dB [L ©© ® OKI ©SK]©y^0 
A.White corpuscles—B. Red corpuscles—C. Masses of Bioplasts. CLINICAL LECTURES 
ON 
DENGUE. 
BY 
T. EDMONDSTON CHAELES, M.D., M.E.C.P., 
SDEGEON, HM MAJESTY’S INDIAN AEMY, 
PEOEESSOK OP MIDWIPEEY AND THE DISEASES OE WOMEN AND CHILDEEN, 
OBSTETEIC PHYSICIAN TO THE MEDICAL COLLEGE HOSPITAL, 
ME MB EE OP THE OBSTETEIC SOCIETIES OP BEELIN, 
EDINBDEGH AND LONDON. 
DELIVERED BEFORE THE STUDENTS ATTENDING THE 
MEDICAL COLLEGE. 
REPRINTED FROM THE “INDIAN MEDICAL GAZETTE.” 
Calcutta 
MESSES. WYMAN AND CO. 
1872. CALCUTTA: 
TEED. LEWIS, CALCUTTA CENTEAL PEESS COMPANY, LIMITED, 
6, COUNCIL HOUSE STEEET. .vIY DEAR Sir, 
In sending you an interleaved copy of some observa 
tions on Dengue, which were addressed to my class, may I ask for 
your assistance and co-operation in an attempt to make a full use of 
the present epidemic in collecting as much material as possible for 
a more thorough account of the disease. 
Should you consider I am wrong on any of the points I have 
brought forward, and find that your experience does not tend to 
corroborate my observations, a pencil note to this effect will be sure 
to meet with attention from me. 
Should you not intend to publish your own views on various points 
of interest other than those referred to in these pages, may I request 
the favour of your allowing me to make use of them, in order to 
make my own account as complete as possible. 
The shortest pencilling in the margin, alluding to the forms of 
death which you have witnessed or heard of, or an allusion to any 
circumstance which I have not alluded to, would aid me in an 
endeavour to supply a more perfect clinical record of the present 
epidemic than that which we possess of previous ones. 
Yours very truly, 
10, Harrington Street. 
T. EDMONDSTON CHARLES 
May, 1872. PREFACE. 
The observations contained in tbe following pages were 
delivered in December last, to my class in tbe Medical 
College, from carefully arranged notes. 
In a rash moment they were promised to the Indian 
Medical Gazette, and had to be written during the few 
minutes which could, day by day, be stolen from other 
urgent duties. 
As they appeared sufficiently early in the epidemic to 
attract the notice of other observers, if the published re- 
sults of my own experience have served in any degree to 
assist my co-labourers in procuring a more exact knowledge 
of Dengue than that possessed by the profession previously, 
or have assisted to any material extent in enabling practi- 
tioners to mitigate the pain and distress caused by the 
prevailing epidemic, the drudgery of writing lectures while 
subject to constant interruptions will have been amply 
repaid. 
A few copies have been bound for transmission? to my 
friends in England, to save the chromolithograph of the 
blood from being injured in the Post Office. 
Calcutta, May, 1872. CONTENTS. 
Page. 
Statement of the Case ... ... ... 2 
The Invasion... ... ... ... ... 5 
The Initial Eash ... ... ... ... 0 
The Pyrexia ... ... ... ... ... g 
Temperature Chart ... ... ... ... 20 
The Pulse ... ... ... ... . 22 
The Pains ... ... ... ... . . 22 
The Catarrhal Symptoms ... ... ... 25 
The Tongue ... ... ... ... ... 26 
The Urine ... ... ... 27 
The Blood ... ... ... 29 
Occasional Symptoms ... ... ... ... 20 
The Terminal Eash ... ... ... ... 23 
Eelapses ... ... ... ... 28 
The Sequehe ... ... ... ... 30 
The Non-identity with Scarlatina ... ... 32 
Temperature Chart ... ... 32 
The Diagnosis ... ... 30 
Treatment ... * ... ... ... 33 CLINICAL LECTURES ON DENGUE. 
DELIVEEED AT THE MEDICAL COLLEGE, 
T. EDMONDSTON CHARLES, m.d , m.e.c.p., London. 
(Tie-published from the “Indian Medical Gazette.”) 
Gentlemen,—I wish you to study along with me, to-day, 
the case of the little girl with dengue, who was seized with 
the disease while in the hospital. Many of you have watched 
this case with interest, from the first day of her illness, and 
as you have seen the case at a more early stage than you 
have often opportunities of seeing similar ones in hospital, I 
think the occasion for speaking more at length about it is 
favourable. 
The present epidemic is the first one which has occurred 
in Calcutta since most of you have commenced to study me- 
dicine, and ns you will doubtless have many facilities for further 
making yourselves acquainted with this disease before the 
epidemic is over, I hope the remarks which I will have to 
make may aid in placing you on vantage ground, from which 
to make the most of such chances as may fall in your way. 
Those of you who are at all regular in your hospital attend- 
ance are already familiar with the term ‘ dengue.’ It sounds 
rather uncouth to unaccustomed ears, but as it has been 
adopted in the nomenclature of the Royal College of Physi- 
cians, and is also recognized by medical men in other countries, 
I will not detain you by attempting to substitute any other 
name for it.. Many of you ask me the derivation of the 
term. I have never heal’d of so plausible a solution of this 
difficulty as the one which recognises in the word the corruption 
of the word “ dandy.” This affection was jocularly termed “ dan- 
dy fever” by the negroes in certain parts of the West Indies, 
owing to the erect or stiff1 carriage assumed by their companions 
while the subjects of the aching joints common in this dis- 
ease ; and the Spaniards seem to have modified the term into 
dengy, or dengue, which has somehow or other crept into our 2 
nosology, Tlie term ‘ scarlatina rheumatica’ lias also been 
rather widely accepted since Copland adopted the name. I 
mention this now to guard you against assuming that this 
disease lias any pathological kinship relating it to scarlatina 
more closely than to measles or any other eruptive disorder. 
To avoid confusion, perhaps it would be better to discourage 
the use of this designation. In Calcutta we often familiarly 
style it “ Goodeve’s red fever,” as my late colleague wrote the 
last account of the disease while describing the epidemic of 
1853. It bears many other names, popular as well as classical, 
for which I must refer you to Dr. Aitken’s monograph, which 
you will find in the first volume of Reynold’s System of Medi- 
cine, and which is the most complete account of the dieases that 
has yet appeared. I almost owe you an apology for entering 
into these details, as well as for further trespassing on the 
domain of the Professor of Medicine in my subsequent remarks, 
but I only last night learned from Dr. Chevers that he had not 
yet lectured to you about this disease, so perhaps you will hold 
me justified if I credit you with some ignorance of the subject, 
and attempt even in a clinical lecture to make good the 
deficiency. Without further delay then allow me to read to 
you the particulars of this child’s illness. 
The Statement of the Case.—Eliza Maequeen; age 
three years; was in hospital ten days ago with some slight 
complaint. Went home to Boitakhana, a part of Calcutta, 
where there are a great many people who have dengue. Her 
mother came to hospital to nurse a sick friend, and brought 
the little girl with her on the 18th December. The child was 
in perfect health, and played about with her old acquaintances 
in hospital. She had a good appetite, and ate heartily. About 
5 o’clock in the afternoon she stopped in her play, and running 
up to the matron of the hospital, complained of severe pain 
in the ring finger of the right hand. Her play was resumed, 
and in about an hour after she again went to the matron, 
complaining of pain in all her bones. A report was now made 
to the House Surgeon that the child wTas getting dengue. 
At this time she had no fever, but later in the evening the 
skin became hot, and the child vomited up the last meal which 
she had taken. On being put to bed the child became very 3 
restless, wakmg up frequently and starting in her sleep as 
if frightened, and in the intervals murmuring almost con- 
stantly. At 7a.m. in the morning of the 19ih, her pulse was 
112 and her temperature was 100° F. 
The face was covered with red patches, but was not notice- 
ably swollen. (T he initial rash). At 4p. m. the patches on the 
face had coalesced, giving it a uniform red appearance, and the 
whole surface of the body was of a homogeneous dull red colour. 
It had not a faint approach to bright scarlet, but was of a din- 
gy crimson tint. The colour disappeared on pressure with the 
finger, and though it was not bright, it could be seen at a dis- 
tance in a comparatively dim light, constituting a very noticeable 
characteristic. 
There was faint redness of the fauces and slight enlargement 
of the tonsils, but the child made no complaint of sore throat 
and could swallow easily. 
The tongue was white, with the edges and tip of bright red. 
Near the tip the reddened and enlarged papillae gave it a 
strawberry appearance. 
The palpebral conjunctivse were much congested ; the eyes 
looked heavy, but were not much injected. 
The child made no complaint of pain, but cried when an 
attempt was made to move the joints. 
On the morning of the 20th the redness of the surface had 
entirely disappeared. The child was found not to have slept 
during the night, but to have been very thirsty and restless, 
and to have vomited two or three times about 3 o’clock. 
The highest temperature noted was at 7 p. m., when it had 
reached 105° F. It began to fall after this, and during the next 
twelve hours, the thermometer ranged irregularly between 105° 
and 10O°5, on three occasions marking 102°. 
At 4 o’clock p. m. the child’s eyes still had a heavy look 
and it was dull and listless, otherwise it seemed well. From 
101.°5 at 9a. m., the temperature fell steadily, till at 3p. m. it 
stood at 97° F. 
On the morning of the 21st it was noted that the child had 
passed a good night, having slept well. 
The temperature had ranged between 97° and 99° F. 4 
There was no eruption on the skin. The red papillae at the 
tip of the tongue were still very evident, and the rest of the 
tongue was covered with a yellowish fur. 
Rather before 3 o’clock a very distinct measly eruption 
began at the root of the neck and upper part of the chest. 
(The terminal rash). The child was covered up in bed with 
the view of making it perspire, hoping that the rash would 
extend and be vivid at the time the students were to see the 
ease an hour later. At four o’clock the rash, though still well 
marked, was much less distinct, and in the course of the even- 
ing had almost entirely disappeared. On the 22nd there was 
no eruption ; the child had slept well and had begun to eat, and 
the skin remained quite cool. On the 23rd the child seemed 
welland played about as usual, but the tongue was a little foul ; 
she had lost her appetite again, and refuse to eat. At 2 
p in., with a temperature of 97°, a measly eruption appeared on 
the palms of the hands and on the legs a short distance above 
the ankles, (the terminal rash), and the child seemed very cross. 
At 9 in the evening the temperature had fallen to 96°5 F. 
On the 24th I did not see the child, but in the morning it 
was reported that the forearms and hands, legs and face were 
a little swollen, and the rash was very distinct at all these 
points. The temperature was 98°. Now the eruption was no 
longer like that of measles, but little prominent wheals of 
urticaria well raised above the surface, and surrounded by a 
red blush, were exclusively met with. At 3 p.m. the tem- 
perature had risen to 100°; the urticarial rash remained on the 
face, hands and legs as before, and was now evident on the 
chest, abdomen and back, which were covered by it. At this 
time the rash had so completely covered the body that there was 
no portion of the surface of the size of the palm of the child’s 
hand that was free from eruption. There was no itching 
present. 
On the morning of the 25th not a trace of the rash re- 
mained : it had not faded gradually, but completely disappear- 
ed. No swelling remained at any point. The temperature was 
96°, and the child seemed in every way well. 
The child was kept under observation in the hospital till 
the 3rd January, 1872, and remained in good health, no abuor- 5 
mality being noted, except that on the 28th; at 5 p.m,, the mo- 
ther noticed the child’s face a little flushed and its hands were 
slightly warm. At 3 p.m. of this day the temperature was 
97°, and at 9 p.m., 98°.5. 
The next day the thermometer rose at 9 p.m. to 99°, and on 
the 31st to 98°5 at 3 pm. No other symptoms of fever were 
noticed on these occasions, the child being apparently in perfect 
health. * 
Throughout the whole course of the disease the bowels were 
regular, the evacuations being natural. 
The urine was tested daily for albumen, but none was found. 
Its specific gravity was steadily 1014. It was abundant and 
clear, no sediment was noticed in it. On this last point, though 
instructions were issued, they were misunderstood, but never- 
theless it seems tolerably certain that on no day was there much 
sediment, and on some days none at all. 
The treatment.—The child was put on two minim doses of 
tincture of belladonna three times a day on the 19th, and 
this was continued till the 22nd. 
On the 23rd ten minims of compound tincture of gentian 
were ordered to be given thrice daily. This was continued till 
the Ist January, when all medicines were stopped. 
