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Difficulty of Micturition 1 Previous Attacks the Rule March, 1926.' DIFFERENTIAL DIAGNOSIS IN THE TROPICS: PROCTOR. 105 recorded. Of course under the head " vomit- " ing- we. have only included cases where vomiting- was the sole symptom complained Original Articles. of. It is scarcely necessary to state that vomiting accompanied by fever, ague, etc., is one of the commonest symptoms. Such cases have been included in the 362 usual DIFFERENTIAL diagnosis in the signs and TROPICS.* symptoms. Figures are dull and I do not propose to By A. H. PROCTOR, m.b.. b.s.. m.d., m.s. discuss percentages or anything of that sort. UKur.-coi.oNKr., i.m.s., The table is only put forward to illustrate the numerous under which malaria Civil Surgeon, Darjeeling. disguises pre- sents itself in your consulting room. I was made a re- Recently one ot my colleagues surprised myself to see how seldom vomiting was very niark that in this country appears in the table. My own experience is diagnosis What in different to what it is at Home. that patients frequently come to see you and case " to I can't was a straightforward their first reply your question is England perfectly all kinds ?f say appendicitis, had in Calcutta keep anything in my stomach." As often as of Possibilities. not when questioned they will say they have out some of my no fever. with mothers who I propose therefore to set Especially bring in the hope that they may their children. Nowadays in the case of .?Wn experiences them to )e of use to and help children who are vomiting one immediately practitioners have made. avoid mistakes which I and others examines their urine for acetone and diacetic to arrange. The is a little difficult acid, finds them present and promptly makes subject to take and after consideration I have decided a diagnosis of acidosis. Blessed word! It describe UP the diseases and has got the doctor out of many a tight corner ordinary tropical other in which have simulated with a persistent mother. But it won't save c^ses they have leases. An alternative method would your reputation with her if after a course of | and describe alkalies someone else examines the blood and )een to take up certain symptoms to them. This diseases to rise finds malarial parasites. So I advise you in !he likely give on in books a ls the method followed every case of vomiting to have blood film usually invalu- differential such as French's taken. Even if you cannot get a blood film " diagnosis not it would never able Index." In this case I feel fail to examine the spleen, it is nearly namely, emphasise the I have in view, always palpable. object of some *le many protean manifestations Here is the type of case described as gastric:? common diseases. Complains that for the last month he has tropical first place Jo begin with we must concede had neuralgic pains from the back of the neck the symptoms 01 malaria. This table gives to the shoulder-blade and then to the stomach. cases admitted originally complained of in 426 Pain settled in the pit of the stomach, felt like to something pulling him crossways, intermit- hospital. 362 Usual symptoms tent, not severe enough to double him up. 4 Anaemia Has never vomited blood, 110 tarry stools, no 7 relation with food?(note that point),?but Vomiting 6 Gastric pain could not retain anything for more than 20 Colic 2 minutes, icteric tinge to conjunctiva, stools Haematemesis 3 always bilious and urine high-coloured. Mus- Diarrhoea and 11 tard plaster relieves his pain. Temperature dysentery 1 Cholera 97.6?, pulse 96, no anremia; tenderness on deep 3 of micturition pressure 1" below the xiphisternum. No mass Difficulty 12 Respiratory conditions felt. Note how up to this point the record- 3 er's mind has run on duodenal or gastric ulcer; Collapse 1 state none of his enquiries suggest a suspicion of Typhoid 7 " Cerebral and nervous symptom malaria. He then continues, Spleen 4 slightly Jaundice enlarged, liver normal, not tender." Three days later malignant tertian rings and cres- 426 cents are found, the patient is put on quinine and discharged cured, but from the date of admission to discharge he never has a rise of that the cliag- I want to bear in mind Had it not been for his you at after a temperature. blood n?s^s ?f was arrived examination he still malaria only all that might have been on bis- in and that, originally, muth and gastric sedatives. He had been on j\ay hospital, the symptoms lese cases complained of were them for the best part of a month before and was * at admission, probably described as a Being a clinical post-graduate lecture, delivered "e type