresh  milk  is  known  to  have  poor  antiscorbutic  properties. 
In  Northern  Russia,  Captain  Stevenson  tested  the  effect  of 

*  An  interesting  historical  fact  in  connection  with  the  use  of  germinating  peas 
in  the  treatment  of  scurvy  has  been  recorded  in  a  "  Retrospective  view  of 
Naval  Medical  Conditions,"  by  Sir  Robert  Hill,  the  Director-General  of  Medical 
Services  in  the  Admiralty,  read  at  the  War  Section  of  the  Royal  Society 
of  Medicine,  on  10th  November,  1919.  He  states  that  "  In  1807,  in  a  ship 
serving  on  the  East  Indies  Station,  the  surgeon  gave  his  scorbutic  patients 
'  green  peas  soaked  in  water  and  allowed  to  vegetate,'  with  excellent  results,  a 
method  which  is  interesting  in  view  of  recent  pronouncements  on  the  subject 
of  scurvy,  and  shows  how  often  throughout  the  ages  an  old  remedy  comes  to 
the  fore  again  in  its  turn." 


SCURVY  421 

milk  fermented  with  lactic  acid  organisms,  two  pints  daily 
being  given  as  an  addition  to  the  dietary  in  a  series  of  con- 
trolled dietetic  tests  on  scurvy  cases.  The  results  obtained 
were  good  and  corresponded  to  those  yielded  in  similar  groups 
of  cases  by  4  oz.  of  lemon  juice  and  8  oz.  of  germinated  peas. 

It  remains  to  be  proved  whether  lactic  acid  milk  is  actually 
rich  in  vitamine  or  acts  indirectly  by  preventing  harmful 
intestinal  bacterial  fermentation. 

With  regard  to  climate  as  affecting  the  incidence  of  scurvy, 
the  maximum  incidence  in  Mesopotamia  was  in  the  hot 
months  May,  June  and  July,  and  this  appeared  to  be  due 
chiefly  to  the  difficulty  of  getting  fresh  vegetables  at  that 
season.  In  Northern  Russia  scurvy  commonly  occurs  in  the 
late  winter  months  owing  to  the  difficulty  of  obtaining  fresh 
foods  during  the  cold  season. 

Mental  depression,  fatigue,  conditions  involving  hardship 
and  intercurrent  diseases  act  as  predisposing  causes.  Patients 
suffering  from  such  diseases  as  dysentery,  those  of  the  enteric 
group,  and  epidemic  jaundice,  which  required  careful  dieting, 
rapidly  developed  scurvy  unless  care  was  taken  that  anti- 
scorbutics formed  a  part  of  the  dietary.  It  was  remarkable 
how  quickly  scorbutic  symptoms  would  develop  in  Mesopo- 
tamia in  such  patients  on  a  dietary  devoid  of  antiscorbutics  ; 
patients  were  seen  to  develop  typical  scorbutic  gums  within 
six  weeks  of  admission  to  hospital.  It  became  a  rule, 
therefore,  to  add  to  the  diet  of  all  patients  in  hospital  a 
sufficiency  of  antiscorbutics  such  as  lemons,  limes  and  oranges. 

The  influence  of  race  shows  itself  indirectly  in  dietetic 
peculiarities.  Thus  in  Indians — where  the  individual  is  com- 
monly quite  satisfied  with  a  diet  consisting  mainly  of  flour  or 
rice,  with  sugar  and  condiments,  does  not  complain  if  only 
a  limited  allowance  of  fresh  vegetables  or  fruit  is  given  him, 
and  commonly  dislikes  meat — there  is  a  racial  predisposition 
to  scurvy.  But  race  has  no  influence  if  the  dietary  is  adequate 
as  regards  vitamine  content. 

The  knowledge  of  scurvy  has  been  placed  on  a  sure  founda- 
tion by  the  experimental  work  on  animals  during  the  last 
few  years.* 

By  means  of  experimental  dieting  the  vitamine  content  of 
a  large  number  of  foodstuffs  has  been  carefully  tested  on 
guinea  pigs  and  other  animals  and  their  approximate  value 
determined. 


*  Much  of  this  work  has  been  done  at  the  Lister  Institute  in  London,  and 
an  important  paper  was  read  at  the  Society  of  Tropical  Medicine  and  Hygiene, 
16th  February,  1917,  by  Miss  H.  Chick  and  Miss  M.  Hume. 


422  MEDICAL  HISTORY   OF   THE   WAR 

Lieut-Colonel  R.  McCarrison,  I. M.S.,  has  shown,  from  a 
number  of  animal  experiments,  the  wide-reaching  effects  of 
a  vitamine  deficiency  diet.  Changes  occur  in  many  of  the 
most  important  organs  of  the  body  and  disordered  endocrine 
function  results.  Thus  a  scurvy-producing  diet  caused  in 
guinea  pigs  an  enlargement  of  the  suprarenal  glands  due 
to  haemorrhagic  infiltration  and  cellular  disintegration  of  the 
cortex  and  medulla. 

Morbid  Anatomy. 

Externally  in  white-skinned  subjects  purpuric  rashes  and 
skin  haemorrhages  are  usually  present  and  also  oedema. 
Characteristic  changes  in  the  gums  are  usually  present. 
Haemorrhages  occur  in  the  muscles  and  tissues  generally,  and 
are  commonly  seen  on  the  serous  membranes  of  the  internal 
organs.  Sanguineous  effusions  are  common  in  the  pleura, 
peritoneal  cavity,  and  joints,  and  under  the  periosteum  of  the 
bones.  These  consist  of  altered  blood  which  may  have  undergone 
partial  clotting  or  even  organization  into  fibrous  tissue.  The 
heart  muscle  shows  degenerative  changes,  brown  atrophy  often 
occurring.  Degenerative  changes  occur  in  the  liver,  kidneys 
and  other  organs.  It  is  probable  that  in  human  scurvy, 
haemorrhagic  swelling  and  degeneration  of  the  suprarenal 
glands,  and  a  general  thinning  and  atrophy  of  the  whole 
intestinal  tract  occur,  such  as  has  been  found  in  experimental 
work  on  monkeys  by  McCarrison.  These  signs  do  not  appear 
yet  to  have  been  specially  described. 

Symptoms. 

With  regard  to  the  incubation  period,  while  it  is  not  possible 
to  give  any  definite  period,  it  is  known  that  the  deficiency 
in  the  diet  may  exist  for  from  four  to  eight  months  before 
symptoms  appear. 

The  symptoms  in  individual  cases  vary  much  in  severity 
and  may  conveniently  be  classified  into  three  groups. 

Group  1. — Mild,  show  slight  gum  changes,  anaemia,  debility, 
and  possibly  skin  haemorrhages. 

Group  2. — Of  moderate  severity,  show  marked  gum  changes, 
haemorrhages  into  skin,  palate,  and  possibly  into  muscles. 
Anaemia  and  debility  are  more  marked. 

Group  3. — Severe,  show  marked  gum  changes  and  haemor- 
rhages into  palate,  skin,  muscles,  joints  or  periosteum  ;  the  con- 
stitutional symptoms,  anaemia,  debility  and  cardiac  weakness, 
are  severe. 

Early  symptoms  are  anaemia,  weakness,  sore  and  bleeding 
gums,  pains  in  the  legs,  and  in  white  races  skin  rashes  of  a 


SCURVY  423 

purpuric  type.  It  is  important  to  remember  that  while  skin 
changes  such  as  purpuric  rashes,  earthy  colour,  and  discolora- 
tion are  very  common  in  white  races,  in  Indians  and  dark- 
skinned  races  these  signs  cannot  usually  be  detected. 

Dr.  H.  Wiltshire  has  called  attention  to  hyperkeratosis  of 
the  hair  follicles  as  a  very  early  sign.  This  sign,  however, 
may  occur  in  other  diseases  associated  with  malnutrition. 

A  hyperplastic  condition  of  the  gums  with  a  tendency  to 
haemorrhage  on  pressure  is  a  very  common  early  sign.  The 
gum  tends  to  project  in  the  spaces  between  the  teeth,  forming 
characteristic  red  buds  ;  this  change  is  often  seen  best  on 
the  buccal  aspect.  Later,  marked  swelling  of  the  gums  occurs 
owing  to  haemorrhagic  exudation,  and  the  appearance  may 
be  that  of  a  fungating  haemorrhagic  swelling,  resembling  a 
new  growth.  As  was  seen  in  many  of  the  Mesopotamian 
cases,  ulceration  and  sepsis  may  occur  at  this  stage,  the  con- 
dition of  the  mouth  being  very  offensive.  Gum  changes 
occur  in  about  90  per  cent,  of  cases,  but  they  may  be  absent 
even  in  severe  cases.  Captain  Sheppard  observed  in  some  of 
the  very  early  cases  of  scurvy  that  the  gums  often  showed 
a  rolled  edge,  running  across  which  fine  parallel  clawlike 
striations  might  be  seen,  and  he  was  of  opinion  that  this  sign 
was  never  due  to  pyorrhoea. 

Pyorrhoea  is  often  present  and  is  likely  to  result  as  a  secondary 
condition  of  the  scorbutic  changes. 

Palate  changes  are  of  frequent  occurrence  and  are  of 
important  diagnostic  value,  especially  in  Indians.  The  palate 
is  pale,  and  small  petechial  haemorrhages,  or  sometimes  patches 
of  a  larger  size  are  seen  on  the  hard  or  soft  palate  or  on  the 
pillars  of  the  fauces.  Dark  crimson  or  purplish  patches  of 
discoloration  are  commonly  seen  extending  upwards  from  the 
gums  of  the  molar  teeth  on  the  inner  aspect  of  the  mouth. 
The  petechial  patches  may  become  brown  when  old.  It  is 
important,  however,  in  Indians  to  distinguish  haemorrhagic 
pigmentation  from  the  natural  pigmentation  which  may  be 
present  on  the  mucous  membrane  of  the  mouth  or 
tongue. 

The  skin  is  dry,  rough,  and  may  be  pigmented  or  of  an  earthy 
colour  in  white  races.  Small  petechial  haemorrhages  are  very 
common  in  white  races  round  the  hair  follicles  of  the  legs  and 
may  occur  in  other  parts  of  the  body.  They  were  observed 
in  some  Indian  cases,  but  were  difficult  to  detect.  Other 
scattered  petechiae  may  occur  on  the  skin.  Subcutaneous 
haemorrhages  occur  as  irregular  purplish  patches,  especially 
in  exposed  parts,  and  undergo  the  usual  changes  in  colour. 
They  are  not  apparent  in  Indians. 


424  MEDICAL  HISTORY   OF   THE   WAR 

Muscle  haemorrhages  frequently  occur  in  the  calf  and  thigh 
muscles,  and  form  a  hard,  brawny  swelling,  hot  to  the  touch 
and  tender  on  pressure.  The  swelling  usually  occurs  in  the 
calf,  round  the  popliteal  space  or  in  the  anterior  tibial  region. 
Any  of  the  muscles  of  the  body  may,  however,  be  affected, 
but  haemorrhages  usually  occur  in  the  groups  of  muscles 
most  used,  such  as  the  leg  muscles  in  infantrymen  and  the 
adductors  of  the  thighs  in  cavalrymen. 

Scorbutic  oedema  sometimes  occurs  in  the  legs  or  feet  and 
around  the  tendo  Achillis.  It  is  of  a  firm,  brawny  type,  quite 
different  from  cardiac  or  renal  dropsy.  It  can  best  be  detected 
around  the  ankles  by  viewing  the  patient  from  behind,  when 
he  is  standing.  (Edema  of  a  cardiac  type  may,  of  course, 
occur  in  scurvy  when  there  is  marked  secondary  cardiac 
weakness. 

Joint  sweJ lings  due  to  haemorrhagic  effusion  sometimes 
occur.  In  North  Russia  contractures  were  common.  They 
were  due  to  involvement  of  the  muscles  round  the  joint. 

Subperiosteal  haemorrhages  may  occur  as  hard,  tender 
swellings,  usually  on  the  tibia  or  ulna. 

Subconjunctival  haemorrhages,  haemorrhage  from  the  bowel, 
haemorrhagic  pleural  effusion  and  haemorrhagic  peritoneal 
effusion  occasionally  occur. 

The  blood  shows  the  features  of  a  secondary  anaemia.  An 
average  count  of  50  cases  reported  by  Captain  Stevenson 
from  North  Russia  was  : — 


Large  lymphocytes  . .  20% 
Small  lymphocytes 

Eosinophiles         . .  . .  4% 

Mononuclears       . .  .  .  2% 


Red  cells 4,080,000 

Haemoglobin         . .          .  .  55% 

Colour  index         ..          ..  0-68 

White  cells            ..          ..  7,510 

Polymorphonuclears       . .  45% 

Coagulation  time  did  not  appear  to  be  much  affected  ;  10 
cases  in  North  Russia  gave  an  average  of  3-5  minutes. 

Alkalinity  was  tested  in  a  few  cases  in  Mesopotamia,  and 
a  few  in  North  Russia.  The  alkalinity  was  somewhat  dimin- 
ished, but  the  observations  made  were  not  sufficient  to  draw 
definite  conclusions  as  to  the  extent  of  the  diminution. 

Dyspnoea  on  exertion  is  often  present,  and  sometimes 
giddiness.  The  severe  cases  show  cardiac  dilatation  with 
rapid  pulse  and  usually  systolic  murmurs. 

Haematuria  was  observed  in  4  per  cent,  of  a  series  of  50 
cases  in  North  Russia  and  albuminuria  in  6  per  cent. 

Night  blindness  occurred  in  7-4  per  cent,  of  a  series  of  200 
marked  cases  in  North  Russia.  This  symptom  was  present 
in  the  indefinite  cases  of  scurvy  referred  to  above  as  occurring 
in  No.  24  Field  Ambulance  in  France,  in  August  1915. 


SCURVY  425 

Healing  of  sores  on  the  skin  is  retarded  and  ulcers  of  an 
indolent  nature  sometimes  occur. 

The  progress  in  severe  cases  is  slow  even  when  under  special 
treatment.  A  few  cases  may  show  pyrexia,  due,  no  doubt,  to 
intercurrent  sepsis.  Occasionally  the  muscle  haemorrhages 
suppurate  and  require  surgical  treatment.  Diarrhoea  is  a  not 
uncommon  complication.  Septic  pneumonia  is  an  occasional 
complication  of  the  very  severe  cases.  The  mortality  in  scurvy 
was  low,  being  only  0-21  per  cent  in  11,440  cases  in 
Mesopotamia  in  1916.* 

Prognosis. 

Mild  cases  will  completely  recover,  after  appropriate  treat- 
ment, in  a  few  weeks. 

Cases  of  moderate  severity  will  recover  after  appropriate 
treatment,  but  a  period  of  a  few  months  is  required  before  the 
patient  is  fit  for  active  military  duty. 

Severe  cases  require  a  long  period  of  treatment  before 
restoration  to  a  fair  degree  of  health  occurs.  In  young  patients 
several  months  will  be  required  before  they  are  fit  for  military 
duty.  In  men  over  35  recovery  to  a  moderate  degree  of  health 
should  occur,  but  these  patients  are  not  likely  to  become  fit 
for  active  military  duty,  and  permanent  invaliding  from  the 
army  is  indicated. 

Diagnosis. 

Diagnosis  should  usually  present  no  difficulty,  but  it  should 
be  remembered  that  gum  changes  are  not  always  present  in 
scurvy.  Pyorrhoea  is  one  of  the  commonest  errors  in 
diagnosis,  and  is  a  very  common  disease  in  soldiers.  It  can 
be  distinguished  from  scurvy  by  the  retraction  of  the  gums 
from  the  interspaces  between  the  teeth,  whereas  in  scurvy  the 
gum  enlarges  and  extends  in  the  form  of  red  buds  between 
the  teeth.  Purpura,  due  to  other  causes  such  as  rheumatism, 
drugs,  various  infections  and  blood  diseases,  must  be  carefully 
distinguished.  Anaemia  with  cardiac  dilatation  and  purpura, 
such  as  is  sometimes  seen  in  malaria,  is  distinguished  by  the 
temperature  record,  enlargement  of  the  spleen  and  liver,  and 
blood  manifestations  characteristic  of  malaria.  Famine  oedema 
must  also  be  distinguished. f 

Several  instances  of  malingering  occurred  in  Mesopotamia. 
Thus,  artificial  oedema  of  the  leg  was  induced  by  the  tying  of 
a  string  or  puttee  round  the  limb  near  the  knee,  the  mark  of 

*  The  symptoms  of  and  mortality  from  scurvy  observed  amongst  some 
thousands  of  cases  in  Port  Arthur  after  its  capitulation  in  January,  1905,  are 
of  interest  in  connection  with  the  symptoms  recorded  in  Mesopotamia.  (See 
Report  No.  15  of  the  Medical  and  Sanitary  Reports  of  the  Russo-Japanese  War.) 

|  See  Chapter  xx. 


426  MEDICAL  HISTORY   OF  THE  WAR 

the  ligature  being  obvious.  Swelling  around  joints  was 
artificially  produced  by  the  insertion  beneath  the  skin  around 
the  knee  of  a  thread  which  had  been  soaked  in  some 
irritant.  Corrosion  of  the  gums,  which  had  been  caused  by  the 
application  of  cresol  or  other  corrosive  fluid,  was  seen  and 
readily  distinguished  from  scurvy  by  the  white  slough  over 
the  affected  area  and  the  presence  of  a  similar  mark  on  the 
opposed  mucous  membrane  of  the  mouth. 

Treatment. 

Treatment  should  be  directed  on  the  following  lines  : — 

(1)  Rest  in  bed  in  the  moderate  and  severe  cases,  and  an 

ample  supply  of  fresh  air  with  cheerful  surroundings. 

(2)  Special  dieting,  giving  a  maximum  amount  of  foods 

rich  in  vitamine  so  far  as   is  consistent  with  the 
patient's  digestion. 

(3)  Local  treatment  of  the  mouth,  or  other  parts  affected 

if  necessary. 

(4)  General  treatment  to  improve  the  blood  condition. 

(5)  Treatment  to  improve  the  mental  state,  such  as  occupa- 

tion and  mild  exercise  in  the  open  air,  when  the 
patient's  condition  admits  of  this. 

The  course  of  treatment  adopted  in  the  Special  Scurvy 
Hospital  for  Indian  patients  at  Baghdad  was  as  follows  : — 

Rest  in  bed  was  essential  as  long  as  the  anaemia  or  cardiac 
dilatation  persisted  ;  also  the  presence  of  muscle  haemorrhage, 
oedema,  periosteal  or  joint  haemorrhages,  or  other  severe 
haemorrhagic  symptoms,  demanded  complete  rest  in  bed.  A 
solution  of  J  per  cent,  salicylic  acid  in  alcohol  was  applied  to  the 
gums  twice  daily.  A  mouth-wash  of  alum  and  carbolic  acid 
was  used  frequently ;  also  dental  treatment,  such  as  scraping 
the  teeth  to  remove  tartar  and  extraction  of  carious  teeth,  was 
carried  out.  A  mixture  of  iron  and  arsenic  in  addition  to  the 
other  measures  was  administered  when  anaemia  was  present. 

The  diet  table  was  : — 

6  a.m.     Tea  and  biscuits  and  2  oz.  fruit. 
8  a.m.     |  oz.  fresh  lime  or  orange  juice. 

10.30  a.m.     Chappatie  or  rice  with  8  oz.  vegetables  and 

two  pints  fresh  milk. 
12  noon.     f  oz.  fresh  lime  juice. 
2  p.m.     10  oz.  fresh  fruit. 

7  p.m.     Meat  14  oz.,  vegetables  8  oz. 

Tomatoes,  cucumbers  and  onions  were  given  raw ;  other 
vegetables  were  boiled  for  twenty  minutes. 


SCURVY  427 

One  of  the  most  effectual  remedies  for  scurvy  is  a  salad  made 
by  cutting  raw  potatoes  into  very  fine  slices,  and  adding  slices 
of  onion  and  a  little  vinegar.* 

Physical  exercises  were  given  for  twenty  minutes  twice  a 
day  to  those  patients  who  were  sufficiently  well. 

In  a  few  isolated  cases  the  muscle  haemorrhages  suppurated 
and  required  surgical  treatment  such  as  incision.  The  cases  of 
scorbutic  haemothorax  required  treatment  by  aspiration. 

In  North  Russia  treatment  on  the  above  lines  was  carried 
out,  the  diet  being  accommodated  as  far  as  possible  to  the 
national  habits  of  the  patients.  Reference  has  been  made  to 
the  excellent  results  given  on  a  series  of  eight  cases  by  the  daily 
addition  of  two  pints  of  lactic  acid  milk  to  the  dietary.  The 
percentage  increase  of  weight  exceeded  that  obtained  by  the 
use  of  the  other  special  antiscorbutics,  such  as  lemon  juice, 
germinated  peas,  germinated  beans  and  fresh  meat. 

With  regard  to  preventive  measures,  a  suitable  selection  of 
the  items  in  the  ration  scale,  so  that  the  dietary  contains  an 
ample  supply  of  the  accessory  food  factor  or  vitamine,  is  the 
essential  measure  of  prophylaxis.  Due  precautions  must  be 
taken  that  the  food  is  not  over-cooked. 

An  important  measure  where  scurvy  is  occurring  in  epidemic 
form  is  the  establishment  of  special  hospitals  for  treatment  of 
cases,  with  a  special  medical  officer  in  charge.  By  the  main- 
tenance of  a  register  of  all  the  cases  and  a  record  of  all  details 
in  each  case,  the  occurrence  of  scurvy  in  any  unit  is  at  once 
recognized,  and  special  preventive  measures  can  be  adopted 
without  delay.  Also  accuracy  of  diagnosis  and  suitable  special 
treatment  are  ensured.  In  Mesopotamia  the  Director  of 
Medical  Services  established  this  procedure  in  Baghdad, 
Basrah  and  Amara,  in  June  1917,  and  its  adoption  gave  most 
satisfactory  results. 

A  convalescent  camp  for  cases  of  early  scurvy  was  established 
in  the  7th  Divisional  area  on  the  Mesopotamian  front  in  October 
1916.  Captain  A.  L.  Sheppard,  I. M.S.,  was  in  command  of  this, 
and  notes  by  him  on  the  early  diagnosis  of  scurvy  were  circu- 
lated throughout  the  division  by  the  Assistant  Director  of 
Medical  Services.  The  object  of  the  scurvy  camp  was  to  pro- 
vide cases  of  early  scurvy  with  a  suitable  dietary  which  would 
enable  them  to  return  to  duty  at  the  shortest  period.  In  the 
very  early  cases  success  was  achieved,  but  cases  showing  marked 
scorbutic  symptoms,  such  as  oedema  or  muscle  haemorrhages, 
were  found  to  improve  so  slowly  as  to  need  evacuation. 

*  At  Colonel  Willcox's  suggestion  this  was  tested  in  1916  on  cases  in  the  scurvy 
camp  at  the  front  area  by  Captain  A.  L.  Sheppard,  I. M.S.  He  found  that  it 
gave  a  better  result  than  any  of  the  antiscorbutics  he  was  then  using. 


428 


MEDICAL   HISTORY    OF   THE   WAR 


Since  the  rationing  of  troops  or  of  a  civil  population  is 
carried  out  usually  by  men  who  do  not  possess  special  medical 
knowledge,  education  in  the  scientific  principles  which  form  the 
basis  of  a  sound  dietary  is  of  the  utmost  importance.  For  this 
purpose  official  memoranda  on  scurvy  and  beri-beri  were 
circulated  in  Mesopotamia,  not  only  to  all  the  medical  units, 
but  to  the  commanding  officers  of  all  combatant  units  in  the 
force.  This  education  of  the  fighting  forces  in  the  principles  of 
rationing  as  regards  protection  from  the  deficiency  diseases 
proved  of  great  value. 


BIBLIOGRAPHY. 

Barber  . .  . .  Report  of  Medical  Meeting  at 
Kut-el-Amara. 

Chick  &  Hume  .  .  Discussion  on  the  Treatment  and 
Management  of  Diseases  due 
to  dietetic  deficiencies. 

,,  „  .  .      The    distribution    among   food- 

stuffs, especially  those  suitable 
for  the  rationing  of  armies,  of 
the  substances  required  for  the 
prevention  of  Beri-beri  and 
Scurvy. 

Chick,  Hume  &  Skelton  The  antiscorbutic  value  of 
some  Indian  dried  fruits  :  (a) 
Tamarind,  (b)  Cocum,  and  (c) 
Mango  (Amchur). 

Fiirst  . .          .  .     Weitere  Beitrage  zur  Aetiologie 

des  Experimentellen  Skorbuts 
des  Meerschweinchens. 

Greig  . .     The    "  sprouting   capacity  "    of 

grains  issued  as  rations  to 
troops. 

Hehir  . .          .  .      Scurvy  (during  the  siege  of  Kut) . 


Korbsch 


McCarrison  . . 


Macpherson . . 
Maynard 
Pickard  &  Lloyd 


Ueber  Skorbut  im  Felde 


Pathogenesis       of       Deficiency 
Disease. 

The  Influence  of  deficiency    of 

Accessory  Food    Factors    on 

the  Intestine. 
The  effects  of  a  Scorbutic  Diet  on 

the  Adrenal  Glands. 
Russo-Japanese    War,    Medical 

and  Sanitary  Reports,  Report 

No.  15. 
Food  Deficiency  states  in  African 

Natives. 

The     early     manifestations     of 
Scurvy. 


B.M.J.,  1917.      Vol. 

i,  p.  26. 
Proc.  Roy.  Soc.  Med., 

1919-1920.       Vol. 

xiii.  Sect.  Therap., 

p.  25. 
Trans.  Soc.  of  Trop. 

Med.    and     Hyg., 

1916-17.     Vol.  x, 

p.  141. 


Lancet,  1919. 
ii,  p.  322. 


Vol. 


Zeitschrift  f.  Hy- 
giene, 1912.  Vol. 
Ixxii,  p.  121. 

Ind.  Jl.  of  Med.  Res., 
1916-17.  Vol.  iv, 
p.  818. 

Ind.  Jl.  of  Med.  Res., 
1919.  Special  Con- 
gress Number,  p.  79 

Deut.  Med.  Woch., 
1919.  Vol.  xlv,  p. 
185. 

Ind.  Jl.  of  Med  Res., 
1918-1919.  Vol.vi, 
p.  275. 

B.M.J.,  1919.  Vol.ii, 
p.  36. 


B.M.J.,  1919. 

ii,  p.  200. 
1908. 


Vol- 


Med.  Jl.  of  S.  Africa, 
1918.  Vol.  xiv,  p. 
271. 

Proc.  Roy.  Soc.  Med- 
1920.  Vol.  xiii, 
No.  6  (Section  of 
Med.)  p.  43. 


Sheppard 

Smith 

Stevenson 

Wassermann 

Weill   &  Mouriquand 

Willcox 
Wiltshire 


SCURVY 

BIBLIOGRAPHY— cont. 
Scurvy  in  Zhob,  Baluchistan 


A  Historical  enquiry  into  the 
efficiency  of  lime-juice  for  the 
prevention  and  cure  of  Scurvy 

Notes  on  the  Etiology  of  an  Out- 
break of  Scurvy  in  N.  Russia 
with  an  experiment  in  Test 
Dieting. 

Das  Verhalten  des  Blutes  beim 
Skorbut. 

Sur  le  moment  d'apparition  de 
la  substance  antiscorbutique 
et  sur  les  accidents  provoques 
chez  les  cobayes  par  les  grains 
d'orge  aux  differents  stades 
de  leurs  germinations. 

The  Treatment  and  Management 
of  Diseases  due  to  deficiency 
of  diet. 


Hyperkeratosis  of  the  Hair  Fol- 
licles in  Scurvy. 
Mesopotamia  Commission  Report 


429 


Ind.  Jl.  of  Med.  Res., 

1916-17.     Vol.  iv, 

p.  340. 
Jl.  of  R.A.M.C.,1919, 

Vol.  xxxii,  pp.  93, 

188. 
Jl.of  R.A.M.C.,  1920, 

Vol.  xxxv,  p.  218, 


Folia  Haematologica, 
1918.      Vol.  xxiii, 

C.R.  Soc.  Biol.,  1919. 
Vol.  Ixxxii,  p.  184. 


B.M.J.,    1920;    Vol. 

i,  p.  73.  Proc.  Roy. 

Soc.  of  Med.,  1919- 

20.  Vol.  xiii.  Sect. 

Therap.,  p.  7. 
Lancet,  1919.      Vol. 

ii,  p.  564. 
1917.    p.  71. 


CHAPTER  XIX. 

BERI-BERI. 

BERI-BERI   is  defined  as  a  disease  primarily  due  to  the 
deficiency  of  a  certain  accessory  food  factor  or  vitamine 
in  the  food  consumed  over  a  long  period,  and  characterized 
by  multiple  neuritis,  oedema,  cardiac  weakness  and  muscular 
atrophy.* 

No  large  outbreak  of  beri-beri  occurred  during  the  war,  due 
no  doubt  to  the  preventive  measures  adopted  in  the  light  of 
recent  knowledge  of  its  causation.  The  disease  has  long  been 
recognized  as  endemic  in  Japan,  China,  the  Malay  Peninsula 
and  the  East  Indies,  including  the  Philippine  Islands,  Java  and 
the  Dutch  Indies.  The  Persian  Gulf  has  been  well  known  as 
an  endemic  centre  from  the  frequent  occurrence  of  cases 
amongst  men  long  stationed  there.  Isolated  epidemics  have 
occurred  in  England,  Ireland,  America  and  various  parts  of  the 
world. 

During  the  war,  limited  outbreaks  of  beri-beri  occurred  in 
men  from  all  parts  of  the  world  where  the  disease  is  endemic, 
in  Chinese  labour  corps,  in  Indian  labour  corps  and  in  Chinese 
sailors.  In  the  last  three  months  of  1915  a  few  cases  of  beri- 
beri occurred  amongst  British  troops  at  Gallipoli  and  at  Mudros. 
The  primary  cause  was  considered  to  be  vitamine  deficiency, 
and  predisposing  causes  were  the  conditions  of  hardship  in- 
separable from  the  campaign,  and  in  many  of  the  cases  the 
influence  of  intercurrent  disease.  No  general  outbreak  of  beri- 
beri occurred,  however,  and  individual  variations  in  dietary 
due  to  some  accidental  cause  could  be  traced  in  many  of  the 
cases.  The  campaign  was  not  of  sufficiently  long  duration 
to  put  the  rations  to  a  severe  test  as  regards  their  vitamine 
sufficiency. 

Beri-beri  cases  also  occurred  in  Mesopotamia  in  British 
troops.  Indian  troops  were  practically  free  from  the  disease, 
the  reason  of  which  will  be  explained  in  considering  the  ration 
scales  for  the  force.  The  admissions  and  deaths  from  this 
disease  amongst  British  troops  in  Mesopotamia  were  :— 

Admissions.  Deaths. 

6th  November,  1914,to  28th  February,  1916  325  Not  recorded. 

1st  July  to  31st  December  ..       1916  104  3 

1917  84  0 

1918  51  6 

"  The  word  "  beri-beri  "  is  said  to  be  derived  from  a  Cingalese  term  meaning 
"  I  cannot,"  expressive  of  the  marked  muscular  weakness  usually  present. 

430 


BERI-BERI  431 

The  figures  given  up  to  28th  February,  1916,  are  those 
obtained  from  hospital  records,  but  as  accurate  statistics  are 
not  available  during  this  period,  it  is  likely  that  the  actual 
number  of  cases  was  considerably  in  excess  of  this  figure. 
Records  of  the  number  of  deaths  are  not  available.  The  cases 
occurring  during  this  period  were  of  a  severe  type.* 

The  cases  occurring  after  1st  July,  1916,  were  of  a  mild  type, 
as  is  evidenced  by  the  small  number  of  deaths.  Also  in  the 
British  cases,  during  this  period,  vitamine  deficiency  was  not 
the  sole  aetiological  factor. 

The  occurrence  of  beri-beri  in  Mesopotamia  in  British  troops 
in  considerable  numbers,  up  to  July  1916,  is  to  be  explained 
by  the  vitamine  deficiency  of  their  rations,  as  will  be  described 
later. 

In  December  1916  an  outbreak  of  beri-beri  occurred  in  a 
battalion  stationed  at  Shaiba  in  Mesopotamia.  Sixty  cases 
were  reported  up  to  24th  December,  1916,  and  no  deaths 
occurred.  The  epidemic  was  investigated  by  the  consulting 
physicians  to  the  force,  Colonel  W.  H.  Willcox,  A. M.S.,  and 
Lieut.-Colonel  H.  G.  Melville,  I. M.S.  Clinically  the  cases  were 
of  a  mild  type,  but  the  majority,  80  per  cent.,  showed  cardiac 
dilatation,  and  some  symptoms  of  early  multiple  neuritis  were 
present  in  all.  The  knee  jerks  were  present  in  75  per  cent,  of 
the  cases,  and  some  weakness  of  the  legs  was  a  common  early 
symptom  ;  a  few  cases  showed  anaesthesia.  Slight  cedema 
over  the  shins  and  ankles  occurred  in  30  per  cent,  of  the  cases, 
but  quickly  disappeared  with  rest  in  bed.  Under  appropriate 
treatment  many  of  the  cases  improved  rapidly  and  were  able 
to  return  to  duty  after  a  few  weeks  in  hospital.  The  battalion 
had  been  encamped  at  Shaiba  since  15th  July,  1916,  and  the 
period  before  development  of  the  early  symptoms  was  between 
four  and  five  months. 

Evidence  of  vitamine  deficiency  was  found.  There  was  over- 
cooking owing  to  the  hardness  of  the  Shaiba  water.  The  cook- 
ing of  vegetables  was  stated  by  the  cook  in  charge  to  require 
five  hours,  and  this  was  the  time  allowed  for  the  preparation  of 
the  stews  for  the  men.  Also,  owing  to  the  hardness  of  the  water, 
lentils  could  not  be  cooked,  and  were  in  consequence  discarded 
from  the  ration.  The  oatmeal  supplied  to  the  battalion  was 
badly  contaminated  with  weevils  and  could  not  be  issued  as  a 
ration.  Marmite,  a  form  of  germinating  yeast,  the  use  of 

*  An  account  was  also  published  in  the  British  Medical  Journal,  6th  January, 
1917,  of  a  medical  meeting  held  at  Kut  on  1st  April,  1916,  during  the  time 
that  troops  were  besieged  and  on  very  short  rations,  when  a  clinical  demon- 
stration of  twenty-six  cases  was  given  by  Captain  E.  G.  S.  Cane,  R.A.M.C. 
These  cases  were  quite  typical  in  their  symptoms  and  were  all  severe. 


432  MEDICAL   HISTORY   OF  THE   WAR 

which  is  described  below,  had  only  been  issued  on  four  occasions, 
and  then  had  been  added  to  the  stews  and  probably  cooked  for 
too  long  a  time.  The  bread  issued  to  the  battalion  was  made 
from  British  flour  from  which  the  germ  and  aleurone  layer  of 
the  grain  were  absent. 

In  addition  to  the  vitamine  deficiency  factor,  other  toxic 
causes  were  found  amongst  many  of  those  affected.  53*5  per 
cent,  of  the  cases  had  a  history  of  malaria,  of  which  20  per  cent, 
had  attacks  of  malaria  while  in  hospital,  the  parasites  being 
found  in  their  blood.  In  two  cases  there  was  a  history  of  recent 
jaundice,  and  a  few  gave  a  history  of  dysentery. 

The  consulting  physicians  consequently  recommended  a 
supply  of  Euphrates  water  for  drinking  and  cooking,  the  daily 
issue  of  marmite,  the  issue  of  bread  made  with  flour  containing 
33  J  per  cent,  of  atta,  an  issue  of  dhall  thrice  weekly,  and  the 
avoidance  of  undue  exertion  on  the  part  of  the  troops,  since 
fatigue  appeared  to  be  a  predisposing  factor  in  some  of  the 
cases.  No  further  cases  of  beri-beri  occurred  in  the  battalion 
at  Shaiba  after  the  adoption  of  these  measures. 

The  outbreak  at  Shaiba  was  also  investigated  by  the  War 
Office  Advisory  Committee  during  their  visit  to  Mesopotamia 
at  the  end  of  1916,  and  on  their  advice  special  bacteriological 
examinations  were  carried  out  by  Major  W.  H.  Stevenson. 

The  cases  in  the  above  outbreak  were  of  a  much  milder 
type  than  those  which  occurred  in  the  Mesopotamian  force 
previous  to  1st  July,  1916,  and  in  many  of  them,  as  stated, 
some  toxic  factor  such  as  malaria  was  an  additional  aetiological 
factor. 

It  is  interesting  to  record  that  in  December  1917  a  slight 
outbreak  of  similar  cases,  nine  in  number,  occurred  in  the  same, 
battalion,  which  had  been  moved  from  Shaiba  to  Nasiriyeh 
in  April  1917.  Major  W.  H.  Stevenson,  I. M.S.,  made  a 
careful  investigation  of  these  cases  and  reported  that  there 
was  no  evidence  of  vitamine  deficiency.  He  considered  that 
these  cases  were  due  to  some  infective  cause,  and  found  that 
dysentery  and  tonsillitis  had  been  present  in  this  battalion  to 
a  much  greater  extent  than  in  other  units  in  the  area.  He 
regarded  the  cases  as  toxic  multiple  neuritis,  and  not  beri-beri. 

Amongst  Asiatics,  beri-beri  was  almost  confined  to  Chinese. 
A  very  severe  outbreak  occurred  amongst  the  men  of  a 
Chinese  porter  corps  from  Singapore  during  the  months  of 
April  to  August  1917.  This  corps  arrived  in  Basrah  in  two 
drafts,  the  first  in  January  and  the  second  in  April.  Cases 
occurred  in  both  drafts  while  on  the  voyage,  and  some  were 
landed  in  Bombay.  Beri-beri  became  very  severe  in  the 
beginning  of  April,  and  in  the  succeeding  three  months  over 


BERI-BERI 


433 


500  cases  were  admitted  to  hospital  from  the  unit.  The 
corps  became  quite  unfit  for  work,  and  the  small  number 
eventually  left  had  to  be  repatriated.  The  Chinese  of  the 
porter  corps  were  on  a  special  diet  composed  as  follows  :— 

Weekly  Issue. 


Daily  Issue. 

Rice    .  .           .                 28  oz. 

Sunday 

Meat 

. 

12   „ 

Vermicelli 

, 

4   „ 

Monday 

Cooking  oil 

. 

2   „ 

Salted  eggs 

£  each. 

Tuesday 

Salt     .  . 

1  oz. 

Pepper 

A      M 

Wednesday 

Vinegar 

. 

T^Pt- 

Sauce 

lox. 

Thursday 

Garlic 

. 

2    „ 

Ground-nuts 

1    „ 

Friday 

Chinese  greer 

peas  . 

H  » 

Tea     .. 

i  „ 

Saturday 

Sugar    ' 

4  " 

•ly  1 

Pickled  vegetables 
Sardines 

Pickled  vegetables 
Salt  pork 
Dried  potatoes  . . 
Dried  fish 
Pickled  vegetables 
Sardines 

Pickled  vegetables 
Salt  fish 

Dried  vegetables 
Sardines 

Pickled  vegetables 
Dried  fish 


oz. 
4 
3 
4 
3 
3 
3 
4 
3 
4 
3 
3 
3 
4 
3 

The  rice  was  "  Siam  rice/'  which  had  been  brought  from 
Singapore  by  the  corps.  It  was  husked  and  polished  rice, 
which  in  Singapore  had  been  looked  upon  as  a  suspicious 
beri-beri  producer.  The  Chinese  preferred  a  rice  of  this  sort, 
and  considered  any  other  grade  of  rice  containing  proportions 
of  husk  and  pericarp  to  be  an  inferior  issue.  As  a  result  of 
an  enquiry  into  the  outbreak,  a  new  scale  of  diet  was  drawn 
up  for  the  Chinese  composed  as  follows  : — 

Bread  (made  with  25  per  cent,  atta)  . .          . .  12  oz. 

Rice 12   „ 

Fresh  meat 12   „ 

Vegetables         4   „ 

Dhall 4 

Fresh  potatoes  . .          . .          . .          . .          . .       4 

Salt  fish 3 

Tea         1 

Sugar 2 

Cooking  oil        .  .          . .          .  .          .  .          . .  1£ 

Marmite  .  .          . .          . .          . .          . .          . .       | 

The  rice  supplied  was  the  ordinary  variety  issued  to  Indian 
troops.  Fresh  fish  was  supplied  when  available.  Beri-beri 
was  well  established  before  the  introduction  of  the  new  diet, 
and  no  immediate  successful  result  was  obtained  by  its  use 
on  the  porter  corps.  Very  few  cases  of  beri-beri  occurred 
amongst  Indians,  and  of  the  cases  occurring  amongst  Chinese 
after  the  departure  of  the  Chinese  porter  corps  most  were 
in  Chinese  employed  by  the  Inland  Water  Transport  depart- 
ment. In  all,  31  deaths  from  this  cause  occurred  during  the 
period,  giving  a  case  mortality  of  5-4  per  cent. 

The  Chinese  were,  however,  very  obstinate  in  their  prejudice 
in  favour  of  polished  rice,  and  the  director  of  medical  services 
brought  the  facts  to  notice  with  a  view  to  disciplinary  action 
in  certain  cases. 


(2396) 


CC 


434  MEDICAL  HISTORY  OF  THE  WAR 

Several  cases  were  observed  amongst  Chinese  sailors  on 
ships  arriving  at  Basrah.  The  cause  was  an  obvious  vitamine 
deficiency  in  the  dietary.  Lieut-Colonel  C.  A.  Sprawson,  who 
was  consulting  physician  at  Basrah,  made  a  special  investigation 
into  the  cases  reported  as  beri-beri  during  the  later  period  of 
the  campaign.  He  concluded  that  the  cases  occurring  on  ships 
in  Mesopotamia  were  entirely  due  to  vitamine  deficiency,  that 
the  cases  occurring  amongst  the  Chinese  labour  corps  in 
Mesopotamia  were  due  to  a  vitamine  deficiency  pre-existing 
before  arrival  in  the  country,  and  accentuated  by  fatigue  and 
other  predisposing  factors,  while  the  British  cases  occurring  in 
the  later  stages  of  the  campaign  he  regarded  as  due  to  some 
infective  cause  and  not  to  vitamine  deficiency. 

In  some  of  the  Indian  labour  corps  attached  to  the  3rd 
Army  in  France,  an  outbreak  of  beri-beri  was  recorded  in 
January  1918.  The  epidemic  was  investigated  by  the 
A.D.M.S.  Sanitation,  France,  and  the  cases,  though  typical 
of  the  disease  as  regards  their  symptoms,  were  of  a  mild  type. 
The.  outbreak  was  due  to  the  main  portion  of  the  ration  being 
of  polished  rice,  the  unpolished  variety,  though  ordered, 
having  been  unobtainable.  The  vitamine  deficiency  was 
remedied  by  the  substitution  of  1  Ib.  of  atta  for  1  Ib.  of  the 
2  Ibs.  allowed  of  rice,  and  an  addition  of  1  oz.  of  dhall  to  the 
daily  ration. 

In  May  1917,  a  number  of  cases  were  reported  at  Noyelles 
amongst  Chinese  labourers  who  had  recently  arrived  in  France. 
An  investigation  showed  that  the  disease  had  developed 
during  the  voyage,  and  was  undoubtedly  due  to  a  vitamine 
deficiency  in  the  rations  received  on  board  ship,  polished  rice 
having  been  given  during  this  period. 

The  cases  were  quite  typical  as  regards  their  clinical 
symptoms,  and  quickly  improved  under  suitable  dietary  in 
hospital.  On  arrival  in  France  the  rations  for  the  Chinese 
labour  corps  were  carefully  adjusted  as  regards  vitamine 
content  and  further  cases  of  beri-beri  did  not  occur  amongst 
them. 

Twenty-four  cases  reported  as  beri-beri  were  transferred  from 
Indian  transports  on  arrival  at  Marseilles  on  25th  September, 
1914.  Nineteen  of  the  cases  were  from  two  British  battalions, 
which  were  stationed  at  the  same  cantonment  in  India  and  had 
encamped  together  on  mobilization,  and  later  travelled  to 
Europe  on  the  same  transport.  The  remaining  five  cases  were 
from  another.  British  battalion.  They  arrived  at  Marseilles 
after  a  long  voyage  broken  by  a  short  stay  in  Egypt.  The 
men  stated  that  they  had  suffered  from  the  heat  on  the 
voyage,  that  the  troop  decks  were  very  crowded,  and  that 


BERI-BERI  435 

at  night  the  air  was  stifling.  The  food  had  been  good  through- 
out, with  the  exception  of  the  bread,  which  was  described  as 
doughy.  The  aetiology  of  these  cases  as  regards  vitamine 
deficiency  appeared  obscure,  and  they  were  probably  cases  of 
multiple  neuritis  of  toxic  origin. 

During  the  war  cases  of  beri-beri  were  reported  from  time 
to  time  at  various  ports  amongst  Chinese  and  Lascar  sailors. 
These  were  due  to  a  vitamine  deficiency  of  the  ship  rations, 
polished  rice  usually  being  trie  offending  article  in  the  dietary. 

In  the  campaign  in  German  East  Africa,  some  cases  of 
apparently  typical  wet  beri-beri  and  instances  of  peripheral 
neuritis  were  found  in  the  hospital  carrier  "  Morogoro  "  and 
in  other  carrier  units.  The  Seychelles  porters  repatriated 
from  Kilwa  early  in  1917  developed  a  severe  form  of  the 
disease  between  Kilindini  and  Port  Louis,  and  they  appear 
to  have  exhibited  symptoms  of  it  when  proceeding  by  sea  from 
Kilindini. 

Mtiology. 

It  has  been  conclusively  proved  that  the  essential  cause 
of  beri-beri  is  the  continued  absence,  over  a  long  period,  of 
an  accessory  food  substance  or  vitamine  in  the  food  consumed. 
It  has  at  various  times  been  supposed  that  the  disease  was 
primarily  due  to  chemical  poisoning,  such  as  chronic  arsenical 
poisoning,  chronic  oxalic  acid  poisoning,  or  poisoning  from 
toxic  products  in  certain  types  of  food  such  as  fish  and  rice ; 
to  deficiency  of  protein,  fat,  combined  phosphorus,  or  cholesterin 
in  the  dietary  ;  or  to  infective  causes  such  as  some  animal 
parasite  of  the  protozoal  group,  some  worm  such  as  Ankylos- 
tomum  duodenale,  or  to  some  vegetable  parasite  such  as  a 
specific  coccus,  bacillus  or  fungus.  These  theories  must  in 
the  light  of  recent  knowledge  be  abandoned. 

Infective  causes,  however,  in  the  absence  of  vitamine 
deficiency,  while  not  causing  beri-beri,  may  give  rise  id  an 
illness  associated  with  multiple  neuritis,  cardiac  weakness  and 
dropsy,  and  the  clinical  picture  is  then  indistinguishable  from 
beri-beri.  Cases  of  this  type  should  be  regarded  as  multiple 
neuritis  due  to  the  particular  infection  concerned.  Where 
there  is  deficiency  in  the  dietary  of  vitamine  and  an  infective 
element  is  superadded,  for  example,  jaundice,  diarrhoea  or 
malaria,  the  latter  acts  as  a  strong  predisposing  cause  to  an 
illness  presenting  all  the  characters  of  beri-beri.  Examples 
of  this  were  seen  in  some  of  the  Dardanelles  cases  and  also 
in  some  of  the  cases  in  the  Shaiba  epidemic  in  Mesopotamia. 

Outbreaks  of  beri-beri  have  undoubtedly  varied  as 
regards  their  aetiological  factors.  Thus  those  due  to  a  dietary 


436 


MEDICAL  HISTORY   OF  THE  WAR 


consisting  mainly  of  polished  rice  may  have  as  the  sole  cause 
vitamine  deficiency,  while  other  outbreaks  have  been  described 
where,  in  addition  to  a  vitamine  deficiency,  some  other  toxic 
influence  was  at  work. 

The  beii-beri  preventive  vitamine  appears  to  be  identical  with 
the  "  water  soluble  B  "  factor  first  described  by  McCollum  and 
Davis.  A  large  number  of  attempts  have  been  made  to 
obtain  this  accessory  food  factor  in  a  pure  condition,  but 
success  has  not  been  yet  achieved. 


Fig.  1. — Diagram  of  a  longitudinal  section  through  a  grain  of  wheat,  showing  : 
B — Pericarp,  forming  the  branny  envelope.  A — Aleurone  layer  of 
cells  forming  the  outer-most  layer  of  the  endosperm  removed  with 
the  pericarp  during  milling.  E — Parenchymatous  cells  of  the 
endosperm.  G — Embryo  or  germ. 

This  vitamine  is  much  more  stable  than  the  anti- 
scorbutic vitamine.  The  former  withstands  desiccation  for 
long  periods  of  time,  and  its  resistance  to  heat  is  considerable, 
the  contrast  being  very  marked  in  these  respects.  Thus, 
heating  for  two  hours  at  100°  C.  causes  only  slight  loss  of  the 
anti-beri-beri  vitamine,  but  temperatures  much  above  100°  C., 
such  as  those  approaching  120°  G.,  result  in  a  rapid  destruction. 


BERI-BERI 


437 


The  baking  of  bread  or  biscuit,  during  which  process  the 
interior  of  the  material  does  not  rise  above  100°  C.,  therefore 
causes  no  serious  diminution  in  anti-beri-beri  vitamine.  On 
the  other  hand,  the  canning  of  food  stuffs  involves  frequently 
a  much  higher  temperature  than  100°,  so  that  tinned  foods 
of  all  descriptions  may  usually  be  regarded  as  vitamine-free. 


Fig.  IA. — Cross-section  through  the  branny  envelope  and  outer  portion  of 
the  endosperm  of  wheat  grain,  showing :  P — the  pericarp ;  E — endo- 
sperm, consisting  of  a,  layer  of  aleurone  cells  and  p,  parenchymatous 
cells. 


(J      \J 


Fig.  2 — Showing  the  various  stages  in  milling  of  the  rice  grain.  I. — Rice 
grain  in  the  natural  condition,  retaining  the  husk  or  enclosing 
glumes.  II. — After  removal  of  the  husk,  but  retaining  the  pericarp 
or  "silver-skin,"  and  the  embryo,  which  is  shaded.  III. — After 
milling  and  polishing;  both  "silver-skin"  and  embryo  are  removed, 
and  the  grains  are  then  "polished"  by  rubbing  with  taic  between 
sheepskins. 


438  MEDICAL  HISTORY  OF  THE  WAR 

The  anti-beri-beri  accessory  factor  is  fairly  widespread 
amongst  natural  foodstuffs,  and  during  recent  years  much 
experimental  work  has  been  done  by  Cooper,  Chick,  Hume 
and  others,  in  order  to  determine  the  approximate  quantitative 
distribution  of  the  protective  factor.  It  is  found  chiefly  in 
plant  seeds  and  in  the  eggs  of  birds.  The  most  important 
source,  from  the  practical  point  of  view  of  drawing  up  scales 
of  rations,  is  cereals.  It  has  been  found  that  the  vitamine 
is  differently  distributed  in  different  parts  of  the  grain  or 
seed.  The  largest  proportion  exists  in  the  embryo  or  germ, 
and  next  in  order  is  the  bran  (pericarp  and  aleurone  layer), 
while  the  endosperm,  or  starch-containing  portion  (for  example 
white  wheaten  flour  or  polished  rice),  is  greatly  deficient 
in  the  vitamine.  There  is  no  doubt  that  this  differentiation 
holds  amongst  all  cereals,  though  the  experimental  work 
has  dealt  mainly  with  rice  and  wheat.  It  is  illustrated  in  the 
accompanying  diagrams  (Figs.  1,  IA  and  2). 

