"
continuous fever"?Most medical men iu India will, I think, agree with me in saying that when a case of continuous feyer comes under treatment, it is generally at least a case of either malarious remittent At least such is my exor true enteric fever. in the Native Army. perience " " By the term continuous fever I mean a fever which lasts for more than a week. The absurdity of the term "simple continued fever,'' when applied to a fever which lasts for more than a week, has, 1 believe, been now generally admitted, and this term should be restricted to those mild cases of fever which generally last for three or four days, and which are caused by slight exposure to sun or chill, or an error iu diet. When a fever persists for more than a week, varying perhaps between a 100? and a 101? Fahr, or more, so far as my experience goes, it has been either a case of malarious remittent or true enteric fever, and the following differential diagnosis are the chief points of which I have observed in actual practice.
Definition of term
(a) Mode of invasion.?In malarious remittent, the "remittent fever" of the nomenclature,
NOTES ON THE DIAGNOSIS AND TREATMENT OF ENTERIC FEVER. By Subg.-Maj. D. B.
SPENCER, Beng. Med. See.,
Xllth Bengal Infantry. Op late years the subject of enteric fever has largely drawn the attention of the medical profession in India, and justly so, considering the number of young officers and soldiers who die from the disease every year. Having treated several cases of true enteric fever in the Native Army within the last few years, I venture to give a few practical notes on the diagnosis aud treatment of this disease.
Diagnosis. is imis not this and doubt, always easy, as the leading symptoms in the early stage of the fever as seen in India are often absent or masked by malaria, which may be said to influence nearly every disease we see in India. Still, I think, a consideration of the following points will generally help one in actual practice to arrive at an early diagnosis.
That an early aud portant there can be
accurate no
diagnosis
the mode of invasion is generally sudden and sharp, temperature often rising at once to a 104? or more?with a rigor and marked constitutional disturbance. In enteric fever, on the other hand, the invasion is slow and insidious, temperature gradually rising from 101? or thereabouts on the first day, to a 103? or 10?? Fahr. Often this primary on the fifth or sixth day. fever is much lower, varying between 99? and 101,? or thereabouts during the first three or four days, simulating a mild attack of ague without much constitutional disturbance. This difference in the mode of invasion is of great practical value in the diagnosis and one which should always be carefully noted when we have to deal with a case of continuous fever. (b) Expression of countenance.? In remittent fever the expression indicates excitement and general irritation of the system; whereas, in enteric, it is generally, if not always, dull, heavy and drowsy. It is difficult to explain this point exactly in words; but there is doubtless of the a marked difference in the expression face and eyes ; iu the one case indicating excitement, in the other depression of the system. This could only be learnt at the bedside of the patieut, and is a point of no small importance iu the diagnosis. (c) Duration offever.?When a fever lasts for more than a fortnight, and when the diagnosis lies betweeu remittent and enteric fever, the probabilities are strongly in favor of enteric The normal and against remittent fever. duration of malarious remittent fever, unattended by any internal complications, has
Dec.
1892.J
SPENCER ON DIAGNOSIS AND TREATMENT OF ENTERIC FEVER.
seldom in my experience exceeded ten days. In enteric, on the other hand, the temperature during the second week always shows an upward tendency, and, even under the influence of strong antipyretics, seldom reaches the normal
line.
(d) Effects of quinine.?In my opinion quinine is of hardly auy value in the early stage of enteric fever. On the other hand, it is the very sheet anchor of treatment in malarious reiyittent, where its beneficial effects are generally marked from 10 to 20 grs. a day administered in the morning during the period of remission, seldom failing to make an early and a decided impression on the fever. (e) Enlargement of spleen.?Splenic enlarge-
may exist in enteric as well as in remitand therefore the enlargement of the organ cannot be looked upon as of much practical importance. If, however, the spleen be not enlarged, the probabilities will be in favor of enteric fever; for in remittent fever the spleen is almost invariably enlarged, and often very considerably, especially if the patient has suffered previously from malarious fever. (f) Pathognomonic signs.?Where such symptoms as rose-colored spots, pain, tenderness, and gurgling in the right iliac fossa, pea-soupy diarrhoea, and other sigus and symptoms of enteric fever exist, which one reads of in books, it is needless to say that the diagnosis is easy; but unfortunately, in actual practice, these book symptoms are generally absent, and it is in these doubtful cases that, I think, a careful attention to the points, which I have noticed above in detail, will help one to form an early and a ment
tent
fever,
correct
diagnosis.