The Invasion,—Dengue attacks suddenly. You have usually 
no history of a day or two, or even of a few hours’ previous de- 
parture from a perfect standard of health. A person in perfect 
health is struck down suddenly, and can often tell you the 
minute that he began to feel ill. A merchant goes to the 
opera, and during the performance is obliged to leave the 
house. A lady at her devotions in church is seized while 
kneeling during a short prayer. Two young women jump into 
a swimming bath; they both are in their element and experience 
much enjoyment ; they leave the bath, and both of them go 
direct to bed in the tortures of dengue. Another lady goes 
into her own bath-room quite well, and after bathing cannot 
dress again as the disease is upon her. A young delinquent falls 
under the chastisement of his father, and is carried to bed 
with dengue. In the case of the child who forms the subject 
of to-day’s lecture, while in perfect health and busy with its 
play, it left its toys abruptly and complained of the pains of 6 
dengue. Such are instances of what I have met with in 
this epidemic, and well exemplify the peculiar suddenness of 
the attack. As in this child, very often the first symptom is 
pain ; even if its true significance is not at first understood, you 
are not left long in doubt as to what is coming. When your 
patients cannot express themselves more exactly, they can tell 
you very decidedly that they “feel ill.” The usual sensations 
which precede fever are now present in more or less distinctness; 
a general feeling of malaise, faintness, giddiness, a tendency to 
sigh or yawn, with weariness, aching in the bones, and a desire to 
lie down, sufficiently indicate the nature of these sensations. 
A feeling of coldness in the spine developed into more general 
chilliness is usually complained of. A tendency to shiver 
rather than a well-marked rigor, ushers in the disease. I have 
hardly ever seen what I would designate a regular rigor, 
though at times there has been a very close approach to 
it. Ido not regard even this as usual, but both in the present 
and in previous epidemics, regular rigors have been seen 
by other medical men. Several times in young women 
I have seen an attack of hysteria to be the first symptom. In 
children I have seen a tendency to convulsion, and in more 
than one case a violent convulsion mark the advent of dengue. 
I have also had occasion to see such convulsion repeated once 
and again. Even when this does occur it need give you no 
cause for anxiety. In children it is not usually of more serious 
import, than the other disordered nervous phenomena which 
you see in those of more advanced age. 
In other epidemics, towards their close, persons have been 
described as not having been attacked so suddenly, but having 
for a day or two before the attack shewn symptoms of being 
out of health, by being listless and languid, having white 
tongues and being off their food. I saw' none of these cases 
till lately, and in the few cases which I have seen such symp- 
toms would, in all probability, not have attracted my attention, 
unless I had known that the same observation had been previ- 
ously made by Twining in the epidemic of 1824, and by others. 
The Initial Rash.—ln this child you have had an oppor 
tunity of seeing one of the best marked forms of this occur 
rence which I have ever met with. It is not seen in every 7 
case of dengue; but when it does occur, it is one of the more 
special characters of tins disease, and serves at once to dis- 
tinguish it from any of the other eruptive fevers which are 
common in India. Unfortunately it is very often absent. I 
have no record which would enable me to tell precisely in what 
proportion of the cases which I have seen it has been absent, 
but I think in fully one-third of the patients I have not been 
able to satisfy myself of its existence. 
In the present instance it began in a very characteristic way 
on the face. It was fully developed on the body before it was 
noticed, and so I cannot say how it began there. The entire 
surface of the body was covered by it, and you will rarely meet 
with it in such an extensive and complete form. Often the 
face alone is affected, at other times the abdomen, chest or 
knees may be the points at which you see it. In one case in 
which the rash was a most marked one, the face was of a bright, 
vivid red, almost scarlet, colour, and there was an irregularly 
rounded patch of a similar colour on the lower part of the 
abdomen, of about the size of a soup-plate. I could not dis- 
cover a trace of the rash on any other part of the body. 
In the same case the face was so swollen as to be quite disfigured. 
This swelling of the face and eye-lids to a less extent is very 
often met with. In the child whom you saw it did not exist, 
and even when it is present, it quickly subsides as the rash dis- 
appears. 
Probably one reason why I have failed to see the initial rash 
in so many cases is that it does not last long and leaves no 
mark behind it. In many cases it has not lasted for six hours, 
and I do not remember ever having seen it remain in a well- 
marked form so long as twenty-four hours. 
In speaking of the initial rash, I always call it the scarlatinal 
rash, as this is the only form in which I have seen it. It is a 
diffuse uniform redness of the surface—erythema if you will— 
and even when it occurs in separate patches on the face, I have 
not noticed any special character which would enable you to 
recognise it as differing from any other large red blotches. 
As in other transient hypersemic conditions of the skin, when 
you press with the finger, you can obliterate all trace of colour 
for the moment, but it instantly returns on removing the finger. 8 
I have never seen it in such an intense form as to leave staining 
of the surface behind, or to be followed by desquamation. I 
can quite understand however that both of these effects might 
follow. I do not think this symptom has attracted the special 
notice it deserves from the earlier observers. That they 
noticed it in their cases is very clear from their writings. Thus, 
in a case which Cavell saw two hours from the commencement 
of the disease, he says, “ the skin was covered with a bright 
scarlet blush.” Mouat in describing tire early symptoms writes 
—“The whole surface became suffused or flushed, the face 
scarlet.” Again Twining mentions that “ the whole countenance 
appeared bloated and swollenand while describing the rash 
at a later period of the disease, expressly mentions paren- 
thetically its being “ seemingly quite distinct from the bloated 
suffusion of visage attending the first day of the disease.” 
You must have already gathered that the initial rash is met 
with at a very early period in the disease. You will in fact often 
find it fully developed the first time you see your patient, even 
an hour or two after the illness began. In rare eases it has 
not attracted attention till the second day. In a few instances 
it has seemed to fade a little, and again become more vivid. 
I have seen it quite disappear and then return, but this does 
not often occur. 
The Pyrexia.—You may regard the fever in this child as 
a very typical example of what is usual in this disease. In 
fact the febrile stage in dengue is one of the only stable 
elements of this disease. In many points one case of dengue 
varies greatly from another, but they all agree very closely 
in the similarity of their attendant fevers. There are excep- 
tions to this rule, but they are very rare. In the child, several 
of the characters of the fever cannot be so well studied as in 
the adult, as there is difficulty in getting it to express its feel- 
ings. When an adult is seized he usually complains of cold- 
ness, and at once his temperature begins to rise. He experi- 
ences great distress, and, as a rule, he is very restless. The 
febrile anguish is out of all proportion greater than is usually 
experienced, with an equal elevation of temperature, in other 
fevers. Quite independently of any special suffering which 
may be present, the general distress constitutes the case a 
perfect picture of misery. Thirst is often much complained of. 9 
Sleep is not often obtained, and in those cases in which the 
patient is not altogether wakeful, his sleep is broken, troubled, 
and not refreshing. This child did not sleep on the second 
night, but in many cases I have seen comparatively good sleep 
obtained at this time. Delirium in the adult is rare, but in 
the child its dreams make it start up, and even when it is 
not so violently affected, it mutters often incoherently. 
Perspiration occurs at intervals, and is at times very profuse 
and necessitates a changing of the clothes. The evidence 
on this point is somewhat contradictory, but, as a rule, I 
think relief is experienced by the sufferer on these occasions. 
As in this child, if a patient is overtaken with dengue soon 
after a full meal has been taken, vomiting may occur. This 
is not at all a constant symptom in dengue. After the fever 
has lasted for some hours vomiting may more or less disturb 
their comfort, but patients with this disease do not usually 
suffer much in such a way. In some cases, however, I have seen 
vomiting give much trouble, and prove a difficult symptom to 
control. 
The fever is distinctly remittent. By this Ido not mean 
that you will find the usual evening exacerbation, and morning 
remission of other febrile states, but distinct periods of in- 
crease and decrease, during indefinite periods both of the day 
and night. In this the pyrexia of dengue is singular, and 
the older observers were struck by this peculiarity. When 
you see a patient he may tell you he feels better now, but 
two or three hours ago he had very intense fever. If you 
congratulate him on such a marked improvement and lead him 
to suppose the fever will soon now be at an end, you will cause 
disappointment, for if you see him again in three or four hours 
you will find the improvement has not continued, that the re- 
mission has again been followed by increased heat of skin. These 
alternations in temperature may occur three or four times in the 
twenty-four hours to a well-marked degree, and in a minor 
extent much oftener than this. We can judge of such changes 
much more accurately now than they could do even a few 
years ago, and our clinical thermometers aid us much in dengue 
and give us confidence by accurately registering the rise and 
fall of the temperature of the body. 
To illustrate this point and others in connection with the 10 
temperature, I have had a chart prepared to show you in a eon 
eecutivo form the range which is usual in such cases. This 
child’s temperature was taken for some time every two hours, 
and subsequently, when this was not necessary, at more distant 
periods. By looking at this one record, you will obtain a very 
good idea of what you will afterwards see in practice, and you 
may accept it as a good model for study. 
Often at first very little rise of temperature takes place. We 
have no record of what occurred during the first twelve hours, 
hut I have no reason to believe that there was then a higher 
temperature than that noted at our first observation. The ther- 
mometer then showed only 100° F. at 7 a.m., and 101° at 2 p.m., 
while during the next three observations it steadily rose one 
degree or one degree and half, during each period of two hours. 
The maximum temperature reached was 105,° and it was attained 
by a steady progressive rise. After this the thermometer at once 
sank again, and rose and fell twice within twelve hours, 102° 
having been three times noted during the night. About 36 hours 
after the first symptom of the disease was noticed, the thermometer 
began to decline steadily, and before the expiry of forty-eight 
bom's from the moment the child attracted attention by com- 
plaining of her finger, not only had a normal temperature been 
regained, but the heat of the body was very decidedly below the 
normal standard, having fallen to 97° F. 
After this the temperature remained normal or depressed, the 
only occasions on which it rose above 98°-5 being at 7 p.m., on 
the 20th to 99°, at 3 p.m. on the 24th to 100° F., and on the 
29th at 9 p.m. to 99°. 
I have already dwelt as long as time will permit, on the 
frequent remissions met with in this fever, and now I have only 
to direct your attention to two or three other points which 
the chart teaches you. The maximum temperature reached was 
105u. I attended many cases of dengue before I knew the 
temperature rose so high, while a little above or a little below 
103° was a temperature often met with. There are two reasons 
for this :—First, in many cases the temperature does not quite 
reach 105° F.; and secondly, even when it does do so, it never 
remains long at this point, but quickly begins to descend 
If your thermometer is not applied during the short period 
of such a high temperature, you are left in ignorance of its hay- Day 
of the 
disease. 
1st. 
2nd. 
3rd. 
4th. 
105° 
• 
1 
- 
rT0 
fcD 
U 
cd 
P3 
o 
5 
3 
104° 
' 
- 
103° 
• 
102° 
• 
• 
• 
• 
101° 
• 
• 
100° 
• 
• 
• 
99° 
\ 
• 
• 
• 
98° 
• 
• 
o 
• 
• 
• 
• 
• 
• 
• 
i 
• 
• 
• 
• 
• 
• 
• 
• 
97° 
• 
• 
• 
• 
• 
• 
«> 
• 
96° 
• 
• 
a 
cd 
a 
P 
S'! 
a 
p 
a 
P. 
to 
a 
P 
a 
P 
05 
a 
P 
g 
a 
cd 
00 
a 
cd 
a 
c> 
a 
cc 
05 
a 
cd 
a 
p 
a 
A 
CO 
5 p. m. 
a 
P 
9 p.m. 
a 
si 
a 
cd 
a 
cd 
CO 
a 
03 
to 
a 
cd 
a 
cd 
05 
a 
cd 
a 
PH 
a 
P 
CO 
b 
PH 
to 
a 
PH 
a 
PH 
05 
a 
cd 
a 
cd 
O 
0 
c 
a 
P 
CO 
~B 
cd 
00 
a 
PH 
a 
- 
05 
a 
cd 
05 
5 
Ph 
CO 
a 
P 
05 
a 
cd 
00 
a 
P 
CO 
9 p. m. 
a 
cd 
00 
a 
P< 
CO 
B 
p 
05 
a 
cd 
00 
a 
P 
CO 
1 9 p. m. 
a 
cd 
00 
1 
a [a 
P P 
CO 05 
a 
00 
a 
P 
CO 
a a 
p cc 
05 00 
a 
P 
CO 
a 
P 
05 
a 
cd 
00 
a 
P 
a 
P 
05 
a 
00 
a 
CO 
a 
05 
a 
00 
a 
P 
a 
P 
05 
Day 
of the 
month. 