Yeast,  eggs,  the  various  pulses,  such  as  peas,  beans  and 
lentils,  are  rich  in  the  vitamine,  Heart  muscle,  liver,  brain 
and  kidneys  contain  a  fair  proportion,  while  milk  and  the 
muscle-fibre  of  meat  are  comparatively  deficient. 

The  history  of  beri-beri  in  the  Mesopotamian  expeditionary 
force  up  to  1st  July,  1916,  furnishes  an  excellent  example  of  its 
causation  by  the  absence  of  the  essential  vitamine  in  the 
dietary.  The  Indian  troops  received  throughout  the  campaign 
a  daily  ration  of  atta*  1 J  lb.,  and  dhall  4  oz.,  both  of  which 
are  rich  in  anti-beri-beri  vitamine.  In  spite  of  the  hardships  to 
which  they  were  subjected  they  remained  free  from  beri-beri. 
The  British  troops,  from  the  commencement  of  the  campaign 
on  6th  November,  1914,  up  to  4th  July,  1916,  received  rations 
according  to  the  scale  of  field  service  rations  given  in  War 
Establishments,  India,  1916. | 

The  bread  or  its  substitute,  biscuits,  issued  to  British  troops 
during  this  period  was  made  from  white  flour  from  which  the 
wheat  germ  and  pericarp  and  aleurone  layer  had  been  removed  ; 
it  therefore  contained  practically  no  anti-beri-beri  vitamine. 
The  small  amount  of  the  protective  factor  present  in  fresh 
meat  and  potatoes  would  probably  be  sufficient  to  prevent 
the  occurrence  of  beri-beri.  But  owing  to  the  exigencies  of 
the  campaign  up  to  1916,  fresh  meat  and  potatoes  were  often 
unobtainable  for  long  periods,  and  the  main  articles  of  the 
dietary  of  the  British  soldier  in  the  front  area  were  then 
tinned  meat  and  biscuits,  both  of  which  lack  the  necessary 

*  A  wheat  flour  prepared  in  India,  containing  the  germ  and  aleurone  layer 
of  the  grain,  part  of  the  bran  or  pericarp  having  been  removed, 
f  See  Chapter  xviii,  p.  415. 


BERI-BERI 


439 


vitamine.     The  British  soldier  thus  became  liable  to  beri-beri, 
and  a  number  of  severe  cases  occurred. 

The  defect  of  the  British  ration  as  regards  protection  against 
beri-beri  was  fully  realized  by  the  medical  authorities  in  Meso- 
potamia in  1916,  and  on  the  representation  of  the  director  of 
medical  services  the  following  scale  of  rations  was  introduced 
on  4th  July,  1916  :— 


Bread 

Fresh  meat 

Bacon 

Potatoes 

Tea 

Sugar 

Cheese 

Chocolate 
Bread 
Lime  juice 
Sugar 
Rum 


1  Ib.  Rice 

f   „  Jam 

3  oz.  Condensed  milk 

1  Ib.  Salt 

1  oz.  Pepper 

1\,y  Oatmeal 

3  ,,  Condensed  milk 

Extras. 

1  oz.  Dates 

4  ,,  Fresh  fruit  . . 

£  fl.  oz.  Dry  lentils  (dhall)  .  . 

|  oz.  Curry  powder 

4  fl.  oz.  Limes  (per  man)     . . 


3  oz. 

3    „ 

2    „ 


4oz. 

2    „ 


4  oz. 

4    „ 
2    „ 

3 


In    this    scale    the    oatmeal 
necessary  protective  factor. 

On  31st  October,  1916,  a  further  improved  ration  scale 
sanctioned  containing  the  following  articles  : — 


and  dhall  both   contain   the 

was 


Daily. 

Bread  1  Ib. 

Or  biscuit  when  bread  not 

available. .          .  .  12  oz. 

Fresh  meat     . .          . .          . .  1  Ib. 

Or    preserved    when    fresh 

not  available      . .          . .  12  oz. 

Pickles     when      preserved 

meat  is  issued    . .          . .  1 

Bacon  . .          . .          . .  3 

Potatoes  or  fresh  vegetables  12 
Or  dried  vegetables  when 

fresh  not  available       . .  3 

Tea J 

Cheese  (not  in  summer)        .  .  3 

Sugar  . .          . .  3 

Jam  or  golden  syrup  .  .  3 

Tinned  milk  . .  2 

Salt      ..          ..  i 

Fresh  fruit      .  .  2 

Or  tinned  fruit  .  .  2 

Or  dried  fruit  when  fresh 

fruit  not  available         .  .  1 

Soup  or  Oxo  (not  in  summer)  2 


Weekly. 


Pepper 
Mustard 


Twice  Weekly. 

Marmite  (Monday  and  Thurs- 
day— not  in  summer) 

Thrice  Weekly. 

Oatmeal  (Monday,  Wednes- 
day and  Friday) 

Tinned  milk  (Monday,  Wed- 
nesday, and  Friday) 

Curry  powder  (Tuesday, 
Thursday  and  Saturday) 

Rice  (Tuesday,  Thursday 
and  Saturday) 

Butter  (Monday,  Wednes- 
day and  Friday — not  in 
summer) 

Lime  juice  (Tuesday,  Thurs- 
day and  Saturday —  not 
in  winter)  . . 


In  this  scale  an  issue  of  marmite  twice  weekly  was  added 
as  an  additional  protective  against  beri-beri. 

In  February  1916,  Colonel  Willcox  suggested  to  the  Sanitary 
Committee  of  the  War  Office  the  advisability  of  an  extract  of 
yeast  being  issued  to  the  troops  as  a  prophylactic  against  beri- 
beri. Experiments  were  then  instituted  by  Colonel  Horrocks 


440  MEDICAL  HISTORY   OF  THE  WAR 

and  carried  out  by  Professor  Starling,  Dr.  S.  M.  Copeman, 
and  their  co-workers.  They  showed  that  extract  of  yeast 
was  a  prophylactic  against  beri-beri,  and  the  preparation 
known  as  marmite  was  issued  to  British  troops  in  Mesopotamia 
in  October,  1916.  Marmite  can  be  mixed  with  warm  water 
and  taken  like  bovril  or  be  added  to  a  stew  after  cooking. 
It  was  undoubtedly  of  great  value  as  a  prophylactic  against 
beri-beri  in  Mesopotamia,  and  it  was  a  valuable  remedy  in  the 
treatment  of  cases  that  occurred.  It  kept  well  in  Mesopotamia, 
and  no  difficulty  was  experienced  in  its  issue  as  a  ration  to  troops. 
In  February  1917,  experiments  were  also  carried  out  at 
Amara  to  determine  the  practicability  of  issuing  to  British 
troops  bread  made  with  a  certain  proportion  of  atta  in  the 
flour.  Loaves  were  made  with  flour  containing  100  per  cent., 
75  per  cent.,  50  per  cent,  and  25  per  cent,  respectively  of  atta. 
The  bread  was  very  palatable,  but  the  addition  of  much  atta 
caused  some  difficulty  in  the  rising  of  the  dough,  so  that  the 
bread  was  somewhat  heavy.  Bread  made  with  25  per  cent, 
of  atta  was  quite  as  palatable,  and  differed  little,  except  in 
the  slightly  brownish  colour,  from  ordinary  bread.  It  was 
issued  to  several  units  at  Amara  with  satisfactory  results, 
and  later  on  a  general  issue  to  the  army  on  three  days  a  week 
was  sanctioned  by  the  General  Officer  Commanding-in-Chief. 
The  issue  to  British  troops  of  bread  rich  in  anti-beri-beri 
vitamines  was  thus  an  important  factor  in  the  reduction  of 
beri-beri  among  them.  After  March  1916,  very  few  cases 
of  beri-beri  occurred  in  the  Mesopotamian  Force,  and  these 
were  generally  of  a  mild  type,  and  in  them  some  intercurrent 
disease  was  usually  an  important  predisposing  factor. 

Rice  has  for  many  years  been  associated  with  beri-beri 
outbreaks.  The  recent  knowledge  on  the  subject  has  very 
clearly  defined  the  part  it  plays.  The  polished  variety  is 
almost  devoid  of  protective  vitamine,  owing  to  removal  of 
the  pericarp  and  germ.  Unfortunately,  Chinese  labourers  and 
other  labour  corps  consider  that  the  polished  rice  from  its 
white  colour  is  of  a  better  quality,  and  often  object  when  the 
unpolished  variety,  which  is  brown  or  reddish  in  colour,  is 
issued  to  them.  Unhusked  rice  is  known  as  "  paddy."  If 
the  husk  is  removed  by  steaming  or  treatment  with  hot  water 
and  subsequent  rubbing  in  a  mortar  or  by  hand,  as  is  the 
case  with  native  rice,  the  pericarp  and  germ  of  the  grain  are 
not  removed,  and  this  variety  of  rice  is  fully  protective  against 
beri-beri.  The  rice  germ  is  one  of  the  richest  substances  in 
anti-beri-beri  vitamine,  and  the  rice  polishings  removed  by 
the  milling  process  have  long  been  known  to  have  a  high 
protective  value. 


BERI-BERI  441 

The  following  table  gives  the  comparative  values  of  common 
articles  of  food  as  regards  protection  against  beri-beri,  arranged 
in  order  of  their  vitamine  content : — 


Yeast  extract  (marmite) 
Rice  germ 


Wheat  germ,  maize  germ 

Yeast   ..      - 

Lentils  (dhall,  peas,  beans,  etc.) 

Egg  yolk 

Liver 

Kidney 

Heart  muscle  . . 


.Rich. 


-  Moderately  rich. 


Sweetbread,  fish  roe 

Oatmeal 

Wholemeal  bread  or  biscuits 

Meat 

Potatoes,  carrots,  fresh  vegetables >Poor. 

Fresh  milk J 

Meat  extract  . .          . .          . .          . .          .  .          . .  ] 

Tinned  meats  . .          . .          . .          . .          . .  (  „. 

Bread  or  biscuits  (made  from  white  milled  flour)  f  v 
Polished  rice  . .          . .          . .          . .          . .          . .  J 

Bur  ghoul  formed  part  of  the  army  ration  of  the  Turkish 
soldier.  This  is  dried  parboiled  wheat,  which  was  used  for 
making  bread,  or  was  added  to  soups  and  stews.  It  was  a 
valuable  constituent  of  the  ration  from  its  richness  in  anti-beri- 
beri vitamine. 

The  toxines  of  other  diseases  which  can  of  themselves  cause 
neuritis  and  cardiac  weakness  may  undoubtedly  play  an 
important  part  in  the  causation  of  beri-beri.  In  these  cases 
some  vitamine  deficiency  can  be  found  on  investigation,  and 
where  the  deficiency  applies  to  a  ration  issued  to  a  large 
number  of  persons  an  outbreak  of  a  considerable  number  of 
cases  is  to  be  expected. 

In  the  Dardanelles  cases  an  intercnrrent  disease,  such  as 
jaundice,  diarrhoea,  dysentery,  or  enteric  group  disease,  was 
present  in  several  of  the  cases,  but  in  them  the  special  hospital 
diet  given  in  consequence  of  the  associated  disease  was  almost 
devoid  of  anti-beri-beri  vitamine  and  doubtless  contributed 
towards  the  development  of  that  disease. 

In  Mesopotamia  the  cases  occurring  in  British  troops  from 
December  1916  to  1918,  were  of  a  mild  type  and  malaria 
was  a  complicating  factor  in  a  considerable  proportion,  also 
the  effects  of  heat,  diarrhceal  disease,  sandfly  fever  and  para- 
typhoid fever  were  sometimes  predisposing  factors.  In  these 
cases  the  knee  jerk  was  often  retained  and  the  loss  of  power 
only  slight  or  moderate  in  extent,  in  marked  contrast  to  the 
Chinese  cases  which  showed  complete  loss  of  knee  jerk  and 
great  loss  of  power  in  addition  to  the  other  classical  symptoms. 


442  MEDICAL  HISTORY  OF  THE  WAR 

In  the  latter  the  predominant  and  sole  cause  was  vitamine 
deficiency,  whereas  in  the  British  cases  the  vitamine  deficiency 
factor,  though  present,  would  probably  have  been  insufficient 
of  itself  to  cause  the  disease. 

In  Mesopotamia  beri-beri  occurred  chiefly  during  the  cold 
months  September  to  January.  Race  did  not  appear  to  be  a 
special  predisposing  cause,  except  in  so  far  as  racial  peculiarities 
of  diet  may  expose  the  individual  to  greater  danger.  Age  did 
not  appear  to  be  a  factor.  Infantile  beri-beri  has  occurred 
in  the  Philippine  Islands  to  a  considerable  extent  amongst 
breast-fed  infants  whose  mothers  were  having  a  diet  consisting 
mainly  of  polished  rice.  Both  mothers  and  infants  developed 
beri-beri.  The  disease  has  recently  been  stamped  out  by  the 
use  of  an  extract  of  rice  polishings  in  the  dietary.  Fatigue 
may  play  a  part  as  a  predisposing  cause.  Overcrowding  and 
unhealthy  surroundings  and  depressing  influences  generally 
may  act  as  predisposing  causes. 

A  considerable  amount  of  experimental  work  has  been 
carried  out  in  connection  with  beri-beri.  Polyneuritis  experi- 
mentally produced  in  pigeons,  rats  and  other  animals  is 
probably  identical  with  beri-beri  in  man.  It  is  also  clearly- 
shown  that  the  anti-neuritic  factor  is  identical  with  the  anti- 
beri-beri  vitamine  and  with  the  water  soluble  B  factor.  In 
pigeons  fed  on  a  vitamine-free  diet,  the  incubation  period 
appears  to  be  from  15  to  25  days.* 

Lieut.-Col.  R.  McCarrison,  I.M.S.,  in  an  experimental 
research  on  animals,  has  pointed  out  that  though  vitamine 
deficiency  is  the  essential  aetiological  factor  in  beri-beri, 
nevertheless  this  is  rarely  so  completely  the  sole  agent  as  in 
scurvy.  This  conclusion  is  in  remarkable  agreement  with  the 
clinical  observations  on  beri-beri  in  Mesopotamia.  He  has 
also  shown  that  in  the  experimentally-produced  polyneuritis 
in  pigeons  there  is  a  chronic  inanition,  a  derangement  of  the 
function  of  digestion  and  assimilation,  and  a  disordered  function 
of  the  endocrine  glands  and  of  all  the  organs  of  the  body. 
Thus  the  remarkable  result  was  obtained  that  in  experimentally 
produced  polyneuritis  a  considerable  enlargement  of  the 
suprarenal  glands  occurred  with  a  corresponding  increase  in 
adrenalin  content.  On  the  other  hand,  atrophy  and  impaired 
function  occurred  in  the  reproductive  glands,  in  the  thymus, 
in  the  pancreas  and  in  the  spleen.  He  found  that  deficiency 
of  anti-neuritic  vitamine  predisposed  to  bacterial  infections, 
such  as  septicaemia  and  tubercle,  and  also  led  to  functional 
and  degenerative  changes  in  the  nervous  system. 

*  See  Report  No.  38  of  the  Medical  Research  Committee,  1919,  for  a  detailed 
account  of  the  experimental  work  carried  out  in  the  past. 


BERI-BERI  443 

Morbid  Anatomy. 

Post-mortem  examinations  were  made  on  two  of  the 
Dardanelles  cases  by  Lieut. -Col.  C.  J.  Martin.  (Edema 
was  present  to  a  marked  degree  in  the  lower  extremities  and 
to  a  less  extent  on  the  trunk  and  upper  extremities.  The 
heart  showed  dilatation  of  the  right  and  left  cavities.  No 
valvular  disease  was  present.  The  heart  muscle  showed  the 
naked  eye  changes  of  fatty  degeneration.  The  lungs  were 
cedematous  and  congested  at  the  bases.  The  stomach  showed 
considerable  redness  of  the  mucous  membrane  which  was  most 
marked  in  the  pyloric  half  where  the  colour  was  a  deep  crimson. 
The  duodenum  showed  intense  crimson  congestion  of  the 
mucosa,  especially  in  the  upper  part.  The  jejunum  and 
ileum  showed  marked  congestion,  some  petechiae  being 
present  in  the  latter.  The  large  intestine  showed  congestion. 
Numerous  small  hsemorrhagic  patches  about  half  an  inch  in 
diameter  were  present  in  the  wall  of  the  ascending  colon.  The 
mesenteric  glands  showed  slight  enlargement.  The  kidneys 
were  congested  and  showed  cloudy  swelling.  The  liver  was 
congested  and  showed  slight  nutmeg  change. 

The  post-mortem  changes  in  the  nervous  system  have  at 
other  times  been  carefully  studied  by  various  observers.  No 
marked  changes  may  be  visible  to  the  naked  eye,  but  special 
staining  methods  and  microscopical  examination  show  extensive 
degenerative  changes  in  the  peripheral  nerves,  the  motor  nerves 
being  most  affected,  the  sensory  branches  suffering  to  a  less 
degree.  Hamilton  Wright  has  shown  that  the  branches  of  the 
vagi  to  the  heart  show  marked  degenerative  changes,  and  in 
acute  cases  the  nerve  ganglion  cells  of  the  heart  and  of  the  first 
and  second  pair  of  the  thoracic  ganglia  show  characteristic 
degenerative  changes. 

The  spinal  cord  is  usually  found  to  be  normal.  Hamilton 
Wright  and  others  have  described  degeneration  of  the  posterior 
spinal  ganglion  and  anterior  cornua  of  the  lumbar  cord,  together 
with  atrophy  of  Coil's  column,  in  which  histologically  there  is 
a  thickening  of  the  glia  tissue,  and  a  complete  disappearance 
of  the  nerve  fibres  with  the  presence  of  many  granular  cells. 

The  degeneration  of  the  nerve  fibres  of  the  peripheral  nerves 
has  been  carefully  studied  by  Scheube,  Hamilton  Wright, 
Baelz,  Duerck,  and  recently  by  Kimura.  The  medullary  sheath 
becomes  vacuolated,  and  the  axone  appears  like  a  wavy  cord,  or 
as  a  series  of  comma-like  segments.  Finally,  both  medullary 
sheath  and  axone  disappear,  while  Schwann's  sheath  collapses 
and  the  nerve  fibres  become  lost  in  the  connective  tissue  of 
the  endoneurium.  Along  with  these  changes  there  is  a  cellular 
infiltration  of  the  perineurium  and  of  the  endoneurium,  and 


444  MEDICAL  HISTORY   OF  THE  WAR 

when  fully  degenerated  the  nerve  may  consist  simply  of  con- 
nective tissue.  In  the  early  stages  the  degeneration  does  not 
always  begin  in  the  distal  ends  of  the  nerves,  but  may  start  at 
a  certain  height  in  a  nerve  fibre.  Also  badly  degenerated  nerve 
fibres  may  be  seen  lying  alongside  normal  fibres.  The  skeletal 
muscles  may  show  degenerative  changes  of  a  fatty  nature  or 
simple  atrophy  in  the  muscle  fibres,  and  similar  changes  have 
been  described  in  the  muscle  cells  of  the  heart.  McCarrison 
states,  from  his  experiments  in  the  production  of  polyneuritis 
on  animals,  that  paralysis  may  result  from  loss  of  function 
before  actual  nerve  degeneration  has  occurred. 

Symptoms. 

With  regard  to  the  period  required  for  the  development  of 
beri-beri,  Eraser  and  Stanton  found  that  amongst  Japanese  fed 
upon  a  diet  consisting  mainly  of  polished  rice,  the  disease 
occurred  after  a  period  of  eighty  to  ninety  days. 

Four  types  of  cases  are  seen. 

I.  The  Wet  or  (Edematous  Type- — In  this,  the  commonest 
type  of  case,  the  earliest  symptoms  are  usually  some  weakness 
of  the  legs,  or  shortness  of  breath  on  exertion,  generally  accom- 
panied by  malaise  and  anorexia.  In  some  cases  the  swelling 
of  the  legs  is  the  first  symptom  noticed.  This  swelling  is  usually 
marked  and  the  oedema  may  extend  to  the  thighs,  scrotum 
and  abdomen.  (Edema  over  the  sternum  may  occur.  It  was 
only  seen  by  Willcox  in  Chinese  cases.  Ascites  and  hydro- 
thorax  may  occur  in  advanced  cases. 

Dyspepsia  is  a  common  early  symptom,  epigastric  discomfort 
and  flatulence  being  complained  of.  Tenderness  on  palpation 
over  the  duodenum  often  occurs. 

Paraesthesia  of  the  legs  occurs  early  in  some  cases,  the  patient 
complaining  of  numbness,  "  pins  and  needles,"  or  alteration  of 
the  tactile  sense.  The  weakness  of  the  legs  is  shown  by  inability 
to  march  or  walk  properly,  the  gait  being  somewhat  unsteady. 
One  of  the  earliest  signs  of  weakness  of  the  legs  is  shown  by 
the  "  squatting  test."  This  test  consists  in  the  patient  bending 
his  knees  and  separating  them  so  that  he  assumes  a  squatting 
position  with  the  buttocks  a  few  inches  from  the  ground.  A 
beri-beri  patient  is  then  usually  unable  to  raise  himself  up  from 
this  position,  and  often  attempts  to  do  so  by  climbing  up  his 
lower  extremities  with  his  hands  very  much  like  a  patient 
suffering  from  pseudo-hypertrophic  muscular  atrophy.  This 
test  should  be  remembered  by  regimental  officers  as  a  simple 
way  of  picking  out  early  cases  of  peripheral  neuritis  amongst 
a  body  of  troops  who  may  be  likely  to  be  affected  with  beri-beri. 

Anaesthesia  and  analgesia  are  common  symptoms  and  their 


BERI-BERI  445 

extent  varies  much  in  different  cases.  In  some  cases  only  the 
feet  may  be  affected  and  in  others  the  feet  and  legs.  The  upper 
extremities  are  affected  in  the  more  severe  cases.  There  is  loss 
of  sensation  to  a  light  touch  and  inability  to  distinguish  between 
a  pin  prick  and  the  finger  touch  over  the  affected  areas.  Ten- 
derness of  the  calves  on  pressure  is  often  present,  and  the 
patients  sometimes  complain  of  cramps  in  the  calves.  Cir- 
cumoral  anaesthesia  occasionally  occurs. 

The  sensory  symptoms  may  be  complicated  by  "  functional  " 
anaesthesia.  Thus,  in  one  of  the  Mesopotamia  cases  a  patient 
suddenly  developed  complete  loss  of  sensation  below  the  neck. 
This  was  of  a  functional  type  and  cleared  up  under  suggestion 
as  rapidly  as  it  developed. 

Motor  weakness  is  shown  first  in  the  lower  extremities,  and 
is  followed  by  marked  wasting  in  severe  cases.  The  extensor 
muscles  are  affected  more  than  the  flexors,  so  that  foot  and 
wrist  drop  occur. 

Laryngeal  paresis  with  loss  of  voice  may  occur,  and  also 
occasionally  pharyngeal  paresis  with  difficulty  in  swallowing, 
especially  liquids. 

Gait  is  affected  in  severe  cases.  It  becomes  unsteady  and 
may  be  somewhat  ataxic  in  type,  with  a  tendency  for  the  toes 
to  drop,  and  sometimes  a  high-stepping  gait  occurs.  The 
ataxic  type  of  gait  has  not  the  stamping  character  peculiar  to 
tabes  dorsalis. 

The  knee  jerks  may  be  increased  in  the  first  few  days.  They 
are  soon,  however,  diminished  and  become  quite  lost  even 
with  reinforcement.  In  some  cases  observed,  the  knee  jerks 
disappeared  before  the  Achilles  jerk,  and  when  both  reflexes 
were  lost  the  Achilles  jerk  recovered  before  the  knee  jerk. 

In  cases  showing  severe  multiple  neuritis,  there  may  later 
be  contractures  of  the  muscles  causing  deformities  such  as 
talipes.  These  are,  however,  rare. 

The  pulse  is  usually  quickened,  especially  on  exertion.  In 
severe  cases  it  may  be  feeble  and  irregular.  Palpitation  is  a 
common  symptom.  The  cardiac  dullness  is  increased  both  on 
the  right  and  left  sides.  The  heart  shows  signs  of  myocardial 
degeneration.  The  impulse  is  feeble  and  the  first  sound  of  the 
heart  is  short  and  poor  in  quality.  Often  a  systolic  murmur 
replaces  the  first  sound  of  the  heart  more  or  less  completely. 
There  may  be  a  definite  galloping  rhythm  in  severe  cases. 

Pyrexia  is  absent  in  beri-beri  cases  unless  they  are  complicated 
by  some  inter  current  affection. 

Vomiting  sometimes  occurs  in  the  severe  cases  and  is  a  bad 
prognostic  sign. 

Loss  of  weight  is  usually  marked. 


446  MEDICAL  HISTORY   OF  THE   WAR 

II.  The  Dry  or  Atrophic  Type. — This  is  similar  in  its  symp- 
toms to  the  cedematous  type  just  described,  except  that  dropsy 
is  absent.     It  may  be  a  late  stage  of  the  wet  type. 

III.  The  Acute  Pernicious  Type. — In  this  type  sudden  death 
may  occur  without  previous  complaint  of  illness,  the  post- 
mortem   examination    showing    signs    of    beri-beri.     Usually 
anorexia,   nausea,  vomiting  and  epigastric  discomfort  occur 
with  marked  cardiac  weakness.     Dropsy  is  usually  present  and 
also  some  signs  of  neuritis,  such  as  paresis  or  paralysis,  anaes- 
thesia and  analgesia,  can  be  detected.     Death  usually  occurs 
from  cardiac  failure  within  a  few  days. 

IV.  The  Mild  or  Rudimentary  Type. — In  this  type  the  symp- 
toms are  slight.     The  patient  complains  of  malaise,  dyspepsia 
with  parassthesia,  anaesthesia  of  the  lower  extremities  and  some 
loss  of  power.     The  symptoms  rapidly  clear  up  under  appro- 
priate treatment.     In  Mesopotamia,  after  July  1916,  many  of 
the  cases  were  of  this  type,  and  were  complicated  by  some 
intercurrent  disease,  such  as  malaria,  which  was  in  them  an 
important  predisposing  factor. 

Prognosis. 

The  prognosis  in  all  except  the  rudimentary  type  is  grave  as 
regards  prolonged  invalidism.  Complete  rest  in  bed  for  a  long 
time  is  usually  necessary  on  account  of  the  cardiac  and  muscular 
weakness.  Recovery  is  slow,  and  a  long  period,  twelve  months 
or  more,  will  generally  be  required  before  the  patient  is  likely 
to  be  fit  for  duty.  Permanent  invaliding  from  the  army  is 
usually  indicated  in  such  cases. 

In  the  mild  or  rudimentary  type  each  case  must  be  judged  on 
its  merits.  In  Mesopotamia  many  of  the  cases  of  this  type 
were  able  to  return  to  active  duty  after  a  few  weeks  in  hospital. 

Diagnosis. 

The  most  important  and  difficult  differential  diagnosis 
is  that  from  multiple  neuritis  due  to  other  causes.  It  is  essential 
that  the  utmost  care  be  taken  in  the  diagnosis  of  beri-beri, 
since  the  faulty  diagnosis  of  beri-beri  in  a  case  of  multiple 
neuritis  from  some  other  cause  such  as  diphtheria  may  lead  to 
much  unnecessary  alarm.  Such  causes  of  multiple  neuritis  as 
diphtheria,  enteric  fever,  malaria,  arsenical  poisoning,  the 
effects  of  heat,  alcohol,  and  dysentery  were  all  met  with  in 
Mesopotamia,  and  the  cases  had  to  be  carefully  differentiated 
from  beri-beri,  for  which  they  were  sometimes  at  first  mistaken. 
It  is  important,  therefore,  that  in  cases  where  no  vitamine 
deficiency  in  diet  has  occurred,  and  where  there  is  some  obvious 


BERI-BERI  447 

cause  for  the  multiple  neuritis,  the  diagnosis  of  "  multiple 
neuritis  "  and  not  beri-beri  should  be  made. 

In  campaigns  where  vitamine  dietetic  deficiencies  occur, 
scurvy  and  beri-beri  may  both  arise.  Errors  of  diagnosis  due 
to  the  mistaking  of  scorbutic  oedema  of  the  legs  for  the  oedema 
of  beri-beri  must  be  guarded  against.  No  difficulty  should  arise 
since  the  oedema  of  scurvy  is  of  a  hard  brawny  type,  while  that 
of  beri-beri  is  of  the  soft  type  like  cardiac  or  renal  dropsy.  The 
other  signs  of  scurvy  serve  to  differentiate  further  the  two 
diseases. 

Diseases  of  the  spinal  cord,  such  as  tabes  dorsalis,  myelitis, 
and  scleroses  of  various  kinds,  may  be  mistaken  for  beri-beri. 
A  careful  examination  for  such  symptoms  as  lack  of  bladder 
control,  extensor  plantar  reflex,  and  ankleclonus,  distinguishes 
myelitis  and  sclerotic  conditions  from  beri-beri.  In  tabes 
dorsalis,  the  Argyll  Robertson  pupil,  the  marked  ataxy,  the 
absence  of  muscular  wasting  or  tenderness  of  the  calves, 
are  signs  distinctive  from  beri-beri. 

Dropsy  may  arise  from  other  causes  such  as  renal  disease, 
where  the  presence  of  albumen  and  casts  in  the  urine  and 
absence  of  neuritis  are  points  of  distinction,  or  from  cardiac 
disease,  where  the  history  of  the  case,  such  as  previous 
rheumatism,  syphilis,  or  other  cause  of  cardiac  disease,  and  the 
long  duration  of  the  symptoms  without  signs  of  multiple 
neuritis  make  the  diagnosis  easy. 

Epidemic  dropsy  is  distinguished  from  beri-beri  by  pyrexia, 
anaemia  and  absence  of  multiple  neuritis. 

It  is  important,  especially  in  the  case  of  native  troops  or 
labour  corps,  to  remember  that  ankylostome  infection  may 
sometimes  closely  simulate  beri-beri.  Symptoms  like  those  of 
peripheral  neuritis  are  not  uncommon  in  ankylostomiasis, 
oedema  is  often  seen,  and  dropsy  is  a  frequent  concomitant 
of  severe  and  advanced  cases.  The  history  will  usually  serve 
as  a  guide,  but  in  all  cases  of  doubt  the  f  seces  should  be  carefully 
searched  for  hookworm  eggs. 

Treatment. 

With  regard  to  treatment,  absolute  rest  in  bed  is  essential 
in  the  early  stages  of  the  disease,  and  until  all  cardiac  symptoms 
have  cleared  up. 

In  an  acute  case  where  gastric  symptoms  are  present,  the 
diet  will  necessarily  be  light  and  mainly  liquid.  A  careful 
selection  should  be  made  of  suitable  articles  on  the  lines  laid 
down  above.  Thus  J  oz.  marmite  should  be  given  thrice  daily, 
or,  if  that  is  not  available,  about  2  oz.  daily  of  yeast,  which  can 
be  given  in  a  palatable  form  stirred  up  with  milk  and  sweetened 


448 


MEDICAL   HISTORY   OF  THE  WAR 


to  taste.  The  yolks  of  eggs  beaten  up  in  milk,  pea  soup  and 
oatmeal  porridge  should  form  part  of  the  dietary.  When  solid 
food  can  be  taken,  a  careful  selection  should  be  made  of  those 
articles  rich  in  anti-beri-beri  vitamine,  which  are  suitable  for  the 
digestive  state  of  the  patient. 

It  is  important  to  remember  that  the  dietary,  though  mainly 
directed  as  curative  for  beri-beri,  must  also  be  protective  against 
scurvy;  therefore  the  juice  of  two  or  three  fresh  lemons  or 
oranges  should  be  given  daily. 

The  after-treatment  of  the  case  will  be  directed  on  the  lines 
of  treatment  most  suitable  for  multiple  neuritis,  such  as  mas- 
sage and  electrical  treatment,  care  being  taken  that  the  diet 
remains  rich  in  protective  vitamine. 

The  preventive  measures  depend  upon  the  dietary  A 
suitable  selection  of  the  items  in  the  ration  scale,  so  that  the 
dietary  contains  an  ample  supply  of  the  necessary  protective 
food  factor  or  vitamine,  is  the  essential  measure  of  prophylaxis. 
Early  notification  of  cases  is  also  essential. 

As  in  the  case  of  scurvy,  an  important  measure,  where 
beri-beri  is  occurring,  is  the  establishment  of  special  hospitals 
for  the  treatment  of  cases,  with  a  special  medical  officer  in 
charge.* 

In  Mesopotamia,  this  procedure  was  adopted  in  Baghdad, 
Basrah  and  Amara,  in  June  1917,  with  most  satisfactory 
results. 


Chick   and    Hume. 


Cooper 


Cox 


Fraser  and  Stanton 
Funk 


BIBLIOGRAPHY. 

The  effect  of  exposure  to  temper- 
atures at  or  above  100°  C. 
upon  the  substance  whose 
deficiency  in  a  diet  causes 
Polyneuritis  in  birds  and  Beri- 
beri in  man. 

The  distribution  in  wheat,  rice, 
and  maize  grains  of  the  sub- 
stance the  deficiency  of  which 
causes  Polyneuritis  in  birds 
and  Beri-beri  in  man. 

On  the  protective  and  curative 
properties  of  certain  foodstuffs 
against  Polyneuritis  induced 
in  birds  by  a  diet  of  polished 
rice. 

Annual  Report  of  Director  of 
Philippine  Bureau  of  Science. 

An  Enquiry  concerning  the 
Etiology  of  Beri-beri. 

On  the  chemical  nature  of  the 
substance  which  cures  Poly- 
neuritis in  birds  induced  by 
a  diet  of  polished  rice. 


Proc.  Roy.  Soc., 
1919.   B.  Vol.  xc, 
p.  60. 


Proc.  Roy.  Soc., 
1919.   B.   Vol.  xc, 
p.  44. 


Jl.  Hyg.,  1912. 
Vol.  xii,  p.  436., 
and  1914.  Vol.  xiv, 
p.  12. 

Manilla,  1918. 

Lancet,  1909.  Vol.  i, 

p.  451. 
Jl.  Physiology,  1911- 

1912.     Vol.    xliii, 

p.  395. 


*  See  Chapter  xviii.,  p.  427. 


BERI-BERI 


449 


Funk 

Hehir 
Kimura,  Onari 

Leggate 
McCarrison  . . 


McCollum    &    Davis 
Me  Walter 

Marchoux 
Rodhain 

Saleeby 

Simpson 
Sprawson 

Willcox 
Wright 


BIBLIOGRAPHY— cont. 

The  preparation  from  yeast  and 
certain  foodstuffs  of  the  sub- 
stance the  deficiency  of  which 
in  diet  occasions  Polyneuritis 
in  birds. 

Beri-beri  (with  special  reference 
to  its  occurrence  in  Mesopo- 
tamia) . 

Histological  degenerative  and 
regenerative  processes  in  the 
peripheral  nerve  system. 


Beri-beri     among 
France. 


Chinese     in 


The  Pathogenesis  of  Deficiency 
Disease. 

The  Influence  of  Deficiency  of 
accessory  Food  Factors  on  the 
Intestine. 

The  Genesis  of  (Edema  in  Beri- 
beri. 

The  Nature  of  the  Dietary  Defi- 
ciencies of  Rice. 

Relapsing  Beri-beri.  (Case  of 
Beri-beri.  in  soldier  who  had 
had  ordinary  diet.) 

Beri-beri  et  Avitaminose 


Observations  m6dicales  recueil- 
lies  parmi  les  troupes 
coloniales  beiges  pendant  leur 
campagne  en  Afrique  Orient- 
ale,  1914-1917. 

The  Treatment  of  Beri-beri  with 
autolysed  Yeast  Extract. 

The  Environment  Factor  in 
the  Causation  of  Beri-beri. 

Beri-beri  in  the  Mesopotamian 
Force. 

Beri-beri,  with  special  reference 
to  prophylaxis  and  treatment. 

The  Treatment  and  Management 
of  Diseases  due  to  Deficiency 
of  Diet  (Scurvy  and  Beri-beri) . 

^Etiology  and  Pathology  of  Beri- 
beri. 

Beri-beri  during  the  siege  of 
Kut  (Indian  Science  Congress 
Report). 


Jl.  Physiology,  1912- 
1913.  Vol.  xlv, 
p.  75. 


Ind.   Jl.   Med.   Res., 

1919.  Supplement 
p.  44. 

Mitteil   a.d.    Pathol. 

Inst.       d.       Kais. 

Univ.   Zu  Sendai, 

Japan,  1919.  Vol.  i, 

pp.  1-146. 
Edin.  Med.  JL,  1920. 

N.    S.    Vol.    xxiv, 

p.  32. 
Ind.     JL     of     Med. 

Res.,      1918-1919. 

Vol.  vi.  p.  275,550. 
B.M.J.,  1919.  Vol.  ii, 

p.  36. 

Proc.      Roy.     Soc., 

1920.  B.  Vol.  xci, 
pp.  103-110. 

Jl.  Biol.  Chem.,  1915. 

Vol.  xxiii,  p.  181. 
B.M.J.,   1916.  Vol.  i, 

p.  201. 

Bull.       Soc.       Path. 

Exot.,       1920. 

Vol.  xiii,  p.  196. 
Bull.       Soc.      Path. 

Exot.,        1919. 

Vol.  xii,  p.  137. 


Philippine  Jl.  Scien., 

1919.      Vol.      xiv, 

pp.  11-12. 
Lancet,  1919.  Vol  ii, 

p.  1027. 
Quart.     JL   of  Med., 

1919    -    1920. 

Vol.  xiii.  p.  337. 
Lancet,  1916.   Vol  i, 

p.  553. 
Proc.       Roy.       Soc. 

Med.,     1919-1920. 

Vol.      xiii,      Sect. 

Therap.  p.  7. 
Singapore.     1902. 

B.M.J.,  1919.  Vol.  i, 
p.  382. 


<2396) 


CHAPTER  XX. 

FAMINE     DROPSY. 

FAMINE  dropsy  has  been  described  by  various  writers 
under  the  names  of  hunger  oedema,  famine  cedema ; 
cedeme  de  la  guerre,  cedeme  de  la  fame  ;  anasarque  essentielle  ; 
hydropsfamelicus;  edema  da  fame ;  CEdemkrankheit,Kriegsddem, 
Hunger  odem. 

It  is  described  as  a  form  of  dropsy  associated  with  brady- 
cardia,  polyuria,  and  asthenia,  which  occurs  in  persons  sub- 
jected to  prolonged  underfeeding.  It  is  unattended  by  albu- 
minuria,  cardiac  dilatation,  or  neuritis.  It  affects  more 
particularly  men  who  are  called  upon  to  perform  hard  physical 
work,  whilst  their  daily  food  ration  contains  from  800-1,200 
calories.  These  calories  are  as  a  rule  embodied  in  a  largely 
fluid  diet  which  comprises  15  per  cent,  more  of  indigestible 
celluloses  with  very  little  fat  and  a  maximum  daily  allowance 
of  50  grammes  of  protein. 

The  occurrence  of  dropsy  has  been  recognized  as  a  result  of 
underfeeding  and  famine  since  the  dawn  of  literature,  Hesiod, 
in  his  "  Works  and  Days,"  speaks  of  the  starvation  a  hard  winter 
brings,  and  advises  prudent  thrift,  "  lest  the  helplessness  of  evil 
winter  overtake  thee,  and  with  wasted  hand  thou  press  thy 
swollen  foot."  Scaliger  attributed  to  Aristotle  the  remark 
that  in  famished  persons  the  upper  parts  of  the  body  are 
desiccated,  the  lower  tumified.  Hecker,  in  his  account  of  the 
destruction  of  the  French  army  before  Naples  in  1528,  refers 
to  soldiers  with  pallid  visages,  swelled  legs  and  bloated  bellies, 
scarcely  able  to  crawl.  Sydenham  refers  to  the  condition 
when  he  makes  use  of  the  quotation  :  "  ubi  desinit 
scorbutus,  ibi  incipit  hydrops."  He  qualifies  his  quotation 
by  calling  it  a  saying  of  the  vulgar  which  means  that,  when  a 
dropsy  has  shown  itself  by  clear  signs,  the  preconceived  notion 
of  a  scurvy  falls  to  the  ground.  Still  the  connection  between 
scurvy  and  dropsy  in  a  popular  saying  suggests  that  the 
conditions  under  which  the  disease  arose  were  closely  allied 
in  the  minds  of  a  seventeenth-century  public. 

Lind,  quoting  Van  der  Mye's  description  of  the  diseases 
observed  during  the  siege  of  Breda  in  1625,  says  :  "Of  those 
who  were  afflicted  with  the  flux  few  escaped  .  .  .  They 
afterwards  became  bloated,  relaxed  and  dropsical.  Watery 
swellings  of  the  testicles  were  frequent  .  .  .  Some  died  early 
in  the  disease,  viz.,  those  who  had  seldom  any  evacuation  of 

450 


FAMINE   DROPSY  451 

blood  by  the  nose  or  stool  and  seemed  from  the  beginning 
indolent,  dispirited,  and  blown  up  as  it  were  with  wind.  Their 
stools  were  greasy,  foetid,  and  of  various  colours,  but  not 
frequent."  In  another  passage  Lind  gives  an  extract  from  a 
letter  written  by  the  surgeon  of  the  "  America  "  ship  of  war, 
dated  llth  November,  1762  :  "  Our  long  cruise  ....  proved 
very  fatal  to  our  East  India  squadron  ;  having  lost  on  our 
return  to  Madrass  eight  or  nine  hundred  brave  fellows  by  an 
extraordinary  species  of  scurvy  .  .  .  The  disease  most 
commonly  began  with  a  soft  swelling  of  the  legs,  which 
ascended  to  the  thighs,  enlarging  them  to  an  enormous  size. 
This  swelling  afterwards  extending  itself  up  to  the  belly  and 
scrotum  gradually  mounted  up  ...  so  that  .  .  .  the  patients 
laboured  under  an  universal  dropsy,  accompanied  with  swelled 
putrified  gums,  a  stiffness  at  the  joints  of  the  knees,  livid 
stains  and  scorbutic  spots  .  .  .  The  patient  after  its  first 
attack  seldom  survived  seven  weeks,  few  lived  longer,  many 
expired  in  a  shorter  time.  They  all  died  of  a  suffocation  from 
water,  except  those  from  whom  the  water  was  constantly 
drained  off  by  means  before  mentioned ;  and  they  after 
languishing  for  some  time,  expired  at  length  when  reduced 
almost  to  perfect  skeletons."  In  this  account  scurvy  certainly 
enters,  but  the  dropsy  is  the  novel  and  most  striking  feature. 

Articles  on  anasarca,  on  famine,  and  on  oedema,  in  the 
Dictionnaire  encyclope'dique  des  Sciences  mddicales,  mention 
famine  dropsy  as  a  well-defined  entity. 

Kollreuther  is  quoted  as  the  authority  for  the  observation  of 
famine  dropsy  during  Napoleon's  retreat  from  Moscow  in  1812  ; 
and  it  is  said  to  have  occurred  in  the  Irish  famine  in  1835. 

The  first  clear  distinction  between  famine  dropsy  and  scurvy, 
beri-beri,  and  the  various  final  cedemas  of  inanition  or  diarrhoea 
was  made  by  Cornish.  He  described  the  condition  with  great 
precision  in  1864  as  occurring  amongst  prisoners  on  certain 
dietaries  in  the  Madras  jails.  "  Under  this  system  of  diet  the 
men  became  unhealthy  and  within  three  months  six  of  the  one 
hundred  (transferred  from  Salem  jail  to  Madras)  had  died  of 
diseases  of  a  scorbutic  type,  such  as  diarrhoea  and  dropsy." 
Speaking  of  post-mortem  appearances,  he  says  :  "  General 
dropsy  and  a  tendency  to  serous  effusions  into  the  cavities  of 
the  pericardium,  thorax  and  abdomen  are  the  only  evidences, 
as  indeed  are  the  other  symptoms  just  noticed  (i.e.,  decay  of 
vital  powers,  dyspepsia  and  ulceration  of  the  large  intestine), 
of  an  impoverished  condition  of  the  blood — of  a  vital  fluid 
deficient  in  reparative  or  plastic  material."  In  the  Indian 
famine  of  1877-78  this  officer  was  Sanitary  Commissioner  for 
Madras.  The  British  Medical  Journal  of  that  period  praises 


452 


MEDICAL   HISTORY   OF  THE  WAR 


"  the  boldness  and  honesty  with  which  ...  he  resisted  the 
measures  of  Sir  Richard  Temple,  the  famine  delegate  of  the 
Calcutta  Government — measures  which  at  one  time  threatened 
to  destroy  more  people  than  the  famine."  The  main  point  at 
issue  between  Temple  and  Cornish  was  Temple's  contention 
that  the  natives  grew  fat  on  his  reduced  relief-ration.  Cornish, 
in  his  official  reply  to  Temple's  minutes,  exposes  the  famine- 
delegate's  uncritical  observation  :  "  Even  in  the  weight  test 
some  caution  is  necessary,  for  many  of  the  people  who  come 
into  camps  appear  to  be  filling  out  and  fattening,  when  in  reality 
they  are  getting  dropsical  and  in  a  fair  way  to  die."  Cornish 
observed  this  form  of  dropsy  under  yet  another  set  of  con- 
ditions. "  In  1872  a  detachment  of  native  troops  was  sent 
from  Burmah  to  occupy  a  post  of  the  Arracan  river  in 
co-operation  with  the  Lushai  expedition.  The  men  had  no 
market  at  hand  to  buy  animal  food,  and  in  attempting  to  live 
on  their  rations  they  sickened  and  died  in  large  numbers." 
He  gives  the  hospital  admissions  as  901  and  the  causes  of 
deaths  as  12  from  dropsy  and  3  from  debility,  out  of  a  total 
of  27. 

Porter  also  described  the  dropsy  of  the  Indian  famine  of 
1877-78.  He  was  in  medical  charge  of  a  famine  relief  camp  in 
the  Madras  Presidency.  He  admitted  to  hospital  3,250  persons, 
of  whom  1,117  died.  "Taken  as  a  whole,  these  patients  were 
emaciated,  the  majority  had  oedema  of  the  feet  and  about 
10  per  cent,  suffered  from  general  anasarca  ...  in  no  case 
were  there  marked  symptoms  of  scurvy  present."  Porter  gives 
the  following  careful  analysis  of  22  cases  of  dropsy  occurring 
in  459  autopsies  :— 


Men. 

Women. 

Children. 

Anaemia 

3 

2 

3 

Cirrhosed  liver 

4 

— 

— 

Bright's  kidney      .  . 
Heart  disease 

3 
3 

1 

3 

- 

13 

6 

3 

He  says  :  "  The  surface  of  the  heart  was  devoid  of  fat  .  .  . 
the  fat  was  replaced  by  oedema  .  .  .  There  was  oedema 
of  the  mesentery  present." 

During  the  siege  of  Paris  (1870-1)  Professor  d'Espine  says 
that  "  oedema  was  regarded  as  the  first  stage  of  scurvy  ;  but 
evidently  this  was  not  correct.  The  number  of  deaths  without 
scorbutic  phenomena  justified  the  view  that  famine  oedema 
was  a  morbid  entity." 


FAMINE  DROPSY  453 

Although  it  has  been  suggested  that  "  epidemic  dropsy,"  as 
described  by  Macleod,  Manson  and  others,  is  identical  with 
famine  dropsy,  this  is  probably  not  the  case.  Macleod,  in  his 
account  of  epidemic  dropsy  in  Mauritius,  states  that  "  this 
dropsical  disease  was  by  no  means  confined  to  the  impoverished 
and  sickly."  It  is  possible  that  Macleod's  cases  were  due  to 
ankylostomiasis. 

In  the  interval  between  the  Indian  famine  of  1877-78  and 
the  war  of  1914  famine  dropsy  fell  out  of  recognition  and  was 
practically  forgotten,  save  for  Greig's  investigations.  Greig's 
account  of  epidemic  dropsy  in  Calcutta  shows  that  it  differed 
from  war  oedema  or  famine  dropsy  in  material  features,  notably 
the  frequent  presence  of  cardiac  symptoms  and  the  relative 
frequency  of  emaciation. 

The  first  recorded  appearance  of  this  form  of  dropsy  during 
the  war  was  at  Lille  in  October  1914.  This  unhappy  town 
was  in  German  occupation,  and  the  large  industrial  population 
was  suddenly  stripped  of  everything  so  that  many  of  the 
inhabitants  had  nothing  to  eat  except  potatoes.  This  dietary 
produced  many  cases  of  a  general  anasarca  unaccompanied 
by  albuminuria.  Fontan's  account  of  the  epidemic  corre- 
sponds in  every  detail  with  famine  dropsy.  Early  in  1915  the 
disease  appeared  in  prison  camps  in  Germany,  associated 
with  various  epidemic  diseases  such  as  relapsing  fever,  dysen- 
tery, malaria  and  typhus.  At  the  same  time  it  was  observed 
among  the  civil  population  in  famine-stricken  Galicia  and 
Poland.  Thenceforward  the  disease  was  reported  frequently 
and  from  many  parts  of  the  Central  Powers,  as  well  as  from 
neutral  countries.  Throughout  the  prison  camps  of  Germany 
and  Austria,  and  especially  in  the  so-called  "  reprisal "  camps 
and  companies  of  prisoners  in  the  hands  of  the  Central  Powers, 
famine  dropsy  was  continually  seen. 

Accurate  statistics  as  to  the  relative  frequency  of  famine 
dropsy  in  any  given  community  are  difficult  to  obtain.  During 
the  war  it  was  practically  unknown  in  the  British  Army  until 
after  the  armistice,  when  many  cases  were  seen  among  British 
prisoners  released  from  German  camps.  These  were  soon 
cured  by  ordinary  care  and  feeding.  There  were  no  deaths 
reported  as  the  direct  result  of  hunger  oedema,  and  there  was 
little  opportunity  for  studying  the  condition.  The  following 
analysis  of  the  disease  is,  therefore,  based  almost  entirely  on 
a  review  of  papers  published  previously  to  the  war  or  of 
observations  made  on  the  abundant  clinical  material  that  was 
available  in  Austria  and  Germany. 

Captain  Park,  of  the  Canadian  Army  Medical  Corps,  saw 
400  cases  whilst  himself  a  prisoner  of  war  between  June  1916 


454  MEDICAL   HISTORY   OF   THE   WAR 

and  January  1918,  but  the  total  number  of  prisoners  amongst 
whom  these  cases  occurred  is  not  known. 

Versmann,  who  was  a  director  of  food  distribution  in  Germany, 
confirmed  the  diagnosis  only  200  times  in  a  total  of  200,000 
applicants.  Malloch  says  that  of  the  first  300  consecutive 
admissions  of  released  prisoners  of  war  to  No.  3  Canadian 
General  Hospital  about  20  per  cent,  showed  some  oedema  of 
the  feet,  and  in  some  of  these  there  was  also  swelling  of  the 
face  about  the  eyes.  None  of  these  cases  had  albuminuria, 
the  blood  pressure  was  not  abnormal,  and  there  was  no 
myocardial  insufficiency  to  account  for  it.  It  is  interesting  to 
compare  with  Malloch's  estimate  the  figures  given  by  Porter 
in  the  Indian  famine  of  1877-78  and  quoted  above. 

Von  Jaksch  reports  that  in  1917  in  Bohemia  22,842  persons 
were  discovered  suffering  from  hunger  oedema,  of  whom  1,028 
died.  Kraus  speaking  of  Germany  as  a  whole  says,  "  You 
could  count  the  cases  by  thousands  and  the  death  rate  in 
some  places  rose  to  50  per  cent,  of  the  cases,"  but  he  gives 
no  exact  figures. 