Treatment. In considering the treatment of enteric fever when once the diagnosis is clearly established, it must first be borne in mind that the fever, as in all other fevers, is but the outward expression of systemic blood poisoning. The indications of treatment therefore are, first, to keep the temperature in check; secondly, to eliminate the poison from the system, and thirdly to maintain the patient's strength while the poison is being eliminated from his system. Antifebrin.?To achieve the first object, namely to reduce the temperature, there is to my no remedy in the whole pharmacopoeia so safe, so simple, and so efficacious as antifebrin. I have used this remedy now for some years, aud can speak very highly of its efficacy as an antipyretic in all forma of fever. It may be given in doses of from five to fifteen grains at a time with perfect safety, unlike autipyriu, which is a dangerous remedy in
knowledge
similar doses acts
frequently repeated.
Antipyrin
is a powerful depressant, and should therefore be avoided in fevers;
directly
on
the
heart,
while, in its antipyretic effects, greatly inferior to antifebrin.
367
it
is,
I
thirilc,
Antifebrin in combination with salicylate of soda.?I generally begin with a five-grain dose of antifebrin, and repeat it every two or three hours guided by the temperature of the patient. If this fails to make a decided impression 011 the fever within 24 hours, I increase the dose to ten grains, and generally combine it with ten grains of the salicylate of soda. It may be necessary to give as many as six powders in 24 hours, representing sixty grains of antifebrin and sixty grains of the saliI have never found it cylate. necessary to exceed this amount even in the worst cases of fever. The fever may not yield on the first day ; it may not yield on the second or third ; but, if the antifebrin be steadily ?persevered in, guided of course by the tempeiature chart, I do not think it will ever fail to produce the desired effect, namely, to control the fever and to modify the course of the disease, no matter how severe the type may be. As antifebrin is not very soluble in water, the best way to administer it is to place the powder on the tongue and make the patient swallow it with a mouthful of water. As the fever lessens, the intervals between the administration of the drug should be increased and the dose should be reduced. Hot water.?Another remedy, which will be found very useful in fever, is hot water. About half a tumbler should be given for each dose, and it should be taken as hot as it can be borne. It often induces copious perspiration, and I think it is a far superior remedy to the ordinary diaphoretic mixture of Sp. Ether Nitrosi and Liq. Amm. Acet. with camphor water. Enema of water.?In all forms of fever whether enteric or otherwise, and whether there be constipation or diarrhoea, an enema of plain cold or tepid water administered once a day, or once every third or fourth day, will invariably be found most valuable in controlling the fever and bringing the disease to a rapid and favourable
day'even
termination.
medical
Some officers may question the utility of this measure where diarrhoea exists; but I do not think it ever does harm even when diarrhoea exists, and may possibly do good by assisting nature in getting rid of effete matters from the intestinal canal. Of course, when diarrhoea exists it is not to necessary administer it every daJ\ The rule I have adopted in my practice is this: If there be constipation, give one enema every day; if there be diarrhoea, give one every third or fourth day. I have used this water-enema treatment systematically in the treatment of fevers, and am firmly convinced of its great value. Pathology of fevers.?In all cases of fever there is a rapid accumulation of ptomaines
3GS
INDIAN MEDICAL GAZETTE.
and'other toxic products iu the intestinal canal as the result of increased tissue metamorphosis
and diminished peristalsis, the absorption of which in the general circulation will naturally tend to keep up the fever. The fever, in fact, will feed itself, or, in other words, there is, I think, in all fevers as much danger of poisoning from within (entero-sepsis) as of poisoning from without.
At all events, the subject of entero-sepis, as it is called, is one well worthy of the serious consideration of the medical practitioner ; and judging from recent literature on the subject, I think it will force itself prominently into notice within the next few years, and may possibly materially modify our present theories The object of of the pathology of fevers. in fevers will, an enema systematically using therefore, be easily understood. I generally use about two pints of water for each enema. When the stools are offensive, it will be found advantageous to add a few drops of Condy's fluid to each enema. A point of some importance to remember is, that when a hospital assistant or compounder is asked to administer an anema, he should always be warned never to pump up the water quickly, but to inject showly and gently.