19 
20 
21 
22 
23 
24 
25 
2e 
27 
28 
29 30 
31 
1 
2 
Temperature in Dengue, case of Eliza Macqueen, 11 
ing occurred. In general terms it may be said that the highest 
temperature occm-s about twenty-four hours after seizure, while 
before twenty-four hours more have expired, the whole of the 
pyrexia is at an end. Such a complete crisis may be delayed for 
a day, but I have not seen many cases when such a departure 
from the standard I have laid down for you has taken place. On 
the other hand I have seen a normal temperature gained some 
hours earlier than it was in this child. 
The depresion below a normal temperature is a very usual 
occurrence. You know that this is common after other severe 
diseases, and in dengue I have often seen it more marked than 
in the case which we have been studying to the extent of one el- 
even two degrees. 
Take note then that within two days all trace of fever was 
gone. This is the rule in dengue ; but the rule is not without 
exceptions, for when speaking about relapses I will have to tell 
you that the fever may return again, not only once but oftener. 
For the present, you will get a much better idea of the disease if 
you leave this occasional event in its natural history out of 
consideration, and regard this case as a type, as it assuredly is, 
of a disease with a sharp febrile period, terminating abruptly, not 
to return again. Though I wish to impress this fact on you, 
I cannot ask you quite to lose sight of the other fact, that the 
thermometer on six occasions marked slight rises of temperature 
over 98°. In most of these the rise was only half a degree or a 
degree ; once only was the rise to 100°. It was chiefly when the 
child was asleep that this slight elevation was noted, and the 
manifestation was only a passing one. There was no regularity 
shewn in the recurrence of thase events, and, but for a careful use 
of the thermometer, we should have remained in ignorance of their 
existence. Nevertheless, if these are looked on in the light of abor- 
tive relapses of the pyrexia, as representatives, in fact, of what in 
other cases constitute true relapses in dengue, it will give addi- 
tional interest to such trifling indications, and will not, I trust, 
lead to any confusion in your minds. You all however are 
familiar with the fact that a temperature of 99° is a perfectly 
normal temperature for a child, and one which you often find 
in a child in typical health ; so, possibly, you may be disposed to 
regard the supposed analogy as a fanciful one, and to look on 
the comparison as overstrained. Without attaching too much 12 
importance to it, 1 must confess my leaning for the present to 
look on these manifestations in the above light, as some weight 
is due to the fact that this slight rise was from an abnormally 
low temperature. 
Tlxe Pulse.—ln many cases the rapidity of the pulse 
is comparatively little affected, and this want of relation to 
the severity of the other symptoms will strike you, if you 
examine with care, as not a familar circumstance in other 
diseases. 
In some few attacks, even when the case seems otherwise 
urgent, you will find the pulse under a hundred ,—lOB is a 
very common pulse even in a patient who suffers much. You 
may consider it exceptional to see the pulse rise above 120 
in the adult. I have, however, counted it over HO, and in 
fatal cases it becomes so quick that you can hardly count 
it. This comparative slowness of the pulse presents a great 
contrast to the habitually quick pulse in scarlatina. 
In the early days of the disease, when you find the pulse 
quick it need not cause you anxiety ; it does not denote any 
undue severity in the case, and portends nothing important 
in the issue. It is chiefly in children that you will observe 
such quick pulses as 130 or HO, and unless you were aware 
of this peculiarity in them, you might justly look anxiously 
to the future. Even when the pulse beats thus, it quickly 
approaches a more natural standard. Such a pulse in the 
later stages of the disease is a very serious matter, and when 
the pulse remains thus high, or increases in frequency beyond 
the first two or three days, your fears will not only be 
properly excited, hut a fatal will too often justify your 
apprehensions. You seldom find the pulse hard : it may be 
full, but there is always a want of power about it, which in 
days gone past used to teach that such patients could not 
bear bleeding well. When the temperature falls the pulse 
usually goes down, but in those cases especially in which there 
is much prostration, it may be some time before it becomes 
quite natural. You often find it for long a weak feeble pulse, 
and its rapidity is easily increased by the least excitement or 
exertion. 
The Pains.'—This symptom in the child was well marked at 
the commencement, but later on in the disease it did not 13 
constitute the very prominent affection which it often does. 
Even when the child made very little complaint of suffering, 
we were easily able to satisfy ourselves that very considerable 
tenderness of the joints existed. On moving the elbows, or 
knees, with extreme gentleness, the child cried bitterly. In 
this way you can often elicit unmistakeable evidence of the 
presence of this symptom even long before the child can talk. 
Infants in arms thus tell their own tale of suffering joints, and 
older children, when they cannot or will not understand what 
you want of them, can be forced to take you into their con- 
fidence. Some of you seemed rather taken with this method 
of extracting an unwilling confession, and had I not pointed 
out to you that it was not warrantable to put our little patient 
through such an ordeal, simply to gratify idle curiosity, I am 
sure every joint in her body would have been thoroughly in- 
vestigated. 
In more than half of the cases of dengue which I have 
seen, this pain of the joints has been a symptom so well marked 
as to distinguish it from all other eruptive fevers. The term 
‘ scarlatina rheumatica’ sufficiently shows that the older ob- 
servers regarded this as being a distinctive manifestation of 
the disease. The pain in many cases during this epidemic has 
been of such intensity that the most superficial observer could 
not help having his attention at once arrested by it. 
In a few cases its exceptional severity has reminded me of 
the suffering caused by a bad attack of gout, and even when 
the intensity of suffering has fallen far short of this, it bore 
no resemblance to the pains complained of in any other form 
of fever which I have seen, except the very severe form of 
ephemera termed ‘ ardent,’ or sun fever which is so common 
among Europeans who have recently arrived in India, and 
attacks them during their first experience of the hot winds in 
Northern India. In this fever, the intense pain in the back and 
head is very similar to the pain of dengue when it affects similar 
situations. 
Both the head-ache and back-ache at times are the cause of 
extreme anguish, but pain attacking the joints is much more 
characteristic of dengue. From the cases of this disease which 
I saw in another epidemic, and from sporadic cases which I 14 
had seen from time to time, I used to regard the pain in the 
small joints as quite pathognomonic of the disease, and as 
one of very general occurrence. An enlarged experience, how- 
ever, has taught me that in many instances the small joints 
are not affected. In many cases in which their implication 
is not very evident by making the patient move the terminal 
phalanx of the fingers, you will find that pain, or at least 
stiffness, will be complained of. When you can gain such 
information, in a doubtful case it will aid you in diagnosis. I 
have seen slight swelling of the joints both large and small, but 
you may regard this as rather exceptional. Some times, but 
more rarely, pain in the muscles is complained of, and this form 
of suffering may be met with when the joints remain free. 
Weakened joints and tissues suffer out of all proportion to 
those whose nutrition has not been previously impaired. A 
medical man whom I attended loudly demanded relief for an 
ankle which had been sprained some time before, but which had 
given him no trouble for two months. A sprained wrist in the 
same way seemed in one case to monopolize the pain to itself, 
though before the attack of dengue it had attracted little notice. 
A hyperaemic uterus by reflecting its agony to the back, enlisted 
very special attention. In a chronic case of ophthalmia tarsi, 
the eyelids proved the source of much trouble. In the same 
way, I have seen overtaxed brains, especially those much worried 
wiih figures, give evidence of anguish out of all proportion 
greater than that experienced in other parts of the body. In 
all these cases not only did the pain in the weakened tissue over- 
shadow that at other points, but it seemed almost to give compa- 
rative exemption from suffering elsewhere. 
A very curious feature in connection with pain in the joints 
consists in its shifting nature. It flies about from one joint to 
another, apparently without any reason. Now, a little finger is 
the cause of your patient’s lamentations ; at your next visit, or 
even before you leave the house, an elbow or a toe may consti- 
tute the chief subject for complaint, and so on through almost 
endless variety. The pain usually begins suddenly, in many 
cases it ends in the same way, while in other's it declines more 
gradually, or before the suffering finally subsides the joint may 
oscillate between periods of repose and those of more or less 
uneasiness. 15 
I have alluded to the fact that such pain is not present in all 
cases. It is seldom entirely absent, but from its comparative 
slightness it may cease to attract special attention, and you may 
be unable to distinguish it from the suffering attendant on other 
cases of fever. This observation is much more applicable to 
other recorded epidemics than to the one now raging. 
I had almost forgotten to tell you that I have seen abdominal 
uneasiness complained of so often, especially by children, that 
I do not consider it as an accidental circumstance, but one 
which deserves to be noted in connection with the pains of 
dengue. 
The Catarrhal Symptoms.—ln this child the catarrhal 
implication of mucous membranes was very slight. In fact, 
the throat affection was so insignificant as not to require any 
treatment; and with the exception of redness of the palpebral 
conjunctivas, there was no evidence of the other raucous mem- 
branes being involved. It is not at all unusual for you to meet 
with such slight implication ; even when you have well-marked 
symptoms of catarrh at various points, it is very seldom indeed 
that you will have to resort to remedial measures on their 
account. The chief interest in such symptoms lies in the fact, 
that by their occurrence they may lead you astray if you are 
not well versed in the different forms they may assume. Thus, 
when the Schneiderian membrane, or the mucous membrane of 
the bronchi, are so much affected as to attract prominent 
attention, if you give undue weight to this symptom alone, 
you may look on the case as being one of measles. So also 
when the throat symptoms are urgent, scarlatina may be upper- 
most in your mind. Again, when the disgestive tract is 
extensively affected, your thoughts may be turned away from 
dengue, unless you have prepared yourselves beforehand to 
meet with such cases. The chief point for you to bear in mind 
is, that all the mucous membranes at these points may not only 
be affected, but that the symptoms caused by such implication 
may be severe, and that it is dangerous for you to attempt to 
found a differential diagnosis, between dengue and other diseases, 
on the presence of any catarrhal condition. 
I believe that the catarrh under such conditions is a specific 
one, but that it is usually determined to one or other point, by 16 
the general conditions which prevail at the time, quite inde 
pendant of the dengue poison. 
Thus, at the end of the rainy season, when diarrhoea was 
prevalent, I did not see any case of dengue with bronchial catarrh 
or sore throat, while more or less bowel affections was very usual- 
ly met with. Immediately after this, when all one’s friends were 
sneezing and having colds of sorts, our dengue patients joined 
in the chorus of coughs. Just before this child came into 
hospital, sore throats were very prevalent, in some cases consti- 
tuting a very serious affection, and many of our dengue cases 
complained of difficulty in swallowing and gave other evidence, 
of throat implication. 
Dr. E. Goodeve describes very clearly the condition of 
the throat which he saw. The passage is too long for me to 
read to you, so I must satisfy myself with the remark that 
you might almost transcribe his descriptions and apply them 
to a case of slight scarlatina. He had not himself seen ulcer- 
ation of the tonsils, but I have seen them thus affected several 
times and well-marked implications of the lymphatic glands at 
the angles of the lower jaw. I have also seen the irritation 
spread from the fauces, and troublesome laryngeal complications 
arise. 
Many more of my patients have had bronchial catarrh 
than sore throat. When this is present, you at times have 
coryza combined with it. Sneezing has been a rare symptom. 
Bowel complaint has not been so frequent a symptom as 
either of the other two, but in two or three cases the profuse 
watery discharges have been so abundant and frquent as to 
cause much more anxiety than that caused by the catarrh 
of other mucous membranes. In some cases the large rather 
than the small intestine has been the part implicated. 
The Tongue.—As in this child, so in most cases the state of 
the tongue is such as to aid you in recognising the disease. A 
white tongue with an angry red tip and edges, and some bright- 
red enlarged papillae anteriorly, contrasting with the white ground 
is sufficiently often met with, to justify you in missing it when it 
is absent. When such appearances are not present, the tongue 
may be natural, or simply white, or slightly loaded over the 
entire surface. If you examine sufficiently far back, you will 17 
not unfrequently find the large papillae at the root of the 
tongue enlarged and of a bright-red colour, standing up promi- 
nently amidst the more heavy coating which is generally seen 
at the back of the tongue. The tongue is usually moist, and 
I have never seen it of the bright-red colour it assumes during 
scarlatina. 
Usually on the second or third day the tongue is more thickly 
coated than at first, and the papillae may not then be so 
apparent. The tongue frequently becomes clean very quickly, 
and ceases to present any characteristic appearances. 
