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the clinical features, as described, are quite unlike those spirillum fever as met with in Uganda.
The disease is certainly not a new one in Uganda, though in times past it was confused with and mistaken for malaria.
Apart from the fact that it is now more definitely recognised and diagnosed, there is no doubt that it is becoming more prevalent. This in a great measure is due to there being more traffic on the main roads than formerly, and it is in the tick-infested camps on these roads that the infection is generally picked up.
Owing to their careless and unobservant habits the natives are the chief sufferers. In order to avoid repetition the notes about to be given will be based on observa- tions on all classes of patients.
The total number of cases which came under observation during the year was 143, as follows:-
Europeans Asiatics Natives
Total
9
12
122
143
In not more than 10 of these cases could the infection be traced to Entebbe, by far the greater number occurred among natives who had recently come off journeys.
Incubation Period.-This is a difficult matter to determine, but from various observations I am inclined to put it at about 10 to 14 days in a susceptible subject.
Immunity. There is little doubt that one attack confers a partial immunity, and it is more than probable that after a second or third infection this immunity becomes complete.
I have seen two cases in natives of what must have been either a very late relapse or a second infection, after a period of six months. In each of these cases only one attack occurred. A case of a European is also suggestive. In this instance In the patient had spirillum fever, with five relapses in July and August of 1905. November he was exposed to the risk of fresh infection while travelling from his station to Entebbe. He arrived on November 22nd and, on December 15th, had a sharp attack lasting three days. Spirilla were found but very scantily. After an interval of 19 days he had a relapse, and this time also the parasites were very sparse. It remains to be seen whether any more relapses will occur, but I am inclined to think the long incubation period of 23 days in this case was due to a partial immunity.
Amongst natives it is quite a common occurrence for a patient to have one single attack without any relapse.
Number of Relapses.-Owing to the long drawn out course of the disease it is difficult to keep patients, especially natives, under observation throughout the whole time. During the apyretic period the general health may be quite good and the patient refuse to remain in hospital.
In only two instances did I have the opportunity of watching European patients from the beginning to the end; reference will be made to these two cases later.
In 30 cases among natives I obtained a fairly complete record. In 21 of them there was only one attack (initial) without any relapse.
In 2 there were 2 attacks, 1 initial and 1 relapse.
1
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3
3 4
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15
2
31
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5 6
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1 1 1 1
2
21
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'3 4
20
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5
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The time which elapsed between the initial attack and the first relapse varied from 5 to 9 days.
The interval between the-
1st and 2nd relapse varied from 5 to 8 days; 2nd and 3rd relapse varied from 5 to 9 days; 3rd and 4th relapse varied from 8 to 36 days; 4th and 5th relapse was 8 days in one case.
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If a period of 10 days elapses after the termination of the initial attack without a relapse none need be anticipated. As a general rule, after the first relapse the intervals tend to grow longer.
This
Presence of the Parasites. In the earlier attacks the parasites are generally more numerous than in the later ones, when they may be extremely scarce. rule does not always hold good, however, for I have found them plentiful at times even in the late attacks. Towards the end of an attack they begin to disappear even before the temperature has fallen to normal. In one fatal case, complicated with tubercular meningitis, spirilla were found even when there was no temperature.
Symptoms.-
Pyrexia. This is, as a rule, high-a temperature of 106° being not uncommon; there is great depression.
Digestive System.-The tongue is quite characteristic; it is moist and deeply coated all over with a white fur; there is thirst and vomiting, the latter especially in Europeans, not so in natives. The bowels are constipated; slight jaundice is common; the liver and spleen are generally enlarged and tender, in some cases only one of these organs is affected.
Pulmonary. Slight cough is common, and there are often physical signs sug- gesting pneumonia; the sputa may be thick and blood-stained.
Cardiac. Pericardial pain and distress are often complained of; towards the end of the attacks syncopal attacks are of frequent occurrence and should be guarded against.
Nervous. Delirium is not common; persistent and excruciating headache is a constant feature, and may persist for some days after the temperature has fallen to normal.
Eye Symptoms.-A curious condition affecting the eye is often met with, as a rule it is unilateral, but have seen both eyes affected. When it occurs it generally comes on about the third or fourth relapse. The symptoms consist of an injection of the deeper vessels of the sclera round the cornea, not unlike that seen in an ordinary iritis, but the conjunctival vessels are hardly, if at all, affected. There is pain, lachrymation, and slight photophobia. The iris looks clear and, on cursory examination, may seem mobile. The first few cases seen by me were diagnosed as a sclerotitis, but more careful examination showed that in reality the iris is affected. If atropine be instilled it will be seen that there are adhesions, but these are rarely tight, in fact it is almost necessary in some cases to watch the process of dilatation, as otherwise the fact of their presence may be over- looked. It will be seen that the iris does not dilate regularly, but is bound down at one or more points, but these adhesions are so slight that in a very short time the dilatation may be complete and regular.
