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 Bradford and his colleagues stated that they were able to culture
these organisms by Noguchi’s method for culturing the organism of
syphilis, but Strong failed to obtain growth. As the organism of typhus
fever has recently been cultured by the same method, it would appear
that the trench fever organism also is cultivable. The virus is present
in the whole blood, in the plasma and in the washed erythrocytes; it is
nonfilterable, and withstands a temperature of 56°C. for 20 minutes
but not one of 80°C. for 10 minutes. These organisms in the
alimentary tract of the louse are extracellular, and not contained within
the cells of the epithelium of the gut of the louse. The trench fever
bodies differ from those of typhus in that they are plumper and stain
more deeply with ordinary aniline dyes.

Epidemiology.—The ordinary method of transmission is by the

agency of infected lice, but the disease can be produced artificially
by the injection of the blood of an infected person. It is probable
that urine also may be a factor in transmission, as Strong brought
about infection by smearing skin abrasions with urinary sediment
from trench fever cases.
It is now considered that the bite of the louse is noninfectious,
although Strong succeeded in transmitting the disease by this means in
five cases. The accepted explanation of the mechanism of infection is
that it takes place through contamination of an abrasion or wound of
the skin with louse faeces or with the juices from the crushed bodies
of infected lice. In this connection, excoriations of the skin resulting
from the scratching of scabies-infested areas makes a scabies patient
peculiarly liable to trench fever infection. The louse faeces become
infective only after seven days from the time of feeding on trench
fever cases, this fact indicating a developmental cycle in the louse.

As the disease of itself is never fatal, there have been no

opportunities for studying the pathological changes.
 S

The period of incubation is usually given as from two to three

weeks. In the experimentally produced cases of the American Red
Cross Commission, the incubation period varied from five to thirty
days; thus with intravenous injection of blood it varied from five to
twenty days, and with inoculation of scarified areas with louse
faeces the period was between seven and eleven days.
The onset is quite abrupt with headache, dizziness and pain on
motion of the eyeballs. There is pain also in the back and limbs.
The conjunctivae are injected. The fever rises rapidly to
102°-104°F. and falls rather abruptly to normal at about the fourth
day. In most of the cases a secondary rise occurs so that we may
have a saddle-back type of temperature chart.
The temperature charts tend to be grouped in three classes: (1)
Those with a short febrile course of a few days, followed by a fall to
normal, with or without a subsequent rise; (2) those with a more or
less sustained type of fever, extending over five or six weeks without
distinct relapses, and (3) those more typically of a relapsing type, with
five or six distinct febrile periods.
In more than one-half of the cases there occurs an eruption of small
(2 to 4 mm.) erythematous spots, which disappear on pressure. They
are usually located on chest, back or abdomen, appear on the second
day of the fever, and fade out by the fourth day. Constipation and
anorexia are usually noted. The spleen is often somewhat enlarged.
There is frequently a trace of albumin in the urine, but it is not
accompanied by casts. The cutaneous hyperaesthesia over the shins is
a prominent feature, but the same disturbance of sensation may be
complained of over the ulna or fibula. Usually we find a leucocytosis
but many cases show a normal white count or even a slight leukopenia.
During the apyrexia there is an increase in mononuclear percentage.
The pulse is rather slow for the temperature.
 D

Notwithstanding the intensive study given this disease during the

war, we do not seem to have any constant or reliable laboratory
test.
In some of the cases where muscle pains of the neck are marked
there may be a stiffness of the neck that is suggestive of cerebro-
spinal fever. Similarly, pain of the abdominal muscles may cause a
suspicion of appendicitis and lead to an unnecessary operation.
The onset of trench fever is very like that of dengue or influenza.
In epidemic jaundice, the occurrence of the jaundice and marked
albuminuria should differentiate.

This is most favorable as to ultimate complete recovery, but

some cases show a prolonged convalescence with manifestations of
irritable heart or neurasthenia.

