A system of practical medicine. By American authors. Vol. 1

by Unknown

¹¹ M. Sheriff, "History of the Epidemic of Dengue in Madras in 1872," Med. Times and Gazette, Nov. 15, p. 543 (reported in Virchow und Hirsch's Jahresbericht für das Jahr 1873).

Simultaneously with the affection of the joints and muscles the fever commences; its duration is from four to five days on the average, with one or, in exceptional cases, even more remissions. The temperature of the body during the first and second days of the fever rises to 102, 103, or even to 105° F; it then declines, to return to the normal standard on the fifth day. According to the measurements made by the late Dr. D'Aquin¹² of New Orleans, the temperature curves of dengue showed a continuous and steady rise until the highest point was reached on the first, second, or third day of the attack; then comes a short stadium of a few hours, and then a remission, soon to be followed by another rise of temperature, which, however, never reaches the maximum point of the first. The pulse rises with the temperature of the body, generally to from 80 to 120 beats a minute, and subsequently declines with the temperature. Delirium is very rarely observed in adults, but frequently in children, though without aggravation of the other symptoms. The face is generally flushed, the eyelids swollen, and the eyes injected and watery. The tongue in the beginning of the disease is covered with a white fur; its edges are red and its body swollen. As the disease advances the coating increases in thickness and assumes a dirty yellow color. The appetite is lost, without excessive thirst. In many cases there is slight irritability of the stomach, accompanied sometimes with nausea, though vomiting rarely takes place. The condition of the bowels is variable. The urine is small in quantity, and highly colored in some cases, whilst in others it has been reported to be pale and copious, and rich in phosphates in the beginning of the disease; it seldom shows any sediments and very rarely contains albumen. The disease generally reaches its acme on the third or fourth day, when the fever commences to subside, and an amelioration of the other symptoms takes place, so that the patient feels greatly relieved. This, however, is only of short duration, for not many hours afterward the fever rises again, while the other symptoms also increase in severity. At this time an exanthematous eruption appears upon the upper part of the body, the face, neck, breast, and shoulders, which in the course of two days extends over the whole body. Simultaneously with the appearance of the eruption the lymphatic glands of the back of the head and those of the neck, axillæ, and groins commence to swell; in severe cases the mucous membranes of the nose, mouth, and pharynx also become congested. The eruption, which is attended with much heat, itching, or even pain, is not uniform in character; for while in some cases it may represent a simple rash or erythema, it resembles in others the eruptions of scarlatina, rubeola, lichen, or urticaria. Frequently it is very light and evanescent, showing itself only for a few hours, and perhaps in the majority of cases it does not appear at all. In the severer cases it generally remains two days, when it commences to fade and disappear with desquamation, while at the same time the fever subsides and disappears entirely, though the stiffness and soreness in the joints and muscles, together with the inflammatory condition of the superficial lymphatic glands, may persist for many weeks. In exceptional cases the eruption, after an intermission of a few days, reappears, generally with greater intensity and with an aggravation of the other symptoms. In others, again, it has been observed to remain a whole week.

¹² D. C. Holliday, "Dengue or Dandy Fever," read before the Amer. Publ. Health Assoc. at New Orleans, December, 1880.

Hemorrhages from the nose and gums are also occasionally observed. Holliday even observed the occurrence of black vomit in the cases of two female children, aged respectively six and twelve, in the same family, who had suffered from yellow fever in 1878; they both recovered from the attack of dengue, though they were extremely ill and much prostrated. In female patients an attack of dengue not unfrequently causes the reappearance of the menstrual flow, while the pains attending the disease equally predispose to premature labor in pregnant women.

In severe cases of dengue the prostration following upon the subsidence of the fever is very great, for the patient is affected with a general weakness both of body and mind, indicating a great loss of nervous energy. In some cases observed by Slaughter the memory for names and words, as well as the ability for correctly writing even short sentences, was lost for one or two weeks after the commencement of convalescence. In children also cases are reported in which the mind remained affected for a short time after the attack. The convalescence in dengue, therefore, is comparatively slow, particularly as the pains in the muscles and joints, as already mentioned, pass away only gradually.

The duration of the disease, including the stage of convalescence, of course depends upon the degree of intensity of the attack, and accordingly varies in different cases. In a great number of cases dengue manifests itself only in its milder form. The average duration of the disease is from three to six days.

