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War Surgery and Medicine

Clinical Features

Clinical Features

Dengue is a distressing, incapacitating illness which strikes with dramatic suddenness. The incubation period, where it could be determined, varied from five to twelve days, most cases occurring after seven or eight days.

There appeared to be no premonitory symptoms.

The disease can usually be divided into three phases:


An initial fever of two to four days' duration.


An interval of twelve to forty-eight hours with temporary relief of symptoms.


A secondary fever of one to four days associated with a rash and a return of the general symptoms of the disease.

Most cases started with a feeling of chilliness which seldom developed into a true rigor. Malaise was marked in all cases but varied in intensity. Headache was severe and almost invariably frontal or fronto-occipital.

Eye symptoms were very prominent and included retro-orbital pain persisting right through the illness and pain on lateral movement of the eyes. The conjunctivae was congested in almost all cases. There was congestion of both bulbar and palpebral conjunctivae which began about the second day and persisted well page 550 on into convalescence. There was occasionally oedema of the lids, but no true conjunctivitis was seen. Photophobia occurred in about one third of the cases. One patient developed central choroiditis with exudate.

Backache was a distressing and constant symptom, usually worst in the lumbar region and more severe during the initial period of fever than later on. The backache was associated with limb pains, especially in the region of the knees. They were not as severe as described in textbooks and would not justify the old name of ‘break-bone’ fever. In the early half of the disease about half the patients complained of abdominal pain which appeared to be muscular in origin and associated with the backache and limb pains.

Anorexia was profound in nearly all patients and was very persistent; nausea occurred in half the patients and vomiting in 20 per cent. Insomnia was a troublesome feature, especially during the first three days, and some sufferers were depressed. On the whole the depression seemed to be much less with dengue than with sandfly fever. In this group of healthy young people depression was present in only a few patients, mostly nurses.

The pyrexia was usually of the ‘saddle-back’ type with an initial fever, a short period of remission, and a secondary fever. In 96 per cent of cases the fever lasted from five to seven days. The pulse was slow throughout.

Most patients had an initial flushing of the face, ears, neck, and upper part of the trunk, but the main or secondary rash which appeared between the third and sixth days was maculo-papular, the majority being rubelliform in appearance. It was first seen on the chest and back and ulnar sides of the forearms, spreading later to the feet and legs. The ‘drawers’ area was relatively free of the eruption. The rash became petechial in 11 per cent of patients, usually over the dorsum of the feet and on the forearms. The rash usually lasted from two to five days.

General glandular enlargement was the rule and persisted long after discharge.

Careful examination of the blood throughout the disease was carried out by Captain Gatman, and a very brief summary of his principal findings were:

Total Leucocyte Count: In all cases there was a leucopenia, the lowest figures being on the fourth, fifth, and sixth days. The average count on the fifth day was 2850 per cmm. and counts as low as 900 per cmm. were observed.

Neutrophils were greatly reduced and the average segmented cell count on the fifth day was 500 per cmm. There was a steep return to normal between the seventh and twelfth days.

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Lymphocytes were also reduced, but not to the same extent as the neutrophils.

Plasma and Turck cells were frequently seen. Eosinophils were absent throughout the disease. Changes in the leucocytes did not bear any relation to the severity of the symptoms or to the type of temperature curve.

Convalescence was fairly rapid in most cases but some complained of malaise and tiredness for a considerable period.

Dengue fever, therefore, although it has no mortality and has few after-effects, can temporarily incapacitate a force with explosive suddenness. Its main danger is for troops in urban areas. It is unlikely to seriously concern a force engaged in jungle warfare or camped in rural areas.