Hiilse  found  in  certain  companies  47-4  per  cent,  affected. 
Enright  collected  300  cases  of  oedema  in  No.  2  Prisoners  of 
War  Hospital,  Cairo,  but  many  of  his  cases  were  suffering 
from  concurrent  diseases,  notably  pellagra,  dysentery  and 
malaria,  and  scorbutic  symptoms  were  frequently  present. 
Moreover,  out  of  54  cases  which  he  selected  for  special  investi- 
gation only  two  had  normal  urine  ;  "  albumen  was  almost 
invariably  present." 

Captain  Gerrard  reported  the  concurrence  of  some  undoubted 
cases  amongst  Turkish  prisoners  of  war  at  Heliopolis,  but  does 
not  quote  numbers. 

All  observers  agree  that  in  the  civil  population  men  are 
affected  out  of  all  proportion  to  women  and  children.  Jansen 
gives  the  relative  incidence  in  certain  civil  institutions  as  12-15 
per  cent,  men,  1-2  per  cent,  women.  In  the  Indian  famine 
of  1877-78  Cornish  and  Porter  recorded  a  great  pre- 
ponderance of  men  affected.  Lichwitz  gives  the  sex- 
incidence  in  a  group  of  144  cases  as  103  men,  39  women,  and 
two  children. 

As  regards  mortality,  Von  Jaksch's  figures  deal  with  the 
largest  number  collected  by  one  observer.  He  records  1,028 
deaths  out  of  22,842  cases  or  4-5  per  cent.  Gerhartz  described 
21  cases  with  3  deaths,  and  Bigland  24  cases  with  8  deaths. 
Park  in  400  cases  says  "  about  20  necropsies  "  were  performed, 
Hiilse  in  145  cases  saw  no  deaths  directly  attributable  to 
hunger  oedema ;  death  was  always  due  to  some  concurrent 
or  intermittent  malady. 


FAMINE  DROPSY  455 

jEtiology* 

The  chief  exciting  cause  of  famine  dropsy  is  long-continued 
underfeeding.  Complete  starvation  leads  to  death  in  eight 
or  ten  days  without  the  appearance  of  dropsy.  As  already 
noted,  when  the  daily  food  ration  contains  between  800  and 
1,200  calories,  and  these  calories  are  drowned  in  a  fluid 
nourishment  which  includes  15  per  cent,  and  more  of  indigestible 
cellulose  with  very  little  fat  and  a  maximum  daily  allowance 
of  50  grammes  of  protein,  then  dropsy  occurs.  It  occurs  more 
readily  if  the  victims  of  such  a  dietary  are  men  called  upon 
to  do  hard  work  and  exposed  to  cold.  Undoubtedly  climate 
plays  a  part,  but,  as  the  Indian  famine  of  1877-78  demon- 
strated, famine  dropsy  can  occur  in  hot  climates  as  well  as 
cold.  In  the  war  of  1914-18,  however,  it  was  seen  that  in  a 
given  community  fed  on  the  same  ration  more  cases  occurred 
in  cold  weather  than  in  warm. 

The  ingestion  of  fluid  in  large  quantity  is  a  contributing 
factor.  The  German  ration  for  prisoners  was  very  poor  in 
protein  and  practically  fat  free.  The  form  in  which  it  was 
given  was  almost  entirely  soup,  to  which  the  men  were  in  the 
habit  of  adding  a  great  deal  of  common  salt.  A  large  amount 
of  fluid  was  therefore  drunk  to  obtain  a  small  amount  of 
nourishment,  and  with  this  an  increased  load  of  sodium 
chloride  was  taken. 

The  nature  and  source  of  the  water  supply  have  no  bearing 
on  the  production  of  the  disease.  Soil  and  race  have  little 
influence.  It  was  said  that  the  British  prisoners  of  war 
suffered  less  on  the  same  ration  than  Russians,  Roumanians 
or  Serbians,  but  the  parcels  of  food  sent  to  the  British  from 
home  increased  their  prison  diet  particularly  as  regards  calorie- 
content. 

Exposure  and  fatigue  hasten  the  onset  of  the  dropsy  ;  whilst 
previous  illnesses  such  as  diarrhoea  and  dysentery  so  constantly 
precede  it  that  at  one  period  of  the  war  it  was  suspected  that 
the  disease  might  be  due  to  an  infection  transmitted  through 
the  alimentary  canal. 

So  far  as  dropsy  was  observed  in  the  civil  populations  of  the 
countries  where  general  food-shortage  existed,  it  affected 
always  the  poorest  first  and  in  greatest  numbers.  Men  between 
the  ages  of  40  and  50  developed  the  disease  most  readily ; 
women  and  children  were  less  frequently  affected,  and  then 
only  in  such  households  as  lived  in  the  direst  poverty.  It  is 
probable  that  a  diet  rich  in  water,  sodium  chloride  and  alkalies 
is  only  a  causal  factor  in  so  far  as  it  is  low  in  calories.  Hindhede 
does  not  think  that  absence  of  fats  from  the  diet  is  of 
great  importance ;  he  says  that  in  Denmark  by  April  1917, 


456  MEDICAL  HISTORY   OF  THE   WAR 

"  after  nine  months'  experience  with  a  fat-free  diet  we  were 
convinced  that  adults  could  live  without  fats,  provided  they 
were  given  greens."  Yet  he  mentions  elsewhere  that  during 
the  war  the  diet  of  the  Danish  people  consisted  chiefly  of  milk, 
vegetables  and  bran.  Where  famine  dropsy  appeared  milk 
was  nearly  always  absent  from  the  dietary. 

Symptoms. 

Famine  dropsy  is  characterized  by  four  cardinal  symptoms, 
oedema,  polyuria,  bradycardia  and  asthenia.  The  onset  is 
gradual.  After  a  few  days'  malaise,  during  which  the  patient 
complains  of  little  beyond  great  lassitude,  physical  weakness, 
headache  and  a  noticeable  increase  in  the  quantity  of  urine 
passed,  there  appears  an  oedematous  swelling  of  the  limbs  and 
trunk.  Sometimes  the  nature  of  the  swelling  is  so  unmistakable 
that  the  patient  diagnoses  his  own  case  as  dropsy. 

The  oedema  begins  in  the  feet,  ankles  and  dependent  parts, 
and  often  extends  over  the  whole  body  even  to  the  hands  and 
face.  Ascites,  hydrothorax  and  hydropericardium  are  of  com- 
mon occurrence.  The  skin  assumes  a  pale  yellow  tint,  muscular 
wasting  may  become  extreme,  and  there  is  usually  very  marked 
apathy.  Night  blindness  and  xerosis  of  the  cornea  have  been 
reported,  but,  since  night-blindness  may  occur  in  any  state 
of  exhaustion  or  mal-nutrition  if  the  retina  is  exposed  to  a 
bright  light,  it  cannot  be  considered  as  a  diagnostic  feature  of 
famine  dropsy.  When  with  appropriate  treatment  the  dropsy 
disappears,  the  emaciation  begins  to  be  obvious.  This 
emaciation  is  an  integral  part  of  the  disease  and  is  always  very 
great.  It  corresponds  in  fact  with  the  total  loss  of  subcu- 
taneous and  other  fat  revealed  by  autopsy,  and  is  a  main  point 
of  distinction  between  famine  dropsy  and  that  due  to  renal 
or  cardiac  disease. 

At  the  first  onset  of  oedema  a  remarkable  polyuria  is  in- 
variably observed.  It  takes  the  form  of  nocturnal  frequency 
(nykturia)  sufficient  to  interfere  seriously  with  the  patient's 
sleep.  Enuresis  is  not  uncommon.  The  heart's  action  becomes 
very  slow  ;  extreme  bradycardia  withoiit  irregularity  occurs 
in  almost  all  cases.  The  rate  is  usually  between  40  and  50 
per  minute,  but  a  rate  of  26  has  been  recorded.  This  brady- 
cardia is  of  sinus  origin.  The  heart  sounds  are  faint  and 
muffled  ;  sometimes  a  soft  systolic  bruit  is  heard  over  all 
the  valvular  areas.  The  pulse  becomes  small  and  feeble,  the 
blood  pressure  low  (90-100  mm.  Hg).  The  lungs  are  as  a 
rule  normal,  unless  there  is  a  considerable  degree  of  hydro- 
thorax,  or  some  complicating  broncho-pneumonia.  Usually 
there  is  a  striking  absence  of  dyspnoea,  cyanosis  and  the  other 


FAMINE  DROPSY  457 

signs  of  failing  pulmonary  circulation.  The  liver  and  spleen 
are  not  enlarged.  There  are  no  changes  referable  to  the 
nervous  system.  Scorbutic  manifestations  are  conspicuously 
absent  except  in  those  cases  where  scurvy  co-exists.  The  skin 
changes  of  pellagra  do  not  occur  in  uncomplicated  cases  of 
famine  dropsy.  The  temperature  is  normal  or  subnormal. 
Fever,  if  present,  depends  upon  some  complication. 

Diarrhoea  is  a  symptom  so  constantly  present  as  to  raise 
considerable  question  whether  it  may  not  be  a  causal  factor. 
There  seems  an  undoubted  relation  between  the  indigestible 
residue  of  the  food  and  the  diarrhoea.  Hiilse  has  shown, 
moreover,  that  owing  to  this  indigestibility  there  is  a  constant 
waste  of  calories  in  the  faeces  notwithstanding  the  general 
calorie-deficiency  and  the  body's  urgent  requirements.  Park 
suggests  on  good  evidence  that  this  diarrhoea  is  sometimes 
at  least  non-infectious.  In  support  of  this  view  Maase  and 
Zondek  point  to  the  absence  of  pain  and  tenesmus,  to  negative 
rectoscopic  appearances,  and  to  the  absence  of  pathogenic 
organisms,  especially  those  of  dysentery,  from  the  stools.  It 
remains  uncertain  whether  this  diarrhoea  is  due  to  the 
mechanical  irritation  of  indigestible  residue,  to  excessive  excre- 
tion of  water  by  the  mucosa  of  the  bowel,  or  to  the  actual  food- 
deficiency  which  is  the  cause  also  of  the  oedema.  Maase  and 
Zondek  observe  that  during  the  second  half  of  the  epidemic  in 
1917,  about  May  or  June  onwards,diarrhcea  was  very  rarely  seen. 

All  observers  agree  that  simultaneously  with  the  first  appear- 
ance of  oedema  there  is  a  great  increase  in  the  amount  of  urine 
and  in  the  frequency  of  micturition.  When  as  the  result  of 
treatment  the  oedema  begins  to  disappear,  there  is  a  second 
rise  in  the  quantity  of  urine  passed.  At  no  time  is  there 
anything  in  the  nature  of  suppression  of  urine,  in  spite  of  the 
amount  of  dropsy  present.  The  polyuria  seems  to  go  hand 
in  hand  with  polydipsia.  The  urine  is  clear,  pale  yellow  in 
colour,  with  a  low  specific  gravity.  The  amount  secreted  in 
24  hours  may  be  as  much  as  3J  to  4  litres — in  one  case  7J  litres 
are  recorded  ;  it  varies  directly  with  the  intake  of  fluid.  In 
true  cases  of  famine  dropsy  no  traces  of  albumin,  sugar  or 
casts  are  found  at  any  period  of  the  disease.  The  chief  altera- 
tion in  the  composition  of  the  urine  upon  which  various 
observers  agree  is  a  marked  increase  in  the  chlorides.  As 
regards  phosphates,  Rumpel  Knack  and  Neumann  report  an 
increase  and  Maase  and  Zondek  report  a  decrease.  Calcium 
and  magnesium  have  been  found  normal  or  increased. 

As  regards  nitrogen  metabolism,  the  majority  of  observers 
agree  with  Maase  and  Zondek  that  there  is  no  constant 
abnormality.  The  total  nitrogen  corresponds  with  the  low 


458  MEDICAL  HISTORY   OF  THE  WAR 

protein  value  of  the  diet,  and  the  urea-nitrogen  is  found 
decreased,  but  improves  with  the  diet.  The  ammonia- 
nitrogen  is  relatively  increased  as  in  all  forms  of  starvation. 
Amino-acids  and  kreatinin  sometimes  show  a  slight  and 
variable  increase,  but  kreatin  is  considerably  increased,  depend- 
ing perhaps  on  disintegration  of  tissue-protein.  Hiilse  and 
Jansen  have  observed  in  some  cases  a  negative  nitrogen- 
balance,  and  consider  that  the  loss  of  nitrogen  represents  a 
breaking-down  of  tissue-protein.  Maase  and  Zondek,  whose 
cases  did  not  exhibit  a  negative  nitrogen  balance,  remark  that 
Jansen's  patients  had  a  much  lower  average  protein-intake 
(50  gm.  protein)  than  theirs  (90-100  gm.  protein).  Urates 
are  as  a  rule  increased  in  the  early  stages  of  the  disease. 
Acetone  has  occasionally  been  found  in  the  urine.  Jansen 
states  that  in  spite  of  the  low  protein  content  of  the  food  there 
is  constant  nitrogen  loss  in  the  faeces  as  well  as  in  the  urine. 
He  is  inclined  to  attribute  this  to  impaired  digestive  powers. 
Franke  and  Gottesmann  attributed  the  condition  to  a 
nephritis  without  albuminuria.  They  claim  to  have  found  the 
renal  function  impaired  on  testing  with  phenol-phthalein. 
Practically  all  other  observers  disagree  with  them  and  have 
found  the  renal  functions  normal.  The  only  constant  altera- 
tion in  the  urine  is  the  increased  output  of  water  and  chlorides. 

Hydraemia  is  constantly  present,  but  the  hydraemia  does  not 
correspond  with  the  degree  of  oedema.  The  specific  gravity 
of  the  blood  is  commonly  between  1 ,047  and  1 ,052  ;  the  lowest 
recorded  is  1,038,  and  in  this  case  there  was  only  slight  oedema, 
The  specific  gravity  of  the  serum  ranges  from  1,021  to  1,027, 
the  minimum  being  1,014.  The  osmotic  pressure  of  the 
serum  as  measured  by  depression  of  freezing  point  (A)  is  from 
-  0-54  to  —  0-58.  Viscosity  and  electrical  resistance  remain 
normal. 

The  number  of  erythrocytes  may  vary  within  wide  limits 
(1,000,000  to  5,300,000).  In  the  majority  of  cases  there  is  a 
moderate  degree  of  oligocythaemia  (3,000,000  to  5,000,000). 
The  haemoglobin  index  is  normal.  In  cases  with  less  than 
three  million  erythrocytes  cell  changes  have  been  observed  ; 
basophilic  granules  with  polychromatophilia,  a  slight  degree 
of  poikilo  and  aniso-cytosis,  and  in  a  few  cases  normoblasts. 

In  general,  leucopenia  is  present.  The  number  of  leucocytes 
commonly  lies  between  2,000  and  8,000  per  c.mm.  Where 
the  count  is  above  8,000  some  complication  may  be  suspected. 
There  is  a  relative  decrease  in  neutrophiles,  and  a  relatively 
large  number  of  immature  (Arneth)  cells  amongst  them. 
Eosinophiles  and  basophiles  are  often  increased ;  but  the 
chief  alteration  is  an  increase  in  mononuclears,  mainly  large 


FAMINE  DROPSY 


459 


mononuclears  of  which  the  proportion  may  reach  55  per  cent. 
These  cells  frequently  attain  a  very  large  size,  six  or  seven 
times  that  of  the  erythrocytes  ;  there  are  numerous  coarse 
basophile  granules  in  their  protoplasm. 

Corresponding  with  the  hydraemia  there  is  a  constant  and 
definite  fall  in  the  total  proteins  of  the  blood  serum.  The 
relative  proportions  of  the  nitrogen  constituents  agree  with 
those  found  in  the  urine.  Urea-nitrogen  is  low,  but  increases 
with  the  protein-intake ;  ammonia  N.  and  kreatin  are 
increased ;  amino-acid  N.  and  kreatinin  are  variable,  and 
never  more  than  slightly  increased.  In  many  cases  there 
is  a  high  degree  of  acetonaemia.  Although  there  is  frequently 
so  great  an  increase  in  the  chlorides  of  the  urine,  Maase  and 
Zondek  have  found  the  sodium  chloride  content  of  the  blood 
practically  normal.  The  blood-sugar  is  said  to  be  deficient 
during  the  stage  of  hydraemia  and  increased  as  the  oedema 
subsides.  Maase  and  Zondek  point  out  that  the  sugar-content 
corresponds  with  normal  blood,  whereas  in  renal  and  ascitic 
dropsy  there  is  hyperglycaemia  without  glycosuria.  The 
lipoid-phosphorus  is  greatly  decreased  in  the  serum,  whilst 
the  acid-phosphates  are  increased.  The  lecithin-content  of 
the  erythrocytes  is  diminished,  the  cholesterin  remaining 
unchanged.  The  fat-content  of  the  serum  has  been  found 
normal  by  Gerhartz  and  diminished  by  Hiilse,  Knack,  and 
Neumann.  Maase  and  Zondek  have  recorded  the  following 
analysis  of  the  transudate  compared  with  that  of  renal  and 
hepatic  dropsy  : 


Famine  Dropsy. 

Renal  Dropsy. 

Cirrhosis  of  Liver. 

Albumen  per  100  c.c. 
Amino-acid  N      ,, 
NH,N 

0-116 
0-0028 
0-0170 

0-343 
0-0150 
0-0085 

0-941 
0-0112 
0-0068 

These  figures  show  the  same  hypo-albuminosis  and  increased 
NH3N  as  have  been  observed  in  the  blood  and  in  the  urine. 

Pathology. 

The  problems  of  oedema  formation  as  a  whole  are  so  little 
understood  that  it  is  impossible  at  present  to  offer  any  con- 
clusive explanation  of  the  pathogenesis  of  famine  dropsy 
Clinical  cedemas  are  of  three  types  :— 

(i)  The  inflammatory  cedemas,  in  which  the  fluid  permeates 
the  cells  of  the  inflamed  area  and  does  not  move 
to  other  parts  of  the  body  under  the  influence  of 
gravity. 


460  MEDICAL  HISTORY   OF  THE  WAR 

(ii)  The  nephritic  cedemas,  in  which  the  fluid  is 
more  or  less  loose  in  the  subcutaneous  tissues 
and  more  readily  changes  its  position,  are  accom- 
panied by  excess  of  water  in  the  blood  with  a 
corresponding  increase  of  sodium  chloride,  the 
percentage  concentration  of  chloride  in  the  blood 
remaining  unchanged,  but  that  of  the  other  con- 
stituents being  diminished. 

(iii)  Cardiac  oedemas,  which  are  also  hypostatic,  but 
are  unaccompanied  by  changes  in  the  relative 
amount  of  water  and  sodium  chloride  in  the  blood. 
But  in  all  forms  of  oedema  recent  observations  tend  to  the 
view  that  some  local  damage  to  the  capillary  endothelium 
exists.  So  far  as  famine  dropsy  is  concerned  no  histological 
evidence  has  been  obtained  of  damage  to  the  capillary  walls. 
It  may  none  the  less  exist.  This  hypothetical  damage  to  the 
capillary  endothelium  may  be  either  a  nutritional  defect,  or 
a  toxic  lesion.  In  nephritis  the  latter  seems  clearly  proved. 
Maase  and  Zondek  are  of  opinion  that  in  famine  dropsy  the 
toxic  elements  play  a  secondary  part.  They  conjecture  that 
increased  protein  disintegration  gives  rise  to  toxic  products 
comparable  to  Volhard's  nephroblabtine  in  renal  oedema.  It 
is  more  probable  that  some  nutritional  defect  alters  the 
permeability  of  the  capillary  walls.  In  this  connection  the 
deficiency  of  lipoids  in  the  blood  seems  an  important  factor. 
For  this  the  absence  of  fats  from  the  food  must  bear  the 
principal  blame.  Experimentally,  Harden  and  Zilva  produced 
oedema  in  monkeys  fed  on  a  diet  deficient  in  fat-soluble  A, 
but  the  diet  was  also  deficient  in  fat  as  a  whole. 

Apart  from  these  two  factors,  toxic  and  nutritional  damage 
to  the  capillary  walls,  three  other  possible  causes  may  be  at 
work.  These  are,  firstly,  the  altered  composition  of  the 
blood,  which  exhibits  hydraemia,  hypoalbuminosis  and  deficiency 
of  lipoids.  There  may  be,  as  a  result,  an  increased  passage  of 
fluid  through  the  capillary  wall.  But  the  blood  changes  appear 
to  be  of  too  slight  a  degree,  and  this  theory  is  also  incompatible 
with  the  rapid  resorption  of  the  oedema.  Secondly,  there  is 
Fischer's  theory  of  oedema  that  the  tissue-cells  damaged  by 
nutritional  defects  become  capable  of  excessive  imbibition  of 
water.  There  is  no  evidence  in  support  of  this  theory,  while 
the  fact  that  the  fluid  in  oedema  gravitates  from  one  part  to 
another  and  can  sometimes  be  drained  off  by  hollow  needles 
proves  that  cell-imbibition  is  not  the  essential  factor.  Finally, 
there  remains  the  theory  that  the  endocrine  glands  are  in  some 
way  responsible.  Eppinger  has  suggested  that  the  thyroid 
gland  controls  the  water-economy.  With  a  little  more  proba- 


FAMINE   DROPSY  461 

bility  and  supported  by  experimental  findings,  McCarrison 
conjectures  that  the  cedema  of  beri-beri  is  connected  with  the 
excessive  production  of  adrenalin.  The  total  adrenal-content 
of  the  hypertrophied  adrenal  glands  in  cases  of  experimental 
beri-beri  in  monkeys  greatly  exceeded  the  amount  found  in 
healthy  animals.  Enright  failed  to  find  hypertrophy  of  the 
adrenal  glands  at  autopsy  in  cases  of  death  with  cedema 
amongst  Turkish  prisoners  of  war  in  Cairo,  but,  as  pointed 
out  previously,  he  does  not  appear  to  have  been  dealing  with 
famine  dropsy. 

Other  causal  factors  have  been  suggested,  which  may  be 
briefly  considered. 

Mere  excess  of  fluid  in  the  diet  undoubtedly  cannot  account 
for  the  dropsy.  Life  can  be  supported  on  fluid  diet  without 
the  appearance  of  oedema,  provided  there  is  a  sufficiency  of 
protein,  calories  and  vitamines.  In  the  polydipsia  and 
polyuria  of  diabetes  mellitus  and  insipidus  the  mere  ingestion 
of  fluid  does  not  produce  dropsy. 

With  regard  to  the  supposition  that  an  excessive  intake  of 

sodium  chloride  is  a  causative  factor,  although  an  excess  of 

common  salt  may  have  been  a  contributory  factor  amongst 

prisoners  of  war,  it  is  not  essential  to  the  production  of  famine 

.   dropsy,  as  proved  by  Harden  and  Zilva's  experiments. 

With  regard  to  the  influence  of  food  deficiencies  and  absence 
of  vitamines,  Kohman,  who  produced  cedema  in  rats  fed  on  a 
diet  composed  largely  of  carrots,  found  that  the  addition  of 
fats,  or  fat  soluble  A,  or  increase  in  salt-content  of  the  diet, 
had  no  noticeable  effect  on  the  occurrence  of  the  cedemas. 
But  there  was  much  more  marked  cedema  where  there  was 
much  water  in  the  diet  than  when  the  animals  were  on  a  dry 
diet. 

There  seems  little  doubt  that  protein-deficiency  plays  a 
part  in  the  production  of  the  disease.  Cornish,  in  his  obser- 
vations on  prison  dietaries  and  Indian  famines  constantly 
attributed  the  appearance  of  dropsy  to  inadequate  nitrogenous, 
rather  than  non-nitrogenous  food.  Denton  and  Kohman 
have  stated  that  dropsy  occurs  in  rats  fed  on  a  carrot  diet, 
when  the  proportion  of  nitrogen  is  reduced  by  the  addition  of 
some  non-nitrogenous  food-stuff,  such  as  fat  or  starch.  Maver 
has  confirmed  these  observations,  and  concludes  that  the 
disease  is  not  a  specific  vitamine-deficiency  disease,  but  is  in 
a  broader  sense  a  "  deficiency  "  disease,  resulting  from  a  pro- 
tracted existence  on  a  diet  poor  in  total  calories  and  especially 
in  protein. 

The  most  striking  feature  in  all  autopsies  is  the  total  absence 
of  fat  throughout  the  whole  body.  At  the  normal  sites  for 


462  MEDICAL   HISTORY  OF  THE   WAR 

fat  deposits,  in  the  subcutaneous  tissues,  in  the  omentum  and 
mesenteries,  about  the  kidneys  and  on  the  heart,  fat  is 
replaced  by  oedema,  producing  a  translucent  gelatinous  tissue. 
Hydropericardium,  hydrothorax,  and  ascites  are  frequently 
seen. 

The  heart  is  in  all  cases  greatly  atrophied,  the  muscle  pale 
and  flabby  exhibiting  histologically  the  changes  of  brown 
atrophy.  There  is  increase  of  pigment  at  the  poles  of  the  cell 
nuclei,  without  true  regressive  changes.  In  spite  of  these 
changes  in  the  muscle,  dilatation  and  hypertrophy  do  not 
occur,  and  the  valves  remain  healthy  and  competent.  The 
lungs  appear  small,  retracted,  anaemic  and  soft.  Sometimes 
there  are  patches  of  at  elect  asis  at  the  margins.  Broncho- 
pneumonia  and  pulmonary  oedema  are  common. 

The  liver  is,  as  a  rule,  small  and  like  the  kidneys  and  spleen 
pale  and  soft.  Hiilse  found  that  no  histological  changes  were 
constant  in  the  liver  and  kidneys  beyond  much  and  varied 
fatty  degeneration.  Jansen  found  no  trace  of  fat  in  the 
liver  cells  when  stained  with  Sudan  red ;  glycogen,  too,  was 
absent  from  the  liver  cells.  The  kidneys  are  healthy ;  his- 
tologically the  epithelium  and  tubules  are  intact,  and  it  has 
been  particularly  noted  that  the  renal  tubules  are  of  normal 
width  and  without  thickened  walls. 

The  spleen  shows  remarkably  few  follicles ;  the  trabecular 
stroma  and  the  vessel  sheaths  stand  out  very  clearly  from  the 
atrophic  pulp.  Fibrous  induration  has  been  observed  round  the 
follicles.  On  the  whole,  no  such  regenerative  processes  as  are 
seen  in  general  infections,  especially  relapsing  fever,  were  found. 

Histologically,  not  only  is  fat  absent  from  the  tissues  of  all 
organs  and  muscles,  but  the  muscle-fibres,  like  the  liver  cells, 
are  totally  devoid  of  glycogen. 

Evidences  of  concurrent  or  intercurrent  disease  are  frequently 
met  with,  particularly  tuberculosis  and  inflammatory  or 
ulcerative  affections  of  the  large  intestine.  Park  regards  these 
changes  in  the  large  bowel  as  an  integral  part  of  the  disease 
not  necessarily  due  to  any  specific  infection.  He  was  struck 
by  the  fact  that,  although  this  form  of  diarrhoea  was  rife  in 
the  prison  camps,  and  the  sanitary  arrangements  were  favourable 
to  the  spread  of  intestinal  organisms,  yet  the  better-fed 
prisoners  were  scarcely  ever  affected. 

Diagnosis. 

The  diagnosis  of  famine  dropsy  rests  chiefly  on  the  exclusion 
of  other  diseases.  The  presence  of  albuminuria  and  casts  in 
the  urine  may  be  taken  as  evidence  of  renal  disease,  but  their 
absence  does  not  prove  that  the  kidneys  are  healthy.  Accord- 


FAMINE   DROPSY  463 

ing  to  Fontan,  persons  with  damaged  kidneys  may  be  the  first 
to  develop  dropsy  as  the  result  of  underfeeding  with  a  dietary 
mainly  liquid  and  rich  in  common  salt. 

Famine  dropsy  differs  from  cardiac  oedema  in  the  slowness 
and  regularity  of  the  heart's  action,  in  the  absence  of  signs  of 
cardiac  dilatation,  and  in  the  absence  of  dyspnoea  and  cyanosis. 
Peripheral  neuritis,  even  in  its  slightest  manifestations  such 
as  pains  in  the  legs  and  paraesthesia,  suggests  beri-beri  rather 
than  famine  dropsy. 

Ankylostomiasis  presents  considerable  difficulty  in  differ- 
ential diagnosis  ;  the  presence  of  eosinophilia  will  suggest  the 
necessity  for  careful  investigation  of  the  faeces.  Pellagra 
should  be  recognised  by  its  characteristic  skin  changes. 
Scurvy  and  famine  dropsy  so  frequently  co-exist  that  it  is 
almost  impossible  to  distinguish  where  the  one  begins  and 
the  other  ends.  It  is  clear,  however,  that  the  haemorrhages 
of  scurvy  are  not  essential  symptoms  of  famine  dropsy. 

Pre-disposing,  concurrent,  and  intercurrent  diseases  are 
so  commonly  met  with  that  they  should  always  be  specially 
looked  for.  The  most  frequent,  and  the  most  important  from 
a  prognostic  standpoint,  are  tuberculosis,  malaria,  and  dysen- 
tery. The  relation  of  diarrhoea  to  famine  dropsy  and  dropsies 
of  inanition  is  interesting  and  at  present  not  clearly  under- 
stood. Park's  comment  is  worth  quoting  in  full :  "  A  common 
complication  of  this  oedema  in  my  experience  was  a  diarrhoea 
with  frequent  watery  stools,  containing  blood  and  mucus 
intimately  mixed.  The  post-mortem  findings  showed  much 
hyper aemia  and  thickening  of  the  lower  bowel,  with  occasional 
ulceration.  Although  so  common  amongst  these  patients  as 
to  suggest  that  it  was  an  infectious  dysentery,  I  did  not  believe 
that  it  was  the  result  of  any  specific  organism,  for  we  scarcely 
ever  found  it  among  the  better-fed  prisoners,  although  the 
sanitary  arrangements  were  such  as  to  give  great  scope  to  the 
spread  of  intestinal  organisms."  There  is  a  possible  parallel 
with  this  in  Edgeworth's  observations  "  on  the  occurrence  of 
general  subcutaneous  non-renal  oedema  as  a  familial  affection/' 
where  in  the  description  of  the  death  of  five  out  of  six  infants 
in  one  family  with  general  oedema  following  upon  diarrhoea 
he  says :  "  It  is  well  known  that  dropsy,  especially  of  the 
face  and  extremities,  may  occur  in  infants  suffering  from  chronic 
diarrhoea  without  albuminuria."  McCarrison  states  emphati- 
cally that '"  the  food  deficiency  is  the  primary  cause  of  the 
diarrhoea  or  dysentery  as  much  as  of  the  deficiency  disease 
syndrome." 

Famine  dropsy  and  inanition  oedema  seem  at  present 
inextricably  mixed.  The  essential  conditions  which  lead  to 


464  MEDICAL  HISTORY   OF  THE   WAR 

famine  dropsy  pure  and  simple  are,  however,  well  established 
—namely,  prolonged  underfeeding  with  a  largely  fluid  diet 
poor  in  calories,  combined  with  exposure  to  cold  and  hard 
physical  exertion. 

Prognosis. 

On  the  whole,  the  prognosis  in  famine  dropsy  is  good,  provided 
that  treatment,  in  the  form  of  improved  diet,  can  be  given. 
According  to  Von  Jaksch,  three  considerations  affect  the  prog- 
nosis in  favour  of  the  patient,  namely,  youth,  early  treatment, 
and  freedom  from  any  other  disease,  especially  tuberculosis. 
Old  people  and  infants  fare  worst.  Budzynski  and  Chelchowski 
place  the  death  rate  in  persons  over  40  years  of  age  at  18*3 
per  cent.,  and  in  children  between  three  and  four  years  old  at 
from  22  to  33  per  cent.  The  mortality  is  greater  in  men  than 
in  women.  This  observation  relates  not  only  to  cases  which 
occurred  in  1914-18,  but  to  all  previous  records  of  famine 
dropsy. 

Uncomplicated  cases  usually  recover  with  rest  in  bed  and 
an  increased  diet.  Relapses,  however,  are  common  when  the 
patient  first  gets  up  and  begins  to  exert  himself.  Malloch 
states  that  the  oedema  cleared  up  within  24  to  48  hours  following 
rest  in  bed  and  ordinary  diet,  but  he  adds  that  at  first  the 
oedema  was  only  absent  if  the  man  stayed  in  bed  all  day,  and 
it  was  some  time  before  he  was  able  to  get  up  without  a  return 
of  the  oedema.  It  is  not  known  how  long  these  men  took  to 
regain  full  physical  efficiency,  because  their  subsequent  history 
in  England  was  not  traced. 

Treatment. 

The  treatment  is  simple.  Rest  in  bed,  warmth  and  a  diet 
rich  in  carbohydrates  wiU  cure  most  cases  in  a  short  time.  The 
diet  at  first  must  be  light,  easily  digested,  and  given  in  small 
quantities  as  in  any  case  of  starvation.  The  amount  of  liquid 
and  of  common  salt  should  be  limited.  Attention  must  be 
paid  to  any  other  disease  that  may  be  present.  Relapses  of 
diarrhoea  are  apt  to  be  troublesome.  Park  lays  particular 
stress  on  the  value  of  cod  liver  oil.  Emphasis  must  be  laid, 
however,  on  the  most  recent  researches,  which  demonstrate 
that  an  adequate  protein-content  is  no  less  essential  to  the 
dietary  than  an  adequate  supply  of  calories.  The  prevention 
of  famine  dropsy  consists  in  maintaining  a  diet  consisting  of 
at  least  2,000  calories,  and  this  calorie-content  is  only  compati- 
ble with  light  work.  The  experience  of  Hindhede  in  Denmark 
shows  that  green  vegetables  and  milk  can  supply  the  deficiency 
of  fats,  starches  and  sugar.  The  minimum  daily  nitrogenous 
intake  necessary  to  avert  dropsy  has  not  yet  been  established, 


FAMINE  DROPSY 


465 


nor  the  part  played  by  vitamines.  It  is  abundantly  clear  that 
in  future  the  estimates  of  minimum  food  requirements  must 
take  into  consideration  the  indispensability  of  each  and  all 
of  the  food  factors  known  and  unknown.  The  researches  of 
Sherman  fix  the  minimum  biological  value  of  protein  in  the 
daily  diet  at  approximately  45  grammes  for  a  man  of  70  kilo- 
grams weight,  although  Hindhede  fixes  it  at  the  much  lower 
figure  of  27 -5  gm.  for  the  same  body  weight.  Bayliss,  in 
referring  to  Hindhede's  experiments,  remarks  that  "care  was 
taken  that  the  total  caloric  value  of  the  food  was  abundant, 
a  point  of  essential  importance." 


Beyermann . . 


Bigland 

Budzynski    & 
Chelchowski 


Cornish 


Digby 
Daniels 

Davidson 


Denton   & 
Kohmann. 

Dictionnaire  Ency- 
clopedique  des 
Sciences  Medicales. 

Edgeworth 


(2396) 


BIBLIOGRAPHY. 

(Edema  disease  in  the  Nether- 
lands. 


(Edema   as  a  symptom  in  so- 
called  food-deficiency  diseases. 
Hunger  swelling  in  Poland 


Observations  on  the  nature  of 
the  food  of  the  inhabitants  of 
Southern  India,  and  on  prison 
diets  in  the  Madras  Presi- 
dency. 

A  reply  to  Sir  Richard  Temple's 
Minutes  of  the  7th  and  14th 
March,  as  to  the  sufficiency 
of  a  pound  of  grain  as  the 
basis  of  famine  wages. 

Famine  Services 

The  famine  campaign  in  South- 
ern India 
Epidemic  dropsy 


Epidemic 
dropsy 


of     acute     anaemic 


Geographical  pathology 


Feeding  experiments  with  raw 

and  boiled  carrots 
Articles  :  "  A  n  a  s  a  r  q  u  e  ," 

"  Famine,"  "  (Edlme  " 


Nederlandsch. 

Tijdschr.v.Genees- 

hunde,  1919.    Vol. 

i,    p.    2265    (Jl.  of 

Am.    Med.    Assoc. 

1919.    Vol.    Ixxiii, 

p.  1172.) 
Lancet,  1920.  Vol.  i, 

p.  243. 
Prezglad     lekarkski, 

1915.  Vol.  liv,  Nos. 

1  and  2  ; 
Jl.  Trop.  Med.,  1916. 

Vol.  xix,  p.  141. 
Madras  Quart.  Jl.  of 

Med.  Scien.,  1865. 

Vol.  viii,  p.  57. 


Madras  Govt. 
Minute,  1877. 


B.M.  J.,  1878.  Vol.  ii, 

p.  38. 
London  :  Longmans, 

1878. 
Trop.  Med.  and  Hyg. 

Part    iii,    London, 

Bale,  1912. 
Edin  Med.  Jl.    1881. 

Vol.  xx vi,    p.  117. 

Vol.  xxvii,    p.  118. 
Edinburgh     &   Lon- 
don :      Pentland, 

1892.  p.  781. 
Jl.  Biol.  Chem.  1918. 

Vol.  xxxvi,  p.  249. 
Paris  :    Masson, 

1876-1882. 


On   the   occurrence   of   general     Lancet,  1911.  Vol.  ii, 
subcutaneous       non-renal        p.  216. 
oedema  as  a  familiar  affection. 

EE 


466 


MEDICAL   HISTORY   OF  THE   WAR 


Enright 
Eppinger 


Eppinger  &  Steiner 

Falta 

»»  .  •  •         •  • 

Falta    &  Quittner.. 
Flesch 

Franke  & 
Gottesmann. 

Fraenkel 
Fridericia 

Fontan 
Gerhartz 

Giles 
Greig 

Guillermin   &  Guyot 
Harden   &  Zilva    . . 

Hecker 
Hindhede     . . 


BIBLIOGRAPHY— cont. 
War  oedema  in  Turkish  prisoners 

of  war. 
Zur  CEdemfrage 


Zur  Pathologic  und  Therapie  des 
menschlichen  CEdems,  zugleich 
ein  Beitrag  zur  Lehre  von  der 
Schilddrusen  Funktion 

Zur  CEdemfrage 


Zur  Pathologic  des  Kriegsodems. 
Zur  Pathologic  des  Kriegsodems. 


Ueber  Chemismus  verschiedener 
CEdemformen. 

CEdemkachexie  . 


GEdemkrankheit,      eine      anal- 
buminurische  Nephropathie. 

CEdemerkrankungen 


War  oedema  and  its  relation  to 
underfeeding. 

Epidemic     d'anasarque     essen- 

tielle. 
Endemische  CEdemkrankheit  . 


Report  on  the  causes  of  the 
diseases  known  in  Assam  as 
kala-azar  and  beri-beri. 

Epidemic  dropsy  in  Calcutta  . . 


Sous-alimentation  et  cedeme  de 
famine. 


(Edema  observed  in  a  monkey 
fed  on  a  diet  free  from  the 
fat-soluble  "  A "  accessory 
food  factor  and  low  in  fat. 

Epidemics  of  the  Middle  Ages . . 

The  effect  of  food  restriction 
during  the  war  on  the  mor- 
tality in  Copenhagen. 

Studien    iiber   Eiweissminimum 


Lancet,  1920.   Vol.  i, 

p.  314. 
Munch.      Med. 

Wchnschr.,     1916. 

Vol.  Ixiii,  p.  1055. 
Berlin  :    J.  Springer, 

1917.  " 


Wien  .  Klin. 
Wchnschr.,  1917. 
Vol.  xxx,  pp.  33  & 

Ber  1  .          Klin  . 

Wchnschr.,     1918. 

Vol.  Iv,  p.  342. 
Munch.     Med. 

Wchnschr.,     1917. 

Vol.  Ixiv,  p.  1539. 
Wien  .        Klin  . 

Wchnschr.,     1917. 

Vol.  xxx,  p.  1189. 
Klin.     Therap. 

Wchnschr.,     1917. 

Vol.  xxv,  p.  125. 
Wien  .        Klin  . 

Wchnschr.,     1917. 

Vol.  xxx,    p.  1004. 
Deutsch.     Med. 

Wchnschr.,     1917. 

Vol.  xliii,  p.  1607. 
Bibliot.  f.  Laeger, 

Kobenhavn,    1917. 

Vol.  cix,  p.  342. 
Gaz.  des  Hop.   1919. 

Vol.  xcii,  p.  913. 
Deutsch.     Med. 

Wchnschr.,     1917. 

Vol  xliii,  p.  922. 
S  h  i  1 1  o  n  g  :   Assam 

Press,   1890. 

Scientific  Memoirs  of 
the  Government  of 
India,  1911,  No.  45, 
1912,  No.  49. 

Rev.  Med.  de  la 
Suisse  Romande, 
1919.  Vol.  xxxix, 
p.  115. 

Lancet,  1919.  Vol  ii, 
p.  780. 


London  :    Sydenham 

Soc.,  1844,   p.  231. 
Jl.  Am.  Med.  Assoc., 

1920.    Vol.    Ixxiv, 

p.  381. 
S  k  a  n  d .      Arch. 

Physiol.,1913.  Vol. 

xxx,  pp.  97-182. 


FAMINE  DROPSY 


467 


BIBLIOGRAPHY— cont. 
Das  Eiweissminimum  bei  Brot- 
kost 

Die  Deutschen  in  Russland,1812 

Pathologische  -  Anatomische 
Untersuchungen  iiber  die 
Ursachen  der  (Edemkrankheit. 

Die  CEdemkrankheit  in  den 
Gef  angenenlagern . 

Das  Hungerodem 


Blutbefunden  bei  (Edemkranken 


Untersuchungen  iiber   Stoffum- 
satz  bei  (Edemkranken. 

Study  of  war  (Edema 


Besteht  ein  Zusammenhang  der 
(Edemkrankheit  in  den  Kriegs- 
gefangenenlagern  mit  Infek- 
tionskrankheiten  ? 

Kriegsodeme  und  Ruhr 


The  experimental  production  of 
edema  as  related  to  protein 
deficiency. 

Preliminary  note  on  experi- 
mental production  of  edema 
as  related  to  war  dropsy. 


Knack   &  Neumann      Beitrage  zur  (Edemfrage 


Hindhede    . 

Holzhausen 
Hiilse 


Jaksch 

Jansen 

Jansson 
Jiirgens 

Kestner    &  Rennen 
Kohman 


Kraus 
Landa 

Lange 

Lind.. 
Lichwitz 

Lippmann 


Die  Aushungerung  Deutschlands 
Deficiency  edema 


Ueber  das  Auftreten  eigenartiger 
(Edemzustande. 

On  the  Scurvy 

Ueber  (Edemerkrankungen 

Ueber  die  (Edemkrankheit 


S  k  a  n  d  .      Arch  . 

Physiol.,1914.  Vol. 

xxxi,  pp.  259-320. 

Bavarian    Military 

Staff,  1912. 
Wi  en  .         Klin  . 

Wchnschr.,     1918. 

Vol.  xxxi,  p.  7. 
Munch.      Med. 

Wchnschr.,     1917. 

Vol.  Ixiv,  p.  921. 
Wien.   Med.      Wchn- 
schr.,   1918.      Vol. 

Ixviii,  p.   1029. 
Munch.      Med. 

Wchnschr.,     1917. 

Vol.  Ixv,  p.  925. 
Munch.     Med. 

Wchnschr.,     1918. 

Vol.  Ixv,  p.  10. 
F  i  n  s  k  a     laksallsk. 

handl.,  1919.    Vol. 

Ixi,  p  235. 
B  e  r  1  .        Klin  . 

Wchnschr.,     1916. 

Vol.  liii,  p.  210. 

Arch.  f.  Schiffs.  und 
Tropenhygiene, 
1919.  Vol.  xxiii, 
p.  148. 

Am.Jl.Physiol.,1920. 
Vol.  li,  p.  378. 

Proc.      Soc.     Exper. 

Biol.      and     Med., 

1919.    Vol.  xvi,    p. 

121  (quoted   Jl.  of 

Amer.  Med.  Assoc. 

1919.     Vol.    Ixxiii, 

p.  274. 
D  e  u  t  s  c  h  .     Med. 

Wchnschr.,     1917. 

Vol.  xliii,  p.  901. 
Berl.  Klin.Wchnschr. 

1919.  Vol.  Ivi,  p.  3. 
GacetaMed.  Mexico, 

1917.  Vol.xi,  p.  67. 

(Jl.  of  Amer.  Med. 

Assoc.  1918,      Vol. 

Ixx,  p.  424). 
Deutsch.     Med. 

Wchnschr.,     1917. 

Vol.  xliii,  p.    876. 
3rd  Edition,  London 

1772. 
Munch.         Med . 

Wchnschr.,     1917. 

Vol.  Ixiv,  p.  983. 
Zeitschr.     f.      artzl. 

Fortbildung,  1917. 

Vol.  xiv,    p.    478. 


468 


MEDICAL   HISTORY   OF  THE  WAR 


Maase   &  Zondek 


McCarrison  .  . 

Macleod,  J.  j.  R. 
Macleod,  K. . . 


Maliwa 

ji 

Manson 
Maver 

Morawitz 
Park 

Patterson 

Petonyi 

Pighini 

Porter 

Prym 

Rosenthal 
Rumpel 


BIBLIOG  RAPH  Y— cont. 
Ueber  eigenartige  (Edeme 

Das  Kriegsodem 


Das  Hungerodem :  eine  klinische 
und  ernahrungsphysiologische 
Studie. 

Effects  of  deficient  dietaries  in 
monkeys. 

Studies  in   Deficiency    Disease. 
Physiology  and  Biochemistry  in 

modern  medicine. 
Epidemic  Dropsy 


Epidemic  Dropsy 


Bemerkungen  zur  (Edemkrank- 
heit. 

(Edemkrankheit . . 


Epidemic  Dropsy 

Nutritional   Edema    and     War 
Dropsy. 

(Edemkrankheit  mit  Hautatro- 

phien. 
War  Edema  (Kriegsoedem) 

Starvation  Edema 


Beitrage    zur    Pathologic    des 
(Ed  emkrankheits. 

L'Edema   da   fame   nelle   terre 
liberate. 


The  diseases  of  the  Madras 
Famine  of  1877-78. 

Allgemeine  Atrophie,  (Edem- 
krankheit und  Ruhr. 

Ueber  Cholesterinverarmung  der 
menschlichen  roten  Blutkor- 
perchen  unter  dem  Einfluss 
der  Kriegsernahrung. 

Zur  .Etiologie  der  (Edemkrank- 
heit aus  russischen  Gefan- 
genenlagern. 


Deutsch.     Med. 

Wchnschr.,     1917. 

Vol.  xliii,  p.  484. 
Berl.  Klin. 

Wchnschr.,    1917. 

Vol.  liv,  p.  861. 
Leipzig  :  Georg 

Thieme,  1920. 

B.M.J.,  1919.  Vol.  ii, 

p.    37;  1920.  Vol. 

i,  p.  249. 
Oxford,  1921. 
London  :     Kimpton, 

1918. 
Trans.  Epidem.  Soc. 

Lond.,         1892-3 

N.S.  xii,  p.  55. 
Allbutt  and   Rolles- 

ton's    System    of 

Medicine.      Lond. 

1907.  Vol.  ii,  Part 

ii,  p.  643. 
Wien.  Klin 

Wchnschr.,     1917. 

Vol.  xxx,  p.  1477. 
Wien.  Klin. 

Wchnschr.,    1918. 

Vol.  xxxi,  p.  957. 
Tropical  Diseases, 

6th  Edit.,  Cassell, 

1917. 
Jl.   Am.   Med.   Ass., 

1920.   Vol.    Ixxiv, 

p.  934. 
Med.     Klin.,     1918. 

Vol.  xiv,  p.  848. 
Jl.  Am.  Med.  Ass., 

1918.         Vol.  Ixx, 

p.  1826. 
N.Y.      Med.      Rec., 

1899.         Vol.   Ivi, 

p.  715. 
Wien.  Klin. 

Wchnschr.,     1918. 

Vol.  xxxi,  p.  953. 
Policlin.  (Roma) 

Sezione       pratica, 

1918.       Vol.   xxv, 

p.  1217. 
Madras  Government 

Press,  1889. 
Deutsch.    Med. 

Wchnschr.,     1918. 

Vol.  xliv,  p.  544. 
Deutsch.  Med. 

Wchnschr.,     1919. 

Vol.  xlv,  p.  571. 

Munch.  Med. 
Wchnschr.,  1915. 
Vol.  Ixii,  p.  1021. 


FAMINE  DROPSY 


469 


Rumpel 


Rumpel   &  Knack, 


Schiff 


Schittenhelm   & 
Schlecht. 

Sherman 


Strauss 
Sydenham  . . 
Tonin 

Versmann  . . 

Wartzoldt  .. 

Warthin  . . 

Weltmann  . . 
Wilson 


BIBLIOGRAPHY— cont. 
Ueber  CEdemerkrankungen 

Ueber  CEdemkrankheit . . 


Dysenterieartige  Darmerkrank- 
ungen  und  CEdeme. 


Das    Vorkommen    des    Kriegs- 
oedems  in  Wien. 

Ueber  die  CEdemkrankheit 


Protein  requirement  of  main- 
tenance in  man.  and  nutritive 
efficiency  of  bread  protein. 

Die  Hungerkrankheit 

Opera  omnia 

Edemi  da  fame  e  poliuria 

Ueber  CEdemerkrankungen 
CEdemkrankheit 


War  Edema 


Zur    Klinik  der 
krankheit. 


sogen.    CEdem- 


Report  of  a  Committee  of 
Inquiry  regarding  the  Preva- 
lence of  Pellagra  among 
Turkish  prisoners  of  war. 


Munch.        Med. 

Wchnschr.,     1917. 

Vol.   Ixiv,  p.    983. 
Berl.  Klin. 

Wchnschr.,     1917. 

Vol.  liv,  p.  857. 
Deutsch.     Med. 

Wchnschr.,     1916. 

Vol.  xlii,  pp.  1342, 

1440. 
Munch .        Med. 

Wchnschr.,     1917. 

Vol.  Ixiv,  p.   1539. 
Zeitschr.      f.      Exp. 

Med.,  1919.  Vol.  ix, 

p.  1. 
Jl.  Biol.  Chem.,  1920. 

Vol.  xli,  p.  97. 

Med.      Klin.,      1915. 

Vol.  xi,  p.  854. 
London  :    Sydenham 

Soc.,  1844.  p.  260. 
Gaz.   degli    ospediali 

(Milan),  1919.  Vol. 

xl,  p.  636. 
Munch.         Med. 

Wchnschr.,     1917. 

Vol.    Ixiv,    p.  983. 
Therap.  d.  Gegenwart 

1918.  Vol.    xx, 
pp.  24,  55. 

Internat.    Ass.  Med. 

Miss.   Bull.,    1918. 

No.  7,  p.  196. 
Wien.          Klin. 

Wchnschr.,     1916. 

Vol.  xxix,  p.  877. 
Jl.    of  R.A.M.C., 

1919.  Vol.   xxxiii, 
p.  508  ;   1920.  Vol. 
xxxiv,  p.  70. 


CHAPTER  XXI. 

PELLAGRA. 

IF   defined   as  "  a  disorder   of   metabolism  with   periodical 
manifestations    characterized    by     gastro-intestinal     dis- 
turbances, skin    lesions,  and  a  tendency  to  changes  in    the 
nervous   system/'    this   disease  was    first   recorded    as   such 
in  Spain  during  1735. 

Its  heaviest  incidence  has  fallen  upon  European  countries 
which  border  the  Mediterranean  and  lower  Danube ;  when 
looked  for  by  experts,  cases  have  been  found  as  far  north  as 
the  Shetland  Islands. 