P T

Prophylaxis consists in attacking the louse problem, although

attention should be given to the disinfection of the urine.
Acetylsalicylic acid may be given to relieve the headache and
the muscle pains; and some laxative for the usual constipation.
There is no specific treatment.
 CHAPTER XLI

HEAT STROKE AND HEAT PROSTRATION

G C

It has been customary to differentiate etiologically, as well as

clinically, the two most common manifestations of the effects of
high temperature. Clinically we note cases (1) with a rapidly rising
temperature, which often reaches a very high point, together with a
hot, dry, reddened skin, heat stroke; and again we note cases (2)
with pale clammy skin, marked evidences of cardiac weakness and
a normal or subnormal temperature, heat prostration.
Brooks in a most excellent discussion of the subject applies the
designation diathermasia to the former group of cases and regards
them as connected with an undue retention of heat within the body. To
the latter group, which he considers to be connected with exposure to
the actinic rays of the sun, he applies the designation phoebism.
In diathermasia he considers that we have so great a strain on the
thermotaxic mechanism that there is loss of balance between the heat
discharge and heat producing centers, while in phoebism there is
primarily an acute cerebral or cerebro-spinal congestion followed by a
chronic inflammatory condition of the meninges and due to damage
from the actinic or ultra-violet rays of the sun.

While admitting that there may be cases where the effects of

certain rays of the sun are responsible for clinical manifestations
varying from death of striking suddenness to vague complaints of
irritability, headache and defective memory, yet the generally
accepted views are that high temperature, high relative humidity
and lack of evaporation from the skin, whether from excessive
humidity or from lack of circulation of the surrounding air, can and
do produce at one time heat stroke and at another heat prostration.
Such factors as muscular exertion, disease conditions, alcoholism
and dietary indiscretions undoubtedly play a part in the production
of and variance in the clinical manifestations brought about by the
effects of heat.
Sambon has suggested that there is a possibility that heat stroke or,
as it is also designated thermic fever or siriasis, is due to a germ
infection, but without advancing any particular evidence in favor of
such an hypothesis.

There is undoubtedly, however, much in favor of the views of

those who regard heat stroke and heat prostration as due to an auto-
intoxication from the accumulation of toxic substances resulting
from increased metabolic activity due to excessive heat retention
and having a selective action on the nerve cells.
Others think that as the result of more active metabolism there is a
retention of carbonic and lactic acid with a demand on the alkali
content of the blood resulting in an acidosis. As a matter of fact
treatment of heat stroke cases with intravenous or rectal injections of
sodium bicarbonate seems to be of marked value.

