A condition of the blood in a case of fever with a swelling near the umbilicus, showing 7*6 per cent* eosinophiles, led me to suspect guinea- worm. Thia was verified later on by the worm shifting over to the other side of the navel and finally becoming extruded. The pus contained 19 per cent, eosinophile corpuscles. Five other cases of guinea^worm infection were examined, and 4*75 per cent., 6*5 per cent., 7*5 per cent., 8 per cent., and 12*25 per centv eosinophiies were found respectively. None of these cases sufiTered from asthma, skin eruption or filaria Banorofti. Two had intestinal worms, the ex- pulsion of which did not influence the leucocyte count to any ap])reciable extent.
Plague, — The blood was examined in 117 cases. In 15 of these bacilli were easily seen in the blood smear. I may remark that IU)manow- sky's stain shows them up well. Several cases of both malarial and relapsing fever have been complicated by buboes. The blood examination has saved them from being condemned to the Plague Hospital.
As regards the recognition of plague bacilli in the finger blood, some years ago^ I was very sceptical about the reports of certain medical men, and until within the past 18 months had been unable to personally detect the bacilli ex- cept on culture.
At the beginning of this year there was a particular type of septiceemic plague, in which the rule was to find bacilli in every field. Such cases always died in my experience. One case seemed to be convalescent and had a normal temperature for three days, but then suddenly died. Plague bacilli were found eleven days before death.
I can confirm Miss Corthorne's observation that the coagulability of the blood, as a rule, is diminished in plague. It is also diminished in relapsing fever.
Malingering, — Perhaps you will not credit the existence of malingering in such a gallant corps as the Bombay Police. However, you will not accuse me of want of esprit de corps when I add that in many cases it has only been detected by the microscope.
If a man comes in saying he has had an attack of quartan or tertian ague, he is sure of a two or three days* holiday in hospital, even in such troublous times for the police as the Mohorrum. It will generally be found that the eve of some such busy or riotous occasion is selected by the malingerer. If you find no parasite and no mononuclear increase in his blood you can, with an easy conscience, send him back to duty.
A more common occurrence is for a sepoy to come in with a clap, a bubo or a chancre which he is too modest to display. He will say, perhaps justly, that he has fever. Very often in gonorrhcBa there is a smart fever of 102° or lOS"" F. on admission which, after a night's rest, falls to normal, and looks like a benign
infection of malaria. When no parasites are found with such a temperature it is marvellous how often a bubo or a clap is exposed on 1*0- moving the dhoti.
In 24 cases in which the existence of gon*- orrhoea or bubo was loudly denied I have been led to a diagnosis by a negative blood examin- ation.
Belapsing Fet)ei\ — This disease was very prevalent in Bombay in the years 1900 to 1902, but seems to disappear entirely in the spring of the latter year. However, in June of this year, I again detected spirilla in the blood of a patient who had but one attack of fever. This seems to have been the beginning of a fresh outbreak, as within a month Colonel Collie had some 40 cases in the jail.
I may here point out that there are many anomalous forms of this disease. Thei^e are mavy cases of relapsing fever, wkidi never relapsCy and such cases are usually recorded under the convenient name of malaria. It is only in hospitals where the blood is systemati- cally examined that these cases are detected.
In its typical foim the temperature is conti^ nuous, but I have seen some' very marked casee of intermittent rise of temperature, particularly in the relapse. In the first attack also a drop to normal or thereabouts on the second day is not rare.
I have seen some most striking cases of tertian intermittence with spirilla in large numbers in the circulating blood while the temperature was high, and wholly absent on the alternate days of remission. One of these cases had benign tertian fever a month or so before the attack of relapsing fever. For this reason during the fever and in the interval he was kept on 20 grains of quinine daily, nevertheleas he had a very typical tertian temperature at the time the relapse of spirilla fever was due. No malaria parasites could be found at any time during this fever, though repeated examinations were made. Spirilla were, however, found each time the temperature went up, and absent during the intermissions. See Chart Na 9.
Are we to conclude that the spirilla caused this intermittent fever? Or did the malarial infection, the parasites of which were driven from the circulating blood by the quinine, cause the rise of temperature, and did this tempera* ture drive the spirilla into the peripheral blood ?
There is a clinical point about spirillar fever which I have not seen mentioned in text-books —the facies. This is most characteristic, and I have at the first glance been able to diagnose several cases. The patient has a peculiar ashy complexion, and a quiet, sad, resigned or docile expression, which contrasts strongly with the dull, blear-eyed, " obfuscated," plague patient.
Pneumonia is another febrile disease, which at the onset is frequently difticult of diagnosis. The signs of disease in the lungs are sometimea ^ very late in appearing; a very small pa^ch onl^[^