Quinine.?-The next important point for consideration in the treatment of enteric fever is the administration of quinine. What doses should be given, how often, and whether from the very commencement of the disease, or later on? Its failure in early stage of enteric fever.? Now quinine is doubtless a powerful internal antiseptic so to speak ; it is also an antipyretic in large doses, and is supposed to retard tissue metamorphosis. Theoretically at least, therefore, quinine is an excellent remedy; yet in recording my experience of the drug, I feel bound to say that it generally fails to make any decided impression 011 the fever during the early stage. Sometimes I have been led to think that it has actually proved injurious, increasing the fever aud depressing the strength of the patient. Its value in later stage.?In the later stage, however, after a marked impression has been
the course of the fever by antifebrin, of soda and water enema, quinine will be found a most excellent remedy. I generally administer from 5 to 10 grains of quinine every morning dissolved with acid. As a rule, I may say that it will be advisable to wait till the morning temperature reaches 100? Fahr.
made
on
salicylate
Treatment
by large
doses
of quinine.? Some
medical officers, I believe, pin their faith on quinine and administer it in very large doses, as much as from 60 to 80 grains or more per day
the very commencement. It would be know this to whether interesting specific treatfrom
[Dec.
1892.
j
ment by quinine ever succeeds in modifying the I course of the disease, and, if so, how far.
|
acid.?Another remedy of some enteric fever is salicylic acid. Its action, I believe, is similar to quinine, only not so strong. I have discarded it altogether in favour of the salicylate of soda, which I think is far more efficacious of the two. General treatment.?At the termination of the case, when the morning and evening tempertures are normal, the following tonic mixture will generally be found useful :?
Salicylic
value
in
R.
Quinise sulph.
...
Acid nitro muriatic dilute
Lig\ Strychnine Aquam
Mist. fiat. t. d.
...
...
...
...
...
...
? grain.
10 minims. 2 minims. 1 ounce.
s.
Diet.?The diet is
important,
but this does
require any special comment. Milk when given alone should be sterilised to be on the safe side ; but, as a rule, plain milk is not well borne. Milk with soda water is excellent, but the quantity of soda water in the 24 hours should be not
restricted to about two bottles. Soda water ad libitum is injurious. Arrowroot cooked in milk and Avater is very valuable, so is rice water and milk. Thin beef or mutton tea in small quantities will always form an important part of the diet. If stimulants be necessary, brandy is the best. Port wine, I think, is generally injurious in fevers, and should be avoided. Solid food should not be commenced until the patient is quite free from fever for at least a week. Temperature chart of a typical case.?A temperature chart of a typical case of enteric fever which lately cameunder my care is herewith annexed. It illustrates the various points I have noted both as regards diagnosis and treatment.
EHTERtC ENTERIC
FEVER
1st Week.?Diagnosed 1st and treated treated as as Malarious Malarious Fever Fever with with Antifebrin Antifebrin and and Quinine. Week.?Diagnosed and Quinine. 2kd Week.?Specific 2nd treatment by Antifebrin and and Salicylate No Quinine of Soda Soda from from the to the of disease. the 8th 8th to the 14th 14th days disease. No Week.?Specific treatment by Antifebrin Quinine Salicylate of days of on 8th established on 8th day. water treatment enema week and of 3rd treatmeut water 2nd week 3rd week". Diagnosis Diagnosis established enema during and part weekday. Systematic by Systematic by during 2nd part oi
[ I !