It would seem advisable to take the ground that heat retention

resulting from lack of heat radiation and insufficient skin
evaporation causes various manifestations of discomfort or bodily
injury. Aron in Manila showed that monkeys exposed to the sun
died in about one hour but that a control monkey, similarly placed,
but kept in a current of air from an electric fan, suffered little or no
injury. The reason that monkey and man react differently to
exposure to the sun is on account of the more numerous and more
active sweat glands possessed by man which give rise to increased
evaporation and resulting loss of heat of the body.
 High relative humidity is a potent factor in checking evaporation.
The rectal temperature in Haldane’s experiments showed a rise of a
little over 1°F. when the wet bulb was at 90°F., 2°F. when at 94°F.
while at 98°F. it was about 4°F. per hour. Leonard Hill has noted that
the air surrounding the victims of the Black Hole of Calcutta became
saturated with water vapour and heated to the temperature of the body
so that it was heat stroke and not suffocation that caused death. The
power of air to hold water vapour and its evaporative power increase
rapidly with rising temperature; thus at 50°F. a cubic foot of air holds
4.08 grains water, at 80°F. 10.9 and at 100°F. 19.7 grains. Hill states
that the limit of an Englishman’s power to keep cool is passed when
the wet bulb exceeds 88°F. in the still air of a room even when
stripped to the waist and resting. If muscular work is performed the
limit may be 80°F. Walking in a tropical climate, wet bulb 75° to
80°F., dry bulb 80° to 90°F. may raise the temperature 2° to 3°F. and
send the pulse up to 140 to 160. All the students of ventilation stress
the importance of circulation of the air in promoting evaporation and
comfort. According to Hill with the air saturated and the wet bulb
reading 89°F. the wet ‘Kata’ readings would be 3.3 with still air, 8.0
with the wind moving 1 meter a second and 15.1 with a velocity of 9
meters per second. In tropical parts of the world when the wet bulb not
infrequently reaches 90°F. the circulation of air by punkahs or electric
fans becomes a necessity. There is great variation in capacity for
sweating which, according to Hearne, is the basis of heat stroke. He
notes that sweating is suppressed from 1 to 48 hours before the attack.
With sweating suppressed the body temperature rises until, when
108°F. or more is reached, unconsciousness and convulsions develop.
Hearne thinks that the inhibition of sweating is local in the sweat
glands, and not central, as diaphoretics fail to cause sweating once it
has stopped. As a practical point Hearne watched subjects for dryness
of the skin and when discovered they were stripped, covered with a
wet sheet and evaporation promoted by a current of air from an
electric fan. Doctor Leonard Hill has noted the inefficiency of the
application of pieces of ice to the hyperpyrexial body as compared
with evaporation. Thus water evaporation at body temperature
abstracts 0.59 calories per gram while melting ice only takes away
0.08 calories. Furthermore the application of ice constricts the
capillaries and interferes with evaporation. He also notes that 70
grams of water evaporated from the skin takes away as much heat as
1000 grams of ice water used as an enema.

Pathologically, there is usually congestion of the brain and

meninges, that of the brain being particularly marked about the
region of the medulla. There may even be punctate haemorrhages
and the nerve cells show chromatolysis. These changes are much
more evident in heat stroke than in heat prostration.
McKenzie and LeCount have noted the following autopsy
findings: Generalized passive hyperaemia of brain and lungs,
oedema of brain and lungs as well as petechial haemorrhages of
various mucous membranes and the skin.
Susceptibility to Heat Stroke.—As a matter of fact in a body of men
exposed to identical conditions of heat of sun and relative humidity we
note certain cases exhibiting typical heat stroke while other men will
only show evidences of heat prostration.
Alcoholism, obesity, diseases of heart and lungs, overcrowding,
muscular fatigue, insufficient circulation of air, with the wet bulb
about 90°F., and not drinking a sufficient amount of water, predispose
to heat injury.
It must always be kept in mind that the hyperpyrexial type of
malignant tertian malaria may give a clinical picture of heat stroke.
Fiske has noted that in oil-burning firerooms, even with a
temperature of 140°F., 10° higher than on similar ships burning coal,
there were no cases of heat prostration. He attributes this to the less
fatiguing work in tending oil-burning furnaces and the smaller number
of men required, this reducing overcrowding.
 S

In heat stroke there are usually prodromata of dizziness, dry

skin, headache, and somnolence, following which the body
temperature shoots up to 105°F. or even above 110°F. There is a
desire for frequent micturition, which may be considered as a
prodromal warning of embarrassment of the sweating function. The
skin is hot and dry and the pupils may be contracted. The pulse
which is at first full and rapid, soon becomes irregular. There may
be delirium or coma or convulsive seizures. The patient is
unconscious with irregular or Cheyne-Stokes respiration.
Hiller divides these cases into (1) those showing an asphyxia
syndrome, as characterized by cyanosis and collapse, with cessation of
respiration and enfeebled circulation. Prolonged artificial respiration
is required in such cases. (2) A paralytic type with deep coma,
recurring convulsions and extreme hyperpyrexia. These cases exhibit
oedema of lungs and brain and necessitate venesection. (3) A
psychopathic type in which there is delirium often of a violent type
with delusions of persecution. Such cases often commit suicide.