When the tongue has been thickly coated, especially in cases 
which have much tendency to relapses, it may not resume its 
natural appearances rapidly, and in doing so, owing to its 
cleaning irregularly, large bright-red patches may give it a 
startling mottled appearance. 
The Urine.—ln this case the rough examination of the urine 
was somewhat neglected, but having paid very considerable 
attention to the point, I can to some extent make good the defi- 
ciency to you. In most cases there is little about the urine 
to attract your attention. Its specific gravity is often natural, 
as it was in this case, but may also fall below a normal stand- 
ard. During the febrile paroxysm you would naturally expect to 
find the urine scanty, and of high color, but in very many cases 
which I have examined I did not find this to be the case. In 
several instances the urine presented very marked characters of 
quite an opposite sort. It was very abundant and limpid, re- 
sembling the urine of hysteria. In the cases in which this 
seemed best marked very considerable nervous disturbance was 
present, and probably this condition of the nervous system may 
have led to a relaxation of the blood vessels in the kidney, as it 
does in epilepsy and hysteria. I have so frequently noticed this 
condition of urine, and so habitually noticed the absence of 
febrile urine, even with comparatively high temperatures, that I 
wish to impress this fact on you as having special relation to 
dengue. It is no accidental circumstance that I have noted, in 
fact, Twining mentions expressly that in 1824 “ the urine was 
copious and pale coloured.” Other observers, curiously enough, 
are at direct variance on this point. Cavell describes it as 
“ scanty and high coloured : ” Mouat as “ high coloured : ” E. 
Gordeve as “scanty.” Occasionally I have seen cases which 18 
would have borne out their opinions, but I am sure that such 
cases are not nearly so frequent as those in which an extra 
amount of particularly clear urine is passed. I have, however, 
noticed cases in which, though the urine was very clear 
and abundant in the commencement, it gradually changed its 
character and became more scanty, high coloured, and inclined 
to deposit at a later stage. This observation may, perhaps, in 
some measure serve to explain the discrepancies in the 
recorded experience of different observers. On cooling, the 
urine usually shows very little tendency to deposit. I have 
often kept it for 24 hours, and at most found only a little cloud 
of epithelia. It has been singularly free from deposits of all 
sorts, but when these have existed I have met with them of all 
shades, from the almost snow-white urate of ammonia to the 
darkest shades in which urates occur through red to brown. 
You must not conclude from this that sedimentous urine is 
common, for though I have seen some very extreme instances of 
it, when such fall under my observation, I regard them as curiosi- 
ties in dengue. In one or two cases I have found the urine 
turbid, even on being passed. In the later stages of the disease, 
or after it is over, deposits of triple phosphate are rather com- 
mon just as they are in other low states of the system. The 
urine is generally neutral, or, perhaps, rather oftener slightly 
acid. In a few specimens the acidity has been more marked. 
Both during this epidemic, and on previous occasions, I have 
paid particular attention to having the urine examined for 
albumen. This child’s urine was examined every day with great 
care for it, and none, was found. In a few cases I have met 
with albumen in the urine of dengue patients, but it has been 
almost exclusively found in the urine of those persons who 
were known previously to have had kidney affections. In no 
case have I yet found more than a doubtful trace of albumen 
in the urine of a person in whom I knew the kidneys to be 
healthy. Previously to my recent opportunities, I only examined 
for albumen in the later stages of the disease, expecting to find 
it as we do often after an attack of scarlatina. On the present 
occasion, I have not been so exclusive in confining myself to this 
period of the disease. You know both in measles and scarlatina, 
on the appearance of the eruption, albumen is now and then 
present in the urine. In some epidemics of these, diseases the 19 
frequency of the occurrence is very much increased. In this 
epidemic of dengue, I made sure I would find it as the second- 
ary eruption appeared, but have been completely balked in my 
expectation, I looked for it even earlier than this, hoping to 
find it occasionally taking the place of other forms of catarrh, 
which are the accompaniments of the first days of the disease, 
but have been no more fortunate. Throughout my investiga- 
tions I have been aware tnat Goodeve on four occasions has 
detected albumen in the urine during this disease, and that its 
occasional occurrence has been noted by others. I have appeal- 
ed thus to the test tube on hundreds of occasions, having 
watched the urine in several cases steadily from day to day, 
besides having made numerous less systematic examinations of 
it, and confess my disappointment at the result. lam aware that 
others even during this epidemic have been more fortunate, but 
my mass of observations have completely satisfied my own 
mind that the occurrence of albumen in the urine in dengue, 
at least in some epidemics, is an extremely rare and exceptional 
occurrence: so rare, indeed, that I would feel inclind to ask 
for proof that the kidneys had not previously been disordered, 
before I would regard its presence as an indication of the work- 
ing of the poison of dengue. 
Th.e Blood.—-I invited Dr. Douglas Cunningham to assist 
me in examining the blood of this patient day by day with the 
microscope. The method of preparation employed was that of 
exposing the blood as soon as it was drawn over a solution of 
osmic acid, then moistening it with a nearly saturated solution 
of acetate of potash. In this way the movements of the white 
cells are suddenly arrested. They remain petrified, as it were, 
in the condition they were in at the time they were subjected 
to the influence of the re-agent, and can be examined some 
time after to great advantage. The only appearance observed 
in the specimens of dengue blood which were examined, differ- 
ing from those to be found in specimens of healthy blood, was 
a considerable relative increase in the numbers of minute bio- 
plastic bodies normally found in small numbers in every speci- 
men of blood. In the specimens in question they were pre- 
sent in abundance, occurring either solitary and free, or in small 
masses, the individual bioplasts in which appeared to adhere to 
one another by means of some gelatinous molecular investment. 20 
These appearances were only met with during a few days, 
and the blood rapidly assumed its normal characters. I cannot 
tell you exactly the period at which these changes begin, but 
from this as from other cases of dengue in which the blood has 
been examined such changes seem to become noticeable as 
early as the third day. They have also been seen to continue to 
as late a period as the sixth day of the disease. In more than 
one case of suspected dengue which has been subjected to this 
test, no changes in the blood have been noticed. In these cases, 
however, the symptoms have proved so mild that a doubt exists 
as to whether they were genuiue examples of this affection. 
The action of the osmio acid does not prevent the protoplasm, 
from taking up carmine, and some specimens of blood have 
been beautifully coloured in this way. I am indebted to Dr. 
Cunningham for a sketch of the appearances observed which 
will, doubtless, give you a much more correct idea of the changes 
which have been seen, than any description I could give you 
would convey. The illustration has been drawn to a scale of 
700 diameters. 
Similar appearances in the blood have been met with in other 
eruptive disorders; for instance, in varicella, and in vaccinia, 
so I do not wish to give you the idea that the appearances are 
in any way peculiar to dengue. This is not the place for me 
to speculate as to the orugin of these bioplasts, whether free 
or collected together in masses. The temptation to regard the 
minute bioplasts present in the blood, as resulting from the 
proliferation of those larger bioplasts which we are in the habit 
of designating white blood-cells, is very great. At the same 
time you are already well aware that Dr. Beale regards similar 
bodies as the result of living material extrinsic to the organisms 
which has in some way found its way into the system. 
These bodies appear to be identical with those described by 
Eallier, as existing in the blood of every specific disease. He 
regards them as the ultimate elements of the individual fungi 
peculiar to the blood of each such disease. 
Occasional symptoms.—There are other occurrences 
which are sometimes met with in the course of the disease, 
which you ought to know of, and though none of them were met 
with in the ease of this child, I think it right, nevertheless, to 
draw your attention to them. 21 
The most common of these is the utter prostration that some 
patients complain of. You are all, in the daily routine of the 
hospital, brought in contact with patients who tell you they 
are very weak after a short attack of fever; it is nothing new 
for you to know that many diseases produce a very debilitating 
effect, but the way that many patients urge on your attention 
the fact that they have been absolutely prostrated by an attack 
of dengue, is not a circumstance that you meet with in other 
diseases. None of you have seen an epidemic of influenza, so 
my referring to the debility which is early felt in that disease 
will not help you much to understand the extreme degree to 
which this symptom is carried. My impressions on this point, 
however, are so vivid, that I cannot help drawing your attention 
to the fact in passing, that I never come in contact with a well- 
marked instance of this excessive debility without my mind 
being carried back to similar phenomena which I have witnessed 
when influenza was prevailing in other latitudes. You often see 
a strong man reduced at once with very little apparent cause 
to a state of abject helplessness—a condition of which he is 
painfully conscious, and to which he is ever ready to direct your 
attention. 
A medical man, on becoming aware of this for the first time 
in his own person, expressed to me the greatest surprise, how 
without any very high temperature, a few hours of fever 
should have so reduced him. Intelligent sufferers have again 
and again dwelt on the fact that they had previously often had 
fever, but they had never known the misery of such a feeling 
of helplessness as that brought on by dengue. Previous obser- 
vers seem all to have recognised the symptom which I have 
been attempting to describe to you, but I do not think that I 
have met with anything in their writings which would have 
led me to expect that I would encounter such exaggerated 
instances of this prostration as I have seen during this epi- 
demic. It is rare to see this weakness passing on to collapse, 
but I have seen the lesser degrees of that state, though never 
occurring to such an extent as to prove fatal. 
Another form in which the nervous system shows that it is 
overpowered by powerful influences consists in wrell-marked 
drowsiness and tendency to stupor. I cannot for the moment 
recall any instance in which I have observed such a symptom 22 
developed to any well-marked extent in an adult. I think it 
has been almost exclusively in children that this drowsiness has 
been observed, and, fortunately, it is far from being a common 
occurrence, for it is a symptom of very evil omen, the insensi- 
bility gradually deepening till the child dies comatose. 
Epistaxis can hardljr be said to he a symptom of dengue, hut 
I have so often seen it occur during the epidemic, that I think 
it deserves mention in this place. I have seen it take place to 
a troublesome extent, and to be repeated more than once, hut 
though it has alarmed relatives. I have never seen it so profuse 
as to call for treatment. I think I have more often met with 
it after all fever had gone, than during the continuance of the 
pyrexia. 
Mellis mentions one case in which there was affection of the 
testicle, and very considerable pain was complained of in that 
organ. Dr. Aitken also alludes to the fact of the testicle 
becoming swollen to a great degree. I think I have elsewhere 
met the statement advanced that the testicle is implicated in 
dengue. At all events, I used to have a very distinct impression 
that such was the case, and often wondered why I never had 
met with such complication. In this epidemic, as well as during 
my previous opportunities of watching the disease, I have had 
my attention directed to this point, and have never met with 
any well-marked instance of it. It is true patients have admit- 
ted, under cross-examination, that they think they may have 
felt something more or less wrong with the testicle, but even 
such an admission was made with so much hesitation, that it did 
not convey a satisfactory idea to my mind that they had suffered 
in reality, and I think I could obtain just as good evidence 
regarding any imaginary symptom, on which I wished to fix the 
attention of patients. Ido not wish to cast any doubt on the 
single fact noted by Mellis, or to deny that swelling of the 
testicle has been seen by others, but simply wish to guard you 
against believing that you will often meet with this symptom 
in dengue. 
In the same way, I have not met with the well-marked 
ptyalism, described by many good observers. The saliva has in 
some instances been secreted in increased quantity, but unless 
the writings of previous authors had prepared me to look out 
for this symptom, I am pretty sure it would not have attracted 23 
my attention, as in no case have I witnessed its existence in any 
remarkable degree. In several cases I have seen enlargement 
of the parotid and sub-maxillary glands, but even when this 
caused considerable inconvenience, I have not seen true saliva- 
tion take place. Mouat states that in this disease very small 
doses of calomel salivate. Perhaps, when this drug was in more 
general use, some of the cases of ptyalism attributed to this 
disease may have resulted from the use of calomel, without the 
causation being traced to it as clearly as it was by Moiat. 
The lymphatic glands, in like manner, are sometimes the 
seat of great irritation, and you may find chains of enlarged 
glands in various situations, as in the groins or neck, or you 
may meet with tender spots just below the skin at any point 
of the surface, at which you may recognise a minute gland 
enlarged to the size of a split pea. 
The Terminal Rash.—The terminal rash in this case has 
in various ways been very instructive. It appeared rather more 
early than usual, and at first occupied a not unusual site at 
the root of the neck and upper pait of the chest. Had it been 
delayed for two to six hours it would have more clearly 7 resem- 
bled the standard which I would propose for your adoption. 
