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
*••*
'i
c/)
Tf
> !2
3 fe
^ ^
PQ s
I I
<N CO n O5 m W W <N
I IX CO <N CO <N t> 1C O
O5 < O I>(N O O CO CO ^
I I
M W CO CC C<1 <N ~
Mil
O ID t^ O5 00 00 C<l N
| |
1 t^
1 00
CO Tf CO rt Tf CO CN <N Tj< T-, *-,
CO CO Tf C^ CO C^ —«
ENTERIC GROUP OF FEVERS 17
drops steadily as the efficiency of the laboratory workers and
the co-ordination between clinician and bacteriologist increase.
At the same time there will always be a small residuum, up to
5 per cent., in which the clinical picture is that of enteric fever
but the bacteriological and serological findings do not support
the diagnosis. This difficulty was apparent in 1915 and
was increased considerably in later years by the adoption
of triple inoculation ; the question will be considered again
when the diagnosis of the enteric group is under discussion.
Just as paratyphoid A was conveyed to the western front
from India and Africa, so was paratyphoid B conveyed to
Mesopotamia by the divisions which proceeded thither from
Europe and Egypt in 1916. Prior to the arrival of these
troops the Mesopotamia force was composed exclusively of
troops from India where, as in Mesopotamia, paratyphoid B
was practically unknown ; so that enteric fever was re-
stricted in 1915 and the early part of 1916 to typhoid and
paratyphoid A. Boney, Grossman and Boulenger state that
paratyphoid B was not diagnosed till March 1916, which
coincides with the arrival of a British division from Gallipoli
and Egypt. These authors find from an analysis of 650 cases
after this date that the proportions were : typhoid 21 per cent.,
paratyphoid A 65 per cent., paratyphoid B 14 per cent., so
that paratyphoid B obtained a firm foothold when once it
had been introduced ; indeed, for 1918 the incidence per
thousand of paratyphoid B, including Indian troops, is
nearly twice that for 1917.
Figures dealing with the incidence of the enteric group in the
Gallipoli expedition are not very reliable, owing to the nature
of the campaign and the extreme difficulty of evacuating the
sick, as well as the long distances between the fighting zone and
the hospital bases. Coutts gives clinical notes of 66 cases of
paratyphoid B and 63 cases of paratyphoid A ; Martin and
Upjohn found paratyphoid A to be nearly twice as frequent as
paratyphoid B. It is noteworthy, in connection with this
campaign, to find that a considerable number of cases evacuated
as dysentery were ultimately proved to be suffering also from
paratyphoid fever, especially paratyphoid B.
In Salonika, paratyphoid A was more frequent than either
paratyphoid B. or typhoid ; and paratyphoid B was more
numerous than typhoid till 1918, when it became the least
common of the three.
In Italy, in 1918, the relative proportions resembled those
obtaining in France, except that paratyphoid A was rather
higher ; the actual incidence of enteric fever per 1 ,000 of ration
strength was, however, more than ten times as high.
(2396) B
18
MEDICAL HISTORY OF THE WAR
In Egypt the very large proportion of group cases in 1916
makes comparison difficult, but it appears that paratyphoid A
was numerically preponderant, both paratyphoid A and para-
typhoid B being higher than typhoid. In 1917 typhoid was
seven times less common than either paratyphoid A or para-
typhoid B but paratyphoid B was fractionally higher than
paratyphoid A ; in 1918 typhoid was still the least numerous,
but paratyphoid A was definitely higher than paratyphoid B.
Mortality.
The total case mortality per cent, for the three varieties of
enteric fever grouped together can be determined fairly accu-
rately, and, as has been shown in Table I, it varies considerably
with the different campaigns but may be summarised as follows :
TABLE V.
Summary of case mortality from the enteric fevers in different-
theatres of war.
France
Salonika
Egypt
Mesopotamia
Italy
East Africa
3-8 per cent.
3-9
6-4
8-7
10-6
27-4
The high death rate in East Africa may be explained by the
extreme rigour of that campaign and the necessity for operating
at a great distance from a properly equipped base in a very
unhealthy climate. It is also probable that many mild cases
of group infection were overlooked, and it is certain that many
of the deaths were due rather to the presence of a coincident
infection, such as malaria or relapsing fever, than to the enteric
infections.
There is one point of special interest in the mortality columns
in Table I., namely, the fact that the low water mark of per-
centage case mortality was reached in 1916 and that a notable
increase occurred in both 1917 and 1918. This increase was
more or less apparent in every theatre of war where reliable
figures are available, as follows : —
TABLE VI.
Showing increase in case mortality after 1916.
1916.
1917.
1918.
France
1-12%
2-8%
5-9%
Salonika
Egypt
Mesopotamia
East Africa
3-62%
2-2%
10-9%
3-78%
4-3%
7-5%
26-4%
4-44%
12-7%
10-9%
28-4%
ENTERIC GROUP OF FEVERS 19
It is necessary to enquire briefly into the possible reasons for
this increase in case mortality. It will be remarked that the
increase dates from the adoption of triple vaccine, so that it
might be thought that triple vaccine to some extent decreases
the immunity conferred against typhoid fever. If this were so,
one would expect to see a definite increase in the case mortality
from typhoid in protected men, and also to find that the
increase is chiefly in typhoid as opposed to paratyphoid cases.
The increase in typhoid mortality is as follows :—
TABLE VII.
Case mortality from proved cases of typhoid.
(Western Front.)
Protected by
Inoculation.
Unprotected by
Inoculation.
1915
1916
1917
1918
7-54%
1-58%
7-73%
13-84%
23-2%
8-3%
12-12%
24-0%
A similar increase is thus shown in the figures for those
who are unprotected, and it is obvious that there must be some
other factor at work to explain the drop to 8-3 per cent, in the
unprotected in 1916 with the subsequent rise to 24 per cent, in
1918. The difficulty of getting satisfactory re-inoculation at
the end of 1917 and throughout 1918 would tend to produce a
higher death rate among the partly protected.
The points which seem to be of great importance in this
connection are, first, the undoubted lowering of all powers of
resistance to infection in the nation as a whole and in the troops
in particular by four years of continuous warfare, and, secondly,
the increased average age and lower physical categories of an
army which became to all intents and purposes a nation under
arms.
In attempting to arrive at the individual case mortality of
the three enteric infections, there is the difficulty, already men-
tioned, of including the cases of the enteric group in which no
final diagnosis has been possible. To ignore these cases might
in some cases give unduly high results by eliminating a consider-
able number of cases with a low death rate. It is probable that
a fairly correct result will be obtained by assuming that the
enteric group cases are made up of typhoid, paratyphoid A,
and paratyphoid B in like proportion to the proved cases for
the same area during the same period of time, and that the
infections causing death in group cases are relatively propor-
B2
20 MEDICAL HISTORY OF THE WAR
tionate to those causing death in proved cases. This method
gives the following results for France, Italy and Egypt : —
TABLE VIII.
Approximate percentage case mortality from typhoid,
paratyphoid A and paratyphoid B.
Theatre of
War.
Year.
Typhoid.
No. of
Cases.
Para.
No. of
Cases.
Para.
B.
No. of
Cases.
France
1914
13-5
340
7
4-9
41
1915
12-0
889
•6
314
2-9
1,148
1916
1-6
839
1-5
668
•7
1,161
1917
6-5
304
•8
233
1-9
529
1918
15-5
104
2-6
50
1-4
180
Italy
1918
22-3
39
3-7
28
6-4
72
Egypt
1916
3-7
659
2-03
1,287
1-6
1,004
1917
Sufficient data" not available as no deaths were
recorded in proved cases of paratyphoid.
1918
37-0
87
6-3
179
7-8
135
The returns from Salonika and Mesopotamia do not permit
of analysis on these lines.
For purposes of comparison the death rate from proved cases
of the three infections is shown in the following table : —
TABLE IX.
Percentage case mortality from proved cases of typhoid and
paratyphoid.
Theatre of
War.
Year.
Typhoid.
No. of
Cases.
Para.
A.
No. of
Cases.
Para.
B.
No. of
Cases.
France
1915
13-0
805
•71
281
1-91
1,043
1916
1-9
729
1-7
580
•7
1,009
1917
8-3
227
•56
173
2-1
471
1918
16-5
90
2-3
43
•6
156
Italy
1918
24-2
33
4-2
23
6-5
61
Egypt
1916
6-06
99
3-2
187
2-08
143
1917
23-0
13
70
—
74
1918
41-0
31
6-06
66
8-6
46
Mesopotamia
1916
-|
1917
>1 1 -4
320
3-6
532
7-5
120
1918
[
The value of the figures in the foregoing tables depends largely
on the totals of the cases, for when there are few cases the value
ENTERIC GROUP OF FEVERS 21
is slight ; but it is evident that the case mortality from all the
enteric infections varies within wide limits from time to time
in the same theatre of war, and also varies directly with the
efficacy of the general hygiene, transport, and medical arrange-
ments.
The proverbial severity of these infections in hot climates is
noticeable in the figures from Egypt and Mesopotamia. The
theory held by many who had worked in India that paratyphoid
A was practically negligible as a cause of death appears to be
fallacious when applied to active service conditions in the East,
for there was in 1918 a case mortality of over six per cent, from
this disease in the Egyptian forces, and in France the death rate
for the same year was more than two per cent. This high
death rate in Egypt was in part explained by an outbreak of
malignant tertian malaria which complicated the enteric
infections.
The relative mortality from paratyphoid A and B appears
to vary greatly with time and place, as shown in Table IX.,
but here again the totals are often too small to be reliable,
and the only safe deduction seems to be that they are both
very much less severe infections than typhoid under like
conditions.
The total figures available at present for proved cases from
France, Italy, Egypt and Mesopotamia give a mortality table
approximately as follows : —
TABLE X.
Typhoid 9-8% mortality in 2,472 cases.
Paratyphoid A 2-6% „ „ 2,023 ,.
Paratyphoid B 1-55% „ ,,3,160 „
Total Paratyphoid 2-1% „ 5,183 „
This is striking in one particular, namely, that the figure for
paratyphoid A is considerably higher than that for paratyphoid
B, a fact that is opposed to the general impression as gathered
from the analyses of smaller series of cases made before the
introduction of triple vaccine. Thus, in 1915, Torrens and
Whittington found the mortality to be four per cent, for para-
typhoid B, and less than one percent, for paratyphoid A, while
Boidin in January 1916 reported a series of cases in the French
Army with a mortality of six per cent, for paratyphoid B and
1-4 per cent, for paratyphoid A. Rathery in a large series of
cases of paratyphoid B found a mortality of over six per cent.
A possible explanation of this difference in the mortality of
the two infections is that the vaccine used from 1916-1918
conferred more protection against paratyphoid B than against
22 MEDICAL HISTORY OF THE WAR
paratyphoid A, a suggestion that is to some extent supported
by the low titre to paratyphoid A, so often shown after triple
inoculation ; or again the severity and frequency of paratyphoid
A in tropical and sub-tropical climates may more than counter-
balance the greater relative severity of paratyphoid B on
the Western Front. Hence it may well be that in a civilian
uninoculated population in Western Europe, an epidemic of
paratyphoid B would be found to be attended with a higher
death rate than would one of paratyphoid A, with a figure for
either disease of from three to five per cent.
JEtiology.
With regard to the various factors affecting the aetiology of
these diseases there is no reason to suppose that any which may
be said to predispose to typhoid fever predispose also in any
greater or less degree to either of the paratyphoid infections.
The predisposing causes can be considered under two headings ;
first, those of environment, which influence the presence and
distribution of the infective material, and secondly, those of
immunity, which influence the individual's capacity to neutralize
a given dose of infective material.
Although a tropical or sub-tropical climate does not favour
the growth of the bacilli of enteric fever outside the body, it
nevertheless favours their distribution by flies and in dust,
while the defective sanitary arrangements amongst the inhabi-
tants of the East and Near East make enteric fever widely
endemic in these regions. Before the war typhoid and para-
typhoid A were very prevalent throughout the East, while
paratyphoid B was practically unknown, so that in a sense it
might be said that a tropical climate predisposes to typhoid and
paratyphoid A rather than to paratyphoid B, and conversely
that a cold or temperate climate predisposes to paratyphoid B
rather than to paratyphoid A. Whether paratyphoid B will
speedily die out in the East and paratyphoid A in the West,
now that their respective sites of election have been enlarged,
remains to be seen. Although epidemics may start at any
time of the year, the summer and autumn are always likely to
show the greatest number of cases and also the most severe ones.
The effect of the external temperature is undoubted. Enteric
fever is more frequent and more severe along the Mediterranean
littoral than in the more northern parts of Europe ; for the
same reason the disease persists in a serious form in Egypt,
India, Central America, and the Philippines.
The number of bacilli present in subsoil water increases
with the utmost rapidity as soon as men are occupying the
surface of the soil. Vincent gives the follo\ving analysis from
ENTERIC GROUP OF FEVERS 23
a camp in which typhoid was constantly occurring. Before
the arrival of the troops the water was very pure and contained
only 100 ordinary bacteria per c.c. Six days later there were
770 bacteria, forty days later 6,960, sixty days later 14,900, and
three months afterwards 38,000 per c.c.
In highly cultivated districts there is a great likelihood of the
subsoil water becoming infected as a result of the practice of
manuring the earth with human excrement. It is true that the
typhoid bacillus does not survive in drinking water more than
three to five days, but under suitable conditions the water is
constantly being re-infected with fresh relays of virulent
bacilli from a saturated soil. The importance of drinking
water as a cause of enteric fever has been proved in numerous
epidemics, and in war time in the field all drinking water should
therefore be sterilized efficiently before use.
It has been shown that flies can carry typhoid and other
pathological bacilli in their stomachs, on their feet, and on
their probosces. Although the curve of enteric fever does not
follow closely that of the fly pest, and the extent to which flies
may be responsible for the spread of enteric fever is not fully
established, these insects and the fingers of the " carrier " may,
however, be regarded as playing the leading parts in causing
the dissemination of typhoid infected material in war time.
The specific bacilli are always likely to be present owing to the
existence of some recent case in the neighbourhood or to the
presence of a " carrier " among the population. A man sick-
ening for enteric fever may be infectious for three or four weeks
before he realizes he is ill. A " carrier " may convey infection
for months or years after he has recovered from the disease
and the bacilli may live in faeces or urine under favourable
conditions of moisture for 100 days, and for upwards of
40 days in the absence of moisture.
Hence the most important factors predisposing to the occur-
rence of enteric fever in war are the manifest impossibility of
securing an absolutely perfect disposal of all faecal and urinary
matter and the difficulty of excluding all " carriers " from an
army. It has been shown experimentally that a large per-
centage of men soil their fingers both during micturition and
def aecation, especially the former ; and the contamination of
food or water is more than likely to result.
Fletcher investigated bacteriologically one thousand men who
were convalescent from enteric fever ; he found that prophy-
lactic inoculation diminished the frequency of " carrier "
development amongst infected men but did not abolish it, and
that 0-6 per cent, of all convalescent male enteric cases are
" carriers." Small epidemics have, in peace time, frequently
24
MEDICAL HISTORY OF THE WAR
been traced to cooks, waiters and others, who were " carriers/'
and the same source of infection has been proved repeatedly
during the war to explain a sudden crop of cases in the same
unit when neighbouring units have been relatively or absolutely
free.
With regard to individual immunity, there are numerous
personal factors upon which immunity from enteric fever seems
to depend. A previous attack confers a very great though not
absolute immunity from re-infection with the same bacillus. It
is estimated by Vincent and Muratet that not more than two
per cent, of persons who have had typhoid fever can contract
it a second time. But there is no experimental evidence that
typhoid fever confers any immunity from paratyphoid fever
or vice versa.
Prophylactic inoculation with triple vaccine confers rela-
tively great immunity against typhoid and both forms of
paratyphoid fever, the degree of immunity increasing up to a
point with the number of injections employed.
Real immunity is only relative, but it appears that the
Japanese and Chinese are not so susceptible as Europeans.
Enteric fever, for example, has been stated to be less frequent
in the Japanese than in the Russian Army in the Russo-
Japanese War, and there was a similar experience in the Chinese
expedition of 1901. The Hindu races appear to suffer but
slightly from enteric fever in spite of their primitive hygienic
and sanitary arrangements. It is held by some that the
immunity of the Eastern races is apparent rather than real, as
it is thought that the bulk of the population gets infected in
childhood. This apparent relative immunity from enteric
fever amongst the Asiatic races is borne out by the figures
from our forces operating in Egypt and Mesopotamia.
TABLE XI.
Showing relative incidence in British and Indian Races.
Incidence per 1,000 of
Ration Strength.
Case mortality per cent.
Egypt :—
British.
Indian.
British.
Indian .
1916
17-35
1*15
2-2
1917
2-8
•9
4-3
7-6
1918
1-87
•5
10-4
9-5
Mesopotamia : — . .
1917
2-5
•4
10-8
22-3
1918
2-5
•8
6-4
18-3
The Indian figures for Mesopotamia, however, include a large
number of followers, of whom only 20 per cent, were protected
by inoculation in 1917 and 50 per cent, in 1918. Of the Indian
ENTERIC GROUP OF FEVERS
25
troops proper about 80 per cent, were protected in 1918 and 50
per cent, in 1917, and of the British troops 75 per cent, in each
year. If we exclude the Indian followers, in order to obtain a
better standard for comparison with British troops, we find that
the mortality for Indians in 1917 was 22 per cent, and in 1918
12-8 per cent., with an incidence of 0-3 and 0-5 per 1,000
respectively. It thus appears that in the Indian races there is
a real insusceptibility to acquiring enteric fever, but that there
is a tendency for the infection when acquired to be exceptionally
severe.
On the other hand, the high death rate in Indian troops can
to some extent be discounted by the probability that many
mild cases were never reported as enteric fever, but were allowed
to run their course as pyrexia of uncertain origin.
If this apparent racial insusceptibility is due principally to
immunity acquired as the result of disease in childhood, it
would be expected that the incidence of paratyphoid B in
Indian troops would be more nearly that obtaining in the British
troops, at any rate in 1918 when the paratyphoid B infection,
which was at first confined to the British troops who brought
it with them to the country, had become more widely dis-
seminated. This view is supported to some extent by the
official figures for 1917 and 1918, dealing only with men
unprotected by triple vaccine.
TABLE XII.
British.
Indian.
Incidence of Paratyphoid B~]
per 1,000 of ration strength ^
in unprotected men J
1917
3-92
•02
(one case only)
1918
•64
•4
The conclusion that enteric fever has run a graver course
when it has attacked the Indian troops than when it has
attacked the British is upheld by Ledingham, who published
the following figures from Mesopotamia for 1916-17-18.
TABLE XIII.
Case Mortality in British and Indian Troops.
British.
Indian.
Typhoid
Paratyphoid A
11-4 percent.
3-6
27-2 per cent.
11-3
Paratyphoid B
7-5
16-6
Enteric Group
10-0
20-7
Enteric Fever as a whole
8'7
20-5
26 MEDICAL HISTORY OF THE WAR
Age is recognized as playing an important part in the suscep-
tibility to the enteric infections. No age is immune, but 46 -5
per cent, of all cases occur between the ages of fifteen and
twenty-five 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«-
100°
£/
Resa
Chart I.
36
MEDICAL HISTORY OF THE WAR
Dauo/Dis
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Chart 111.
106
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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.
|g ia \$_ 1 5 .1 6 IT" 18 J9 20 21 2?. 23 2^ ZS Z6_ 27 29 29. 3O
3I_ 32 55
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Chart VI.
9 MO
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98
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Chart VII.
38
MEDICAL HISTORY OF THE WAR
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ENTERIC GROUP OF FEVERS
39
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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
II
CM «C — < 00 *-< CO CO-^tx
^^ CO 00 00 ^* CO C^ ^*
CM CM CM O CM CD
8S§
1C CD O5
CM CM
"o
Protected.
^H 1 1 f* 1 1 CO CD CM
1C ^H 1 O5 10 CD
1C CD CM CO
-^ O5 CD
05 CO-*
»-< »- 1 CO
CD CO Cl
.
I
OTJ
M 4)
CO 00 t>.
COICM CMt^O) COt>>t>«
t!SS
8 | ,
^
£
53
t^. CO CO "-i 00 1-"
<N CM CO
S
1
Case Mortal
1
00 CO CM
00 | | » | | u-^cp
1C l> '-"-'
JC ^ !^
•^f oo
00 IN t^
CO CM
1
1
it
CO
CO CO CO
i-< O »-«
cS 1 )
b
PH
O
0*
1-1
1
-M
2
1
I
8
§CO CM
88
00 O CO
SS8
£88
O O O
S)
P
£
i
|
||
^^CN
822
O5 r»< M
-<0<N
i
i
' ' ' « • ^ ' co<^
i— i i— i ^<
3
1
'C
1
III CO 1 1 !>«>-"
Ill 05 1 1 ICCMCO
o i>a-
Soc5
'"i
a
£
§
t
(
!
li Si i
fijjjj
jH«
figg
1
i
Tf* 1C CO
»-« »-H »— t
O5 O5 O5
O5
00
s
Theatre of
M
PS
£
1
58 MEDICAL HISTORY OF THE WAR
It will be seen from this table that the influence of protective
inoculation on the liability to infection from enteric fever is
undoubted, and equally undoubted is the very much lower case
mortality in typhoid fever. It is difficult to say from these
statistics whether triple vaccine has any pronounced effect on
the case mortality of paratyphoid fever. The 1917 figures
suggest that it had, but the 1918 figures do not confirm this.
It must be noted, however, that in this latter year the total
number of cases of paratyphoid fever on the Western Front
was too few to be of much value. Only two deaths occurred,
one in paratyphoid A and one in paratyphoid B, and it is
probably quite accidental that both these happened in protected
men. The incidence of complications seems to be lowered in
all three infections by the use of triple vaccine.
Since one result of infection by one of the organisms of enteric
fever is the appearance of specific agglutinins in the patient's
blood serum and identical agglutinins are produced by the
injection of the appropriate vaccine, it is reasonable to suppose
that the amount of agglutinin to Bacillus typhosus, Bacillus
paratyphosus A and Bacillus paratyphosus B, respectively
present in the blood serum after prophylactic inoculation with
triple vaccine, affords some approximate idea of the relative
immunity conferred against each of the three infections. It
must be remembered, however, that the infections themselves
do not produce identical amounts of agglutinin in every case
and that the response to paratyphoid A is habitually very
much less than that to either paratyphoid B or typhoid ; so
that a quite low agglutination titre to paratyphoid A might
conceivably indicate the same actual degree of immunity as a
much higher agglutination titre to paratyphoid B or typhoid.
It might appear from the preceding remarks that prophylactic
inoculation was the only necessary preventive measure against
enteric fever. This is far from being the case, and the success
of the campaign against enteric fever has been in no small
measure due to the unremitting care and energy of the army
sanitary authorities.
For the details connected with the diverse sanitary measures
rendered necessary by the varying features of the different
campaigns, reference must be made to the volumes on the
Hygiene of the War; but the general principles may be
summarised here.
The water supply must be beyond reproach ; in the case of
the trenches this can best be secured by the daily provision in
tins of an adequate supply which must be chlorinated before
use, or by the individual use of bisulphate of sodium tabloids.
Water which has not been either boiled or sterilized in this
ENTERIC GROUP OF FEVERS 59
manner must be used for no personal purpose whatsoever.
Behind the line the precautions must be equally strict ; but it
is, of course, easier there to arrange for the provision of large
tanks of properly chlorinated water. All vessels used for the
carrying of water for cooking and for washing up must be kept
scrupulously clean and covered up. In European countries the
town water supply usually requires careful testing and super-
vision. At Rouen, Boulogne and elsewhere in France the
supply was by no means safe, and it was found necessary to
install a chlorinating plant at the source of supply.
In the Eastern theatres of war the troops may often be
compelled to rely on a single water supply such as a river with
its subsidiary canals ; such water is highly dangerous and should
only be used after sedimentation or clarification with alum and
chlorination or after prolonged boiling. Since it may often be
lecessary for large bodies of mobile troops to be several hours
it of reach of their own water supply, the utmost care must be
taken to ensure that their water bottles are clean, properly
corked and as large as possible. Tablets of bisulphate of sodium
ly be issued when there is a likelihood of temporary shortage
>f chlorinated water ; these destroy cholera vibrios and all
icilli of the coli group in twenty minutes. It is customary to
ink large quantities of soda water in the East, and the very
ictest supervision is necessary over all soda-water factories
ensure that the returned bottles are properly washed in
tlorinated water before being refilled, and that only properly
terilised water is used for aeration.
