September 1,
1879.J
DIAGNOSIS BETWEEN ENTERIC AND REMITTENT FEVER.
ORIGINAL COMMUNICATIONS. ON THE DIAGNOSIS
BETWEEN ENTERIC
OR TYPHOID FEVER AND REMITTENT OR INTERMITTENT FEVER. By Surgeon-Major T. E. Burton Brown, F. R. C. S.,
Principal, Lahore Medical College. Great difficulty is often experienced in this country in determining whether a case of fever in which remissions occur, but no true intermission, is to be regarded as one of enteric or of remittent fever ; and, as not only the prognosis but the treatment mainly depends on the correct determination of this point, it is of considerable to have distinct ideas as to the mode in which this may be ascertained. In England where remittent fever is a most rare disease, but enteric fever is very common,this difficulty is not met with, and very little is said about this point in onr English test books ; it is not even mentioned in Tanner's or Aitken's Manual, nor even in Ziemsen's Cyclopoedia of
importance
Medicine, but Murcliison writes in his book
on continued fevers as follow : "The diagnosis between enteric and remittent fever is often extremely difficult in countries where both prevail together. The pyrexia of enteric fever is essentially remittent, and cases have occurred in my own practice and been noted by Trousseau and other observers, especially in malarious countries, where it has
put
on
at first an intermittent
type. Moreover, vomiting
and diarrhoea may occur in both diseases, while enlargement of the spleen, cerebral symptoms, and the typhoid state are common to both. The eruption is perhaps the only distinctive mark of enteric fever to be relied on ; and, in every case of remittent fever
ought
complicated with abdominal symptoms, it carefully looked for. The close resemblance
to be
of enteric to remittent fever accounts for the fact that it is only within the last few years that the former malady has been recognised as occurring in India. In other writers on fever the diagnosis between remittent and enteric fevers is not so much noticed, thus it is not mentioned at all by Watson or in Copland's dictionary of medicine. In actual practice in comes a
most
India, however, it frequently beimportant consideration, not only to the pa-
tient and medical attendant but also to the anxious friends and relatives, whether the disease be typhoid fever or A patient suffers from fever which lasts remittent. for several days, being rather less in the morning and
245
it is only on the 4th evening that it reaches in remittent fever the first attack is generally while 104?; more marked, being attended with great prostration, a feeling of cold and shivering followed by great heat of skin and intense fever, the temperature often rising to 104? or 105? on the evening of the first day of the disease,but the attack is not always so decided at first; sometimes it commences more insidiously with slight feverishness, most
cases
some days before the severe attack begins; the other hand in some cases of typhoid fever the patient does not notice or conceals his illness for several days while he is really suffering from a mild attack of typhoid fever, so that the disease is supposed
for
lasting while
on
day of the real atsince it is then alone that he appears to be seriously ill. In many cases too remittent fever suddenly declares itself by closing abruptly or by being changed into intermittent fever with apparently temporary recovery while the intermission lasts ; this frequently occurs at the end to have commenced on the 4th or 5th
tack,
of the first week, especially when the proper treatment employed ; but this recovery is not always the case even in remittent fever, as the disease may continue longer, and then the resemblance to tyyhoid fever is most marked. In both diseases the temperature and pulse are increased, especially in the evening, while on In both there is every morning these are lowered. usually diarrhoea with liquid yellowish stools, and in both this symptom is sometimes absent for a long time. In both affections delirium occurs and gradual exhaushas been
but this usually comes on earlier in remittent fever than in enteric fever. On examining the abdomen there is found in both kinds of fever some amount of swelling and tenderness, but in the case of remittent fever this is usually most marked at the epigastrium, while in
tion,
typhoid fever the right iliac region is more particularly affected, and gurgling accompanies it. In both diseases also the spleen is enlarged and tender on pressure; sometimes it becomes very much increased in size and painful. One great distinction between the two affections is the rose-red eruption, which occurs on the abdomen, of typhoid fever, the spots being small, circular, slightly raised about one line in diameter; they disappear on pressure, but again return when the pressure is removed, and each spot fades permanently after three or four days, but it is replaced by other similar spots in its neighbourhood, so that the eruption continues till the end of the illness by the alternate appearance and fading
anxious, with slight feverishness, headache and a tendency diarrhoea, but very usually he is able to move about and to eat solid food for some days. The temperature
of these spots. When this rash is very distiuct the diagnosis is rendered easy, excepting that in India similar spots may arise from exposure to heat or from the bites of insects ; in the latter case however a minute puncture may often be found in the centre of each spot if it is carefully examined. A more important objection is that the spots rarely appear before the eighth day, and very often not till the end of the second week ; while in remittent fevers it is very important for the treatment to make the diagnosis at an earlier time when this is possible. A still
also is
more
somewhat increased in the evening; in such cases it is often equally necessary and difficult to determine what is the nature of the disease. If the illness has been carefully watched from the very first the diagnosis becomes more easy, for in typhoid fever the invasion is usually very gradual, the patient feels languid and to
ing,
only slightly increased ; at first it rises every evenbut is rather less on the following morning, and in
unfortunate circumstance for the diagnosis by the eruption is, that on a dark skin the spots are often not
THE INDIAN MEDICAL GAZETTE.