It is usual for the terminal rash to appear during the course of 
the fourth day, and not at the end of the third. I was dis- 
appointed in ray endeavour to make it more general at the hour 
at which the class was to see the case, and so far from being a 
better example of the eruption, it was not half so distinct as it 
had been nearly an hour before. You may justly regard this 
fugacious character of the eruption as one of its special cha- 
racteristics. It is quite the rule for it to be fugitive, and in 
this way it often evades detection. Had it taken place 
during the night, we would in all probability have remained in 
ignorance of the fact that it had appeared. In many cases it 
appears thus suddenly between the visits of a medical man, and 
disappearing leaves no trace behind. Very frequently an atten- 
tive nurse or observant mother will tell you that y7our patient 
was covered fora few hours with an abundant rash, without your 
being able to confirm her assertion. In no other eruptive 
fever is this the case. In measles, for example, even when the 
rash does recede suddenly, it leaves well-marked appearances on 
the skin; and, besides this, recession of the eruption is attended 24 
with the most alarming symptoms, such cases almost always 
ending fatally, lu dengue, when the rash recedes thus, nothing 
noticeable occurs, the child remains perfectly well. I beg yon 
to note also as a very prominent peculiarity which at once 
distinguishes the affection which we are studying to-day, that the 
rash appeared while the temperature of the body was natural. 
In the great majority of the cases which you will see, you 
will find this to be the case. In a few instances the thermo- 
meter will mark 100° F. at the time the terminal rash appears, 
but this is so exceptional an occurrence that I am by no means 
prepared to say, whether in such case even this slight rise of 
temperature is caused by the disease, or whether some trivial 
accidental circumstance may not have led to the slight elevation 
of temperature. 
Dengue is the only fever that I am acquainted with which 
possesses the peculiarity of the eruptive period being habitually 
without fever. The rash of scarlatina appears during intense 
pyrexia. Though, as the eruption occurs in small-pox, a fall in 
the temperature takes place, the high temperature when the rash 
begins is something quite distinct frcm the nominal temperature of 
a patient with dengue, in whom the terminal rash is appearing. 
In measles, the temperature, so far from falling, often rises when 
the eruption begins, and the general distress is often aggravated. 
Keeping all this in view you will be better prepared to attach 
to this circumstance the importance that it deserves. 
The rash which you saw can be very easily described. It 
was a measly rash. So very exact, indeed, is the resemblance, 
that mothers learned in the various eruptive fevers of infancy 
will argue the question with ymu, and insist that the child with 
such a rash must have measles. More than this, medical men 
who think they have special experience in measles, treat a suc- 
cession of such cases, under the impression that they have to 
do with measles. Other medical men have told me that they 
had never seen measles with the same attendant symptoms as 
those of the cases they were now treating, and yet they regarded 
the eruption as so peculiarly distinctive, that they lulled to rest 
their doubts on the subject, and tried to persuade themselves that 
the disease must be measles. Any dermatologist, if he were 
shown a case in which the eruption was at all general, if he 
attempted to found a diagnosis on the characters of the erup- 25 
tion alone, would infallibly find himself in error, and pronounce, 
without hesitation, that the case before him was measles. I can- 
not tell you any means of distinguishing between the measly 
rash of dengue and that of measles. Not only are the elements 
of which the rash consists similar, but in many cases they 
arrange themselves on the skin in the same crescentic manner. 
In dengue, however, I have noticed that the arrangement of the 
irregularly-rounded patches and crescentic margins of the 
eruption is seldom so marked as in measles. It seldom begins 
on the face as in measles, and often first appears at the root of 
the neck or on the knees, or elbows, or palms of the hands. It 
is sometimes quite as general an eruption as that of the best 
marked case of measles, but, as a rule, it is not so, and much 
larger spaces are generally met with in which there is no erup- 
tion than are usually left uncovered by the eruption of measles. 
So far from constituting a general eruption it is very often 
extremely limited in its appearance. In this case, when the 
eruption first came out, four inches at the upper part of the 
chest was all that was occupied by it. This is often the case, 
hut more usually even when it is limited in extent, some other 
part of the body, as one or both knees, for example, may consti- 
tute the whole surface affected by it. 
In most of the cases which I have seen, the eruption having 
once disappeared, does not return again. This child, however, 
constituted an exception to this rule. After remaining nearly 
forty-four hours without eruption, having had no fever in the 
meantime, and no rise of the thermometer marking its advent, 
the rash again showed itself, but it began at quite different 
points, the palms of the hands and legs above the ankles being 
now the parts affected by a measly rash. In measles, you some- 
times see a similar phenomenom in a second outbreak of the 
eruption, but in such a case the rise in temperature which 
heralds in the first appearance of the rash is again repeated 
when the exanthem reappears. 
On the next morning, about eighteen hours after the rash had 
reappeared, it was still distinct, and had not spread much. I 
did not see the child then, but reliable witnesses state that the 
eruption had quite changed its characters. It no longer resem- 
bled measles, but the parts affected by the eruption were swollen, 
and covered by the wheals of urticaria. each element of the 26 
eruption was prominent and surrounded by a red blush. Within 
twenty-throe hours of the time this rash began, and rather more 
than six hours after it was seen to have assumed the characters 
of urticaria, it spread and covered the whole body. With this 
urticarial rash, there was no itching. The morning after the 
rash had become general, as soon as it was light, a search was 
made for the rash, but it had vanished, the skin being left 
without a blemish. 
It is by no means uncommon for the terminal rash to appear 
as urticaria. In fact, one of my medical friends consulted me 
about a fever which he had never seen before, and which was 
invariably followed by urticaria. Nurses and mothers recog- 
nise this as nettle rash, and it possesses the usual characters 
of this eruption, as it occurs under other circumstances. 
Its fugitive nature is often well marked, as it may remain 
visible for only half an hour. The distressing itching it occa- 
sions is at times very troublesome. While alluding to this let me 
mention that the itching, though it was at no time present 
in the case of this child, often proves the source of great 
annoyance and calls for treatment. You must be prepared 
to meet with it in cases in which the rash has not assumed 
the characters of urticaria : the itching of the surface is some 
times a very prominent symptom even in those cases in which 
no eruption has been seen. 
In this case, the urticaria was preceeded by a measly rash, pro- 
bably the one form of eruption was developed into the other. 
I have no other observations bearing on this point. In fact, I 
have been singularly unfortunate in being unable to see the 
first commencement of any of the forms of rash. They are 
usually so evanescent, and reach their full development so early, 
that opportunities for watching how they begin are rare. No- 
thing that I have observed would lead me to think they begin 
differently from the rash of measles. Indeed, competent obser- 
vers have assured me that they have seen the eruption begin in 
the minute red points observed in measles. 
About the termination of the rash I can speak with more 
confidence. In almost all the cases that I have seen, it disap- 
peared entirely after remaining out for a few hours. In other 
cases I have seen it remain out for two or three days and vanish 27 
suddenly. I think I observed it to remain for five days in an 
exceptional case. 
In several cases it did not end in this way. It gradually 
declined like most other rashes, or even when gone left a 
motling of the surface behind, not unlike the appearance seen 
after measles. This was not common in my experience, but 
other observers have told me they have met with it so frequent- 
ly as to cause them to regard it as the rule. 
In rare cases the hypersemia attendant on the rash is so 
great as to lead to distinct ecchymoses. I have seen the tiny 
elements of the eruption thus hoemato graphed on the skin with 
vivid minuteness, and remaining distinct for many days after 
the eruption proper had gone. 
I have already dwelt so long on the characters of the terminal 
rash, that though I have very much more to say regarding it, 
I must be extremely bi’ief in order to find time for other points 
of importance The terminal rash you have seen to be one that 
usually very closely resembles measles, while at times the form 
it assumes is that of urticaria. 
A third form is that of scarlatina. In my experience, this 
has very seldom occurred. During this epidemic one of my me- 
dical brethren assures me he has seen more of this form of rash 
than of any other. This quite coincides with what was seen 
in others of the recorded epidemics, and in 1853 the rash seems 
much more often to have resembled scarlatina than measles. 
A fourth form of rash is lichen, a fifth roseola, while sixthly, 
vesicles and bullae have been met with in this as in previous 
epidemics. 
I have already incidentally mentioned that at times no 
terminal rash is observed. I use this expression advisedly, 
because the rash is often overlooked. In the case of any 
fugitive rash, it is easy to understand how it is so. Knowing 
this to be the ease, I have had several patients carefully 
watched, and examined every second hour during the night. 
Special provision has been made for good light, and yet in many 
cases I have failed to obtain evidence of any rash having 
appeared. lam confident that I have seen many cases without 
a trace of rash, and that the absence of the exanthem which we 
regard as a rare occurrence in other eruptive fevers, is very 
common in dengue. I can not give you any exact idea of how 28 
often the eruption is absent, but I should not be a bit surprised 
if subsequent observations proved it to be absent in about a 
third of all the cases. 
You may well be astonished at what I tell you on this point, 
and about the diversity of the forms in which the eruption ap- 
pears. To show you, however, that I am by no means singular 
in my observations of this disease, let me read to you a 
sentence or two that were written nearly half a century ago. 
Of the Calcutta epidemic of 1824, Cavell wrote as follows; 
“ Although some eruption was common, we cannot consi- 
der this an eruptive disease, since in a great many cases there 
was none. How unlike any former history of eruptive disease, 
is it that the eruption should assume so many characters! In 
one case it belonged to the class papula ; in a second exanthema ; 
in a third vesicula; in a fourth .bullse ; and a fifth to that of 
wheal. All of these varieties I have seen.” 
Relapses.—ln the case of this child, when once the pyrexia 
was over, within forty-eight hours from her first seizure, she 
had no return of fever, though sub-febrile temperatures were 
occasionally noted. By stretching a point, I tried to recognise 
in these slight elevations of temperature a resemblance to the 
relapses of fever which we sometimes see in dengue. If the 
defervescence lias not been very perfect, and the temperature, in 
any case, instead of going down to sub-normal limits, remains 
say at 99° F., a rise of a degree and a half at once brings you 
into the range of febrile temperatures. It is by no means rare 
to meet with such cases, and then patients tell you,—“l felt a 
little hot at such an hour, and I think I had a little fever,” 
while, when you see them shortly after, the thermometer marks 
99°. This is the simplest form the relapse takes, and it may 
be repeated several times within a week. In most of your 
cases even this slight form is not met with, and even when it 
occurs once it need not be repeated again. A slightly more 
severe form of relapse than this is not very rare. A patient, 
with a normal or even sub-normal temperature on any day of 
the disease, say the fourth, fifth, or sixth is again seized with 
fever, about which there can be no doubt, and has to lie down 
for some hours, in such cases you often find a temperature 
ranging between 102° and 103° F. Under such circumstances, 29 
the fever may even last for twenty-four hours, and the pains of 
the first attack may return in the relapse : usually, however, in a 
modified form. In rare eases a more severe form of relapse 
than this even is met with, in which temperatures over 104° P. 
may be I have seen such a relapse occur on the 
third day, some twelve hours after the first attack was over, 
and when it occurs on the fourth day or later when the 
secondary rash is out, a high temperature with a measly 
rash is apt to lead you to make a diagnosis of measles. I wish 
you to keep this fact in mind, as I shall have to refer to it 
again. I have never been able to notice any regularity in the 
occurrence of these relapses, and can not lead you to any law 
which guides them. Perhaps more close watching may enable 
you to make advance in this direction, but, for the present, I 
can only regard them as accidental manifestations, not fol- 
lowing any system in their coming or remaining away. This 
tendency of febrile action to recur is one of the features of 
dengue which deserves prominent mention, as I do not think 
you meet with it in any of the other febrile exanthematia, 
except as an index of serious local disease, while here it has no 
such significance. These relapses chiefly take place within the 
first ten days after seizure, but a condition sometimes remains 
which seems to render persons liable to irregular attacks of 
fever for long after they are well and about. Even when no 
relapse has taken place immediately after the attack, such 
people now and again get fever for a few hours—while they 
never before were liable to similar attacks, and seem thus to be 
rendered easily affected by influences, which would not pre- 
viously have influenced them. You will do well not to regard 
these attacks of fever as specific in any way, as they probably 
depend on the weakening tendency of an attack of dengue, 
which, lowers the powers of resistance of the individual, and 
makes him an easy prey to even slight exciting causes of 
disease. I have more than once seen repeated relapses within 
the first ten days after the attack in those who had been much 
subjected to malarious influences. The curves illustrating 
the temperature in relapsing dengue require little comment. 