At the base and behind the line all excrement should be burnt
in an incinerator ; the urine pails should be emptied twice
daily into a suitable soakage pit. In the vicinity of the front
line deep trenches must be dug when practicable, and should
be covered with a board to exclude flies. The site of all ground
used for this purpose must be carefully marked to prevent its
being used again. All urine must be passed into special tins
which are emptied regularly into properly constructed soakage
pits. Cresol should be placed in every tin before it is used. In
permanent camps urine must be disposed of in soakage pits or
evaporated in incinerators.
Latrines and cookhouses must be rendered fly-proof as far
as possible by the use of canvas screens, wire gauze, etc. Special
attention must be directed to the breeding places of flies, and
manure must be suitably treated and disposed of.
Vegetables and fruits must not be eaten uncooked except
after efficient cleansing in pure water.
Every case suspected to be enteric fever should be notified,
isolated at once, and sent without delay to a hospital for
60
MEDICAL HISTORY OF THE WAR
infectious diseases. The occurrence of a sporadic case should
lead to strict investigation as to a possible carrier in the troop
or company. Spot maps must be kept of all cases and their
probable place of origin. Every patient should be kept
isolated until he is definitely proved not to be a carrier.
In the event of an outbreak of enteric fever in the civilian
population of a town or district necessarily occupied by troops,
special hospitals must be provided and all cases should be
compulsorily sent to them. Infected houses and areas must
be recognized and placed strictly out of bounds. Immediate
notification to the sanitary authorities of all suspects is essential.
The efficiency of the measures outlined above depends very
largely on cordial co-operation between the combatant and the
medical or sanitary authorities. This co-operation will be very
much closer if steps are taken to explain the reason for the
various rules and regulations. This can readily be accomplished
by means of an occasional short address by the medical or
company officer.
BIBLIOGRAPHY.
Achard & Bensaude Infections Paratypho'idiques . .
Archibald
Bainbridge
Boidin
Boney, Grossman &
Boulenger
Bourke, Evans &
Rowland
Buxton
Carles ..
Coutts
Gushing
Enterica in the Soudan
Paratyphoid Fever and Meat
Poisoning.
Sur la mortalite des fievres
typhoides
Report of Base Laboratory in
Mesopotamia.
Autogenous living Vaccine in
the treatment of Enteric
Fever.
. . La Fievre Typhoide du Com-
battant
. . Paratyphoid in the Army at
the Dardanelles
. . A comparative study of some
members of a pathogenic
group of bacilli of the hog
Cholera or B. enteritidis
(Gartner) type.
Dawson & Hume . . Jaundice of Infective Origin . .
Bull, et Mem. Soc.
Med. des H6p. de
Paris, 1896. 3e S.,
Vol. xiii, p. 820.
Journ. Trop. Med.,
1918. Vol. xxi,
p. 229.
Lancet, 1912. Vol. i,
pp. 705, 771, 849.
Arch, de Med. et
Pharm. Mil., Paris,
1916. Vol. Ixvi,
p. 514.
Jl. of R.A.M.C., 1918.
Vol. xxx, p. 409.
B.M.J., 1915. Vol. i,
p. 584.
Journ. Med. Research,
1904-1905. Vol.viii,
N.S., p. 431.
Journ. de M6d. de
Bordeaux, 1916.
Vol. xlvi, p. 65
Can. Med. Ass. Journ.
Toronto, 1917. Vol.
vii, p. 97.
Johns Hopkins Bul-
letin, 1900. Vol.
xi, p. 156.
Quar. Journ. Med.,
1916-17. Vol. x,
p. 90.
ENTERIC GROUP OF FEVERS
61
BIBLIOGRAPHY— cont.
Dawson & Whittington Paratyphoid Fever,
of Fatal Cases.
Durham
A Study Quar. Journ. Med.,
1915-16. Vol. ix,
p. 98.
Dreyer & Ainley Walker The diagnosis of the Enteric Lancet, 1916. Vol. ii,
Fevers in inoculated indi- p. 98.
viduals by the Agglutinin
Reaction.
Some theoretical considerations Jl.
on nature of agglutinins, to-
gether with further obser-
vations on B. typhi abdomin-
alis, B. enteritidis, B. colicom-
munis, B. lactis aerogenis and
some other bacilli of allied
character.
The Paratyphoid Problem in
India.
Paratyphoid Infections
of Experimental
Med., 1900-01. Vol.
v, p. 353.
Firth
Fletcher
Fortescue-Brickdale
Glynn & Lowe
Goodall
Grattan & Harvey
Grattan & Wood
Gwyn
Harvey
Hirschfeld
Hichens & Boome
Job & Ballet
Ledingham
MacAdam
Jl. of R.A.M.C., 1911.
Vol. xvii, p. 136.
Jl. of R.A.M.C., 1904.
Vol. ii, p. 241.
Jl. of R.A.M.C., 1918.
Vol. xxx, p. 51.
Report on Bacteriological Ex-
amination of Soldiers conva-
lescent from Diseases of the
Enteric Group.
Notes on the Symptomatology Lancet, 1917. Vol. i,
of Paratyphoid Fever. p. 611.
Observations on the Serum Re- Jl. of R.A.M.C., 1916.
action of 300 Unselected Vol. xxvii, p. 663.
Cases of Enteric from the
Eastern Mediterranean, with
the Oxford Standard Agglu-
tinable Cultures.
Enteric Fever in Flanders, 1914 Proc. Roy. Soc. Med.,
and 1915. 1918-19. Vol. xii
(Epid. Sect.), p. 18.
Inquiry into small Epidemic of Jl. of R.A.M.C., 1911.
Paratyphoid Fever in Camp. Vol. xvi, p. 9.
Paratyphoid Fever in India . . Jl. of R.A.M.C., 1911.
Vol. xvii, p. 143.
On infection with a paracolon Johns Hopkins Bui-
bacillus in a case with all the letin, 1898. Vol.
clinical features of Typhoid
Fever.
The Causation and Prevention
of Enteric Fever in Military
Service, with Special Refer-
ence to the Importance of
the Carrier.
A New Germ of Paratyphoid . .
ix, p. 54.
Jl. of R.A.M.C., 1915.
Vol. xxiv, p. 491 ;
Vol. xxv, pp. 94,
193.
Vol. i.
Lancet, 1919.
p. 296.
A fatal case of Paratyphoid B.M.J., 1918. Vol. i,
B simulating Typhus Fever. p. 398.
Contribution a 1'etude de Bull, et Mem. Soc.
1'anatomie pathologique des Med. des Hdp. de
fievres paratyphoides. . . Paris, 1915. Vol.
xxxix, 3e S.,p.991.
Dysentery and Enteric Disease Jl. of R.A.M.C., 1920.
in Mesopotamia. Vol. xxxiv., p. 306.
An account of an infection in Jl. of R.A.M.C., 1919.
Mesopotamia due to a bacil- Vol. xxxiii, p. 140.
lus of the Gaertner-para-
typhoid Group.
62
MEDICAL HISTORY OF THE WAR
MacAdam
Mackie & Bowen
Martin & Upjohn
Marris
Miller
Morley & Battinson
Smith
NobScourt & Peyre . .
Perry & Tidy
Perry ..
Rathery & Ambard . .
Rodet .
BIBLIOGRAPHY— cont.
Thrombosis of Cerebral Arteries Lancet, 1916. Vol. i,
in Paratyphoid B. p. 243.
Note on the characters of an Jl. of R.A.M.C., 1919.
anomalous member of the Vol. xxxiii, p. 154.
Paratyphoid Group met with
in Mesopotamia.
The distribution of Typhoid Jl. of R.A.M.C., 1916,
and Paratyphoid Infection Vol. xxvii, p. 583.
amongst Enteric Fevers at
Mudros, Oct.-Dec., 1915.
The use of Atropine as an aid B.M.J., 1916. Vol. ii,
to the Diagnosis of Typhoid p. 717.
and Paratyphoid A and B
Infections.
Goulstonian Lectures on Para- Lancet, 1917. Vol. i,
typhoid Infections. pp. 747, 827, 901.
Acute Gangrenous Cholecystitis B.M.J., 1916. Vol. i,
p. 444.
Complications observees au Bull, et Mem. Soc.
cours des fievres typhoi'des Med. des Hop. de
et paratyphoiides. Paris, 1916. Vol. xl
3eS.
A Report on an Epidemic Med. Research Comm.
caused by Bacillus aertrycke. Spec. Report Series
No. 24. London,
1919.
Illustrations of the Agglutina- Lancet, 1918. Vol. i,
tion Method of Diagnosis in p. 593.
Triple inoculated Individuals.
Les Fievres Paratyphoides B Paris, 1916.
a 1'Hopital Mixte de Zuyd-
coote, de Dec. 1914 a Fev.
1916.
Serotherapie antityphoi'dique : Bull. Acad. de Med.,
preparation du serum.
Rodet & Bonnamour. Serotherapy of typhoid fever .
Serotherapy in typhoid fever
Paris, 1916. Vol.
Ixxvi, pp. 83-85.
Serotherapie antityphoidique : Bull. Acad. de Med.,
application. Paris, 1916. Vol.
Ixxvi, pp. 114-116.
Bull. Acad. de Med.,
Paris, 1919. Vol.
Ixxxi, p. 759.
PresseM6dicale, Paris,
1920. Vol. xxviii,
p. 81.
The Blood pressure in Typhoid Med. Press & Circular,
Fever. 1916. Vol. i, p. 234.
A new chromogenous bacillus Proc. Amer. Ass. Ad-
vanced Sc., 1885.
Vol. xxxiv, p. 303.
Sarrailhe & Clunet .. La Jaunisse des Camps et 1'epi- Bull, et Mem. Soc.
demie de Paratyphoide des Med. des H6p.
Dardanelles. Paris, 1916. Vol. xl,
3e S., p 45.
Brain Abscess in a Case of Para- Lancet, 1915. Vol. i,
typhoid B. p. 852.
Report on the probable pro- M.R. Committee,
portion of Enteric Infections Spec. Rep. Series
among undiagnosed Febrile No. 48. London,
Cases invalided from the 1920.
Western Front since Oct.,
1916.
Rolleston
Salmon & Theobald
Smith
Scott & Johnston . .
Topley, Platts & Imrie
ENTERIC GROUP OF FEVERS
63
Torrens & Whittington
Vincent & Muratet . .
Webb- Johnson
Weeks
Whittington
Willcox
Wiltshire & McGilli-
cuddy
BIBLIOGRAPHY— cont.
A Preliminary note on the
Clinical Aspects and Diag-
nosis of Paratyphoid Fever.
Typhoid Fevers and Para-
typhoid Fevers.
Hunterian Lecture on the Sur-
gical Complications of Ty-
phoid & Paratyphoid Fevers.
Empyema due to infection by
B. paratyphosus A.
Report on the use of Stock Vac-
cine in infection by B. ty-
phosus, with analysis of 230
cases.
Paratyphoid Fever, its clinical
features and prophylaxis.
Experience in Treatment of
Typhoid Fever by Stock Ty-
phoid Vaccine.
Jl. of R.A.M.C., 1915.
Vol. xxvi, p. 359.
Military Medical
Manuals. Trans.
by J. D. Rolleston.
London, 1917.
Lancet, 1917. Vol.
ii, p. 813.
Lancet, 1916. VoL
ii, p. 433.
Jl. of R.A.M.C., 1916.
Vol. xxvii, p. 422.
Lancet, 1916. Vol. i,
p. 454.
Lancet, 1915. Vol. ii,
p. 685.
Note. — Vincent and Muratet also quote Chevrel, Joltrain and Petitjean,
Lenglet and Sacquepee, and Miller quotes Sawasaki, to all of whom
reference is made in the text of this chapter.
CHAPTER III.
DYSENTERY.
THE subject of dysentery is very extensive and comprises
the knowledge of a considerable number of parasites,
bacterial, protozoal and metazoal, which may cause
inflammation and ulceration of the intestinal canal. The term
" dysentery" is in many ways inappropriate and indicates solely
the passage of blood and mucus in the stools accompanied by
abdominal pain and tenesmus, symptoms which are common to
several infections specifically distinct. The war presented an
opportunity hitherto unrivalled for the study of bowel diseases,
and this has been made full use of by bacteriologists and proto-
zoologists. Notable advances in our knowledge of these sub-
jects have been recorded by workers attached to the British
forces.
Intestinal disorders, especially dysentery, furnished a con-
siderable proportion of casualties on all fronts ; more especially
was this the case in the tropical and subtropical theatres of
war. In Gallipoli, Salonika, Egypt, Palestine, Mesopotamia,
East Africa, and even in France and Flanders, dysentery at
different times and seasons raged in epidemics of great magni-
tude, and as a cause of invaliding and death it supplanted the
enteric fever of British troops in more recent wars, though,
taking the magnitude of the forces into account, there is no
evidence to show that its incidence was higher than in the
South African War.
So far as figures are available the incidence of dysentery in
British Expeditionary Forces is shown in the following table : —
Table of Incidence of Dysentery (both Bacillary and Amoebic),
1914-1918.
Aug.-Dec.
1914
1915
1916
1917
1918
Ratio
Ratio
Ratio
Ratio
Ratio
Total
per
Total
per
Total
per
Total
per
Total
per
Cases
1000
Cases
1000
Cases
1000
Cases
1000
Cases
1000
France
East A/rica . .
11
•05
20
•03
5,754
4-09
6,031
9,369
3-76
486-56
12,211
1,646
•79
116-51
Salonika
5,987
63-89
5,842
28-89
9,318
58-23
Italy
897
9-54
Egypt
5,599
31-19
4,341
23-13
4,906
21-80
Mesopotamia
1,839
50-94
4,960
60-34
5,445
51-12
64
BACILLARY DYSENTERY 65
Three types of dysentery, correlated to three different kinds
of parasites, are now recognized. They are not mutually
exclusive ; one type may be superimposed upon and complicate
another. The principal types and their associated parasites
are as follows : —
Bacterial . . . . Bacillary or epidemic dysentery.
Bacillus dysenteries (Shiga and
Flexner-Y).
Protozoa! . . (a) Amoebic dysentery and hepatic
abscess (amcebiasis) .
Entamceba histolytica.
(b) Balantidial dysentery.
Balantidium coli.
Verminous . . (a) Bilharzial dysentery.
(Schistosoma mansoni, S. hcema-
tobium and S. japonicum) .
(b) " Dysentery " associated with
(Esophagostomum apiostomum,
Ascaris lumbricoides, and Ankylo-
stoma duodenale.
Of these only the first two are of military importance, namely,
the epidemic or bacillary, and the endemic or amoebic forms.
They require, therefore, more lengthy consideration ; the re-
maining types, together with the other conditions which they
may simulate, are of importance chiefly in connection with
differential diagnosis.
BACILLARY DYSENTERY.
The characteristics of bacillary dysentery are the acuteness
of its onset, a well-marked initial pyrexia, severe abdominal
pain and tenesmus, the presence of Bacillus dysenteries in the
stools, and a tendency of the disease to occur in epidemic form.
After recovery from the initial attack, there is little tendency
to relapse. The . pathological process consists of an initial
diphtheritic necrosis of the large intestine, together with a
toxaemia of varying degree.
This type of dysentery was prevalent throughout the whole
war. It first claimed serious attention when it broke out in
epidemic form in Gallipoli in August 1915, where in three
months it was responsible for a high proportion of the 120,000
casualties evacuated from the Peninsula on account of sickness.
From that date onwards it was much in evidence in all the
Eastern theatres, being responsible for at least 90 per cent, of
the acute clinical dysentery recorded.
In France and Belgium a milder form of bacillary dysentery
(2396) E
66 MEDICAL HISTORY OF THE WAR
commenced in July 1916 and reached its maximum in September
of that year ; similar epidemics also occurred in the autumn of
the succeeding two years of war. The maximum incidence
recorded was 126-62 cases per 100,000 troops in September 1916.
In the other theatres of war it was also prevalent : the ad-
mission rate to hospital per 100,000 of ration strength varied
from 7,900 in Mesopotamia in 1916 to 1,300 in Egypt and 990
in Salonika in 1919 ; it exhibited also a distinct seasonal
incidence, occurring in epidemic form as a disease of the late
summer and autumn with a maximum prevalence in October,
though minor outbreaks were noted during the spring months
of March and April. Sporadic cases were apt to occur through-
out the whole year ; but, on the other hand, during the hot
summer months in Macedonia, Egypt, and Mesopotamia, the
disease was almost entirely in abeyance. The case mortality
rate is difficult to estimate ; probably it assumed its greatest
virulence during the Gallipoli epidemic, though even there the
death rate cannot have exceeded 5 per cent. ; statistics show
that in Macedonia, Egypt and Mesopotamia from 1915 onwards
it rarely exceeded 2-7 per cent.
The true importance of this disease, as a military factor, is
not to be reckoned solely from the point of view of the death
rate, but from the amount of invalidism it causes, for in indi-
viduals recovering from a severe attack the mucous membrane
of the intestine may be so damaged as to render them unfit for
further service.
Mtiology.
With regard to its aetiology, circumstances which predispose
to the development of bacillary dysentery are just those which
are unavoidable under the conditions of modern warfare ; that
is, close contact of one man with another, physical exertion, a
monotonous diet of preserved food, and one must add to these
another factor upon which sufficient importance does not seem
to have been laid, namely, the mechanical irritation of the
intestinal mucous membrane by dust or sand ingested in the
food. In desert warfare, or in arid regions such as Gallipoli
and Egypt, it is almost impossible at times to avoid swallowing
a considerable amount of sand with the food. This in itself is
sufficient to produce a lienteric diarrhoea and so prepare the
way for the activities of the dysentery bacillus, which is
mainly disseminated by means of flies and polluted water.
The first outbreak of dysentery on a large scale in France
occurred during the first battle of the Somme, when the British
occupied ground from which the enemy had been driven. It
was known at the time that dysentery was prevalent in his
BACILLARY DYSENTERY 67
lines, and it was suspected that one source, at any rate, of the
disease was the contamination of this ground. In 1918 dysentery
prevailed at the time of the British advance under the same
conditions. Indeed, at every phase of active movement and
almost at any time in the fighting line, sanitary regulations
could hardly be carried out with complete accuracy. Latrines
could not be dug or kept so well as desirable, garbage and
faeces could not be burnt, and the provision of water was often
difficult. Under the latter difficulty the use of disinfecting
water tablets was largely increased. Experience goes to show
that all these dangers are increased when enemy lines are
captured and occupied.
Another cause that temporarily predisposed towards in-
creasing the spread of the disease was found in the crowded
state of the infantry base depots in France. Camps designed
for 1,200 men sometimes contained between 2,000 and 3,000.
In the event of carriers being present — an accident which, in
)ite of all precautions, occurred and always will occur — such
mditions of overcrowding materially aided the spread of the
>ease.
It is known that epidemics occurred amongst British prisoners
)f war in Germany, a fact which was brought to the notice of
War Cabinet by the Admiralty, War Office, Air Ministry,
)lonial Office and Prisoners of War Department in a special
>int memorandum dated 25th September, 1918.
The dysentery bacillus was discovered in Japan in 1897 by
)higa, and in 1900 an organism, morphologically similar, but
differing in its power of fermenting mannite, was isolated by
Flexner in the Philippines. Since that date a great deal of
attention has been paid to this subject, with the result that
many variants of these two organisms have been described.
The bacteriology of bacillary dysentery attracted a considerable
amount of attention during the war. Interest centred chiefly
around the mannite-f ermenting bacilli first described by Flexner
and afterwards elaborated by Hiss and Russell, Strong and
others. This work was important mainly from the point of
view of laboratory diagnosis and the preparation of effective
anti-sera, and it was undertaken by Murray, Gettings, Dudgeon,
Andrewes and Inman.
The species of bacteria which are now recognized in bacillary
dysentery are : Shiga's bacillus, the Flexner-Y group of bacilli,
and certain atypical bacilli.
Shiga's bacillus, fermenting glucose only amongst the sugars
and alcohols* employed as tests, and forming no indol, has
* The fermentable substances of real service in the classification of the
dysentery group are four in number : glucose, mannite, lactose and dulcite.
68 MEDICAL HISTORY OF THE WAR
been abundantly proved to be the cause of dysentery. Being
much the most toxic of dysentery bacilli, it is responsible for
the most serious cases and for the greater number of fatalities.
It was recorded commonly from all theatres of war. In the
East it accounted for about half the number of cases and showed
no special epidemic prevalence ; in France and Belgium, on
the other hand, it apparently played a minor part, on the whole
accounting for 15 per cent, of the dysenteries. It predominated
at the commencement of the epidemic in August and September
1916, but was more or less replaced by Flexner bacilli later on
in the late autumn. In about 2 or 3 per cent, of bacteriologi-
cally diagnosed cases both Shiga and Flexner bacilli co-existed.
The Flexner-Y group of bacilli apparently belongs to a single
species, fermenting glucose and mannite, but not lactose or
dulcite. As in the case of the former organism, the evidence
connecting this species with dysentery is complete. The
researches of Gettings, Murray, Andrewes and Inman
undertaken on a large scale have indicated that serological
races of the species exist. It may be regarded as a
group formed of at least four distinct antigenic components
which have been provisionally lettered V, W, X and Z.
Any of these four components may so preponderate in
different strains as to impart a distinct serological facies.
The corresponding agglutinins are not mutually absorbed,
except in a slight degree. In addition to the four serological
races thus denned, there remains the true Y bacillus of Hiss and
Russell, which presents differences in its agglutinability and
agglutinogenic capacities. These bacilli are not nearly so toxic
as is Shiga' s bacillus and are responsible for the milder and
more chronic forms of the disease, though occasionally they may
become virulent and cause death. That is to say, two species,
namely the Shiga and the Flexner-Y bacilli of various sero-
logical races, are responsible for the vast majority of cases of
bacillary dysentery.
Other organisms which have been described during the war*
and have been called atypical bacilli are bacilli resembling
Flexner's bacillus but fermenting dulcite and separable
from the latter on serological grounds, and a bacillus
resembling Shiga' s in its sugar reactions, but forming indol and
not agglutinating with Shiga antiserum, first described by
Schmitz, in Austria, as the cause of dysentery and apparently
identical with the B. ambiguus of Andrewes and the one
* Dumas has lately shown that the atypical organisms may be distinguished
further by their power of producing fluorescence in media impregnated with
neutral red, as well as by reduction of 1 per cent, lead acetate, thereby produc-
ing a black line in a stab culture of agar containing this substance.
BAGILLARY DYSENTERY 69
described by Remlinger and d'Herelle. Together with these may
be grouped organisms which ferment lactose early and differ
serologically from the Flexner-Y group. There is no evidence
for inculpating either of these groups, and they may be
classified as " atypical" or " inagglu tumble " strains.
These latter need not claim the serious attention of the expert
bacteriologist, though they constitute a source of fallacy to the
beginner.
Morbid Anatomy.
With regard to the morbid anatomy of bacillary dysentery,
the gross pathological appearances of the organs vary con-
siderably according to the acuteness of the process in different
individuals, and indeed in different epidemics, though the under-
lying process is essentially the same in all cases. It is probable
that no such opportunity has ever before presented itself for
studying the effects of the dysenteric toxins upon the intestinal
mucosa as was afforded to pathologists in the Eastern theatres
of war. In mild cases it is naturally difficult to define the
exact appearances of the earliest lesions ; the inflammatory
changes originate in the first instance in the solitary lymphoid
follicles of the large intestine. From these, superficial " snail
track " liberations spread across the bowel, especially upon the
free transverse folds, and the surrounding mucous membrane
is involved in a greater or lesser degree with hypersecretion
of viscid mucus. The abdominal viscera do not exhibit any
striking changes.
In 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.
BACILLARY DYSENTERY.
. . Dysentery Bacilli : The Differ-
entiation of the True Dysen-
tery Bacilli from Allied Species.
. . Dysentery in the British Medi-
terranean Expeditionary
Force (a reply to G. B.
Bartlett).
. . War Experiences in Dysentery,
1915-18.
. . On Dysentery in the Mediter-
ranean Expeditionary Force.
Ranque, Etude bacteriologique d'une
Senez, Coville & Paraf . epidemic de dysenterie bacil-
laire.
Boehncke, Hamburger Untersuchungen iiber Ruhrimpf-
& Schelenz. stoffe in vivo und vitro.
Boehncke & Elkeles Ruhrschutzimpfungen mit Dys-
bakta.
Boyd . . . . A case of Bacillary Dysentery
in which Flexner-Y was re-
covered from the Blood Stream
during Life.
Le diagnostic bacteriologique de
la dysenterie bacillaire.
Burnet &Legroux .
Cowan & Miller
Cowan & Mackie .
Crouzon
Delille, Paisseau, .
& Lemaire.
Dopter
Dysentery. A clinical study.
A note upon the mode of infec-
tion in bacillary dysentery.
La conjonctivite et le rhuma-
tisme dysent6riques.
Note sur une 6pid6mie de
dysenterie bacillaire a 1'armee
d'Orient.