CHART. CHART*
3rd modified. 55 grains of disease disease materially 3HQ Week.?Effects course of oi specific Week. Effects i materially modified. grains Quinius specific treatment, treatment, course Quinine every every morning morning on 21st 21stday. Termination Termination by day. Result?Recovery, Result?Recovery, lysis on by lysis = of Soda of Soda 2-enema, S^Salicylaic Q-Quinine per Quinjnt day. e?enema. per day. per k=motions A=Antifebrin per >3ay- S=Salicylate k?motions per dav. A=Aiitifebrinptjr'3ayday Q per day. per dav.
continuous fever"?Most medical men iu India will, I think, agree with me in saying that when a case of continuous feyer comes under treatment, it is generally at least a case of either malarious remittent At least such is my exor true enteric fever. in the Native Army. perience " " By the term continuous fever I mean a fever which lasts for more than a week. The absurdity of the term "simple continued fever,'' when applied to a fever which lasts for more than a week, has, 1 believe, been now generally admitted, and this term should be restricted to those mild cases of fever which generally last for three or four days, and which are caused by slight exposure to sun or chill, or an error iu diet. When a fever persists for more than a week, varying perhaps between a 100? and a 101? Fahr, or more, so far as my experience goes, it has been either a case of malarious remittent or true enteric fever, and the following differential diagnosis are the chief points of which I have observed in actual practice.
Definition of term
(a) Mode of invasion.?In malarious remittent, the "remittent fever" of the nomenclature,
NOTES ON THE DIAGNOSIS AND TREATMENT OF ENTERIC FEVER. By Subg.-Maj. D. B.
SPENCER, Beng. Med. See.,
Xllth Bengal Infantry. Op late years the subject of enteric fever has largely drawn the attention of the medical profession in India, and justly so, considering the number of young officers and soldiers who die from the disease every year. Having treated several cases of true enteric fever in the Native Army within the last few years, I venture to give a few practical notes on the diagnosis aud treatment of this disease.
Diagnosis. is imis not this and doubt, always easy, as the leading symptoms in the early stage of the fever as seen in India are often absent or masked by malaria, which may be said to influence nearly every disease we see in India. Still, I think, a consideration of the following points will generally help one in actual practice to arrive at an early diagnosis.
That an early aud portant there can be
accurate no
diagnosis
the mode of invasion is generally sudden and sharp, temperature often rising at once to a 104? or more?with a rigor and marked constitutional disturbance. In enteric fever, on the other hand, the invasion is slow and insidious, temperature gradually rising from 101? or thereabouts on the first day, to a 103? or 10?? Fahr. Often this primary on the fifth or sixth day. fever is much lower, varying between 99? and 101,? or thereabouts during the first three or four days, simulating a mild attack of ague without much constitutional disturbance. This difference in the mode of invasion is of great practical value in the diagnosis and one which should always be carefully noted when we have to deal with a case of continuous fever. (b) Expression of countenance.? In remittent fever the expression indicates excitement and general irritation of the system; whereas, in enteric, it is generally, if not always, dull, heavy and drowsy. It is difficult to explain this point exactly in words; but there is doubtless of the a marked difference in the expression face and eyes ; iu the one case indicating excitement, in the other depression of the system. This could only be learnt at the bedside of the patieut, and is a point of no small importance iu the diagnosis. (c) Duration offever.?When a fever lasts for more than a fortnight, and when the diagnosis lies betweeu remittent and enteric fever, the probabilities are strongly in favor of enteric The normal and against remittent fever. duration of malarious remittent fever, unattended by any internal complications, has
Dec.
1892.J
SPENCER ON DIAGNOSIS AND TREATMENT OF ENTERIC FEVER.
seldom in my experience exceeded ten days. In enteric, on the other hand, the temperature during the second week always shows an upward tendency, and, even under the influence of strong antipyretics, seldom reaches the normal
line.
(d) Effects of quinine.?In my opinion quinine is of hardly auy value in the early stage of enteric fever. On the other hand, it is the very sheet anchor of treatment in malarious reiyittent, where its beneficial effects are generally marked from 10 to 20 grs. a day administered in the morning during the period of remission, seldom failing to make an early and a decided impression on the fever. (e) Enlargement of spleen.?Splenic enlarge-
may exist in enteric as well as in remitand therefore the enlargement of the organ cannot be looked upon as of much practical importance. If, however, the spleen be not enlarged, the probabilities will be in favor of enteric fever; for in remittent fever the spleen is almost invariably enlarged, and often very considerably, especially if the patient has suffered previously from malarious fever. (f) Pathognomonic signs.?Where such symptoms as rose-colored spots, pain, tenderness, and gurgling in the right iliac fossa, pea-soupy diarrhoea, and other sigus and symptoms of enteric fever exist, which one reads of in books, it is needless to say that the diagnosis is easy; but unfortunately, in actual practice, these book symptoms are generally absent, and it is in these doubtful cases that, I think, a careful attention to the points, which I have noticed above in detail, will help one to form an early and a ment
tent
fever,
correct
diagnosis.