In heat prostration we have giddiness and possibly nausea with

pale face, often bathed in cold perspiration and dilated pupils. The
pulse is very weak and syncope may ensue. The temperature is not
elevated and may be subnormal. Rarely the temperature is slightly
elevated. The respiration is shallow and sighing. Headache is often
complained of after recovery. Following this or the more dangerous
heat stroke we may have lack of mental concentration or loss of
memory with recurring headache upon even moderate exposure to
the sun.
Heat Cramps.—Among those working in firerooms on board
ships cruising in tropical waters, there is met frequently a condition
characterized by cramps of the voluntary muscles, chiefly those of
the extremities and abdomen.
Ill health and individual susceptibility appear to predispose toward
attacks, but apparently hard physical labor, in conjunction with the
environmental conditions, is the factor that determines the occurrence
of the cramps. Their causation is usually attributed to dehydration of
the tissues, or to accumulation of metabolic products, but some believe
that they represent a condition differing from all other conditions
recognized as being due to heat. Cases, probably identical in nature
and having the same causative factors, have been noted as occurring
among workers in steel-mills.
The cramps are usually preceded by fibrillation of the muscles later
to be affected. When frankly spastic attacks are developed, they recur
at intervals of from 2 to 10 minutes, and may be severe and very
painful. The pupil is dilated, but so far as known, no other organs are
involved. The cramps are commonly accompanied by signs of heat
prostration. This, however, is not necessarily so, there often being
absolutely no thermal disturbance.
The treatment is in general that of heat prostration. Immediate relief
may be obtained by sudden slapping of an affected muscle. For mild
cases, immersion in a warm bath is recommended. Apomorphine in
sub-emetic doses is said to confer immediate relaxation.

With heat stroke we have a condition in which every moment

lost before the institution of proper treatment reduces the chances
of recovery. The two important measures are reduction of
temperature and elimination of toxic material. For the former ice
packs or ice baths are the most efficient. When the temperature
starts down it may fall with great rapidity and collapse result.
Consequently when giving these ice packs or baths the treatment
should be discontinued when the temperature by rectum reaches
about 103°F., the patient then being removed from the bath and
covered with a blanket. If the temperature again shoots up the ice
bath can be repeated. Many have reported great benefit from the
use of enemata cooled with ice. Some prefer to apply ice to the
head and rub the body with pieces of ice. This can be carried out on
a rubber sheet placed on a cot. If there is no ice available a sheet
wet in dilute alcohol, plus the effects of a current of air from the
electric fan or otherwise, may be tried. In a case with marked
cyanosis venesection may be necessary. In asphyxial types of sun
stroke prolonged artificial respiration is indicated.
Above has been noted the inefficiency of ice in reducing
temperature and the far greater effect from evaporation, brought
about by directing the current from a fan on the body covered with
a wet sheet.
To promote elimination of toxic products venesection plus the use of
intravenous injections of normal saline is the best treatment. In those
terrible paralytic type cases which show a mortality of more than 50%
it is well to think of acidosis and give slowly about a liter of a 1 or 2%
solution of sodium bicarbonate. (See under treatment of cholera.) The
use of alkaline enemata often gives good results, about a liter of a
solution containing 2% of sodium chloride and 2% of sodium
carbonate or bicarbonate.
As soon as possible after the more urgent hydrotherapeutic methods
have controlled the case we should give calomel followed by salines.
The coal tar products should be avoided as far as possible, from the
danger of cardiac depression.

In the nonfebrile heat prostration the treatment is entirely

eliminative and stimulant. The patient should be placed on his back
in a cool shady place and tight clothing released, particularly about
the neck. Rubbing the limbs as for any syncope-type affection, with
hot water bottles if the collapse is marked, should be one line of
treatment. Many give a little aromatic spirits of ammonia or
whiskey but a hypodermic of strychnine would be better in a severe
case.
Calomel and salines should be given after cardiac weakness
disappears. To avoid these dangers of the tropical heat one should
keep the body clean to promote good action of the sweat glands. The
clothing should be light and loosely fitting and should permit a free
circulation of air to assist evaporation. There does not seem to be any
indication for the wearing of orange-colored clothes as the actinic rays
are apparently unimportant. Puntoni recommends green-colored
clothing for neck and spine. The green cloth should be covered with
white material.
The head and nape of the neck should be protected by a light well-
ventilated helmet. Alcohol should be avoided, or at any rate absolutely
so, until evening. Water or lemonade should be taken freely and a
siesta in the middle of the day is an important conserver of one’s
resisting powers.
 CHAPTER XLII