La Dysenterie Bacillaire dans
les Armees en Campagne.
Lancet, 1918. Vol. i,
pp. 560-563.
Quart. Jl. of Med.
1918. Vol. xi., p.
349.
Jl. of R.A.M.C.,
1919. Vol. xxxii,
pp. 268-275.
Quart. Jl. Med.,
1916-1917. Vol. x,
pp. 185-244.
Bull. Acad. de M6d.,
1918. 3e S. Vol.
Ixxix, pp. 275-277.
Berlin. Klin.
Woch., 1918. Vol.
lv, pp. 134-137.
Munch. Med. Woch.,
1918. Vol. Ixv,
pp. 785-787.
Lancet, 1919. Vol.
ii., p. 482.
Bull. Inst. Past.,
1919. Vol. xvii,
pp. 449-465.
Jl. of R.A.M.C.,
1918. Vol. xxxi,
pp. 217-228, 277-
295
Jl. of R.A.M.C.,
1919. Vol. xxxii,
pp. 209-214.
Bull, et Mem. Soc.
Med. des H6pit.
de Paris, 1916.
3e S. Vol. xl, pp.
1926-1928.
Bull, et M6m. Soc.
Med. des H6pit.
de Paris, 1916.
3« S. Vol. xl, pp.
1302-1308.
Paris Med., 1915.
Vol. xv, pp. 510-
512.
DYSENTERY
107
Dumas
Dudgeon
BIBLIOGRAPHY— cont.
Caracteres differentials des
Bacilles observes au cours de
la dysenteric bacillaire.
. . The Dysenteries : Bacillary and
Amoebic.
Enright & Bahr . . On a pyaemia due to organisms
of the Bacillus coli group
occurring in Turkish soldiers.
Fisher . . . . A short Description of Eight-
Cases of Severe Collapse,
which were regarded as the
Choleraic Type of Bacillary
Dysentery.
Fletcher . . . . Preliminary agglutination in the
Isolation of Typhoid and
Dysentery Bacilli from the
Excreta.
Florand, Bezan9on & Sur une epid6mie de dysenteric
Paraf. bacillaire a bacille de Shiga.
Flu
Experimenteele bijdrage tot de
kennis van het bacillendragen
bij de bacillaire dysenteric.
Friedemann & Stein- Zur Aetiologie der Ruhr,
bock.
Ghon & Roman . . Ueber Befunde von Bacterium
dysenteriae-Y im Blute und
ihre Bedeutung.
Gibson . . . . A new method of preparation of
a vaccine against bacillary
dysentery which abolishes
severe local reactions. Also
experiments with this vaccine
on animals and men.
Graham, G. . . . . Arthritis in Dysentery, its causa-
tion, prognosis and treatment.
Graham, D. . . . . Some Points in the Diagnosis
and Treatment of Dysentery
occurring in the British
Salonika Force.
Grussendorf . . . . Zur Behandlung der dysenteri-
schen Leberabszesse.
Gunson . . .-r Cardiac Symptoms following
Dysentery among Soldiers.
D'H£relle . . . . Sur un bacille dysent£rique
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.,
1917. Vol.xxviii,
pp. 97-104.
Jl. of R.A.M.C..
1918. Vol. xxx,
pp. 500-509.
Bull, et Mem. Soc.
M6d. des H6pit. de
Paris, 1918. Vol.
xlii,3eS.pp.81-84.
Geneesk. Tijdschr.
v. Nederl.-Indie
1918. Vol. Iviii,
pp. 67-84.
Deut. Med. Woch.,
1916. Vol. xlii,
pp. 215-218.
Wien. Klin. Woch.,
1915. Vol. xxviii,
pp. 579-583, 620-
624.
Jl. of R.A.M.C.
1917. Vol. xxviii,
pp. 615-657.
Proc. Roy. Soc.
Med., 1919-1920.
Vol. xiii, Med. Sect.
pp. 23-42.
Lancet, 1918. Vol. i.
p. 51.
Munch. Med. Woch.,
1916. Vol. Ixiii,
pp. 1503-1505.
Lancet, 1916. Vol.
ii, pp. 146-147.
Ann. Inst. Pasteur,
1916. Vol. xxx,
pp. 145-147.
C.R. Soc. Biol.,
1917. Vol. Ixxx,
pp. 835-839.
108
MEDICAL HISTORY OF THE WAR
Inglis
Jacobitz
Ledingham
fold.
Ledingham
& Pen-
Manson-Bahr
Manteufel
Martin, Kellaway &
Williams.
Martin & Williams . .
Martin, Kellaway &
Williams
Martin, Hartley &
Williams.
Maxwell & Kiep ..
Medical Research
Committee.
BIBLIOGRAPHY— cont.
Bacillary Dysentery among
British Troops in France,
1918.
Ueber Ruhrbacillen Agglutina-
tion.
Serological Tests in Dysentery
Convalescents.
Dysentery and enteric disease in
Mesopotamia from the labora-
tory standpoint. An analysis
of laboratory data during the
eighteen months ending De-
cember 31st, 1918.
The correlation of the Pathology
and Bacteriology of Bacillary
Dysentery. A Dissertation
on some of the Laboratory
Problems arising in connexion
with this disease in the East-
ern Theatres of War.
The commoner complications of
Bacillary Dysentery in
Military Practice.
Untersuchungen iiber die Bazil-
lenruhr in Deutsch-Ostafrika.
Notes on the Etiology of Dysen-
tery ; (i) Types of Dysentery
Bacilli, (ii) The Value of
Agglutinins, (iii) Bacteriology
of Stools.
Types of Dysentery Bacilli
isolated at No. 3 Australian
General Hospital, Cairo,
March — August, 1916, with
observations on the variability
of the Mannite Fermenting
Group.
Epitome of the results of the
Examination of the Stools of
422 cases admitted to No. 3
Australian General Hospital,
Cairo, for Dysentery and
Diarrhoea, March to August,
1916.
Agglutination in the Diagnosis
of Dysentery.
Notes on six cases of iritis and
cyclitis occurring in dysenteric
patients.
Reports upon investigations in
the United Kingdom of
dysentery cases received from
the Eastern Mediterranean.
II. Report on 878 cases of
bacillary enteritis.
Med. Jl. Australia,
1919. Vol. i, pp.
313-314.
Berlin. Klin. Woch.,
1916. Vol. liii,
pp. 718-719.
B.M.J., 1916. Vol. i,
p. 47.
Jl. of R.A.M.C.,
1920. Vol. xxxiv,
pp 189-203. 306-
320.
Jl. of R.A.M.C.,
1919. Vol. xxxiii,
pp. 117-138.
B.M.J. 1920. Vol.i.,
p. 791.
Zeitschr. f. Hyg. u.
Infektionskr.,
1915. Vol. Ixxix,
pp. 319-335.
B.M.J. , 1917. Vol.
i, pp. 479-480.
Jl. Hygiene, 1917-
Vol. xvi, pp. 257-
268.
Jl., of R.A.M.C.
1918. Vol. xxx,
p. 101-102.
B.M.J., 1918. Vol. i,
pp. 642-644.
Brit. Jl. Ophth.,
1918. Vol. ii,
p. 71-79.
M.R.C. Special Re-
port Series. No. 5,
Lond. 1917.
DYSENTERY
109
Medical Research
Committee.
Michaelis
Moorhead
Oppenheim ,
Payan & Richet fils
Phear
Pine
Remlinger & Dumas
Rist
Roccavilla
Rogers
»»
Schelenz
Schiemann .
BIBLIOGRAPHY— cont.
III. Report upon recovered cases
of intestinal disease in the
Royal Navy Hospital, Haslar,
1915-1916. IV. Report upon
combined clinical and bacter-
iological studies of dysentery
cases from the Mediterranean.
A Contribution to the Study of
Chronicity in Dysentery Car-
riers.
An Investigation of the Flexner-
Y Group of Dysentery Bacilli.
Ueber kombinierte Eiweiss-
Saureagglutination, insbeson-
dere zur Unterscheidung von
Koli-und Ruhrbazillen.
A Note on Dysenteric Arthritis
L'insuffisance surrenale dans la
dysenteric bacillaire et les
ententes graves.
Un cas de dysenteric balanti-
dienne observee en France.
Medical Experiences in Mace-
donia and the Caucasus, 1920.
Observations on East African
Bacillary Dysentery.
Insuffisance surrenale au cours
de la dysenteric.
Arthropathies et conjonctivites
dysenteriques.
Diaree ed enterocoliti dissen-
teriformi in alcuni settori del
nostro fronte.
Sensitized Shiga and Flexner
Vaccines in the Treatment of
Chronic Bacillary Dysentery.
Ergebnisse bei kombinierter
Serum- Vakzinetherapie der
Ruhr.
Ueber Schwierigkeiten bei der
serologischen Diagnose der
Shiga-Kruse-Ruhr und iiber
Modifikation der Tecknik der
Agglutination.
M.R.C. Special Re-
port Series, No. 6,
Lond. 1917.
M.R.C. Special Re-
port Series, No.
29, Lond. 1919.
M.R.C. Special Re-
port Series No. 30,
Lond. 1919.
Deut. Med. Woch.,
1917. Vol. xliii,
pp. 1506-1507.
B.M.J., 1916. Vol. i,
p. 483.
Progres Med., 1915.
No. 41. pp. 507-
512.
Bull, et Mem. Soc.
Med. des H6pit,
de Paris, 1915.
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
12 17 E2 27 I
N'ew cases
D
Deaths
12 17 122 33 123 129 1 122 174 2092041197 183 255 137 1 135 231 78 106 I Si 42 35 38 116 56
73 I 72
145
49
29 1 55
252 1 296
4-13 1 380
392
366
184
103
84
548
793
7J
>€
2£
17
i 2.0
82
222
22
2
10
8
TYPHUS FEVER
137
COURSE OF EPIDEMIC OF TYPHUS FEVER IN SEB.e>iAj9'/>, AND ITS
RELATION TO PREVENTIVE MEASURES ADOPTED.
SjDOC
8,000
7.000
epoq
5,000
*,000
3.000
3000
1,000
CHART II. — Number of cases of typhus in hospital in Serbia on dates
specified, January 1 to June 9, 1915.
March 4. — Arrival of Mission in Serbia. June 10. — Departure of Mission
from Serbia, a, March 8. — Barrel disinfector devised, b, March 13. — Barrel
disinfector made and tested, c, March 15. — Suspension of railway traffic.
d, March 22. — Van disinfector devised ("Van 1"). e, April 5". — Van
disinfector ("Van 2") formed in Nish ; van bath devised. /, April 15. —
Resumption of railway traffic, g, April 19. — English sanitary train (inocu-
lation, disinfection and bath vans). h, April 25-30. — Sudden check in
fall of epidemic ten to fourteen days after the resumption of railway traffic.
138 MEDICAL HISTORY OF THE WAR
typhus epidemic showed that the army areas in the north were
chiefly affected, 49 per cent, of the cases in hospital being in
these areas, and only 28 per cent, in the southern civilian areas.
The infection had thus been introduced specially into the armies
and thence to the civilian areas. Accordingly two great pre-
ventive measures, suspension of all railway traffic and stoppage
of all leave from the army combined with delousing, were
put in force on 16th March, 1915, and within ten to fourteen
days (the incubation period of the disease) the number of patients
in hospital reached its maximum. The number of new cases
was reduced to one-half in two weeks, and one-fifth in four
weeks. The number of daily admissions to the whole of the
hospitals decreased from 1,500 cases on March 16th to 230
cases on April 16th, and 100 by May 31st. The epidemic was
so completely arrested in a month's time that by the middle
of April movements of troops began again, and, although this
caused a slight temporary increase in the number of cases
admitted to hospital, the epidemic could be reported at an
end by May 17th, and the British mission was consequently
recalled on June 1st.
If an epidemic can be said to have a useful purpose, this
epidemic was probably useful in two ways. It gave the
Serbians, exhausted as they were by their military efforts,
complete military peace for nine months, since the fear of
entering a country infected by typhus may have deterred the
Austrians, Germans and Bulgarians from attack ; and it
demonstrated the striking effect of preventive measures when
applied simultaneously to the whole country.
The subsequent incidence of typhus in Serbia is interesting.
Apart from an article in the German press in 1916 by Doren-
dorff , who gives his observations on a limited epidemic of typhus
which had broken out among the troops operating in Serbia,
no definite information is available concerning the regions
occupied by the Austrians, Germans and Bulgarians from
November 1915, to October 1918. It is known, however, that
although the Serbian army in its retreat lost thousands and
tens of thousands from exposure, diarrhoea and starvation, it
had only a few deaths from typhus, owing to the use of the
barrel disinfectors introduced into Serbia by the British
Mission, and, in May 1916, arrived 150,000 strong in Salonika,
developing only three or four cases of typhus on the voyage
from Durazzo and Corfu to Salonika.
Typhus from 1892 to the outbreak of the war was practically
non-existent in Germany, but exact data from 1914 onward
are not known. The Germans had difficulties in Poland iA
1914, and early in 1915 reports were received that the diseas
TYPHUS FEVER 139
had broken out in prisoners' camps — Hamburg, Wittenberg and
Gardelegen. In Gardelegen there were 12,000, chiefly Russian
and French prisoners, with 1,000 Belgian and 230 British. A
historic report on this camp was published by Major P. C. T.
Davy and Captain A. J. Brown of the R.A.M C. In the Witten-
berg camp the epidemic raged for the first six months of 1915.
There were between 250 and 300 cases among the British
prisoners, of whom 60 died. The mortality amongst the
French and Russians was very much higher. A full report
was written by Major Priestly, Captains Vidal and Lauder, all
of the R.A.M.C., and all prisoners of war. The conditions
which existed in these camps form the most appalling reading
connected with the history of typhus in prisoners' camps during
the war.
A certain number of cases was reported in Greece in 1914,
but the Greek authorities, being alive to the necessity of pre-
ventive measures, applied them with such success that only
200 cases occurred in Salonika during the period of the Serbian
epidemic.
A mild epidemic broke out in Bucharest during the latter
part of 1915 and early in 1916. From January to June 1917,
a severe epidemic attended with a high mortality raged in
Moldavia.
With regard to the incidence of typhus in the British Armies,
in Gallipoli there were no cases. In Salonika from 1916 to 1918
there were no cases ; but subsequently in 1919 five cases
occurred. During 1919 and 1920, 17 and 12 cases respectively
were reported from the army of the Black Sea, with six deaths,
a mortality of 27-6 per cent. In Egypt and Palestine there
were 22 cases during 1916-1917, when the troops were for the
most part in Egyptian territory, and 344 cases in 1918-1919
when they conquered and occupied Palestine. The number of
deaths was 80, or a mortality of 21 • 8 per cent. In Mesopotamia
the infection spread to British troops from Turkish prisoners
of war, Arabs and refugees ; during 1917 and 1918 there were
385 cases amongst the Indian troops, with 149 cases amongst
the British troops and 59 cases in 1919. The mortality was
22-7 percent.
In France and Italy there were only five cases. Preventive
measures are responsible for the freedom from the disease
testified by these figures, notwithstanding the prevalence of
lice and the risk of infection from Egypt and Portugal.
Typhus broke out in Oporto in March 1918, and from May
to November 1,811 cases are stated to have occurred in
Portugal, so that the risk of its introduction into the armies
in France through the Portuguese contingent was very great.
140
MEDICAL HISTORY OF THE WAR
Altogether the total number of typhus cases among the
British forces in all war areas was 998, of which 221 were fatal.
Their distribution is shown in the following table : —
Incidence of Typhus in British War Areas, 1916-1920.
19
16
1£
17
19
18
19
19
19
20
Total.
.
J3
«.
.C
in
1
8
1
S
fl
U)
•3
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),
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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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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
CHART I.
CHART II.
INFLUENZA
183
CHART III.
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184
MEDICAL HISTORY OF THE WAR
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CHART VIII.
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CHART IX.
CHART X.
INFLUENZA 185
prolonged by irregular persistence for several days, ending in
recovery ; Chart IX a fall by lysis in a severe case that seemed to
be doing well, with subsequent rapid rise and death. Chart X
shows a rapid fall on the third day of the disease as though the
patient had terminated his illness by crisis, but the pyrexia
rose again by steps to a second maximum about the tenth day,
when a second apparent crisis occurred, and yet the illness
continued, pyrexia recurring after the second apparent crisis and
terminating in death. While all varieties occurred, definite
termination by crisis and recovery, as shown in Chart II, was
very rare indeed. On the whole the temperature chart was of
little use for prognosis.
The respiration rate was a much more helpful guide than
was the pyrexia. The rapidity of breathing in the fatal cases
was even greater than that in ordinary lobar pneumonia.
Rates that were nearer 40 than 30 to the minute were very
common, but in the worst cases the rapidity of breathing was
generally over 40 and often 50 or even 60 to the minute, and
this sometimes before the fatal cyanosis became evident.
The sputum was very variable. Some cases had hardly any
sputum at all. Sometimes there was nothing but pure froth ;
again there might be froth only with some bouts of coughing,
and nummular pellets of muco-pus at other times in the same
patient ; or the sputum might be glairy and mucoid, or stringy,
or simply purulent. Again it might be tinged with blood
streaks, or pure clotted blood might be coughed up separately,
or there might be liquid red blood expectorated in a way
recalling a moderate haemoptysis from phthisis. Or the more
purulent type of sputum might be tinged red or brown with
altered blood, or it might be definitely glairy rusty sputum like
that of ordinary lobar pneumonia. No conclusion could be
drawn from the appearances of the latter as to what degree of
the malady the patient had.
No ulceration of the stomach was found in fatal cases, but
acute congestion was common. Bleeding per rectum was rare.
A number of cases of spontaneous rupture of one or both recti
abdominis muscles was met with, and in a still larger number
this muscle was found at autopsy to be in a haemorrhagic
necrotic state, such as precedes rupture. Almost invariably
this lesion had affected only that part of the muscle which is
below the umbilicus.
Delirium and coma occurred in bad cases, but more striking
was the number of cases in which they were entirely absent.
Big, strong men, cyanotic, breathing 30 to the minute and
obviously dying, would be fully conscious and would talk
rationally, not realizing their danger in the least, to within
186 MEDICAL HISTORY OF THE WAR
half an hour of death. Subsultus tendinum was marked in
many cases and was usually of bad prognosis.
Acute meningitis due to one of the infecting organisms found
in other organs, B. influenza, diplo-, strepto-, or pneumococcus,
occurred in a small number of cases. Acute otitis media with
otorrhoea was rare, though temporary deafness and pain
suggesting this condition were not uncommon. Of special im-
portance in relation to the local pain behind the eyes frequently
noted during the attack, and perhaps to the headaches which
in some patients persist long after the acute illness, is the
condition of the ethmoidal and sphenoidal sinuses described
under the heading of morbid anatomy.
Albuminuria was common, and since in a total of over 100
autopsies there was no instance in which the kidneys were not
definitely inflamed, the inference is that some at least of the
albuminuric cases which survived had some degree of nephritis
also. The number of cases in which permanent lesion has
resulted is not yet known.
Jaundice was uncommon. Its degree and type were similar
to those of the ordinary catarrhal form.
Unilateral or bilateral parotitis was not uncommon. It was
exceptional for suppuration to occur.
Panophthalmitis was seen twice.
Pericarditis was occasionally reported. Endocarditis was not
observed during the epidemic, nor was it seen at any autopsy,
but it is noteworthy that throughout the year 1919 it was
common to meet with cases of the chronic type of infective
endocarditis whose origin was obscure.
Symptoms amongst Troops in the Field.
The incubation period lasted from two to four days according
to various observers.
In the summer epidemic the onset was in most cases sudden.
In a small minority it began gradually and reached its height
within six hours. Rigors occurred in many cases. The initial
symptoms were headache, pains in the back and limbs, and a
feeling of weakness. In a report by Major Scarisbrick on
440 cases, the following relative frequency in the sites of pain
was noted : —
Pains in the head occurred in 73 per cent,
back „ 45
eyes „ 43
limb muscles ,, 41
knees „ 32
„ „ hips „ 22
„ ankles and shoulders rarely.
INFLUENZA 187
Pains in the head and eyes, and pains in the back and muscles
of the limbs were associated respectively. The pains were of
a severe aching character. That in the head was referred
usually to the frontal sinuses, that in the eyes to the back of
the globe.
These initial symptoms lasted as a rule for two or three days ;
the temperature commonly reached its height on the first, but
sometimes on the second day. The highest level was usually
between 102° and 103° F., but 105° has been noticed. In some
cases the temperature never rose above 100°. It usually fell
by lysis, but in a small minority a fall of three or four degrees
was completed in twenty-four hours. In the First Army's
Report of 18th June, the disease was called " three days' fever,"
and it was stated that the great majority of the patients were
fit for duty in a week. But a week or two later it was
found that many cases remained febrile till the sixth day. The
pulse was rapid during the first two days, though it seldom
reached 120, but was usually between 70 and 80 by the fourth
day. At first there were hardly any other symptoms. On
12th June, Colonel Soltau, the consulting physician of the
Second Army, reported :—
' There has been a remarkable absence of physical signs. In
no case has the spleen been enlarged, nor has there been any
rash. Rarely has anything abnormal been heard in the lungs,
nor has there been any increase above the usual in the number
of cases of broncho-pneumonia under treatment."
But a fortnight later he found that there had been an increase
both in incidence and virulence, and mentioned the prevalence
of pharyngitis with a tendency to spread down the respiratory
tract.
Several symptoms of less importance were noticed. In some
cases a rash was observed, usually of a mixed urticarial and
erythematous character, principally seen on the neck, the
shoulders, the wrists and the dorsum of the feet. This was
noted also in Italy by Morelli, and in Germany. Labial herpes
was sometimes seen, and became more common as pulmonary
complications increased. Conjunctivitis and coryza were re-
ported by several medical officers. Enlargement of the spleen
was found occasionally during life, and has been reported post-
mortem. The tongue, except for a clear marginal zone, was
usually covered with a slight fur. This was grey or white,
according to its degree, but the yellow or brown fur common
in trench fever seems to have been rare. Anorexia was common.
Loss of taste and loss of smell were observed. Vomiting was
common in the first day or two, diarrhoea less frequent. At
the commencement of the epidemic in May, several localized
188 MEDICAL HISTORY OF THE WAR
outbreaks were ushered in by vomiting and tenesmus in a
majority of the cases.
Colonel W. E. Hume and Captain Todd at No. 42 Casualty
Clearing Station noted the following relative incidence of
symptoms :—
Headache and general muscular
pain 76 per cent.
pain . . . . . . . . /t>
Shivering or definite rigors . . 41
Suffused eyes . . . . . . 78
Pharyngitis 100
Furred tongue . . . . . . 100
Constipation 52
Spleen palpable 14
In the earlier stages of the epidemic recovery was remarkably
rapid, and convalescence was established without any sequelae.
The mental depression often associated in previous epidemics
with a post-influenzal state was very rarely seen.
Towards the end of June 1918, however, the disease gradually
became rather more severe. A short relapse of fever and
symptoms about the seventh day began to occur and grew more
frequent. Bronchitis, broncho-pneumonia, and lobar pneumonia
began to appear. The two former were severe and prolonged,
with a high irregular temperature, a rapid pulse, dyspnoea and
cyanosis. The sputum was often of the green nummular variety.
The few cases which resembled lobar pneumonia showed a more
regular fever, but frequently terminated by lysis. Many cases
proved fatal.
Pleurisy and pleura! effusion occasionally occurred, and in
one or two cases an inter-lobar empyema was found in which
the B. influenza was the only infection.
A very few cases of pericarditis and suppurative otitis were
noticed, but the chief complications after the pulmonary were
albuminuria and nephritis. In some of the cases of nephritis,
according to Symonds, a profoundly toxic condition super-
vened, with which were associated a dry, black tongue,
pronounced mental symptoms, and a grey lividity of the face.
A rare complication was meningitis both of brain and cord,
in which the B. influenza was found. In a few cases presenting
similar symptoms, the cerebro-spinal fluid was found to be
considerably increased, but to be sterile.
This wave of the epidemic died down at the end of July 1918.
The autumn epidemic which began at the end of September
of the same year differed from that of the summer, chiefly in
the increased proportion of pulmonary cases. Purulent
bronchitis, broncho-pneumonia and acute pneumonia of the
INFLUENZA 189
lobar type were all present. The temperature charts varied
much. Some, and these were the most favourable, showed
a high and level pyrexia falling by crisis as in pneumonia.
Others with a similar high level fell by lysis. In others the
temperature though high was irregular from the first. The
two latter classes varied much in the duration of the primary
fever. It sometimes fell at the end of a week, in other cases it
persisted for three weeks or more. Some remained febrile for
even six weeks. But the worst feature was the tendency
to relapse. The fever would fall to normal and remain so
for some days, and then, without any external cause, would
rise again to its former height. A patient might recover from
two such bouts and die in the third.