Treatment. In considering the treatment of enteric fever when once the diagnosis is clearly established, it must first be borne in mind that the fever, as in all other fevers, is but the outward expression of systemic blood poisoning. The indications of treatment therefore are, first, to keep the temperature in check; secondly, to eliminate the poison from the system, and thirdly to maintain the patient's strength while the poison is being eliminated from his system. Antifebrin.?To achieve the first object, namely to reduce the temperature, there is to my no remedy in the whole pharmacopoeia so safe, so simple, and so efficacious as antifebrin. I have used this remedy now for some years, aud can speak very highly of its efficacy as an antipyretic in all forma of fever. It may be given in doses of from five to fifteen grains at a time with perfect safety, unlike autipyriu, which is a dangerous remedy in
knowledge
similar doses acts
frequently repeated.
Antipyrin
is a powerful depressant, and should therefore be avoided in fevers;
directly
on
the
heart,
while, in its antipyretic effects, greatly inferior to antifebrin.
367
it
is,
I
thirilc,
Antifebrin in combination with salicylate of soda.?I generally begin with a five-grain dose of antifebrin, and repeat it every two or three hours guided by the temperature of the patient. If this fails to make a decided impression 011 the fever within 24 hours, I increase the dose to ten grains, and generally combine it with ten grains of the salicylate of soda. It may be necessary to give as many as six powders in 24 hours, representing sixty grains of antifebrin and sixty grains of the saliI have never found it cylate. necessary to exceed this amount even in the worst cases of fever. The fever may not yield on the first day ; it may not yield on the second or third ; but, if the antifebrin be steadily ?persevered in, guided of course by the tempeiature chart, I do not think it will ever fail to produce the desired effect, namely, to control the fever and to modify the course of the disease, no matter how severe the type may be. As antifebrin is not very soluble in water, the best way to administer it is to place the powder on the tongue and make the patient swallow it with a mouthful of water. As the fever lessens, the intervals between the administration of the drug should be increased and the dose should be reduced. Hot water.?Another remedy, which will be found very useful in fever, is hot water. About half a tumbler should be given for each dose, and it should be taken as hot as it can be borne. It often induces copious perspiration, and I think it is a far superior remedy to the ordinary diaphoretic mixture of Sp. Ether Nitrosi and Liq. Amm. Acet. with camphor water. Enema of water.?In all forms of fever whether enteric or otherwise, and whether there be constipation or diarrhoea, an enema of plain cold or tepid water administered once a day, or once every third or fourth day, will invariably be found most valuable in controlling the fever and bringing the disease to a rapid and favourable
day'even
termination.
medical
Some officers may question the utility of this measure where diarrhoea exists; but I do not think it ever does harm even when diarrhoea exists, and may possibly do good by assisting nature in getting rid of effete matters from the intestinal canal. Of course, when diarrhoea exists it is not to necessary administer it every daJ\ The rule I have adopted in my practice is this: If there be constipation, give one enema every day; if there be diarrhoea, give one every third or fourth day. I have used this water-enema treatment systematically in the treatment of fevers, and am firmly convinced of its great value. Pathology of fevers.?In all cases of fever there is a rapid accumulation of ptomaines
3GS
INDIAN MEDICAL GAZETTE.
and'other toxic products iu the intestinal canal as the result of increased tissue metamorphosis
and diminished peristalsis, the absorption of which in the general circulation will naturally tend to keep up the fever. The fever, in fact, will feed itself, or, in other words, there is, I think, in all fevers as much danger of poisoning from within (entero-sepsis) as of poisoning from without.
At all events, the subject of entero-sepis, as it is called, is one well worthy of the serious consideration of the medical practitioner ; and judging from recent literature on the subject, I think it will force itself prominently into notice within the next few years, and may possibly materially modify our present theories The object of of the pathology of fevers. in fevers will, an enema systematically using therefore, be easily understood. I generally use about two pints of water for each enema. When the stools are offensive, it will be found advantageous to add a few drops of Condy's fluid to each enema. A point of some importance to remember is, that when a hospital assistant or compounder is asked to administer an anema, he should always be warned never to pump up the water quickly, but to inject showly and gently.