CLIMATIC BUBO, AINHUM, GOUNDOU, JUXTA-

ARTICULAR NODULES AND VISCERAL MYCOSES

C B

General Considerations
The naval surgeons of various countries have for many years
been interested in a condition where inguinal buboes develop
which have no relation to venereal infection.
All attempts to find any organism in these lesions have so far
failed. Cultures from excised glands or from the necrotic centers of
such glands fail to show any growth.
Stained smears and India ink preparations alike fail to show any
causative organism. The Wassermann test is also negative. The disease
seems much more common in the West Indies than elsewhere,
statistics showing it to be about 10 times as often contracted by sailors
in those waters as by crews in the seaports of China. In a recent article
Rost states that he thinks there is evidence to show that the disease is
contracted by sexual intercourse with prostitutes of the colored races.
Of his 17 cases all had exposed themselves in this way.
Children never show climatic bubo and it seems peculiarly to affect
the young adults composing the crews of ships. Even among the native
prostitutes such a condition does not seem to exist and climatic bubo
does not affect the male natives.

There may or may not be a periadenitis but there is thickening of

the capsule and fibrous septa of the glands. At times an apparently
healthy gland may show a necrotic centre, the contents of which,
however, will be found to be sterile. One often notes in sections
haemorrhagic infiltrations and oedema in the region of the
peripheral lymph sinuses. A point of differentiation from ambulant
plague buboes is the great increase in plasma cells in climatic bubo.
It will be remembered that Cantlie suggested that climatic bubo
was an attenuated plague but this idea has never been accepted. It
has been suggested that malaria might cause climatic bubo.
Symptomatology
The period of incubation is a rather long one, Rost in a well-
controlled case noting a period of at least five weeks. The onset is
very gradual, so the first intimation of a swelling in the groins may
be when a sense of heaviness is noted in that region after prolonged
work. For this reason they have been called “fatigue” glands.
The glands of one side of the groin are usually involved although
the swellings may affect both sides. The deep iliac glands also often
show marked increase in size but the glands of the other parts of the
body, as axillary or cervical, are practically never involved.

The swollen glands are only slightly tender and at first are
discrete and not attached to skin or underlying tissues. Later on
with the development of a periadenitis they may be firmly attached.
In size they are usually as large as a hen’s egg but may become
much larger.
The overlying skin is as a rule normal and one may at times palpate
a soft center in an otherwise hard gland. Fever tends to come on as an
irregular remittent type and I have seen cases showing temperature
curves covering periods of two or three months which were not unlike
those of Malta fever. With increase in size of the buboes there would
be a two or three weeks’ rise to be followed, with the subsidence of
the swelling, by lysis and later on to be renewed with reappearance of
the bubo.