It was often possible at the time of the relapse to discover
that a fresh part of the lung had been invaded, or that consoli-
dation had taken place in a part where formerly only rales had
been heard. But in other cases it was impossible to obtain
any physical explanation of the recurrence of fever.
Even when the temperature fell and remained low, the lungs
remained affected for a long time. The patient appeared to
have no power to absorb the exudation or to recover his normal
condition. It seemed that the infecting microbes had overcome
his power to resist them. Many men died several days after
their fever had subsided, and in nearly all it took many weeks
before the lungs were free from signs of disease.
In many cases the patient was admitted in a state of cyanosis,
which was not accounted for by the physical examination of the
lungs. In some cases death occurred within the first few days,
and while cases were described in which the post-mortem appear-
ances showed little amiss, most of them showed extreme con-
gestion, with a large amount of oedema fluid in the tubes and
in the parenchyma. It may be said in general that the cyanosis
was such as is hardly ever seen in ordinary hospital practice.
Entering a ward, one might see six or eight of these cyanotic
cases, some heliotrope, as it has been well called, others really
purple, yet not appearing as much distressed in their breathing
as might be expected from their colour. The opinion was
expressed by some that such cases never recover. This was
not true, yet no doubt on the whole it was a most
unfavourable sign.
The explanation of this cyanosis was not easy. There was
not in these cases such failure of the circulation as would account
for it. In some instances the same may be truly said of the
state of the lungs. The condition of congestion with oedema
seen in others recalled phosgene poisoning, in which cyanosis
is common.
190 MEDICAL HISTORY OF THE WAR
The sputum was sometimes mucous, often purulent and
nummular, often rusty. Not infrequently there was haemop-
tysis like that of phthisis. Sometimes, on the other hand, there
was little or no sputum.
The pulse in these cases was usually rapid for many days, and
in some remained rapid after convalescence. The tongue,
which in the early epidemic was almost always moist, became
in bad cases dry and brown like the tongue of typhoid. Such
patients fed badly, but many who fed well died. Indeed, one
was struck by the fact that many died who almost up to the
last ate well, slept well, and were in full command of their
senses. Some, however, became restless and delirious, and
closely resembled typhoid patients.
Pleurisy and empyema were not uncommon. Pleurisy with
haemorrhagic effusion was often seen.
Nephritis was a common complication. It occurred in a large
number of the cases with pulmonary symptoms. The urine
contained blood or albumin, sometimes in large amount ; the
patient complained of pain in the back and for a time passed
little urine. But there was little of the oedema which was a
marked feature of the primary war nephritis. It was some-
times difficult to tell which the case really was. For instance,
an officer was admitted for nephritis. He had blood and albumin
in very large quantity in the urine, but he had no oedema, and
he had considerable fever and marked signs in the lungs.
Although his illness had not begun acutely, it seemed probable
that it was influenza, and the opinion was given that the urine
would soon become normal. It did so, but a fortnight later he
again passed blood and again rapidly recovered. A similar
attack occurred after exposure to severe cold two months later.
The diagnosis lay between ordinary war nephritis with
bronchitis, the febrile haematuria that was often seen in
France, and influenza.
There was a marked tendency to haemorrhage. Haemoptysis
has already been mentioned. Epistaxis was a common feature.
Colonel Pasteur, the consulting physician of the Third Army,
saw no less than 30 cases of haemorrhage into the sheath
of the rectus abdominis, and in cases reported by others
this was found so large as in one instance to bulge into
the abdominal cavity, and in another to rupture the sheath.
A purpuric condition of the feet sometimes leading to the
formation of blebs was also noticed. Haemorrhages in the
pleura and pericardium were frequently found post-mortem.
Jaundice had been seen on the American transport " Nestor "
in September, but was infrequent in France until the beginning
of 1919, when it became much more common. It occurred at
INFLUENZA 191
all stages of the disease and was not of bad prognosis. In cases
examined there was no obstruction in the ducts of the liver.
The gastro-intestinal symptoms which in some countries were
so marked as to differentiate a special type of the disease were
not prominent amongst the British troops.
The white blood cells did not in uncomplicated cases present
any significant variation in France. Leucopenia was found in
27 out of 100 German cases.
Pathology.
Although expert bacteriologists in various countries, who
were thoroughly familiar with the appearance of Pfeiffer's
bacillus and the technique necessary to demonstrate its
presence, examined numerous cases in the first few months,
they isolated bacilli in so small a percentage of cases that
even those who recognised most fully that this latest pandemic
reproduced in all essential particulars that of the early
nineties, came to the conclusion that Pfeiffer's bacillus could
at the most be regarded as associated with, but not as the
essential and specific organism of influenza. And for a time
its death-knell appeared to have been tolled when, one after
another, Nicolle and Lebailly in Tunis, Gibson, Bowman
and Connor at Abbeville, and Rose Bradford, Wilson and
Bashford at Etaples, reported results which appeared to
demonstrate the presence of a filterable virus capable of
reproducing the disease in monkeys and the lower animals.
But as 1918 progressed, and as the different army laboratories
became more expert in the technique necessary for the recog-
nition of Pfeiffer's bacillus, steadily more and more observers
reported the presence of this organism. More particularly, the
bacillus was reported to be constantly isolated when " choco-
late " medium was used — that is agar to which, when hot and
just under the boiling point, blood or washed blood corpuscles
are added, a medium so favourable to the growth of Pfeiffer's
bacillus that within 24 hours large, easily recognisable colonies
show themselves — and when swabs were secured from the upper
air passages, or cultures made from the sputum in the early,
as distinct from the late, stages of the disease.
Subsequently grave doubt was thrown upon the technique
employed by those who reported the presence of a filterable
virus. The criticism, it is true, did not explain away the
statements of those who claimed that, employing the filtra
from acute and typical cases of the disease, they had reproduced
in monkeys what are admitted to be the characteristic lung
lesions of the disease, namely haemorrhages and oedema, and
patchy peribronchial infiltration.
192 MEDICAL HISTORY OF THE WAR
Thus at the end of the war there was no consensus of
opinion regarding the bacteriology of the disease. Each
of the following views had its upholders : —
1. That Pfeiffer's bacillus is the essential causative agent, the
other organisms found in great numbers in the pneumonic lung
of the fatal cases, streptococci haemolytic and non-haemolytic,
pneumococci of the various types, staphylococci and gram-
negative cocci being secondary invaders varying in their
incidence in different regions.
2. That Pfeiffer's bacillus is not the essential causative agent,
but either : —
(a) That like the streptococci and pneumococci Pfeiffer's
bacillus is, during periods of epidemic influenza, so
frequently to be found in the throats of those not
affected with influenza, that even the fact of its
being present in 100 per cent, of influenza patients
would not prove it to be specific. Or—
(b) That the disease is due to the symbiotic or combined
action of several organisms of which the B.
influenza may be one, and streptococci or pneu-
mococci most commonly the others. Or —
(c) That the essential cause is a filterable virus which in
pneumonic and fatal cases most often paves the way
for the growth in the respiratory passages of
Pfeiffer's bacillus, and of sundry species of cocci.
While during 1919 small epidemics have occurred here and
there, they have been of diminished virulence, with great
reduction in mortality, so that, as in 1893, little opportunity
has been afforded to any one individual to deal with an
adequate amount of suitable material. Any predilection for
one or other of these views must, therefore, be taken as the
expression of an individual opinion and not as the commonly
received view of bacteriologists in general.
There is the evidence brought forward by careful observers
that the blood serum of influenza patients possesses a definite
though slowly manifested power of agglutinating Pfeiffer's
bacillus, which at the end of the first week rises from 1 in 50 to
1 in 80 according to various observers, the blood of normal
individuals not agglutinating the bacilli in dilutions greater
than 1 in 20. It is true that, as one observer points out, this
reaction might show itself were the bacillus a secondary
invader, true also that with complement fixation and absorption
tests the results are irregular, indicating the existence of a
great number of strains.
INFLUENZA 193
As regards the first objection, it is not an objection proper,
only an alternative explanation. As regards the second, the
same is true regarding B. dy sentence, yet this does not prevent
one from regarding dysentery as a disease induced by various
strains of the bacillus. One must however admit that the
variation shown in Valentine and Cooper's New York results is
extreme.
In the second place, there is the evidence afforded by vac-
cination, employing as vaccine B. influenza alone. Here the
results at first appear to be very conflicting, but evidently
everything depends on the mode of preparation of the vaccine.
As pointed out by Duval and Harris, to kill off the bacilli by
heat, after the method employed by Wright and Leishman in
the preparation of typhoid vaccine, is futile. Even so low a
temperature as 56° C. renders cultures practically worthless as
an antigen. Trier esol and phenol derivatives also are not to be
considered. Even 0.25 per cent, tricresol has a deleterious
effect. Chloroform rapidly kills the bacteria without
apparently having any harmful effect
Properly prepared with chloroform, the pure B. influenza
vaccine was found by Duval and Harris to confer protection for
from ten weeks to three months. Of 3,072 persons vaccinated,
2,608 with three injections, 346 with two, and 118 with one, 3-3
per cent, developed influenza, whereas among 866 unvaccinated
controls the incidence was 41.6. Not one of the vaccinated
developed pneumonia, whereas among the controls refusing
vaccination there were 41 cases. Duval calls attention to the
severity of the reaction induced by his vaccine. Constitutional
effects following the administration were noted in 90 per cent
of those inoculated, and in 30 per cent, they were severe and
simulated in symptom complex the early toxaemia of true
influenzal infection : — lassitude, severe frontal and occipital
headache, neuralgic pains over the body, not infrequently
ushered in by chills and nausea, and followed by a temperature
of 101° to 102°.
And thirdly there are the observations upon the existence
and actions of an endo-toxin by Huntoon and Hannum. These
observers were unable to demonstrate the existence of a soluble
toxin or ecto-toxin, but by growing 10 strains of the bacillus,
drying the growths in vacuo and grinding them up with salt
they were able to extract what apparently is an endo-toxin of
which 0-25 c.c. was fatal to white mice, whereas similar salt
extracts of meningococci, streptococci, and pneumococci were
not fatal in four times the amount. The lesions induced by
the bacillary extracts particularly involved the lungs, producing
congestion with haemorrhages.
194 MEDICAL HISTORY OF THE WAR
The latest strong evidence in favour of regarding Pfeiffer's
bacillus as the specific organism of the disease comes from the
army medical laboratory at Washington, where Major Blake
and Captain Cecil, starting from the assumption that the
pathogenicity and virulence of the B. influenza is rapidly
lost in artificial media, preceded to raise the virulence by
rapid successive passage through eleven white mice followed
by thirteen monkeys. Intraperitoneal inoculations were given,
and fluid was drawn from the peritoneal cavity from eight to
ten hours after injection, that is, at a time when the bacteria
were still actively growing in the cavity. The first and second
cultures were employed for inoculation. The strain employed
had been obtained six weeks previously from a child with
influenza and pneumonia and at first had no virulence for white
mice. After the eleventh passage, 0-01 c.c of a 16-hour blood-
broth culture injected intraperitoneally killed a white mouse in
48 hours.
Twenty-two monkeys were next employed, some used for
intraperitoneal injections and passage, the rest for infection
through the respiratory passages, in part by swabbing or
instillation through the mouth and nose, in part by direct
intratracheal injection just below the larynx. Major Blake
and Captain Cecil conclude that the disease initiated in
monkeys by inoculation with these cultures of Pfeiffer's bacillus
of exalted virulence appears to be identical with influenza in
man ; that when injected into the trachea the cultures produced
in monkeys a tracheo-bronchitis and broncho-pneumonia, the
pathology of which appears to be essentially identical with
that which has been ascribed to pure influenza bacillus
infection of the lungs in man ; so that it seems reasonable to
infer that B. influenza is the specific cause of influenza. (Fig. 1 .)
The question arises as to how these observations can be
co-ordinated in the first place with those of the capable
observers who have reproduced the lung condition by
employing the filtrate from fluids obtained from influenza
patients, but have failed to obtain cultures of B. influenza
from the affected organs, or again with those observations
of first-class observers employing the best methods, who,
in localised epidemics which clinically were of the same
disease, reported that 100 per cent, of the cases examined
failed to afford influenza bacillus either by culture or by
microscopic examination of the discharges or the lung tissue.
There is one possibility that cannot be passed over, namely,
that Cecil and Blake employed mixed cultures of the influenza
bacillus and an almost invisible virus. Another, that those
who have failed to obtain the influenza bacillus from cases
Plate III.
A. — Monkey Lung (Group I, No. 4) showing inflammatory exudate in alveoli
and bronchiole (mucous membrane iutact) (x700).
B.— Monkey Lung (Group I, No. 6) showing margin of inflammatory exudate
(left), clear lung (right) (x500).
INFLUENZA 195
which clinically were apparently identical, studied mainly
old-established cases in which pneumonia had developed at a
period when the influenza bacillus had been over-grown and
destroyed by secondary invaders. These are points which
have yet to be decided. It is worthy of note how frequently
Cecil and Blake found the disease self-limited in the monkey,
bacilli disappearing after the fourth or fifth day. In the mean-
time, however, one is impressed with the fact that the lesion
common to mild and to severe and complicated cases is an acute
congestion and inflammation of the trachea ; that the one
member of the characteristic group of minute bacilli of what is
termed the influenza group, pathogenic in man, is the Bordet-
Gengou bacillus of whooping cough, and that this also
particularly affects and involves the epithelial lining of the
trachea, as has been convincingly demonstrated by Mallory
and his pupils.
It is true that the argument from analogy is dangerous, yet
an arrest of the proper educent action of the ciliated epithelium
of the trachea and bronchi, either by actual destruction and
exfoliation of the epithelium, or, as in whooping-cough, by
massive growth of the bacilli on the surface and between the
cilia, affords the most satisfactory explanation of the frequent
secondary infection of the lungs by organisms from the mouth
and throat, with the development of forms of pneumonia
varying according to the micro-organism which gains eventual
dominance.
On the question of immunity it has hitherto been widely
believed that a previous attack of influenza predisposes rather
than protects. There have, however, been no accurate statistics,
nor are there any on a sufficient scale now. A few reports from
schools have shown a little evidence that those affected by the
summer epidemic escaped that of the autumn. An analysis
of the statistics of the war may throw some light upon the
question. At present the only evidence worth considering is
that provided by the preventive inoculation carried out in the
army.
Morbid Anatomy.
The morbid anatomy of the disease presented a variety of
pathological changes in the organs of the body. Autopsies
were made in France during June and July 1918, by
Captain Shore upon 30 cases in which the clinical diagnosis
was " influenza." They illustrate the gross pathological
changes met with and the frequency with which they occurred
in the summer epidemic there. The patients were not all
previously healthy for in seven cases, 23-3 per cent., obsolete
196 MEDICAL HISTORY OF THE WAR
tuberculosis, pulmonary or glandular, was found. In a pre-
vious series of 1,500 consecutive autopsies the total incidence
of tuberculosis was 9-6 per cent. Two patients had chronic
nephritis and one unilateral hydronephrosis. Old pleuritic
adhesions were present in 12 cases. With these exceptions,
the patients were apparently previously healthy. None were
suffering from wounds. The most striking lesions were those
in the lungs and heart.
In one form or another pneumonia was present in every case.
The majority had broncho-pneumonia, which had a distinct
tendency to become confluent, and to show a condition closely
resembling the early grey stage of lobar pneumonia. Un-
doubted lobar pneumonia was only once found. In five cases
the pneumonic areas were small and shotty when felt between
the fingers, closely resembling miliary tuberculosis. On
microscopic section the small patches were found to consist of
consolidated lung, generally with fibrinous exudate, surrounding
inflamed bronchioles. The name " bronchiolitis " was applied
to the condition, but " miliary pneumonia " seemed more
descriptive. No bacteriological investigations were made of
these cases, so it is not possible to say if they differ from the
more usual form of broncho-pneumonia in that respect. In
two cases the process passed on from confluent broncho-
pneumonia to abscess formation. Marked emphysema occurred
in two cases, involving chiefly the anterior border of the lungs.
In five there was an excessive amount of collapse, chiefly along
the vertebral border of the lung. Two of these cases showed a
small amount of pleura! fluid, but in the other three the pleura
was dry. Subpleural and interstitial haemorrhages were seen in
eighteen cases but only as small localized areas. Purulent
bronchitis was present in fourteen cases.
Twenty-four cases showed recent pleurisy ; fourteen of
these were dry, but in ten a varying amount of purulent or
sero- purulent fluid was found, never more than a pint and gener-
ally only a few ounces. In fifteen cases the bronchial or tracheal
glands were markedly enlarged and inflamed. In a few cases
more distant glands, such as the retroperitoneal and even
inguinal, were affected.
One of the most striking features of the morbid anatomy of
these cases was the constant occurrence of dilatation of the
heart, accompanied by nearly as constant myocardial changes.
Twenty-nine out of thirty cases showed marked dilatation of
the heart, chiefly of the right side but very commonly of the
left side as well, and twenty-one cases showed myocarditis
demonstrable to the naked eye. The latter took the form of a
general pallor and softness of the myocardium, with mottling
INFLUENZA 197
and frequently subpericardial and subendocardial haemorrhages
similar to those seen beneath the pleura. These were not in-
frequently noticed on the interventricular septum, and on the
papillary muscles. Endocarditis of the mitral valve was found
in two cases. The vegetations were small and numerous, and
obviously recent ; in one case there was a fair amount of recent
thrombus adherent to the vegetations. In practically all cases
the right side of the heart was distended with the yellow
" agonal " or " chicken fat " clot found so constantly in
pneumonia. Pericarditis was not found.
In most cases the spleen was a little enlarged. The largest
weighed 15 oz., the smallest 4 oz., and the average weight of
the series was 1\ oz. The spleen was generally pale and soft, and
showed a marked enlargement of the Malpighian corpuscles.
In a few cases it was congested. No infarcts were found.
The liver did not present any striking features. In most
cases it was pale and inclined to show early fatty changes.
Some few cases showed chronic or relatively chronic congestion,
presenting a " nutmeg " appearance. In three cases a mild
degree of jaundice was present, but there were no signs of
biliary obstruction.
Apart from the two cases already mentioned as having
chronic nephritis, ten cases showed a marked degree of " toxic
nephritis." Sections were made of only two of these, but
they showed no glomerular change, only cloudy swelling and
a little fatty change in the tubules. In these ten cases the
kidneys were flabby, pale and a little swollen. The capsule
was easily removable without tearing the surface. Stellate
veins were prominent on the surface. There appeared no
divergence from the normal proportions of cortex, medulla,
and intrapelvic fat. Their average weight was 12J ozs. the
pair, the average for the series being 12 ozs. In one case the
kidney had a " flea-bitten " appearance, and on section
showed, as well as the condition described, hyaline thrombosis
of the afferent glomerular vessels. The glomeruli appeared
to be practically all affected, which would account for the
sudden and complete suppression of urine, without previous
haematuria, which led to the patient's death. This was one
of the cases which showed abscess formation in the lung.
Cerebral abscess was found in one case, in which purulent
bronchitis but no particular bronchiectasis was present.
Meningitis was not found.
Reports of 46 additional autopsies were contributed from
various other pathologists in France. The predominating
lesion was purulent bronchitis in 12, broncho-pneumonia in
29, and lobar pneumonia in five of the cases. In all but two
(2396) N
198 MEDICAL HISTORY OF THE WAR
cases the respiratory passages contained purulent exudate.
In the two exceptions consolidation was of lobar type and
confined to one lobe. In the cases with purulent bronchitis
there appears to have been little or no consolidation. The
commonest condition described is one of purulent bronchitis
with broncho-pneumonia often associated with fibrinous
exudate upon the pleural surface. The lungs are described
as greatly congested and as exuding blood-stained watery
fluid from the cut surface. The extent of the broncho-
pneumonic areas varied from numerous areas a few millimetres
in diameter, surrounded by regions in which haemorrhage had
occurred, to confluent broncho-pneumonia involving the
greater portion of a lobe. Sections of the lungs showed the
same irregular patches of consolidation with alveoli filled with
leucocytic exudate or blood and often interspersed with emphy-
sematous portions. The surrounding vessels were greatly
distended, and the mucous membrane of the bronchioles
swollen and disintegrating. Pneumococci were seen in the
alveoli amidst the leucocytes, and sometimes in immense
numbers, but in only a few instances were bacilli resembling
Pfeiffer's bacillus recorded.
Cultures were made from the broncho-pneumonic areas in
53 instances. Pneumococci were invariably recovered, and
in 40 cases bacilli resembling B. influenza also. Similar
bacilli have been isolated from the meninges in cases dying
with meningitis and, along with pneumococci, from the
fibrino-purulent pleural effusion.
The only lesions in other organs recorded were congestion
of the kidneys with small haemorrhages in the pelvis of the
kidney. In one instance small haemorrhages in the white
matter of the brain were observed.
Autopsies made in England during the summer and winter
confirmed these observations and amplified them in the
following directions.
In 22 consecutive cases the results of examination of the
cranial sinuses were as follows : — One case was normal, in 21
cases the lining membrane was congested, in 6 there was
definite yellow pus, in 15 turbid fluid yielding in every case
the same micro-organisms as were found in the lungs. To the
naked eye the ethmoidal sinuses were less affected than
the sphenoidal, and the frontal least of all, but there was little
difference in the results of culture.
The lesions found in the lungs included acute congestion,
giving a more or less dark red colour to the whole lung ; diffuse
haemorrhage producing still darker red, often almost black-red
areas in the already deep-red lung, varying in size from miliary
Plate V.
WHOLE LUNG IN A CASE OF INFLUENZAL PNEUMONIA.
INFLUENZA 199
to massive, and scattered at random throughout the lungs ;
hsemorrhagic infarcts similar in colour to diffuse intrapul-
monary haemorrhages, but differing from the latter in their
pyramidal shape ; broncho-pneumonia, sometimes recognizable
only on careful search, sometimes widely disseminated, and
occasionally confluent ; miliary abscesses, often aggregated
together in little focalized groups of from three or four to a
score or more, similar to those seen in the midst of septic
infarcts due to infected emboli ; croupous pneumonia, met
with very rarely indeed ; purulent bronchiolitis, with thick
pus expressible from the bronchioles seen in the cut lung ;
collapse, sometimes superficial only, sometimes associated
with multiple areas of broncho-pneumonia, sometimes massive ;
passive oedema of the bases ; active oedema with extensive
albuminous exudate into all parts of the lungs, not definable
by the naked eye, but shown to be extreme in many histological
sections, a peculiar and apparently highly important feature
of these cases ; and interstitial emphysema, often widespread
throughout the lung tissue.
It is worthy of note that here and there a case occurred with
the same clinical picture as the rest and yet with lungs so little
altered to the naked eye that one might easily have passed
them as almost normal. Microscopically there would be
bronchiolitis, peribronchiolitis and diffused inflammatory
albuminous exudate, both interstitial and infra-alveolar, yet
without any discernible broncho-pneumonia, and no obvious
consolidation anywhere. No part of any lobe, larger than
a minute fragment, would sink in water, and yet the clinical
picture of the case was indistinguishable from that in which
extensive broncho-pneumonia would be found at autopsy.
In short, though broncho-pneumonia was usually found
in little or greater degree, it was only part, but not an
essential part, of a much more complex mixture of lesions.
Microscopically the lung lesions were found to be just as
protean as the macroscopic appearances would suggest. The
most remarkable were the " Gruyere cheese " changes, which
were common and entirely unlike what is met with in any
ordinary form of pneumonia. The condition has been illus-
trated in the special report series* of the Medical Research
Committee, and it is not very dissimilar to the initial results
of the action of acute irritant gases on the lungs (Plate V).
All through the section of the lung — filling the alveoli in
some places, distending the interalveolar walls or the
peri-bronchial connective tissue in others, or blocking the
* No. 36.
200 MEDICAL HISTORY OF THE WAR
bronchioles, or infiltrating all parts of the section simul-
taneously— there was a hyaline or homogeneous material,
staining faintly pink with eosin, but containing few cells,
resulting apparently from the rapid outpouring of an
albuminous, non-cellular, coagulable exudate which in the
process of fixation of the tissues becomes converted into
what looks like hyaline material. (Fig. 2.)
Amid this are seen outlines of normal alveoli in some places,
alveoli whose walls are disintegrating in other places, and, in
yet others, spaces which are not alveolar at all, round or ovoid
holes of varying sizes without any defined walls, but reminiscent
of the air holes which characterize a Gruyere cheese. Some
of these may be the result of breaking down of interalveolar
walls so that two, three or more original alveoli have been
thrown together into one larger one. Some, on the other
hand, appear to be gas-bubbles — microscopic interstitial
emphysema — in the albuminous intrapulmonary exudate.
Similar non-cellular exudate is seen after acute gas poisoning.