of influenza. The notes do not Calcutta School of Tropical Medicine. gastric 106 THE INDIAN MEDICAL GAZETTE. [March, 1926. record his diagnosis prior to admission to hos- had contracted malaria in the Punjab before pital. sailing and developed this unusual nervous Numerous cases of this type come under type immediately on arrival. I can assure observation and I can only conclude that the you I had considered the possibility of several pain is splenic in origin. We know little at nervous diseases, but malaria had not crossed present as to the cause of pain in the abdo- my mind. So far as I remember I was in minal viscera, but it is easy to suppose that favour of an acute anterior poliomyelitis. We with an enlarged and engorged spleen, pain are all acquainted with the ordinary cerebral may well, be referred to areas associated with type of malaria, but it is as well to bear in the stomach. While on the subject of pain mind that almost any abnormal nervous symp- due to affections of the spleen, it occasionally toms may be due to malaria, more especially if happens that it is referred to the left shoulder, accompanied by fever, and that treatment is much as liver pain is referred to the right. I urgent if the patient is to be saved. Thus we have seen this happen in a case of kala-azar, may meet with coma, convulsions, apoplexy, a disease we do not usually associate with aphasia, paraplegia and meningeal cases. Con- pain. vulsions and meningeal types are particularly Of colic two cases are recorded. These common in children. were intestinal colic associated with fever. Neuralgia, more especially supra-orbital The most striking case however was one of neuralgia, is stated to be commonly associat- renal colic. As Medical Officer of the Officers' ed with malaria, but in my experience it is a Hospital in Mesopotamia I was sent for to rare complication or sequela. I should hesi- see a case of renal colic. The attack was tate to attribute even a supra-orbital neural- typical in every way of renal calculus. It gia to malaria till I had exhausted all the more followed on a hard game at tennis and was probable causes such as carious teeth, nasal accompanied by a transient hematuria and sinus affections, ophthalmic affections, and moderate rise of temperature. Under the syphilis. usual treatment the was better in the patient The presence of loose stools and the passage next morning. The evening he had another of blood,and mucus in the stools sometimes attack with the same result. When a third leads to an erroneous diagnosis when it is due attack occurred at the same time the follow- to malaria, the blood being attributed to we decided it was time to take a ing evening dysentery or to haemorrhage in a case of ty- blood film. The result was and on positive phoid. Perhaps the most difficult cases are his renal colic and as fat- quinine disappeared the algid type, of which you will see one which as I know never returned. is described as cholera and the others as col- The result was dramatic in its sudden ter- lapse. These are'not common, but when they mination. The pathology I have no doubt are first seen mimic the collapse stage of was a blocking of the renal capillaries by para- cholera very closely and I have known them sites, and haemorrhage, resulting as it usually treated as cholera. An examination of the but does in marked renal colic, owing to the pas- blood and stools usually clears up the point, sage of clots. as one's attention is usually concentrated ofl Let us now turn to the cerebral and nervous giving hypertonic saline and not on laboratory examinations it is useful to remember that types of malaria. My attention was first the intravenous in cases of cholera drawn to the possibilities of error many injection results in the of cho- years ago in China. I have not the notes of usually passage typical lera stools and fresh This is not the case with me now, but it so impressed it- vomiting. the case in nor does the case self on my memory that I can quote them malaria, improve fairly accurately. to the same extent with the injection. Of jaundice it may be said that a He was a Punjabi recruit only recently mily icteric ting is an almost universal arrived and was brought to hospital with a accompani- ment of malaria, but that occasionally one see? that he had wakened up that story morning cases of of malarial in both On examination he deep jaundice, origin- paralysed legs. in these cases is due to excessive had no but of a com- Jaundice temperature symptoms destruction of blood cells and whether this plete transverse He said he was myelitis.
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