At  the  onset  of  the  war,  theories  regarding  its  aetiology  were 
divisible  into  two  main  groups — the  dietetic  and  the  infective. 
Holders  of  the  former  view  were  turning  from  search  in 
cereals,  especially  in  maize,  for  a  hypothetical  toxin,  and  were 
inclining  to  the  American  setiological  theory  of  food  deficiency. 
Exponents  of  the  latter  theory  had  recently  suggested  that 
there  might  be  an  insect-vector,  such  as  Stomoxys  calcitrant 
or  some  species  of  Simulium. 

An  outbreak  of  pellagra  among  Turkish  prisoners  of  war  in 
Egypt  afforded  unique  opportunities  for  research  upon  a  scale, 
and  under  favourable  conditions,  such  as  could  hardly  obtain 
in  a  civilian  community.  A  special  investigation  was  com- 
pleted on  31st  December,  1918,  and  upon  the  conclusions 
then  reported  is  based  the  following  account  of  pellagra  from 
the  military  standpoint. 

The  committee  of  enquiry  consisted  of  two  members — Colonel 
F.  D.  Boyd,  consulting  physician  to  the  Egyptian  Expeditionary 
Force,  and  Lt.-Colonel  P.  S.  Lelean,  the  A.D.M.S.  for  Sani- 
tation, having  as  collaborators  recognized  experts  in  bromat- 
ology,  bio-chemistry,  pathology,  bacteriology,  protozoology 
and  hsematology. 

Incidence  and  Distribution. 

The  monthly  per  mille  incidence,  as  recorded  by  the  hospital 
admissions  of  all  prisoners  of  war  suffering  from  pellagra,  from 
the  first  cases  in  November  1916  to  the  end  of  1919,  is  shown 
in  Chart  I. 

The  maximum  corresponds  to  1,540  cases  admitted  to 
hospital  in  November  1918,  and  the  total  for  the  charted 
period  amounts  to  9,257  cases— or  8- 5  per  cent,  of  all  prisoners 
captured. 

470 


PELLAGRA 


471 


Amongst  British  and  Indian  troops  comprising  the  Egyptian 
Expeditionary  Force,  with  a  maximum  strength  of  316,605, 
there  occurred,  so  far  as  is  known,  only  a  single  and  doubtful 
case  :  an  Indian  was  diagnosed,  but  was  repatriated  before 
the  uncertain  diagnosis  could  be  established.  British  garrisons 


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in  Egypt,   where    pellagra  is  rife  among  the  fellahin,   also 
remained  unaffected. 

Among  men  of  the  Egyptian  labour  corps,  drawn  from 
highly  pellagrous  districts,  the  prevalence  of  this  disease  was 
such  that  245  cases  were  found  in  one  actively  working  gang 
of  1,000  labourers.  This  affords  a  most  striking  contrast  to 


472 


MEDICAL   HISTORY   OF  THE  WAR 


the  immunity  of  British  troops,  beside  whom  throughout 
the  war  thousands  of  these  men  worked  by  day  and  camped 
by  night. 

Among  German  and  Austrian  prisoners,  some  of  whom  had 
been  in  captivity  for  two  years,  no  case  had  been  reported  up 


MAP      SHOWING 

,a)    DOMICILE     OF    518     PELIAGROUS      PofW. 

(b)    PLACE.  OF  FIRST    ONSET    OF    THC  PF.LLAGROUS  SYMPTOMS  OF    474     Rof  W 
ONSET    BEFORE    CAPTUHE    405 
_,._      AFTER        -, 69 


o 


FIG.  1. 

to  31st  December,  1918,  when  the  special  investigation  was 
completed.* 

Among  518  unselected  pellagrins,  enquiries  were  made  re- 
garding the  areas  in  which  they  were  enlisted  and  the  districts 

*  Cases  which  have  occurred  since  that  date  will  be  referred  to  later.  The 
original  heading  of  "  Europeans,"  with  sub-headings  "  Germans  "  and 
"  Others,"  having  afforded  "  nil  "  returns  for  so  long,  the  sub-headings  were 
eventually  omitted  for  a  time  and  only  revived  during  April  1919.  The 
per  mille  rates  since  then — the  only  official  figures  available — are  included  in 
Chart  I. 


PELLAGRA  473 

in  which  they  were  when  the  initial  pellagrous  rash,  with  which 
these  aggregated  patients  were  thoroughly  familiar  when 
questioned,  appeared. 

That  a  definite  onset  was  common  was  suggested  by  the  fact 
that  474  of  these  men  (91  per  cent.)  were  able  to  give  a  date 
and  locality.  The  results  of  this  enquiry  are  shown  in  the 
map  on  the  opposite  page. 

With  reference  to  the  possibility  of  these  cases  dating  back  to 
the  areas  in  which  they  were  enlisted,  it  is  noted  that  only  one 
stated  that  his  rash  preceded  his  enlistment,  while  only 
five  had  seen  similar  rashes  among  their  acquaintances 
before  the  war.  Moreover,  only  one  of  the  many  captured 
medical  officers  of  all  nationalities  and  from  many  districts 
had  seen  a  case  of  pellagra  in  his  practice — a  Damascus 
practitioner  who  had  seen  five  cases  in  thirteen  years.  While 
the  tendency  to  overlook  cases  in  temperate  climates  is  recog- 
nized, it  is  justifiable  to  conclude  that  its  prevalence  in  Turkey 
before  the  war  was  slight. 

The  facts  which  call  for  special  notice  are  that  cases  began 
to  occur  in  Gallipoli ;  that  the  map,  taken  in  conjunction  with 
dates,  indicates  a  great  preponderance  in  those  vilayets  where 
the  Turks  were  aggregated  towards  the  end  of  the  war ;  and  that 
there  are  sufficient  cases  to  show  that  troops  on  the  Mesopotamia 
front  were  also  affected. 

Cases  which  denied  any  previous  symptoms  were  admitted 
to  hospital  from  all  prisoner  camps,  whether  in  the  wooded 
and  watered  Palestine  plain,  the  arid  desert  bordering  the  Suez 
Canal,  the  cultivated  land  beside  the  Nile  at  Maadi,  or  by  the 
seaside  at  Alexandria.  At  first  it  was  thought  that  the  labour 
camp  at  Ludd,  Palestine,  was  free,  but  when  1,840  prisoners 
were  transferred  thence  to  Kantara,  where  medical  officers 
with  greater  experience  in  diagnosis  were  available,  122pellagrins 
from  among  their  number  (6  per  cent.)  were  admitted  to 
hospital  for  pellagra  within  48  hours  of  their  arrival. 

Of  484  prisoners,  unselected,  who  were  able  to  give  an 
approximate  date  for  the  onset  of  symptoms,  85  per  cent,  were 
pellagrous  before  capture.  Of  the  359  able  to  fix  a  definite 
date  within  six-monthly  periods,  this  date  was  : — 

From  12  to    6  months  before  capture  in    40  cases  (11-1%). 
6  „     0       „  „  „        „  279     „     (77-8%). 

0  „     6       „        after  capture    in    27     „     (  7-5%). 
6  „   12       „  „  „        „     13     „      (  3-6%). 

The  discovery  of  236  definite  cases  in  one  batch  of  1,300 
prisoners  (18  per  cent.)  examined  in  October  1918,  on  the  day 
after  their  arrival  direct  from  the  front,  confirmed  the  belief  that 
pellagra  in  prisoners  had  usually  occurred  before  their  capture. 


474 


MEDICAL   HISTORY   OF  THE  WAR 


The  conclusions  drawn  from  these  facts  are  that  pellagra 
among  the  Turkish  forces  was  a  result  of  the  war ;  that  it  was 
due  to  a  cause  progressively  increasing  in  intensity  towards 
the  end  of  the  war ;  and  that  this  cause  became  abruptly 
less  active  coincidently  with  capture. 

As  regards  the  incidence  on  Turkish  military  formations, 
51  divisions  and  6  corps  troops  were  represented  among  505 

Seasonal    Prevalence  Canves 


JFMAMJJASOND 


Normal   fo  Eov  pf  (  Co  shell  a  ni ) 

""Per  Mille  rate  onTarkish  prisoners  in  1919. 
CHART  II. 

consecutive  pellagrins.  While  one  division  provided  53  cases, 
33  other  divisions  only  provided  54  cases  among  them — with 
a  maximum  of  4. 

This  clearly  indicates  that  the  essential  factor  in  causation 
was  of  wide  spread  application,  and  affords  evidence  that 
pellagra  is  not  infectious  from  case  to  case. 


PELLAGRA 


475 


In  relation  to  social  grade,  although  several  admissions 
occurred  from  the  officers'  prisoners  of  war  camp  at  Alexandria 
during  1917,  that  camp  reported  no  new  case  and  only  three 
recurrences  in  1918,  during  which  year  the  strength  rose  from 
1,900  to  4,400.  Incidence  was  thus  markedly  lower  upon  the 
officer  class  than  upon  the  rank  and  file.  Rations  were 

Peilogry  incidence  on  loboar*  and  non-  labour* 
*-^TcipKish   prisoners  in   1916. 

Labour*     (avet»o^e  sfrenglfi  5OOO  appro*). 

Non-  loboar  (overage  Sfrengffi  25.0QO  pppr»ox  ). 


Mi  lie 
240 

2*0 


200 
ISO 
L60 
IdO 
I20 
IOO 
80 


ON      D 


(B)    (c) 

ncreased  From  900  V*  60OO. 


vol  y  hi  oh  SicK  paT^  occcir»ped. 
rdfaonosisoF  Pelloofa    was   eSfobli*h«d. 


CHART  III. 

identical ;  but  officers  supplemented  theirs,  other  ranks  could 
not  do  so. 

In  1917  the  prisoner  population  was  small ;  in  1918  it  was 
subject  to  abrupt  trebling.  The  per  mille  ratios  for  1919  are, 
therefore,  adopted  for  preparing  Chart  II  of  the  seasonal 
prevalence  for  purposes  of  comparison  with  the  curve 
of  normal  Egyptian  prevalence  as  given  by  Castellani  in  actuals. 


476  MEDICAL   HISTORY   OF  THE   WAR 

To  restrict  the  population  dealt  with  to  those  present  from 
the  beginning  of  1919,  there  are  excluded  from  the  chart  12,600 
emaciated  prisoners  who  had  been  besieged  at  Medina  for  many 
months.  On  arrival  in  Egypt  in  February  and  March  1919, 
these  had  58  pellagrins  among  them,  and  275  others  were  ad- 
mitted for  that  disease  within  a  short  period. 

In  1919  practically  no  fresh  cases  were  admitted  on  the  diet 
then  in  use,  the  admissions  in  that  year  being  recurrent  cases. 

With  regard  to  the  relation  between  pellagra  incidence  and 
labour,  pellagra  was  first  diagnosed  in  the  chief  Turkish 
prisoners'  labour  camp,  which  was  at  Kantara,  when  the  high 
sick-rate  there  during  May  and  June  1918,  led  to  the  special 
investigation.  The  importance  of  this  factor  is  indicated  by 
the  comparison  shown  in  Chart  III  between  the  incidence 
in  this  camp  and  that  in  four  other  camps,  where  Turkish 
prisoners  were  not  employed  as  labourers,  but  where,  after 
careful  medical  inspection  by  an  officer  with  special  ex- 
pert knowledge  of  the  disease,  they  were  being  enlisted  as  paid 
labourers  previous  to  their  transfer  to  the  chief  labour 
camp. 

The  Kantara  labour  camp  was  close  to  British  and  Indian 
units,  on  clean  and  absolutely  barren  sand,  over  a  mile  east  of 
the  Suez  Canal,  and  under  extremely  good  sanitary  conditions. 
During  the  day  the  labourers  worked  in  gangs  about  the  camp 
on  duties  involving  a  maximum  energy  expenditure  of  some 
80,000  kilogramme  metres  a  day.  This  work  was  in  no 
way  exacting,  nor  liable  to  be  excessive.  The  energy 
expenditure  was  only  two-thirds  that  of  Egyptian  hard- 
labour  convicts.  Of  100  pulse-rates  taken  immediately 
on  the  men's  return  to  camp  after  the  heaviest  labour  observed, 
only  two  failed  to  return  to  normal  after  15  minutes'  rest,  and 
both  these  men  were  found  to  have  slight  fever  although 
refusing  to  go  sick. 

In  spite  of  these  favourable  conditions,  men  transferred  to 
this  camp,  after  selection  by  the  most  experienced  pellagra 
experts  as  free  from  suspicion  of  the  disease,  rapidly  became 
pellagrous  after  starting  work,  although  the  troops  beside  them 
remained  wholly  free. 

If  allowed  to  continue  at  work — at  their  own  request — they 
became  hospital  cases  within  about  eight  weeks  of  onset  of  the 
initial  diagnostic  symptoms  ;  if  placed  in  hospital  as  soon  as 
the  diagnosis  was  confirmed  by  experts,  they  recovered  so 
rapidly  that  in  many  cases  the  symptoms  subsided 
almost  to  vanishing  point  in  the  few  days  that  elapsed  pending 
their  transfer  to  Egypt,  the  only  treatment  being  rest  and 
dieting. 


PELLAGRA  477 

The  total  admissions  for  pellagra  were  1,540  out  of  a  total 
prisoner  strength  of  109,000,  and  in  November  1918,  no  less 
than  1,067  of  the  hospital  admissions  for  pellagra  came  from  this 
camp  with  a  strength  averaging  some  5,000  Turkish  prisoners. 

Symptoms. 

The  characteristic  symptoms  of  a  developed  case  are  dryness 
and  wrinkling  of  the  skin,  with  pigmentation  over  the  whole 
body,  but  more  especially  over  the  face,  neck,  arms  and  hands, 
but  the  symptoms  in  general  conformed  to  the  usual  text-book 
descriptions  of  the  intestinal,  cutaneous  and  nervous  mani- 
festations of  the  disease.  Certain  symptoms,  however,  observed 
in  the  earliest  stages  are  important  for  the  purpose  of  diagnosis. 

The  earliest  observable  sign  was  dryness  and  loss  of  elasticity 
of  the  skin  on  the  dorsum  of  the  hands  and  wrists.  Later,  it 
was  found  that  the  affected  areas,  going  on  to  the  characteristic 
pigmentation,  remained  dry  when  copious  sweating  elsewhere 
followed  injection  of  pilocarpine.  Hypo-chlorhydria  was  also 
amongst  the  earliest  indications  of  the  disease,  and  progressed 
towards  an  ultimate  achlorhydria.  Very  early,  too,  there  was 
a  notable  fall  in  systemic  blood-pressure.  A  little  later  there 
occurred  a  marked  loss  of  muscle  tone  and  substance,  usually 
appearing  first  in  the  upper  arm  and  shoulder-girdle.  In  the 
Kantara  labour  cases  this  was  usually  observable  within  six 
weeks  of  the  earliest  suspicion  of  a  man  being  pellagrous. 
Parotitis  occurred  in  a  limited  number,  and  oedema  of  the  ankles 
in  a  very  limited  number  of  cases.  Later,  pigmentation  was 
likely  to  affect  all  scar  tissue  and  pressure  areas,  even  those  so 
little  exposed  to  light  as  the  great  trochanters  and  the  zone 
constricted  by  waist-girdles. 

Indicanuria  was  common  in  developed  cases,  progressed  with 
the  disease  and  subsided  as  slight  cases  were  arrested.  For 
example,  amongst  296  men  specially  examined,  64 -3  per  cent, 
of  healthy  Turkish  prisoners  had  no  indicanuria,  and  35  •  7  per 
cent,  only  a  slight  amount ;  whereas  amongst  pellagrins  in  the 
quiescent  stage,  54-2  per  cent,  had  slight,  and  11-5  per  cent, 
well-marked  indicanuria ;  while  in  pellagrins  in  the  active  stage, 
marked  indicanuria  was  present  in  28-2  per  cent.,  and  slight 
indicanuria  in  64-8  per  cent.,  only  7  per  cent,  showing  an 
absence  of  indicanuria. 

Treatment. 

With  regard  to  treatment  and  prognosis,  general  experience 
indicated  that  early  cases  treated  by  rest  and  a  generous  dietary 
rapidly  lost  all  symptoms  of  the  active  disease,  although  no 
drugs  were  exhibited.  Advanced  cases  progressed  to  a  fatal 
end  despite  all  measures  adopted. 


478  MEDICAL  HISTORY   OF  THE  WAR 

Morbid  Anatomy. 

Among  178  autopsies  carried  out  in  prisoner  hospitals  in 
Egypt  there  were  only  two  in  which  pellagra  could  be  regarded 
as  the  determining  cause  of  death  ;  the  fatal  ending  was  almost 
invariably  due  to  a  supervening  acute  infection  such  as  pneu- 
monia, dysentery,  tuberculosis,  or  malaria.  Lesions  of  former 
dysentery  and  pulmonary  tuberculosis  were  also  found  in 
61  per  cent,  and  17  per  cent,  of  these  autopsies  respectively, 
and  ascarides  were  found  in  16  per  cent. 

No  reliable  estimate  could  thus  be  made  of  the  mortality  of 
pellagra  in  the  absence  of  acute  terminal  infections  of  other 
diseases,  the  lowered  resistance  to  which  is  so  conspicuous  a 
feature  of  pellagrins. 

Findings  at  the  above  autopsies  were  so  obscured  by  the 
effects  of  the  terminal  complicating  infections  as  to  be  of  nega- 
tive value,  with  two  exceptions  ;  the  adrenals  were  found  of 
an  average  lighter  weight,  and  ganglion  cells  of  the  sympathetic 
nervous  system  were  found  in  certain  cases  to  be  plasmolysed. 

^Etiology. 

An  aetiological  theory,  to  be  acceptable,  must  satisfactorily 
explain  how  it  came  about  that  in  an  army  enlisted  in,  and 
subsequently  occupying,  areas  where  pellagra  was  previously 
almost  unrecognized,  the  disease  became  widely  distributed  and 
increasingly  prevalent  towards  the  end  of  a  long  war,  while 
the  incidence  abruptly  declined  on  capture  and  transfer  of 
prisoners  to  a  pellagrous  country,  but  continued  to  occur  in 
all  the  widely  separated  prisoner  camps,  although  the  British 
and  Indian  troops  camped  alongside  them  remained  wholly 
unaffected.  Further,  why  it  was  that  officers  were  less  affected 
than  other  ranks,  and  European  far  less  than  Asiatic  Turks, 
and  why  previously  healthy  labour  prisoners  were  the  most 
heavily  and  rapidly  affected,  but  as  rapidly  recovered  on  rest 
and  good  diet  without  leaving  the  working  area,  must  also  be 
explained. 

The  essential  or  dominant  cause  of  this  outbreak  must  thus 
be  some  factor  exclusively  or  predominantly  applicable  to  the 
affected  prisoners  as  compared  with  unaffected  British  and 
Indian  troops.  It  is  noted,  however,  that  this  disease  may 
possibly  be  due  to  associated  predisposing  and  determining 
causes,  and  that  one  or  both  may  be  operable  for  a  longer 
period  than  the  two  years  with  which  this  analysis  deals. 

Water  supplies,  climatic  conditions,  biting  flies  and  special 
local  conditions  were  definitely  excluded  as  factors  inconsistent 
with  the  above  facts.  General  hygienic  conditions  were  ex- 
cluded as  they  were  at  their  best  in  the  Kantara  labour  camp, 


PELLAGRA  479 

which  was  most  affected.  Case  to  case  infection  was  eliminated 
because  of  480  cases  from  150  tents  in  one  compound,  395 
were  aggregated  in  a  purely  chance  distribution.  Thirty-seven 
cases  corresponded  with  a  greater  aggregation  in  tents  and  38 
with  less  aggregation  than  the  average.  Of  253  orderlies  in  the 
chief  hospital  treating  pellagrins  in  all  stages  for  over  two  years 
not  one  showed  any  sign  of  the  disease.  No  recorded  case 
occurred  among  the  many  captured  medical  orderlies.  No 
evidence  of  a  bacteriological  or  protozoological  infective  agent 
was  found  in  544  special  examinations,  among  many  others, 
of  faeces,  blood,  urine  and  cerebro-spinal  fluid  of  patients  in  all 
stages  and  from  various  camps  both  labour  and  non-labour. 
Helminthic  entozoa — although  possibly  amongst  contributory 
factors — were  not  considered  to  play  an  essential  part  because 
non-pellagrous  prisoners  were  as  badly  infested  as  the 
pellagrins,  for  ascaris  was  estimated  as  infecting  63  per  cent,  of 
prisoners,  and  the  immune  Indian  troops  were  also  generally 
and  heavily  infested  by  this  parasite. 

There  remained  for  consideration  the  theory,  propounded  by 
Professor  W.  H.  Wilson,  that  pellagra  is  associated  aetiologically 
with  an  actual  or  relative  deficiency  in  the  biological  protein 
value  of  the  diets.  The  biological  value  of  a  protein  is  the 
ratio  which  its  power  to  maintain  nitrogenous  equilibrium 
bears  to  that  of  pure  animal  protein.  The  actual  minimal  daily 
needs  of  a  standard  male  are  estimated  by  Wilson  as  being  of 
the  biological  value  of  40  grammes  of  protein  for  no  labour 
or  light  labour,  and  45  grammes  for  hard  labour.  The  relative 
value  must  obviously  be  diminished  if  the  total  calories  ex- 
pended in  labour  exceed  the  total  energy  provided  by  the  diet, 
as  amino-acids  on  their  way  to  the  tissues  are  then  oxidized  to 
make  good  the  immediate  energy-deficit.  American  work  by 
Goldberger  indicates  that  a  low  protein  diet  produces  pellagrous 
symptoms  in  about  five  months,  but  it  is  reasonable  to  suppose 
that  this  period  may  be  modified  both  by  varying  intensity  of 
the  deficiency  and  by  idiosyncrasy  in  the  power  of  digesting, 
assimilating  or  metabolizing  protein.  A  deficient  supply  of 
protein  to  the  tissues  may  thus  be  due  to  faulty  diet,  defective 
assimilation,  or  adverse  disparity  between  energy  intake  and 
energy  expenditure. 

The  extent  of  mal-assimilation  of  food  by  pellagrins  was 
specially  investigated,  comparative  groups  of  healthy  and  pella- 
grous Turkish  prisoners  being  segregated  and  given  the  same 
ration  food  under  carefully  controlled  conditions.  In  the 
pellagrous  group  there  was  a  faecal  loss  amounting  to  35  per 
cent,  of  the  ingested  protein  and  28.2  per  cent,  of  the  ingested 
fat.  The  further  subsequent  loss  of  assimilated  nitrogen,  by 


480 


MEDICAL  HISTORY   OF   THE   WAR 


its  rapid  excretion  as  indican  without  having  been  available  for 
metabolism,  has  already  been  referred  to. 

This  leads  up  to  consideration  of  various  dietaries  in  use  by 
the  various  bodies  of  troops  and  prisoners  concerned,  with  a 
view  to  ascertaining  how  far  this  theory  affords  an  adequate 
explanation  of  the  occurrence  and  distribution  of  pellagra 
among  the  troops. 


The  above  graph  and  following  table  give  the  data  from 
which  conclusions  may  be  drawn.  The  graph  indicates  that 
the  only  dietetic  factor  in  this  wide  variety  of  diets,  which 
constantly  correlates  pellagra  incidence,  is  the  biological  value 
of  protein  (B.V.P.).  The  table  gives  the  estimated  amount  of 
grammes  of  each  constituent  daily. 


PELLAGRA 


481 


Protein. 

Fat. 

C.-Hy. 

Calories 

B.V.P. 

Gross. 

BRITISH. 

European  troops,  1918  scale.normal 
„     less  10% 

92-6 
83-3 

124-8 
112-3 

116-2 
104-6 

492 
443 

3610 
3250 

Indian    troops,     1918  scale.normal 

55-1 

120-4 

96-1 

592 

3810 

„      less  10% 

49-6 

108-4 

86-5 

533 

3430 

TURKISH    PRISONERS. 

Before  capture. 

Sept.,    1917.      (Documentary  evi- 

30-4 

82-4 

27-5 

490 

2603 

dence.) 

Aug.-Nov.,     1918,    average    27th 

— 

— 

— 

— 

2606 

Div.     (Document.) 

Aug.-Nov.,   1918,  43rd  Regt.,  1st 

— 

— 

— 

— 

2214 

F.  Art.     (Document.) 

After  capture. 

(i)    Non-Labour. 

Apr.-Sept.,  1918,  average 

37-2 

90-5 

30-7 

492 

2684 

ration  issues,  actuals. 

(ii)  Labour. 

June-Oct.,  1918,  average 

45-6 

102-4 

33-3 

560 

3026 

ration  issues,  actuals. 

Rations,  plus  canteen  stores, 

49-6 

110-4 

41-3 

'619 

3370 

Kantara,  1918. 

EUROPEAN    PRISONERS. 

After  capture. 

May-Aug.,  1918,  ration  scale 

54-7 

90-3 

28-8 

351 

2069 

Nov.,    1918,  rations  plus  canteen 

89-7 

144-3 

120-7 

458 

3589 

stores. 

The  British  troops,  on  adequate  B.V.P. ,  remained  wholly 
free  from  pellagra  throughout  the  war.  The  Turks  suffered 
from  an  absolute  deficiency  of  B.V.P.,  both  prior  to  capture 
and  as  non-labour  prisoners,  although  their  rations  conformed 
to  the  standards  of  diet  laid  down  by  hygienists  before  the 
importance  of  the  B.V.P.  factor  was  recognized.  The  B.V.P. 
of  the  labour  diet  was  so  near  the  hard-labour  minimum  of  45 
grammes  that  defective  cooking  or  assimilation  or  excess  of 
work  would  reduce  it  to  a  relative  deficiency,  unless  high  B.V.P. 
extras  were  purchased  in  canteens. 

Special  interest,  as  regards  the  incidence  among  European 
prisoners  of  war,  centres  in  the  Maadi  camp  beside  the  Nile,  where 
6,000  Turkish  and  2,000  German  prisoners  were  in  grass  huts 
adjoining  each  other,  the.  only  discoverable  difference  in  con- 
ditions being  that  of  diet.  A  committee  of  enquiry,  appointed 
in  October  1918,  investigated  the  conditions  in  these  camps  in 
November  of  the  same  year,  because  at  that  time  the  Turks  had 

(2396)  F  F 


482  MEDICAL   HISTORY   OF   THE   WAR 

had  sixty  admissions  for  pellagra  within  two  months,  while  the 
Germans,  many  of  whom  had  been  there  for  two  years,  had 
remained  wholly  free.  Two  hundred  of  the  latter  were  carefully 
examined  by  highly  experienced  experts,  who  discerned  no  case 
of  pellagra  amongst  them.  No  German  case  occurred  until 
early  in  1919,  when  two  pellagrins  were  admitted  to  hospital 
after  the  committee  of  enquiry  had  dispersed.  The  crucial 
point  connected  with  these  facts  is  that  in  November  1918  the 
Turks  had  no  means  of  supplementing  their  rations  ;  whereas 
the  Germans  received  2s.  a  day  from  a  neutral  consul, 
and  practically  the  whole  of  this  amount  passed  through  the 
canteen  accounts.  No  information  was  available  at  the  time 
as  to  whether  this  sum  was  continued  to  be  paid,  and,  if  so, 
whether  these  two  pellagrins  spent  it  on  food  or  transmitted 
it  to  their  families  when  opportunities  for  so  doing  occurred 
on  the  armistice  being  signed  in  November  1918,  but  in- 
vestigation of  the  canteen  accounts  of  30  out  of  79  sub- 
sequent cases  proved  that  they  had  not  supplemented  their 
rations  in  this  manner.  As  they  lived  on  their  rations,  the  low 
calorie  value  sufficed  to  reduce  the  B.V.P.  to  a  marked  relative 
deficiency.  One  of  the  difficulties  in  obtaining  precise  infor- 
mation as  to  the  incidence  amongst  German  prisoners  is  due 
to  the  fact  that  the  returns  did  not  differentiate  "  Germans  " 
from  "  Other  Europeans  "  until  31st  December,  1919.  The 
German  cases  have  been  cited  as  evidence  against  the  B.V.P. 
theory,  on  the  grounds  that  the  Germans  were  excellently  fed 
prior  to  capture,  and  that  some  cases  developed  pellagra  after 
having  been  some  time  in  hospital.  But  the  information  re- 
garding the  German  ration  prior  to  capture  was  obtained  from 
a  German,  who  may  have  been  influenced  by  a  desire  to  exagge- 
rate. It  was  unsupported  by  document,  and  suggested  an 
improbably  high  dietetic  standard  for  troops  whose  food- 
shortage  was  notorious,  and  who  were  serving  with  an  army 
badly  fed  and  with  its  transport  disorganized.  At  a  time  when 
food-shortage  reduced  the  protein  ration  of  British  troops  to 
112  grms.  a  day,  only  reliable  evidence  would  justify  the  belief 
that  some  7,000  Germans  serving  throughout  the  Turkish  forces, 
both  on  the  lines  of  communication  and  at  the  front,  were  all 
receiving  a  ration  averaging  a  protein  content  of  170  grammes. 
As  regards  the  hospital  cases  it  is  noted  that  95  per  cent,  of  the 
German  pellagrins  had  suffered  from  dysentery  or  diarrhoea 
during  the  preceding  two  years  ;  their  powers  of  assimilation, 
certainly  as  regards  the  60  per  cent,  of  dysenteries,  were 
probably  impaired.  That  two  of  them  suffered  from  scurvy 
is  sufficient  to  discount  the  statement  that  their  diet  contained 
450  grammes  of  fresh  vegetables  daily. 


PELLAGRA 


483 


It  is  evident,  therefore,  that  no  other  aetiological  theory  fits 
the  definitely  ascertained  facts,  and  that  there  is  ample  support 
for  the  conclusion  that  "  Lack  of  sufficient  biological  value  of 
protein  stands  in  cetiological  relation  to  pellagra  certainly  as  an 
exciting  factor  and  possibly  as  the  determining  factor." 

A  similar  conclusion  was  reached  during  an  independent 
investigation  of  a  pellagrous  outbreak  among  Armenian 
refugees.  The  following  graph,  prepared  by  the  committee  of 
enquiry  referred  to  above,  shows  the  relation  of  this  outbreak 
and  its  subsidence  to  the  diet  of  these  refugees.  Their  camp 
remained  throughout  on  the  same  isolated  site,  on  barren  desert 
beside  the  Suez  Canal,  where  the  general  conditions  remained 
unaltered. 


f 


a 

— 


484  MEDICAL   HISTORY   OF   THE   WAR 

The  investigation  throws  light  upon  the  possible  mechanism 
of  production  of  pellagrous  symptoms  as  a  result  of  B.V.P. 
deficiency. 

The  ascertained  facts  were  that  in  the  early  stages  there  were 
hypochlorhydria,  loss  of  protein  by  lienteric  diarrhoea  and 
indicanuria,  adrenal  atrophy,  lowering  of  the  blood-pressure, 
and  degenerative  changes  in  the  sympathetic  ganglia. 

The  sequence  of  the  stages  between  these  established  changes 
from  knowledge  of  physiological  processes  may  be  regarded 
according  to  Professor  H.  E.  Roaf  as  being  as  follows  :— 

Hypochlorhydria,  defective  protein  assimilation,  deficient 
supply  of  amino-acids  (especially  tryptophane)  to  the  adrenals 
or  the  thyroid,  deficient  production  of  adrenalin,  lack  of  this 
natural  stimulus  to  the  sympathetic  nervous  system,  functional 
failure  of  sympathetic  action,  leading  to  lowering  of  the  blood- 
pressure  and  to  diarrhoea,  degenerative  changes  in  the  sympa- 
thetic structure,  and  profound  deterioration  of  the  metabolic 
processes  of  all  tissues  in  the  body. 

Establishment  of  the  disease  tends  to  the  development  of  a 
vicious  cycle  of  malassimilation  of  protein,  putrefactive  diar- 
rhoea and  rapid  evacuation  of  the  lessened  amount  of  protein 
available  for  assimilation.  Prior  to  the  development  and 
establishment  of  that  cycle  and  its  resultant  changes,  arrest  of 
symptoms  may  occur,  but  experience  suggests  that  there  re- 
mains some  permanent  condition,  possibly  hypochlorhydria, 
which  keeps  the  pellagrin  on  the  borderland  of  safety,  but 
liable  to  relapse  at  any  time  if  the  precarious  balance  of  protein 
metabolism  be  disturbed. 

There  is  no  special  bibliography  which  deals  with  pellagra 
during  the  war,  but  a  very  extensive  bibliography  is  published 
in  a  work  on  Pellagra  by  Dr.  A.  F.  Harris,  of  Atalanta,  in  1919. 
The  report  of  the  Committee  of  Enquiry  regarding  the 
prevalence  of  pellagra  among  Turkish  prisoners  of  war,  was 
published  in  Volumes  xxxiii  and  xxxiv  of  the  Journal  of  the 
Royal  Army  Medical  Corps. 


CHAPTER  XXII. 

NEPHRITIS. 

THE  term  trench  nephritis  was  applied  in  1915  to  describe 
a  series  of  cases  of  nephritis  that  occurred  in  the  spring 
of  that  year  in  the  British  Armies  in  France  and  Flanders. 
In  the  early  months  of  the  campaign,  from  August  1914  to 
February  1915,  very  few  cases  of  renal  disease  were  admitted 
to  hospital,  but  from  March  1915  onwards,  and  in  1916  and 
1917,  considerable  numbers  of  cases  of  nephritis  occurred. 
Inasmuch  as  the  clinical  course  of  the  malady  was  in  some 
respects  different  from  that  usually  associated  with  the  nephritis 
of  civil  life,  the  term  "  trench  nephritis  "  was  applied  to  these 
cases,  under  the  impression  that  possibly  they  were  of  a  nature 
different  from  other  recognized  forms.  Later,  when  observation 
showed  that  such  cases  were  not  restricted  in  their  incidence 
to  men  serving  in  the  trenches,  the  term  "  trench  nephritis  "  was 
replaced  by  that  of  "war  nephritis."  This  term  may  be  used 
with  propriety  if  it  be  held  to  be  descriptive  of  nephritis  as 
seen  under  war  conditions,  but  it  cannot  be  regarded  as  proved 
that  war  nephritis  is  a  malady  distinct  and  separate  from 
other  forms  of  nephritis. 

Nephritis  has  not  been  specially  noted  by  military  medical 
writers  in  former  years,  except  during  the  American  Civil  War. 
In  that  war  there  was  a  considerable  outbreak  of  the  disease, 
especially  in  the  years  1862  and  1863.  The  case  incidence 
reached  as  high  a  level  as  150  per  100,000,  and  there  were  in 
all  some  14,000  cases. 

In  the  more  recent  wars  of  the  last  fifty  years,  acute  nephritis 
does  not  seem  to  have  been  prevalent,  and  very  few  cases  of  renal 
disease  in  any  form  occurred  in  the  British  Armies  in  France  and 
Flanders  until  February  1915.  Prior  to  this  date  a  few  cases  of 
chronic  nephritis  were  seen,  especially  in  reservists  who  had 
joined  the  colours  on  mobilization,  and  a  very  small  number 
of  cases  of  fatal  uraemia,  sometimes  of  a  very  acute  type,  and 
associated  with  the  presence  of  latent  chronic  nephritis  with 
small  contracted  white  kidneys.  Such  cases  were  identical  with 
those  seen  from  time  to  time  in  civil  practice,  where  the  fatal 
acute  uraemia  is  the  first  indication  that  an  extensive  chronic 
lesion  is  present.  It  is  remarkable  that  men  with  chronic 
lesions  of  this  nature  should  have  been  able,  as  some  of  them 
were,  to  go  through  the  hardships  of  the  campaign  during  the 

485 


486 


MEDICAL   HISTORY   OF  THE    WAR 


first  three  or  four  months  of  the  war.  There  was  nothing 
otherwise  remarkable  in  the  occurrence  of  these  cases  of  chronic 
renal  disease,  and  such  cases  were  seen  in  small  numbers  through- 
out the  war  ;  but  the  number  of  cases  of  chronic  renal  disease 
that  escaped  detection  and  were  admitted  to  the  army  was  very 
small.  This  is  shown  by  the  results  of  the  examination  of  the 
urine  in  50,000  men  by  Captain  H.  MacLean,  R.A.M.C.  Casts 
were  found  by  him  to  be  present  in  1-87  per  cent.,  and  of  these 
0-84  per  cent,  had  definite  epithelial  casts,  but  doubtless  in 
only  a  certain  proportion  of  these  was  serious  chronic  disease 
present.  In  February  1915,  a  few  cases  of  renal  dropsy  were 
observed  in  the  hospitals  on  the  lines  of  communication  for 
the  first  time,  and  in  the  subsequent  months  of  1915  the  number 
of  such  cases  increased  considerably. 

The  following  table*  gives  the  rates  of  incidence  of  nephritis 
per  100,000  for  the  years  1915,  1916  and  1917  in  France. 

Rates  of  Nephritis  and  Albuminuria  per  100,000  of  strength. 


1915. 

1916. 

1917. 

January 

8-93 

69-22 

99-27 

February 

, 

21-08 

72-73 

100-50 

March 

g 

34-63 

68-49 

93-09 

April 

. 

47-28 

54-25 

53-01 

May 

. 

39-63 

38-38 

51-66 

June 

. 

55-97 

41-60 

42-79 

July 

57-96 

39-28 

50-51 

August 

53-02 

32-91 

49-08 

September 

41-87 

37-86 

48-42 

October 

52-35 

61-24 

61-30 

November 

73-98 

64-97 

63-70 

December 

72-28 

104-40 

55-62 

The  number  of  cases  increased  throughout  the  year  1915, 
with  a  slight  drop  in  the  months  of  May  and  September.     In 

1915  the  highest  incidence  occurred  in  November  and  December, 
but  the  rate  was  also  high  during  June,  July  and  August.      In 

1916  the  highest  rates  were  observed  during  the  winter  months, 
and  there  was  a  notable  fall  from  May  to  September.     The 
rates  were  especially  high  from  December  1916  to  March  1917, 
but  during  this  period  respiratory  diseases  were  very  prevalent, 
especially    bronchitis     and    lobular     pneumonia.      Nephritis 
occurred  in  association  with  these  maladies  and  not  infrequently 
was  a  complication  of  primary  respiratory  disease.    The  cases 
not  only  swelled  the  nephritis  records,  but  also  greatly  increased 

*  From  Report  No.  3,  dated  7th  June,  1918,  by  a  committee  appointed  in 
France  to  investigate  war  nephritis. 


NEPHRITIS  487 

the  mortality  rates,  and  in  so  far  as  they  were  instances  of 
secondary  nephritis  complicating  bronchitis  or  pneumonia,  they 
really  belonged  to  a  different  category  from  that  of  primary 
acute  nephritis.  It  is  difficult  to  separate  them  from  primary 
nephritis  in  all  cases,  because  in  some  instances  pneumonia 
occurred  as  a  complication  of  nephritis,  whereas  in  others  the 
nephritis  was  a  complication  of  pneumonia. 

Secondary  or  complicating  nephritis  was  most  often  seen  in 
association  with  respiratory  diseases,  such  as  bronchitis,  lobular 
pneumonia  and  influenza,  but  other  varieties  also  occurred. 
Nephritis  sometimes  occurred  in  association  with  cerebro-spinal 
meningitis,  sometimes  as  a  definite  complication  in  a  well- 
marked  and  typical  case,  but  in  others  with  a  more  obscure 
connection.  Thus  a  small  number  of  cases  were  seen  where 
the  onset  of  disease  was  characterized  by  the  presence  of 
nephritis  and  the  absence  of  obvious  meningeal  symptoms,  so 
that  the  case  seemed  at  first  to  be  one  of  ordinary  nephritis  ; 
yet  after  the  lapse  of  a  variable  time,  usually  a  few  days, 
sometimes  as  long  as  a  fortnight,  meningeal  symptoms 
developed,  and  the  case  then  followed  the  course  usual  in 
cerebro-spinal  meningitis.  Nephritis  of  a  severe  type,  and  often 
haemorrhagic,  was  not  an  uncommon  complication  of  infected 
wounds.  These  forms  of  secondary  nephritis,  with  the 
exception  mentioned  above,  where  the  disease  occurred  in 
association  with  respiratory  affections,  are  not  included  in  the 
rates  of  incidence  of  nephritis  in  the  army. 

JEtiology. 

The  causation  of  nephritis  is  obscure  and  not  as  yet  certainly 
determined.  Two  factors  are  usually  held  to  be  of  considerable 
importance  in  the  aetiology  of  any  given  case  of  nephritis :  firstly, 
the  presence  of  chronic  renal  disease,  and  secondly,  the  occur- 
rence of  some  acute  infection  prior  to  the  onset  of  nephritis, 
or  a  history  of  a  previous  attack  of  nephritis  that  has  com- 
pletely cleared  up.  It  is  well  known  that  it  is  often  difficult,  if 
not  impossible,  to  distinguish  clinically  between  primary  acute 
nephritis  and  an  acute  exacerbation  of  chronic  or  latent  renal 
disease.  In  several  instances  in  1915,  where  a  clinical  diagnosis 
of  acute  nephritis  had  been  made,  post-mortem  examination 
revealed  that  the  lesion  was  really  an  exacerbation  of  an  old 
and  chronic  lesion.  Further,  many  writers  have  suggested  that 
albuminuria  due  to  trivial  causes,  e.g.  functional  albuminuria, 
might  predispose  to  nephritis  and  be  an  important  factor  in  its 
production.  The  experience  gained  in  the  war  at  any  rate 
throws  light  on  these  questions,  and  affords  distinct  evidence 
that  these  factors  were  not  operative  in  the  great  bulk  of  the 


488  MEDICAL   HISTORY   OF  THE   WAR 

cases  of  acute  nephritis.  MacLean's  observations  on  50,000 
healthy  soldiers  showed  that  in  about  5  per  cent,  some  degree 
of  albuminuria  was  present,  and  that  in  less  than  2  per  cent, 
casts  of  some  kind  were  visible.  In  0-84  per  cent,  definite 
epithelial  casts  were  present,  and  in  1-03  per  cent,  only  hyaline 
casts  were  found.  MacLean  is  of  opinion  that  the  army  on 
active  service  contained  at  least  1-1  per  cent,  of  men  whose 
kidneys  were  inefficient  and  were  suffering  from  some  degree 
of  disease,  and  "  that  not  more  than  2  per  cent,  of  the  men  give 
any  definite  indication  of  kidney  disease  as  indicated  by  the 
presence  of  albuminuria  and  fairly  large  numbers  of  casts." 
He  had  the  opportunity  of  observing  the  influence  of  this 
albuminuria  on  the  aetiology  of  nephritis,  as  nephritis  developed 
in  161  men  whose  urine  had  been  examined  by  him  prior  to 
their  admission  to  hospital  as  cases  of  nephritis.  Of  these  161 
cases,  only  28  had  shown  albuminuria  when  examined  before 
going  into  the  trenches,  while  in  the  remaining  133  cases  the 
urine  had  been  found  to  be  free  from  protein.  It  is  therefore 
evident  that,  in  the  great  majority  of  cases,  nephritis  occurred 
in  men  whose  urine  was  known  to  be  free  from  albumin  a  short 
time  before  the  onset  of  the  disease,  and  that  it  cannot  be 
regarded  as  an  exacerbation  of  some  previously  existing  chronic 
lesion.  Although  MacLean's  observations  show  conclusively 
that  the  great  majority  of  cases  of  nephritis  occurred  in  men 
free  from  renal  disease  at  the  moment  of  onset,  there  remains 
the  further  question  as  to  the  proportion  of  cases  that  occurred 
in  men  who  had  recovered  completely  from  a  previous  attack. 
In  a  series  of  571  cases  personally  investigated  by  Sir  J.  Rose 
Bradford,  a  distinct  history  of  previous  renal  disease  was  elicited 
in  62  cases,  thus  in  10-8  per  cent,  of  cases  of  acute  primary 
nephritis  the  patients  gave  a  history  of  having  previously 
suffered  from  an  attack  of  dropsy  similar  to  that  present  at 
the  time  of  examination,  or  else  stated  that  they  had  been  in 
hospital  or  under  treatment  for  "  inflammation  of  the  kidneys  " 
or  for  "  Bright 's  disease."  It  is  probable  that  a  former  attack 
of  nephritis  had  occurred  in  more  than  10-8  per  cent.,  inasmuch 
as  nephritis  occurs  not  uncommonly  without  its  recognition  by 
the  patient,  especially  when  dropsy  or  haematuria  is  absent. 

It  maybe  concluded  that,  in  the  great  majority  of  the  cases 
of  nephritis  in  the  troops,  the  attack  was  not  due  to  an  exacer- 
bation of  a  chronic  or  latent  lesion  of  the  kidneys,  nor  to  the 
previous  occurrence  of  nephritis.  Further,  the  previous  exist- 
ence of  albuminuria  cannot  be  regarded  as  an  aetiological  factor 
of  importance. 

Nephritis  is  well  known  as  a  complication  of  many  infections, 
and  in  many  instances  the  initial  illness  may  be  of  a  trivial 


NEPHRITIS  489 

character.  In  278  cases  of  nephritis  a  history  of  a  preceding 
slight  illness,  such  as  "  severe  cold,"  "  diarrhoea,"  "  influenza," 
or  "  sore  throat  "  was  obtained  in  10  •  4  per  cent.  It  is,  however, 
remarkable  that  in  30  per  cent,  of  the  cases  the  patients  gave 
a  history  of  or  had  distinct  signs  and  symptoms  of  bronchitis 
at  the  actual  onset  or  in  the  early  stages  of  the  disease  when 
admitted  to  hospital.  The  bronchitis  was  not  of  a  severe  type, 
and  this  association  with  nephritis  was  seen  in  the  early  cases 
in  1915.  This  is  a  point  of  some  importance,  as  at  that  date 
influenza  was  not  prevalent  in  the  armies,  and  gas  had  not 
been  used  in  warfare.  The  bronchitis  was  mild  in  type,  caused 
no  anxiety,  and  was  only  of  interest  in  its  association  with  the 
nephritis.  In  100  consecutive  cases  blood  examination  for  the 
Wassermann  reaction  gave  negative  results.  This  result  is  rather 
striking,  as  in  civil  practice  cases  of  acute  nephritis  of  specific 
origin  are  not  very  rare. 

The  disease  was  more  prevalent  during  the  winter  months 
and  decreased  during  the  summer,  with  the  exception  of  the 
first  summer,  that  of  1915,  when  the  incidence  was  unduly  high 
in  June,  July  and  August.  The  winter  of  1914-1915  was  very 
cold  and  also  very  wet,  but  the  outbreak  of  nephritis  did  not 
occur  until  the  spring,  and  lasted  all  through  the  summer.  The 
greatest  number  of  cases  of  nephritis  occurred  in  the  winter  of 
1916,  and  was  associated  with  the  great  prevalence  of  very 
serious  bronchitis  and  lobular  pneumonia  at  this  period.  It  is 
probable  that  exposure  to  wet  and  cold  may  act  as  a  predis- 
posing cause,  and  De  Wesselow  and  MacLean  have  adduced 
evidence  to  suggest  that  infantrymen,  who  are  necessarily  much 
exposed,  have  contracted  the  disease  after  shorter  periods  of 
service  at  the  front  than  other  branches  of  the  service.  The 
malady,  however,  affected  large  numbers  of  men  in  all  branches 
of  the  service,  and  was  by  no  means  confined  to  men  serving  in 
the  trenches.  Thus,  in  1915,  cases  occurred  in  hospital  orderlies 
living  in  buildings,  and  men  who  had  never  been  to  the  front, 
but  had  served  continuously  on  the  lines  of  communication. 
In  the  later  years  of  the  war  facts  such  as  these  could  not  be 
determined,  since  the  exigencies  of  the  service  caused  a  greater 
interchange  of  personnel.  In  many  instances,  where  men  on 
the  lines  of  communication  were  affected,  there  was  no  undue 
exposure  to  climatic  conditions.  Further,  a  small  number  of 
cases  occurred  amongst  nurses  living  under  very  good  conditions. 
In  a  series  of  332  cases  seen  in  1915,  285  cases  occurred  in  men 
serving  at  the  front,  and  25  cases  in  men  serving  on  the  lines 
of  communication  who  had  never  been  to  the  front ;  in  the 
remaining  22  the  record  of  service  was  not  sufficiently  accurate 
to  be  of  value. 


490  MEDICAL   HISTORY   OF  THE   WAR 

No  evidence  has  been  obtained  in  favour  of  the  view  that 
nephritis  could  be  attributed  to  diet,water,  or  metallic  poisoning. 

Cases  of  nephritis  occurred  in  men  who  had  only  been  one 
week  in  France,  but  the  number  of  instances  in  which  the 
disease  has  occurred  in  men  with  less  than  two  months'  service 
in  the  field  is  small.  In  a  series  of  326  cases  analysed  in  1915, 
195  cases  occurred  in  men  who  had  served  six  months  or  less  in 
France,  and  131  in  men  who  had  served  from  six  to  twelve 
months  in  France. 

Although  nephritis  occurred  in  all  branches  of  the  service,  it 
was  remarkable  that  only  a  small  proportion  of  officers  was 
affected.  Thus,  in  1916,  only  two  officers  died  from  nephritis, 
and  there  were  no  deaths  from  this  disease  amongst  officers 
in  1917. 

The  malady  was  not  confined  to  any  particular  age.  Cases 
were  met  with  at  all  ages  from  15  to  56  years  of  age,  but  the 
great  bulk  of  cases  occurred  in  men  under  35  years  of  age.  In 
an  analysis  of  2,297  cases,  68-72  per  cent,  of  the  cases  occurred 
in  men  over  20  years  and  under  35  years  of  age,  and  28-3  per 
cent,  of  the  cases  occurred  in  men  under  25  years  of  age.  It 
is  thus  evident  that  a  very  large  proportion  of  the  cases  occurred 
in  young  men,  and  that  it  was  not  a  disease  limited  in  its 
incidence  to  the  older  men.  Further,  the  age  incidence  of  the 
disease  was  apparently  closely  similar  to  that  of  the  age  dis- 
tribution of  the  army,  since  Colonel  Hume  found  that,  in  a 
foody  of  some  3,000  hospital  patients,  68 '42  per  cent,  were 
between  the  ages  of  20  and  35  years.* 

Perhaps  the  most  striking  fact  in  the  aetiology  of  the  disease 
was  the  immunity  of  the  native  Indian  troops.  Nephritis  was 
practically  unknown  amongst  these  troops  in  1915  in  France. 
Although  large  numbers  of  Indian  sick  in  three  large  hospitals 
were  under  Sir  J.  Rose  Bradford's  observation,  he  saw  no  case 
of  the  disease  amongst  them.  These  troops  suffered  severely 
from  the  hardships  of  the  campaign  in  the  winter  of  1914-1915, 
and  more  especially  from  maladies  due  to  exposure  to  wet  and 
cold,  such  as  bronchitis,  lobular  pneumonia  and  trench  foot. 
Notwithstanding  the  severity  of  the  respiratory  affections, 
especially  bronchitis  and  pneumonia,  nephritis  did  not  occur. 
This  immunity  of  the  native  troops  is  most  difficult  of  explana- 
tion, since  the  only  difference  between  them  and  the  British 
troops,  putting  aside  the  question  of  race,  is  that  their  diet  and 
clothing  were  different ;  yet  there  is  no  evidence  to  support 
the  view  that  the  disease  had  a  dietetic  origin  in  the  British 
troops.  On  the  other  hand,  the  absence  of  the  malady  amongst 

*  See  Chap,  xxiii,  p.  520. 


NEPHRITIS  491 

the  Indians  is  undoubtedly  an  argument  against  the  disease 
being  due  to  an  infection,  probable  as  this  is  on  other  grounds, 
and  at  the  present  time  no  satisfactory  explanation  of  the 
immunity  of  the  native  Indian  troops  is  available.  The  case 
of  these  troops  also  throws  some  doubt  on  the  view  that 
nephritis  was  the  result  of  some  respiratory  infection,  since,  as 
mentioned  above,  respiratory  diseases  were  prevalent  amongst 
the  Indians. 