It seems likely that it is this acute inflammatory oedema of
the lung tissue which, preventing inspired air from gaining
access to the intra-capillary blood, accounts for the anoxaemia
and heliotrope cyanosis of the worst cases.
The lesions found in the lungs may be summed up as con-
sisting of bronchitis, usually of the severe purulent type ;
haemorrhagic oedema, especially in cases rapidly fatal ; and
inflammation and consolidation of the parenchyma, which may
be miliary or lobular, sometimes so confluent as to involve
large areas, but is rarely true lobar consolidation. Micro-
scopically the characteristic change is that of vacuolation
with fibrinous exudation.
The thyroid gland was uniformly enlarged in nearly every
case, a phenomenon which attracted attention, though its
causation was not obvious. The gland was sometimes quite
three times the average size, and the isthmus was swelled
as well as the lateral lobes, much in the same way that it is
in Graves' disease. The swollen gland was firm and uniform in
consistence, generally of its ordinary dull-red colour, and micro-
scopically it did not show evidence of being acutely infected.
The condition seemed to be one of simple uniform swelling of the
gland secondary to the acute toxaemia of the general disease.
The alimentary canal seldom presented microscopic evidence
of infection ; but a group of cases was observed in which
the colon was in a state of extensive and acute ulcerative colitis,
with destruction of the mucosa similar in type and degree
to that which results from acute dysentery.
Important investigations into the pathology of epidemics
Plate IV.
. ";•
7; , « v
'>•.'
/
•. V •
** .
\;
«f
A.— Human Lun^, area of oedematous pneumonia, showing alveoli filled with
albuminous exudate. Leucocytic reaction not marked. (x700).
B. — Human Lung, area of multiple abscess formation, showing total destruction
of bronchial mucous membrane with rupture and solution of the surrounding
alveolar walls. (x700).
INFLUENZA 201
of pneumonia, which occurred in the army concentration
camps in America during 1918, have some bearing on the
epidemics of influenza. A full account of the work has
been written by MacCallum in a monograph of the Rocke-
feller Institute and in other papers.
MacCallum points out that, during the period referred to,
examples of the classical type of lobar pneumonia, ending
by crisis, were met with in the usual numbers to be expected
under camp conditions and at the season of the year in which
they occurred. There arose, however, in addition, outbreaks
of pneumonia of a very different character, which appeared
to follow in the train of other epidemics of some predisposing
disease of which measles and epidemic influenza were the
chief. It is in its ultimate application to the epidemics of
influenza that the work of the American pathologist requires
particular attention. During the winter and spring 1917-18
there were extensive epidemics of measles in the American
camps, complicated by a very fatal pneumonia shown to be
due to the invasion of the lungs by a haemolytic strepto-
coccus. During the great epidemic wave of influenza in the
latter part of 1918 similar pneumonic complications were
observed, and in these the secondary infecting organisms
were observed to be the haemolytic streptococcus, the
bacillus of Pfeiffer, and Staphylococcus aureus. MacCallum
showed clearly that there were important differences in the
pathological pictures of these various pneumonias, and that
they depended on a variety of factors, such as the nature
of the predisposing or primary disease ; the organism which
secondarily invades the lungs ; the virulence of the organismal
strains ; and the resistance of the infected person.
Though it is possible to describe typical appearances as
brought about by a single variety of invading organism, such
a clean picture is not commonly met with. The various
secondary invaders may all be present, or they may invade
the lungs one after the other, and each produce additional
effects. It is, however, common for one or other of the
organisms to multiply quickly, and assume a predominant
role in the pathology. Subsequently another organism may
multiply, and add to, or even completely cover up, the lesions
produced at the earlier stage. All these changes increase
greatly the difficulty of elucidating the pathology of different
aetiological types of the disease. It should be mentioned that
MacCallum assumes that in the present state of knowledge
neither of the main predisposing diseases, measles and epidemic
influenza, can be considered as caused by bacteria, but that
they must be ascribed to a virus of unknown nature.
202 MEDICAL HISTORY OF THE WAR
The first epidemic of pneumonia investigated by MacCallum
occurred during a great outbreak of measles in a Texas camp
in February 1918. In this epidemic the main secondary
invader which brought about the pneumonia was clearly shown
to be a hsemolytic streptococcus. So obvious did this become
that ultimately the prophylactic measure was adopted of
segregating all cases of early measles in which the haemolytic
streptococcus could be obtained in the throat. This was
followed by excellent results in diminishing the pneumonia
incidence in other cases of measles.
A later epidemic in another camp occurred without the
co-existence of measles at all, from the bulk of which again
the haemolytic streptococcus was obtained. In this epidemic
the streptococcus was apparently virulent enough to set up
pneumonia without the usual primary predisposing disease
coming into play.
The characteristic lesion of all these cases may be
summarized as being that of an interstitial broncho-pneumonia
of an unusual type. Macroscopically the cut surface of the
lung showed branched grey projecting foci of consolidation,
surrounded by areas of oedema, haemorrhage and collapse.
The essential feature of the lesion on histological examination
was the rapid infiltration of the walls of the alveoli and
bronchioles with wandering cells, followed by new formation
of connective tissue in these situations, so that the walls of
the alveoli become greatly thickened. The streptococci were
present in the lesion in relatively small numbers, and were
confined practically to the bronchi and lymphatic channels
of the lung. This is in great contrast to the findings in lobar
or lobular pneumonia, where the main lesion consists in
exudation of fibrin and leucocytes into the alveolar spaces, and
where myriads of pneumococci or other organisms are to be
seen in the alveolar exudate. The peculiar acute inflammatory
change in the alveolar walls, with cellular infiltration followed
by fibrosis, appears then to be a particular pathological change
characteristic of the disease caused by the haemolytic strep-
tococcus after measles.
The appearances varied somewhat according to the stage at
which death occurred. In cases where death supervened within
a few days of the onset, no actual areas of consolidation were
seen on the cut surface of the lung. All the bronchi were
intensely reddened, and their walls were swollen. Micro-
scopically such a lung showed in the bronchi an accumulation
of leucocytes containing streptococci. The damage extended
beyond the bronchi only into the closely adjacent alveolar
walls, which were thickened by oedema and infiltrated by
INFLUENZA 203
mononuclear wandering cells. If the illness had lasted more
than a week, the post mortem changes were far more advanced.
There was then generally pleural exudate, thin, watery and
turbid, often with a greenish brown sediment, and swarming
with streptococci. The lung surrounded by the fluid exudate
was collapsed, airless and flabby, but contained obvious
palpable areas of consolidation. In section, the lung surface
showed nodules of consolidation which projected above the
cut surface and were surrounded by areas of haemorrhage and
oedema. Each bronchus contained thick pus. The infection
was essentially confined, in the first place, to the interstitial
tissues either of the wall of the bronchioles or of the alveoli,
and the organisms showed a tendency to pass from these areas
to the surface of the lungs by the lymphatic drainage channels,
which in consequence might be distended with such large
collections of pus as to resemble a choked bronchus.
Microscopically the same interstitial changes were predominant,
but further advanced. The interlobular septa were greatly
thickened, and the alveolar walls were thick both from
infiltration with wandering cells and from the formation of
new connective tissue, which was well vascularized. The
alveolar spaces might contain at this stage dense plugs of
fibrin, mixed with catarrhal cells from the alveolar walls, but
leucocytes and red corpuscles were scanty.
In certain cases the familiar lesion of lobular pneumonia
was also present in other parts of the lungs, the alveoli being
filled with exudate of fibrin and leucocytes containing in the
meshes very abundant streptococci. This change MacCallum
regarded as evidence of lowered resistance on the part of the
host, so that there was no restriction to the invasion and multi-
plication of the streptococci. The alveoli became filled with
organisms in contrast to the course of events in the interstitial
pneumonia where the organisms were " imprisoned in the bronchi,
and carried to the pleura only by migration along the lymphatics. ' '
In these epidemics MacCallum found that all the cases
could be divided pathologically into the following types : —
(1) Lobar pneumonias caused by the pneumococcus.
(2) Pneumonias caused by the haemolytic streptococcus,
either pure interstitial broncho-pneumonias, or
interstitial pneumonia added to lobular pneumonia,
or rarely lobular pneumonia without any of the
changes in the framework of the lung.
MacCallum's subsequent work refers to the pneumonias
met with during the great influenza epidemic in the autumn
of 1918. He again affirms that the nature of the primary
204 MEDICAL HISTORY OF THE WAR
disease is unknown, but that it lowers the powers of resistance
to a degree scarcely paralleled in any other disease.
In this epidemic the secondary pneumonia was brought about
by invasion of the lungs with many kinds of bacteria, including
the various types of the pneumococcus, the staphylococci, and
the bacillus of Pfeiffer, invading singly or all together.
The type of pneumonia was here again found to be quite
different in different epidemic areas in America, according to
the predominant secondary invading organism.
In the cases where the various types of pneumococci were
identified as the predominating organism, the consolidation
was seen to be at first lobular, but soon these solid areas
coalesced until the greater part of a lobe might be solid and
airless. The bronchi in these cases were not red, but pale.
Microscopically the aveoli were found filled with a light fibrinous
reticulum, entangling red corpuscles, leucocytes and desqua-
mated endothelial calls. This exudate contained as a rule
abundant pneumococci, and in fact the lesion was very little
different from a typical early lobar pneumonia.
In the cases where the haemolytic streptococcus was the
chief secondary invader, the appearances in the lungs corre-
sponded to those described in the earlier epidemic as character-
istic of the invasion of tissues in cases with lowered resistance.
None of the typical interstitial connective tissue changes were
present, but there were large areas of lobular consolidation
packed everywhere with streptococci, and often undergoing
rapid necrosis. In these cases again intense inflammatory
redness of the trachea and bronchi was evident.
The few cases in which the staphylococcus appeared to
predominate were too scanty in number to give absolute
conclusions, but in one the lesion was similar to that induced
by the pneumococcus.
In the cases in which Pfeiffer's bacillus was present in
abundance the changes found resembled very closely those
described as acute interstitial pneumonia caused by the strep-
tococcus after measles infection. There was again the same
thickening of the alveolar walls with round-celled infiltration
and newly formed connective tissue, while the small bacilli
were practically confined to the bronchi and did not invade the
alveoli. It was evident from the lesion that the tissues here
were stoutly resisting the invasion of the bacilli.
MacCallum concludes one of his papers by saying that stress
must be laid on the epidemic character of the secondary invasion
of the lungs in all the outbreaks. In one camp all the pneumonic
cases might show a pneumococcal type of lesion, in others
almost every case might be due to Pfeiffer's bacillus. In this
INFLUENZA 205
way Pfeiffer's bacillus might carry conviction to some people as
the true cause of epidemic influenza, whereas it might be almost
absent in other areas where pneumococci and haemolytic
streptococci were the opportune secondary invaders. This all
leads him to the reiterated conclusion that we are still quite
ignorant of the cause of epidemic influenza.
Acute interstitial pneumonia was recognized microscopically
in France by Dunn and McNee in December 1916, in individual
cases of "broncho-pneumonia" before the influenza epidemic.
The general observations of MacCallum and Cole in 1918 were
fully confirmed during the epidemic by Tytler, Janes and
Dobbin in work at Boulogne ; in these latter cases staphylo-
cocci were frequently present among the secondary infecting
organisms, and staphylococci were especially prominent in a
group from Malta, recorded by Captain Patrick.
Diagnosis.
With regard to diagnosis, influenza has to be distinguished
from the onset of any other acute fever. In the case of the
zymotics the subsequent course and the rash proper to each
form the main points of diagnosis. Trench fever can sometimes
only be distinguished by its relapsing character as the rash
may be inconspicuous. Severe influenza may closely resemble
typhoid fever ; in this case the diagnosis turns upon the
presence of the signs of the latter disease. Some regard a
relatively slow pulse as characteristic of severe influenza, but
this may occur in typhoid also, and is not universal in cases
of influenza. Malaria may resemble influenza. The history
and the presence of the malarial parasite will usually provide
grounds for diagnosis.
Prognosis.
The prognosis of the disease is indicated in the descriptions
of its symptoms and progress. Inquiries made seem to show
that the epidemic has not produced any large number of
those mental sequelae which have been noticed on previous
occasions. There is some suspicion that a rather chronic form
of infective endocarditis may be the consequence of an attack
of influenza. Also it is said there are some cases of fibrosis of
the bases of the lung resulting from the epidemic. It is
suggested above that the kidneys may be left affected. Such
cases are not, however, numerous.
Treatment.
The treatment of influenza is both preventive and curative.
Segregation was attempted in France On 23rd June, 1918, a
206 MEDICAL HISTORY OF THE WAR
committee appointed to investigate the outbreak reported to
the D.G.M.S. as follows :—
"1. The contagion of this disease appears to be air-borne, although its
exact nature has not yet been ascertained. The main principle to be followed,
therefore, is to spread troops as widely as possible, avoiding the crowding of
men in tents, billets, messrooms, etc.
"2. Whenever the military situation permits, it is advisable that troops
should sleep in individual blanket-shelters in the open air.
"3. As the infection appears to be spread by the movement of infected
individuals, drafts arriving at reinforcement depots from England or the
bases should as far as possible be accommodated in separate lines for a period
of four days. Individual shelters should be insisted on, in order to avoid the
necessity for quarantine if any cases arise.
"4. In medical units arrangements should be made for the separation of
these cases from other patients.
"5. In billets where infection has occurred all blankets and kits should
be taken out and aired, and the usual precautions taken so far as circumstances
permit."
Later a further segregation was made by separating cases of
broncho-pneumonia from the remainder.
In most influenza wards the nurses and orderlies wore masks.
The incidence of infection among them was on the whole
surprisingly small, but it can hardly be attributed to the masks,
which were carelessly used, for it was small too even in those
wards where masks were not worn.
In Mesopotamia, where the disease was recognized, its
incidence was so great that the hospitals were overtaxed. In
the 15th Indian Division regiments were ordered to form their
own hospitals and detain cases. Tents were set aside, latrines
made, personnel detailed for nursing, water and cooking
arranged, and drugs and comforts supplied. For prophylactic
purposes games were stopped and units were paraded twice
daily when every man gargled his throat and inserted in
each nostril some menthol and camphor ointment.
Preventive inoculation was employed to some extent. Eyre
and Lowe in England had some time before inoculated a body
of New Zealand troops with a mixed vaccine against respiratory
diseases. These troops during the following six months showed
as compared with unvaccinated New Zealand troops a rate of
respiratory disease lower in the proportion of 12 vaccinated to
73 unvaccinated of those attacked. A War Office conference
reported in favour of a prophylactic vaccine containing :—
B. influenzae . . 60 millions }
Pneumococci . . 200 ,, r in 1 c.cm.
Streptococci . . 80 ,, J
the first dose to be J c.cm., the second, to be given 10 days later,
1 c.cm. But both dosage and composition were criticized by
Matthews and Wynn, Eyre and Lowe again reported favour-
ably on their results during the autumn epidemic.
INFLUENZA 207
In the autumn epidemic in France it was considered inad-
visable to use the prophylactic vaccine upon the combatant
troops, as it was impossible to be sure that men were not already
infected, and there was some evidence that a negative phase
was produced which might in that case be dangerous, but at
Boulogne a test on a small scale was made on the base personnel
with equivocal results.
Prophylactic vaccine did not arrive in Mesopotamia till April,
by which time the epidemic had so far died down that no
satisfactory trial of its use could be made.
Leishman's statistics, published in 1920, show a much lower
rate of incidence among those previously inoculated with this
vaccine. Further, among 221 inoculated patients who caught
influenza only two died, whereas among 2,059 non-inoculated
patients 98 died. The numbers included in his returns are
approximately 60,000. There are one or two anomalous returns,
and there are one or two which appear unreliable. Expert
statisticians also claim that the circumstances of infection
diminish to a certain extent the difference between the rates.
Yet a balance of evidence is left in favour of inoculation as a
means of preventing the disease, and the low death rate of
the inoculated affords considerable evidence of the creation
of temporary immunity.
It was, however, considered advisable to increase the propor-
tion of B. influenza and the vaccine eventually issued by the
War Office contained : —
B. influenzse . . 400 millions "j
Pneumococci . . 200 „ V in 1 c.cm.
Streptococci . . 80 ,, J
the first dose in | c.cm., and the second, 1 c.cm., as before.*
* Extreme measures of protection against the pandemic of influenza in
1918 were taken on board the Japanese cruiser " Nukata," which was in
Simon's Bay and Table Bay during the progress of a very severe and fatal
outbreak in the Cape Peninsula during the latter part of the year. The
personnel of the ship entirely escaped infection. The preventive measures
included stoppage of shore leave or of visitors from shore, the wearing of masks
by men necessarily sent on duty on shore, disinfection of everything taken
on board and inoculation with anti-influenza vaccine. Vegetables from the
shore were washed and exposed to sunshine ; bread was exposed to heat in
kitchen ovens, meat and fish were exposed to air and the covers on them
changed on the pier at Cape Town ; newspapers and letters were sprayed
with formalin and dried in the sun ; men returning from shore duty gargled
with 1 in 1,000 solution of perchloride of mercury and cleansed their clothing
and boots with a 3 per cent, solution of carbolic acid on the pier before returning
to the ship. They were given formalin tabloids to use on shore and instructed
to avoid crowds. The men on board gargled with salt after every meal and with
perchloride of mercury solution before turning in. Temperatures were taken
every day and men with signs of inflammation of the naso-pharyngeal passage
searched for and isolated. All table dishes were boiled after use and at the
height of the epidemic on shore no provisions from shore were allowed on board.
(See Vol. I. General History of the Medical Services, p. 319.)
208 MEDICAL HISTORY OF THE WAR
Preventive inoculation with mixed vaccines has been tested
in New York, on 6,000 persons by Jordan and Sharp, and on
over 4,500 by Park, with doubtful result. The dose of influenza
bacilli was 500 and 1,000 millions in their respective vaccines.
With regard to curative measures alike in France and in
England treatment was mainly symptomatic. There were not
wanting, however, advocates of specific remedies.
Turner advised 20 grain doses of salicin every hour, and
stated that out of 2,500 cases thus treated he had lost
none, and had never seen bronchitis or pneumonia develop. In
France the cases came in too late to give this method a trial,
and there has been no corroboration of his statements on a large
scale in England. Quinine and the salicylates were of little
use. Corrosive sublimate and colloidal arsenic or silver, the
former recommended by Ferrarini in 1 cgm. doses, the latter by
Capitan, as intravenous injections, were each praised by some
officers, whose reports were controverted by others. Large
doses of alcohol were ineffective. Oil of camphor and musk
were advocated as restoratives. The usual expectorants
were given. Cyanosis was temporarily relieved by oxygen
inhalation through the Haldane apparatus. Oxygen was of
about as much value as it is in cases of ordinary lobar pneumonia
and, whereas in gas poisoning it undoubtedly saved life and
that frequently, in influenza it at the most sometimes prolonged
it. Venesection is never permissible.
Treatment by the serum of convalescents advocated by
Benj afield and Hohlweg was not tried in France. Its efficacy
depends upon the degree of immunity conferred, which is yet
uncertain; but further trial is very desirable, for clinical evidence,
though difficult to estimate, is in such a case the final test.
Curative vaccine treatment was not employed in France, and
was not found of value by those who tried it in England.
The points of main importance are that a patient with
influenza should be sent to bed at once, and should not be
sent long journeys if these can be avoided ; yet even when
these precautions were taken and the best possible conditions
secured throughout, experience showed that the attack might
be very severe.
At Aldershot the overcrowding was so great that the most
hopeless cases were placed under shelter in the open air, to make
room in the wards for those whose chances seemed more favour-
able. It was found, to the surprise of the physicians, that an
unexpectedly large number of these apparently hopeless cases
recovered, though it was winter time. This accidental obser-
vation may be of great importance, and the open-air method
should certainly be tested again.
INFLUENZA
209
Empyema was uncommon in France, and is not even men-
tioned in the account of the disease in England, but it seems to
have been more frequent in the American army. It should be
borne in mind, and, when found, should be treated first by
aspiration, and, if it collect a second time, by resection.
Abrahams, Hallows
& French
Burnford
Capitan
Eyre & Lowe
Ferrarini
Fildes, Baker &
Thompson
Fleming
Foster & Cookson . .
Friedemann
Gibson, Bowman &
Connor
Gotch & Whitting-
ham
Hohlweg
Huntoon &Hannum
Jordan & Sharp
Leishman . .
MacCallum
BIBLIOGRAPHY.
A further Investigation into
Infl uenzo-pneumococcal
Septicaemia.
On Influenza with special refer-
ence to Pneumonia.
Traitement de la grippe grave
par 1'arsenic et 1'argent col-
loidaux purs.
Prophylactic Vaccinations
against Catarrhal Affections
of the Respiratory Tract.
Cura dell' influenza colle in-
jezioni endo venose di subli-
mate corrosive .
On the Pathology of the present
Epidemic.
On some simply prepared Cul-
ture Media for B. Influenzee.
On a small localized Epidemic
of Influenza.
Ueber Serum-therapie der
Grippe-pneumonic.
A filtrable virus as the cause of
the early stage of the present
Epidemic of Influenza.
On the Influenzal Epidemic of
1918.
Zur Behandlung von Grippe-
kranken mit Rekonvaleszen-
tenserum.
The Role of Bacillus Influenza
in Clinical Influenza
Effect of vaccination against
influenza, etc.
Results of Protective Inoculation
against Influenza.
Pathology of the Pneumonia
following Influenza.
Pathology of Epidemic Pneu-
monia in Camps and Canton-
ments in 1918.
Lancet, 1919. Vol.i,
p. I.
Proc. Roy. Soc. Med.
1918-1 9 19. Vol. xii,
Med. Sect. p. 49.
Lancet, 1919 Vol i,
p. 794.
Bull. Acad. de M6d.
Paris, 1918. 3« S6r.
Vol. Ixxx. p. 388.
Lancet, 1918. Vol. ii,
p. 484. 1919. Vol.i,
p. 553.
Riforma Med., 1918.
Vol. xxxiv. p. 893.
Lancet, 1918. Vol. ii,
p. 697.
Lancet, 1919. Vol. i,
p. 158.
Lancet, 1918. Vol. ii,
p. 588.
Deut. Med Woch.,
1918. Vol. xliv,
p. 1293.
Brit. Med. Jour.,
1918. Vol. ii, p.
645.
Brit. Med. Jour.,
1918. Vol. ii. p. 82.
Miinch. Med. Woch.,
1918. Vol. Ixv,
p.' 1247.
Proc. New York
Path. Soc., 1919.
March 12.
Jour, of Immuno-
logy 1919. Vol. iv,
p. 167.
Jour. Infect. Dis.
1921. Vol. xxviii,
p. 357.
Lancet, 1920. Vol. i,
p. 366.
Jour, of Amer. Med.
Ass., 1919.
Vol. Ixxii, p. 720.
Med. Rec., 1919.
Monographs of the
Rockefeller Insti-
tute for Med. Res.,
New York, 1919.
210
MEDICAL HISTORY OF THE WAR
MacCallum
Matthews
Morelli
Nash
Nicolle & Le Bailly
Patrick
von Sholly & Park
Smith
Symonds
Whittingham & Sims
Wilson
Wirgman
Wynn
Yamanouchi &
others.
Miscellaneous
Reports.
BIBLIOGRAPHY— cont.
The Pathology of the Pneumonia
in the United States Army
Camps during the winter of
1917-1918.
Influenza, a Preventive Inocu-
lation.
Osservazioni cliniche ed epi-
demiologiche sopra 1'epidemia
della influenza estiva.
The Age Incidence of the pre-
vailing Epidemic of Influenza.
Quelques notions experimentales
sur le virus de la grippe.
Note on Staphylococcus aureus
Septicaemia as a Complication
of Influenza in an Epidemic in
Malta.
Report on the prophylactic vac-
cination of 1,536 persons
against acute respiratory
diseases 1919-20.
Cases of Influenza in the Wool-
wich district.
Nephritis in relation to Influenza
Bacteriology and Pathology of
Influenza.
Post-Influenzal Haemoptysis . .
An Influenza Outbreak
Influenza, and Preventive Inocu-
lation.
The Infecting Agent in Influenza
Influenza Committee of the Ad-
visory Board, Report to
D.G.M.S. in France.
War Office Conference
Memo. Royal Coll. of Physi-
cians.
Memo. Med. Research Com-
mittee.
London County Council Report
by Medical Officer (Hamer).
Discussion at Joint Meeting of
sections of Medicine, Preven-
tive Medicine, and Pathology,
Brit. Med. Assoc.
Discussion
Lancet, 1918. Vol. ii,
p. 602.
Policlinicall., Rome,
1918. Vol. xxv,
Soz. Prat. p. 926.
Brit. Med. Jour.,
1918, Vol. ii,
p. 686.