In the case of the adult on the fourth day the temperature 
rose to over 104° E. In both cases quinine was given as soon 30 
as it was seen that the attacks were not becoming slighter, 
and at once checked the disease. I am glad to be able to 
shew yon these two tracings of the temperature, as such 
cases are far from common. 
The Sequelae.—As you might expect, when fbe secondary 
rash has been a prominent feature of the complaint, desqua- 
mation often follows. In this child, we could not discover 
any tendency to removal of the cuticle in this way. In most 
cases of dengue you will fail to find desquamation, but still, 
in many cases, it constitutes a sufficiently noteworthy occurrence. 
When it takes place it resembles very much the desquamation 
after an attack of measles ; small bran-like scales separate, or 
the scurf may be much finer than this, and almost resemble 
white dust. At times the desquamation is very partial in 
extent, but you will sometimes find it extremely general. 
When it is so, and much desquamation takes place, the ap- 
pearance it produces on the dark-skined races is a very 
loathsome one, as the white fragments of cuticle are chiefly 
confined to the points at which the elements of the rash were 
situated, and the dark intervening skin gives rise to a remark- 
able contrast. Sometimes the amount of layers of cuticle 
shed is very considerable, and quite reminds one of pityriasis 
furfurans. When you rub such a skin in a strong sun-light 
you raise quite a little cloud of epidermic debris. Such an 
extreme form, however, is far from common. The scales are 
much finer than those usually separated after scarlatina. I 
have never seen any large Hake or layer of skin separate ; in fact, 
desquamation lias been altogether insignificant in my experi- 
ence when compared to what is frequent in scarlatina, and I 
have never met with any cases in which large continuous 
patches of the skin separated from the hands and feet, as one 
may see often enough to occur in scarlatina. Occasionally, 
desquamation proceeds to a much greater extent than it has 
done in my experience, and in at least one recorded case it 
proved so severe as to leave quite a raw painful surface behind. 
You will understand that this case is quite one of the curiosities 
of medical practice, and, so far from expecting to meet such 
cases in your after experience of this disease, you must be 
prepared to see many cases of dengue before you meet with 31 
one in which you can recognize well marked desquamation. 
Sometimes the irritation caused while this process is going on 
is very considerable, and patients ask to be relieved of distress- 
ing itching, tingling, or burning, but more commonly it attracts 
very little attention. 
Pains of a rheumatic character are very common after an 
attack of dengue. They are chiefly complained of in the joints, 
and resemble somewhat those which occur during the pyrexia, 
only they are usually not nearly so severe. They do not 
occur in all cases, but when they are met with they may 
give rise to most urgent distress. Sometimes they are present 
when the sufferer from dengue first gets out of bed. At other 
times he may pass some days before he is attacked by these 
after pains. They may last for a day or two, or pass off in ten 
days or a fortnight, but they are often much more persistent 
than this, and last for six weeks or three months. Even when 
they do not continue long they are sufficiently annoying, but 
when week after week passes away without the suffering coming 
to an end, the bravest heart gives in, and they are regarded 
with feelings akin to despair. In a few cases they give rise 
to quite as much suffering as an atlack of acute rheumatism or 
gout, but in most cases they are not nearly so distressing. 
Even when they are not severe, and little complaint is made 
while the sufferer is at rest, the moment an attempt is made to 
use the affected joint, at once he finds himself disabled. If a 
knee or ankle is affected, either he cannot walk at all, or hobbles 
along in a manner you would style grotesque were it not such 
a serious matter for him. In the same way, if an elbow or wrist 
is attacked, he cannot lift a book or feed himself, and laments 
his helplessness, while expressing himself otherwise well. 
These pains fly about from one joint to another, and after, by 
your treatment, you have relieved one joint, your gain may be 
little, for another joint becomes the seat of the malady. There 
is a sense of fulness connected with the pain, and if you are 
guided by your patient’s sensations, you will always meet with 
swelling of the affected part. If you trust to your own 
perceptions, you will often discover no change in the size of' 
the joint. Occasionally you may meet with a little swelling, 
and iu rare instances you may find a little puffiness of the 82 
textures round the joint. I have never seen the tissues in such 
a state that oedema would be a fit term to apply to it, and even 
when there is a little swelling you may regard it as insigni- 
ficant. I have never seen ulceration of the cartilages, or 
disorganisation of any joint follow on dengue. So, although this 
pain is a very distressing sequela, you need not look on it in 
any more serious light than that of the distress entailed. 
An irritable state of the mucous membrane of the intestines 
sometimes follows on dengue, and very intractable diarrhoea 
or dysentei’y may continue for long. Luckily such a compli- 
cation is not common, as it may prove so severe as to carry your 
patient to the brink of the grave. In other cases, when it is 
present, it is by no means serious, and hardly requires treatment. 
As a rule, the bowels are not disordered in any way after 
dengue. 
A more rare, but. still interesting, event, following on 
dengue, is deafness. I suppose it depends on affection of the 
eustachian tube. I have never seen it proceed to such an 
extent as after scarlatina, and have not yet met with any 
instance in which the auditory apparatus lias become disorga- 
nized. 
Sometimes the state of health is most cruelly broken down 
by an attack of dengue, and the constitution remains in a 
shattered state for long. 
The Non-identity with Scarlatina.—Before proceeding 
to speak of the diagnosis of this disease, I think I ought here to 
say a few words to you on a kindred matter of such import- 
ance that, without having settled convictions on the point, it 
will be very difficult for you to follow me in what I have to 
say. I allude to the supposed resemblance or identity of 
dengue with scarlatina. 
If you admit that the two diseases are identical, of course, 
there is no necessity for attempting to formulate a diagnosis 
between them, and the sooner the term “ dengue” is got rid of, 
and the term scarlatina substituted for it, the better. I hope 
in the sequel to prove to you that this can never be—and 
that, therefore, we can safely confine ourselves to a consi- 
deration of the supposed resemblance between the two dis- 33 
eases. That there must be some resemblance, I am forced 
to admit, as men thoroughly versed in medicine, have not 
felt quite certain whether this fever were not scarlatina; 
the symptoms modified, it may be, by the difference of climate, 
but still caused by the working of the scarlatina poison. 
When I tell you that Dr. Goodeve left the question in this state 
of doubt when he wrote in 1853, you will see that there is 
weighty reason why I should bring the subject before you. 
I have told you that I am forced to admit there must be some 
resemblance. I hasten to say I have never been able to see it. 
I have met with cases of dengue which were not at all well 
marked instances of the disease, which it might be difficult 
to surround with well marked lines of demarcation serving to 
separate them from equally indefinite instances of scarlatina; 
but it is not to such imperfect specimens that we should 
appeal when we want to establish either the similarity or the 
difference between two objects which we wish to compare. 
Take an average case of dengue, such a case as you can meet 
with every day when the disease is about, and compare it with 
a similarly selected case of scarlatina, and then you can have 
no doubt regarding the essential difference between these two 
diseases. I take it for granted, of course, that you are familiar 
with both diseases, but a great deal depends on this. You all 
know that strangers dwell much on the resemblance between 
the children of a family, while those within the family circle 
are impressed rather by the points in which the resemblance 
between one and another is deficient. To those who have seen 
both diseases the resemblances pass unnoted, the points of 
want of similarity alone impress themselves on the mind. 
It is right that it should be so: both of these diseases belong 
to the same class of febrile exanthemata, and, as such, necessarily 
possess certain characters in common, exactly as they do with 
small-pox or measles. By looking at their points of resem- 
blance, under these circumstances, you can gain nothing. It is 
by studying the points in which they differ that you can hope 
to understand rightly the true relationship between the two 
diseases. In coming to the enquiry, I must ask you not to 84 
allow your minds to be biased by tbe fact that certain points 
of similarity have led observers to question the non-identity 
of these two diseases. It may help you to do so if you call 
to remembrance that there was a time when the identity of 
small-pox and measles was believed in ; that it is not yet very 
long ago that the distinctions between typhoid fever and 
typhus came to be recognised ; while, even in the present 
day, the battle requires yet to be fought to establish again 
the non-identity of small-pox and varicella. 
We are more fortunate now than our predecessors in being 
able to appeal to a single, crucial, undeniable test, which, of 
itself, is sufficient to put the question at rest. Our clinical 
thermometers, if properly used, furnish the most unanswerable 
proof that dengue is not scarlatina. Gave the history of any 
case of dengue, purposely dwell on the points of resemblance 
to scarlatina, and keep back all the evidence which goes against 
this view, and furnish along with it a temperature chart, and 
no one versed in medical thermometry will accept your diagnosis 
of scarlatina. It is difficult to compare things so utterly 
dissimilar as temperature charts of dengue with similar delinia- 
tions of the temperature in scarlatina. I will not occupy 
your time with any laboured explanations. I send round a 
number of such illustrations which appeal forcibly to the eye, 
and a casual glance even will satisfy you how very different 
are the two diseases. During the initial stage there is a certain 
resemblance. The temperature mounts gradually up, and 
attains its maximum rapidly. This type of pyrogenetic stage is 
also common in intermittent fever, in ephemera, and in many 
other diseases besides scarlatina, so you must not lay undue 
stress on this point of similarity. Even here, however, I think 
that there is a difference. It occupies twenty-four hours in 
dengue to reach a temperature of 104° or 105° F., while, if I am 
not mistaken, the rise is much more rapid in scarlatina, and 
may be accomplished in perhaps a fourth of that time. 
As soon as this high temperature is reached, the similarity, 
be it more or be it less, ceases, and the two diseases pursue 
totally different courses, and finally decline in a totally different Measles, (wunderlich) 
Relapsing Dengue child (severe) 
Litho. at the Survr. Genl’s. Office. Cal. April 1872 
Mild Dengue, 
Relapsing Dengue adult, (severe) 
Mild Scarlatina, (wunderlich) 35 
manner. In scarlatina the fastigium, the stage of fully deve- 
loped fever, is prolonged for days. In it temperatures of 104° F. 
are very usually met with, and before the fourth day of the 
disease a temperature of 102° F. may be considered exceptional. 
In dengue, on the other hand, the fastgium is accumulated, and 
as soon as such temperatures as 101°, 105°, and 106° F. are 
reached, an immediate fall takes place, and it is quite exceptional 
to find a continuous temperature over 102° F. In very many 
slight cases of dengue, indeed, the temperature does not rise 
over 102° F. at all. Here we have at once a sharp, well-defined 
difference, and in tracing the course of the disease still further, 
we meet with equally conclusive proofs of want of identity. In 
dengue, the defervescence takes place by crisis, and not only 
so, but by a singularly, rapid crisis which carries the tempera- 
tures down to sub-normal ones, in fact, at times, to those of 
moderate collapse. In scarlatina, a return to normal tempera- 
tures is effected in a widely different way as it occurs by lysis 
Here the tissue changes are much more serious than in dengue ; 
and' a longer time for reparative action is necessary before a 
normal temperature can be re-gained. This period of lysis 
extends over several days in scarlatina, and is interrupted by 
slight evening exacerbations, contrasting strongly with the 
abrupt crisis of dengue which is effected in a few hours. 
I wish to impress these facts strongly on you, and even at 
the risk of provoking your mirth, will ask you to allow me to 
compare the course of these two fevers by applying familiar 
names to their stages, so that I may be able to bring out 
strongly how unlike they are to one another as judged bv the 
test of temperature. Let me then call the pyrogenetic 
the head, the fastigium the body, and the period of defer- 
vescence the tail, and you have scarlatina and dengue resem- 
bling each other more or less in their heads ; scarlatina having 
a long bulky big body in contrast to the short, imperfect, 
almost rudimentry one of dengue, while dengue has a short 
straight perpendicular tail, quite a different sort of thing from 
the long curly horizontal tail of scarlatina, as depicted in the 
chart of the temperatures met with during the pyrexia. 36 
The Diagnosis.—Fortunately, in Calcutta, the diagnosis 
between dengue and scarlatina is not one you will be often 
called upon to make, as the latter disease so rarely occurs that 
most of those who have the largest opportunities of seeing it, 
did it appear, have never seen an instance of the disease. In 
other latitudes should the two diseases ever chance to prevail 
at the same time, in many of the least marked instances of 
either affection, which are by no means rare, the differential 
diagnosis might be sufficiently perplexing. 
When the characteristic symptoms of either disease are well 
developed, the distinctions between them would be sufficiently 
easy even at the commencement of the malady. 