Morbid  Anatomy. 

With  regard  to  the  morbid  anatomy,  the  renal  lesions  found 
in  fatal  cases  of  war  nephritis  were  essentially  similar  in  char- 
acter to  those  described  in  other  varieties  of  acute  nephritis. 
In  early  cases  there  was  intense  congestion,  with  some  swelling 
and  irregularity  of  the  epithelium  of  the  convoluted  tubules, 
and  haemorrhage  in  varying  amounts  was  very  constantly 
present  in  the  tubules.  In  these  early  cases  glomerular  changes 
might  be  very  slight  and  inconsiderable.  In  cases  fatal  at  a 
later  stage  the  tubular  lesions  were  much  more  marked,  and 
in  these  the  glomeruli  showed  marked  inflammatory  changes, 
haemorrhage,  exudation  and  proliferation  of  the  glomerular 
epithelium,  together  with  hyaline  degeneration  of  the  vessels 
of  the  glomerular  tuft.  The  interstitial  tissue  was  oedematous 
and  infiltrated  with  lymphocytes  and  polymorphs.  Lipoid 
infiltration  of  the  epithelium  of  the  tubules  was  described,  and 
in  some  cases  of  more  prolonged  duration  lesions  identical  with 
those  of  the  large  white  kidney  were  recorded.  Although  acute 
lesions  in  the  interstitial  tissue  were  common  in  the  early  cases, 
overgrowth  of  fibrous  tissue  has  not  been  observed. 

Shaw  Dunn  has  drawn  attention  to  the  presence  of  pulmonary 
lesions  in  fatal  cases  of  nephritis,  such  as  loss  of  the  epithelial 
lining  of  the  bronchi  and  the  presence  of  a  fibrinous  exudate, 
together  with  the  presence  of  minute  thrombi  in  the  pulmonary 
capillaries.  Capillary  haemorrhages  were  also  found  in  the 
spleen  and  brain,  and  Dunn  has  suggested  that  the  renal  lesion 
may  be  the  result  of  capillary  embolism.  Capillary  haemor- 
rhages in  the  brain  are,  however,  not  uncommon  in  other 
varieties  of  nephritis,  especially  perhaps  when  they  are  fatal 
as  a  result  of  uraemic  seizures  of  an  epileptiform  type. 

Symptoms. 

With  regard  to  symptoms,  on  the  whole  there  was  a  remark- 
able uniformity  in  their  character  in  the  great  majority  of  cases  ; 
such  differences  as  were  present  were  more  especially  related 
either  to  the  mode  of  onset  of  the  disease,  or  to  the  presence  of 
one  or  other  of  the  two  main  clinical  types  of  the  malady. 


492  MEDICAL   HISTORY   OF  THE  WAR 

Thus  the  onset  might  be  gradual  and  insidious,  or  else  more 
or  less  sudden,  although  when  apparently  sudden  careful  en- 
quiry would  sometimes  elicit  the  fact  that,  for  a  variable  time 
before  the  appearance  of  the  more  urgent  symptoms,  there  had 
been  an  indefinite  feeling  of  ill-health  of  some  duration.  Clini- 
cally, two  main  types  of  the  disease  were  recognized ;  one,  the 
less  frequent,  where  the  leading  symptoms  were  the  presence  of 
a  moderate  pyrexia  together  with  haematuria,  and  the  other, 
and  much  more  common  form,  characterized  by  the  presence  of 
dropsy,  in  which  pyrexia  was  either  absent  or  very  slight  in 
amount.  There  were  also  cases  where  neither  haematuria  nor 
dropsy  were  obvious,  but  in  many  of  these  dropsy  had  been 
present  but  very  transitory  in  character,  and  had  disappeared 
by  the  time  the  patient  came  under  observation  in  hospital. 
In  the  haematuric  cases  associated  with  pyrexia  the  onset  was 
often  sudden,  and  this  might  also  be  the  case  where  dropsy 
was  a  leading  feature  of  the  illness,  but  in  many  of  the  latter 
types  the  onset  was  more  insidious,  and  although  the  patient 
might  date  his  illness  from  the  day  on  which  the  swelling  was 
first  noticed,  enquiry  often  revealed  the  presence  of  other  and 
earlier  symptoms. 

Cases  of  the  haematuric  or  haemorrhagic  type  occurred 
from  1915  onwards,  but  they  formed  only  a  small  proportion 
of  the  total  number.  The  onset  was  usually  sudden  and 
characterized  by  the  presence  of  general  aching  pains  in  the 
limbs  and  back,  often  rather  severe,  together  with  headache 
and  pyrexia.  The  fever  was  usually  moderate — 101°  F.  or 
102°  F.  ;  exceptionally  it  might  be  as  high  as  103°  F.  Haema- 
turia was  marked  and  the  urine  obviously  bloody  rather  than 
smoky.  The  pyrexia  and  the  limb  pains  presented  some 
analogy  to  the  initial  phenomena  of  trench  fever,  and  it  is, 
therefore,  of  some  interest  that  instances  of  this  type  were  seen 
amongst  the  first  cases  of  nephritis  observed  in  the  early  spring 
of  1915,  and  similar  cases  occurred  during  the  following  years. 
The  pyrexia  usually  persisted  for  only  a  few  days,  but  recur- 
rences of  pyrexia  of  short  duration  were  not  infrequent.  In 
some  cases  these  recurrences  were  of  a  peculiar  type,  in  that  a 
sudden  rise  of  temperature  of  two  or  three  degrees  took  place, 
lasting  only  a  few  hours  and  accompanied  by  a  return  or 
increase  in  the  haematuria.  These  rises  of  temperature,  or 
"  spikes,"  resembled  the  recurrent  "  spikes  "  seen  in  trench 
fever,  and  they  also  resembled  the  transitory  pyrexia  associated 
with  the  occurrence  of  renal  embolism.  The  resemblance  to  the 
latter  condition  was  rendered  closer  by  the  fact  that  the  pyrexia 
was  accompanied  by  an  increased  or  recurrent  haematuria. 
It  is  probable  that  the  occurrence  of  these  cases  led  some 


NEPHRITIS  493 

observers  to  associate  trench  fever  with  nephritis .  Further,  both 
trench  fever  and  nephritis  first  attracted  attention  in  the  spring 
of  1915,  although  nephritis  was  observed  somewhat  earlier  than 
the  time  when  clinical  features  of  trench  fever  were  recognized. 
The  more  detailed  study  of  trench  fever  has  failed  to  show  that 
this  malady  is  complicated  by  the  occurrence  of  nephritis,  and 
thus  it  is  probable  that  these  peculiar  recurrent  pyrexial  attacks 
were  really  to  be  associated  with  the  nephritis,  and  were  not 
dependent  upon  the  presence  of  trench  fever  together  with 
nephritis.  Dropsy  was  usually  absent  in  these  haemorrhagic 
pyrexial  cases,  and  if  present  was  only  slight  in 
amount. 

In  the  dropsical  type  the  onset  might  be  either  sudden  or 
gradual.  If  sudden,  the  most  usual  initial  symptom  was  short- 
ness of  breath,  especially  on  exertion,  such  as  marching,  but 
sometimes  nocturnal  dyspnoea  of  an  urgent  character  was  the 
first  symptom  to  attract  attention.  The  frequency  and 
prominence  of  dyspnoea  as  a  symptom  was  one  of  the  most 
characteristic  features  of  so-called  war  nephritis,  and  is  probably 
to  be  explained  by  the  unusual  conditions  of  active  service. 
Dyspnoea,  although  a  well-recognized  symptom  of  renal  disease, 
is  not  usually  the  symptom  on  which  the  patient  lays  most  stress 
in  describing  the  onset  of  the  disease  in  civil  life,  but  it  may 
well  be  that  on  active  service,  where  severe  exertion  and  fatigue 
are  so  frequent  and  necessary,  other  symptoms  are  overshadowed 
by  the  shortness  of  breath  caused  by  marching  with  a  pack. 
If  this  be  the  true  explanation,  it  is  an  interesting  example  of 
how  the  classical  symptoms  of  a  well-known  disease  may  vary 
owing  to  the  conditions  under  which  it  manifests  itself.  In 
many  cases  dropsy  was  the  first  sign  of  illness  to  attract  the 
patient's  notice,  but  this  is  also  a  well-known  phenomenon  in 
the  nephritis  of  civil  life.  Although  most  patients  in  whom 
dropsy  was  obvious  also  suffered  from  dyspnoea  as  an  early 
symptom,  dyspnoea  might  be  present  without  dropsy. 
Headache  was  also  a  frequent  early  symptom,  vomiting  was 
often  specially  prominent.  In  a  very  small  proportion  of 
cases,  the  onset  of  illness  was  characterized  by  the  occurrence 
of  very  severe  uraemic  seizures,  such  as  epileptiform  fits  or 
amaurosis.  In  many  of  these  cases  there  was  a  chronic  and 
latent  lesion  present,  such  as  contracted  white  kidney  or  the 
acute  exacerbation  of  a  chronic  lesion,  and  it  is  at  least  doubtful 
whether  such  an  onset  occurred  with  primary  acute  nephritis. 
Such  symptoms  at  the  onset  always  suggest  the  presence  of 
chronic  disease,  notwithstanding  the  fact  that  the  patient  has 
been  apparently  well  up  to  a  short  period  before  the  develop- 
ment of  the  urgent  symptoms. 


494  MEDICAL   HISTORY   OF  THE  WAR 

(Edema  was  a  frequent  early  sign,  and  not  uncommonly  was 
the  first  definite  sign  that  led  to  the  man's  reporting  sick.     It 
was  often  first  noticed  in  the  legs,  but  swelling  of  the  face  or 
of  the  abdomen  and  subcutaneous  tissue  was  not  infrequent. 
The  occurrence  of  ascites,  usually  moderate  in  amount,  was 
common  even  in  cases  where  the  general  oedema  was  slight. 
In  a  few  cases  the  ascitic  effusion  was  very  large.     At  the  time 
when  the  patient  was  admitted  to  hospital  ascites  was  present 
in  a  large  proportion  of  the  cedematous  cases,  and  in  a  not 
inconsiderable  number  the  pleural  cavities  also  contained  fluid. 
Two  facts  stand  out  prominently  with  reference  to  the  oedema. 
In  the  first  place,  although  usually  present  and  often  quite 
marked  in  amount,  it  was  very  exceptional  to  see  the  extreme 
anasarca  familiar  to  all  in  the  renal  disease  of  civil  hospitals  ; 
and,  secondly,  the  anasarca,  even  when  marked  in  amount,  was 
in  the  great  majority  of  cases  of  short  duration.     This  also  is 
in  contrast  to  what  is  usually  seen  in  civil  practice.     In  a  very 
large  proportion  of  cases,  perhaps  in  half  the  cases,  the  anasarca 
disappeared  in  from  one  to  two  weeks,  and  many  more  cleared 
up  after  the  lapse  of  one  to  two  weeks  more.     This  rapid  sub- 
sidence of  the  dropsy  occurred  in  cases  where  it  was  considerable 
in  amount  and  was  not  limited  to  the  slighter  and  less  severe 
cases.      In  these  slighter  cases  it  was  not  uncommon  for  the 
dropsy  to  be  present  only  for  a  few  days ;   many  cases  were 
seen  where  it  had  disappeared  before  the  patient  was  admitted 
to  a  hospital  on  the  lines  of  communication,  that  is  to  say, 
where  its  duration  had  not  been  more  than  three  or  four  days. 
In  a  very  small  number  of   cases  the  anasarca  was  as  severe 
and  persistent  as  that  seen  in  cases  of  chronic  parenchymatous 
nephritis.     Occasionally  cases  were  seen  where  the  patient  gave 
a  history  of  having  suffered  from  a  slight  transitory  dropsy 
without  being  sufficiently  ill  to  seek  hospital  treatment,  and 
then,  whilst  remaining  on  duty,  the  dropsy  had  recurred  to  a 
greater  degree  and  the  nephritis  had  become  obvious.      Ana- 
sarca was  not  always  an  initial  manifestation ;    thus  in  some 
cases  of  the  hsemorrhagic  febrile  type,  where  dropsy  was  absent 
at  the  onset,  it  supervened  later  and  ran  the  ordinary  course, 
and  dropsy  also  supervened  in  many  of  the  cases  of  gradual 
and  insidious  onset. 

In  a  considerable  proportion  of  cases  the  onset  of  the  disease 
was  gradual  and  characterized  by  a  general  failure  of  health, 
together  with  shortness  of  breath  on  exertion,  lassitude,  back- 
ache, loss  of  appetite,  and  headache.  Many  of  these  men  also 
complained  of  having  suffered  from  epistaxis.  Such  symptoms 
might  persist  for  some  days,  or  even  weeks,  and  then  the  urine 
was  noticed  to  be  bloody,  or  dropsy  supervened  in  the  legs  or 


NEPHRITIS  495 

face.  Shortness  of  breath  was  a  prominent  symptom  both  in 
the  cases  of  sudden  and  in  those  of  gradual  onset.  It  was 
frequently  accompanied  by  cough,  which  was  usually  dry,  but 
sometimes  a  watery  mucoid  sputum  was  expectorated  in  scanty 
amount.  It  was  remarkable  that  the  shortness  of  breath, 
cough  and  such  pulmonary  signs  as  crepitations  were  not 
accompanied  by  any  profuse  expectoration.  The  dyspnoea 
was  not  only  a  very  constant  early  symptom,  but  sometimes  it 
was  of  a  rather  severe  type,  necessitating  an  upright  posture, 
and  often  causing  considerable  distress  at  night.  In  a  few  cases 
severe  dyspnoea  of  the  type  seen  in  the  most  severe  and  fatal 
forms  of  uraemia  occurred,  but  one  of  the  main  clinical  features 
of  all  the  cases  of  nephritis,  even  when  not  very  severe  and 
where  ultimate  recovery  took  place,  was  the  frequency  of  the 
presence  of  dyspncea  of  a  moderate  degree  of  severity. 

Vomiting,  although  not  a  frequent  symptom  at  the  onset, 
was  not  infrequent  in  the  subsequent  progress  of  the  more 
serious  cases,  and  diarrhoea  was  also  sometimes  observed. 

At  the  onset,  and  more  especially  in  the  numerous  cases 
where  dropsy  occurred,  the  quantity  of  urine  was  considerably 
diminished,  and  the  total  quantity  secreted  in  the  twenty-four 
hours  might  be  less  than  twenty  ounces.  In  a  few  cases 
temporary  suppression,  partial  or  complete,  occurred  at  the 
onset  for  short  periods  of  twenty-four  hours.  No  case  of  death 
from  suppression  came  under  the  observation  of  Bradford. 
During  the  onset  and  persistence  of  the  dropsy  the  quantity 
of  urine  usually  remained  low,  but  the  subsidence  of  the  dropsy 
was  accompanied  by  very  considerable  diuresis.  This  diuresis 
was  often  of  abrupt  or  sudden  onset,  and  was  frequently 
noticed  before  there  was  any  marked  alteration  in  the  degree 
of  dropsy.  The  increase  in  the  quantity  of  urine  was  often 
very  considerable,  and  quantities  of  one  hundred  and  fifty 
ounces  might  be  passed  in  twenty-four  hours.  The  diuresis, 
like  the  subsidence  of  the  dropsy,  was  prone  to  occur  in  the 
first  two  weeks  of  the  illness  and  was,  of  course,  accompanied 
by  a  considerable  loss  in  weight  of  the  patient.  It  might 
also  be  accompanied  by  marked  sweating,  and,  speaking 
generally,  it  may  be  said  that  sweating  was  more  common  and 
could  be  induced  more  readily  in  these  acute  cases  of  war 
nephritis  than  is  usually  the  case  in  the  nephritis  of  civil 
hospitals.  In  the  latter  class  of  cases  the  skin  is  not  only 
abnormally  dry,  but  it  is  often  extremely  difficult  to  cause 
sweating  by  any  means. 

In  the  haemorrhagic  type,  blood  corpuscles  were  present  in 
the  urine  in  abundance,  and  blood  and  granular  casts  were  also 
present.  In  the  anasarcous  cases,  blood  corpuscles  could 


496  MEDICAL   HISTORY   OF   THE  WAR 

usually  be  found  on  microscopic  examination.  In  the  slighter 
cases,  where  dropsy  was  absent,  blood  corpuscles  might  be 
absent  so  long  as  the  patient  was  kept  in  bed,  but  even  in  cases 
where  the  albuminuria  had  almost  cleared  up  it  was  remarkable 
how  readily  blood  reappeared  in  the  urine  if  the  patient  was 
allowed  to  get  up.  Casts,  hyaline,  granular  and  epithelial,  were 
present  in  all  acute  cases,  and  it  was  not  uncommon  for  hyaline 
casts  to  be  present  in  large  numbers.  In  cases  of  short  duration, 
where  the  dropsy  and  albuminuria  cleared  up  rapidly,  the  casts 
also  disappeared  quickly,  and  in  such  cases,  where  only  a 
small  quantity  of  albumin  was  present,  hyaline  casts  were  only 
found  in  very  scanty  numbers  and  with  difficulty.  The  centri- 
fugalized  deposit  contained,  in  addition  to  casts,  white  blood 
corpuscles,  renal  cells,  and  cells  from  the  lower  renal  tract. 
Mononuclear  leucocytes  were  present  in  36  per  cent,  of  the 
cases  observed  by  Captain  J.  A.  Wilson.  In  fourteen  cases 
out  of  a  consecutive  series  of  100  cases  examined  by  him, 
organisms  were  found  in  catheter  specimens  of  the  urine  ;  in 
three  instances  Streptococcus  fczcalis,  in  three  Streptococcus 
pyogenes,  in  other  instances  the  B.  pneumonia,  B.  acidi 
lactici,  and  Proteus  vulgaris.  Twelve  of  the  fourteen  cases 
were  of  the  haemorrhagic  type,  but  the  urine  contained  no  pus, 
and,  although  the  organisms  were  virulent,  Wilson  regarded 
them  as  saprophytes  and  in  no  way  related  to  the  renal  lesion. 
Calcium  oxalate  and  uric  acid  crystals  have  been  occasionally 
observed  in  the  urinary  deposits. 

Albuminuria  varied  greatly  in  amount,  but  in  severe  cases  it 
was  considerable  and  the  coagulum  formed  on  boiling  settled 
on  standing  to  a  volume  of  from  one-quarter  to  two-thirds  of 
the  urine  volume.  In  some  exceptional  instances  the  urine 
became  solid  on  boiling ;  in  the  less  severe  cases  the  amount 
was  less,  and  even  in  cases  where  appreciable  dropsy  was 
present  the  amount  of  albumin  present  might  still  be  small. 
Many  cases  came  under  observation  after  the  subsidence  of 
the  dropsy,  when  this  had  only  been  present  for  a  few  days 
at  the  onset  of  illness,  and  such  cases  only  showed  a  slight 
degree  of  albuminuria.  The  albuminuria  was  more  persistent 
than  the  dropsy,  and  was  prone  to  last  for  several  weeks  even 
when  the  dropsy  only  lasted  for  a  fortnight  or  less.  It  was 
also  liable  to  increase  again  when  it  had  begun  to  subside  if  the 
patient  were  allowed  to  get  up  and  undergo  even  mild  exertion. 
Nevertheless,  a  very  considerable  proportion  of  the  cases  were 
evacuated  to  England  with  only  the  merest  trace  of  albumin 
in  the  urine  ;  in  other  words,  the  nephritis,  with  the  resultant 
albuminuria,  cleared  up  with  considerable  rapidity.  In  some 
cases  the  albuminuria  persisted  in  the  manner  so  common  in 


NEPHRITIS  497 

many  varieties  of  nephritis  of  civil  life,  but  this  was  decidedly 
exceptional. 

Symptoms  referable  to  the  vascular  system,  such  as  palpita- 
tion with  some  praecordial  distress,  were  not  uncommon  in 
established  cases  of  moderate  severity,  and  tachycardia  was 
fairly  often  seen.  Headache,  often  associated  with  a  heightened 
arterial  tension,  was  also  common  and  sometimes  very  severe 
Not  infrequently  it  was  of  an  intermittent  or  even  paroxysmal 
type,  and  an  intense  headache,  with  or  without  an  increase  in 
the  blood  pressure,  sometimes  heralded  the  onset  of  uraemic 
fits.  The  blood  pressure  was  raised  in  the  great  majority  of 
cases  and  in  the  dropsical  cases  the  onset  and  increase  in  the 
dropsy  was  probably  invariably  associated  with  a  rise  of  blood 
pressure.  The  rise  of  pressure  was  usually  moderate  and  read- 
ings above  180  mm.  of  mercury  were  exceptional,  the  usual 
height  being  between  140  mm.  and  180  mm.  of  mercury  as 
systolic  pressures,  and  from  70  mm.  to  110  mm.  as  diastolic 
pressures.  Diurnal  variations  in  the  blood  pressure  were 
common  and  the  evening  pressure  was  the  higher.  In  some 
cases  the  difference  might  amount  to  as  much  as  40  mm.  of 
mercury.  As  the  malady  progressed  towards  convalescence 
the  blood  pressure  fell  to  the  normal,  or  even  below  it,  and  this 
fall  might  take  place  either  suddenly  or  gradually.  The  fall 
in  blood  pressure  occurred  at  the  time  that  diuresis  set  in  with 
subsidence  of  the  dropsy,  and  when  the  pressure  reached  and 
remained  at  the  normal  height,  the  diuresis  and  subsidence  of 
the  dropsy  were  usually  completed.  In  exceptional  instances, 
the  blood  pressure  might  fall  to  a  low  level  before  the  dropsy 
had  completely  disappeared,  and  in  others  a  high  blood  pressure 
might  persist  notwithstanding  the  fact  that  all  dropsy  had 
cleared  up.  In  some  cases  a  persistent  high  blood  pressure 
indicated,  as  is  well  known,  the  presence  of  chronic  disease, 
but  this  could  not  be  regarded  as  certain  if  based  only  on  the 
presence  of  increased  tension,  since  all  observers  were  agreed 
that  one  of  the  most  constant  phenomena  seen  in  these  cases 
of  acute  nephritis  was  a  very  considerable  increase  in  the 
height  of  the  blood  pressure,  and  that  such  rise  occurred  quite 
early  in  the  course  of  the  disease.  This  is  quite  in  harmony 
with  what  has  been  described  in  former  studies  of  nephritis  in 
civil  life. 

De  Wesselow  and  MacLean's  observations  show  that  a 
considerable  degree  of  hydraemia  was  present  in  the  cases  of 
acute  nephritis,  and  that  this  hydraemia  was  closely  related  to 
the  increased  tension  and  usually  was  also  in  direct  relationship 
to  the  degree  of  dropsy  present.  In  some  cases,  however, 
anasarca  occurred  with  little  or  no  hydraemia,  and  in  others 

(2396)  G  G 


498  MEDICAL  HISTORY   OF  THE   WAR 

considerable  hydraemia  might  be  present  with  but  little 
anasarca.  Exceptionally,  a  high  blood  pressure  might  exist 
without  any  evidence  of  the  presence  of  hydraemia. 

Although  a  heightened  tension  and  hydraemia  were  such 
constant  occurrences,  the  heart  did  not  in  the  majority  of  cases 
show  definite  signs  of  enlargement,  but  in  a  considerable 
minority  the  apex  beat  was  either  in  the  nipple  line  or  external 
to  it,  and  returned  to  a  position  internal  to  it  on  the  subsidence 
of  the  dropsy  and  after  the  fall  in  the  blood  pressure.  In 
many  of  the  cases  cardiac  symptoms,  such  as  palpitation, 
praecordial  distress  and  inability  to  sleep  on  the  left  side,  were 
present.  In  some  cases  the  enlargement  of  the  heart  was 
persistent,  and  was  in  certain  instances  dependent  upon  the 
presence  of  chronic  renal  disease,  but  this  was  excluded  in  the 
cases  where  it  was  temporary  in  character,  and  its  subsidence 
coincided  with  the  return  to  health.  The  cardiac  impulse  was 
usually  vigorous  and  the  first  sound  of  the  heart  was  often 
louder  than  normal  and  of  a  rumbling  character. 

Anaemia  was  not  a  conspicuous  feature  of  the  disease  except 
in  the  rarer  instances  where  the  illness  was  prolonged  and  of  a 
type  similar  to  that  of  chronic  parenchymatous  nephritis,  and 
even  in  cases  where  dropsy  was  very  marked  it  was  uncommon 
to  see  the  pale  and  waxy  facies  which  is  typical  of  renal  disease. 
Ascites  and  hydrothorax  have  already  been  mentioned  as 
frequent ;  pulmonary  oedema  in  varying  degrees  was  also  not 
uncommon  and  in  some  cases  with  uraemic  symptoms  was  very 
marked.  Occasionally  the  pulmonary  cedema  was  exception- 
ally well  marked  at  the  apices  of  the  lungs,  and  the  abundant 
crepitations  present  in  such  cases  sometimes  produced  signs 
liable  to  be  mistaken  and  regarded  as  pneumonic  in  origin.  It 
is  possible  that  some  of  the  signs  seen  in  early  cases  where 
dyspnoea  was  a  marked  symptom  were  more  correctly  to  be 
attributed  to  cedema  than  to  bronchitis. 

Inflammatory  complications  such  as  pericarditis,  pleurisy 
and  peritonitis  were  quite  exceptional,  but  some  of  the  more 
severe  cases  developed  inflammatory  pulmonary  complications, 
more  especially  lobular  pneumonia  and  bronchitis. 

In  striking  contrast  to  the  comparative  rarity  of  inflam- 
matory complications,  the  frequency  of  uraemic  phenomena 
was  a  feature  of  interest,  and  it  is  remarkable,  when  the 
protean  nature  of  uraemic  attacks  is  taken  into  consideration, 
that  the  very  great  majority  of  the  uraemic  seizures  were 
of  the  epileptiform  type.  Other  manifestations  of  acute 
uraemia,  such  as  coma,  mania,  urgent  dyspnoea  or  air 
hunger,  were  quite  exceptional,  and  when  they  occurred  the 
case  was  not  infrequently  one  of  an  acute  exacerbation  of  a 


NEPHRITIS  499 

chronic  or  even  of  a  congenital  lesion,  such  as  hydronephrosis, 
rather  than  a  true  case  of  primary  acute  nephritis.  The 
epileptiform  attacks  were  generally  quite  sudden  in  their  onset, 
and  frequently  occurred  in  cases  where  the  general  condition 
was  good,  and  not  likely  to  suggest  the  probability  of  such  an 
attack.  They  might  be  heralded  by  the  presence  of  severe 
headache,  and  sometimes,  but  by  no  means  always,  were 
associated  not  only  with  a  markedly  raised  tension  but  also 
with  a  sudden  increase  in  such  tension.  In  other  cases  a 
general  feeling  of  vague  malaise  preceded  the  attack.  The  fits 
were  generally  of  a  severe  type  and  often  a  series  of  them 
occurred.  Notwithstanding  their  frequency  and  severity,  they 
were  very  rarely  fatal,  either  directly  or  indirectly,  and 
generally  the  patient  recovered  completely.  Such  attacks, 
even  of  a  severe  character,  were  not  limited  to  serious  cases,  and 
although  in  most  cases  the  urinary  flow  was  scanty  at  the  time 
of  the  seizure,  such  attacks  occurred  in  men  passing  quantities 
of  urine  equal  to,  or  greater  than,  the  normal.  Subacute 
chronic  uraemic  manifestations  were  rare  and  were  seen  more 
especially  in  the  exceptionally  severe  cases  that  ran  the  pro- 
longed course  of  the  large  white  kidney.  Analysis  of  the  blood 
showed  that  in  some  of  these  cases  of  acute  uraemia  very  large 
quantities  of  urea  might  be  present,  but,  on  the  other  hand,  in 
some  instances  of  severe  epileptiform  seizures  the  urea  content 
of  the  blood  was  not  above  the  normal. 

The  examination  of  the  urine  in  cases  of  acute  nephritis 
showed  that  the  excretion  of  urea  was  not  materially  affected 
in  the  majority  of  cases,  the  diminution  in  the  output  of  the 
earlier  stages  being  followed  by  a  notable  increase  during  the 
diuresis  accompanying  the  subsidence  of  the  dropsy.  The 
excretion  of  chlorides  was  often  diminished,  but  here  also  the 
kidney  rapidly  regained  its  power  of  excretion  in  the  large 
number  of  cases  that  progressed  favourably. 

Changes  in  the  fundus  oculi  were  rare  in  the  early  stages  of 
the  malady,  but  retinitis  similar  to  that  seen  in  chronic  renal 
disease  was  found  in  cases  running  a  protracted  course.  Retinal 
haemorrhage  was,  however,  rare. 

The  review  of  the  clinical  course  of  the  disease  shows  that  it 
is  essentially  similar  to  that  familiar  in  civil  life,  but  there  are 
some  minor  differences.  Thus  the  frequenoy  of  dyspnoea  as 
an  early  symptom  is  striking,  and  the  very  transitory  duration 
of  quite  serious  anasarca  is  another  feature  that  attracts  notice. 
Further,  the  severity,  frequency  and  character  of  the  uraemic 
seizures  are  peculiar.  Such  differences,  however,  do  not  render 
it  necessary  to  regard  the  malady  as  a  new  one,  or  one  different 
from  other  forms  of  nephritis.  Cases  have  been  seen  not  only 


500  MEDICAL   HISTORY   OF   THE   WAR 

under  conditions  quite  different  from  those  of  civil  life,  but  also 
in  very  large  numbers,  and  at  a  very  early  stage  in  the  evolution 
of  the  malady,  owing  to  the  exigencies  of  military  life  compelling 
a  man  only  slightly  ill  to  seek  medical  treatment.  It  is, 
therefore,  possible  that  the  war  has  afforded  an  opportunity  of 
acquiring  a  more  correct  view  of  acute  nephritis,  especially  in 
its  early  stages,  and  that  the  classical  picture  hitherto  described 
is  more  applicable  to  the  more  severe  forms  and  the  later  stages 
of  the  disease.  Such  differences  as  exist  in  the  clinical  course 
of  war  nephritis,  when  contrasted  with  the  nephritis  of  civil 
life,  may  therefore  be  attributable  either  to  the  fact  that 
the  man  was  exposed  to  fatigue  and  strain  at  the  onset  of  the 
disease,  or  else  to  the  fact  that  large  numbers  of  cases  were 
seen  at  a  very  early  stage  of  the  malady. 

Prognosis. 

On  the  question  of  prognosis,  the  mortality  during  the  acute 
stage  of  the  disease  was  very  low  ;  thus  in  a  series  of  cases 
observed  in  1915,  it  was  only  0-4  per  cent.,  and  the  average 
annual  mortality  rate  for  all  cases  in  1916  was  0-93  per  cent., 
and  1  •  32  per  cent,  in  1917.  In  both  of  these  years  the  mortality 
rate  was  raised  by  the  inclusion  of  cases  of  secondary  nephritis 
that  occurred  as  a  complication  of  serious  cases  of  bronchitis 
and  of  lobular  pneumonia.  Further,  in  some  cases  diagnosed 
as  acute  nephritis  post-mortem  examination  revealed  the  fact 
that  the  malady  present  was  really  an  acute  exacerbation  of  a 
chronic  lesion,  or  the  occurrence  even  of  acute  nephritis  com- 
plicating a  congenital  anomaly  of  development  of  the  kidneys. 
The  great  majority  of  the  cases  cleared  up  in  a  short  time,  that 
is  to  say,  in  a  few  weeks,  but  a  residual  albuminuria  might 
persist  somewhat  longer  and  such  cases  might  relapse  if  they 
returned  to  duty  prematurely.  A  small  proportion  did  not 
improve  and  the  albuminuria  remained  with  or  without 
dropsy,  while  some  of  them  ran  a  course  similar  to  that  of 
the  large  white  kidney,  and  might  be  ultimately  fatal  after 
the  lapse  of  weeks  or  months  of  illness. 

Hunter  gives  the  following  table  for  the  twelve  months, 
1st  October,  1916,  to  30th  September,  1917. 

Number  of  nephritis  cases  admitted  to  six  central 

hospitals  in  England        . .  . .          . .          981 


Number  discharged 

(a)  To  duty  or  employments 
(6)  To   military  convalescent  hos 
pitals   .  . 

(c)  To  command  depots 

(d)  Invalided 

(e)  Died 

Transferred  to  other  hospitals 


741 


234=31-5% 

143=19-2% 

229  =  30-9% 

120=16-2% 

15=  2-0% 


50 
Remaining  in  hospital  or  command  depot. .          . .          190 


NEPHRITIS 


501 


Abercrombie  had  171  cases  under  his  personal  care  in  France 
between  April  1915  and  February  1916.  The  results  are  as 
follows  : — 

Discharged        . .          . .          . .          . .          . .          . .          171 

(a)  Showing  no  further  history  of 

nephritis          109  =  63-7% 

(b)  Invalided            54=31-5% 

(c)  Variously  accounted  for           ..  2=    1-3% 

(d)  Died         6=  3-5% 

Dyke  in  49  cases,  followed  up  for  various  periods  under  12 
months  from  the  attack,  found  that  29  or  60  per  cent,  recovered 
and  were  discharged  to  command  depots  or  to  convalescent 
hospitals;  and,  of  the  remainder,  five  were  discharged  to 
employment  classified  as  C3,  and  15  were  invalided  as 
chronic  cases.  He  also  found  that  the  prognosis  became 
worse  as  age  advanced. 

It  is  desirable  that  the  after  history  of  a  group  of  cases 
should  be  followed  up  for  a  number  of  years,  as  the  development 
of  chronic  nephritis  or  granular  kidney  is  too  insidious  to  allow 
any  accounts  drawn  up  at  the  present  time  to  be  accepted  as 
final.  Still  the  presumption  is  that  such  cases  are  exceptional. 
Albuminuria  even  if  profuse  might  ultimately  disappear  even 
after  having  been  present  for  many  months.  Patients  who  had 
completely  recovered  so  that  all  albuminuria  had  disappeared 
might,  however,  suffer  from  second  or  recurrent  attacks 
especially  when  exposed  to  the  vicissitudes  of  military  life; 
hence  in  all  cases  even  of  complete  and  rapid  recovery  a  pro- 
longed period  of  some  months  should  precede  the  return  to  the 
conditions  of  active  service  No  man  should  be  considered  fit 
for  full  duty  whose  urine  contains  albumin  and  casts  when  it  is 
known  that  these  are  results  of  a  recent  attack  of  nephritis. 
The  question  of  permanent  disability  must  be  answered  by 
a  consideration  of  the  condition  of  the  urine,  the  presence 
of  casts  and  albumin  in  reference  to  the  period  that  has 
elapsed  since  the  original  attack,  and  the  condition  of  the 
cardio-vascular  system. 

Number  of  Days  under  Treatment  in  Cases  of  Nephritis. 


Force  from  which 
derived. 

No.  of 
Cases. 

Total  No.  of  days 
under  treatment. 

Average  No.  of 
days 
under  treatment. 

France 
Salonika 
Egypt     
Mesopotamia 
Italy        

1,928 
9 
35 
7 
21 

214,942 
1,995 
1,637 
630 
3,058 

111-5 

221-6 
46-8 
90 
145-6 

Total   .  . 

2,000 

222,262 

111-1 

502  MEDICAL  HISTORY   OF  THE   WAR 

The  foregoing  table  comprises  a  series  of  2,000  cases  of 
nephritis,  taken  from  the  records  of  patients  treated  in  military 
hospitals  in  France,  Salonika,  Egypt,  Mesopotamia  and  Italy, 
compiled  by  the  Medical  Research  Council.  It  shows  the 
number  of  days  during  which  patients  suffering  from  nephritis 
were  under  treatment. 

Diagnosis. 

Diagnosis  does  not  as  a  rule  present  any  very  serious  diffi- 
culties with  the  exception  that  sometimes  it  is  difficult  to 
differentiate  between  a  case  of  primary  nephritis  and  the 
occurrence  of  nephritis  complicating  an  old  and  chronic  lesion. 
The  mistake  commonly  arises  from  the  assumption  that  the 
sudden  onset  of  symptoms  necessarily  indicates  the  occurrence 
of  a  primary  lesion,  but  renal  disease  in  some  of  its  most 
chronic  and  insidious  forms  may  exist  for  long  periods  without 
obvious  impairment  of  health,  and  then  quite  suddenly  urgent 
and  often  fatal  symptoms  rapidly  develop.  Such  cases  can 
often  be  recognized  owing  to  the  presence  of  signs  of  cardio- 
vascular lesions  such  as  well-marked  cardiac  hypertrophy  and 
high  tension  associated  with  arterial  degeneration.  The  cases 
of  secondary  nephritis  complicating  acute  pulmonary  lesions  or 
septic  wounds  must  be  carefully  distinguished  from  the  primary 
cases.  In  military  medicine  it  is  also  necessary  to  bear  in 
mind  that  such  a  serious  disease  as  cerebro-spinal  meningitis 
may  have  an  onset  with  nephritis,  and  the  meningeal  symptoms, 
if  present,  may  be  erroneously  attributed  to  the  supposed 
presence  of  uraemia.  In  all  cases  of  doubt,  lumbar  puncture 
should  be  practised  without  delay. 

Treatment. 

The  treatment  calls  for  no  special  notice  since  it  is  similar 
to  that  usually  employed  in  this  disease.  During  the 
early  stages,  when  hsematuria  is  present  or  dropsy  in- 
creasing, the  diet  should  be  greatly  restricted,  and  milk  is 
most  suitable,  but  a  milk  diet  should  not  be  continued  for 
prolonged  periods  merely  on  the  ground  of  the  presence  of 
albuminuria.  When  dropsy  is  increasing,  some  restriction  of 
the  fluids  is  advisable,  and  many  such  cases  do  better  on  a 
vegetable  or  fruit  diet  than  on  one  consisting  solely  of 
milk.  It  is  also  advisable,  if  possible,  to  restrict  the  taking  of 
salt  in  such  cases. 

Moderate  purgation,  especially  with  salines,  is  useful,  and 
sweating  should  be  encouraged  by  the  use  of  hot-air  baths. 
Very  good  results  were  obtained  by  the  use  of  improvised  lamp 
baths  made  with  25-candle  power  electric  lights  fixed  on  an 


NEPHRITIS  503 

ordinary  cradle  and  covered  with  blankets.  Venesection  is  of 
value  in  the  treatment  of  the  uraemic  seizures,  and  sometimes, 
if  practised  in  the  prodromal  stage  when  the  tension  is  high  and 
headache  severe,  will  apparently  prevent  the  occurrence  of  the 
seizures.  After  the  subsidence  of  the  dropsy  the  diet  should 
be  increased  and  should  not  be  restricted  merely  because  some 
albuminuria  is  present.  Diuretics  are  of  very  uncertain  value, 
but  sometimes  caffein,  digitalis  or  theocin  are  of  service  in 
starting  diuresis,  and  so  leading  to  the  subsidence  of  dropsy. 
Caffein  should  only  be  given  for  short  periods  of  two  or  three 
days,  and  discontinued  unless  it  promptly  produces  diuresis, 
otherwise  it  is  apt  to  cause  vomiting.  Tonics  should  be  given 
during  convalescence,  especially  iron  and  arsenic. 

The  patients  must  at  all  times  be  protected  against  exposure 
to  cold,  because  chilling  may  induce  a  relapse  or  convert  a 
favourable  case  into  one  of  the  chronic  type.  This  precaution 
is  very  necessary  during  long  journeys  by  rail  transport. 

BIBLIOGRAPHY. 

Abercrombie  ..     Prognosis  in  War  Nephritis.     An     B.M.J.  1918.     Vol.  i, 

analysis  of  171  cases.  p.  504. 

..     Acute  phase  of  five  hundred  cases    Journ.  R.A.M.C.1916. 
of  War  Nephritis.  Vol.  xxvii,  p.  131. 

Dunn  and  McNee  . .     The  Study  of  War  Nephritis.  B.M.J.  1917.    Vol.  ii, 

p.  745. 
Dvke  Prognosis  in  "Trench"  Nephritis     Lancet  1918.  Vol.  ii, 

p.  320. 

Keith  and  Thompson  War  Nephritis.  Quart.   Journ.  Med. 

1917-1918.     Vol    ii, 
p.  229. 

MacLean  . .  . .  Albuminuria  and  War  Nephritis  Report  No.  43,  Med. 
among  British  Troops  in  Res.  Com.,  Lon- 
France.  don,  1919. 

MacLean     and     De     Effects    of  War     Nephritis    on     Quart.  Journ.    Med. 
Wesselow  ..         Kidney  Function,   &c.  1918-1919.      Vol. 

xii,  p.  347. 

Moore         . .         . .     Renal      Retinitis       in        Soldiers    Lancet     1915.   Vol. 
suffering  from     Epidemic    Ne-        ii,  p.  1348. 
phritis. 


CHAPTER  XXIII. 

DISORDERS  OF  THE  CARDIO-VASCULAR  SYSTEM. 

THE  functional  affections  of  the  heart  from  which  soldiers 
suffer,  known  as  disordered  action  of  the  heart,  are  of 
very  great  importance  from  a  military  point  of  view.  They 
had  already  been  studied  by  several  observers,  but  recent 
advances  in  the  knowledge  of  heart  disease  have  enabled 
the  immense  material  provided  by  the  war  to  be  utilized  more 
fruitfully  than  was  possible  before.  The  discoveries  of 
Mackenzie,  of  Lewis,  and  of  others,  had  impressed  upon 
physicians  the  importance  of  observing  this  great  problem 
from  'new  standpoints,  and  by  new  methods,  and  the  large 
number  of  the  soldiers  affected  rendered  it  imperative  that 
every  possible  facility  should  be  given  for  their  treatment. 
The  results  thus  obtained  may  be  said  to  have  placed  the 
whole  subject  on  a  completely  different  footing,  and  to  have 
produced  a  standard  of  knowledge  higher  than  was  previously 
attained. 

From  the  earliest  days  of  the  war  it  was  evident  that  cardio- 
vascular disorders  would  form  a  large  group  of  medical 
disabilities  and  wrould  present  special  points  of  difficulty.  After 
the  retreat  from  Mons  many  men  of  the  original  expeditionary 
force  were  sent  to  England  suffering  from  exhaustion  after  a 
period  of  exceptional  physical  exertion  and  little  or  no  sleep. 
Amongst  these  weary  men  were  many  who  complained  of 
pain  in  the  chest,  shortness  of  breath  and  palpitation  on 
exertion,  and  were  discovered  to  have  a  persistent  tachycardia. 
These  patients  early  presented  difficulties  in  treatment  and 
prognosis. 

Difficulties  also  began  to  arise  in  the  interpretation  of 
certain  physical  signs.  During  the  first  rush  of  recruiting 
apparently  healthy  men  were  discovered  to  have  abnormal 
heart  sounds  and  irregularities  which  threw  doubt  on  their 
physical  fitness.  Again,  some  who  had  been  passed  as 
physically  fit  broke  down  early  in  training  with  various  com- 
plaints referable  to  the  cardio- vascular  system.  Sir  James 
Mackenzie  was  one  of  the  first  to  realise  that  the  interpretation 
of  various  murmurs  heard  over  the  heart  during  examination 
of  recruits  would  give  rise  to  uncertainty  of  diagnosis,  and 
he  published  a  memorandum  on  this  subject.  So  impressed 
was  he  with  the  difficulties  which  he  foresaw  that  he  drew  up 

504 


CARDIO-VASCULAR    DISORDERS  505 

a  scheme  requiring  that  doubtful  cases  should  be  examined 
by  those  who  had  given  special  attention  to  this  subject. 
At  this  time,  however,  the  authorities  were  unable  to  adopt 
Mackenzie's  scheme.  The  question  soon  became  more  and 
more  urgent,  as  hospitals  throughout  the  country  were  receiving 
large  numbers  of  recruits  or  of  soldiers  back  from  France  who 
complained  of  pains  in  the  chest,  shortness  of  breath,  palpitation 
and  giddiness  on  exertion,  but  in  whom  no  organic  disease 
of  the  heart  could  be  found.  The  War  Office  and  the  Medical 
Research  Committee  consequently  arranged  for  the  special 
study  of  such  cases  at  the  Hampstead  Hospital  in  London, 
where  Dr.  Thomas  Lewis  at  first  worked  in  co-operation  with 
an  Advisory  Committee.  Later  this  work  was  moved  to  the 
military  hospital,  Sobraon  Barracks,  Colchester.  A  large 
amount  of  valuable  information  was  soon  forthcoming  from 
the  studies  made  by  Dr.  Lewis  and  his  colleagues  at  these 
two  hospitals.  It  was  soon  realized  that  the  hospital  at 
Colchester  could  not  possibly  deal  with  the  large  number  of 
cases  which  arose  in  England  and  with  those  which  came  from 
overseas,  and  in  1918  heart  centres  were  established  in  the 
various  home  commands. 

In  France  it  had  been  early  realized  that  men  were  being 
sent  over  to  England  with  a  diagnosis  of  valvular  disease  of 
the  heart  in  whom  this  diagnosis  was  not  justified,  and  that 
a  very  much  larger  number  was  being  sent  home  who  com- 
plained of  trivial  symptoms  referable  to  the  heart.  In  1916 
at  one  base  in  France  an  effort  was  made  to  collect  all  cases 
sent  down  the  line  with  a  diagnosis  of  valvular  disease  of  the 
heart  (V.D.H.)  or  disordered  action  of  the  heart  (D.A.H.)  into 
one  centre,  where  such  cases  could  be  sorted  and  as  many  as 
possible  saved  to  France.  In  1917  similar  centres  were  started 
in  four  other  bases,  and  by  this  method  50  to  60  per  cent, 
of  such  cases  were  kept  in  the  country,  a  huge  majority  of 
whom  were  previously  being  sent  over  to  England.  These 
centres  continued  their  work  up  to  the  time  of  the  armistice. 
In  certain  other  war  areas  a  similar  effort  was  made  to  segregate 
and  sort  the  various  types  of  cardio-vascular  diseases. 

Both  the  medical  service  and  the  army  were  greatly  aided  by 
the  ultimate  development  of  this  organization  of  centres  with 
specially  skilled  medical  officers  in  charge  of  the  "  heart  "  cases. 
The  cases  in  hospital  were  quickly  sorted,  and  those,  in  whom 
real  organic  disease  made  full  recovery  and  return  to  duty 
impossible,  were  without  delay  recommended  for  discharge 
from  the  army. 

Still  more  important  was  the  early  return  of  mild  cases  to 
duty  together  with  the  skilled  medical  control  of  mild  cases, 


506  MEDICAL   HISTORY   OF  THE   WAR 

so  that  they  should  not  be  overstrained  by  too  early  return 
to  work.  The  network  spread  by  five  heart  centres  at  the 
chief  hospital  bases  in  France  caught  in  its  meshes  a  large 
proportion  of  the  cases  of  disordered  action  of  the  heart, 
and  50  to  60  per  cent,  of  these  were  detained  for  duty  in  France. 
Transport  to  England,  loss  of  time  by  unduly  long  stay  in 
hospital  there,  and  the  softening  of  the  soldier  under  home 
conditions  were  all  saved  in  respect  of  about  15,000  men 
retained  in  France  by  this  organization.  The  economy  of 
man-power  might  have  been  larger  still  if  the  instructions, 
directing  that  all  D.A.H.  cases  should  be  sent  to  the  heart 
centres  and  not  evacuated  to  England,  had  been  strictly  carried 
out.  But  the  principles  of  diagnosis  and  treatment  of  these 
heart  cases  were  only  slowly  acquired  by  the  medical  services 
in  general,  and  even  when  the  organization  of  special  centres 
in  France  and  in  England  had  been  achieved,  there  still 
remained  a  hesitation  to  make  full  use  of  them. 

The  total  number  of  cardio-vascular  cases  dealt  with  at  the 
several  centres  in  France  was  very  large.  From  March  1917 
to  November  1918,  over  23,000  cases  passed  through  the 
various  centres.  Up  to  May  1918,  36,569  men  had  been 
discharged  from  the  army  and  the  navy  for  cardio-vascular 
disorders ;  and  Lewis  estimates  that  at  least  70,000  men 
must  have  reported  sick,  but  there  is  little  doubt  that  the  true 
figure  is  much  in  excess  of  this  calculation.  Since  the  war 
it  is  estimated  that  one  out  of  every  10  pensioners  suffers  from 
some  cardio-vascular  disorder. 

The  magnitude  of  these  figures  has  to  be  considered  in 
relation  to  the  large  number  of  men  engaged  in  the  war. 
Probably  the  same  percentage  of  men  engaged  in  previous 
wars  had  suffered  similarly  and  Da  Costa  gave  an  account  of 
the  cardio-vascular  disorders  of  soldiers  who  had  fought  in 
the  American  Civil  War.  Da  Costa  analysed  300  cases  and 
his  description  embraces  nearly  all  the  clinical  features  of  the 
so-called  "  soldier's  heart  "  as  known  to-day. 

Amongst  recruits  and  young  soldiers  in  training,  cases  of 
soldier's  heart,  irritable  heart,  and  so  on,  had  frequently  been 
met  with.  From  1864  to  1868  a  committee  sat,  under  the 
chairmanship  of  Earl  de  Grey,  to  enquire  into  the  condition  of 
soldier's  heart  in  the  British  Army.  It  was  said  to  be  due  to 
the  nature  of  the  accoutrements  which  the  soldiers  had  to 
carry  at  that  time  and  certain  alterations  were  made  in  them. 
From  1876  to  1896  various  authors  ascribed  the  condition 
in  the  British  Army  to  the  setting-up  drill  then  in  vogue. 

With  regard  to  the  classification  of  cardio-vascular  disorders, 
he  official  nomenclature  of  diseases  includes  the  terms 


CARDIOVASCULAR  DISORDERS  507 

valvular  disease  of  the  heart  (V.D.H.)  and  disordered  action 
of  the  heart  (D.A.H.).  There  can  be  no  objection  to  the  first 
title  if  the  diagnosis  is  correct.  Against  the  application  of 
the  term  "  disordered  action  of  the  heart,"  to  the  type  of  case 
which  was  so  common  during  the  war,  much  criticism  has 
been  directed.  The  patients  who  were  labelled  with  this 
diagnosis  were  found  to  be  suffering  from  various  diseases  in 
which  cardiac  symptoms  were  secondary  manifestations  or 
were  sequelae  only.  It  has  been  frequently  stated  that  the  title 
D.A.H.  gives  too  much  importance  to  the  cardiac  manifesta- 
tions, draws  the  patient's  attention  to  his  heart,  and  induces 
in  every  man  labelled  V.D.H.  or  D.A.H.  the  firm  belief  that 
he  has  heart  disease.  He  naturally  makes  no  discrimination 
between  V.D.H.  and  D.A.H.,  and  the  mere  diagnosis  of  "  heart 
disease  "  suggests  to  his  mind  either  early  death  or  a  crippled 
future. 

The  evil  results  of  such  diagnosis  on  the  mentality  of  the 
patients  have,  however,  been  exaggerated.  When  a  man 
feels  his  heart  beating  rapidly,  is  short  of  breath  and  feels 
pain  in  the  area  of  his  body  where  he  knows  his  heart  resides, 
he  naturally  considers  that  the  heart  is  amiss.  Whatever 
diagnosis  is  placed  on  his  labels  and  papers,  his  mind  will  be 
chiefly  focussed  on  his  heart  because  he  knows  that  his  symp- 
toms can  only  arise  from  some  unusual  action  of  his  heart. 
The  man's  sensations  will  always  be  more  important  to  him 
than  the  technical  diagnosis  that  he  may  read  on  his  papers. 