Comptes Rendus de
1'Acad. des Sciences
1918. Vol. clxvii,
p. 607.
Lancet, 1919. Vol. i,
p. 137.
Jour, of Immunology
1921. Vol. vi,
p. 103.
Lancet, 1919. Vol. i,
p. 421.
Lancet, 1918. Vol. ii,
p. 664.
Lancet, 1918. Vol. ii,
p. 865.
Lancet, 1919. Vol. i,
p. 137.
Lancet, 1919. Vol. i,
p. 357.
Lancet, 1918. Vol. ii,
pp. 642, 874.
Lancet, 1919. Vol. i,
p. 971.
Brit. Med. Jour.,
1918. Vol. ii, p. 505.
Lancet, 1918. Vol. ii,
p. 565.
Brit. Med. Jour.,
1918. Vol. ii.p. 546.
Lancet, 1918. Vol. ii.
p. 717.
Med. Res. Com.,
Special Report,
No. 36. Lond.,
1920.
1919.
Brit. Med. Jour.,
1919. Vol. i, p. 488.
Proc. Roy. Soc. of
Med., 1919. Vol. xii,
p.l.
INFLUENZA
211
Miscellaneous
Reports.
King, Barty
BIBLIOGRAPHY— cont.
War Office Daily Review of
Foreign Press, Med. Supple-
ment.
Influenza
Studies of Influenza in Hospitals
of the British Armies in
France, 1918.
Studies in Influenza and its
Pulmonary Complications.
Lond., 1918 & 1919.
Medical Science
Abstracts and
Reviews, 1919-20.
Vol.i, pp. 38, 141.
Med. Res. Com.,
Special Report
Series No. 36,
Lond., 1919.
London, 1922,
Churchill.
CHAPTER VIII.
PURULENT BRONCHITIS AND BRONCHO-PNEUMONIA.
DURING the campaign in France and Flanders respiratory
affections were common, and at certain periods the num-
bers affected were large, more especially during the cold
and wet seasons. These maladies were of the usual and well-
known types, such as bronchitis, pleurisy and varieties of
pneumonia, and they do not call for special notice. They
varied in their severity and character and in their incidence
amongst the troops, derived as they were from different parts
of the world and often of different races. Such affections were
prevalent from time to time during the earlier years before the
occurrence of the pandemic of influenza in 1918, and in some
years, notably in the winter of 1916, they assumed considerable
proportions. In 1918, however, they occurred in very large
numbers in association with the severe epidemic of influenza
prevalent in the autumn of that year.
Bronchitis was one of the diseases that occurred, as might
be expected, in different degrees of severity and in varying
numbers in different years, and it also presented varying forms,
sometimes catarrhal, sometimes muco-purulent and not un-
commonly frankly purulent. Such varieties are well known
and universally recognised. But, in addition to these, another
and remarkable form of the disease was seen from time to time
in isolated instances, and, in certain years, in considerable
numbers. It is this variety of bronchitis to which the term
acute purulent bronchitis is given. The outstanding features
of the malady are the remarkable and peculiar sputum, the
high fever and prolonged course of the disease and in a certain
proportion of cases tachycardia. Other striking features such
as cyanosis, and the patient's mental state, although also of
much clinical interest, are phenomena that are by no means
unusual in other severe forms of bronchitis, especially when
acute, and hence although they are prominent features of puru-
lent bronchitis, they are not so special as the sputum and the
prolonged and high pyrexia.
In France, although sporadic cases were seen from time to
time throughout the campaign, the bulk of them occurred in
the winters of 1914 and 1916, while very few were seen in the
winters of 1915 and 1917. In the autumn and winter of 1914
the weather was cold and very wet and the troops suffered
212
PURULENT BRONCHITIS 213
considerably from exposure. The winter of 1916 was also
severe ; the malady was then more prevalent but the number of
men serving was much greater than in 1914. The remarkable
feature is rather the fact that so few cases occurred in 1915.
In addition to the cases occurring in healthy men, purulent
bronchitis was not an uncommon complication in the wounded,
and many cases were seen as complications of chest wounds,
especially where the wounded men had not been picked up
until the lapse of some time. Hence it seems that exposure
was a factor of importance in the causation of the disease. It
is of interest that although the bacillus of Pfeiffer was the organ-
ism most constantly found in the sputum, the disease occurred
in the years 1914 and 1916, when there was no epidemic of
influenza in the armies.
The disease attacked strong, healthy men, and although most
cases occurred in the more mature men, some were seen in
quite young soldiers, and the disease was by no means one
which chiefly affected the older men. This was more especially
seen in 1914 and 1916, when the aetiological problem was not
complicated by the presence of the influenza epidemic. The
1914 cases occurred in the men of the old army, and the 1916
in the men of the new armies, and both these categories were
exceptionally vigorous and strong men. The influence of cold
and exposure in causing the development of this more virulent
type of bronchitis was very evident among men who came from
India to Flanders during the winter of 1914-15, and naturally
felt the climatic conditions more severely than did the relatively
acclimatized troops from home. Certain British battalions,
which were recalled from India and arrived for service in France
in December, suffered severely from the disease. Indian
troops serving in Flanders were similarly affected.
Hospital returns never made a reliable differentiation between
purulent bronchitis and other respiratory diseases, but the
following figures for 1914 and 1915 from the Meerut Stationary
Hospital, at Boulogne, serve to illustrate the frequency of
these maladies amongst Indians : —
Total admissions .. .. .. .. 20,107
Respiratory diseases . . . . . . 2,485
Deaths from latter .. :. .. 84
These cases included 233 returned as pneumonia, with 58
deaths ; and in many the pneumonias were in reality cases
of purulent bronchitis.
The incidence of similar types of disease amongst troops in
the United Kingdom was first brought to notice early in 1916,
when Major Abrahams and Colonel French observed at the
(2396) O
214 MEDICAL HISTORY OF THE WAR
Connaught Hospital, Aldershot, that certain cases admitted
as " pneumonia " differed very materially from any ordinary
cases of lobar pneumonia in the paucity of their physical
signs, their atypical pyrexia and course, their peculiar
cyanosis, their abundant expectoration of almost pure pus —
often 10 ounces a day or more — their high mortality and the
atypical character of the autopsy findings. Bacteriological
investigation carried out by Eyre showed that these cases
were examples of a double infection of the respiratory
passages — either influenzo-pneumococcal or influenzo-strepto-
coccal. These results were published in the Lancet, and agreed
in almost every respect with those of similar researches carried
out independently in France by Hammond, Rolland and Shore.
Previous to 1917 the cases were for the most part
returned under the comprehensive heading of " pneumonia " ;
but, after they were differentiated from ordinary " pneumonia "
and began to be recognized as distinct under the name
" purulent bronchitis, " cases were returned from nearly
every command, with minor epidemics in some, such as Alder-
shot, and larger outbreaks in others, notably at Oswestry, and
amongst the New Zealand troops in the Southern Command in
the neighbourhood of Salisbury.
Etiology.
In 18 out of 20 cases examined in France by Rolland in the
winter of 1916, the Bacillus influenza was found to be present,
and in a considerable portion of the cases a pneumococcus was
also detected ; less frequently a streptococcus, and Diplococcus
catarrhalis were found in association with Pfeiffer's bacillus.
In ten cases the B. influenza was the predominating organism,
and in three no other organism could be seen in the films pre-
pared from the sputum. It seems from these results, and also
from similar work of other observers, that the organism most
constantly found in the sputum of these cases was the B.
influenza, but that the pneumococcus was frequently also
present especially in the cases where Pfeiffer's bacillus was
abundant. Pfeiffer's bacillus was constantly present in
various infections of the respiratory tract throughout the
campaign, and naso-pharyngeal swabs from men who were being
examined because they had been in contact with cases of cerebro-
spinal meningitis, frequently showed its presence in perfectly
healthy individuals. It is reasonable to assume that specially
debilitating influences of cold and exposure might weaken an
individual so that Pfeiffer's bacillus had the opportunity to
develop rapidly and, probably in symbiosis with pneumococci
PURULENT BRONCHITIS 215
or other organisms, to produce this novel picture of acute
suppurative bronchitis without broncho-pneumonic extension.
The essential point in connection with the bacteriology of
the Aldershot cases was that the infection was shown to be
a double one, a combined attack by influenza bacilli
and by pneumococci. The influenza bacilli were found mostly
early in the malady, the pneumococci prevailed later, and
Eyre's conclusion was that the acute beginning and the
infectiveness of the disease were both due to influenza bacilli,
pneumococci thereafter continuing the attack and causing
the purulent bronchitis itself and death from a greater or lesser
degree of pneumococcal septicaemia. Practically all the cases
in the Aldershot Command that were investigated in this way
proved to be influenzo-pneumococcal, but precisely similar
cases, especially amongst the New Zealand troops in the
Salisbury district, proved on investigation to have a form of
streptococcus as the organism associated with the influenza
bacillus and not the pneumococcus, so that, whereas the
Aldershot cases were influenzo-pneumococcal, other cases
were influenzo-streptococcal, and the general impression was
that there was no intrinsic reason why yet other organisms
might not sometimes be associated with the primary influenza
infection in causing the severe purulent bronchitis syndrome.
In other words, the bacteriology of purulent bronchitis is not
apparently constant. The influenza bacillus seems to be an
important factor in its epidemiology, but another micro-
organism, associated with the influenza bacillus, plays an
important part in the severity of the illness, the combination
being in some epidemics influenzo-pneumococcal, in others
influenzo-streptococcal, with a presumption that yet other
micro-organisms might be found if further epidemics could
be investigated.
Morbid Anatomy.
The lungs on post-mortem examination were large and bulky,
owing to the presence of much emphysema, but the most
characteristic lesion was the presence of thick greenish-yellow
pus in all the small bronchi and bronchioles, so that on a section
of the lung a large number of greenish-yellow points of varying
size were seen scattered over the surface of the section wherever
a bronchus was cut across. The pus was thick and completely
filled the lumen of the smaller bronchi and bronchioles, so that
these were obstructed and contained no air. The mucous mem-
brane of the larger bronchi was congested, and the pus here
might be discoloured from admixture with blood. The lung
contained many areas of collapse, small in size and scattered in
216 MEDICAL HISTORY OF THE WAR
distribution, usually best marked in the lower lobes and towards
their posterior borders. No case of massive collapse as a result
of purulent bronchitis was observed by Bradford, although
some instances of purulent bronchitis were seen as a complication
of cases of primary collapse in gunshot wounds of the chest.
(Edema of the lungs, together with much congestion, was
frequently present. In at least half the cases that terminated
fatally the bronchitic lesions described above were found without
any broncho-pneumonia, but in a considerable number of cases
small areas of broncho-pneumonia forming nodules, in the centre
of which the affected bronchiole could be seen, were also present.
Exceptionally these broncho-pneumonic areas were of larger
size and by their coalescence considerable areas of consolidation
might be produced.
The bronchial glands were frequently enlarged and pinkish
in colour, and in some instances the lymphatic glands generally
were enlarged. Pleurisy was frequently present but was usually
slight, a small amount of lymph being found on the pleura and
occasionally a few ounces of clear fluid in the pleural cavity.
Empyema was rare. The heart usually showed signs of dila-
tation especially on the right side, and the muscular substance
was pale and soft. The signs of dilatation were most evident in
cases where marked cyanosis had been present during life. The
kidneys in approximately half the cases showed evidence of
change, in that the cortex was pale and swollen and the texture
flabby. The renal epithelium was found on microscopic exami-
nation to have undergone degenerative changes, and frequently
desquamation of the epithelium, much congestion and some
round cell infiltration were also present, changes similar to those
found in acute nephritis.
The spleen, the liver, and sometimes the kidneys, showed
generally signs of engorgement, and fatty changes were not
infrequent in the liver.
There was nothing constant about the morbid anatomy of
the fatal cases amongst troops in the United Kingdom, except
the amount of pus exuding from nearly all the bronchioles
when the cut lungs were squeezed. In those cases that had
survived a number of days there was generally a con-
siderable amount of diffuse broncho-pneumonia with interstitial
haemorrhage as well ; and acute pleurisy, generally without
effusion, was frequently present in addition. But amongst the
considerable number seen there were several in which, in spite
of careful search, no macroscopic evidence could be found of
any broncho-pneumonia at all, though the clinical course-
beyond perhaps being rather more acute than the remainder-
was otherwise similar to those in which broncho-pneumonia
PURULENT BRONCHITIS
217
was present. In such cases the histological examination of the
lung showed remarkable inflammation not only in, but around
the smaller bronchioles, a pronounced and extensive bronchitis
with peribronchitis, as shown in the following illustration.
FIG. 1. — Section of lung tissue, under low power of microscope, showing
the alveoli to be hardly affected at all, while the bronchiole is filled with cells
and debris, and its wall and the immediately surrounding parts are
characteristically infiltrated with small round cells.
Symptoms of Cases in France and Flanders.
There was some variety in the clinical picture of the malady
in different cases. Some were not only acute in onset, but
might be more appropriately described as fulminating, owing
to the very rapid development of severe and often fatal lesions.
Others were more gradual both in their origin and in their
subsequent development.
In the acute type the onset and early symptoms present some
analogy to those seen at the onset of acute pneumonia. Thus
the onset of illness is sudden and accompanied by high fever,
cough and expectoration that may be tinged with blood.
Although these symptoms resemble those of pneumonia, there
are really certain differences. Thus the pyrexia is not usually
as high in purulent bronchitis as in pneumonia, and there is not
usually the definite rigor that is characteristic of pneumonia.
Local pain in the chest is also not common although there may
be much discomfort and sense of oppression. The sputum is
not rusty ; if blood is present it occurs as streaks of blood in
(2396) 0*
218
MEDICAL HISTORY OF THE WAR
the sputum, and this rapidly becomes frankly purulent and of
a peculiar greenish hue. Cough and oppression are very promi-
nent features, and the dyspnoea soon becomes urgent and is
accompanied by cyanosis. This cyanosis develops with great
rapidity, and in some of the most severe cases it may take only
a few hours for it to become one of the most marked features
of the illness. In many cases the patient is of a pale leaden
hue, in others the cyanosis is of the usual livid colour. Quite
early in the course of the malady the pulse rate is rapid, and
quite out of proportion to the pyrexia present. These acute
cases may terminate fatally on the fifth day of illness, and in
the most severe forms even earlier. Active delirium and
excitement such as are seen in pneumonia do not occur ;
the patient is more apt to be lethargic, although mild
delirium may be present.
In the less acute cases the disease runs a very remarkable
clinical course. The onset is more gradual, the symptoms of
cough and dyspnoea less urgent, although there may be and
usually is much fever. The temperature probably reaches
103° F., but it is not sustained and there are daily remissions
leading to the production of a chart that presents considerable
resemblance to that of a case of tuberculosis or even of enteric
fever. In these chronic cases the pulse rarely rises to 120, and
it may even be somewhat slow in relation to the temperature.
This pyrexia may persist for six or even more weeks, reaching
perhaps 102° F., or even 103° F. every day. The pyrexia is
accompanied with much sweating and very considerable wast-
ing, so that in many cases there is a resemblance to phthisis,
and sometimes it may not be easy to determine apart from
sputum examination whether tuberculosis is present or not.
Some cases also have a remittent pyrexia, with two, three,
or perhaps more bouts of high fever each lasting several days,
separated by intervals of comparatively low temperature.
*.
CHART I. — A less acute case, showing the prolonged, rather swinging
temperature and the fall by lysis without diminution of pulse-rate just before
death. Bacillus influenzce isolated.
PURULENT BRONCHITIS 219
The fever may terminate by a critical fall even as late as the
third week of illness, more usually it subsides gradually by
lysis, but death may nevertheless occur several days after the
temperature has reached and remained at the normal
level.
The sputum is remarkable in several respects. In the first
place it is very abundant. A patient will expectorate from six
to ten ounces in less than twenty-four hours, and soon after the
onset the sputum consists of nummulated non-aerated masses,
each one discrete, roughly the size of a shilling and remaining
discrete in the sputum cup. They are of a peculiar greenish
or greenish-yellow colour, not offensive, and very occasionally
streaked with blood ; this is very rare except at the onset and
the amount of blood is always small. The character of the
sputum and the very large quantities expectorated suggest at
first the sputum common in phthisis and in bronchiectasis ;
but it differs in that it is uniformly homogeneous and purulent,
there is no separation into layers, and no expectoration of mucus
and muco-catarrhal matter, in fact no liquid expectoration at
all, only these nummulated masses. This peculiar sputum is
one of the main clinical features of the disease.
Cough is frequent and at the onset painful and distressing ;
for a short time there may be but little expectoration, and it is
at this period that the sputum is apt to contain streaks of
blood. When the sputum has assumed its typical purulent and
nummular character, the cough, although necessarily very fre-
quent, is often not painful, and the sputum is expelled easily.
In the very acute and fulminating cases the cough is often
ineffectual, the sputum more scanty, and this is one of the
factors in the grave nature of these cases.
The pulse rate is rapid and frequently over 120 even in
cases that recover, and, as mentioned above, this tachycardia
is one of the main clinical features of the disease. The volume
and the tension of the pulse are often good notwithstanding the
rapid rate. In severe and unfavourable cases the tachycardia
is still more marked.
Dyspnoea and cyanosis are also prominent symptoms ; the
rate of respiration in all cases except the slightest is considerably
increased, and a respiratory rate of 30 to 40 per minute is not
unusual when the fever is not higher than 102° F. to 103° F.
The dyspnoea causes considerable distress, and in the more
severe forms, anxiety ; but in the most severe cases where
mental dullness or torpor is present, dyspnoea may reach a high
degree without apparently causing much discomfort. The
cyanosis is very marked and very persistent ; it is always a
sign of bad omen and the pallid form is the more serious. In
220 MEDICAL HISTORY OF THE WAR
the acute and fulminating forms, the cyanosis is most marked
and such cases are of the utmost gravity.
The physical signs are usually well marked, although they
are not so prominent a feature of the illness as is the case in
pneumonia, and the significance of some of the signs, more
especially the importance of the presence of areas in which the
breath sounds are weak, may be overlooked unless due care is
taken. In the earlier stages of the disease, rales and crepita-
tions, fine in character and perhaps rather limitedin distribution,
are the most marked signs, but together with these the breath
sounds are weak and distant, and areas may be found of
varying size where they are almost inaudible. The rales are
especially fine in character. These signs are most marked in the
lower axillary region, and posteriorly between the angle of the
scapula and the vertebral column. They may become more or
less rapidly generalized, but attention should be especially
directed to weakness of the breath sounds, without the presence
of any marked impairment of the percussion resonance or any
great alteration in the character of the breath sounds. In cases
where broncho-pneumonia is also present, the usual tubular
breathing and other physical signs of this condition may be
made out. The weakness of the breath sounds is doubtless
dependent upon the presence of areas of collapse, but these are
not generally sufficiently large to cause dullness on percussion,
although the resonance may be somewhat diminished. The
complete occlusion of the finer bronchioles by the purulent
exudate is the probable reason for the absence of tubular
breathing over the areas of collapse.
A pleuritic rub in the axillary region may sometimes be heard,
but often the presence of pleurisy is not detected clinically
owing to the presence of abundant rales masking the pleura!
friction .
In cases characterized by the presence of cyanotic lividity the
usual signs of over-distension of the right heart may be detected,
such as epigastric pulsation, fullness and pulsation of the veins
of the neck, and increase in the area of cardiac dullness to the
right of the sternum.
In many cases, even apart from cyanosis, considerable albu-
minuria is present and not uncommonly nephritis of a severe
type, with not only considerable quantities of albumin in the
urine, but also blood. The nephritis, even when severe, is not
accompanied by dropsy, but its presence adds greatly to the
gravity of the case.
The course of the malady varies ; in the acute cases it is
measured by days, and in the most severe death may occur on
the fifth day, or earlier still in cases of the fulminating type
PURULENT BRONCHITIS 221
associated with much cyanosis. In the less acute cases the
illness lasts many weeks and the high fever may persist for from
three to six weeks, or in some cases even longer. In such cases
even when recovery ultimately takes place there is great
prostration and much wasting.
A remarkable feature of the illness is that death may occur
after the subsidence of the fever both in the cases where this
occurs by crisis and also where lysis is seen, and the fatal event
may not take place until the lapse of two or three days after the
return of the temperature to the normal level. Death in these
cases is dependent upon one or other of the forms of asphyxia,
the result of the blocking of the bronchioles by the purulent
exudation.
Symptoms of Cases in the United Kingdom.
The characters of a typical case were briefly as follows. The
onset was usually acute, the man falling sick with what he
would regard generally as a " feverish cold in the head " and
with little about him to suggest that he was suffering from more
than acute " coryza " or " febricula." Many such cases would
recover quickly and not pass on to the next phase ; some would
not even report sick that day at all ; but those cases that were
going to be serious — and there was no means of distinguishing
these from others — had a temperature of 101° F. or 102° F.
the next day, felt ill, began to have a cough and were sent to
hospital. The cough was dry at first but within a very short
time phlegm began to come up, and by the third or fourth day
the sputum attracted particular notice by reason of its large
amount. Simultaneously the respiration rate rose to 28, 30, 35,
40, 45 or even 50 to the minute. So rapid and shallow was the
breathing in these cases that ordinary lobar pneumonia was
at once suspected, and it would have been difficult to persuade
those who had not attended post-mortem examinations in such
cases that the condition was not really lobar pneumonia.
The physical signs found were the same as those found in
France and as in France were remarkable for their atypical
character. Death might occur without any consolidation at
all, and during life the physician was struck by the paucity of
abnormal lung signs, although the case was one of obviously severe
pulmonary infection. The pulse might be accelerated no more
than was to be expected from the temperature — often indeed less
so — and the heart's action might remain good almost to the end.
The three most striking clinical features at first were the
abundance and character of the pus-expectoration, the relative
fewness of physical signs, and the rapidity of the respiration
rate. A little later in the disease a fourth point attracted
222 MEDICAL HISTORY OF THE WAR
notice, namely a peculiar dusky cyanosis of the face, lips, ears
and finger nails, which was always a grave omen. Over half
the cases died when once this cyanosis had become obvious. It
depended upon the man's natural ruddiness or otherwise what
his actual colour became ; a sallow man would look dusky-
ashen in his forehead, cheeks and nose, but his lips and ears and
nails would have the pale bluey-purple hue ; whilst a naturally
high-coloured man would change from red to a more and more
purple or blue-purple hue which might be obvious from the
other end of the ward. It was the cyanotic look, not the
actual colour, which portended the fatal issue.* The pulse
remained good ; the cyanosis was not due to heart failure, and
it was not benefited by venesection ; it seemed to result from
anoxaemia, oxygen being unable to gain access to the capillaries
by reason of the abundance of purulent secretion in the tubes.
Recovery at this stage might occur, but by the time the
cyanosis had become at all pronounced the prognosis was
extremely bad, although the number of days the patient sur-
vived in spite of it was sometimes surprising.
By this time the dyspnoea had often become very marked,
respiration consisting of short shallow movements, which in bad
cases amounted almost to gasps reminiscent of the effects of gas
poisoning. In less severe cases dyspnoea might be in abeyance
when the patient lay quite still, yet the slightest effort, such as
turning to one side for examination of the back, might send the
respiration rate up at once from 30 to 50 or over, this rate not
falling to the lower figure again for quite a long while afterwards.
The patients were consequently best left undisturbed.
The character of the sputum — pus in abundance — would
remain the same for days, though sometimes it would be blood-
stained or pure blood might be coughed up independently of
the pus. Rusty sputum was exceptional. In the later stages
of the illness areas of impaired note or actual dullness might be
found, particularly at the bases, associated with bronchial
breathing and crepitant rales. These might be due to progres-
sion of the purulent bronchitis into hypostatic pneumonia or
into actual broncho-pneumonia ; or they might be the result of
massive collapse secondary to the bronchitis and obstruction of
the bronchioles by thick pus ; or, again, as the result of pleurisy.
This last was not uncommon and not infrequently caused an
exudate of a pint or more of thin turbid fluid, which more
often than not cleared up after simple aspiration. An actual
empyema followed only in exceptional cases.
Defervescence was usually by lysis rather than by crisis,
* The plates at page 181 illustrate this condition.
PURULENT BRONCHITIS
223
and convalescence slow. Troublesome cough and persistent,
though diminished, expectoration might last for weeks, and
recrudescence of the mischief, possibly with a fatal termination,
after all had seemed to be going well, might occur even several
weeks after the primary attack. Many patients, on the con-
trary, made a complete recovery in a fortnight or three weeks.