PATHOLOGY.—The pathological changes taking place in the different organs during the course of dengue are unknown, on account of the almost constantly favorable termination of the disease. From the peculiar features of some of the clinical symptoms accompanying the disease, however, we may speculate to a certain extent upon the nature of the pathological processes to which they are due. The sudden appearance of the characteristic pains in the muscles and joints, but particularly those in the head, neck, and loins, accompanied by a comparatively high fever, evidently point to the presence of an infectious poison in the system, though the question whether the noxious influence of this poison primarily affects the blood or the nervous system will be difficult to answer. But, judging from the early appearance of the pains, as well as from the physical and mental depression of the patient, we may presume that the nervous system is involved from the very beginning of the disease, and that the pains depend upon a hyperæmic condition of the affected parts, probably caused by a vaso-motor paralysis. The great resemblance of the painful affection of the muscles and joints in dengue to that of acute articular rheumatism leads to the supposition that the pathological condition in these joints is the same in both diseases; this view appears to be held by the majority of medical observers. In dengue, as in rheumatism, the pain due to the pressure of the hyperæmic and swollen tissues upon the irritated sensory nervous filaments is increased by motion—a phenomenon generally absent in neuralgia. The persistent headache, restlessness, and want of sleep, as well as the delirium and loss of memory observed in the severer cases, furthermore indicate a hyperæmic condition not only of the pia mater, but even of the brain-substance.

It is to be regretted that the literature of dengue within our reach shows no record of a quantitative analysis of the urine, from which we might have learned the quantity of urea secreted during the different stages of the disease, and which might have enabled us to form some idea of the extent of the destruction of the albuminous substances during the febrile stage, though, judging from the high grade of fever observed in the severer cases, we may well presume that the interchanges of matter are considerably augmented during this stage; while, on the other hand, the great nervous prostration of the patient directly after the subsidence of the fever, as well as the tardy convalescence, sufficiently shows that a large part of this waste is derived from the nervous tissues. The exanthematous eruption, representing a hyperæmia, or even an inflammation, of the skin, furthermore contributes to depress the nervous system by the pain and itching which it causes. This eruption, together with the inflammation and swelling of the superficial lymphatic glands, we are inclined to associate with the final elimination of the infectious poison from the organism.

Very little also is definitely known about the condition of the remaining organs, such as the kidneys, liver, and alimentary canal. The examinations of the urine in dengue recorded in literature are very few in number, and appear too unreliable for drawing any definite conclusions from them with regard to the condition of the kidneys. As albuminuria is met with in other infectious diseases, it is not impossible that it has also occurred in severe cases of dengue; though from the favorable termination of the disease it appears quite improbable that organic changes take place in these organs. In the same way may the liver be functionally deranged, or, judging from the destruction of matter during the febrile stage, a slight fatty infiltration of the organ may even occur—conditions which are apt to pass away with the exciting cause. The gastric irritability, whenever present, may be of nervous origin, though the vomiting, and particularly that of black hemorrhagic matters, observed in exceptional cases, evidently depends upon a hyperæmia of the stomach.

ETIOLOGY.—There is nothing positively known of the origin of dengue, but in perusing the accounts given by a number of medical observers from the different localities of the globe where it prevailed, we may presume that it existed in some parts of Asia and Africa long before it appeared in Europe and America. Perhaps the earliest record of dengue is the one dating from Cadiz and Seville, and concerning the epidemics prevailing in the cities in 1764 and 1768, when it was believed by the people that the disease had been imported from Africa. In Zanzibar (Christie), during the epidemic of 1870, the older native inhabitants remembered that fifty years before the disease had prevailed in this place. The Arabians living at this island also had known the disease in their own country, while the inhabitants hailing from the East Indies had never seen it. From the accounts of other writers we may presume that dengue has been known in Arabia for many generations. But, leaving aside its origin, it is authentically known that wherever dengue has appeared it has almost always been in the form of an epidemic, spreading from place to place and from family to family, without respect to race or nationality, to age, occupation or position, until every one susceptible to the disease was affected. Slaughter reports from India that even domestic animals, especially dogs and cats, were not exempt, as they appeared to suffer from rheumatoid affections of the joints.