Quinine.?-The next important point for consideration in the treatment of enteric fever is the administration of quinine. What doses should be given, how often, and whether from the very commencement of the disease, or later on? Its failure in early stage of enteric fever.? Now quinine is doubtless a powerful internal antiseptic so to speak ; it is also an antipyretic in large doses, and is supposed to retard tissue metamorphosis. Theoretically at least, therefore, quinine is an excellent remedy; yet in recording my experience of the drug, I feel bound to say that it generally fails to make any decided impression 011 the fever during the early stage. Sometimes I have been led to think that it has actually proved injurious, increasing the fever aud depressing the strength of the patient. Its value in later stage.?In the later stage, however, after a marked impression has been
the course of the fever by antifebrin, of soda and water enema, quinine will be found a most excellent remedy. I generally administer from 5 to 10 grains of quinine every morning dissolved with acid. As a rule, I may say that it will be advisable to wait till the morning temperature reaches 100? Fahr.
made
on
salicylate
Treatment
by large
doses
of quinine.? Some
medical officers, I believe, pin their faith on quinine and administer it in very large doses, as much as from 60 to 80 grains or more per day
the very commencement. It would be know this to whether interesting specific treatfrom
[Dec.
1892.
j
ment by quinine ever succeeds in modifying the I course of the disease, and, if so, how far.
|
acid.?Another remedy of some enteric fever is salicylic acid. Its action, I believe, is similar to quinine, only not so strong. I have discarded it altogether in favour of the salicylate of soda, which I think is far more efficacious of the two. General treatment.?At the termination of the case, when the morning and evening tempertures are normal, the following tonic mixture will generally be found useful :?
Salicylic
value
in
R.
Quinise sulph.
...
Acid nitro muriatic dilute
Lig\ Strychnine Aquam
Mist. fiat. t. d.
...
...
...
...
...
...
? grain.
10 minims. 2 minims. 1 ounce.
s.
Diet.?The diet is
important,
but this does
require any special comment. Milk when given alone should be sterilised to be on the safe side ; but, as a rule, plain milk is not well borne. Milk with soda water is excellent, but the quantity of soda water in the 24 hours should be not
restricted to about two bottles. Soda water ad libitum is injurious. Arrowroot cooked in milk and Avater is very valuable, so is rice water and milk. Thin beef or mutton tea in small quantities will always form an important part of the diet. If stimulants be necessary, brandy is the best. Port wine, I think, is generally injurious in fevers, and should be avoided. Solid food should not be commenced until the patient is quite free from fever for at least a week. Temperature chart of a typical case.?A temperature chart of a typical case of enteric fever which lately cameunder my care is herewith annexed. It illustrates the various points I have noted both as regards diagnosis and treatment.
EHTERtC ENTERIC
FEVER
1st Week.?Diagnosed 1st and treated treated as as Malarious Malarious Fever Fever with with Antifebrin Antifebrin and and Quinine. Week.?Diagnosed and Quinine. 2kd Week.?Specific 2nd treatment by Antifebrin and and Salicylate No Quinine of Soda Soda from from the to the of disease. the 8th 8th to the 14th 14th days disease. No Week.?Specific treatment by Antifebrin Quinine Salicylate of days of on 8th established on 8th day. water treatment enema week and of 3rd treatmeut water 2nd week 3rd week". Diagnosis Diagnosis established enema during and part weekday. Systematic by Systematic by during 2nd part oi
[ I !
CHART. CHART*
3rd modified. 55 grains of disease disease materially 3HQ Week.?Effects course of oi specific Week. Effects i materially modified. grains Quinius specific treatment, treatment, course Quinine every every morning morning on 21st 21stday. Termination Termination by day. Result?Recovery, Result?Recovery, lysis on by lysis = of Soda of Soda 2-enema, S^Salicylaic Q-Quinine per Quinjnt day. e?enema. per day. per k=motions A=Antifebrin per >3ay- S=Salicylate k?motions per dav. A=Aiitifebrinptjr'3ayday Q per day. per dav.