The following chart is typical of the longer cases :—
The patient was a mechanic in the Royal Air Force, age 35 ; service four
months. He was admitted to hospital on April 4th, 1917, with a history of
having been out of sorts with a cold and bronchial cough for ten days
previously. On admission his temperature was 103° F. ; pulse-rate, 112;
respiration-rate 36. Abundant blood-stained purulent sputum. The
accompanying temperature chart indicates the course of the disease. The
man was seriously ill with purulent bronchitis for ten days ; improved
considerably for a short time ; then relapsed for a week, becoming seriously
ill again, but ultimately recovering completely. Throughout the whole time
he was in hospital he was coughing up abundant thick yellow pus, which, at
first bloodstained, was latterly yellow and free from visible blood. No tubercle
bacilli were found. The treatment was mainly by the use of antiseptic
inhalations.
The bacteriological findings were as follows. The sputum showed the
presence of B. influenza, pneumococcus, and Micrococcus catarrhalis.
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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
BIBLIOGRAPHY.
Pathogenic de Faeces palustre.
La crise hemoclasique initiale.
Pathogenic de 1'acces palustre.
La crise hemoclasique. Causes
et consequences.
Researches on the Treatment
of Benign Tertian Fever.
Notes sur quelques cas de palu-
disme primaire observes en
Macedoine.
Considerations relatives a la
conception uniciste des Hem-
atozoaires des fievres tierces
b6nigne et maligne.
Anti-mosquito measures in Pal-
estine during the campaigns of
1917-1918.
The treatment of Malaria
A method of Concentrating
Malaria Plasmodia for diag-
nostic and other purposes.
The transmission of Malaria by
Egyptian Anopheles.
The Treatment of Malaria
Mode d'action de la quinine sur
les diverses formes d'hema-
tozoaires ; traitement pro-
phylactique et curatif le plus
emcace du Paludisme.
Les Bilieuses paludeennes
Sur le mecanisme de la dispar-
ition des schizontes dans le
sang peripherique au cours
des acces de paludisme.
Culture de I'Hematozoaire du
paludisme
The treatment of Malaria
Bull, et Mem. Soc.
Med. des H6pit. de
Paris, 1919. 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
~elr~5f
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CHART II
PHLEBOTOMUS FEVER
351
CAY or
OJSCASE
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CHART III.
F .
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CHART IV.
352
MEDICAL HISTORY OF THE WAR
103
102
101
100
99
98
97
CHART V.
103
102
101
100
99
98
97
V
r
CHART VI.
flMJPM
;m|win|pn
CHART VII.
The pulse rate throughout is comparatively slow, and in
the later stages the pulse itself may be weak. The blood
picture is rather typical, and presents a leucopenia with a
relative decrease in the polymorphs. There is some increase
PHLEBOTOMUS FEVER 353
in the large and small mononuclears. The eosinophiles
diminish during the fever, but increase after it. The liver and
spleen are not enlarged.
Recovery appears to be the invariable rule, and most cases
of phlebotomus fever recover speedily and completely, so that
invaliding need merely be of a temporary nature. In a certain
proportion of cases, however, convalescence may be protracted
and characterized by mental depression, loss of memory,
lethargy, bone pains, neuritis, insomnia and dyspepsia.
Phlebitis has been noted as a complication. General disability
appears never to be permanent.
Opinions differ as regards acquired immunity. It was
formerly thought that a high degree was developed, but reports
of re-infection during the war were not lacking, more especially
perhaps in Macedonian cases. Secondary attacks are milder
than the primary ones. Re-infections must, of course, be dis-
tinguished from relapses which may possibly occur. Brack
is emphatic as to there being no acquired immunity, but
Adelmann, speaking of German cases in the Dardanelles,
states that one attack almost always gave immunity to the
soldiers.
Diagnosis.
There is no certain method of diagnosis, but in places where
sandflies are present phlebotomus fever may be suspected in
cases of acute fever occurring during the hot season and
characterized by sudden onset, short duration, face flush,
headache, injected eyes, rheumatoid pains and absence of
splenomegaly. The disease must be distinguished from
dengue, paratyphoid, abortive enteric fever, malaria, influenza,
undulant fever, typhus, heat stroke and minor septic conditions.
Phlebotomus fever and dengue were at one time considered
to be the same disease, and some still adhere to this view.
The chief protagonists of this theory are Sarrailhe and Megaw.
The former deals with the diseases as seen in the Mediterranean
war area, and indeed speaks of a " Mediterranean Dengue "
which, however, would appear to be merely a special form
of phlebotomus fever exhibiting an eruption like that of
dengue. Megaw draws attention to the great similarity of
the two fevers in India. He states that he would subscribe
to the following statement as regards phlebotomus fever: —
" It is a disease which is either one of the modifications of dengue or is closely
related to dengue. Those who consider it to be different from dengue say that
it can be distinguished by the absence of a rash and by the absence of a secon-
dary rise of temperature, though it must be admitted that in many outbreaks
of undoubted dengue numbers of the cases show neither rash nor secondary
fever. There is also a possibility that dengue is conveyed by a mosquito,
while sandfly fever is conveyed by a phlebotomus."
354 MEDICAL HISTORY OF THE WAR
Since this was written the infection of dengue has been defin-
itely shown to be transmitted by a mosquito, Stegomyia fasciata,
and, although there is no doubt that clinically dengue and phle-
botomus fever are very much alike, it would appear advisable to
regard them as distinct diseases. Seventy per cent, of cases of
dengue show the characteristic rashes while in some varieties
of dengue the temperature curve differs from that of sandfly
fever. The conjunctival congestion seen in the latter is also
rather characteristic. Castellani states that in 30 to 70 per
cent, of cases of dengue the superficial lymphatic glands,
especially those of the neck, are enlarged. This is occasionally
seen in pappataci fever. It is conceivable that the virus
of both diseases is similar, but is modified according as it
passes through the phlebotomus or the mosquito.
The absence of splenomegaly serves to distinguish sandfly
fever from paratyphoid, and the sudden onset is against
enteric. Malaria may be distinguished by the severity of
the rigor, the splenic enlargement and the presence of parasites
in the blood. In influenza, catarrh is usually more pronounced,
the pulse is quicker, and there is a leucocytosis and some
decrease in the lymphocytes. Weinberg mentions as points
of distinction the extremely rapid onset and quick rise to its
maximum of phlebotomus fever, the intensity of the con-
stitutional symptoms almost immediately prostrating the
patient, the greater severity of the pains affecting particularly
the ocular muscles, the greater injection of the conjunctiva
and the rarity of involvement of the respiratory tract. He
also draws attention to the evidence of the puncture marks
of sandflies and their presence in great abundance in the
locality. In Mediterranean fever the diagnosis is confirmed
by the agglutination test or by blood cultures, while in typhus
there is no leucopenia. In heat-stroke the temperature is
higher and the nervous symptoms more pronounced. Lumbar
puncture will show the cerebro-spinal fluid to be under increased
tension.
Treatment.
The following table, compiled by the Medical Research
Council from admission and discharge books, comprises a series
of 2,000 cases treated in military hospitals in Mesopotamia
and Salonika in 1916, 1917 and 1918. It shows the number
of days the patients were under treatment for sandfly fever
in those theatres of war.
PHLEBOTOMUS FEVER 355
Duration of Treatment in cases of Sandfly Fever.
Force from which derived.
No. of cases.
Total number of
days under treat-
ment.
Average number
of days under
treatment.
Salonika
Mesopotamia
120
1,880
1,873
21,995
15-6
11-7
Total
2,000
23,868
11-9
There is little doubt that the most valuable drug is
opium, especially if given early. Its efficiency was shown in
Mesopotamia and has been demonstrated in India and the
Sudan. A full dose (30 drops) of liquid extract of opium
administered at the outset will be found to afford great relief.
Failing this, the tincture may be given, also in a full dose.
Aspirin and the salicylates in fairly large doses often afford
comfort, and pyramidon has been found to assuage pain.
Myalgia is benefited by the application of hot sandbags.
Tonics are indicated during convalescence. Quinine is useless
and may aggravate the symptoms. It is advisable to apply
tincture of iodine to sandfly bites. It allays irritation and
lessens the risks of sepsis.
With regard to preventive measures, cases treated in infected
areas in hospital should be kept under fine-mesh nets during
the first forty-eight hours of fever to prevent the risk of others
becoming infected. A sandfly net should have a mesh of
twenty-two holes to the linear inch. Unless the material of
which it is composed is very fine such a net is oppressive in
a hot climate. Sandfly nets were, however, used with marked
success in Macedonia, were not found too hot and, apart
from the prevention of infection, enabled the men to sleep
in comfort. Those living in infected areas, and especially new-
comers, should use fine-mesh nets if at all possible. It is
important to see that there are no flies inside the net before
using it at night. They should be looked for in the angles
formed by the top and sides of the net.
It has been stated that sandflies do not fly high, and
Higgins, who records an outbreak of the fever from an island
in the Eastern Mediterranean, found that moving men from
the ground floor of a building to a lobby on the first floor
was a very effective preventive measure.
Repellents smeared on the skin may be tried. Of these
the vermijelli preparation containing some oil of citronella is
one of the most useful. Hewlett strongly recommends oil
356 MEDICAL HISTORY OF THE WAR
of cassia, a good formula being oil of cassia, one part ; brown
oil of camphor, two parts ; vaseline, lanoline or salad oil,
4-5 parts. Eucalyptus oil alone or combined with the oils of
anise and turpentine may be employed, a suitable prescription
being : —
Ol. anisi "^
Ol. eucalypti >aa Tl\iii
Ol. terebinth J
Lanolini 5i.
M. ft. ung.
,A lump of camphor may be taken to bed, as the flies dislike
its odour. Tobacco smoke keeps them away to some extent,
and electric fans, especially if depending from the ceiling,
are excellent deterrents. Lights in tents and bedrooms at
night attract the flies. In the case of billets and houses
generally, heavy furniture should stand well out from the walls,
as the insects are apt to hide behind cupboards and sideboards.
Frequent cleaning, dusting and removal of hangings help
to get rid of them, as do whitewashing and free ventilation.
When it can be managed camps should be placed on high-
lying sites exposed to the wind and should be well away and up-
wind from horse-lines. Breeding places in the neighbourhood
of drinking-water fountains should be avoided after dark.
The following general measures should also be adopted.
Where possible, ruined walls, masonry, heaps of rubble and
stones, and old damp latrines, which harbour the larvae, should
be removed. When this cannot be done all crevices should
be filled up by pointing the walls, if of stone or brick, or
plastering them smoothly if of mud, as, for example, in the
case of trenches and dug-outs. Where such breeding places
are limited it may be possible to make advantageous use of
some form of flame as, for example, a powerful painter's
lamp or the Lucal Comet Heater. Rat-holes and ant-holes
should be stopped. Vegetation about these places should be
cleared away and kept down. Cracks in the ground, and
especially in black cotton soil, should be filled up, or, if this
is impossible, treated with kerosene oil. Cultivation and
systematic watering prevent cracks from re-forming.
Measures should also be taken to capture the flies. For
this purpose biscuit boxes blackened on the inside and placed
in dark corners of the room are useful. Austen recommends
that sheets of " tangle-foot " with lights in front of them
should be affixed to the walls. These sheets should be slightly
warmed before use. Fumigation with sulphur may be employed
and spraying with 1 per cent, formalin has been recommended.
PHLEBOTOMUS FEVER
357
Adelmann
Birt
Brack
Castellan!
Delmege & Staddon
Graham
Hartley
Higgins
Legendre
Megaw
Sarrailhe
Weinberg
BIBLIOGRAPHY.
Beitrag zur Kenntnis des Pap-
patacifiebers
Phlebotomus Fever
Pappatacimiicken und Pappa-
tacierkrankungen
Notes on Tropical Diseases met
with in the Balkanic and Adri-
atic Zones
Clinical Notes on Phlebotomus
Fever
Sand-fly Fever in Chitral (N.
India)
Notes on an Outbreak of Phle-
botomus Fever
Note on Cases of Phlebotomus
Fever at an Island in the
Eastern Mediterranean.
Sur 1'existence dans La Somme
du Phlebotomus papatasii.
Scop.
Sandfly Fever and its Relation-
ship to Dengue
Dengue et Fievre de trois jours
Pappatacifieber und Influenza.
Archiv fur Schiffs-
u n d Tropenhy-
giene, 1919. Vol.
xxiii, p. 81.
B.M.J. 1915. Vol. ii,
p. 168.
Archiv fur Schiffs-
und Tropenhy-
giene, 1917. Vol.
xxi, p. 381.
Jl. of Trop. Med. &
Hyg. 1917. Vol. xx,
p. 170.
B.M.J. 1918. Vol i,
p. 396.
B.M.J. 1915. Vol. ii,
p. 169.
Jl. of R.A.M.C. 1918.
Vol.xxxi, p. 317.
B.M.J. 1916. Vol. i,
p. 166.
Comptes Rendus de
la Societe de Bio-
logic, 1916. Vol.
Ixxix, p. 25.
Ind.Med. Gaz. 1919.
Vol. liv, p. 241.
Bulletin de la So-
ciete de Pathologic
Exotique, 1916.
Vol. ix, p. 778.
Archiv fur Schiffs-
und Tropenhy-
giene, 1919. Vol.
xxiii, p. 331.
CHAPTER XVI.
TRENCH FEVER.
npRENCH fever is an infectious disease characterized by
J_ febrile periods which tend to recur at regular intervals,
by local pains, by an erythematous rash, and by enlarge-
ment of the spleen.
It was first noticed in the British troops in Flanders by
Graham in the summer of 1915, in Salonika by Hurst in the
latter part of the same year, in French troops in France in
1916, and about the same time in Italy. It occurred in
the German and Austrian Armies, but most of the accounts
given of it there, under the names of " Wolhynian fever,"
" five days' fever," " Polish, Russian intermittent, or
Meuse fever," and " His- Werner disease," evidently confuse
it with other diseases, and are not of great value as clinical
records. It has also been termed "shin fever," " gaiter-pain
fever," and " trench shin." It differs from any disease known
to medicine before the war. Allusions to a quintan fever by
ancient and mediaeval writers are too vague for identification.
The name " trench fever " was first used by Hunt and
Rankin. McNee, Renshaw and Brunt were the first to prove
its infectious character by injection of a patient's blood into
the vein of a healthy man. The clinical features of the disease
were studied, and the louse was early suspected to be the
vehicle, but nothing was certainly known until in 1917 the
Medical Investigation Committee commenced work in France,
and the War Office Trench Fever Committee in England. The
American Research Committee co-operated with the former
and carried out the experimental part of the work done in
France, and regular communication was kept up between the
groups of workers.
The disease was recognized in Flanders, France, Macedonia
and Italy and in the German and Austrian Armies. It is not
therefore much affected by climate or soil. All Europeans and
races originally European are subject to it. It was in no army
so carefully studied as in the British, but as it is easily confused
with other diseases the statistical returns give no exact idea
of its prevalence even in the British, still less in other armies.
Age has apparently no influence. In France patients were of
all ages up to 43, and in England volunteers of 70 seemed as
susceptible as younger men. There was no effect traceable
358
TRENCH FEVER 359
to food or drink. It was rightly named trench fever, for it
originated in the front area, and for a long time was hardly
noticed to arise at the base. Hospital officers, nurses and
orderlies caught it, and later when officers and other ranks
were sent from the front to army schools they brought the
infection into the back areas.
It is impossible to give with any accuracy the rate of inci-
dence among the troops. The name trench fever was not
sanctioned until 1917, and the fever was not made notifiable
till 1918, by which time it was much less common. In July 1918,
Colonel Soltau reported that for the preceding 12 months the
total admissions for all forms of sickness into the clearing
stations of the Second Army were 106,247, of which
15,392 cases were diagnosed as pyrexia of uncertain origin.
5,244 , , trench fever.
4,755
635
2,535
2,587
, myalgia.
, rheumatism.
, debility.
, cardiac (nearly all disordered action of
the heart).
Those who could fully examine the cases received as
pyrexia of uncertain origin were satisfied that the bulk of
them and many also of myalgia and rheumatism were really
trench fever. Without pretending to exactness, experience
justifies the statement that 15,000 to 20,000 of the 26,026 cases
diagnosed as P.U.O., trench fever, myalgia or rheumatism, were
probably cases of trench fever. This is confirmed by the
accurate observations in four base hospitals at Boulogne
by Lewis, Thursfield, Jex-Blake, and Foster, who received
1,241 cases labelled pyrexia of uncertain origin, trench fever,
or myalgia, and found that 822 or 66 per cent, were true
trench fever. The 26,026 cases above mentioned would
with the same ratio produce 17,350 cases of trench fever
which would thus form 16 per cent, of the total sickness.
In addition trench fever was probably responsible for a
considerable number of the 5,000 chronic cases. The
importance of the disease may be gathered from the following
estimates. The average evacuation for sickness, as distinct
from the result of wounds, from armies to base in France was
0-6 per cent, of the strength weekly. During the worst year
of trench fever, 1917, the percentage figure for this disease,
at, say, 15 per cent, of 0-6 per cent., would be somewhere
about -09 per cent. ; that is an army of 1,000,000 would lose
in a year by evacuation to the base at least 45,000 casualties
from trench fever. Of these casualties, as is shown below,
80 per cent, would lose on the average 60 days in hospitals
or depots, and at least three months in all off duty ; and of
360 MEDICAL HISTORY OF THE WAR
the remaining 9,000 more than 2,000 would be incapacitated for
a period of over six months. There were no deaths, but the
total loss of man-power resulting from this apparently new
disease was a very heavy drain on the army.
Mtiology.
When first recognized clinically in the spring of 1915, the
disease, from its general symptomatology, was suspected to
belong to the enteric group of fevers, possibly modified by
preventive inoculation. Much of the early work on aetiology
was therefore directed to proving or disproving this theory,
until evidence that the disease was a separate and complete
entity was gradually collected. All cultures from the blood,
stools and urine were negative, while the fact that B. para-
typhosus A and B had not then been introduced into the
preventive vaccine made the agglutination reactions simple
in their interpretation. The experimental work of McNee,
Renshaw and Brunt, showing that the blood was infective,
was strongly against the enteric theory, and the proof
was finally completed by the work of the American Com-
mittee.
Since the early experimental work demonstrated that the
virus circulated in the peripheral blood, long search was made
in blood films for a parasite, either intra or extra-corpuscular,
without result. These examinations of films, moreover, did
not reveal anything of diagnostic or prognostic significance
for the clinical pathology of the disease. Later work has all
tended to show that the virus circulating in the blood belongs
to the " filter-passing " group, and is therefore ultra-micro-
scopic. Observations on the possible nature of the virus con-
tained in the excreta of infected lice are dealt with below. It
has also been shown that the virus circulates free in the plasma
during the illness.
The body louse was early suspected to be the means of
transmission of the infection, and complete proof that this
is the case has been afforded by the experiments of the British
and American Committees. Both committees are agreed
that the blood of an infected man, and the faeces of an infected
louse, can be used to infect a new host, while the American
workers have also shown that in some cases the urinary
sediment and sputum may contain the virus. There is a
point of difference in the findings of the two committees
which merits attention. Whereas the American Committee
hold that the disease can be transferred from man to man
by the simple bite of the louse, the British Committee believe
that the mere bite is insufficient, that the virus is only present
TRENCH FEVER 361
in the faeces of the infected insect, and that a bite, scratch, or
abrasion of any kind, is of equal importance as a point
of entrance of the infection when .contaminated with in-
fected lice excreta. On this latter view Byam has brought
forward evidence to show that a louse must have bitten a
case of trench fever five to eight days previously before its
faeces become actively infective.
In work on the faeces of infected lice, Arkwright has fully
confirmed the observations of da Rocha Lima on the almost
invariable presence of so-called " Rickettsia bodies " in the
excreta of insects which have fed on patients suffering from
trench fever. These bodies, originally found by Ricketts
(1909) in the tick which transmits the disease known as Rocky
Mountain spotted fever, and later by Ricketts and Wilder
in the excreta from lice on cases of typhus fever, are of very
small size. The following criteria are given by Arkwright,
Bacot and Duncan for their recognition :—
(1) Minute size — smaller than M. melitensis or B. influenza
.—usually about 0-3 x 0-3 or 0-3 x 0-5mm.
(2) Irregularity in shape — round, oval, diplococcal, or
bacillary with stained poles.
(3) Occurrence in very large numbers, or even in masses,
especially in flakes of solid material in the excreta.
(4) Well-stained appearance when coloured by Giemsa's
stain, the colour being purple like that of the
nucleus of a leucocyte.
These bodies appear to be in some way closely connected
with the virus, but their exact relationship to the aetiology
of trench fever is so far uncertain.
The remaining points of importance in the aetiology of
the disease which have been clearly established concern the
powers of resistance of the virus and the period of infectivity
of cases of trench fever to lice, and therefore to other men.
It was established by the American Committee that the
virus " resists a temperature of 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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SPIROCILETAL JAUNDICE 393
Spirochaetosis ictero-haemorrhagica may therefore be regarded
as a disease in which certain symptoms and lesions can be
referred to a definite known cause, and acute yellow atrophy
as a provisional term denoting a condition in which the same
symptoms and lesions occur but the cause is unknown.
The spirochaete can sometimes be found in the peripheral
blood stream of patients suffering from the disease. Injection
of infected human blood into the peritoneal cavity of the
guinea-pig will, after an incubation of about a week, produce a
characteristic fatal illness in that animal, in whose tissues the
spirochsetes are present in large numbers. The spirochaete has
occasionally been isolated in pure culture from the blood, and
the guinea-pig inoculated from such culture contracts the disease.
The disease has been produced in man by accidental inoculation
from an infected guinea-pig. After the first fortnight of the
disease the spirochaete may be found in the patient's urine, and
in the third week of the disease the patient's serum agglutinates
the spirochaete.
At the commencement of the illness there may be difficulty
in diagnosis from the fact that the early symptoms may be
limited to those common to this and other diseases such as
influenza, enteric fever, trench fever or cerebro-spinal meningitis.
The complete clinical picture with jaundice is not present until
the fourth or fifth day. The occurrence of haemorrhages will
certainly suggest Spirochaetosis ; the same will be true, though
in less degree, of conjunctival suffusion and herpes. Both of
these may also occur in trench fever, though the herpes in the
latter is not haemorrhagic.
The guinea-pig test should be carried out the moment that
suspicion arises, for the blood of the patient suffering from
Spirochaetosis is only infective during the earlier stages of the
disease. After the fifth day the chances of a positive result
diminish, and after the eighth day are few. Since the average
day of appearance of jaundice is the fourth or fifth, it is easy to
see that the opportunity of inoculating a guinea-pig in time
may easily slip. Though, therefore, this diagnostic test is
conclusive, it has in practice its limitations. In mild cases
and non- jaundiced cases these limitations are even greater, for
in the former the infectivity of the patient's blood is of more
brief duration, and in the latter the manifestations suggesting
the presence of this disease will often be too late in
appearing.
During the second week of the illness the differentiation of
the enteric group will be assisted by the fact that the reaction
of the patient to atropine (1/30 gr. hypodermically) is normal,
whereas in enteric the acceleration of the pulse is often absent.
394 MEDICAL HISTORY OF THE WAR
A study of the clinical manifestations of the enteric group of
diseases during the war will show how closely they can
resemble spirochaetosis in its earlier stages. The onset of
paratyphoid fever was often sudden, there were head and body
pains, vomiting was sometimes an early feature, the abdomen
was commonly flat and the spleen was frequently not palpable.
The occurrence of stupor, haemorrhage and jaundice would
enable a diagnosis to be made.
Between spirochaetosis and trench fever in their earlier stages
clinical differentiation is often impossible.
After the ninth day, if the disease is spirochaetosis, spiro-
chaetes appear in the urine, reach their maximum about the
fifteenth day and disappear at the end of four or five weeks.
Jaundice in typhoid or paratyphoid fever does not usually
appear before the end of the second week, that is, a week later
than in spirochaetosis. Cases of enteric fever do, however,
occasionally occur in which jaundice appears early, and the
resemblance in the manifestations of the two diseases is then
very close. Blackwater fever and bilious remittent fever may
both of them be mistaken for spirochaetosis. Yellow fever also
closely resembles it.
Prognosis.
The Japanese found the mortality of the disease to be 30 per
cent. In Europe it has certainly been much less. Stokes and
his colleagues observed 100 cases of which six died. Dawson
and Hume observed 78 cases of which five died. McNee
estimates the mortality as not over four per cent. Death usually
occurs from the severity of the disease within the first fortnight,
but has occurred at twenty-one days from nephritis, at twenty-
eight days, cause not stated, and after three months when
extreme atrophy and cirrhosis of the liver were found. The
suspicion arises that the foundations of chronic disease of the
liver or kidneys may be laid in some patients who recover from
the spirochaetosis, but as yet there is no definite knowledge on
this point.
Treatment.
The Japanese prepared an antitoxic serum, but found little
advantage from its use. Pettit and Martin prepared a curative
serum from the horse which they found effective in the case
of guinea-pigs. This has since been confirmed by Noguchi.