But  it  was  early  recognized  that  many  underlying  causes 
were  responsible  for  causing  shortness  of  breath,  pain  in  the 
chest  and  palpitation,  in  soldiers,  and  that  one  disadvantage 
of  the  title  D.A.H.  was  to  give  too  much  importance  to  the 
cardiac  aspect  of  whatever  illness  or  disability  was  responsible 
in  each  case.  Lewis  suggested  the  term  "  effort  syndrome," 
as  the  symptoms  were  chiefly  produced  on  exertion.  Though 
the  paramount  importance  of  exertion  is  true  for  most  cases, 
in  some  instances  the  symptoms  occurred  chiefly  on  emotional 
excitement,  and  in  others  they  were  most  distressing  at  rest 
in  bed.  The  ideal  diagnosis  of  this  type  of  case  would  be  that 
of  the  primary  disease.  At  the  present  moment  knowledge 
of  the  condition  is  not  sufficiently  advanced  to  enable  such 
a  diagnosis  to  be  made  in  all  cases.  The  symptoms  in  most 
cases  can  be  attributed  to  an  inherent  physical  defect,  an 
infection,  a  nervous  defect,  or  to  injury  to  the  lung  by  poison 
gases.  Even  though  many  cases  can  be  thus  roughly  classified 
there  will  still  remain  many  for  whom  some  indefinite  diagnosis 
is  necessary,  and  for  whom  the  title  "  effort  syndrome  "  is 
probably  more  appropriate  than  disordered  action  of  the  heart. 


508 


MEDICAL  HISTORY   OF  THE   WAR 


The  cardiovascular  disorders  met  with  during  the  war  can 
then  be  most  conveniently  divided  into  two  main  types 
(1)  organic  or  valvular  disease  of  the  heart,  (2)  the  functional 
condition  known  as  soldier's  heart,  irritable  heart  or  the  effort 
syndrome. 

ORGANIC   DISEASE. 

Certain  figures  are  available  which  show  the  number  of  cases 
of  valvular  disease  of  the  heart,  among  those  patients  who 
complained  of  symptoms  indicating  a  failure  on  the  part  of 
the  cardio- vascular  system  to  respond  to  effort.  Amongst 
1,000  men  in  France  who  went  sick  with  such  complaints,  only 
55  could  be  shown  to  be  suffering  from  valvular  disease.  The 
following  table  shows  the  varieties  of  valvular  disease  encoun- 
tered and  the  incidence  or  otherwise  of  a  previous  history  of 
rheumatic  fever  : — 


Number  of  Cases. 

Previous 
Rheumatic  Fever. 

Aortic  regurgitation 
Mitral  stenosis 
Mitral  incompetence 
Mitral  stenosis  and  aortic  regurgitation 
Paroxysmal  tachycardia 

Total         

11 
17 
19 
5 
3 

6 
10 
11 
4 
0 

55 

31=56-3% 

Though  169  cases  had  been  sent  down  the  line  with  a  definite 
diagnosis  of  valvular  disease  of  the  heart,  in  only  55  was  there 
any  justification  for  such  an  opinion.  A  later  series  of  7,803 
cases  from  the  same  base  in  France  showed  an  even  smaller 
percentage  of  valvular  disease  of  the  heart,  viz.,  289  or  3-7  per 
cent.  The  varieties  of  valvular  disease  and  the  incidence  or 
otherwise  of  a  previous  rheumatic  fever  in  these  cases  are  as 
follows  : — 


Number  of 

Previous 

Cases. 

Rheumatic  Fever. 

Mitral  regurgitation 

91 

53 

Mitral  stenosis 

88 

55 

Mitral  regurgitation  and  stenosis 

26 

18 

Aortic  regurgitation 

59 

24 

Aortic  regurgitation  and  mitral  stenosis 

24 

16 

Aortic  stenosis 

1 

1 

Total         

289 

167  =  57-8% 

CARDIOVASCULAR   DISORDERS  509 

From  Lewis'  figures  of  cardio- vascular  cases  seen  in  England, 
which  were  naturally  of  a  severer  type  than  those  examined 
in  France,  the  percentage  of  organic  disease  was  about  10. 

A  subsequent  analysis  of  500  heart  cases  examined  at  a 
cardiac  clinic,  in  connection  with  the  Ministry  of  Pensions, 
shows  that  the  incidence  of  valvular  disease  amongst  pensioners 
is  considerably  higher  than  that  found  on  active  service.  The 
following  organic  cases  were  found  amongst  them  : — - 


Aortic  regurgitation 

Mitral  stenosis 

Aortic  regurgitation  and  mitral  stenosis 

Arteri  o-sclerosis 

Rheumatic  carditis 

Mitral  incompetence 

Auricular  fibrillation   (cardio-sclerosis) 


33 
16 
21 
28 

4 
15 

6 


Total 123  =  24-6% 


The  considerably  higher  incidence  of  valvular  disease  of  the 
heart  found  amongst  pensioners  than  amongst  serving 
soldiers  is  very  striking.  Certain  explanations  seem  to 
account  for  this.  A  large  number  of  men  who  complained 
of  cardiac  symptoms  on  active  service  probably  ceased 
to  attach  importance  to  these  symptoms  after  the  armistice  or 
after  demobilization.  The  falling  off  of  cases  of  functional 
disease  (D.A.H.,  effort  syndrome)  would  then  relatively  raise 
the  incidence  of  organic  disease.  Medical  examiners,  realizing 
the  secondary  nature  of  functional  cardiac  symptoms, 
may  have  diagnosed  the  disability  under  the  heading  of  the 
original  disease,  such  as  malaria  or  dysentery. 

It  had  been  thought  probable  that  most  of  the  cases  of 
valvular  disease  of  the  heart  dated  their  origin  from  some 
period  before  the  war,  and  it  was  frequently  a  matter  of 
surprise  how  well  such  patients  had  undergone  the  physical 
and  mental  hardships  of  active  warfare.  Acute  rheumatic 
fever  was  not  a  common  disease  amongst  soldiers  in  France, 
and  it  is  improbable,  therefore,  that  much  V.D.H.  originated 
during  war  service.  Yet  men  with  early  valvular  disease 
are  being  seen  on  pensions  boards  who  have  probably  con- 
tracted the  endocardial  infection  during  the  war,  and  since 
1918  various  observers  have  remarked  upon  the  greater 
frequency  of  infective  endocarditis.*  This  observation  is 
certainly  borne  out  by  recent,  findings  amongst  pensioners. 
Both  the  history  and  post-mortem  examinations  make  it  clear 
that  infection  in  a  large  percentage  of  these  cases  has  invaded 
the  valves  of  the  heart  de  novo,  without  evidence  of  previous 

*  See  Chapter  vii,  p.  197. 


510  MEDICAL   HISTORY   OF  THE   WAR 

endocarditis.  In  other  respects  thevarieties  of  valvular  disease  are 
in  no  way  different  from  similar  lesions  met  with  in  civil  life. 

Whenever  a  diagnosis  of  valvular  disease  of  the  heart  is 
made  in  a  young  soldier,  the  patient  ought  to  be  discharged 
from  the  army.  It  is  unfair  to  the  army  and  to  the  soldier  to 
continue  his  service,  both  from  the  risk  of  further  damage  and 
from  the  fact  that  the  valvular  defect  has  already  drawn 
on  the  reserve  of  heart  power. 

FUNCTIONAL  DISORDERS. 

The  functional  disorders  of  the  heart  have  been  described 
under  the  terms  soldier's  heart,  irritable  heart  of  soldiers, 
disordered  action  of  the  heart  (D.A.H.),  and  the  effort  syndrome. 

During  active  warfare  various  observers  found  that  only 
5  to  10  per  cent,  of  those  who  complained  of  symptoms  referable 
to  the  heart  could  be  shown  to  be  suffering  from  organic  disease 
of  the  heart.  Another  8  to  10  per  cent,  whose  only  complaints 
had  reference  to  the  heart  were  discovered  to  be  suffering 
from  diseases  which  had  little  or  no  relation  to  the  circulatory 
system.  The  remaining  80  per  cent,  complained  of  shortness 
of  breath,  pain  in  the  chest,  palpitation  and  giddiness  as  their 
most  prominent  symptoms.  It  is  to  this  particular  class  that 
special  attention  has  been  directed.  It  has  been  pointed  out 
above  that  a  large  number  of  men  from  the  expeditionary  force 
and  a  greater  number  of  recruits  at  home  suffered  from  these 
symptoms,  and  that  in  these  patients  no  organic  disease  of 
the  heart  could  be  found.  It  was  soon  realized  that  many 
different  conditions  gave  rise  to  these  symptoms. 

Symptoms. 

In  1,000  cases  in  France,  not  suffering  from  any  organic 
disease  of  the  heart  or  cardio-vascular  system,  seven  hundred 
and  sixty-eight,  or  76-8  per  cent.,  complained  of  pain  in  the 
region  of  the  heart.  The  position  and  character  of  the  pain  varied 
considerably.  The  pain  was  more  frequently  limited  to  the  region 
of  the  apex  and  to  an  area  extending  to  a  hand's  breadth  below 
the  apex  than  to  any  other  part  of  the  left  chest.  At  times  the 
pain  was  localized  in  the  region  of  the  third  left  interspace,  and 
occasionally  it  radiated  from  one  spot  in  the  region  of  the 
heart  to  a  wide  area  on  the  left  side,  sometimes  also  extending 
to  the  right  side  of  the  chest.  Rarely,  the  pain  radiated  down 
the  left  arm  and  less  frequently  down  both  arms.  The 
character  of  the  pain  was  most  frequently  described  as  a  sharp 
stabbing  pain  ;  sometimes  an  ache  or  a  feeling  of  soreness 
was  described  and  many  patients  likened  it  to  toothache.  The 
pain  hampered  the  breathing  and  might  be  accompanied  by 
a  sensation  of  choking  in  the  throat.  After  the  acute  pain 


CARDIO-VASCULAR   DISORDERS  511 

had  subsided  patients  complained  that  a  varying  area  of  the 
chest  wall  remained  sore.  A  study  of  the  histories  showed 
that  the  first  attack  of  pain  was  usually  determined  by  some 
effort  or  by  some  sudden  mental  disturbance,  and  that,  as 
further  stiains — physical  and  mental — were  superadded,  the 
attacks  of  pain  became  more  frequent  and  lasted  longer  until 
they  persisted  for  two  or  three  hours.  Complaint  was  fre- 
quently made  that  pain  in  the  chest  prevented  sleep  and  that 
lying  on  the  left  side  was  an  impossibility.  It  was  ascertained 
that  when  pain  in  the  heart  followed  a  mental  shock  some 
interval  of  time  frequently  elapsed  before  the  pain  was  felt 
in  the  chest,  though  the  heart  palpitated  from  the  moment 
of  shock.  This  seemed  to  suggest  that  the  pain  was  the 
result  of  the  excitability  and  overaction  of  the  heart.  The 
pain  was  always  intensified  by  exertion  and  frequently  by 
emotional  disturbances.  In  the  majority  of  cases  the  pain 
was  associated  with  hyperaesthaesia  or  praecordial  tenderness 
of  the  chest  wall,  though  at  the  time  of  examination  this  might 
not  be  present.  Two  hundred  and  sixty-eight,  or  26  •  8  per  cent, 
of  the  cases,  had  this  tenderness.  The  examination  took  place 
within  forty-eight  hours  of  the  patients'  arrival  at  the  base. 

Six  hundred  and  seventy-five,  or  67-5  per  cent.,  volun- 
tarily complained  of  shortness  of  breath  on  exertion,  though 
on  enquiry  the  remaining  32-5  per  cent,  acknowledged 
that  they  were  short  of  breath  on  slight  exertion.  The 
majority  showed  no  increased  respiratory  rate  at  rest,  but 
they  were  more  breathless  than  normal  individuals  after  the 
same  amount  of  exertion.  Occasionally,  however,  even  when 
the  patient  was  at  rest,  his  breathing  was  rapid  and  shallow, 
a  type  seen  in  civil  life  in  definite  cases  of  hysteria.  In  such 
cases  a  respiratory  rate  of  60-80  per  minute  was  frequently 
counted  and  a  rate  of  200  per  minute  is  recorded  by  Lewis. 
Sighing  respiration  was  common.  It  was  noteworthy  that 
the  pulse  rate  might  be  very  high  (140-150),  and  the 
respiratory  rate  only  very  slightly  increased  (24-26). 

Four  hundred  and  three,  or  40-3  per  cent:,  mentioned 
giddiness  as  the  chief  subject  of  complaint.  It  sometimes 
occurred  with  exertion,  but  more  frequently  on  the  re- 
sumption of  the  erect  posture  after  sitting  or  after 
recumbency.  Occasionally  it  was  sufficiently  severe  to  cause 
the  individual  to  fall,  and  the  vertigo  has  been  sufficient  to 
cause  a  man  to  fall  from  his  horse.  It  was  frequently  noticed 
that  men  were  giddy  after  certain  Swedish  exercises,  parti- 
cularly on  rising  to  the  feet  after  the  completion  of  leg  movements 
while  lying  on  the  back  Attacks  of  palpitation  were  usually  ac- 
companied by  sensations  of  giddiness  or  fullness  of  the  head. 


512  MEDICAL   HISTORY   OF   THE   WAR 

Not  all  patients  with  a  rapid  heart  action  were  conscious  of 
discomfort.  Three  hundred  and  fifty-four,  or  35-4  per  cent., 
complained  of  palpitation,  fluttering  of  the  heart  and  heavy 
beating  of  the  heart.  Complaints  of  the  heart  turning  over 
and  isolated  heart  thumps  were  usually  indicative  of  the 
occurrence  of  premature  ventricular  beats.  Palpitation 
usually  occurred  in  bouts  and  the  rate  of  the  heart 
during  an  attack  often  reached  180  beats  per  minute.  The 
attacks  lasted  a  variable  period  from  20  minutes  to  five  or  six 
hours.  Many  graphic  records  were  taken  during  attacks  of 
palpitation  and  these  showed  in  all  cases  a  normal  rhythm. 
Records  of  paroxysmal  tachycardia  and  auricular  fibrillation 
placed  the  cases  in  the  categories  of  organic  disease.  Ordinary 
palpitation  followed  most  acutely  on  exertion  or  after  some 
emotional  disturbance.  Frequently  patients  complained  that 
palpitation  prevented  sleep.  One  hundred  and  twenty- three,  or 
12-3  per  cent,  of  the  cases  stated  that  they  were  subject  to 
fainting  attacks.  It  was  frequently  difficult  to  diagnose  the 
attacks  which  patients  described  as  faints.  Some  were  un- 
doubtedly syncopal  attacks,  and  Lewis  and  Macllwaine  have 
described  in  detail  their  observations  during  such  attacks. 
Their  accounts  make  it  clear  that  the  attacks  observed 
were  vagal  in  origin.  Many  patients  stated  that  giddiness 
and  a  failure  of  vision  compelled  them  to  lie  down,  indicating 
a  pre-syncopal  condition.  Some,  however,  who  had  complained 
of  fainting  attacks,  were  observed  to  have  undoubted 
hysterical  seizures. 

In  addition  to  the  above  there  were  certain  disabilities  in 
most  cases,  which  had  less  reference  to  the  cardio- vascular 
system,  and  were  probably  directly  due  to  the  original  disease. 

Nearly  every  patient  complained  that  he  was  exhausted 
by  degrees  of  physical  exertion  which  he  wras  previously  well 
able  to  support.  Many  had  a  worn  out  and  fatigued  aspect, 
and  while  in  hospital  it  was  almost  impossible  to  keep  them 
from  lying  down. 

Headache  was  a  common  complaint,  as  also  was  sleeplessness. 
Many  stated  that  they  had  been  sleepless  for  some  weeks  before 
they  finally  broke  down.  The  irritability  of  temper  commonly 
encountered  was  an  evidence  of  the  general  exhaustion  of  the 
nervous  system. 

With  regard  to  the  physical  signs  in  these  cases,  about  one- 
third  had  tenderness  of  the  left  side  of  the  chest  wall.  The 
muscles  and  ribs  were  tender  on  pressure  and  pinching.  The 
tender  area  varied  in  size  and  distribution  ;  the  area  which 
was  found  to  be  most  commonty  affected  was  that  in  the 
neighbourhood  of  the  apex  beat.  A  less  common  area  involved 


CARDIOVASCULAR   DISORDERS 


513 


the  third  and  fourth  ribs  with  the  intervening  interspace.  At 
times  the  whole  of  the  praecordial  area  was  tender  together 
with  the  left  pectoral  muscles  and  the  inner  side  of  the  left  arm. 
The  degree  of  tenderness  varied  from  time  to  time  in  the  same 
individual,  and  was  a  guide  to  the  grade  of  exercise  which  the 
patient  ought  to  undergo.  According  to  Lewis  praecordial 
tenderness  seemed  to  be  more  frequent  in  those  patients  who 
gave  a  history  of  rheumatic  fever.  It  was  always  considered 
to  be  a  bad  prognostic  sign  if  the  tenderness  continued 
throughout  a  course  of  treatment  by  graduated  exercises.  In 
eliciting  information  of  any  kind  from  patients  of  this  class  it 
was  always  important  to  avoid  suggestion.  If  real  tenderness 
was  present  the  patient  would  invariably  wince  if,  without 
any  remark  to  the  patient,  the  ribs  and  interspaces  were  pressed 
upon. 

Many  observations  have  been  made  on  the  rate  of  the  heart 
under  varying  conditions  of  rest  and  activity.  The  average 
rate  of  the  heart  was  about  85  per  minute  in  unselected  cases. 
During  the  waking  hours  the  rate  remained  quick,  but  in  the 
majority  it  appeared  to  become  slower  in  sleep.  In  this  con- 
nection an  interesting  observation  was  made  by  Harris  in  France 
on  a  case  of  tachycardia  following  typhoid  fever.  While  taking 
a  continuous  polygraphic  record  he  noticed  that  the  rate 
suddenly  halved.  On  looking  at  the  patient  he  found  that  he 
had  fallen  asleep.  Immediately  on  awakening  the  rate  returned 
to  its  original  rapidity.  This  was  corroborated  during  an  en- 
quiry into  the  cardiac  disorders  of  Soldiers  in  France  for  the 
purpose  of  noting,  in  a  large  number  of  cases,  the  heart  rate 
when  the  patient  was  asleep.  It  was  found  to  be  the  almost 
invariable  rule  that  the  rate  fell  remarkably  in  this  class  of 
cases  ;  for  instance,  heart  rates  of  120  or  thereabouts,  which 
persisted  during  the  whole  of  the  waking  hours,  would  be 
counted  at  60-70  when  the  patient  slept.  Further  enquiry  in 
cases  of  tachycardia  in  every  sort  of  disease  will  show  the  value 
of  this  observation.  It  seems  to  suggest  the  preponderating 
influence  of  the  nervous  system  in  this  class  of  tachycardia. 

The  following  table  indicates  the  pulse  rates  of  the  1,000 
cases  examined,  taken  in  the  erect  position,  after  a  rest. 

Pulse  Rates. 


Rate. 

Percentage. 

Rate. 

Percentage. 

Rate. 

Percentage. 

40-50 

0-1 

80-90 

13-5 

120-130 

11-3 

50-60 

0-5 

90-100 

22-4 

130-140 

1-4 

60-70 

1-8 

100-110 

23-8 

140-150 

0-9 

70-80 

9-5 

110-120 

14-7 

150-160 

0-1 

(2396) 


H  H 


514  MEDICAL  HISTORY   OF  THE   WAR 

In  response  to  exercise  the  rate  increased  to  a  higher  level 
than  in  normal  individuals,  and  after  slight  exertion  it  was  quite 
common  to  find  the  rate  increased  to  170-180  beats  per  minute. 
Further,  a  longer  interval  of  time  elapsed  after  exertion  before 
the  pulse  returned  to  its  original  rate.  In  healthy  men  an 
increase  of  20-30  beats  per  minute  after  brisk  exercise  will 
disappear  and  the  rate  will  return  to  normal  in  a  minute  or  less. 
In  the  D.A.H.  type  of  case  it  frequently  required  an  interval 
of  more  than  two  or  three  minutes  after  the  cessation  of  the 
exercise  before  the  heart  returned  to  its  original  rate.  Con- 
siderable stress  is  laid  on  this  phenomenon  at  the  examinations 
by  pensions  boards.  Most  patients  in  whom  there  is  a  tardy 
return  to  the  pre-exercise  heart  rate  show  considerable  respira- 
tory distress  and  may  complain  of  pain  in  the  left  side  after 
such  an  exercise  as  mounting  a  chair  ten  times  with  each  leg. 
As  Lewis  points  out,  the  pulse  rate  as  a  guide  to  capacity  has 
to  be  circumspectly  used,  and  in  France  it  was  frequently 
noticed  that  men  who  had  a  persistent  pulse  rate  of  120  could 
play  a  hard  game  of  football  or  go  for  a  march  without  ill 
effect. 

The  two  chief  types  of  arrhythmia  met  with  in  cases  with  the 
effort  syndrome  are  sinus  arrhythmia  and  premature  contrac- 
tions of  the  ventricles.  The  discovery  of  heart  block  or 
auricular  fibrillation  immediately  places  the  case  in  some  cate- 
gory of  organic  disease.  In  young  people  with  slowly  acting 
hearts,  e.g.,  60-70,  a  degree  of  sinus  arrhythmia  is  common.  The 
irregularity  is  complete  and  is  much  influenced  by  the  varying 
phases  of  inspiration  and  expiration,  the  heart  usually  becoming 
markedly  slower  at  the  beginning  of  expiration  after  a  deep 
inspiration.  When  the  heart  is  quickened  by  exertion  or 
excitement  the  arrhythmia  disappears. 

Frequent  premature  contractions  arising  in  the  ventricles  were 
noted  in  5-7  per  cent,  of  the  1,000  cases.  These  were  usually 
felt  as  intermissions  in  the  radial  pulse  but  the  premature  con- 
tractions of  the  ventricles  could  be  heard  with  the  stethoscope. 
They  tend  to  disappear  when  the  heart  rate  is  quickened. 
In  fact,  this  characteristic  response  to  effort  with  disappear- 
ance of  the  irregularity  separates  the  irregularities  which  are 
significant  of  disease  of  the  heart  from  those  which  are  of  no 
importance.  The  only  common  irregularity  which  is  of  great 
importance  is  auricular  fibrillation,  and  in  this  type  of 
arrhythmia  the  irregularity  becomes  more  marked  after 
exertion  and  the  breathing  of  the  patient  is  usually  impaired. 

Minor  differences  in  the  size  of  the  heart  were  extremely 
difficult  to  detect,  and  usually  the  earliest  reliable  sign  of 
increase  was  some  displacement  of  the  apex  beat  towards  the 


CARDIO-VASCULAR   DISORDERS  515 

axilla.  The  maximum  impulse  of  the  heart  is  often  forcible 
and  the  powerful  thrust  against  the  chest  wall  gives  the  im- 
pression of  hypertrophy.  Two  facts  seem  to  militate  against 
the  view  that  a  forcible  impulse  at  the  apex  indicates  hyper- 
trophy in  this  class  of  case  ;  first,  the  impulse  is  found  at  a 
normal  distance  from  the  mid  line  of  the  sternum,  and  secondly, 
it  is  only  forcible  when  the  heart  is  beating  excitably  and 
becomes  much  less  obvious  after  the  patient  has  lain  in  a  re- 
cumbent position  for  some  time.  Careful  orthodiagraphic 
measurements  by  Meakins  and  Gunson  support  the  view  that 
the  heart  is  not  enlarged,  either  at  rest  or  immediately  after 
exertion.  By  careful  measurements  of  the  distance  of  the  apex 
beat  from  the  mid  line  of  the  sternum  and  by  percussion, 
it  was  never  possible  to  demonstrate  any  change  in  the  size  of 
the  heart  while  the  patient  was  under  observation,  though  in 
some  the  apex  beat  appeared  to  be  diffuse.  In  such  cases  it 
is  necessary  to  localize  the  maximum  impulse,  and  it  will  be 
found  that  it  lies  well  within  normal  limits.  Diffusion  of  the 
impulse  is  often  found  in  cases  which  suffer  from  palpitation. 

A  sharp  distinction  has  usually  been  drawn  by  all  observers 
between  the  murmurs  which  occur  in  diastole  and  those  which 
occur  during  systole  of  the  ventricles,  namely  that  diastolic 
murmurs  invariably  indicate  an  organic  lesion.  Systolic  mur- 
murs were  extremely  common  in  the  effort  syndrome  patients, 
and  they  were  heard  in  200  out  of  500  cases  in  which  special 
attention  was  directed  to  this  point.  The  significance  of  systolic 
murmurs  heard  over  the  prsecordium  has  given  rise  to  much 
discussion  and  frequently  to  gross  misinterpretation.  Many 
men  were  refused  admission  to  the  army,  have  been  discharged 
from  the  army,  and  have  been  wrongly  assessed  by  pensions 
boards,  on  account  of  the  misinterpretation  of  a  systolic  murmur. 
In  the  early  days  of  the  war,  Mackenzie  published  a  brief  instruc- 
tion on  this  point  by  direction  of  the  Director-General  of  the 
Army  Medical  Service.  He  pointed  out  that  an  estimate  of  the 
fitness  of  any  heart  should  not  be  judged  by  the  hearing  of  a 
murmur  alone,  and  that  in  ever}'  case  the  position  of  the  maxi- 
mum impulse  and  the  response  of  the  heart  to  effort  should  be 
the  guiding  factors  in  forming  an  opinion.  Most  hearts  beating 
at  a  rate  of  110  or  more  are  prone  to  generate  praecordial 
systolic  murmurs.  Many  murmurs  which  have  no  untoward 
significance  can  be  detected  by  their  auscultatory  character- 
istics alone.  A  systolic  murmur  heard  best  over  the  pulmonary 
cartilage  can  usually  be  immediately  disregarded  ;  this  area 
has  always  been  referred  to  as  the  "  romantic  area."  Systolic 
murmurs  heard  best  over  the  aortic  cartilage  are  less  common 
than  those  heard  over  the  pulmonary  cartilage.  In  men  over 


516  MEDICAL   HISTORY   OF   THE   WAR 

forty  a  systolic  murmur  over  the  aortic  cartilage  may  indicate 
loss  of  elasticity  and  some  dilatation  of  the  aorta  without  any 
incompetence  of  the  aortic  valves,  and  without  any  evidence 
of  hypertrophy  of  the  left  ventricle.  Systolic  murmurs  heard 
best  over  the  aortic  cartilage,  have,  however,  a  sinister  signifi- 
cance when  they  are  associated  with  a  diastolic  murmur,  usually 
heard  best  at  the  left  of  the  sternum,  and  with  obvious 
hypertrophy  of  the  heart. 

The  chief  difficulties  are  met  in  connection  with  systolic 
murmurs  heard  best  in  the  neighbourhood  of  the  apex  beat. 
Probably  the  murmurs  heard  in  this  locality  are  generated  by 
varying  factors,  as  for  instance  the  cardio-respiratory  murmur 
which  is  dependent  upon  the  relationship  of  the  heart  to  the  lung. 
It  may  be  caused  by  a  normal  breath  sound  being  broken  into 
two  or  three  short  murmurs,  each  of  which  accompanies  a 
cardiac  systole  ;  at  times  it  is  accentuated  by  inspiration  and 
at  times  by  expiration  ;  it  disappears  when  the  breath  is  held, 
and  pressure  with  the  bell  of  the  stethoscope  against  the  chest 
wall  tends  to  obliterate  it  altogether.  There  are  other  systolic 
murmurs  heard  best  in  the  neighbourhood  of  the  apex,  whose 
characteristics  appear  to  suggest  a  leak  at  the  mitral  or  tricuspid 
orifices.  These  are  blowing  murmurs  which  are  conducted 
towards  the  axilla  and  may  be  heard  at  the  angle  of  the  left 
scapula.  More  rarely  a  high  pitched  blowing  murmur  may  be 
heard  best  toward  the  lower  end  of  the  sternum  which  has  the 
characteristics  of  the  murmur  in  a  similar  position  in  uncom- 
plicated tricuspid  regurgitation.  In  a  case  where  such  murmurs 
are  to  be  heard  no  importance  should  be  given  to  the  murmur 
unless  there  is  some  displacement  of  the  apex  towards  the  axilla 
and  unless  there  is  some  limitation  of  the  heart's  response  to 
effort.  In  all  cases  of  systolic  murmurs  about  the  apex  beat 
particular  attention  should  be  paid  to  the  accentuation,  or 
otherwise,  of  the  pulmonary  second  sound.  Whether  the 
tricuspid  and  mitral  valves  may  be  temporarily  incompetent 
in  perfectly  normal  hearts  is  not  known  but  in  all  cases  no  im- 
portance should  be  placed  on  the  mere  hearing  of  a  systolic 
murmur  without  other  evidences  of  cardiac  disability. 

With  regard  to  blood  pressure,  when  patients  were  going 
about  in  a  convalescent  camp  in  France  it  was  found  that  the 
systolic  pressure  ranged  between  130-150  mm.  Hg.,  while  Lewis 
found  under  conditions  of  rest  the  blood  pressure  was  usually 
more  or  less  normal.  Lewis  points  out  that  the  reaction  of  the 
blood  pressure  to  effort  was  exaggerated  in  cases  of  D.A.H. 
With  the  same  amount  of  work  the  systolic  pressure  rose 
48  mm.  Hg.  in  two  patients  with  effort  syndrome,  while  in  three 
controls  the  average  rise  was  only  19  mm.  Hg. 


GARDIO-VASCULAR    DISORDERS 


517 


Cold,  blue  hands  and  feet  were  frequently  seen  and  many 
instances  of  Raynaud's  disease  were  encountered.  Many 
patients  were  quite  positive  in  their  statement  that  the  cir- 
culation of  the  hands  was  quite  normal  before  the  onset  of  their 
other  circulatory  symptoms.  The  skin  of  these  patients  readily 
perspired  and  it  was  not  uncommon  to  find  them  becoming 
bathed  in  perspiration  during  examination.  The  pilomotor  and 
other  reflexes  of  the  skin  were  usually  very  active. 

Blood  counts  revealed  a  leucocytosis  in  many  cases. 

Physical  evidences  of  excitability  of  the  central  nervous 
system  were  two  in  number ;  first,  general  tremulousness 
was  common  and  a  fine  tremor  of  the  outstretched  hands  was 
noticeable  in  many  patients.  Secondly,  the  knee  jerks  were 
usually  accentuated. 

^Etiology. 

With  regard  to  the  predisposing  causes  of  disordered  action 
of  the  heart,  the  symptoms  and  signs  may  be  due  to  so  many 
underlying  causes  that  it  is  necessary  to  have  a  detailed  history 
of  each  man's  previous  health  and  occupation  and  his  own 
account  of  the  factors  which  seemed  to  lead  to  his  breakdown. 
Particular  attention  must  be  paid  in  each  case  to  the  date  of 
the  onset  of  the  symptoms  and  it  is  noteworthy  that  in  542  out 
of  1,000  cases  the  disability  had  been  noticeable  before  enlist- 
ment. The  following  show  the  various  conditions  which  were 
alleged  by  these  patients  to  be  the  cause  of  their  disability  : — 

Cases  occurring  before  Enlistment. 

Indefinite  gradual  onset  in  308  cases,  of  whom  191  were  discharged  fit. 

40 

30 

12 
9 
7 
4 

1  was 
6  were 
1  was 

1  „ 

2  were 
1  was 

1  „ 

0  were 

2  „ 

Onsets  before  enlistment,,  542     „       „       „      308     „ 

Of  these  cases  56  attributed  the  onset  of  their  symptoms  to 
some  definite  effort  and  strain  or  to  some  sudden  mental 
excitement  and  shock.  Of  the  various  infectious  diseases, 
rheumatic  fever  largely  predominates,  though  the  patients  did 
not  show  signs  of  valvular  disease  of  the  heart.  As  the 
pathological  process  in  rheumatic  fever  is  the  deposit  of  small 


Rheumatic  fever 

82 

Definite  effort  or  shock 

56 

Faints  and  fits 

21 

Pneumonia 

18 

Typhoid  fever 
Scarlet  fever 

14 
9 

Influenza 

9 

Pleurisy 
Rheumatism 

6 
4 

Diphtheria 
Malaria 

3 
3 

Tonsillitis 

2 

Asthma 

2 

Jaundice 
Other  conditions 

1 
4 

518 


MEDICAL   HISTORY   OF  THE  WAR 


inflammatory  collections  of  cells  in  various  parts  of  the  heart 
muscle  and  valves,  it  is  quite  conceivable  that  an  impaired 
muscle  results  from  the  disease  without  any  deformation  of 
the  valves.  Four  hundred  and  fifty-eight  of  the  1,000  cases 
of  D.A.H.  analysed  occurred  after  enlistment,  and  were 
attributed  to  : — 

Cases  occurring  after  Enlistment. 

An  indefinite  gradual  onset  in  238  cases,  of  whom  148  were  discharged  fit. 


Definite  effort 

Shell  shock 

Pyrexia  of  uncertain  origin 

Being  buried 

Being  gassed 

Wounds 

Trench  fever 

Dysentery 

Influenza 

Fits  and  faints 

Bronchitis 

Rheumatic  fever 

Scarlet  fever 

Tonsillitis 

Jaundice 

Rheumatism 

Measles  and  pneumonia 

Pleurisy  and  anaemia 


57 

36 

31 

21 

18 

11 

8 

8 

6 

5 

4 

3 

2 

2 

2 

2 

2 

2 

458 


26 
20 
26 
13 

8 

6 

6 

3 

6 

1  was 

2  were 
0 

0 
2 

1  was 
0  were 

2  „ 
2     „ 

272 


The  patients  who  were  unable  to  attribute  the  onset  of  their 
symptoms  to  any  definite  cause,  stated  that  the  exertion  of 
training  or  the  additional  strain,  both  mental  and  physical,  to 
which  they  were  subjected  in  France,  had  gradually  told  upon 
them.  The  other  special  predisposing  factors,  peculiar  to  the 
conditions  of  active  service  in  the  field,  were  wounds,  being 
buried  or  gassed,  shell  shock  and  various  infections.  In  the 
case  of  the  wounded  who  later  complained  of  cardiac  distress, 
there  had  usually  been  a  prolonged  period  of  sepsis  and  rest 
in  bed,  and  the  effects  of  both  on  the  circulatory  system  were 
probably  analagous  to  those  following  infectious  fevers.  More 
and  more  importance  has  been  given  to  infection  as  a  cause  of 
effort  syndrome,  and  many  of  those  whose  onset  was  indefinite 
may  have  belonged  to  this  category. 

Investigations  in  a  convalescent  camp  in  France  showed  that 
many  cases  were  still  suffering  from  what  was  probably  trench 
fever  at  the  time  of  admission.  Lewis  gives  the  following 
percentages  as  demonstrating  the  greater  frequency  of  a  history 
of  previous  infection  in  patients  suffering  from  the  effort  syn- 
drome than  in  those  suffering  from  various  gunshot  wounds 
but  with  no  effort  syndrome. 


CARDIO-VASCULAR   DISORDERS 


519 


Prevalence  of  previous  diseases  in  effort  syndrome  patients  observed 
in  1914-1915,  as  compared  with  patients  without  effort  syndrome. 


Previous  Illnesses. 

Effort  Syndrome 
(558  Cases 
observed)  . 

Heart  Disease 
(101  Cases 
observed)  . 

Gunshot  Wounds 
(100  Cases 
observed). 

No    past   illness    or 

accident  .  . 

18% 

11% 

82% 

Rheumatic  fever  or 

chorea 

23% 

61% 

4% 

Pyrexia     of     uncer- 

tain origin  or  in- 

fluenza 

12% 

6% 

0% 

Enteric  or  enteritis 

8% 

1% 

4% 

Dysentery  . 

6% 

3% 

2% 

Pneumonia. 

6% 

10% 

3% 

Scarlet  fever 

5% 

1% 

1% 

Bronchitis  . 

3% 

0% 

4% 

Tonsillitis    . 

8% 

6% 

0% 

Malaria 

3% 

0% 

6% 

Venereal  disease 

2% 

4% 

5% 

Pleurisy 

16% 

1% 

3% 

Trench  fever 

5% 

0% 

0% 

Trench  foot 
Other  illnesses 

9% 
87% 

3% 
5% 

0% 
0% 

It  has  long  been  recognized  with  what  frequency  patients 
complain  of  their  hearts  during  convalescence  from  various 
infective  diseases.  In  civil  practice  influenza  is  one  of 
the  commonest  of  these  infections.  During  the  war 
certain  observations  on  the  physical  impairment  of  the 
circulatory  system  following  typhoid  fever  and  trench  fever 
have  been  made  ;  in  both  diseases  a  persistent  tachycardia 
may  arise  after  the  acute  phases  of  the  disease  have  passed 
away,  even  before  the  patient  has  left  his  bed.  These  observa- 
tions seem  to  show  that  such  infections  upset  the  nervous 
control  of  the  heart  or  impair  its  musculature  before  any 
additional  strain,  such  as  the  resumption  of  the  erect 
posture,  has  been  thrown  upon  the  heart.  A  quick  pulse- 
rate  during  convalescence  from  diphtheria,  for  example, 
necessitates  prolonged  recumbency  if  danger  is  to  be 
averted. 

As  regards  the  age  incidence  of  D.A.H.,  56 -4  per  cent,  of 
1,000  cases  analysed  were  between  20  and  30  years  of  age. 
The  majority  of  men  serving  in  France  were  probably  of  this 
age  group,  for  an  analysis  of  the  age  groups  of  2,000 
patients  who  were  not  suffering  from  effort  syndrome  gave 
a  similar  percentage  of  men  between  20  and  30  years  of  age. 
The  percentages  in  quinquennial  periods  are  almost  identical 


520 


MEDICAL  HISTORY   OF   THE  WAR 


in  both  the  effort  syndrome  and  other  cases,  as  is  shown  in  the 
following  table. 


Age. 

Percentage    1,000 
cases  D.A.H. 

Percentage  2,000 
other  cases. 

15-20  years 

7-9 

11-15 

20-25 

33-3 

32-95 

25-30 

23-1 

22-05 

30-35 

13-8 

13-05 

35-40 

10-9 

11-55 

40-45 

8-4 

7-5 

Over  45 

2-6 

1-75 

100-0 

100-00 

Analyses  of  cases  made  by  Hume  and  Lewis  seem  to  indicate 
that  soldiers  who  eventually  suffered  from  the  effort  syndrome 
had  been  drawn  mainly  from  sedentary  or  light  occupations. 
This  was  the  case  in  64  per  cent,  of  the  cases  coming  to  a  heart 
centre  in  France. 

Various  incidental  inquiries  into  the  influence  of  other  factors 
in  the  production  of  the  symptoms  of  the  effort  syndrome  have 
been  carried  out  by  different  observers. 

Parkinson  and  Koefod  came  to  the  conclusion  that  the 
smoking  of  a  single  cigarette  raised  the  blood  pressure  and 
increased  the  frequency  of  the  pulse  both  in  controls  and  in 
cases  of  disordered  action  of  the  heart.  They  also  found  that 
the  smoking  of  a  few  cigarettes  rendered  healthy  men  more 
than  usually  breathless  on  exertion,  but  breathlessness  occurred 
more  frequently  and  more  severely  in  a  large  proportion  of 
patients  with  the  effort  syndrome.  They  were  of  opinion  that 
excessive  cigarette  smoking  was  not  the  essential  cause  in  most 
cases  of  disordered  action  of  the  heart,  but  that  it  was  an  im- 
portant contributory  factor  in  the  breathlessness  and  praecordial 
pain  of  many  of  them.  That  the  condition  is  frequent  in  the 
Sikh  soldier,  to  whom  smoking  is  forbidden,  is  a  further  proof 
that  tobacco  does  not  play  a  large  part  in  the  production  of  the 
effort  syndrome. 

Lewis  pointed  out  that  palpable  enlargement  of  the  thyroid 
was  only  found  in  19,  or  4  per  cent,  of  502  soldiers  specially 
examined,  amongst  whom  was  one  case  which  showed  the 
associated  phenomena  of  Graves'  disease.  Further,  there  is  no 
increased  incidence  of  tachycardia  in  those  soldiers  who  have 
a  palpable  enlargement  of  the  thyroid.  That  the  thyroid  gland 
does  not  play  a  part  in  the  causation  of  the  tachycardia  in 
this  class  of  case  is  further  supported  by  the  fact  that  in  D.A.H. 


CARDIO-VASCULAR   DISORDERS  521 

patients  the  pulse-rate  falls  markedly  in  sleep,  whereas  in 
exophthalmic  goitre  the  drop  in  the  pulse-rate  is  never  complete. 

Of  the  various  gases  used  by  the  Germans,  phosgene  was 
accountable  for  more  cardiac  disabilities  than  any  other.  It 
is  probable  that  far  more  men  were  gassed  by  mustard  gas 
than  by  phosgene;  but  those  patients  who  suffered  from 
D.A.H.  symptoms  shortly  after  poisoning  by  mustard  gas  were 
almost  invariably  those  who  had  spent  a  considerable  period 
in  hospital  with  bronchitis  or  broncho-pneumonia  following  the 
gassing,  and  in  the  production  of  whose  symptoms  a  large 
element  of  sepsis  entered.  The  various  sternutatory  gases 
never  produced  circulatory  after-effects. 

About  8  per  cent,  of  cases  dated  their  disability  from  mental 
disturbance  following  the  bursting  of  a  particular  shell  or  as 
the  result  of  a  long-continued  intensive  bombardment.  The 
impression  obtained  in  the  shell-shock  centres  in  France  was 
that  tachycardia  developed  in  about  20  per  cent,  of  the  cases 
while  the  patients  were  still  in  bed.  Many  of  those  whose 
disabilities  began  imperceptibly  and  gradually,  attributed  their 
condition  to  the  wear  and  tear,  mental  and  physical,  of  life  in 
the  trenches. 

With  regard  to  venereal  disease  as  a  predisposing  cause,  the 
patients  were  for  the  most  part  of  an  age  at  which  syphilitic 
conditions  in  the  heart  and  arteries  do  not  occur.  A  history 
of  recent  infection  could  be  obtained  in  only  4  per  cent,  of 
Lewis's  cases.  Without  any  particular  inquiry  it  was  certain 
that  very  few  of  the  D.A.H.  cases  in  the  various  centres  in 
France  were  suffering  from  gonorrhoea.  These  men  were 
closely  scrutinized,  and  the  routine  inspections  for  scabies  and 
staining  of  the  clothes  with  discharges  sufficed  to  detect  most 
cases  of  gonorrhoea. 

With  regard  to  alcohol  as  a  predisposing  cause,  Lewis  found 
that  53  per  cent,  of  effort  syndrome  cases  were  total  abstainers, 
as  compared  with  33  per  cent,  total  abstainers  amongst  cases 
of  wounds  and  not  suffering  from  D.A.H.  Conscientious  reasons 
were  chiefly  given  for  total  abstinence  and  this  explanation 
gains  support  from  the  greater  refinement  and  more  frequent 
introspection  found  in  cases  suffering  from  the  effort 
syndrome.  They  were  usually  men  who  took  great  care  of 
themselves. 

In  estimating  the  prime  factors  which  underlie  the  disability 
of  the  effort  syndrome,  the  above  evidences  of  previous  history, 
previous  infections,  the  symptoms  of  which  the  patient  com- 
plains and  the  signs  found  on  examination  have  to  be  taken 
into  consideration.  By  so  doing,  most  cases  can  be  placed  in 
one  of  six  fairly  distinct  categories.  To  illustrate  this  the 


522  MEDICAL   HISTORY   OF   THE  WAR 

following  table  was  compiled  from  the  detailed  examination  of 
375  effort  syndrome  pensioners  seen  at  a  cardiac  clinic : — 

17  or     4-5%  poor  physique. 
137         36-6%  previous  infections.     ' 


110 
33 
24 
15 
39 


29-3%  had  neurasthenia. 

8-8%  had  been  gassed. 

6  •  4  %  had  history  of  single  strain. 

4-0%  had  long  service. 

10-4%  were  of  doubtful  category. 


375       100-0% 

With  regard  to  the  poor  physique  group,  the  men  stated  that 
they  attempted  an  apprenticeship  to  some  strenuous  occupa- 
tion, such  as  shipping  and  coal  mining  industries,  but  that  they 
were  compelled  to  leave  such  work  for  a  less  severe  and  usually 
sedentary  form  of  occupation.  When  such  men  become  soldiers 
they  are  called  upon  to  undergo  exertion  which  is  beyond  their 
physical  powers.  In  the  war  many  young  men  of  this  type 
might  have  developed  into  efficient  soldiers  by  a  slow  and 
gradual  training,  if  sufficient  time  and  gradation  of  training 
had  been  possible,  but  the  sudden  rush  of  the  civil  population 
into  the  army  precluded  this  gradual  method  of  development. 

In  France  a  careful  physical  examination  was  made  of  some 
hundreds  of  patients  who  passed  through  the  heart  centre  at 
Boulogne  with  a  view  to  their  physical  comparison  with  German 
prisoners,  of  whom  nearly  a  thousand  were  similarly  examined. 
The  differences  in  certain  directions  were  extremely  marked. 
The  later  muscular  development  around  a  rickety  chest 
wall  may  be  taken  as  an  example.  In  a  German  of  poor 
natural  physique,  or  one  who  had  some  acquired  deformity 
such  as  a  rickety  chest,  the  defect  was  minimized  by  com- 
pulsory service  involving  exercises  in  the  gymnasium  or 
swimming  baths.  Youths  in  Germany  had  been  educated 
and  compelled  by  their  Government  to  take  this  form  of 
exercise.*  The  universal  provision  of  gymnasia  and  swimming 
baths  in  towns  and  villages  enabled  them  to  continue  their 
physical  training,  the  value  of  which  they  had  been  taught 
during  compulsory  service  in  the  army,  and  for  which  the 
majority  had  a  real  liking.  On  rickety  frames  the  German  had 
often  built  a  good  musculature,  and  at  the  same  time  had 
developed  the  lung  and  heart  capacity  to  the  maximum.  On 
the  other  hand,  it  is  probable  that  only  a  small  percentage 
of  the  new  armies  formed  in  the  United  Kingdom  during  the 
war  had  ever  played  any  game  or  undergone  physical  training. 
Interest  in  games  had  been  to  a  large  extent  confined  to  watch- 
ing instead  of  participating  in  them,  and  the  result  showed  itself 
in  the  poor  expansion  of  the  chest  and  under-development 


CARDIO-VASCULAR   DISORDERS  523 

of  the  general  musculature,  in  which  the  heart  participated. 
The  physical  effort  necessitated  by  training  and  service  in 
the  army  very  soon  proved  too  much,  therefore,  for  individuals 
with  a  naturally  poor  physique. 

With  regard  to  the  group  of  cases  which  had  suffered  from 
previous  infections,  the  conditions  of  active  service  inevitably 
cut  short  the  necessary  rest — mental  and  physical — required 
for  complete  recovery  from  the  various  infectious  diseases. 
In  typhoid  fever  and  trench  fever  a  tachycardia  may  arise 
towards  the  end  of  the  illness  at  a  time  when  the  fever 
has  disappeared  and  while  the  patient  is  still  <  in  bed. 
Again,  severe  infections  tend  to  reduce  the  systolic  blood 
pressure  during  the  course  of  the  fever.  This  is  invariable 
in  typhoid  fever  and  pneumonia,  but  is  less  constant  in  trench 
fever.  Consequently  cardio-vascular  symptoms  arising  after 
recent  attacks  of  typhoid,  trench  fever,  influenza  and 
pneumonia  are  usually  clearly  related  to  the  infections  of 
these  diseases.  Occasionally,  however,  the  relationship  is  not 
so  obvious. 

Residual  abscesses  from  wounds,  causing  in  themselves  little 
inconvenience,  have  been  found  to  give  rise  to  an  intoxication 
which  produces  a  clinical  picture  of  D.A.H.  Similarly,  small 
collections  of  pus  in  deep  wounds  of  the  leg,  and  small  septic 
collections  round  foreign  bodies  in  the  pleural  cavity,  have  been 
the  immediate  cause  of  the  more  general  symptoms  of  shortness 
of  breath,  palpitation  and  pain  in  the  region  of  the  heart  on 
exertion.  The  removal  of  the  infection  and  the  opening  and 
draining  of  the  abscess  have  led  to  the  complete  disappearance 
of  the  symptoms. 

The  influence  of  rheumatic  fever  in  producing  D.A.H. ,  quite 
apart  from  the  production  of  valvular  disease,  has  also  been 
brought  to  light  by  different  investigations.  It  was  found 
that  the  percentage  of  D.A.H.  cases  who  had  previously 
suffered  from  rheumatic  fever  varied  from  11  to  23  per  cent, 
of  the  cases  examined.  It  must  therefore  be  assumed  that 
the  micro-organism  of  rheumatic  fever  causes  some  permanent 
damage  to  the  muscular  fibres  of  the  heart,  and  this  is  suggested 
by  the  observations  of  Carey  Coombs  on  the  pathology  of  the 
disease.  He  points  out  that  the  characteristic  feature  of  this 
infection  is  the  collection  of  small  subsidiary  nodules  among 
the  heart  muscles  and  between  the  bases  of  the  valves. 

It  is  probable  that  many  other  infections  may  be  as  respon- 
sible for  the  persistence  of  symptoms  of  the  effort  syndrome 
as  those  already  mentioned,  but  their  relationship  has  not 
been  so  clearly  proved.  Many  soldiers  who  had  gone  sick 
and  had  come  down  the  line  with  only  D.A.H.  symptoms  were 


524  MEDICAL   HISTORY   OF   THE   WAR 

found  to  be  pyrexial,  and  it  was  evident  that  they  had  suffered 
recently  from  fever.  Many  had  obviously  suffered  for  some 
time  from  trench  fever.  It  is  possible,  too,  that  mild,  inde- 
terminate fevers,  such  as  occur  in  catarrhs  of  the  upper 
respiratory  passages,  might  alone  bring  on  the  symptoms  of 
the  effort  syndrome  in  men  tired  or  strained  during  active 
righting. 

In  associating  the  symptoms  with  any  particular  fever,  the 
interval  of  time  between  the  occurrence  of  the  fever  and  the 
onset  of  the  symptoms  is  of  considerable  importance.  In 
the  case  of  rheumatic  fever  the  infection  is  known  to  produce 
permanent  changes  in  the  heart  muscle,  and  a  remote  history 
of  rheumatic  fever  is  always  to  be  considered  as  a  possible 
causative  factor.  In  other  infections  the  association  in  point 
of  time  ought  to  be  much  closer  than  in  rheumatic  fever.  But 
if  the  patient  has  passed  a  period  of  perfect  health  and  has 
been  well  able  to  sustain  exertion  between  the  period  of  con- 
valescence from  the  fever  and  the  onset  of  the  symptoms,  some 
other  causative  factor  ought  to  be  sought. 

Of  the  various  poison  gases,  phosgene  was  the  most  potent 
in  its  effects  on  the  heart.  Occasionally  soldiers  who  had 
been  exposed  to  phosgene  gas  suddenly  dropped  dead  at 
varying  intervals  up  to  some  days  after  exposure.  This 
usually  occurred  after  exertion  and  was  only  partly  due  to 
sudden  oedema  of  the  lungs ;  the  cause  seemed  to  lie  in  heart 
failure.  The  more  remote  effects  of  breathlessness,  pain  in 
the  chest,  palpitation  and  giddiness  occurred  in  a  larger 
majority  of  men  poisoned  by  phosgene  than  of  those  poisoned 
by  any  of  the  other  gases.  The  after  effects  of  mustard 
gas  seemed  to  depend  rather  on  the  severity  and  nature  of 
the  septic  pulmonary  complications  than  on  any  clinical 
evidence  of  direct  implication  of  the  heart  itself. 

The  "  sneezing  "  gases,  blue  cross,  never  produced  any  after 
effects  on  the  lungs  or  on  the  heart,  and  some  other  cause 
than  gassing  must  be  sought  in  men  who  had  been  exposed 
to  this  type  of  gas  alone,  and  who  developed  later  the  symptoms 
of  the  effort  syndrome. 