The pains of dengue are not met with in scarlatina at the 
commencement of the disease—though they may be occasionally 
simulated at a later stage, as the rash is disappearing, by the 
suffering caused from the larger joints becoming swollen. The 
rapid pulse even early in the disease in scarlatina presents a 
marked contrast to the much slower one in dengue. Even here 
you must exercise caution in making your observations, for 
if you count the pulse while your dengue patient is sitting or 
standing, especially if he has been making any slight exertion 
immediately before, the pulse may have risen to 120 or 130 
heats, while in the same patient, after a little rest, in a state 
of recumbency, it may again regain a more normal equilibrium 
of about 100 heats in the minute. Then, the initial rash of 
dengue is a much more early feature in the disease than the 
eruption is in scarlatina—although on rare occasions you may 
find the rash of scarlatina appear in the first day, it is habi- 
tually on the second day that it occurs. 
In making a diagnosis from measles likewise, the initial rash 
of dengue, when it is present, will assist you, for there is no 
corresponding manifestation in measles. Tne high temperature 
104° F. on 105° F. which you almost invariably meet with during 
the first day of the disease distinguishes dengue from measles, 
in which affection you expect lower temperatures such as those 
below 103° F., until the time that the rash appears. 
In most cases of dengue, the complete or even comparative 
absence of the characteristic catarrhal symptoms of measles, 
will of itself serve to prevent you from committing any 
mistake in discriminating between these two affections. The 37 
only occasions on -which I think jrou will have any difficulty 
in making a diagnosis between measles and dengue, will be in 
cases which you have not seen till the fourth or fifth day, 
and find the patient with a measly eruption. In such cases, the 
diagnosis may be sufficiently doubtful, if both diseases are epide- 
mic at the same time, and your patient have a relapse of the 
pyrexia, the thermometer marking for instance 104° F. With the 
usuai cool" skin of dengue, the measly rash need never 
cause you any uncertainty, as the higher temperature of 
measles at this period would prevent any doubt. In the few 
cases of dengue in which the terminal rash has appeared during 
a relapse of the pyrexia, the very decided history of the 
pains of dengue, has served in each case to enable me to pro- 
nounce with certainty on the nature of the affection, hut had 
I been compelled to found a diagnosis on any general symptoms, 
gathered from unobservant friends, I confess I would have felt 
myself in difficulties. Those of you who wish to possess a 
more exact delineation of the differences between the various allied 
exanthemata will find in Aitken’s work a tabular form under 
the head of Rotheln, which was drawn up by Dr. I’aterson. If 
you will head a fourth column “ dengue,” and under each divi- 
sion sketch in the most prominent symptoms that I have des- 
cribed to you, you will easily see that there are many other points 
than those I have dwelt on, which will more or less assist you 
in framing a diagnosis. 
From other febrile affections, the diagnosis is usually an easy 
matter. In most cases, the well marked stiffness or pain at the 
onset of the disease is of itself sufficient to guide you to recog- 
nise that you have to deal with dengue. When you see your 
patient very early in the attack, and you do not find the pains 
developed in a characteristic manner while the initial rash also 
fails you, you will find dengue written in bright red characters 
on the mucous membrane of the under eye-lid, and after everting 
it, you need hardly ever delay in pronouncing your verdict. 
Although generally you have no difficulty in arriving at 
a diagnosis, when the disease occurs in a sporadic form, as it 
does annually in Calcutta, I have seen it often mistaken for 
measles, and unless you are on the alert, you will find it too 
easy to make such a mistake. Again, you meet with cases of den- 
guis latens, in which, with the characteristic pains of the dis- 38 
ease, perhaps in an aggravated degree, you have no fever, or 
at least when you see such a case some days after your 
patient has been confined to bed with it, you can get no his- 
tory of a hot skin. 
Then, there are very slight forms of the disease, quite pro- 
tective against a second attack, instances of denguis mitis if you 
will, in which your patients are scarcely ill, where it is not at all 
easy to decide on its exact nature. A trifling sore throat, and 
slight malaise, may be all you can lay hold of, till the terminal 
rash appears to shew you what you have had to deal with. Or, 
even this may not be seen, and then all the evidence you have to 
guide you consists in your patient not being seized with 
dengue again vhile all others in the house have taken it. 
Again, denguis maligna may occur, and throw difficulties in the 
way of a ready diagnosis. A huge over dose of dengue poison 
may so overpower your patient’s nervous system as to obscure 
all the usual symptoms. Drowsiness may have passed into 
coma, some convulsion may have taken place, and you see your 
patient, for the first time, with a temperature verging on hyper- 
pyretic, a failing heart and oedematous lungs, with the whole 
surface highly cyanotic. Under such circumstances, I know 
of nothing which will assist your diagnosis, beyond a know- 
ledge of the fact that dengue is epidemic, and that its specific 
poison is capable of giving rise to such serious manifestations. 
I have often wondered how it was that in America' and the 
West Indies they thought it necessary to discriminate between 
dengue and yellow fever. I have ceased to do so, however, 
since I have seen cases of dengue attended by jaundice, and 
have also seen in other cases typical instances of black vomit 
and black stools. These symptoms, however, are very rare, and 
need not, I think, interfere much with the diagnosis. 
The Treatment.—At the outset I have to impress on you the 
fact that dengue is a specific disease, and runs a certain course 
of its own, uninfluenced by remedies. The days are past 
when you would attempt to cut short a disease such as small- 
pox, and I think your faith will be strengthened in what 
I have afterwards to tell you about the treatment of dengue; 
when you start from such a fixed and certain basis as that, 
nothing that you can do will avail much in altering the course 
that the disease takes. You can do much good by treatment, 39 
you can do much harm by treatment, to the individual who 
is the subject of this affection, but during all the times I have 
been brought in contact with this disease, I have not been 
able to collect a shadow of proof that I have ever succeeded 
in shortening its duration or in converting a severe case 
of dengue into a mild one. Mouat thought he had proof 
of this; the many years which have elapsed since he wrote, 
make us weigh such evidence as he trusted to more carefully, 
with the result of rejecting much, that in his day seemed 
good. I have told you already that there are slight forms 
of the disease which give little trouble, as well as more severe 
ones, which, besides being very distressing, entail a long train 
of bad health. If you adopt any favourite line of treatment, 
especially if the remedies you employ are rather violent ones, 
insensibly you allow yourselves to indulge in the belief that 
your therapeutic measures tend to convert cases, which would 
otherwise have been severe, into those of a mild nature. If you 
change your plan of treatment, and more certainly if you adopt 
an expectant line of dealing with dengue, you will meet with 
the same sort of slight cases, and be able to recognise them as 
ordinary examples of the disease uninfluenced by treatment. 
Emetics and purgatives both have their advocates as effi- 
cient means to be employed in this disease, with the view 
of checking or curtailing it, or modifying its severity. Many 
practitioners have employed both of these measures in a way, 
that pei'haps now we might be justified in regarding as heroic 
practice. I strongly advise you not to he led astray by their 
recommendations, and to reject both emetics and purgatives as 
measures not only unworthy of your confidence in dengue, but, 
on the contrary, means to be avoided as far as you possibly can. 
I treated a few cases some years ago by emetics, having been 
led to use them by the recorded experience of others. It was 
my good fortune to have my eyes opened in this wise to the 
unnecessary use of a remedy which I should feel inclined now 
to regard as an abuse of it. One of my early patients with 
dengue was a gentleman of refined education, and gifted with 
rare discrimination. He took twenty grains of ipecacuanha on 
the first day of the disease, and its operation was very violent. 
He had a most mild attack, and was ungrateful enough to 
upbraid me with the tauut that my remedy was worse than 40 
his disease, I at once treated some cases without any emetic, 
and soon felt certain that most patients got on better without 
such a violent remedy. I hope you will not run into the 
extreme of believing that because emetics are not necessary 
in all cases, in no case are they to be resorted to. Avoid 
them by all means as far as you can, but when a much loaded 
tongue, gastric derangement and nausea, or any condition 
which your general familiarity with disease points out to you 
as being a morbid state of the system likely to be relieved by 
free emesis, do not let anything I have said prevent you from 
resorting to the use of an emetic as an exceptional expedient. 
In the same way, even to a greater degree, make sure that 
any purgative you think right to prescribe is only given 
to combat some especial symptoms. 
There are two very cogent reasons why you should, if pos- 
sible, not resort to purgatives as a routine mode of treatment 
for this disease. In those cases in which the pains are severe, 
the movements entailed during the operation of a purgative 
are productive of extreme agony to the sufferers. I have always 
held this full in view, and have never yielded to the temptation 
of prescribing such remedies as long as there was much fear 
of their leading to suffering. I have, however, had several 
opportunities of watching the results when prescribed by others, 
or when taken by the patients on their own responsibility. In 
several of these cases where all the resources of the sick room 
were available, the results were described, as a mani-fold 
aggravation of the tortures of the disease and in any case in 
which pain constituted a prominent symptom, nothing would 
tempt me to sanction the use of any medicine likely to cause 
purgation. 
The other reason why in my opinion you should abstain 
from acting freely on the bowels in dengue, is that in cases 
in which there is much tendency to prostration, the weaken- 
ing effects of such a- line of treatment are ill-borne. Not 
unfrequently such debility is extreme, and any addition to 
it comes to be a serious matter. I have seen syncope produced 
during the operation of a purgative, and though I have not seen 
actual collapse, I have witnessed such a close approach to it as 
to lead me to dread its possible occurrence. At times I have felt 
inclined to indulge in the uncharitable suspicion that perhaps it 41 
was from noticing minor degrees of such a condition our pre- 
decessors allowed themselves to deal so freely in this means 
of treatment. I have seen a free watery evacuation abruptly 
take the temperature down 6°F. 
This you might be inclined to think a most successful result 
to achieve, but when 1 tell you that the heat of the body is 
quickly regained again, and that such a casual remission is fol- 
lowed by great weakness—temporary at least, if not more per- 
manent—l hope you will see I have sufficient grounds for asking 
you to use purgatives with all caution. The bowels very often 
act daily without any assistance, and even when they do not do 
so, no great inconvenience seems to result by their remaining 
confined for two days. In the older epidemics considerable im- 
portance appears to have been attached to the unhealthy nature of 
the evacuations. If you do not irritate the bowels, I think you 
will have little reason to be dissatisfied on this score, so little, 
indeed, that you may attend a score of such cases without having 
to ask anything more about the bowels, than the simple question 
as to whether they have acted or not. In severe cases, then, I 
believe purgatives to be contraindicated; during seasons when 
catarrhal implication of the mucous membrane of the intestinal 
tract constitutes a prominent feature of dengue, purgatives should 
be withheld ; in slight cases they are unnecessary as a rule, but 
should distress be experienced owing to constipation, you must 
be prepared to deviate from your ordinary rule, and employ 
such mild measures to secure efficient evacuation, without any 
unnecessary cathartic action, as the symptoms in any individual 
case may seem to indicate as appropriate. If you act on the 
principle of allowing the bowels to take care of themselves 
as long as movement is likely to cause much pain, you are far 
from liable to do any harm by using laxatives when occasion 
demands. 
It has attracted the attention of most of you that this child was 
put on belladonna, many of you asked me why she was treated 
in this way. I was led, many years ago, to suggest the use of 
belladonna for the relief of the severe pains experienced in 
ardent fever. The power which I believed this drug to possess 
in producing contraction of the vessels in the membrances 
surrounding the spinal cord was the idea which promted me to 
make a trial of this agent. For long I have used it as a 
sovereign remedy in the pains of dengue, though I attach very 42 
little credit to the hypothesis which first guided me to make use 
of belladonna under similar circumstances. Ido not for the pre- 
sent propose to theorise on its mode of action. In Dr. Harley’s 
valuable work you will find much information on this subject. 
I prefer to bring it forward to your notice as an empirical fact 
—a fact which you will find of immense value to you—that in 
belladonna, we possess an agent of surprising power, when used 
against the very severe symptom which pain often constitutes 
in this disease. 
It is little short of marvellous how case after case yields as 
soon as the drug is given. 
You do not require to push the belladonna very far—medium 
doses very soon produce the results you want. The preparation 
given to this child was the tincture, and I habitually use it in 
this form as little likely to lead to accident. 
When I first began to use it, I prescribed one drachm of 
the tincture of belladonna, and five drachms of orange syrup, 
and directed that a sixth part should be taken every hour 
by an adult till the third dose had been given. In this 
way you can regulate the effect, and stop the medicine 
if a first or second dose gives the desired result. I very sel- 
dom, however, find that less than three doses prove sufficient 
in any cases in which the pains are really troublesome. So, 
when immediate relief is wanted, you may give two or three 
doses in one. In a bad case you may require to give rather 
larger doses, but I have not often had to do so. Some 
times three doses give such marked relief, that no more of the 
medicine requires to be taken. More often, though the relief 
is very decided, the pain still remains, and in some hours again 
become so troublesome as to lead to a repetiton of the dose. 