Climatic bubo runs a protracted course and does not respond at

all well to treatment. The cases often develop a moderate secondary
anaemia, which is most often noted in the relapse cases.
Diagnosis and Treatment
The history aids in differentiating gonorrhoeal, chancroidal and
syphilitic buboes. There is not the hardness and marked absence of
tenderness we get in syphilitic inguinal glands, and the reddened
overlying skin of the other veneral buboes should differentiate.
Plague buboes are exquisitely tender and the patient usually
manifests signs of extreme illness. In climatic bubo the patients rarely
seem sick.
Surgical treatment is usually recommended and some advocate a
radical enucleation of all glands in the region involved as we find at
times apparently normal glands to show necrotic centers. My objection
to enucleation is that the deep iliac glands are also often involved and
it is not only impossible to remove all affected glands in such an
inaccessible region but the surgical risks of wounding the deep veins
are great. I have seen this accident occur more than once. Again the
radical removal of all glandular structures in the groins, with
subsequent scar tissue formation, obstructs lymph return so that
elephantoid conditions result.
Rest in bed and hot compresses are of value when periadenitis sets
in. When softening occurs the aspiration of the pus with an aspirating
syringe and the subsequent injection of glycerite of boroglycerine
containing 10% of iodoform are to be recommended. Some apply
ointment of ichthyol, others pressure by shot bags. X-ray treatment has
been recommended.
Emily strongly recommends the injection of 3 or 4 drops of
iodoform ether (5%) into the center of the enlarged gland. This effects
a rapid cure. The author also employs other measures such as rest in
bed, wet compresses, and light mercurial ointment inunctions over the
bubo at night.

General Considerations
This disease, equivalent clinically to a spontaneous amputation
of the little toe, has been chiefly noted in the natives of the West
Coast of Africa, especially among the Kroomen and in Brazil.
Cases have been reported from the West Indies and rarely from the
Southern States of the United States. It does not attack white
people and the susceptibility of black races is probably connected
with their tendency to keloid development.
There have been all sorts of suggestions as to etiology: (a) that it is
related to leprosy, (b) that it is a tropho-neurosis, (c) that it results
from wearing constricting bands or rings on the toe, (d) that it is
connected with frequent injuries to the under surface of the little toe.

Pathologically we find a fibrous cord which has replaced the

bony structures normally attaching the toe to the foot. We have,
according to Unna, a ring-form sclerodermia with thickening of the
epidermis causing an endarteritis with the production of a rarefying
osteitis.
The disease is chiefly found in male adults between twenty-five
and thirty years of age.
Symptomatology and Treatment
In 90% of cases the little toe is the one affected, more rarely the
fourth toe or very rarely both the fourth and little toe. The little toes
may be attacked at the same time but the condition usually first
starts in one toe. At first we have a crack in the digito-plantar fold
of the little toe. This extends laterally and finally appears on the
dorsum. The distal portion of the toe enlarges and becomes bulbous
so that it looks like a small potato. The connection between the foot
and the bloated-looking toe is a limp fibrous cord which permits
the toe to wabble in various directions and to interfere greatly with
walking.
The course of the disease extends over several years if the toe is not
amputated by cutting through the fibrous pedicle or as the result of
ulceration from injury to the pedicle.

General Considerations
This is a disease which almost exclusively affects the black race
and is chiefly found in the West Coast of Africa, where it is called
big-nose or dog-nose. It is also found occasionally in China and the
Malay Peninsula.
The prominent root of the nose is due to exostoses from the nasal
processes of the superior maxillary bones.

Nothing definite is known as to etiology. Suggestions have been

made that it is connected with yaws, syphilis or leprosy. Again that
it is due to rhinoscleroma. Maclaud thought the hypertrophied
tissues to be incident to irritation from dipterous larvae in the nasal
fossae. Pathologically we have spongy bone covered by a thin layer
of compact bone.
Symptomatology and Treatment
At first there is complaint of headache and an associated nasal
discharge. At times the nasal passages may be obstructed by the
developing growth, which however usually projects externally on
both sides of the root of the nose just below the inner angle of the
eyes. Breathing through the nose is not as a rule interfered with.
The bony exostoses develop in a downward and outward direction.
The shape is generally oval. The disease commences in childhood and
the bony outgrowths slowly increase in size so that by adult life they
attain the size of a walnut. The overlying skin is normal and not
attached to the bony tumor. As the tumors grow they tend to interfere
with the vision of the patient. This is purely from obstructing the lines
of vision as the growth does not usually invade the orbits. The
treatment is entirely surgical and consists in chiselling away the bony
outgrowth.