On examining with the ophthalmoscope it will be noted that there is an abundant deposit of spots of pigment on the lens, which I believe occurs far more frequently than in an ordinary iritis. Often it appears in the form of a complete ring on the lens. The vitreous is cloudy, so much so that it may be impossible to see the fundus. The patient complains of a cloud before the eye, or he will state that there is a dark patch over one part of his field of vision. The condition clears up entirely after the lapse of a few months.
My own impression is that it is not a real inflammatory iritis, but a condition which results from a thrombosis of vessels of the ciliary bodies and iris. For want of a better name I would call it an iridocyclitis.
Prognosis. This is good as regards recovery. The attacks cause a great deal of acute suffering-headache, vomiting, &c., but they run their course and cure them- selves. Patients who have had four or five attacks get into a somewhat debilitated state, but there is no striking anaemia. More accurate observations on this point are required. The eye symptoms described cause great inconvenience, but, if treated, no permanent ill effects follow.
Out of 134 cases seen this year only three proved fatal. In one the actual cause of death was basal tubercular meningitis; the second was a female who aborted during her initial attack, and it is possible the fatal issue was due to septic com- plications; and the third was a baby in arms, probable age about five months. ful observations in the last two cases were not possible.
Care-
Treatment. So far I cannot speak with confidence in regard to any specific line of treatment. For the actual attacks symptomatic treatment must be adopted;
28187
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PUBLIC RECORD OFFICE
Reference :-
C.O.885
18 PUBLIC RECORD OFFICE, LONDON
ALLY WITHOUT PERMISSION OF THE BE REPRODUCED PHOTOGRAPHIC-
COPYRIGHT PHOTOGRAPH-NOT TO
131
ys elapses after the termination of the initial attack without anticipated. As a general rule, after the first relapse the
onger.
rasites. In the earlier attacks the parasites are generally the later ones, when they may be extremely scarce. This
5.
ld good, however, for I have found them 'plentiful at times Towards the end of an attack they begin to disappear ature has fallen to normal. In one fatal case, complicated itis, spirilla were found even when there was no temperature.
is a rule, high-a temperature of 100° being not uncommon;
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-The tongue is quite characteristic; it is moist and deeply vhite fur; there is thirst and vomiting, the latter especially
a natives. The bowels are constipated; slight jaundice is I spleen are generally enlarged and tender, in some cases s is affected.
t cough is common, and there are often physical signs sug-
sputa may be thick and blood-stained.
ial pain and distress are often complained of; towards the pal attacks are of frequent occurrence and should be guarded
1 is not common; persistent and excruciating headache is a nay persist for some days after the temperature has fallen
curious condition affecting the eye is often met with, as but I have seen both eyes affected. When it occurs it ut the third or fourth relapse. The symptoms consist of an vessels of the sclera round the cornea, not unlike that seen out the conjunctival vessels are hardly, if at all, affected. ition, and slight photophobia. The iris looks clear and, on nay seem mobile. The first few cases seen by me were is, but more careful examination showed that in reality the opine be instilled it will be seen that there are adhesions, ght, in fact it is almost necessary in some cases to watch on, as otherwise the fact of their presence may be over- that the iris does not dilate regularly, but is bound down at these adhesions are so slight that in a very short time the lete and regular.
th the ophthalmoscope it will be noted that there is an ots of pigment on the lens, which I believe occurs far more ordinary iritis. Often it appears in the form of a complete
vitreous is cloudy, so much so that it may be impossible to atient complains of a cloud before the eye, or he will state ch over one part of his field of vision. The condition clears use of a few months.
1 is that it is not a real inflammatory iritis, but a condition rombosis of vessels of the ciliary bodies and iris. For want Id call it an iridocyclitis.
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good as regards recovery. The attacks cause a great deal lache, vomiting, &c., but they run their course and cure them- ave had four or five attacks get into a somewhat debilitated triking anaemia. More accurate observations on this point e symptoms described cause great inconvenience, but, if ll effects follow.
en this year only three proved fatal. In one the actual cause >ercular meningitis; the second was a female who aborted k, and it is possible the fatal issue was due to septic com- 1 was a baby in arms, probable age about five months. Care- last two cases were not possible.
I cannot speak with confidence in regard to any specific the actual attacks symptomatic treatment must be adopted;
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