In this way, by having resort to two or three doses of the 
belladonna from time to time, you get over the period 
when this symptom is troublesome, with very little suffering. 
I cannot commend my formula to you as a very elegant one, 
it is much too sweet for most palates, but this fault is easily 
forgiven as your patients are very grateful for the immediate 
relief they experience. In very few cases will more than two 
drachms of the tincture be expended in a single case, and you 
will find it a safe precaution not to order any large quantity 
of the medicine to be at the bedside at one time. 43 
I began to use the tincture, and having hit on an active 
sample of it, very often send to the same druggists, to have pre- 
scriptions containing this tincture dispensed. You may prefer, 
however, to use the succus belladonnas in similar doses, or if 
chance restricts you to the use of the extract, a third of a grain 
repeated twice or thrice in twenty-four hours will generally 
suffice, or in a case with severe pains, half grain doses may bo 
necessary. You will sometimes find it useful not to give it in 
the form of pill, but to dissolve the extract, and give it in 
some mixture which conceals its taste. 
I think you will find it safer not to use atropine frequently, 
but if in any case you wish to employ it hypodermically, you 
will do well to use Dr. Harley’s solution of one grain of the 
sulphate of atropia in an ounce of water, as this is a very con- 
venient strength for ordinary use. Five minims of the solution 
containing of a grain of the drug, will be enough for a 
small woman or a child of twelve, of a grain—eight minims 
—is a full dose for most cases, while ten minims containing yg- 
of a grain is the full dose for a powerful well-developed adult, 
and is a dose which should seldom be required, and must not be 
exceeded in any case. In my own practice, I restrict the use 
of atropine in dengue to cases in which the pain is very intense, 
and has lasted for some time before I see the suffeter, and I 
use it then because the relief it affords is so rapid. I always, 
however, dissuade enthusiastic followers from using it more 
extensively, as I think its place as a therapeutic measure should 
be limited to the position I have attempted to assign to it. 
If you can not secure trustworthy attendance on any case 
of dengue, you must make sure that the belladonna is left 
within reach of your patient, for often a sufferer is quite 
unable to go any distance to hunt for the medicine. I know 
the case of a medical man who, after having experienced the 
immediate relief of a previous dose of belladonna, was quite 
unable to avail himself of another dose, as he was deserted by 
his attendant and suffered hours of misery, though the charmed 
antidote was within a few yards of him, simply because he 
was unable to get at it. 
You will find that belladonna helps you much in another 
way besides by that of its power of relieving pain. Restlessness, 
distress, and anguish quite apart from pain, are often very pro- 44 
minent features of the attack. Even in cases where the pain 
is not very severe, your patient may experience sufficient misery. 
You will find nothing alleviate all this so well as belladonna. 
You have seen me use the drug under similar circumstances in 
typhoid fever with very happy results, and even if there were no 
pains to be relieved in dengue, I would use belladonna to 
soothe these other symptoms. 
The only occasion in which I had an opportunity of noting 
any decided physiological action from the drug was in the case 
of an over-zealous patient who, in spite of my instructions to 
the contrary, persisted in taking six drachms of an active 
sample of the succus belladonnse (Thompson’s) within two days. 
Its mydriatic action was here considerable; though with the 
assistance of double convex lenses he could read small type 
quite close to the eye, reading without this aid was impossi- 
ble. Where no belladonna had been taken, I have seen the 
power of accommodation of the eye so much impaired after 
an attack of dengue, that you must be cautious in attributing 
to belladonna all the faulty vision you may chance to meet with 
in this disease. 
Belladonna does not relieve the headache materially. For 
this symptom, I have found a sponge bag filled with ice, if 
kept on the pillow in loose contact with the head to be the best 
palliative. In cases in which the headache was described as 
maddening, I have seen relief obtained by the application of 
leeches to the temple, but regard this measure as one which 
should seldom be resorted to. 
During the pyrexia, I think a coffee cupful of strong soup 
taken every six hours is more easily digested than any other 
food. When there is an objection to soup, milk answers 
tolerably well. Soda water and iced water may be given freely. 
For myself, I prefer to treat the pyrexia of dengue purely 
expectantly, and seldom, unless I find the urine to be scanty, 
give even a few grains of citrate of potass. If you think you 
must medicate, make your fever mixtures as simple and innocu- 
ous as passible. I was led into believing that twenty grain doses 
of quinine and large doses of aconite were beneficial, by finding 
often that a lower temperature supervened soon after these drugs 
were given. Now, I know that such remissions are normal charac- 
ters of dengue, and occur without the assistance of medicine, so 45 
Ino longer use this class of remedies. When the temperature 
rises over 105° F., I use cold water sponging to .assist in producing 
a fall of temperature. The natives of this country and some Eu- 
ropeans dread the use of cold water in this way. You may, how- 
ever,avoid coming in collision with such a prejudice by prescribing 
a lotion containing compound tincture of lavender, to be used 
in the same way. Besides the disadvantage of staining the 
sheets red I know of no other drawback, and even this is of 
little consequence, as it gives rise to the idea of salutary medi- 
cation, more than a colourless lotion would do. 
As soon as the temperature rises over 106° F., I advise you to 
have a cold bath made ready, and to familiarise yourselves 
beforehand with this form of treatment for hyperpyrexia as 
worked out for us by Dr. Wilson Fox. I have never had occa- 
sion to employ it, though I have seen the preparations made 
ready, and left instructions for the patient to be put into the bath 
as soon as a temperature of 107° F. had been reached. In a case 
where a relapse of the pyrexia at a late period of a fair convales- 
cence'had taken place, I found a temperature, when for the first 
time I saw the child, to be 109-5° F. Judging this to be the 
pro-agonistic stage, and that death was too close at hand for a 
cold bath to influence the result, I did not advise this means to 
be used, and under similar circumstances I counsel you to act 
with caution. 
The danger from these high temperatures, during the hot 
months of the year, is very great, as it is precisely under such 
conditions that heat apoplexy is apt to supervene. If you see 
cases under such circumstances you will do well to remember 
that vessels with ice kept near your patient are sometimes of 
use under similar circumstances. 
I have already told you that convulsions are common in 
children during the course of dengue. Provided this symptom 
occurs early in the disease, and the child wakens completely 
after the attack is over, you need be under no apprehen- 
sion, as the symptom, though very alarming, is not dangerous. 
I have treated many such cases expectantly, and they have 
all recovered. When the convulsions recur frequently, even 
if the child continues to regain sensibility after the fits 
are over, you will do right to make an attempt to put a 
stop to such undesirable manifestations. I think I have seen 46 
bromide of potassium assist in arriving at this result, but I 
am much more sure that conium has a very decided action in 
such cases. As soon as I see that the excitement of the motor 
centres does not pass off of itself, I at once prescribe this drug 
with confidence. Two drachms of the succus conii in twenty four 
hours is a fair dose for a child of a year old, and Dr. Harley 
cautions you, that to give this drug in too small doses is simply 
to trifle with it. When other medical men have prescribed 
it, at my recommendation, I have found that the druggists 
have lessened the dose prescribed, so in addition to signing 
such prescriptions, I advise you to take the precaution of placir g 
your initials after the amount of the conium which you order, 
to shew cautious dispensers ■ that you have made no mistake in 
what strikes them as being an unusually large dose 
As I have seen cases in which these convulsions returned 
several times, recover without any very special treatment, you 
will understand why I have been somewhat guarded in my 
estimation of the value of therapeutic agents. 
Such convulsions are also often dependent on the irritation 
caused by the cutting of a tooth, during the attack of dengue, 
so you must not neglect to have the gums examined on every 
occasion when this’symptom occurs during the period of denti- 
tion to have them freely divided, if necessary. 
For the distressing itching and other sensations which afflict 
some patients about the period of the terminal rash, you will 
find nothing so good as a free application to the skin of a drachm 
of camphor in fifteen drachms of mustard oil. As I have seen 
loss of sleep produced by patients getting out of bed again 
and again to have hunts for imaginary ants which they 
thought were stinging them, you will do well to guard against 
the possible necessity for the use of such an application by 
having the remedy prepared before hand. 
The little girl whose case has served as a good text for my 
remarks, took a little compound tincture of gentian for a 
few days after the terminal rash had disappeared. Any 
other simple tonic would have answered equally well. In 
many cases yon will find the convalescence after dengue 
sufficiently rapid without any assistance from medicine. The 
majority of cases, however, stand sadly in need of some tonic 
when the disease is over, as besides being much pulled down the 47 
convalescent has lost all appetite. Use your own favourite reme- 
dies under such circumstances, but keep in mind that when the 
nervous tissues have had their nutrition much impaired, and the 
brain refuses to work, you possess in strychnine a means of pro- 
moting rapid recovery which you will find invaluable. 1 often 
combine xg- of a grain of strychnine with 15 minims of dilute 
phosphoric acid and a sufficiency of water to cover the extreme 
bitterness, and prescribe such a combination to be taken three 
times a day. A generous diet is essential, and a few ounces of 
good wine often necessary. A pint bottle of really good after- 
dinner claret during 24 hours is my favourite stimulant after 
dengue, or a similar quantity of sound full bodied burgundy, 
but as long as you are sure your wine is good, you may consult 
your patient’s likings or your own whims within very con- 
siderable limits. 
For the pains in the joints which occasionally trouble patients 
for a few days after an attack of dengue, I usually prescribe 
nothing, as they often pass off without any treatment. When 
they are more persistent, or so severe as to demand treatment, 
any of the usual liniments, which you would use under similar 
circumstances afford temporary relief here. Combinations con- 
taining opium, or a chloroform and belladonna liniment are more 
or less useful. Advantage is sometimes derived from frictions 
with any of the more stimulating compounds as those contain- 
ing ammonia, oil of cajeput, &c. The remedy, however, which 
I would most strongly advise you to employ is turpentine. As 
a fomentation, or a constituent of a liniment, or simply rubbed 
on by itself it often gives marked relief. During the epidemic 
of acrodynia which began in Paris in 1828—as well as in pre- 
vious epidemics of this disease elsewhere, all observers seem to 
have agreed that turpentine was their most reliable resource in 
combating the distressing pains, which were so often met with. 
In acrodynia, the pains seem very much to have resembled 
those of dengue, and indeed in other respects, as in the curious 
variety of the eruptions observed, the two diseases possess many 
points of similarity. As in the Paris epidemic, various forms of 
paralysis, and other symtoms not common in dengue, were 
frequently observed, and as the pyrexia which is so prominent 
a symptom of dengue at the commencement of the disease 
seems to have been entirely wanting, we must conclude the 48 
two diseases were different, though we avail ourselves of the 
experience accumulated in acrodynia while treating the after 
pains of dengue. 
The endermic application of morphia after Trousseau’s method 
with which you are familiar, is an expedient you should always 
bear in mind, 
Among internal remedies, you will find alkalies and colchi- 
cum, and, indeed, all the more usual mode of treatment of very 
little use. The only treatment which, I think, I have seen do 
much good, has been that of iodide of potassium, combined with 
a fatty diet. Dr. Ilaye tells me he has seen bromide of potass 
succeed after the iodide had failed. 
Galvanism and electricity are some times useful in these 
pains. I think I have found the continuous current to be more 
effective than any other form. 
Whatever treatment you employ, you will find that sudden 
changes of temperature and slight gastric derangements are 
apt to bring the pains back, even when you thought you 
had got rid of them—so you must be particular in guarding 
sufferers against both sources of danger. The expedient of 
immediately using additional clothing as soon as the temperature 
of the air falls suddenly—a strict attention to diet—and above 
all, avoiding wines with the slightest suspicion of acidity, are 
measures which are absolutely indispensable, and a disregard of 
them will bring discredit on any line of treatment which 
you may adopt. 
I have already casually remarked that quinine is efficacious 
in arresting the relapses of the pyrexia which I have described 
to you ; ten grains a day was given to the adult whose case 
furnished the curve which is in your hands. It was begun on 
the fifth day of the disease, and you can judge of the result. 
In the case of the child whose temperatures are delineated in 
the other chart, quinine in five-grain doses twice a day was 
begun late on the eleventh day of the disease, and quickly put 
a stop to further paroxysms of fever.