J - N

General Considerations
These nodular masses were first noted by Macgregor from cases
in New Guinea but since then have been described from various
parts of the tropical world.
These tumor masses were given the name juxta-articular nodules by
Jeanselme, who studied the affection in natives of Siam. It may be
stated that at present we know nothing definite as to etiology although
several authors have reported fungi as the cause. This fungus has been
stated to be a species of Nocardia. Some of the cases which have been
reported would seem to be late manifestations of yaws.

Symptomatology and Treatment

These tumor masses vary in size up to that of a golf ball and are
very hard in consistence. The skin over them is at first freely movable,
but later on may become attached. They are located subcutaneously,
especially about the external surfaces of the extremities and
particularly in relation to the joints. They are not sensitive and rarely
or never suppurate. The course is most chronic and but rarely do they
become absorbed.
 F . 144.—Juxta-articular nodules. (After Steiner; from Mense.)

In those parts of Africa where the tumors due to Onchocerca

volvulus are found there may be confusion in diagnosis but these
filarial nodes are elastic. By aspirating the swelling microfilariae
should be found in onchocerciasis.
The treatment of juxta-articular nodules is by excision should they
give trouble.
 V M

The majority of cases of visceral mycoses reported from tropical

regions have been considered as caused by species of Monilia, but
not infrequently fungi of the genus Cryptococcus have been
incriminated. As a rule the mycosis is reported as occurring in
cases which had been regarded as pulmonary tuberculosis. In some
of the cases there were cutaneous lesions, enlarged glands and even
generalized conditions as well as lung involvement.
Among the fungi reported for the lungs we have: Rhizomucor
parasiticum, Nocardia pseudotuberculosis, Aspergillus fumigatus,
Penicillium crustaceum, Monilia tropicalis, Monilia candida,
Cryptococcus gilchristi, Coccidioides immitis and various other
species. A satisfactory study of the true nature of the causative fungi
has been made in only certain instances and a scientific investigation
of this phase of tropical pathology is desirable.
Bronchomoniliasis.—Castellani has used this designation for two
types of cases in which various species of Monilia have been reported
as causative. In one type the symptoms are mild with but slight
impairment of health, there being only a cough with expectoration of
muco-purulent sputum. No fever is present. In the severe type we have
the symptomatology of pulmonary tuberculosis with abundant reddish-
gray sputum. In both types the diagnosis is made by finding the fungi
in perfectly fresh sputum. This should be cultured in a hanging-block
culture using Sabouraud’s medium. The mycelium and budding forms
can best be studied in such a preparation. Negative findings for
tubercle bacilli are important in diagnosis. Potassium iodide is
recommended in treatment.
Sporotrichosis.—The infection with various species of
Sporotrichum usually gives rise to gummatous lesions along the lines
of the lymphatics of the extremities. These tumor masses break down
and discharge a yellowish-brown pus. Rarely the process generalizes,
then often invading the lungs. Culturing of the pus or sputum is
necessary for diagnosis. In cultures the sporothrix shows a narrow
(2µ) mycelium with grape-like clusters of oval spores at the end of a
filament. The treatment recommended is iodide of potash.
Blastomycosis.—The causative organism, Cryptococcus gilchristi, is
found in the purulent discharge as oval to round, doubly contoured,
budding yeast-like cells 10 to 16µ. In cultures we have formation of a
mycelium resembling that of an oidium. The lesions may be solely
cutaneous or generalized in which latter case the lungs are apt to be
involved giving a condition resembling pulmonary tuberculosis.
Coccidioidal granuloma.—This is a very rare and fatal infection
caused by Coccidioides immitis, a fungus somewhat similar in cultures
to C. gilchristi but differing in tissues in that it gives rise to
endogenous spore formation in the cells found in the granulomatous
material. The spores are about 3µ in diameter and contained in a large
cell (30-60µ) which does not bud. We may have skin lesions
accompanying visceral involvement or the latter alone. When
involving the lung the infection closely resembles pulmonary
tuberculosis. The spores metastasize readily by way of the lymphatics
involved and we may have a picture of pyaemia. Skin lesions, when
present, are ragged and punched out. About 40 cases have been
reported, chiefly from California.