Various  pathological  changes  in  the  lungs  have  been  described 
as  the  after  effects  of  phosgene  and  mustard  gases.  Emphysema 
and  peribronchial  fibrosis  are  two  sequelae  to  which  attention 
has  been  drawn  by  French  observers  in  particular.  Such 
pulmonary  changes  may  interfere  with  the  respiratory  exchange 
of  oxygen  and  carbon  dioxide  in  the  alveoli  and  so  produce 
breathlessness  and  cardiac  distress  on  exertion. 

As  regards  the  effect  of  sudden  exertion  and  strain,  a  small 
percentage  of  men  stated  that  they  felt  perfectly  well  unf 


CARDIO- VASCULAR   DISORDERS  525 

they  were  buried  and  as  a  result  had  to  struggle  and  strain 
every  muscle  in  the  body  to  escape.  Added  to  the  physical 
effort  there  was  in  all  such  cases  a  severe  nervous  shock,  and 
it  is  always  difficult  to  assess  the  respective  value  of  the  physical 
or  the  mental  strain  as  the  causative  factor. 

It  has  been  disputed  by  many  whether  muscular  exertion 
acting  on  a  healthy  heart  can  ever  produce  any  lasting  effect. 
Those  who  deny  that  any  physical  effort,  however  severe  and 
however  mechanically  disadvantageous,  can  produce  any  lasting 
effect  on  the  heart  attribute  the  effort  syndrome  to  the  effects  of 
exertion  on  a  damaged  heart  muscle.  According  to  this  view  the 
strain  merely  determines  the  failure  of  a  heart  damaged  by 
some  infection  or  toxic  agent.  If  this  is  the  case,  it  is 
extremely  difficult  to  point  to  the  infective  or  toxic  agent  in 
some  cases  of  this  group  whose  previous  history  and  examination 
give  no  evidence  of  recent  or  remote  infection.  Nor  can 
nervous  influences  play  any  part,  as  this  type  was  frequently 
seen  in  men  working  at  a  base,  whose  symptoms  dated  from  a 
merely  physical  strain  such  as  cranking  up  a  car..  In  civil 
practice  healthy  boys  and  young  men  get  similar  symptoms 
after  strenuous  games,  and  in  industrial  life  perfectly  healthy 
miners  have  complained  of  the  same  train  of  symptoms  after 
struggling  to  get  a  full  tub,  which  had  become  derailed,  on  to 
the  lines  again.  Many  other  instances  could  be  quoted,  and 
the  balance  of  clinical  evidence  is  certainly  in  favour  of  the 
view  that  sudden  exertion  or  prolonged  effort  may  be  the 
starting  point  of  the  symptoms  of  the  effort  syndrome. 

Various  phenomena  indicative  of  nervous  exhaustion  were 
frequent  amongst  men  whose  chief  complaints  had  reference 
to  the  circulatory  system.  Besides  complaining  of  breathless- 
ness,  pain  in  the  chest,  palpitation  and  giddiness,  very  many 
complained  of  a  feeling  of  general  exhaustion,  headaches, 
insomnia,  irritability  of  temper,  loss  of  appetite  and  other 
more  general  symptoms.  Anyone  who  has  lived  much  with 
D.A.H.  cases  is  impressed  with  the  neurasthenic  element 
in  the  vast  majority  ;  many  even  believe  that  the  prime  cause 
in  all  cases  has  to  be  sought  in  the  central  nervous  system. 
This  opinion  is  supported  by  the  large  numbers  of  cases  of 
effort  syndrome  which  occurred  during  the  war,  and  by  the 
fact  that  neurasthenic  cases  in  civil  life  frequently  complain 
chiefly  of  their  cardiac  sensations.  Both  in  civil  and  military 
practice  such  patients,  besides  suffering  from  cardiac  symptoms, 
are  found  to  be  tremulous  ;  they  look  tired  and  exhausted 
and  have  an  impaired  digestion  and  a  dirty  tongue.  In  about 
30  per  cent,  of  all  cases  of  D.A;H.  the  nervous  manifestations 
dominated  the  picture,  and  a  still  larger  percentage  had 


526  MEDICAL   HISTORY   OF   THE   WAR 

symptoms  of  a  lowering  of  the  tone  of  the  central  nervous 
system.  There  was  certainly  a  larger  number  of  effort  syn- 
drome cases  with  nervous  phenomena  during  the  period  of 
active  fighting  than  after  the  armistice,  and  the  number  was 
still  further  reduced  after  demobilization. 

The  capacity  of  every  human  being  to  sustain  with 
impunity  both  physical  and  mental  strain  is  limited.  Some 
have  great  capacity  for  sustaining  either  or  both,  but  in  the 
majority  the  breaking  point  is  soon  reached.  The  war  called 
for  extraordinary  powers  of  both  mental  and  physical  endur- 
ance. During  trench  warfare,  men  had  not  to  undergo  unusual 
muscular  effort  while  waiting  to  make  the  supreme  effort  of 
attack,  but  the  period  of  waiting  would  be  frequently  spent 
in  great  physical  discomfort  and  under  great  mental  strain. 
Resting  under  such  disadvantageous  circumstances  was  a  bad 
preparation  for  a  physical  and  mental  effort  exceeding  any- 
thing the  individual  had  been  previously  called  upon  to  undergo. 
After  the  effort  had  been  made,  further  calls  would  be  made 
for  even  greater  endurance,  and  frequently  on  insufficient  food 
and  with  no  opportunity  of  recuperation  by  sleep.  For  instance, 
on  one  occasion  200  men  and  one  officer  were  all  that  were 
left  out  of  one  battalion,  and  this  remnant  was  ordered  to  dig 
a  new  trench.  When  at  length  relieved  a  very  large  percentage 
of  those  that  remained  complained  of  symptoms  of  cardiac 
distress  on  exertion  during  the  weeks  that  followed.  Such 
was  a  common  experience.  Many  officers  who  had  shown  no 
fear,  and  who  for  months  had  been  unconscious  of  any  mental 
or  physical  distress  under  the  circumstances  incidental  to 
trench  life,  stated  that  there  came  a  time  when  they  felt  their 
hearts  thumping  during  a  bombardment  or  after  a  shell  had 
burst  particularly  close  to  them.  When  the  excitement  was 
over  the  palpitation  ceased,  only  to  be  repeated  on  the  next 
occasion.  Possibly  on  this  second  occasion  palpitation  per- 
sisted longer  after  the  'cessation  of  the  disturbing  influence. 
In  other  cases  the  tachycardia  continued  persistently  and  was 
intensified  by  exertion  or  further  mental  excitement.  In 
this  way  a  habit  of  tachycardia  seemed  to  be  established,  and 
with  it  shortness  of  breath  and  pain  in  the  left  side  of  the  chest 
on  exertion.  In  those  with  smaller  powers  of  endurance  the 
amount  of  exertion  and  mental  distress  necessary  to  cause 
a  breakdown  was  considerably  less. 

It  has  already  been  pointed  out  that  20  to  30  per  cent,  of 
those  admitted  to  shell  shock  centres  developed  symptoms 
of  the  effort  syndrome,  usually  after  being  some  days  in  the 
centre.  Many  of  these  rapidly  regained  their  nervous  equili- 
brium when  they  arrived  at  a  heart  centre  at  the  base,  though 


CARDIO-VASCULAR   DISORDERS  527 

the  cardiac  symptoms  persisted.  Such  patients  were  usually 
able  to  return  to  the  line.  In  others,  however,  the  neurasthenic 
symptoms  persisted  in  a  milder  degree  and  an  air  raid  sent 
them  flying  all  over  the  countryside.  On  the  other  hand, 
there  were  many  men  who  had  reported  sick  with  pain  in  the 
chest,  breathlessness  and  palpitation,  who  were  not  nervous 
and  in  no  way  belonged  to  the  neurasthenic  class.  The 
symptoms  in  them  had  developed  after  an  illness  or  after  some 
period  of  unusual  exertion  and  occasionally  after  some 
particular  physical  effort. 

In  any  enquiry,  after  careful  analysis  of  the  past  and  present 
history  and  after  thorough  examination,  there  will  always 
remain  about  10  per  cent,  of  the  cases  in  whom  no  satisfactory 
explanation  for  the  symptoms  can  be  found.  They  seem  to 
have  become  gradually  worn  out  and  exhausted  by  waiting 
in  the  line,  loss  of  sleep,  physical  discomfort  and  occasionally 
improper  or  insufficient  food. 

It  is  abundantly  clear  from  the  symptoms  and  the  physical 
signs  of  effort  syndrome  and  its  various  possible  causes  that 
the  effort  syndrome  is  more  of  the  nature  of  a  group  of  symptoms 
than  a  clinical  entity.  The  same  phenomena  are  common  in 
civil  life  and  occur  also  in  women  and  children,  and  further 
the  symptoms  may  merely  signify  the  onset  of  some  organic 
disease  such  as  pulmonary  tuberculosis.  The  problem  of 
causation  has  to  be  treated  in  the  broadest  possible  manner, 
as  the  necessary  physiological  and  pathological  facts  are 
wanting  to  complete  the  links  in  the  chain  of  knowledge  of 
the  exact  causation  of  the  group  of  symptoms.  For  instance, 
the  mode  of  production  of  pain  in  the  chest  under  so  many 
different  clinical  states  is  not  understood  as  yet.  The  even 
simpler  problem  of  the  mechanism  of  the  tachycardia  is  far 
from  clear.  It  is  not  known  whether  it  is  a  removal  of  control 
by  inhibition,  a  continual  speeding  up  by  stimulation,  or  an 
endeavour  to  achieve  in  frequency  that  which  cannot  be 
achieved  by  force.  Stress  is  laid  on  this  aspect  of  the  problem 
because  some  have  approached  the  subject  from  too  narrow 
a  point  of  view,  and  many  of  the  investigations  which  have 
been  carried  out  have  been  in  a  very  limited  field.  The  true 
fact  appears  to  be  that  everyone,  at  some  time  or  other,  suffers 
from  the  symptoms  of  D.A.H.  or  the  effort  syndrome.  After 
unwonted  exertion  a  perfectly  normal  person,  or  after  ordinary 
exertion  an  individual  in  a  lowered  state  of  health  from  any 
cause,  may  suffer  from  pain  in  the  chest,  breathlessness  and 
palpitation,  or  may  have  an  attack  of  giddiness.  After  any 
illness  the  convalescent  may  suffer  from  these  symptoms, 
and  in  addition  may  feel  exhaustion  after  the  smallest 


528  MEDICAL   HISTORY   OF   THE  WAR 

expenditure  of  mental  and  physical  energy.  The  attempt  to  fit 
each  case  into  one  or  other  of  the  above  categories  can  therefore 
only  be  imperfect,  though  by  grouping  the  cases  into  them 
the  proper  course  of  treatment  and  disposal  of  each  case  is 
indicated. 

Pathology. 

With  regard  to  the  pathology  of  disordered  action  of  the 
heart,  certain  investigations  have  been  made,  of  which  the 
following  are  the  more  important  results.  Pathological  con- 
ditions in  the  two  ductless  glands,  the  thyroid  and  the 
suprarenal,  have  been  investigated. 

The  hyperexcitability  of  the  nervous  system,  tremors, 
tachycardia,  and  a  proneness  to  sweating  and  flushing  are 
common  to  both  Graves'  disease  and  the  effort  syndrome. 
They  are,  however,  merely  evidences  of  the  overaction  of  the 
sympathetic  nervous  system  and  are  common  in  various  other 
conditions.  In  517  cases  of  effort  syndrome,  Lewis  found 
no  enlargement  of  the  thyroid  in  483  cases  ;  general  enlarge- 
ment in  five  cases ;  slight  enlargement  in  four  cases  ;  one 
lobe  enlarged  in  one  case ;  one  lobe  slightly  enlarged  in  three 
cases  ;  isthmus  enlarged  in  one  case  ;  isthmus  slightly  enlarged 
in  five  cases  ;  and  doubtful  enlargement  in  15  cases. 

The  thyroid  gland  was  thus  only  palpably  enlarged  in  4  per 
cent,  of  cases.  If  the  condition  of  D.A.H.  was  in  many  cases 
a  mild  form  of  Graves'  disease,  one  would  expect  the  more 
serious  cases  to  cross  the  border  line  and  become  obvious 
instances  of  this  disease.  But  in  spite  of  the  nerve  strain  of 
the  war,  there  were  comparatively  few  cases  of  exophthalmic 
goitre,  and  no  case  of  the  effort  syndrome  was  ever  seen  to 
develop  into  the  more  serious  disease. 

Both  excessive  and  diminished  secretion  of  the  suprarenal 
gland  have  been  alleged  to  be  the  cause  of  disordered  action 
of  the  heart,  The  evidences  of  hyperexcitability  of  the  sym- 
pathetic nervous  system  and  the  rather  higher  range  of  systolic 
blood  pressure  in  the  cases  suggest  overaction  of  this  gland. 
To  test  the  theory  the  reaction  of  the  circulatory  system  to 
intravenous  injection  of  adrenalin  chloride  was  investigated. 
It  is  known  that  patients  suffering  from  Graves'  disease  tolerate 
the  artificial  injection  of  thyroid  substance  less  readily  than 
do  normal  persons.  By  the  same  analogy  it  was  anticipated 
that  intravenous  injections  of  adrenalin  would  produce  a 
result  different  from  the  injection  of  the  same  dosage 
into  normal  individuals.  Fraser  and  Wilson  concluded  that 
the  subjective  sensations  produced  by  intravenous  injection 
were  more  marked  in  the  patients  than  in  the  controls. 


CARDIO-VASCULAR   DISORDERS  529 

Others  came  to  the  same  conclusion.  Normal  individuals, 
however,  vary  in  their  sensibility  to  such  an  extent  that  no 
deductions  can  be  made  from  these  experiments. 

Fraser  and  Wilson  in  the  same  way  injected  apocodeine, 
a  drug  which  stimulates  ganglion  cells  on  the  vagus  nerve, 
but  obtained  results  which  were  inconclusive. 

It  has  been  suggested  that  the  products  of  faulty  metabolism, 
engendered  in  many  cases  by  an  infective  process,  cause  some 
of  the  symptoms  of  the  effort  syndrome.  Barcrof t,  Lewis  and 
others  brought  forward  evidence  that  there  was  a  lack  of 
"  buffer  salts  "  in  the  blood  of  such  patients,  and  that  the 
breathlessness  was  due  to  a  hyperacid  condition  of  the  blood. 
Exercise  causes  an  increase  of  lactic  acid  and  carbonic  acid 
in  the  blood  which  when  uncompensated  and  unneutralized 
increases  the  hydrogen  concentration  of  the  blood  with  resulting 
stimulation  of  respiratory  movements.  Bainbridge,  however, 
concludes  that  the  chief  "  buffer  salt  "  in  the  blood  is  sodium 
bicarbonate  and  that  this  is  not  lacking  in  the  blood  of  patients 
with  the  effort  syndrome.  He  suggests  that  the  normal 
equilibrium  between  the  reaction  of  the  red  cells  and  the 
plasma  may  be  disturbed.  But  in  whatever  way  the  breath- 
lessness may  be  produced,  Lewis  and  his  co-workers  do  not 
suggest  that  deficiency  of  "  buffer  salts  "  is  responsible  for  the 
disturbances  of  the  circulatory  system. 

Bainbridge  suggests  that  the  exaggerated  circulatory  and 
respiratory  response  to  exercise,  characteristic  of  the  effort 
syndrome,  may  originate  in  some  primary  defect  in  the  adjust- 
ments of  the  circulatory  system  which  normally  ought  to  occur 
during  exercise. 

It  would  appear  that  every  gradation  exists  between  the 
fully  trained  man  on  the  one  hand  and  the  most  severe  case 
of  effort  syndrome  on  the  other  hand.  In  health,  in  response 
to  the  greater  venous  inflow  consequent  upon  exercise,  the 
heart  dilates  more  fully,  contracts  more  powerfully  and 
increases  its  speed.  It  is  suggested  that  in  cases  of  effort 
syndrome  the  contractile  power  of  the  heart  is  diminished, 
and  that  the  heart  has  to  beat  more  frequently  in  order  to 
bring  about  a  given  output  per  minute.  Bainbridge  points 
out  that  only  in  this  way  can  the  normal  relationship  between 
the  demands  of  active  organs  for  oxygen  and  the  necessary 
supply  of  oxygen  be  maintained.  It  is  suggested  that 
intoxications  of  bacterial  origin  or  any  factor  which  will 
deprive  the  heart  muscle  of  sufficient  foodstuffs  will  impair 
the  contractile  power  of  the  heart  muscle.  According  to  this 
line  of  argument  the  heart  makes  up  by  rapidity  what  it  lacks 
in  contractile  force.  This  lack  of  contractile  power  may  be 

(2396)  I  I 


530  MEDICAL  HISTORY   OF  THE  WAR 

produced  temporarily  by  poisoning  or  malnutrition,  may  even 
be  present  from  birth  or  have  resulted  from  a  sedentary  life. 
Though  this  may  be  the  explanation  of  the  circulatory  and 
respiratory  phenomena  in  many  cases,  it  is  not  of  universal 
application.  It  has  already  been  pointed  out  that  there  is 
an  extraordinary  difference  in  many  cases  between  the  rate 
of  the  heart  when  the  patient  is  at  rest  and  awake  and  the  rate 
when  he  is  at  rest  and  asleep.  The  heart  rate  may  be  at  all 
times  fast  during  the  waking  hours,  but  the  moment  the 
patient  drops  off  to  sleep  the  rate  may  actually  be  halved  in 
frequency.  Since  the  body  is  at  rest  in  both  cases  it  seems 
that  the  mere  reception  of  impressions  from  the  outside  world 
are  alone  sufficient  to  excite  the  heart  to  unnecessary  activity, 
and  this  phenomenon  suggests  a  purely  nervous  explanation  of 
the  effort  syndrome. 

To  what  extent,  therefore,  hyperexcitability  of  the  central 
or  peripheral  nervous  system  would  account  for  the  rapidity 
of  the  heart  rate  and  breathlessness  requires  investigation. 
The  difference  between  the  heart  rate  awake  and  asleep 
certainly  suggests  that  nervous  impulses  alone  may  be  sufficient 
to  keep  up  an  abnormal  heart  frequency.  As  far  as  respiration 
is  concerned  the  nervous  mechanism  is  often  obviously  at  fault. 
Effort  syndrome  patients  with  neurasthenic  symptoms  are 
prone  to  breathe  rapidly,  shallowly  and  ineffectively,  rates 
of  60  to  80  being  frequently  counted.  It  is  extremely  difficult 
to  get  a  patient  of  this  type  to  take  a  deep  breath  and  almost 
impossible  for  him  to  stop  breathing  for  more  than  a  moment 
or  two.  He  seems  to  have  no  nervous  control  at  his  disposal. 
Much  of  the  abnormality  in  the  breathing  is  obviously  depen- 
dent on  nervous  influences  and  is  not  merely  a  compensatory 
effort  to  restore  a  lost  balance  between  oxygen  demand  and 
oxygen  supply.  Indeed  Haldane  has  shown  that  rapid  shallow 
breathing  is  much  less  effective  than  is  the  ordinary  rate  for 
lung  ventilation,  and  that  it  may  in  itself  lead  to  actual 
deficiency  of  oxygen  supply  to  the  heart. 

The  onset  of  tachycardia  and  palpitation  in  men  under 
repeated  emotional  disturbances  suggests  also  that  the  con- 
tinuing tachycardia  in  some  cases  is  a  persistence  of  a  normal 
heart  response  to  emotional  stimuli. 

It  may  be  stated  generally  that  tachycardia  and  dyspnoea 
are  primarily  dependent  on  many  factors,  some  nervous  and 
some  toxic  or  metabolic.  In  the  main,  the  abnormal  responses 
in  the  circulatory  and  respiratory  systems  are  largely  an 
exaggeration  of  those  which  are  normal  and  physiologically 
necessary  in  the  natural  response  to  exertion.  In  some, 
habits  become  established,  and  in  others  a  weakness  in  one 


CARDIO-VASCULAR   DISORDERS  531 

direction  brings  forth  over-action  in  another.  Further  than 
this  present  physiological  knowledge  of  biological  processes 
does  not  go. 

Diagnosis. 

In  order  to  distinguish  between  organic  and  functional  cases 
of  cardio-vascular  disorders,  Lewis  states  that  the  following 
are  abnormalities  of  organic  heart  disease  : — 

(a)  Aortic  diastolic. 

(b)  Distinct  over-distension  of  the  veins  of  the  neck. 

(c)  Definite  signs  of  enlargement  of  the  heart. 

(d)  An  irregular  heart  action  which  is  maintained  on  exercise,  the  heart- 

rate  being  high. 

(e)  A  diastolic  rumble  at  the  apex. 

(/)    A  basal  or  apical  thrill.    The  thrill  must  be  an  unmistakable  "  purr  "  ; 

a  suspicion  of  thrill  is  insufficient. 
(g)  Widespread  arterial  disease  or  a  persistent  blood  pressure  of  180  or 

over  in  an  elderly  man,  arterial  disease  or  a  persistent  blood  pressure 

of  160  or  over  in  a  young  man. 

He  notes  further  that  a  systolic  murmur  most  audible  at 
the  apex  is  not  a  sufficient  sign  of  disease,  even  though  the 
murmur  is  harsh  and  constant  in  all  attitudes,  but,  if  the 
murmur  is  associated  with  an  unequivocal  history  of  recent 
rheumatic  fever,  ten  years,  or  occurs  in  a  man  of  forty  years 
of  age,  it  is  more  difficult  to  overlook; 

Treatment. 

With  regard  to  treatment  it  was  early  recognized  that  treat- 
ment in  hospital,  at  any  rate  in  war  areas,  was  contra-indicated 
in  patients  of  this  class.  It  was  a  common  experience  that 
patients  sent  down  the  line  with  a  diagnosis  of  V.D.H.  and 
D.A.H.  were  prone  to  be  in  or  on  their  beds  the  whole  of  the 
day.  The  discipline  and  graduated  routine  of  exercise  which 
is  necessary  in  all  types  of  this  disability  cannot,  therefore, 
be  so  well  carried  out  in  a  hospital  as  in  a  convalescent  depot. 

The  first  essential  in  proper  treatment  is  the  careful  examina- 
tion of  each  patient  suffering  from  cardio-vascular  symptoms, 
and  a  full  understanding  of  his  physical  and  mental  history. 
Those  found  to  be  suffering  from  organic  disease  of  the 
circulatory  or  any  other  system  are  suitably  disposed  of.  The 
discharge  from  the  army  of  cases  of  organic  disease  of  the 
circulatory  system  ought  invariably  to  be  recommended.  It 
is  essential  that  evidences  of  any  other  organic  disease  should 
be  carefully  investigated,  because  the  symptoms  may  arise 
from  such  diseases  as  tuberculosis.  The  remainder  of  the 
cases,  about  80  per  cent.,  will  fall  into  one  of  the  six  categories 
of  the  effort  syndrome,  and  the  placing  of  patients  in  one  or 
other  of  these  groups  suggests  special  lines  of  treatment  and 
frequently  indicates  the  prognosis. 


532  MEDICAL   HISTORY   OF   THE  WAR 

It  has  been  pointed  out  that  the  actual  cause  in  any  par- 
ticular case  is  very  elusive.  Any  infection  must  be  sought 
and  the  patient  treated  accordingly.  If  there  is  fever,  rest 
is  necessary  before  the  building-up  process  is  commenced. 
Those  who  have  some  physical  defect  from  birth  will  have  to 
be  put  to  work  suitable  to  their  physique.  The  causes  which 
have  been  traced  to  a  nervous  breakdown  must  be  removed 
when  this  is  possible.  Those  who  break  down  during  active 
service  in  the  line  are  more  likely  to  recover  when  treatment 
is  carried  out  away  from  danger,  always  bearing  in  mind  that 
the  greater  the  distance  away  a  man  gets  from  the  line,  the 
more  difficult  will  it  be  to  get  him  back  there. 

The  patient  is  naturally  alarmed  about  the  state  of  his  heart. 
Pain  in  the  left  side  of  the  chest,  breathlessness  and  palpi- 
tation are  sufficient  indications  that  there  is  something  amiss 
with  the  heart.  The  patient  will  come  to  this  conclusion 
whatever  diagnostic  label  is  attached  to  him.  It  is  useless 
to  attempt  to  tell  a  man  with  such  symptoms  that  there  is 
nothing  the  matter  with  his  heart.  Such  only  suggests  to 
the  patient  ignorance  on  the  part  of  the  medical  officer.  It 
must  be  explained  to  the  patient  that  he  has  no  "  heart 
disease  "  in  the  ordinary  acceptance  of  that  term.  He  will 
then  enquire  how  it  comes  about  that  he  should  feel  his  heart 
beating  so  forcibly  and  should  have  pains  over  it,  if  there  is 
nothing  the  matter  with  his  heart.  The  patient  can  usually 
be  satisfied  if  it  can  be  explained  to  him  that  his  nerves  are 
too  sensitive  and  that  this  causes  the  heart  to  beat  too  fast, 
and  then  that  the  sensitiveness  of  the  nerves  is  due  to  the 
infection,  the  gassing,  or  the  strain  through  which  he  has 
recently  passed.  He  must  be  further  told  that  his  cure, 
though  often  prolonged,  is  certain  in  the  end  and  that  there 
is  nothing  in  his  heart  which  will  lead  to  real  disease  or  which 
will  shorten  or  cripple  his  life.  Most  men  are  considerably 
relieved  when  their  condition  is  explained  to  them  in  some  such 
manner. 

Graduated  exercises  are  of  benefit  from  both  the  prognostic 
and  therapeutic  points  of  view.  The  effects  of  exertion  of 
various  degrees  on  the  individual  form  the  surest  guides  as 
to  fitness  for  work,  and  it  is  by  gradual  building  up  and  training 
that  a  condition  of  fitness  can  be  restored.  The  mornings 
should  be  occupied  by  graduated  exercises  under  the  super- 
vision of  special  instructors.  The  exercises  may  be  those  of 
the  physical  training  of  recruits,  and  so  arranged  that  the 
lowest  grade  includes  only  easy  standing  exercises,  the  second 
grade  is  intermediate  in  severity,  and  the  highest  grade  includes 
exercises  required  by  trained  soldiers. 


CARDIO-VASCULAR   DISORDERS  533 

Lewis  prescribed  the  following  exercises  at  Colchester  : — 

Drill  7.  (15  minutes). 

Heels  raise  and  knees  bend. 

Arms  sideways  stretch,  one  arm  upward,  one  arm  downward  stretch. 

Trunk  turning  (feet  apart). 

Feet  close  and  full  open. 

Trunk  bending  sideways. 

Slow  march. 

Drill  II.  (15  minutes). 
Heel  raising  and  knee  bending  quickly. 
One  arm  upward,  one  arm  downward  stretch. 
Foot  placing  sideways. 
Trunk  bending  sideways. 
Trunk  backward  bend. 
Slow  march. 

Drill  III.  (30  minutes). 

This  drill  consisted  of  Drills  I.  and  II. 

Men  on  Drills  II.  and  III.  were  sent  for  slow  route  marches  of  one  to  two 
miles  in  the  afternoons,  and  were  entitled  to  subsequent  passes  from  the  precincts 
of  the  hospital. 

Drill  IV.  (30  minutes). 

This  drill  consisted  of  Drill  II.,  to  which  the  following  exercise  was  added  : — 
Arms  forward  bend. 
Trunk  turning. 
Knee  raising. 
On  the  hands  down. 
Quick  march. 

Knee  raising,  quick  mark  time. 
Slow  march. 

Drill  V.  (30  minutes). 

Heels  raise,  knee  bend,  arm  stretching  sideways. 

Head  backward  bend. 

Arm  swinging  upward. 

Trunk  turning  quickly. 

Foot  placing  sideways. 

Leg  placing  sideways. 

Trunk  bending  sideways  quickly. 

Lying  on  the  back  down,  leg  raising. 

On  the  hands  down,  arms  bend. 

Trunk  forward  bend,  arm  stretching  sideways. 

Knee  raising,  quick  march. 

On  alternate  feet  hop. 

Upward  jumping. 

Slow  march. 

Arm  raising  sideways,  upward,  sideways,  downward. 

Men  on  Drills  IV.  and  V.  were  sent  for  longer  route  marches  of  four  to  five 
miles  at  an  ordinary  marching  pace,  and  were  entitled  to  longer  passes  from 
the  grounds  of  the  hospital.  The  men  on  Drill  V.  enjoyed  additional  privi- 
leges. 

But  graduated  games  under  good  instructors,  particularly 
when  accompanied  by  music,  were  infinitely  superior  to  the 
set  army  exercises.  The  interest  and  pleasure  of  the  patient 
are  more  easily  secured  by  the  former  than  by  the  latter. 


534 


MEDICAL  HISTORY   OF  THE  WAR 


Whenever  possible,  exercises  and  games  should  be  conducted 
in  the  open  air.  In  the  afternoons  route  marches  with  a  band 
should  be  arranged  for  the  separate  grades.  All  grades  march 
off  together,  and  the  lowest  grade  returns  by  itself  after  a 
certain  distance  ;  the  intermediate  grade  goes  further  before 
return,  while  the  highest  grade  does  a  full  one-and-a-half  to  two 
hours'  marching  with  the  band.  Instead  of  the  route  march 
some  are  selected  for  games  in  the  afternoon — football  or 
cricket. 

It  was  very  noteworthy  how  badly  the  effort  syndrome 
patient  did  army  exercises  or  a  route  march  without  a  band, 
and  how  much  better  his  bearing  was  when  his  interest  and 
emotions  were  excited  during  games  and  marching  with  a 
band. 

While  the  patient  is  under  treatment  he  should  be  well  fed, 
and  sleep  should  be  procured  by  sedatives,  if  necessary. 

An  endeavour  should  be  made  to  send  a  man,  on  discharge 
from  treatment,  to  work  suitable  to  his  physical  and  mental 
capacity.  This  cannot  be  completely  carried  out  in  an  army, 
though  much  useful  work  was  accomplished  in  France  in  this 
direction  by  mutual  co-operation  between  officers  in  charge 
of  heart  centres  and  assistant  inspectors  of  drafts. 

Prognosis. 

It  is  only  by  a  consideration  of  the  results  of  treatment  that 
a  prognosis  can  be  attempted.  No  man  was  considered  fit 
for  ordinary  duty  unless  he  had  been  on  Grade  1  exercises 
and  marches  for  10  days. 

The  disposal  of  1,000  men  in  1917  after  treatment  in  a 
cardiac  centre  in  France,  was  as  follows  : — 


Permanent  base  duty  —  ordinary 
Permanent  base  duty  —  light 
Temporary  base  duty 
Hospital 
England  —  unfit 
Unknown 
Still  in  camp 

f 

172 
44 
86 
50 
6 
17 
45 

17-2o/0 
4-4% 
8-6% 
5-0% 
0-6% 
1-7% 
4-5% 

1,000  „  100-0% 

Those  discharged  "  fit  "  were  fit  for  the  duty  which  they 
had  left  at  the  time  of  reporting  sick ;  this  did  not  always 
mean  ordinary  duty  in  the  line. 

The  percentages  of  disposal  of  similar  cases  from  the  heart 
centre  in  Colchester  in  1918  were  as  follows  : — 


Fit  for  general  service 
Fit  for  hardening  or  labour 
Fit  for  light  or  sedentary  work 
Permanently  unfit 


20% 
30% 
30% 
20% 


CARDIO-VASCULAR   DISORDERS  535 

During  the  war  it  was  extremely  difficult  to  check  the 
accuracy  of  these  estimates  of  fitness.  The  following  figures 
are  given  by  Lewis  to  show  how  239  cases  were  classified  on 
discharge  from  hospital  and  their  disposition  eleven  months 
later. 

On  discharge  from  hospital. 

Fit  for  general  service  . .          . .          . .          . .         72 

Likely  to  become  fit  for  general  service  within  three 

months  . .          . .          . .          . .          . .          . .         47 

Light  duty  and  unlikely  to  be  fit  for  overseas  within 

three  months  . .          . .          . .          . .          . .          . .         20 

Light  duty  and  unlikely  ever  to  be  fit  for  service 

overseas  .  .          .  .          .  .          .  .          . .          . .          68 

Sedentary  work  in  the  United  Kingdom  . .  . .  32 

239 

Condition  eleven  months  after  discharge  from  hospital. 

Employed  on  full  duty  overseas          . .          . .          . .  79 

Employed  on  full  duty  in  the  United  Kingdom       . .  38 

Employed  in  labour  companies  in  the  United  Kingdom  23 

Employed  on  light  duty  overseas        .  .          . .          . .  7 

Employed  on  light  duty  in  the  United  Kingdom     . .  33 

Employed  on  sedentary  work  in  the  United  Kingdom  16 

Still  under  medical  treatment . .          . .          . .          . .  5 

Discharged  from  the  Service  as  permanently  unfit  . .  38 

239 

Twenty- three  thousand  cases  passed  through  the  various  heart 
centres  in  France  between  November  1916  and  November  1918, 
and  weekly  nominal  rolls  of  all  cases  were  sent  to  the  Boulogne 
centre.  The  number  of  cases  who  passed  more  than  once 
through  any  heart  centre  was  only  3  per  cent.  This  figure 
was  surprisingly  small,  even  when  it  is  allowed  that  many  who 
went  sick  a  second  time  with  D.A.H.  symptoms  may  have 
escaped  the  mesh  of  the  cardiac  centres. 

Throughout  the  war  the  danger  of  allowing  the  symptoms 
of  the  effort  syndrome  to  be  taken  too  seriously  were  fully 
realized.  Too  great  laxity  always  meant  an  unnecessary 
escape  of  men  from  military  service.  The  main  objects 
should  always  be,  primarily,  to  prevent  as  far  as  possible 
the  occurrence  of  the  symptoms,  and  secondly,  when  they 
occur,  to  render  men  fit  again  to  take  their  place  in  the 
army  Prevention  can  be  achieved  in  the  infective  group 
by  a  more  prolonged  convalescence  and  more  graduated 
return  to  full  duty.  During  convalescence  the  principles 
of  treatment  applicable  to  patients  with  the  effort  syndrome 
ought  in  reality  to  be  applied  to  patients  recovering  from 
illness  of  any  kind,  because  all  are  potential  sufferers  from 
the  effort  syndrome.  All  convalescents  should  therefore  be 


536  MEDICAL  HISTORY    OF    THE  WAR 

systematically  and  gradually  trained  under  medical  super- 
vision. If  this  were  done  universally  it  would  be  almost 
unnecessary  to  make  special  provision  for  the  cardiac  cases. 

The  knowledge  of  a  man's  capacity  gained  by  the  medical 
officers  in  convalescent  depots  should  be  passed  on  to  the 
inspectors  of  drafts,  and  the  latter  should  be  largely  guided 
by  this  information  in  allotting  convalescents  to  the  various 
types  of  duty. 

Cardio-Vascular  Disorders  in  Recruits. 

The  lessons  which  have  been  taught  by  the  war  in  connection 
with  effort  syndrome  have  a  special  bearing  on  recruiting. 

Recruiting  for  a  small  standing  army  is  a  very  different 
problem  from  the  enrolment  of  practically  the  whole  manhood 
of  the  nation.  The  principles  of  selection  are  the  same  in  both 
cases,  but  the  selecting  tests  can  be  made  much  more  severe 
when  the  recruits  required  are  comparatively  few.  The  tests 
are  the  history  of  the  recruit's  previous  physical  capabilities, 
a  history  of  rheumatic  fever,  the  position  of  the  maximum 
impulse  of  the  heart  and  the  circulatory  and  respiratory 
response  to  an  exercise  test.  These  are  the  most  important 
factors  with  which  to  form  an  idea  of  physical  fitness.  A 
simple  test  of  physical  fitness  is  the  mounting  of  a  chair  ten 
times  with  each  leg,  counting  the  pulse  before  and  immediately 
after  the  test,  and  again  two  minutes  later,  when  the  pulse  ought 
to  have  fallen  to  the  pre-exercise  rate. 

In  future  wars  the  same  problems  will  arise  as  those  which 
arose  during  the  examination  of  recruits  in  1914  to  1918. 
Whether  special  administrative  arrangements  will  be  necessary 
to  deal  with  cases  of  effort  syndrome  amongst  them  will 
largely  depend  on  the  number  of  men  required.  In  future 
campaigns  some  of  the  multitudinous  causes  of  this  disability 
will  be  prevalent,  and  the  human  machine  will  break  down 
exactly  as  it  has  done  in  the  past. 

BIBLIOGRAPHY. 

Abraham     . .          . .      "  Soldier's  heart  "          . .          . .     Lancet,  1917.    Vol.  i, 

p.  442. 

Bainbridge  . .          . .     The     physiology     of     muscular     Longmans,  Green   & 
exercise.  '  Co.,  Lond.,  1919. 

Cotton,    Rapport    &     After-effects  of  exercise  on  pulse-     Heart,    1915-1917. 
Lewis  rate  and  systolic  blood  pres-         Vol.  vi,  p.  269. 

sure  in  cases  of  irritable  heart. 
Cotton          . .          . .     Observations  on  aortic  disease     Lancet,    1919.     Vol. 

in  soldiers.  ii,  p.  470. 

Da  Costa      . .          . .     On  irritable  heart  . .          . .     Amer.    Journ.    Med. 

Scien.,  1871.    Vol. 
Ixi,  p.  17. 


CARDIO-VASCULAR  DISORDERS 


537 


Fraser  &  Wilson 
Gosse 

Gunson 

Hume 

Lewis 


Lewis,  Cotton,  Bar- 
croft,  Milroy,  Duf- 
ton  &  Parsons. 

Macllwaine 


Mackenzie   . . 
Mbrison 

Murray 


Oppenheimer  & 
Rothschild 


Parkinson 


BIBLIOGRAPHY— cont. 

The  sympathetic  nervous  sys- 
tem and  the  "  irritable  heart 
of  soldiers." 

Some  experiences  of  disordered 
action  of  the  heart  with  the 
Mesopotamian  Force. 

Cardiac  symptoms  following 
dysentery  among  soldiers. 

A  study  of  the  cardiac  disabili- 
ties of  soldiers  in  France. 

Studies  of  the  relation  between 
respiration  and  blood  pressure. 

The  pathology  of  heart  function. 

Report  upon  soldiers  returned 
as  cases  of  "  disordered  action 
of  the  heart"  (D.A.H.)  or 
"  valvular  disease  of  the 
heart"  (V.D.H.). 

Memoranda  supplementary  to 
the  report  upon  soldiers  re- 
turned as  cases  of  "  disordered 
action  of  the  heart  "  (D.A.H.) 
or  "  valvular  disease  of  the 
heart  "  (V.D.H.). 

Medical  reports  on  soldiers  dis- 
charged from  the  Army  for 
the  condition  known  as 
"  D.A.H."  and  "  V.D.H." 

Cardinal  principles  in  cardio- 
logical  practice. 

The  soldier's  heart  and  the 
effort  syndrome. 

Breathlessness  in  soldiers  suffer- 
ing from  irritable  heart. 

A  clinical  study  of  some  func- 
tional disorders  of  the  heart 
which  occur  in  soldiers. 


The  recruit's  heart 

The  value  of  amyl  nitrite  in- 
halations in  the  diagnosis  of 
mitral  stenosis. 

The  common  factor  in  "  dis- 
ordered action  of  the  heart." 

The  psychoneurotic  factor  in 
the  "  irritable  heart "  of 
soldiers. 

An  enquiry  into  the  cardiac 
disabilities  of  soldiers  on 
active  service. 

The  pulse-rate  on  standing  and 
on  slight  exertion  in  healthy 
men  and  in  cases  of  "  soldier's 
heart." 

Digitalis  in  soldiers  with  cardiac 
symptoms  and  a  frequent 
pulse. 


B.M.J.,    1918. 
ii,  p.  27. 


Vol. 


B.M.J.,  1919.  Vol. 
ii,  p.  269. 

Lancet,  1916.  Vol.  ii, 
p.  146. 

Lancet,  1918.  Vol.  i, 
p.  529. 

Jl.  of  Physiol.,  1908. 
Vol.  xxxvii,  p.  233. 

Lancet,  1914.  Vol 
ii,  p.  883. 

M.R.C.  Special  Re- 
port Series,  No.  8, 
Lond.,  1917. 


December,  1917. 


B.M.J.,    1918. 
ii,  p.  647. 


Vol. 


Vol. 


B.M.J.,    1919. 

ii,  p.  621. 
Shaw  &  Sons,  Lond.,. 

1918. 
B.M.J.,    1916.     Vol. 

ii,  p.  517. 

Ulster  Medical  So- 
ciety, 1917,  Dec. 
6th. 

Jl.ofRA.M.C.,  1918. 
Vol.  xxx,  p.  357. 

B.M.J.,  1915.  Vol. 
ii,  p.  563. 

B.M.J.,  1918.  Vol.  i, 
p.  452. 

B.M.J.,  1918.  Vol.ii, 

p.  6*0. 
B.M.J.,  1918.  Vol.ii,, 

p.  29. 

Lancet,  1916.  Vol.  ii, 
p.  133. 

Heart,  1915-1917.. 
Vol.  vi,  p.  317. 


Heart,     1915-1917. 
Vol.  vi,  p.  321 


538 


MEDICAL  HISTORY   OF  THE   WAR 


Parkinson    &  Drury 
Parkinson  &  Koefod 


Patterson,   Piper    & 

Starling. 
Poynton 


Price 
Yenning 
Wells 
West 
Wilson,  C.    .. 

Wilson,  R.M. 


BIBLIOGRAPHY— cont. 

The  P.-R.  interval  before  and 
after  exercise  in  cases  of 
"  soldier's  heart." 

The  immediate  effect  of  cigarette 
smoking  on  healthy  men  and 
on  cases  of  "  soldier's  heart." 

Left  scapular  pain  and  tender- 
ness in  heart  disease  and 
distress. 

The  regulation  of  the  heart-beat. 

Failure  of  the  right  side  of  the 

heart  as  a  result  of  extensive 

pulmonary  disease. 
Common  errors  in  diagnosis  and 

treatment  in  cardiac  diseases. 
The  aetiology  of  disordered  action 

of  the  heart. 
Ten     thousand     recruits     with 

doubtful  heart  conditions. 
On    the    murmurs    in    dilated 

hearts,  and  their  explanations. 
Irregular  action  of  the  heart    . . 

The  significance  of  cardiac  mur- 
murs. 
The  meaning  of  tachycardia     . . 


Heart,     1915-1917. 
Vol.  vi,  p.  337. 

Lancet,  1917.  Vol.  ii, 
p.  232. 

Lancet,  1919.    Vol.  i, 
p.  550. 

Jl.  of  Physiol.,  1914. 

Vol.  xlviii,  p.  465. 
Lancet,  1916.   Vol.i, 

p.  1212. 

B.M.J.,  1914.   Vol.i, 

p.  1339. 
B.M.J.,  1919.  Vol.  ii, 

p.  337. 
B.M.J.,  1918.   Vol.i, 

p.  556. 
B.M.  J.,  1914.   Vol.  i, 

p.  1337. 
B.M. J.,  1915.    Vol  i, 

p.  957. 
B.M.J.,  1918.  Vol.  i, 

p.  687. 
Lancet,  1920.  Vol.  i, 

p.  146. 


INDEX. 


Abrahams,  Maj.  :   213. 

Aders,  Dr.  M.  :   255  n. 

Albuminuria  :  in  influenza  cases,  186  ;  in  nephritis,  496-7. 

American  Army  :    enteric  fever  in  (Spanish- American  War),  12  ;    pneumonia 

in  camps,  201. 
American  Civil  War  :  «8,  147,  485  ;  jaundice  in,  374  ;  cardio- vascular  disorders 

in,  506. 
Antimony :     use   in    trypanosomiasis,    312 ;     administration    of,    313,    314 ; 

reaction  to  injections,  313  ;   dosage  of,  313-4. 
Anaemia  :   post-malarial,  269  ;   treatment  to  counteract,  276. 
Army  Medical  Laboratory,  Washington  :    194. 

Army  Medical  Service  :  need  to  consult,  in  planning  a  campaign,  10. 
Arsenic  :    use  of,  for  anaemia,  276  ;    for  malaria,  281  ;    in  trypanosomiasis, 

312  ;    administration  of,  312-3. 
Arthritis  :   as  complication  of  dysentery,  73-4. 
Atropine  Test  :   used  in  enteric  fever,  50. 

Atrophy,  Acute  Yellow  :  similarity  to  spirochaetal  jaundice,  392. 
Austro-Hungarian  Army  :    cholera  in,  116  ;    trench  fever  in,  358. 

Bacteriological  Examination  :  for  enteric  bacilli,  51-3  ;  for  dysentery  bacillus, 
79-81. 

Bacteriological  Research  :  value  of,  in  preserving  efficiency  of  Army,  9  ; 
in  enteric,  26-8 ;  in  bacillary  dysentery,  67-9 ;  in  influenza,  191-5  ; 
in  cases  of  purulent  bronchitis,  214-5  ;  in  epidemic  jaundice,  397-8. 

Balfour,  Lt.-Col.  A.  :  viii ;  his  report  on  medical  conditions  in  East  Africa, 
412-3. 

Barraud,  Lt.  P.  :   253. 

Baths  :   need  for  further  provision  of,  9. 

Belgian  Army  :    suffers  from  relapsing  fever  in  East  Africa,  330. 

Beri-beri :  in  Russo-Japanese  War,  4 ;  memoranda  on,  circulated  in 
Mesopotamia,  428  ;  definition,  430  ;  regions  in  which  endemic,  ib. ; 
outbreaks  during  the  war,  ib. ;  cause  of  these,  ib.  ;  statistics  of  (Mesopo- 
tamia), 430-1  ;  cases  in  Mesopotamia,  431,  441-2  ;  these  investigated, 
431,  434;  results  of  vitamine  deficiency,  431-2,  435,  438;  other 
toxic  causes,  432  ;  effects  of  investigations,  ib. ;  in  Chinese  porter 
corps,  432-3  ;  in  labour  corps  (France),  434  ;  in  British  battalions 
from  India,  434-5  ;  other  outbreaks,  435  ;  aetiology,  435-42  ;  diagram 
of  sections  of  wheat,  436,  437  ;  diagram  showing  milling  of  rice  grain, 
ib. ;  infective  causes,  435 ;  comparative  value  of  foods  affording 
protection  against,  441  ;  contributing  causes,  ib.  ;  effect  of  diet  in 
intercurrent  diseases,  ib. ;  predisposing  causes,  442 ;  experimental 
work,  ib.  ;  morbid  anatomy,  443-4  ;  symptoms,  444-6 ;  period  of 
development,  444 ;  types  of,  444-6 ;  prognosis,  446 ;  diagnosis, 
446-7 ;  treatment,  447-8 ;  diet,  ib. ;  preventive  measures,  448 ; 
special  hospitals  for,  ib. 

Blackwater  Fever  :  developed  after  malaria,  270  ;  infected  areas,  294,  295  ; 
prevalence  during  war,  294 ;  susceptibility  of  white  troops,  ib.  ; 
statistics  of  (Macedonia),  294-5  ;  seasonal  incidence,  ib.  ;  aetiology  of, 
295-6;  theories  of  causation,  ib.  ;  morbid  anatomy,  296-7  ;  symptoms, 
297-300 ;  changes  revealed  by  blood  examination,  298-9 ;  by 
examination  of  urine,  299  ;  methods  of  determining  severity  of  attack, 
ib.  ;  complications,  299-300  ;  sequelae,  300  ;  susceptibility  increased 
by  attack,  ib.  ;  mortality,  ib.  ;  conditions  minimizing  chances  of 
recovery,  ib.  ;  prognosis,  ib.  ;  diagnosis,  301  ;  treatment,  301-3  ; 
during  convalescence,  303 ;  danger  of  neglect  of  mild  attack,  ib.  ; 
preventive  measures,  ib. ;  jaundice  occurring  in,  375. 

539 


540  MEDICAL  HISTORY  OF  THE  WAR 

Blake,  Maj.  :    194. 

Bowlby,  Sir  A.  :   8. 

Boyd,  Col.  F.  D.  :   470. 

Bradford,  Sir  J.  Rose  :   488,  490. 

British  Sanitary  Mission  to  Serbia,  1915  :  composition  of,  133 ;  checks 
spread  of  typhus,  136-8. 

Bronchitis  :  types  of,  occurring  during  war,  212. 

Bronchitis,  Purulent:  in  military  camps,  177-8,  213,  214;  symptoms,  212; 
incidence  in  France,  212-3  ;  causation,  213  ;  men  most  easily  affected, 
ib. ;  organisms  found  on  examination,  214  ;  aetiology,  214-5  ;  morbid 
anatomy,  215-7  ;  illustration  of  lung  tissue,  217  ;  symptoms  of  cases 
in  France  and  Flanders,  217-21  ;  chart  illustrating  less  acute  case, 
218;  symptoms  of  cases  in  United  Kingdom,  221-4  ;  a  typical  case, 
221-3  ;  charts  illustrating  longer  typical  cases,  223-4  ;  complications, 
224  ;  prognosis,  224-5  ;  diagnosis,  225  ;  treatment,  225-6  ;  question 
of  contagion,  226  ;  inoculation,  ib. 

Brown,  Capt.  A.  J.  :    139. 


Cane,  Capt.  E.  G.  S.  :  431  n. 

Cardio- Vascular  Disorders  :  advances  in  knowledge  regarding,  504  ;  many 
affected  with,  after  retreat  from  Mons,  ib.  ;  difficulties  in  interpreting 
signs  of,  ib.  ;  Mackenzie's  memorandum  on,  504-5  ;  special  hospitals 
for,  505 ;  centres  in  France,  ib.  ;  value  of  these,  506  ;  statistics  of, 
506,  535  ;  in  American  Civil  War,  506  ;  history  of,  in  British  Army, 
ib.  ;  classification  and  nomenclature,  506-7  ;  types,  508  ;  organic 
disease,  508-10  ;  percentage  suffering  from  valvular  disease,  508-9  ; 
functional  disorders,  510-36 ;  symptoms,  510-7 ;  cetiology,  517-28  ; 
pathology,  528-31  ;  diagnosis,  531  ;  treatment,  531-4  ;  prognosis,  534-6  ; 
in  recruits,  536.  See  also  Heart,  Disordered  Action  of,  and  Heart, 
Valvular  Disease  of. 

Catarrh,  Naso-pharyngeal :   its  relation  to  cerebro-spinal  fever,  149. 

Cecil,  Capt.  :   194. 

Cere bro- Spinal  Fever  :  history,  147 ;  statistics,  ib.  ;  dates  of  appearance, 
148  ;  aetiology,  148-50  ;  incidence,  148  ;  preventive  measures,  148  n., 
168-70;  predisposing  factors,  149;  carriers,  ib.,  168-9;  overcrowding 
as  cause  of,  149-50,  168 ;  exciting  cause,  150  ;  mode  of  infection, 
ib. ;  morbid  anatomy,  150-1  ;  symptoms  and  course,  151-60  ;  incu- 
bation period,  151  ;  complications,  154-5;  types  of,  155;  fulminating, 
155-6  ;  acute,  156-7  ;  abortive,  157  ;  suppurative,  ib.  ;  hydrocephalic, 
157-9;  recrudescent  and  relapsing,  159;  sequelae,  159-60;  prognosis, 
161-3  ;  period  of  invalidism,  161-2  ;  pensionable  disability,  162-3 ; 
condition  of  convalescents,  163  ;  diagnosis,  163-4  ;  treatment,  164-8  ; 
mortality,  165,  166  ;  treatment  centres,  166-7 ;  prevention,  168-70 ; 
methods  of  disinfection,  169-70  ;  chart  illustrating  fatality  of,  167  ; 
chart  illustrating  relation  of  distance  between  beds  to  carrier  rate,  169. 

