THE RECURRENT TYPE OF "TRENCH" FEVER IN MESOPOTAMIA
183 only a transient condition. Lastly, the terminal hyperpyrexia, the temperature rising just before death to 107° F., which occurs not uncommonly in infective conditions, is an 'interesting point to note. As regards the relationship between diabetic coma and the presence of the acetone-bodies in the urine, Cammidge states that all cases of diabetes are not complicated by acetonsemia, although it is a constantly present menace, since a deficiency in the oxidative process of the body is an
... tial element of the condition. It is only when this reaches a certain stage that the acetone bodies appear in the urine as a necessary consequence." Further, he states the acetone and aceto-acetic acid, though usually present in the urine when the coma supervenes, are not so abundant as before, but that the amount of beta-oxybutyric acid is generally much increased. The completed history of the case, with its transient glycosuria, indicates the neurogenous origin of the glycosuria. Regarding this condition, Cammidge 2 states that such a transitory glycosuria, apparently of central origin, has been noticed in connexion with lesions of both the central and peripheral nervous system, such as tumours and hæmorrhages at the base of the brain, lesions of the floor of the fourth ventricle, cerebral and spinal meningitis, concussion of the brain, fracture of the cervical vertebrae, tetanus, and sciatica. It has also been met with after epileptic, hysteroepileptic, and apoplectic seizures, in traumatic neuroses, such as those following railway accidents, mental shocks, mental strain, worry, fatigue, and great anxiety." The practical lesson which this case enforces is the danger of concluding that the presence of sugar in the urine of a comatose individual is necessarily due to diabetes. Further investigations and a critical survey of the history of such a case are essential for the accurate elucftlation of the cause of the condition. We have to thank Captain H. S. Morton, R.A.M.C., for the clinical history of this case, and Surgeon-General J. Dallas Edge, C.B., A.M.S., commanding the Queen Alexandra Military Hospital, for permission to publish it. THE following case came under my observation recently at Amara, in Mesopotamia. The patient, an officer aged about 36, was employed at the advanced base and had never been to the fighting line ; he had been pulled down a little by one or two attacks of diarrhoea. Towards the end of April he had an attack of fever lasting two or three days, unaccompanied by rigor, and almost certainly not malarial. It seemed to belong to the category of short fevers, of which there were many examples in Amara. These attacks were generally traceable to exposure to the sun, which was beginning to get hot at that time. In this case the fever passed off, leaving the patient perhaps a little more vulnerable to the sun than before, but without definite sequelae. Soon after a small degree of footdrop developed in the right foot, with some anaesthesia of the dorsum of the foot, but this did not seem to have any direct connexion with the febrile attack which had preceded it. About the middle of May, after a day of premonitory malaise and depression, the temperature ran up one afternoon to 1030 F. and over. There was some mental excitement, the back and head ached, and the fall of temperature which soon followed was accompanied by a drenching sweat. After a couple of days in bed the patient returned to duty, but felt very tired and slack. Just a week after this last febrile attack another one developed. The fever was not so high, but it lasted two or three days. The pains accompanying it in back and limbs were more pronounced. Four similar attacks followed at intervals of exactly six days. Each attack exhibited a little less fever and a little more prostration than those which preceded it. In the later ones the pains were more pronounced, especially in the shins and tarsal bones. These pains were much aggravated by walking, and at night they were sometimes severe enough to 1 Cammidge, P. J.: Glycosuria and Allied Conditions, p. 214, London: Edward Arnold. 1913. 2 Loc. cit., p. 169. prevent sleep. Latterly they tended to persist after the febrile bout was over. Possibly there was a fifth attack, but if so the rise of temperature was slight. As it occurred, if at all, during transfer from one hospital to another, this slight rise may have been overlooked. In all, therefore, there were six pyrexial bouts. None of them were marked by definite rigor. There was always a day of premonitory discomfort. During the two earlier apyrexial intervals the patient felt comparatively fit, but each returning attack, though in itself less severe, induced a progressive loss of strength and flesh, the latter amounting in all to nearly one quarter of the total body weight. He became very pale and a little short of breath on exertion. The pulse was persistently quickened. The bowels were constipated and the urine normal. The foot-drop already alluded to cleared up slowly with the rest in bed. The blood was examined several times. No spirilla or other protozoa could be found. Cultures were negative and agglutination results equivocal. There was a mild polynuclear leucocytosis between the fifth and sixth attacks.