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THE JOURNAL OF TROPICAL MEDICINE.
itself. until two, three, or five years after the patient
has left the endemic centres. A case occurred in
England in a Congo boy whohad resided in this country
for.three years without showing any particular sign of
unhealthiness. During the time of the slave trade
the disease was not uncommon in the West Indies
among the imported slaves, breaking out Jong. after
they had left Africa. According to Corre,’ the natives
of'.Gorée (Senegambia), when obliged to dwell for a
time. within the endemic centres of sleeping sickness,
do not consider themselves quite safe until seven years
alter their return.
The long incubation period of sleeping sickness may be compared to that of hydrophobia, a disease which offers other points of hkeness. The incubation period of ‘hydraphobia may be prolonged for one or more years, but its average length is from six weeks to two months. . Possibly, in: sleeping sickness, the average length of the incubation period does not exceed a few months.
After the onset of the characteristic symptoms the disease may run a very rapid course. As a rule it lasts: from three to four months, but a large pro- portion of. cases have been known to continue for twelve months.or even longer. Not infrequently the fatal issue 1s hastened by inanition or by an intercurrent disease such as dysentery or pneumonia.
The drowsy stage creeps on slowly and insidiously. The patient is languid, taciturn, slow, dejected; his customary spirit and activity are gone, he grows dull and listless. He has a. fecling-of weight or even pain inthe head; and occasionally suffers from giddiness. He is unable to carry on his work on account of a great, overpowering lassitude: He may fall asleep while at work, while at his amusements, and even while he is eating: With the progress of the disease his gait becomes unsteady and tottering, like that of a decrepit old: man. He is found -lying in the sun, in a state of drowsiness, with the eyes half closed and the limbs extended. He can easily be roused, and replies to questions intelligently,-but slowly and in monosyllables. If- he attempts to_rise he does so with difficulty, and his: mrevements are accompanied by muscular tremor.
There. may be some puffiness about the face and a. characteristic drooping.of the upper eyelids, which give the patient-a pecullar heavy expression. The skin has lost: its. glossiness and looks dry, ash-coloured and seurly. A. closer inspection will almost invariably reveal a papulo-vesicular eruption, especially marked on. the front of the chest, over the abdomen, and on the inner surface. of the thighs. This eruption gives rise to severe itching, and the patient is nearly always soratching- some part of his body, In a large majority of cases the lymphatic glands of the head and neck are appreciably enlarged. . Very often other groups of Jeep and superficial glands are swollen. The ‘swollen glands show no tendency to suppurate. As arule the. patient is: well nourished, and his appetite is fair. He may be liable. to diarrheea.or to constipation. His tongue, when protruded, is..characteristically tremulous. We have no’ very definite knowledge of the temperature in sleeping sickness. In. some mstances the disease is afebrile ;
the surface, temperature may even be sub-; normal. Asa rule there seem to be irregular attacks. of fever during the course of the disease, the tempera- ture varying from 100° to 103° F. Corre speaks of a regular evening rise. A day or two before death it may fall below normal. Somemene there is hyper- pyrexia.
Alter a time the drowsiness becomes more marked, the patient appears to be always asleep, and it becomes difficult to rouse him. He does not reply readily to questions, but the replies, when made, are correct and rational. He takes food when it is given to him, but unless constantly prompted he will invariably relapse into somnolence whilst conveying food to his mouth, or with the half-chewed victuals in his cheek. This stage is occasionally attended with remissions, some- times sudden and sometimes gradual—deceitful ap- pearances of amendment—but mvariably it relapses, and these fallacious symptoms of improvement may occur more than onces..
At length the muscular debility becomes excessive, the drowsiness almost continuous, and the patient becomes greatly emaciated. His limbs are agitated with tremors or become powerless and contracted, the cornee may become opaque, bedsores form upon the sacrum, the ilia and the shoulders, the lips swell, and saliva dribbles from the mouth; he passes the feces and urine inveluntarily, and dies occasionally in convulsions, but oftener without a struggle. These are the broad outlines of sleeping sickness.
Morpip ANATOMY.
The coarse anatomical features of sleeping sickness — were described many. years ago by Clarke,’ Dangaix,* Gore,” Guérin,® and others. In 1898, Regis and Gaid™ published a detailed microscopical examination, and attributed the symptoms of sleeping sickness to a diffuse meningo-encephalitis, but their observations referred to a single case in the region of Timbuctoo. In 1900, Mott” published the changes he had found in» the central nervous system of two cases of the disease, and remarked that sleeping sickaess is due “ to a poison, of micro-parasitic or other source, which affects eon
it pertaining to the centra] nervous system: S excellent observations were confirmed by the Portu- guese Commissioners ‘in 1901, and by Warrington® in 1902.
The chief characteristics after death from sleeping sickness are: general emaciation, enlargement of the lymphatic glands, slight opacity and thickening of the pia- -arachnoid, and serous effusion into the meshes o the pia mater or into the ventricles. The microscop reveals an intense. chronic meningo-encephalo-myeliti ns, The emaciation is very marked in certain cases, thi enlargemeut of the lymph glands is. constant, and ma; be noticed in the cervical, axillary, mesenteric, and inguinal groups. In: the cerebro-spinal system the macroscopical changes are seldom marked. In most cases there is only a slight opacity of the pia-arachnoid over the convexities and some serous exudation in thi subarachnoidal space. . In some rapid cases the exudat may be considerable i in amount, As a Tule it is some