Its use in man is doubtful. Renaux and Wilmaers reported in
favour of it, and Bassett-Smith recommended that it should
EPIDEMIC JAUNDICE 395
be supplied to the naval forces in France, but Gamier found
no benefit from its use in thirteen cases. Stokes showed that
guinea-pigs infected from rats could be cured from the serum of
a convalescent human patient.
EPIDEMIC CATARRHAL JAUNDICE.
Under the titles epidemic catarrhal jaundice of campaigns,
epidemic jaundice of campaigns, and camp jaundice, is
included a form of jaundice usually slight in degree in
which the constitutional symptoms are mild. It has the
features of an infection, either a blood infection which
has localized in the duodenum, for example, or less often per-
haps an infective gastritis which has extended to the duodenum.
The usual symptoms are malaise, transient fever, headache,
anorexia, nausea, abdominal discomfort, with jaundice super-
vening later. In France and Flanders these cases of jaundice
only occurred singly or in small groups, and not in epidemics as
they did in the Eastern theatres of war.
Epidemic catarrhal jaundice broke out in certain camps in
Alexandria in July 1915, and thereafter spread rapidly to
Gallipoli, Mudros, Salonika, and ultimately to Mesopotamia.
Gunson and Gunn described the group of cases occurring at
Alexandria among British troops during the summer of that
year. Early in 1916 Willcox published an account of epidemic
jaundice in the Dardanelles. This paper was supplemented by
C. J. Martin's article on the pathology and aetiology of the
outbreak and by the bacteriological reports of Archibald,
Hadfield, Logan and Campbell, working at the Mudros labora-
tories.
It was so prevalent as to be an important cause of
invaliding. Thus in Helles between 15th October and
November 1915, out of a total of 2,062 sick cases, 385 or 18
per cent, were cases of jaundice. The number of cases of
jaundice in Helles from 5th September to 6th November
was 2,195.
Out of a total of 22,810 sick evacuated from Suvla from
8th August to 7th November, 676 or three per cent, were cases
of jaundice ; and a large number were treated in the field
ambulances. Between 12th August and 1st December the
number of cases in the three field ambulances of the 53rd
Division in Suvla was 456 as compared with 612 cases of
" pyrexia " and 4,026 cases of dysentery and diarrhoea.
Its rate of incidence and relation to the above-mentioned
conditions are shown in the following tables.
396
MEDICAL HISTORY OF THE WAR
Number of cases of Dysentery and Diarrhoea, Pyrexia and
Jaundice evacuated from Suvla Bay.
Diarrhoea
Week ending
and
Dysentery.
Pyrexia.
Jaundice.
August 15, 1915
161
5
„ 22 „
339
16
„ 29 „
913
101
8
Sept. 5 „
840
58
4
12 „
827
147
7
„ 19 „
1080
189
17
26 „
1037
178
17
Oct 3 „
1144
309
38
10 „
971
242
52
17 „
790
154
123
24 „
922
206
109
31 „
875
251
169
Nov. 7 „
621
282
132
Total
10,520
2,138
676
Incidence of Dysentery and Diarrhoea, Pyrexia and Jaundice,
in 53rd Division, Suvla Bay.
Diarrhoea
Week ending
and
Pyrexia.
Jaundice.
Dysentery.
August 19, 1915
441
1
„ 26 „
354
2
5
Sept. 2 „
544
14
1
9
326
47
—
„ 16
256
60
,
„ 23
237
,58
2
„ 30
224
48
Oct. 7
229
48
3
14
201
62
10
„ 21
292
66
20
„ 28
206
35
51
Nov. 4
172
37
70
11
t
154
57
72
„ 18
225
32
61
„ 25
t
120
24
103
Dec. 1
•
•
•
45
21
58
Total
4,026
612
456
Between 24th September and 31st October the number of
cases admitted into the field ambulances of the 13th Division
at Suvla was 74 ; in November it rose to 287 and then fell to 92
by 19th December when Suvla was evacuated — a total of 453
EPIDEMIC JAUNDICE 397
cases. Similar rates of incidence occurred in every unit on the
Gallipoli Peninsula.
On evacuation of the Peninsula in December 1915, jaundice
from Suvla Bay was brought back to Egypt by the 53rd
Division, but it rapidly died out by the end of January 1916.
It was carried by the 10th Division from Suvla Bay to Salonika
in November 1915, and prevailed in that division during the
intensely wet weather in December, high up on the Bulgarian
mountains. Cases of jaundice there constituted a third or
more of the total sick admitted into hospitals in December
1915. It then died out and did not reappear.
The 13th Division which had also been badly affected -in
Suvla Bay returned to Egypt for the first three months of 1916,
and afterwards went to Mesopotamia carrying the infection with
it, for a sharp outbreak of 555 cases occurred in this division
in June 1916. The incidence fell rapidly during July and
August.
The usual history in any battalion affected commenced with
one or two isolated cases ; then there was an interval of about
three or four weeks with an occasional case ; then a large
number of cases for three weeks ; and finally an occasional
case for a few more weeks.
JEtiology.
The epidemic character of the disease in the Dardanelles and
Mesopotamia was beyond doubt. There were numerous in-
stances of a large proportion of the cases occurring in one unit.
In general, infection appeared to be due to a common cause,
though cases occurred in which it appeared to be conveyed from
person to person. There was close association between the
incidence of epidemic jaundice and that of the dysentery and
enterocolitis groups of affections. The charts of the two groups
showed that the jaundice curve reached its summit about three
weeks after the dysentery curve. Moreover, a recent history
of diarrhoea was not uncommon in the jaundice cases. On
the other hand, no jaundice occurred in Gallipoli till early in
August, although dysentery and diarrhoea were very prevalent
from June onwards.
Bacteriological investigation of epidemic catarrhal jaundice
was carried on with great persistence by many observers. Cases
here and there were found in which an organism of the enteric
group, typhosus or paratyphosus, was present. Spirochastal
infection as a cause was definitely excluded in those cases which
were studied after the recognition of spirochastosis ictero-
haemorrhagica. Blood and urine cultures yielded no results.
Mackie found an organism of B. coli communis type during life
(2396) AA
398 MEDICAL HISTORY OF THE WAR
on two occasions — once from liver puncture and once from the
urine.
In one case where duodenal intubation was tried, Martin and
Hurst, in Mudros, obtained a bacillus of the faecalis alkaligenes
group in six out of eight cases, and in three out of four control
cases.
The typhoid-coli group of organisms produces many varieties
of infection, the clinical manifestations of which are only very
imperfectly determined. In the war there were infections
whose symptoms did not conform to atypical paratyphoid fever.
The facts point to this epidemic catarrhal jaundice being
due to an infection which is localized in the upper part of the
alimentary tract, but the actual organism is unknown.
Observation suggests that the incubation period of the
infection is at least two weeks, and according to Hunter in most
cases even more. The uniformity in its mode of incidence and
its subsequent spread is of importance in connection with the
question of its aetiology, namely, whether it is only an incidental
complication of other known infections, e.g., typhoid, para-
typhoid, or dysentery, or on the other hand an infection sui
generis. Taken as a whole the facts speak for the specificity of
the infection.
Symptoms.
The clinical picture appears to have been fairly constant.
The illness was, as a rule, ushered in with headache, general
malaise, loss of appetite, fever, nausea, and sometimes vomiting,
with discomfort and tenderness over the upper abdomen. The
abdominal symptoms would sometimes precede the onset of
pyrexia. Constipation was as common as diarrhoea. The
tongue was usually furred but in some cases remained clean.
Jaundice appeared on the third or fourth day of illness,
sometimes with the decline of pyrexia ; it reached its height
about the tenth day and then gradually faded. It varied
much, however, in intensity and duration ; when severe it
was liable to last several weeks, but it seldom ran parallel
with the malaise. The jaundice was sometimes associated
with swelling and tenderness of the liver and less often of
the gall-bladder, and with enlargement of the spleen (Chart VI).
In Mesopotamia, Willcox frequently observed that about the
third or fourth day precordial dullness increased on the right
side. This increase lasted only for four or five days and then
subsided. During the fever the pulse quickened to 80 or 90,
but in some cases it was noticed that it was only 50 when
jaundice commenced. The urine contained bile, and slight
albuminuria was not unusual. The stools were clay-coloured.
Persistent pain in the back and legs was a feature of some cases.
EPIDEMIC JAUNDICE 399
There was a liability to relapses of four or five days' duration.
Many patients suffered from persistent weakness accompanied
often by a marked loss of weight. Convalescence lasted two
or three months.
M
u
M
tr
ii
29
3D
sfr
rf-
3
1
f
6
,-fr
I0i
102
101
T
a
-^
IE.
L
.1..
,..u,_.
"J
J
j
100
\ *
1
99
-
h
*
V
j\
/
\
^
97
J
3
S^
A
j
V
^*
V
£
96
y
v
CHART VI. — Epidemic Catarrhal Jaundice.
Jaundice appeared on 24th September. On 26th September liver and spleen
enlarged and right heart dilated (Willcox).
Generally speaking, infective catarrhal jaundice, both in the
sporadic and epidemic forms, was a mild though somewhat
exhausting illness. Here and there, however, more severe
infections occurred, and sometimes what appeared to be a typi-
cally mild case passed on to icterus gravis and ended fatally.
During the jaundice stage acute toxic symptoms developed and
death ensued two or three days after their onset.
V= Vomited.
D = Delirious.
C = Coma.
Post-mortem, pale
yellow atrophy.
TSHf>
IQ3
108
107
/06
105
10*
103
102
101
100
99
98
97
3?Jl *B
?9
•V
1(
?
>
1
M [f
&
3
ai
M r
HJI
lie
1|C
V
D
D
c
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A
K
f
* {
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f
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/
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WistM
7Q
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71
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80
Z'O
CHART VII. — Epidemic Catarrhal Jaundice with Icterus Gravis.
Jaundice before Admission.
The grave symptoms usually supervened about ten days
after the first appearance of the jaundice, though in one case
they developed as early as two days, and in another as late as
twenty-nine days. There was no foreboding of these grave
developments in such cases. The following case illustrates this
occurrence (Chart VII).
400 MEDICAL HISTORY OF THE WAR
Patient taken ill 24th December, 1917, with slight fever and usual symptoms
of epidemic catarrhal jaundice. On 28th December, temperature normal,
liver enlarged and tender, spleen palpable and slightly tender, tongue furred,
constipated, definitely jaundiced, urine bile-stained, mental condition normal.
Several attacks of vomiting, with no blood, occurred during the next three days.
2nd January, 1918 : — Vomit contained streaks of blood and was bile-stained.
Jaundice now deep. Very restless and maniacal during last night and this
morning.
3rd January, 1918 : — Vomit as on previous day. Epistaxis in morning,
liver dulness much diminished, being only two inches vertically ; knee jerks
increased. Very restless and noisy.
4th January, 1918 : — Patient became comatose in morning, urine contained
albumen, bile, and a few red corpuscles, no spirochaetes found in urine or blood.
5 p.m. — Cheyne Stokes breathing, extensor plantar reflex.
10 p.m. — Temperature suddenly rose to 109°, death occurring at 10.30.
Post-mortem Examination. — Liver 39£ ozs. stained yellow. Spleen enlarged
and soft, kidneys yellowish. Small haemorrhages in pleura, pericardium,
omentum, mesentery, and lungs. Wall of stomach and duodenum con-
tained petechiae and contents were blood-stained.
Microscopical examination and animal experiments for spirochaetes of liver,
kidney, and spleen were negative. Liver showed almost complete destruction
of hepatic cells in blocks, only isolated islets of cells remained, in parts total
necrosis of all but trabecular tissue. Kidney, extensive degeneration of tubu-
lar cells. Pancreas, early but definite cell necrosis, with shrinkage and loss of
•outline of the cells that remain, in some places great reduction in number of
-cells.
The following case is an example of a more severe infection
from the outset.
Onset was gradual with chilliness, fever, weakness, anorexia, abdominal pain
and vomiting. On the fourth day, patient declared sick, and the temperature
•was 108°. On the fifth day the temperature was normal and j aundice appeared .
The upper half of the abdomen was tender and the spleen could be felt for 1 \
inches below the costal margin. The jaundice rapidly became deep, but,
though apathetic, the patient never was in a toxic condition. The urine con-
tained bile and a trace of albumin.
On the ninth day the jaundice was slightly less. On the tenth day there
was a return of fever and the spleen remained palpable, but there was no
deepening of the icterus. The temperature did not finally settle till the
eighteenth day ; the jaundice and the enlargement of the spleen had dis-
appeared on the twentieth day, and by that time convalescence was established,
The atropin test was made twice — on the sixth day, when there was an
escape of 20 (60-80), and on the fifteenth day, when there was an escape of
16 (66-82).
Agglutinations were tested three times — on the ninth, fourteenth and nine-
teenth days. They were negative to paratyphoid A and B, and typhoid
remained constant at 1 in 215. The patient had been inoculated against
typhoid only two years previously.
A blood culture was made during a relapse of fever, and two cultures from
urine and two from fasces were negative to the enteric group. On two occa-
sions the urine was thoroughly searched for spirochaetes, but with negative
results.
The fasting stomach and duodenum were intubated. Cultures from the
gastric contents were negative, while those from the duodenum contents
showed a growth of a gram negative coccobacillus. The characters of this bacil-
lus were tested by putting it through broth, gelatine, agar, litmus milk, litmus
whey, peptone, and the sugars. Litmus milk and whey became alkaline in
twenty-four hours without clot formation in the former. The sugars were not
acted upon, with the exception of glucose, from which acid without gas was
formed after forty-eight hours' incubation.
This coliform organism was the sole positive result from the investigations.
It was not agglutinated by the patient's own serum.
ENTERIC JAUNDICE
401
JAUNDICE IN THE ENTERIC GROUP OF FEVERS.
Jaundice is an uncommon though interesting feature of
enteric fever. During the first two and a half years of the war
its incidence among cases of enteric in the British armies in
France and Flanders was 1*38 per cent., and amongst cases
occurring at the Dardanelles and in Mesopotamia, according to
Willcox, as much as 5 per cent. The jaundice may occur
early in the illness, that is, before the tenth day, or during the
later stages ; it may present every grade from faint to deep
pigmentation. If severe, the icterus will make the patient
more drowsy and toxic, otherwise it seems to have little effect
on the course of the illness and its appearance in the later weeks
10 II 12 13 14 15 16 17 18 19 20 21
CHART VIIJ.
is not necessarily associated with either return of fever or
exacerbation of symptoms. Of the early symptoms, headache
is the most constant, and vomiting is common. In a series of
26 cases the following were the manifestations with their relative
frequency : headache 19, vomiting 12, abdominal pains 8,
back and leg pains 8, diarrhoea 5, shivering 2, extreme lassitude
2, epistaxis 1. Spots were present in four cases, and the spleen
was palpable in four cases, but the relative infrequency of these
two manifestations, as also of abdominal distension, was charac-
teristic of the clinical picture of enteric fever in France and
Flanders throughout the war. When the jaundice occurred
early its onset was more often sudden, whereas when it occurred
at a later stage a gradual onset was more usual.
(2396)
AA*
402
MEDICAL HISTORY OF THE WAR
When jaundice occurs early in a febrile illness, the possibility
of one of the enteric groups being the underlying cause may
easily escape notice, and this is especially the case if the fever
is of short duration, or moderate in degree, as is illustrated by
the following case of infection by B. typhosus '(Chart VIII).
There was a sudden onset with extreme lassitude and headache, which
forced the patient to bed within a few hours. On the second day there were
pains in the head, legs and across the abdomen, and the temperature was 104°.
On the fifth day there was repeated vomiting, and icterus, which had shown itself
on the previous day, had become definite. By the sixth day the jaundice was
marked, though the temperature had fallen and the pulse-rate was 88 ; the
abdomen was flat, but tender in its upper half ; the spleen was not enlarged,
but the liver extended three fingers' breadth below the costal margin ; no
herpes ; the glands were shotty ; the patient was apathetic and drowsy. The
next day the apathy continued and there was vomiting. On the eighth day
the white cells were 23,800 per c.mm., the red cells 4,800,000 and the
haemoglobin was 80 per cent. Films showed the red cells to be normal. On
CHART IX.
the tenth day there was still apathy, the tongue was dry in the centre and
furred at the side, the spleen was enlarged to percussion, but not palpable ;
the urine had a specific gravity of 1,01 1, was acid, contained bile and numerous
hyaline and granular casts, a few red blood cells, but no albumin. The casts
had disappeared two days later and a trace of albumin had appeared.
On the fifteenth day the patient's condition had improved ; the jaundice,
though still marked, was diminishing ; the spleen, however, had become dis-
tinctly palpable. Blood pressure was 118 systolic and 58 diastolic. In
spite of a slight rise of temperature on the seventeenth day the patient's
condition steadily improved, and the jaundice faded.
On the tenth day after the injection of ^ grain of atropin, the maximum
acceleration of the heart was only six beats (70 to 76) in 50 minutes. On the
sixteenth day the same dose of atropin produced an escape of twenty-four
beats (68 to 92) in half an hour. The difference in these two observations
illustrates what Captain Harris has pointed out — that the locking of the heart
ENTERIC JAUNDICE
403
under atropin in the enteric group may be limited to a few days, the favourite
period being about the tenth day.
Bacteriological cultures from the blood, stool and urine were negative.
Agglutinations on the eighth day showed a big rise in typhoid, viz., 1 in 2,500,
rising after delay to 1 in 3,675. On the sixteenth day the agglutinations had
fallen to 1 in 2,822. Paratyphoid A and B were negative to 1 in 5. The patient
had been inoculated against typhoid about a year previously but not against
paratyphoid.
Investigation was made for spirochaetosis ; a guinea-pig was injected with
the patient's blood on the sixth day, but with negative results ; the urine was
examined twice for spirochaetes, the last time on the seventeenth day, and
with negative results.
This is a case of interest, for it might easily have been mis-
taken for either spirochaetal or catarrhal jaundice. The acute
onset, lassitude and pains, the jaundice developing as the tem-
perature fell, the shotty glands, could justly have pointed to
spirochaetosis ; and if the atropin test had not been applied
till the sixteenth day, the escape of the heart might have been
an argument against enteric fever. On the other hand, the
very brief period of fever, the flat abdomen, and the absence
^ j- g y ^ ^ jQ jl |5 J3 |4 I*- ic |^r jo |
^FSI
^
v y
CHART X.
of splenic enlargement in the early part of the illness might
well have led to a diagnosis of catarrhal jaundice.
Chart IX represents the chart of a case of infection by paratyphosus B.
Here again the onset was sudden, the patient being seized with pains in the
legs, which were so bad that he was unable to stand. Later he vomited. At
the onset of the illness the temperature reached 104°. On the third day
jaundice appeared in the conjunctivas and rapidly spread all over the body.
On the eighth day the temperature was 101 '2° and the pulse rate 96 ; the
patient was deeply jaundiced and drowsy and complained of a general aching
The liver extended three fingers' breadth below the ribs ; the spleen could not
be fe.lt, but the splenic region was very tender.
On the twelfth day the temperature rose further, and the patient became
worse. On this day the atropin test was applied, and after the injection of
3^ grain the heart only quickened four beats, from 100 to 104. He was more
drowsy ; there were bronchitic rales throughout both lungs and the pulse was
markedly dicrotic. He remained very ill for three weeks, during which he
passed through a serious relapse, associated at its commencement with an
increase in the jaundice.
About the twenty-first day the jaundice began to diminish and the symp-
toms to improve, and at the end of five weeks of illness convalescence was
established.
Chart X represents the chart from a case of paratyphoid A in which the
jaundice appeared on the sixth day. Paratyphoid A was recovered from the
stools.
404 MEDICAL HISTORY OF THE WAR
Such cases indicate the importance of being on one's guard
lest catarrhal jaundice is not in reality disguising enteric fever.
When jaundice occurs late in a case of enteric fever there is
seldom any added difficulty of diagnosis owing to its presence.
The jaundice appears without special symptoms, though, ex-
ceptionally, these are suggestive of cholecystitis. Thus, in a
case of paratyphoid B, during the fourth week, there were three
rigors, jaundice appeared, and the region of the gall bladder
became tender. Bacillus paratyphosus B was found in a stool,
and the agglutination curve pointed to that organism.
Pathology.
The cause of the jaundice in these cases would seem to be
some obstruction in the biliary tract. The symptoms are not
usually severe or lasting enough for there to be any involvement
of the smaller ducts within the liver, and are best explained by
swelling of the papilla of Vater as part of a duodenal inflam-
mation due to the localization of the infection in the duodenum.
The localization of typhoid and paratyphoid infections, though
showing a strong selectiveness for the ileum and colon, does not
limit itself always to that part of the intestine, and the lesions
may rarely be found not in the intestine at all, but in some
other organ — for example, abscess of the spleen.
In a case which occurred in the Dardanelles, jaundice de-
veloped on the third day and death occurred on the ninth day.
The duodenum was found to be of a velvety appearance and
the walls of the common bile duct and hepatic ducts showed
acute inflammation. Paratyphosus B was recovered from the
bile in the gall bladder. This was clearly an ascending
inflammation from the duodenum.
On the other hand, Brule argues that the classical explanation
of the origin of jaundice — namely, that there is a mechanical
obstruction of the larger or smaller bile ducts, or of both — is
not wholly satisfactory in the light of modern investigations.
He seeks to prove that in view of the infective origin of most
cases of jaundice, excluding those caused by gross obstructions
of bile ducts, the biliary retention must be due to a hepatitis
rather than to angiocholitis, and that the derangement of
secretion must occur in the liver cells themselves. His work as
a whole throws some new light on the problems of hepatic
disease. Holding that injury of the secretory cells of the liver
is the usual cause of jaundice, he believes that jaundice caused
by obstruction of the bile ducts is relatively uncommon.
Jaundice associated with pylephlebitis may very rarely be
caused by infection due to one of the enteric group of organisms,
and one such case occurred in France.
Archibald, Hadfield,
Logan & Campbell
Bassett-Smith
Bietzke
Brute
Carpi
Chambers . .
Coles
Cockayne
Costa & Trosier
Cristau
Dawson & Hume .
Dawson, Hume &
Bedson
Dawson . . % .
Fiessinger
Fraenkel
Frugoni & Cannata
Gamier & Reilly . .
JAUNDICE
BIBLIOGRAPHY.
Reports of the M. & H. Labora-
tories dealing with the diseases
affecting the troops in the
Dardanelles.
A short laboratory study of
Spivochcsta ictero-hcemorrhagics.
Ueber die pathologische Anato-
mie der anstechenden Gelb-
sucht.
Recherches re'centes sur les
icteres.
Osservazioni sulla spirochetosi
itterogena.
An outbreak of infectious Jaun-
dice.
Rat-Bite Fever
A note on the occurrence of
Spirochata HcBmovrhagics in
the common rat in England.
Catarrhal Jaundice, Sporadic &
Epidemic (with full historical
bibliography) .
Mort du Lapin et Survie du
Cobaye dans la Spiroche'tosa
Icterohe'niorragique Exp6ri-
mentale.
Reactions Cytologiques et Chim-
Iques du Liquide Cephalora-
chidien dans la Spiroch6tosa
Ict6roh6morragique.
De la Dilatation Cardiaque Aigue
dans la Spirochetosa Ict6ro-
h^morragique.
Note sur la Spiroch6tose a
Lorient.
Jaundice of Infective Origin . .
Infective Jaundice (Spirochae-
tosis Ictero-hasmorrhagica) .
An Address on Spirochaetosis
Ictero-haemorrhagica .
A propos des Spirochetes du
M6at et de 1'Urine de 1'Homme
Normal.
Icterus Infectiosus
Ittero epidemico al campo da
bacillo paratifo B.
L'Ictere Infectieux a Spirochetes
La Recherche du Spirochete
Icte"rigene dans 1'Urine de
l'Homme et du Cobaye.
405
Jl. of R.A.M.C.,1916,
Vol. xxvi, p. 695.
Parasitology, 1918-
19. Vol.xi, p. 198.
Berl. Klin. Woch.,
1916. Vol. liii, p.
188.
1919.
Policlinico (Rome),
1917. Vol. xxiv,
Sez Prat., p. 949.
Jl.ofR.A.M.C., 1917.
Vol. xxix, p. 108.
B.M.J., 1918. Vol. i,
p. 275.
Lancet, 1918. Vol.
i, p. 468.
Quart. Jl. of Med.,
1912-13. Vol. vi.
p. 1.
Compt. Rend, de la
Soc. de Biol., 1917.
Vol. Ixxx, p. 27.
Ibid. 191 7. Vol. Ixxx,
p. 29.
Bull. Soc. M6d. des
Hdp. de Paris, 1917.
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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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
I! s a
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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
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