Chemical  Warfare  :   jaundice  arising  from  impure  gas,  375. 

Chick,  Miss  H.  :   419,  421  n. 

Chinese  Porter  Corps  :   outbreak  of  beri-beri  in,  432  ;   rations,  433. 

Cholera  :  outbreaks  during  the  war,  116  ;  infected  areas,  ib.  ;  Mesopotamian 
outbreak,  118-20;  diagrammatic  map  of  Cholera  Creek,  117;  causes 
of  infection,  118-20,  121;  statistics,  118-20;  diagrammatic  sketch 
of  river  steamer,  119;  occurrence  in  Egypt  and  Sinai,  120-1; 
aetiology,  121-2 ;  bacillus,  ib.  ;  carriers,  ib.  ;  symptoms,  122 ; 
incubation  period,  ib.  ;  complications,  ib.,  126 ;  prognosis,  122-3 ; 
mortality,  ib.  ;  diagnosis,  123-4;  treatment,  124-7;  diet,  126;  need 
for  special  medical  units  for  treating,  127 ;  prevention,  127-31  ; 
preventive  inoculation,  127-8,  131  ;  other  preventive  measures, 
128-31;  in  France,  128-9;  in  Salonika,  129-30;  in  Mesopotamia, 
130-1  ;  in  Egypt,  131  ;  in  Sinai,  ib. 

Christophers,  Maj.  :   carries  out  malarial  surveys  (Mesopotamia),  256. 

Commissions  :    British  and  American,  discoveries  in  trench  fever,  360-1,  361. 


INDEX  541 

Committees  :  W.O.  trench  fever,  9,  358,  362  ;  Medical  Research,  149,  199, 
442  n.,  505  ;  Medical  Investigation,  1917,  358  ;  American  Research, 
on  trench  fever,  ib.,  362,  368  ;  Medical  Advisory,  Mesopotamia 
Enquiries,  investigates  scurvy,  1916,  416 ;  W.O.  Sanitary,  1916, 
investigates  beri-beri  (Mesopotamia),  432  ;  on  Mesopotamian  ration, 
439  ;  on  pellagra,  470  ;  on  soldier's  heart,  506. 

Conferences  :    W.O.,  on  vaccine  for  influenza,  206. 

Conjunctivitis  :    as  complication  of  dysentery,  74. 

Convalescent  Depots  :   for  dysentery  patients,  75,  91. 

Convalescents  :   from  dysentery,  89. 

Copeman,  Dr.  S.  M.  :    440. 

Cummins,  Capt.  :   232. 


Davy,  Maj.  P.  C.  T.  :    139. 

de  Grey,  Earl :   506. 

Dengue  :    identification  with  phlebotomus  fever,  353-4. 

Diarrhoea  :    at  Suvla  Bay,  396. 

Dietary:  of  Indian  soldier,  unscientific,  6-7,  411  ;  faults  in  (Mesopotamia), 
410  ;  anti -scorbutic  additions  to,  420-1  ;  influence  of  various,  on 
pellagra,  480-3. 

Diets  :  in  enteric  fever,  53  ;  in  dysentery,  84  ;  in  cholera,  126  ;  in  blackwater 
fever,  303;  fresh  meat  juice,  in  scurvy,  418;  hospital,  in  scurvy, 
426-7  ;  in  beri-beri,  447-8  ;  in  nephritis,  502. 

Disease  :  inefficiency  from,  exceeds  killed  and  wounded,  1  ;  statistics  of, 
South  African  and  Russo-Japanese  Wars,  ib.  ;  Great  War,  1-2,  3-4  ; 
average  number  of  days'  treatment,  3  n.  ;  comparison  with  Russo- 
Japanese  and  South  African  Wars,  4-5  ;  wastage  of  minor,  7  ;  main 
groups  of  these,  ib.  ;  44  per  cent,  preventible,  8  ;  lessons  of  Great  War, 
9-10  ;  at  Suvla  Bay,  395-7. 

Dropsy,  Famine  :  description  of,  450  ;  early  accounts,  450-3  ;  in  Madras 
jails,  1864,  451  ;  in  Indian  famine,  1877-8,  451-2,  452  ;  in  Lushai 
expedition,  1875,  ib.  ;  in  siege  of  Paris,  1870-1,  ib.  ;  probably  differs 
from  epidemic  dropsy,  453  ;  first  appearance  in  Great  War,  Lille, 
October,  1914,  ib.  ;  epidemic  in  Central  Empires,  453-4  ;  in  prison 
camps  in  Germany,  453  ;  among  Turkish  prisoners,  454  ;  relative 
sex  incidence,  ib.  ;  mortality,  ib.,  464  ;  aetiology,  455-6  ;  exciting 
cause  underfeeding,  455  ;  other  contributory  causes,  455-6  ;  symptoms, 
456-9  ;  pathology,  459-62  ;  possible  physical  causes,  460-1  ;  con- 
current diseases,  462,  463 ;  diagnosis,  462-4 ;  prognosis,  464  ; 
treatment,  464-5  ;  prevention,  ib. 

Dudgeon,  Col.  :    235. 

Dysentery:  4,  9-10;  average  number  of  days'  treatment  for,  2  n.-3  n., 
76-7 ;  statistics,  3  ;  incidence  of,  5-6 ;  diagnosis,  5  ;  meaning  of 
term,  64  ;  study  of,  during  the  war,  ib.  ;  incidence  of,  1914-18,  ib.  • 
types  of,  65  ;  among  prisoners  of  war  in  Germany,  67  ;  diet,  84  ; 
cases  of  suspected,  segregated,  89-91  ;  convalescents,  89,  91  ; 
examination  of  suspicious  cases,  90  ;  special  accommodation,  90-1  ; 
precautions  against  transmission,  ib.  ;  forms  of,  other  than  bacillary 
and  amoebic,  104-5  ;  malarial,  105  ;  conditions  easily  mistaken  for, 
ib.  ;  routine  management  of,  to  ensure  adequate  treatment,  105-6  ; 
at  Suvla  Bay,  396. 

Dysentery,  Amoebic  :  meaning  of  term,  92 ;  comparison  with  bacillary, 
92-3 ;  aetiology,  92-5 ;  prevalence,  92 ;  incidence,  93-4  ;  morpho- 
logical research,  94  ;  predisposing  causes,  94-5  ;  morbid  anatomy, 
95  ;  symptoms,  95-7  ;  incubation  period,  95-6  ;  causes  of  death,  97  ; 
prognosis,  97-8  ;  assessment  of  pension  in  case  of,  97  ;  diagnosis, 
97-8 ;  treatment,  98-101  ;  complications,  100-1  ;  prevention,  101-3  ; 
carriers,  ib.  ;  method  of  transmission,  103. 


542  MEDICAL  HISTORY  OF  THE  WAR 

Dysentery,  Bacillary :  characteristics,  65  ;  prevalence  in  war  areas,  65-6  ; 
case  mortality,  66  ;  invalidism  due  to,  ib.  ;  aetiology  of,  66-9 ;  pre- 
disposing circumstances,  66-7  ;  outbreaks  in  France,  ib.  ;  bacteriology 
of,  67-9 ;  morbid  anatomy,  69-72 ;  symptoms,  72-5 ;  incubation 
period,  72 ;  clinical  types,  73  ;  fulminating,  ib.  ;  gangrenous,  ib.  ; 
chronic,  ib.  ;  complications,  73-5  ;  sequelae,  74  ;  prognosis,  75-7  ; 
disposal  of,  patients,  75,  89-91  ;  fitness  for  convalescent  depot,  how 
determined,  75  ;  cases  unfit  for  duty,  76  ;  cases  entitled  to  pensions,. 
ib.  ;  danger  of,  when  complicated  with  other  fevers,  ib.  ;  diagnosis,, 
77-81  ;  laboratory,  78-80  ;  sero-,  81  ;  treatment,  81-6  ;  of  chronic, 
85  ;  of  complications,  85-6 ;  prevention,  86-91  ;  carriers,  86-7  ; 
transmission  by  flies,  87  ;  by  contaminated  water,  87-8 ;  by  dust,  88  ; 
prophylactic  inoculation,  ib. 

East  Prussian  Campaign,  1806  :  8. 

Elliott,  Col.  T.  R.  :    viii. 

Emetine  :    treatment  of  amoebic  dysentery  with,  98. 

Endocarditis  :   an  infective  factor  in  V.D.H.,  509-10. 

Enteric  Fever  :  4;  statistics  (Great  War),  3,  4,  15-7;  previous  wars,  11-2; 
comparison  between  South  African  and  Great  Wars,  4-5  ;  measures  to- 
prevent,  5,  55-6,  58-60 ;  value  of  inoculation,  5,  56  ;  definition  of 
term,  11  ;  effect  of  inoculation,  15,  19,  22,  24,  32,  43-5,  56-8  ;  diagnosis, 
15-7;  clinical,  49-51  ;  laboratory,  51-3  ;  mortality,  18-22  ;  comparative- 
of  the  three  groups,  19-20  ;  aetiology,  22-8  ;  influence  of  environment, 
22  ;  carriers,  23-4,  48  ;  immunity  from,  24  ;  relative  incidence  and 
mortality  in  British  and  Indian  races,  24-5  ;  effect  of  age,  26  ;  pre- 
disposing factors  in  war,  ib.  ;  exciting  causes,  ib.  ;  bacteriological 
research,  26-8 ;  morbid  anatomy,  28-31  ;  complications,  44,  47 ; 
mixed  infection  of  different  groups,  45  ;  association  with  other  diseases, 
46  ;  prognosis,  46-7  ;  invalidism,  47-9  ;  duration  of  treatment,  47-8  ; 
discharge  from  military  service  after,  48  ;  diagnosis,  49-53  ;  treatment, 
53-5 ;  prevention,  55-60 ;  comparative  statistics  (protected  and 
unprotected),  57  ;  relative  immunity  conferred  by  inoculation  in  the 
three  groups,  58  ;  jaundice  in,  401-4  ;  charts  illustrating,  401,  402,  403, 

Flexner  Bacillus  :    causes  dysentery,  68 ;    bacteriological  examinations  for, 

80-1  ;   carriers,  86-7. 
Flexner,  Dr.  :   378. 

Flies  :    as  carriers  of  enteric  fever,  23  ;    of  dysentery,  87,  103. 
Food  Poisoning,  Diseases  due  to  :    differentiated  from  enteric  fever,  51. 
Foster,  Col.  :    156. 

Franco-German  War  :   enteric  in,  12. 
French  Army  :    345  ;    enteric  in  (Tunis  operations),  12  ;    malaria  in  (Italy), 

257  ;    blackwater  fever  in  (Eastern  campaign),  295  ;    trench  fever  in,. 

358;    jaundice  in,  378;    famine  dropsy  in,  1528,  450. 
French,  Col.  :   213. 
Fruit :  grown  in  Mesopotamia,  417  ;  precautions  against  infections  from  raw,, 

418. 

Gas    Gangrene :     8 ;     pathological    laboratories    investigate,    9 ;     jaundice 

resulting  from,  376. 

Gases,  Poison  :   effect  of,  on  the  heart,  52,  524  ;   on  the  lungs,  ib. 
German  Army :    enteric  fever  in   (Franco- German    War),    12 ;    cholera  in 

(Great  War),  116;    typhus  in,  145;    blackwater  fever  in  (E.  Africa), 

294  ;    trypanosomiasis  in,  305  ;    relapsing  fever  in  (E.  Africa),  330  ; 

trench  fever  in,  358  ;  jaundice  in,  378  ;  rations  in  Turkey,  482  ;  physical 

training  of,  recruits,  522. 
Gerrard,  Capt.  :   454. 
Glover,  Capt.  :    149. 
Greig,  Maj.:    121. 


INDEX  543 

Hargreaves,  Sgt.  :   258. 

Heart,  Disordered  Action  of  :  359  ;  after  enteric,  48-9  ;  in  trench  fever 
cases,  366,  369  ;  difficulty  of  nomenclature,  507  ;  symptoms  attri- 
butable to  inherent  physical  defect,  ib.  ;  descriptive  terms,  510 ; 
symptoms  of,  not  necessarily  organic,  ib.  ;  manifestations  of,  510-1  ; 
physical  signs,  512-3  ;  rate  of  heart,  513  ;  irregularities  of  heart, 
514-5  ;  diastolic  and  systolic  murmurs,  515  ;  significance  of  systolic 
murmurs,  515-6 ;  blood  pressure,  516 ;  circulatory  and  nervous 
symptoms,  517  ;  cause  of  disability  in,  cases  of  pre-war  onset,  ib.  ; 
cases  occurring  after  enlistment,  518  ;  influence  of  previous  diseases 
in  comparison  of  cases  with  and  without  effort  syndrome,  519  ;  age 
incidence,  ib.  ;  lesser  contributing  factors,  520  ;  enlargement  of  thyroid 
in,  520-1 ;  effect  of  poison  gases  on,  521  ;  a  result  of  mental  disturbance, 
ib.  ;  other  predisposing  causes,  521-2  ;  pathology  of,  528-31  ;  dis- 
tinction between  organic  and  functional  cases,  531  ;  treatment,  531-6  ; 
graduated  exercises  for,  532-4  ;  value  of  graduated  games,  533—4  ; 
disposal  on  discharge  from  treatment,  534-5  ;  results  of  treatment,  ib.  ; 
prevention  of  occurrence  and  recurrence,  535-6. 

Effort  Syndrome,  prime  factors  underlying,  in,  521-2  ;  cases  due  to 
poor  physique,  522  ;  to  previous  infections,  523-4  ;  to  poison  gases,  524  ; 
to  sudden  exertion,  524-5  ;  nervous  phenomena  in,  525-6  ;  cases  of, 
due  to  physical  and  mental  strain,  526-7 ;  problem  of  causation,  527—8  ; 
in  connection  with  recruiting,  536. 

Heart,  Valvular  Disease  of  :  varieties  of,  508-9  ;  previous  history  of  rheumatic 
fever  in  cases  of,  508 ;  usually  of  pre-war  origin,  509  ;  need  of 
discharging  patient  with,  from  army,  510,  531  ;  treatment,  531-4. 

Hepatic  Abscess  :    see  Liver  Abscess. 

Herringham,  Maj.-Gen.  Sir  W.  :    viii. 

Hill,  Professor  L.  :  investigates  outbreak  of  scurvy  in  prisoners  of  war  camp, 

413. 

Hill,  Sir  R.  :   420  n. 
Hine,  Lt.-Col.  T.  G.  M.  :    170. 
Hodgson,  Col.  E.  C.  :   253. 
Horrocks,  Col.  :    439. 
Hume,  Miss  M.  :   419,  421  n. 
Hume,  Col.  W.  E.  :   188,  490. 

Hunter,  Col.  W.  :   in  charge  of  British  Sanitary  Mission  to  Serbia,  133. 
Huts  :   mosquito-proof,  245  ;   method  of  rendering  tick-proof,  343-4. 

Influenza :  statistics,  174-6 ;  in  France,  174-5 ;  world-wide  nature,  175 ; 
in  Mesopotamia,  175-^6,  206  ;  symptoms  amongst  troops  in  United 
Kingdom,  176-86  ;  epidemics,  176-8  ;  summer  epidemic,  1918,  176-7  ; 
incidence  of  "  pneumonic  "  (q.v.),  cases  in  autumn  epidemic,  178 ; 
mortality,  176  ;  infectivity,  ib.  ;  symptoms  amongst  troops  in  the 
field,  186-91  ;  incubation  period,  186  ;  course  of  summer  epidemic, 
188;  course  and  symptoms  of  autumn  epidemic,  188-90;  complica- 
tions, 190-1,  209 ;  pathology,  191-5 ;  effect  of  vaccination,  193  ; 
question  of  immunity,  195  ;  morbid  anatomy,  195-205  ;  diagnosis, 
205  ;  prognosis,  ib.  ;  treatment,  205-9  ;  preventive  measures,  205-8  ; 
on  Japanese  cruiser  "  Nukata,"  207  n.  ;  inoculation,  206-7  ;  statistics 
of  results,  207 ;  occurring  with  jaundice,  376-7  ;  charts  illustrating 
variability  of  temperature  in,  182-4. 

Influenza,  Pneumonic:  description  of,  178-9;  types,  179;  symptoms  and 
course,  179-86 ;  heliotrope  cyanosis,  181  ;  its  nature  and  causation, 
181-2  ;  complications,  186. 

International  Commission  of  Hygiene  :    129. 

Italian  Army  :  malaria  in,  257. 


544  MEDICAL  HISTORY  OF  THE  WAR 

Japanese  Army  :   24  ;   sickness  in  Russo-Japanese  War,  4. 

Jaundice  :  attributable  to  enteric  fever,  41  ;  a  complication  of  influenza, 
190-1  ;  a  symptom  in  many  diseases,  374  ;  area  of  epidemics,  ib.  ; 
pathological  research,  374-5,  378-81,  386  ;  maladies  in  which,  may 
occur,  375-6 ;  types  of,  375-8 ;  in  cases  of  influenza,  376-7 ;  in 
enteric  fever,  401-4 ;  charts  illustrating,  401,  402,  403 ;  symptoms, 
401-2  ;  description  of  cases,  402-3  ;  diagnosis,  404  ;  pathology,  404  ; 
theories  of  origin,  ib. 

Jaundice,  Epidemic  (Camp)  :  symptoms,  395,  398-400 ;  catarrhal,  infected 
localities,  395  ;  accounts  of,  ib.  ;  statistics  of,  395-7  ;  carried  to  new 
localities,  397  ;  aetiology  of,  397-8  ;  course  of  epidemic,  ib.  ;  association 
between  incidence  of,  and  of  other  diseases,  397 ;  bacteriological 
research,  397-8 ;  incubation  period,  398 ;  question  of  specificity  of 
infection,  ib.  ;  course  of  infection,  399 ;  description  of  cases,  400 ; 
charts  illustrating,  399  ;  cause  investigated,  400. 

Jaundice,  Spirochaetal :  micro-organism  identified,  November  1914,  374, 
378  ;  cause  of,  375  ;  in  British  Army,  378  ;  aetiology  of,  378-81  : 
illustration  of  SPIROCHJETA  ICTERO-H&MORRHAGim,  379; 
ditto,  in  blood  of  guinea-pig,  380  ;  antiserum  for,  380-1  ;  symptoms, 
381-6 ;  incubation  period,  381  ;  course,  382  ;  description  of  cases, 
383-5  ;  charts  illustrating,  ib.;  diagnosis,  386,  392-4;  morbid  anatomy, 
386-92 ;  illustrations  of  section  of  liver,  387,  388,  389,  390 ;  illustrations 
of  section  of  kidney,  391  ;  differentiation  from  other  diseases,  393-4  ; 
prognosis,  394  ;  treatment,  394-5. 

Kaye,  Dr.  H.  A. :    162. 

Laboratories  :  pathological  investigations  regarding  gas  gangrene,  9  ;  mobile 
bacteriological  research,  work  of,  9-10 ;  Army,  their  blood-film 
examinations  (malaria),  236. 

Lauder,  Capt.  :    139. 

Laundries  :   need  for  more,  9. 

Ledingham,  Lt.-Col. :    compiles  malaria  statistics  (Mesopotamia),  257  n. 

Leishman's  Stain  :    272. 

Lelean,  Lt.-Col.  P.  S.  :    470. 

Lewis,  Dr.  T.  :   studies  in  cardio-vascular  disorders,  505. 

Lice  :  disease  resulting  from  infestation  by,  8 ;  as  cause  of  typhus,  1 33-4  ; 
life  history  of,  134  ;  as  cause  of  relapsing  fever,  316  ;  how  conveyed  by, 
318  ;  proved  cause  of  trench  fever,  360  ;  method  of  infection,  360-1. 

Lime  Juice:  no  anti-scorbutic  value  (Mesopotamia),  419;  freshly  prepared 
in  India,  ib. 

Lister  Institute,  The  :    421  n. 

Liver  Abscess  :  relationship  with  amoebic  dysentery,  100;  symptoms,  100-1  ; 
diagnosis,  101  ;  treatment,  ib. 

Mackie,  Maj.  :    257. 

MacLean,  Capt.  H.  :   486. 

Malaria:  4,10;  figures  for,  1916-18,  3,  227  ;  difficulty  of  prevention  in  war, 
6  ;  responsibility  of,  for  disease  pensions  (1920),  ib.  ;  in  Macedonia, 
227-45  ;  map  illustrating  area  occupied  by  British,  228 ;  effect  of 
climate  on,  227  ;  description  of  country  with  reference  to,  problem, 
228-30 ;  effect  of  advance  on,  230-1  ;  admissions,  1916-18,  ib.  ; 
extent  of  infection,  231,  235  ;  chief  carriers,  232-5  ;  reason  for  greater 
prevalence  in  valleys,  233-4  ;  association  of  one  mosquito  with  one 
type  of,  not  justified,  233 ;  outbreaks,  234,.  240-1  ;  cases  among 
hospital  personnel,  234  ;  relative  incidence  of  benign  and  malignant 
tertian,  234-5  ;  chart  illustrating  incidence,  236 ;  results  of  army 
laboratories'  examinations,  236-7  ;  infections  in  civil  population,  237-8, 
242-3;  mortality,  241-2;  arrangements  for  outbreak  inadequate,  ib,', 
predisposing  causes,  242 ;  forms  of,  parasites,  ib. ;  anti-mosquito 
measures,  243-4,  246  ;  their  results,  244-6. 


INDEX  545 

Malaria —  continued. 

In  Army  of  the  Black  Sea,  246-7  ;    consequences  of  lack  of  protection, 

247  ;    Russian  Government's  schemes  for  prevention,  ib. 
In  Palestine  and  Egypt,  247-53  ;    statistics  of,  247-8 ;  areas  of  infection, 
248 ;     conditions    favouring,    in    different     sectors    (Palestine),    ib.  ; 
means  of  combating,  249-50  ;    incidence,  251-3  ;    effects  of  advance, 
252-3  ;    relative  incidence  (Eastern  war  areas),  253. 
In  E.  Africa,  253-5  ;  infected  localities,  254,  255  ;  insufficient  precautions 

against,  254,  255  ;    incidence  and  mortality,  254-5. 
In  Cameroons,  255. 
In   Mesopotamia,    255-7 ;     admissions,    255-6 ;     effect   of   climate   and 

topography  on,  256  ;  surveys,  ib.  ;  statistics  of  incidence,  256-7. 
In  Italy,  257-60  ;  infection  in  front  line,  257  ;  on  lines  of  communication, 
257-8 ;  at  Taranto  camp,  258-9 ;  anti-mosquito  operations,  ib.  ; 
comparative  difficulty  of  these,  in  different  war  areas,  260. 
Causes  of  death,  264-5  ;  morbid  anatomy,  ib.  ;  symptoms,  265-70  ; 
tertian  periodic  pyrexias,  265-6  ;  quartan,  266  ;  subtertian  infections, 
ib. ;  cases  easily  confused  with,  ib.  ;  types  of  malignant  tertian,  ib., 
267-9  ;  symptoms,  266-7  ;  how  produced,  267  ;  diseases  simulated  by, 
267-9,  270-1  ;  sequelae,  269-70  ;  danger  of  co-existing  diseases,  270  ; 
diagnosis,  270-3;  special  units  for,  271-2;  treatment,  273-80; 
of  convalescents,  275-6 ;  of  serious  cases,  277-80  ;  disadvantages  of 
intra-muscular  administration  of  quinine  in,  277-9 ;  quinine  poisoning, 
280-3  ;  treatment  of  malarial  invalids,  283-8  ;  invaliding  of  chronic 
cases,  283  ;  types  invalided,  283-4 ;  duration  of  invalidism,  284 ;  anti- 
relapse  treatment,  284-5  ;  measures  to  render  infected  battalions  fit 
for  service,  285-7  ;  results  of  these,  287  ;  as  cause  of  blackwater  fever, 
296  ;  jaundice  occurring  in,  375. 

Marjori banks,  Maj.  :    418. 

Marmite  :   a  prophylactic  against  beri-beri,  440. 

Harris,  Capt.  :   402. 

Martin,  Lt.-Col.  C.  J.  :   443. 

Maude,  Gen.  :    120. 

McCarrison,  Lt.-Col.  R.  :  proves  wide-reaching  effects  of  vitamine  deficiency 
diet,  422,  442. 

Medical  Research  Council :    76,  284,  354,  370,  502. 

Medicine,  Clinical :   high  standard  of,  in  war,  10. 

Melville,  Lt.-Col.  H.  G.  :  consulting  physician,  Mesopotamia,  431  ;  his 
recommendations  for  the  prevention  of  beri-beri,  432. 

Meningitis  :   occurring  in  influenza,  186. 

Meningococcus  :    exciting  cause  of  cerebro-spinal  fever,  150  ;    types,  ib. 

Mercury  :    used  in  treatment  of  relapsing  fever,  340. 

Mitchell,  Maj.  T.  J.  :   viii. 

Morphological  Research  :  in  amoebic  dysentery,  94. 

Mosquitoes  :  breeding-places  (Macedonia),  230-1,  231-2  ;  types,  ib.  ;  relative 
distribution,  232-3  ;  chief  carriers  of  malaria,  ib.  ;  suggested  difference 
in  carrying  powers,  233  ;  association  of  certain,  with  one  type  of 
malaria  not  justified,  ib.  ;  how  infected,  236  ;  infectivity  of,  237-8  ; 
period  of  hibernation,  238-9  ;  survival  powers  of  larvae,  239  ;  develop- 
ment of  presporozoite  cysts  in  winter,  239-40  ;  effects  of  quinine  on, 
240 ;  anti-,  measures,  240,  245,  249  ;  their  results,  243-5  ;  prevalence 
in  Tiflis-Baku  area,  246  ;  types  in  Egypt,  247  ;  in  Palestine,  249-50  ; 
observations  on  development  of  (Palestine),  253  ;  in  E.  Africa,  255  ; 
in  Mesopotamia,  256,  257  ;  destruction  of  (Italy),  258-9 ;  types  in 
Italy,  259 ;  experiments  in  infectivity,  259-60  ;  list  of,  found  in  war 
areas,  260-2. 

Mosquito  Nets  :    245. 

Myalgia  :   8,  359. 

(2396)  KK 


546  MEDICAL  HISTORY  OF  THE  WAR 

Napoleonic  Wars  :    147. 

Nephritis  :  statistics,  3  ;  occurs  in  American  Civil  War,  8,  485  ;  a  complication 
of  influenza,  190  ;  war,  485  ;  incidence  of,  486-7,  489  ;  in  association 
with  respiratory  disease,  486-7,  489,  490  ;  with  cere bro-spinal  meningitis, 

487  ;    with  infected  wounds,  ib. ;    aetiology,  487-91  ;    causation,  487-8  ; 
difficulty  of  diagnosis,  487  ;  influence  of  previous  attack  of  renal  disease, 

488  ;  as  a  complication,  488-9  ;  troops  most  liable  to  attack,  489-90 ; 
freedom  of  Indian  troops,  490-1  ;    morbid  anatomy,  491  ;    symptoms, 
491-500  ;   in  hcsmorrhagic  type,  492-3  ;   in  dropsical  type,  493  ;   clinical 
course,   494-5,   499-500;    pathology,   495-8;    complications,   498-9; 
results  of  urine  examination,  499 ;    comparison  between  war,  and,  of 
civil   life,    499-500 ;     prognosis,    500-2 ;     mortality,    500 ;     statistics 
showing  results  of  treatment,  500-1  ;    chronic  or  recurrent  cases,  501  ; 
duration  of  treatment,  ib. ;   diagnosis,  502  ;   treatment,  502-3. 

Neuritis,   Multiple  :    446-7 ;    of  toxic  origin,   mistaken  for  beri-beri,   435  ; 

how  distinguishable  (from  beri-beri),  ib. 
Nicholson,  Capt. :    377. 

(Edema,  Famine  :  see  Dropsy,  Famine. 
(Edema,  Hunger  :  see  Dropsy,  Famine. 
(Edemas  :  clinical,  types  of,  459-60  ;  defects  in  capillary  walls  giving  rise  to, 

460  ;    other  possible  causative  factors,  460-1  ;    frequent  early  sign  in 

nephritis,  494. 
Opium  :    to  be  avoided  in  bacillary  dysentery,  82  ;    use  of,  in  phlebotomus 

fever,  355. 

Paratyphoids:  incidence  of,  1914-18,  13;  distribution  at  outbreak  of  war,  15; 
how  developed  in  new  areas,  ib.,  17  ;  comparative  incidence  of,  and 
typhoid,  15-7;  case  mortality,  20  ;  compared  with  typhoid,  ib.,  21,  32  ; 
in  the  East,  21  ;  of,  A.  and  B.  compared,  21-2  ;  relative  incidence  of, 
B.  in  British  and  Indian  troops,  25  ;  cause  of  infection,  26  ;  morbid 
anatomy,  29-31  ;  incubation  period,  32 ;  symptoms,  32-40 ;  con- 
valescence, 40;  complications,  40-1,  43-4;  clinical  types,  41; 
dysenteric,  ib.  ;  biliary,  ib.  ;  rheumatic,  42  ;  respiratory,  ib.  ;  influenzal, 
ib.  ;  septic&mic,  ib.;  diagnosis,  49,  49-53;  charts  illustrating,  A., 
35-7 ;  charts  illustrating,  B.,  37-9. 

Park,  Capt.  :   453. 

Pasteur,  Col.  :   190. 

Pathological  Research  :    in  trench  fever,  360  ;    in  jaundice,  374,  378,  381. 

Pathologists  :  American,  their  discoveries  regarding  trench  fever,  9  ;  their 
investigations  of  pneumonia,  200-2  ;  Japanese,  their  research  in 
jaundice,  374,  378. 

Patrick,  Capt.  :  205. 

Pellagra  :  first  recorded,  1735,  470 ;  locality,  ib.  ;  outbreak  among  Turkish 
prisoners,  ib.  ;  committee  on,  1918,  ib. ;  incidence  and  distribution, 
470-7  ;  chart  illustrating,  471  ;  map  illustrating,  472 ;  monthly 
incidence  among  prisoners  of  war,  470  ;  absence  of,  among  British  and 
Indian  troops,  471  ;  prevalence  in  Egyptian  Labour  Corps,  471-2  ; 
German  and  Austrian  prisoners  not  infected,  472 ;  ante-bellum 
prevalence  slight,  473  ;  affected  districts,  ib. ;  largely  of  pre-capture 
onset  among  prisoners,  ib.  ;  incidence  in  Turkish  Army,  474  ;  question 
as  to  cause,  474-5,  478-9  ;  seasonal  prevalence,  475  ;  chart  illustrating, 

474  ;    relation  between  incidence  and  labour,  476 ;    chart  illustrating, 

475  ;    need  for  early  treatment,  476 ;    statistics  of  prisoners  of  war 
admissions,  477;    symptoms,  ib. ;    treatment,  ib.  ;    morbid  anatomy, 
478 ;    death  usually  due  to  supervening  infection,   478 ;    etiology, 
478-84  ;    due  to  deficiency  in  biological  protein  value  of  diets,  479 ; 
mal-assimilation  of  food  in,  479-80  ;   influence  of  various  dietaries  on, 
479-83  ;    chart  illustrating  dietetic  values,  480  ;   incidence  in  German 
and  Turkish  prisoners  of  war  contrasted,  481  ;    reasons  for  German 
freedom  from,  481-2  ;  among  Armenian  refugees,  483  ;  chart  illustrating 
incidence  among,  483  ;   physiological  processes  in  production  of,  484. 


INDEX  547 

Pensioners  :  numbers  suffering  from  cardio-vascular  disorders,  506  ;  incidence 
of  V.D.H.  among,  509. 

Pensions  :  for  disabilities  due  to  enteric,  49 ;  of  dysentery  patients,  76,  97 
granted  after  cerebro-spinal  fever,  162  ;  after  relapsing  fever,  338 
after  trench  fever,  369. 

Pfeiffer's  Bacillus  :    alleged  causative  agent  in  influenza,  191-5. 

Phlebotomus    Fever :     definition   of,    345 ;     geographical    distribution,    ib. 
in  Macedonia,  ib.  ;    aetiology  of,  345-8  ;    carried  by  sand-flies,  345-6 
predisposing  causes,  346  ;  exciting  cause,  ib.  ;  how  transmitted,  346-7 
illustration    of    Phlebotomus   papatasii    and    larva,    347  ;    symptoms 
348-53 ;     incubation   period,    348 ;     charts   illustrating   temperatures 
during,    350-2 ;     convalescence,    353 ;     question    of    immunity,    ib. 
diagnosis,  353-4  ;    identification  with  dengue,  353  ;    distinction  from 
other  diseases,  354  ;    treatment,  354-6  ;    duration  of,  355  ;    preventive 
measures,  355-6. 

Physique  :  comparison  between  British  patients  at  heart  centre,  and  German 
prisoners,  522. 

Pike,  Surg.-Gen.  ;   his  report  on  medical  conditions  in  E.  Africa,  412-3. 

Pleurisy  :  in  influenza  cases,  196. 

Pneumonia  :  in  influenza  cases,  196  ;  outbreaks  after  measles  and  influenza 
in  American  camps,  200-2  ;  pathological  investigation  of,  201  ;  morbid 
anatomy,  202-3,  204  ;  types,  203-4  ;  jaundice  in  lobar,  377. 

Pneumonia,  Broncho- :   see  Bronchitis,  Purulent,  and  Pneumonia. 

Priestly,  Maj.  :    139. 

Prisoners  of  War :  dysentery  among,  in  Germany,  67 ;  cholera  among 
Russian,  116;  Austrian,  spread  typhus  in  Serbian,  135-6;  typhus 
among  Austrian,  136,  140;  typhus  in  German,  camps,  138-9;  scurvy 
among  Turkish,  411;  among  Russian,  412;  among  German,  1917, 
413  ;  rations  in,  camps,  ib.,  481  ;  famine  dropsy  among,  in  Germany, 
453  ;  poverty  of  rations,  455  ;  outbreak  of  pellagra  among  Turkish, 
470,  477  ;  this  largely  of  pre-capture  onset  among,  473  ;  Kantara 
labour  camp,  476,  478-9 ;  relative  incidence  of  pellagra  among  German 
and  Turkish,  481-2. 

Pyorrhoea  :  in  cases  of  scurvy,  423. 

Pyrexia  of  Uncertain  Origin  :   8  ;   trench  fever  mistaken  for,  359. 

Pyrexias  :   statistics  at  Suvla  Bay,  396. 

Quinine  :  effect  of,  on  mosquitoes,  240  ;  protection  afforded  by  prophylactic, 
246  ;  treatment  in  malaria,  273-4  ;  prescriptions,  274-5  ;  methods  of 
administration,  277-9  ;  excretion  of,  by  urine,  280  ;  tests  for  presence 
of,  ib.  ;  preparations  of,  280-1  ;  dangerous  effects  of,  281-3  ;  blindness, 
281-2  ;  a  factor  in  precipitating  blackwater  fever,  296  ;  opinion  on 
use  of,  in  blackwater  fever,  202. 

Rationing,  Principles  of :  fighting  forces  educated  in,  against  deficiency 
diseases,  428. 

Rations  :  of  Indian  troops,  in  Mesopotamia,  6-7,  409,  438  ;  and  in  India, 
409  ;  lack  of  anti-scorbutic  vitamines  in,  410  ;  of  German  prisoners  of 
war,  413;  field,  in  Mesopotamia,  415-7,  438-9;  addition  of  anti- 
scorbutic articles,  414  ;  fresh  meat  issued  in,  418  ;  of  Chinese  Porter 
Corps  (Mesopotamia),  433 ;  German,  for  prisoners,  455  ;  value  of 
British,  Ottoman  and  European  (enemy),  in  calories,  480-1  ;  German 
Army,  in  Turkey,  482. 

Rats  :   carriers  of  jaundice,  378-9. 

Relapsing  Fever  :  characteristics,  316  ;  types,  ib.,  322  ;  infection,  how  trans- 
ported, 316 ;  aetiology  of,  316-8 ;  conditions  favouring,  316-7 ; 
epidemics  in  Serbia,  317  ;  chart  showing  course  of,  ib.  ;  exciting  cause, 
317-8 ;  illustration  of  Sp.  recurrentis,  318 ;  infection,  how  conveyed, 
318  ;  morbid  anatomy,  319 ;  symptoms,  319-22  ;  chart  of  typical, 
320;  incubation  period,  319;  convalescence,  322;  complications, 
ib.  ;  prognosis,  322-3  ;  varying  intensity  of  epidemics,  322  ;  period  of 
invalidity,  323 ;  immunity,  ib.  ;  diagnosis,  323-4  ;  diseases  easily 
confused  with,  324  ;  treatment,  324-6  ;  preventive  measures,  326  ; 
aundice  n  377.  See  also  Jaundice,  Spirochaetal. 


548  MEDICAL  HISTORY  OF  THE  WAR 

Relapsing  Fever,  E.  African  :  occurs  in  tropical  Africa,  329 ;  account  of,  in 
Carrier  Depot  Hospital,  Dar-es-Salaam,  329-30  ;  races  liable  to  attack, 
ib.  ;  amongst  Belgian  troops,  330  ;  aetiology,  330-2  ;  illustrations  of 
insect  vector,  331  ;  method  of  infection,  332  ;  morbid  anatomy,  ib.  ; 
symptoms,  332-8  ;  incubation  period,  332  ;  illustrations  of  infection, 
333;  charts  illustrating,  334,  335,  336,  337;  course  of,  334-7; 
observations  of  Manson  and  Thornton,  335  ;  involvement  of  different 
organs,  337 ;  complications,  338 ;  prognosis,  ib.  ;  treatment  of 
convalescents,  ib. ;  diagnosis,  338-9 ;  presence  of  other  diseases 
excluded  by  blood  examination,  339 ;  treatment,  339-44 ;  charts 
illustrating,  341-3  ;  preventive  measures,  340-4. 

Renal  Disease  :  few  cases  in  British  Army  prior  to  February  1915,  485  ; 
examination  of  troops  to  detect,  486  ;  results  of  this  examination, 
488 ;  previous  attack  of,  predisposes  to  nephritis,  ib. 

Respiratory  Affections  :  prevalence  in  France  and  Flanders,  212 ;  statistics 
from  Meerut  Stationary  Hospital,  1914  and  1915,  213. 

Rheumatism  :    8,  359. 

Rice :  polished,  a  beri-beri  producer,  433,  440 ;  Chinese  preference  for 
polished,  433,  440. 

Rickettsia  Bodies  :  361  ;  description  of,  ib. ;  in  connection  with  trench  fever, 
ib. 

Roaf,  Prof.  H.  E.  :   484. 

Robertson,  Col.  J.  C.  :   his  reports  on  anti-malarial  work  at  Taranto,  260  n. 

Rogers,  Sir  L.  :   his  treatment  for  cholera,  122. 

Rolleston,  Sir  H.  :   his  observations  on  cerebro-spinal  fever,  149. 

Ross,  Sir  R.  :  his  experiments  in  effects  of  auinine,  285. 

Russian  Army  :  24  ;  enteric  fever  (Russo-Turkish  War),  12  ;  cholera  among 
prisoners  of  war  in  Germany,  116. 

Russo-Japanese  War :  statistics  of  sick  and  wounded,  1  ;  comparison  with 
Great  War,  4  ;  enteric  fever  in,  24  ;  scurvy  in  Port  Arthur,  425  n. 

Russo-Turkish  War  :   enteric  in,  12. 


Salvarsan  :  for  treating  relapsing  fever,  324-5,  340  ;  jaundice  in,  poisoning, 
377. 

Sand-flies  :  carriers  of  phlebotomus  fever,  345-6,  347  ;  illustration  of,  347  ; 
how  rendered  infective,  346-7  ;  distribution  of,  347  ;  description  of, 
347-8  ;  larvae,  348  ;  repellents  of,  355-6  ;  methods  of  destruction  of, 
356. 

Sanitary  Measures :  disease  preventible  by,  8 ;  possible  reforms  in,  9  ; 
(necessity  of)  for  preventing  enteric  fever,  58-60. 

Scurvy :  in  Mesopotamia,  teaches  lessons  in  dietary,  6-7 ;  a  deficiency 
disease,  409;  incidence  in  Mesopotamia,  1916-18,  ib.;  causative 
factors,  409-10,  411,  414;  outbreaks  among  Indian  troops,  410; 
in  France,  1915,  411  ;  in  South  African  Native  Labour  Corps,  1918, 
ib.  ;  in  British  troops,  1915,  411-2;  in  N.  Russia,  1919,  412;  period 
of  development,  ib.,  422  ;  amongst  civil  population  (Murmansk) 
412;  amongst  natives  in  E.  Africa,  412-3;  in  Great  Britain,  414; 
aetiology  of,  414-22;  chart  illustrating  admissions,  418;  preventive 
rations  in  N.  Russia,  420-1  ;  effects  of  climate  on,  421  ;  other  pre- 
disposing causes,  ib.  ;  influence  of  race,  ib.  ;  experimental  work  on, 
ib.  ;  morbid  anatomy,  422 ;  symptoms,  422-5 ;  groups  of,  422  ; 
progress,  423-5  ;  mortality,  425  ;  prognosis,  ib.  ;  diagnosis,  425-6  ; 
simulated  by  malingerers  (Mesopotamia),  425-6  ;  treatment,  426-7  ; 
preventive  measures,  427  ;  special  hospitals  for  (Mesopotamia),  ib.  ; 
convalescent  camp  for,  ib.  ;  memoranda  on,  circulated  in  Mesopotamia, 

Sera  :  anti-dysenteric,  82-4  ;  storage  of,  83-4  ;  for  prophylactic  inoculation 
against  dysentery,  88  ;  M.R.C.,  for  cerebro-spinal  fever,  165. 

Serbian  Army  :  cholera  in,  116  ;  precautions  against  cholera,  129  ;  conditions 
in  retreat,  138. 

Sheppard,  Capt.  A.  L.  :  423,  427  n. ;  his  notes  on  early  diagnosis  of  scurvy, 
427. 


INDEX  549 

Shiga's  Bacillus  :  discovered  1897,  67  ;  causes  dysentery,  67-8 ;  bacterio- 
logical examination  for,  80-1  ;  carriers,  86  ;  in  flies,  87  ;  in  water,  ib. 

Shore,  Capt.  :    195. 

Sick  and  Wounded  :  statistics  (South  African  and  Russo-Japanese  Wars),  1  ; 
proportions  of  (Great  War),  2;  estimate  of,  in  R.A.M.C.  Training 
Manual,  ib. 

Skin  Diseases  :  sick  wastage  due  to,  7-8  ;    in  South  African  War,  8. 

Sleeping  Sickness  :   see  Trypanosomiasis. 

Small  pox  :   4. 

Smith,  Miss  A.  Henderson  :   419. 

Soltau,  Col.  L.  :  8  ;  analyses  admissions  for  disease  in  a  casualty  clearing 
station,  7,  359  ;  his  report  on  influenza,  187. 

South  African  War  :  statistics  of  sick  and  wounded,  1  ;  comparison  with 
Great  War,  4  ;  skin  diseases  in,  8  ;  enteric  in,  11  ;  jaundice  in,  374. 

Spanish- American  War  :   enteric  in,  12. 

Spirochasta  ictero-haemorrhagiae  :  micro-organism  of  jaundice,  378  ;  descrip- 
tion of,  379-80  ;  illustrations  of,  379,  380. 

Spirochaetosis  :    see  Relapsing  Fever. 

Spironema  :  species  of,  317-8  ;  illustration  of  Sp.  recurrentis  in  human  blood, 
318. 

Sprawson,  Lt.-Col.  C.  A.  :  investigates  cases  of  beri-beri  (Mesopotamia),  434. 

Stammers,  Lt.-Col.  G.  E.  F.  :    133,  144. 

Starling,  Prof.  :   440. 

Stevenson,  Capt.  A.  J.  :  419,  424 ;  investigates  cause  of  scurvy,  412 ; 
experiments  in  N.  Russia,  420-1. 

Stevenson,  Maj.  H.  W.  :  investigates  beri-beri  (Mesopotamia),  432. 

Supplies  :  difficulties  of  transport  (Mesopotamia),  410;  transport  improved, 
417. 

Taylor,  Capt.  :   231. 

Tetrachlorethane  :   poisoning  from,  causes  jaundice,  374,  377-8. 

Tick  :  cause  of  relapsing  fever,  317,  331  ;  description  of,  ib.  ;  illustrations  of, 
ib.  ;  habitat,  331-2  ;  method  of  determining  infection  of,  339. 

Tick  Fever  :    see  Relapsing  Fever,  E.  Africa. 

Tidy,  Capt.  H.  Letheby  :  observes  cases  of  dysentery  (France),  75. 

Todd,  Capt.  :    188. 

Topeley,  Capt.  W.  W.  C.  :    133. 

Trench  Fever  :  statistics,  8  ;  first  observed  in  Great  War,  ib.  ;  pathological 
research  in,  8-9,  360-2  ;  report  of  committee  on,  9 ;  definition,  358  ; 
areas  of  incidence,  ib.  ;  other  titles  of,  ib.  ;  history  of,  ib.  ;  incidence, 
359 ;  made  notifiable,  1918,  ib. ;  cases  wrongly  diagnosed,  359 ; 
statistics,  359-60  ;  aetiology  of,  360-2  ;  first  recognized,  1915,  360  ; 
dissociated  from  enteric,  ib.  ;  incubation  period,  362  ;  symptoms, 
362-8  ;  charts  illustrating,  364,  365  ;  course  of,  367-8  ;  chronic  cases 
of,  ib.  ;  period  of  incapacitation,  368,  369  ;  invaliding,  368-70  ;  after- 
effects, 369  ;  disposal  of  convalescents,  ib.  ;  duration  of  invalidism, 
370 ;  prognosis,  370-1  ;  persistence  of  infection,  ib.  ;  diagnosis, 
371  ;  treatment,  371-2  ;  preventive  measures,  372  ;  no  epidemic  of, 
in  United  Kingdom,  ib.  ;  not  associated  with  nephritis,  492-3. 

Trench  Foot :  observed  in  E.  Prussia,  1806,  8  ;  measures  to  prevent,  ib.  ; 
statistics  of,  1917,  ib. 

Trinitrotoluene  :  poisoning  from,  causes  jaundice,  374,  377. 

Trypanosoma  :   different  strains  of,  305^6. 

Trypanosomiasis  :  characteristics  of,  305  ;  confined  to  Africa,  ib.  ;  statistics 
of,  ib.  ;  cases  among  British  forces,  ib.  ;  aetiology  of,  305-7  ;  causative 
organism,  305-6;  types  of,  306;  carriers,  ib.  ;  infected  areas,  ib. ; 
morbid  anatomy,  307  ;  symptoms,  307-1 1  ;  charts  illustrating,  308, 
309  ;  incubation  period,  307-8  ;  complications,  310  ;  course  of,  310-1  ; 
prognosis,  31 1-2  ;  difficulty  in  pronouncing  a  case  cured,  ib.  ;  diagnosis, 
312  ;  treatment,  312-5  ;  prophylactic  measures,  314-5. 

Tsetse  Fly  :    carrier  of  trypanosomiasis,  306  ;    habitat,  306-7. 

Turkish  Army  :  lack  of  anti-mosquito  measures  in,  249 ;  relapsing  fever  in 
(Mesopotamia),  316  ;  pellagra  resulting  from  war  in,  474. 


550  MEDICAL  HISTORY  OF  THE  WAR 


Typhoid:  incidence  of,  1914-18,  13;  distribution  at  outbreak  of  war,  15; 
how  developed  in  new  areas,  ib.,  17  ;  comparative  incidence  of,  and 
paratyphoid,  15-7;  case  mortality,  19-20;  compared  with  paratyphoid, 
20,  21,  32  ;  cause  of  infection,  26  ;  clinical  features,  31-2  ;  incubation 
period,  32  ;  complications,  43-4  ;  diagnosis,  49-53. 

Typhus  :  4  ;  most  widespread  epidemic  of  the  war,  133 ;  British  Sanitary 
Mission  to  Serbia,  ib.  ;  aetiology  of,  133-4  ;  history  of,  133  ;  means  of 
infection,  133-4;  distribution,  134-42;  infected  areas,  134;  in  Russia, 
134-5  ;  in  Poland,  135  ;  in  Turkey,  ib.  ;  in  Austria,  ib.  ;  cause  of 
(Serbian  epidemic),  136 ;  chart  showing  course  of  epidemic,  136  ; 
statistics  of,  ib.  ;  inadequate  hospital  accommodation,  ib.  ;  preventive 
measures  allied,  136-8,  144;  chart  showing,  137;  enemy,  144-5;  lessons 
in,  145  ;  subsequent  incidence  in  Serbia,  138 ;  in  prisoners  of  war 
camps  in  Germany,  138-9  ;  in  Greece  and  Roumania,  139  ;  statistics  of, 
in  British  Army,  139-40 ;  in  Portugal,  139  ;  seasonal  incidence,  140  ; 
symptoms,  140-2 ;  incubation  period,  140  ;  clinical  features,  141-2  ; 
chart  showing,  141  ;  diagnosis,  142 ;  prognosis,  143 ;  mortality  in 
Serbia,  ib.  ;  treatment  and  prevention,  143-5  ;  in  German  armies,  145, 

Vaccines:  triple,  for  enteric,  introduced  January  1916,  15,  56;  its  effect, 
19,  21-2,  24,  56-8  ;  its  contents,  56  ;  therapeutic  use  of,  in  enteric,  55  ; 
treatment  for  dysentery,  85 ;  for  prophylactic  inoculation  against 
dysentery,  88  ;  cholera,  128,  130  ;  influenza,  193,  206. 

Vegetables  :  grown  in  Mesopotamia,  417;  precautions  against  infections  from 
raw,  418  ;  value  of  germinated  lentils  in  scurvy,  420. 

Vermin  :   prominence  of  infection  by,  8  ;   need  for  more  destroyers,  9. 

Vidal,  Capt.  :    139. 

Vitamine,  Anti-beri-beri :  nature  of,  436  ;  distribution  in  food-stuffs,  438  ; 
rations  lacking  in  (Mesopotamia),  ib.  ;  addition  to,  of  factors  containing, 
439  ;  comparative  value  of  foods  containing,  441. 

Vitamine,  Anti-scorbutic  :  foods  containing,  414 ;  methods  to  avoid 
destruction  of,  in  cooking,  ib.  ;  dietaries  deficient  in,  414-5  ;  value  of 
fresh  meat,  418  ;  relative  value  of  lime  and  lemon  juices  in,  419  ;  value 
of  Indian  dried  fruits  in,  419-20  ;  discovery  of  value  in,  of  germinated 
lentils,  420. 

Water  :  bacilli  in  subsoil,  22-3  ;  cause  of  enteric  fever,  23  ;  contamination  of, 

by  dysentery  organisms,  87-8,  103. 
Water  Supply  :    means  of  securing  pure,   58-9 ;    defective,   causes  cholera 

(Mesopotamia),  118-9,  120;   in  Sinai  desert,  131. 
Watts,  Lt.-Col.  R.  C.  :    253. 
Weil's  Disease  :   see  Jaundice,  Spirochcetal. 
Wellcome  Bureau  of  Scientific  Research  :   379. 
Willcox,  Col.  W.  H.  :   419,  427  n.,  439  ;   consulting  physician  (Mesopotamia), 

431  ;    his  recommendations  for  the  prevention  of  beri-beri,  432. 
Wilson,  Capt.  J.  A.  :   496. 

Wilson,  Prof.  W.  H.  :   his  theory  on  cause  of  pellagra,  479. 
Wiltshire,  Dr.  H.  :    423. 


UH      Macpherson,  (Sir)  William  Grant 

258     (ed.) 

1914/18    Medical  services 

M3 

T.1 


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