246
visible, particularly if the skin is dirty, as is the with most natives who come to hospital. The diagnosis of remittent from enteric fever may be In confirmed by the other symptoms which occur. remittent fever jaundice is a common symptom, but it is
at all
a
case
succeeded
in enteric fever ; the liver also is more often affected in remittent fever. On the other hand haemorrhage from the bowels often occurs in typhoid fever, but only rarely in remittent, and even then it usually takes the form of meloena, being of a dark colour, while the blood in enteric fever has generally an arterial character. The
rare
urine also more often contains albumen in typhoid fever than in remittent. Perforation of the intestine with subsequent peritonitis also occurs in enteric fevers in some cases, but not in remittent fever, and tympanitis is more excessive in the former affection, and often enables one to distinguish it from disease of the brain, in which there is no distension but rather retraction of the abdominal parietes. In remittent fever also the distension of the abdomen is seldom very great, as it may be in typhoid fever. The same state of exhaustion may occur in either disecise, attended with great prostration, black, dry tongue, quick, feeble or irregular pulse, and low muttering delirium called the typhoid state, and death may happen similarly in both diseases ; but in typhoid fever there is usually more tympanitis, and more often death is preceded by htemorrhage from the bowels and other changes already described. Temperature.?During the course of the diseases also differences occur in the temperatures of the skin ; thus the temperature in typhoid fever generally rises slowly during the first week, but falls a little every morning ; it is nearly at the same high level during the second week, and it often varies considerably in the 3rd and 4th weeks,
rising
and
sinking irregularly, but usually
remaining
high till the
4th week. In remittent fever there is sudden ris?, followed by a high temperature for one, two or more days, and then a remission succeeded by another sudden rise ; at length the elevations and
usually
a
depressions
occur
more
rapidly,
and
become
may
intermittent. Causes.?A difference also occurs between the causes of enteric and remittent fever. The latter is only
produced by exposure generally epidemic, and
to malaria, while the former is is believed to be caused by frecal contamination of the water or air. Unfortunately in India both causes are very prevalent, and in most cases of fever in India it will be found that the patient has been exposed at once to malaria and to the
of absorption of the cause of typhoid fever. In fact the only way in which an appreciation of the cause can affect the diagnosis here is when the fever attacks about the same time more than one member of a family where it is probable that there has been some
probability
contamination of the
typhoid
drinking
water which has
produced
fever.
The most important means of diagnosing these diseases is by the results of treatment. In remittent fever if large doses of quinine are given the fever will be in most cases cut short, but this is not the case with
typhoid
fever ; in this disease the
quinine only
causes
[September 1,
187&
temporary depression of temperature, which is again
by an increase of feverishness. In remittent fever, however, it is often necessary to employ some preliminary treatment before giving the quinine, particularly if the liver is congested and the bowels confined, in which case acholagogue purgative must first be given ; or if the spleen is enlarged and tender, it is better to use counter-irritants to the spleen first ; if there are any dysenteric symptoms, Ipecacuanha should first be given, and if there is much cough, expectorants should be used together with these remedies ; quinine should be given in some form either in solution or in pills, and in most cases it will be necessary to give it in doses of from 20 to 30 grains to an adult. In some cases it may be advantageously combined with opium and aromatic stimulants, a3 in Warburg's tincture, which is really a mixture o! quinine, aromatics and opium, and which has often proved of great service in the cure of malarious fever. Under this plan of treatment remittent fever is generally cured between the Gth and 10th days, but typhoid fever would continue for many days longer, though it mights be diminished for a time by the action of the quinine. Lastly, the post-mortem appearances differ greatly in " remittent and in enteric" fever. In both there is hypostatic congestion of the under part of the body with congestion of the larger veins, and an enlarged and congested condition of the spleen ; but in enteric fever the principal lesion is situated in the small intestines, especially at the lower part of the ileum, where the agminated glands or Peyer's patches are very much altered ; at first there swollen condition of the glands, which and contain a peculiar deposit called the gested deposit, but afterwards the mucous membrane
is only
a
are con-
typhoid covering
glands sloughs off, leaving minute ulcers correspondto each gland ; these gradually unite into a large oval ulcer with its long diameter parallel to the axis of the bowel. It has irregularly excavated borders, and often extends deeply intothe muscular coat of the intestine, or sometimes reaches to the peritoneum, It occasionally lays open a small vessel, thus causing htemorrhage. The mesenteric glands corresponding to this part of the intestine are swollen and congested, and contain a similar typhoid deposit to that in Peyer'a glands. In the
ing
remittent fever these lesions do not occur, but in many cases there is congestion of the liver, and very often a deposit of pigment granules in the interior of the liver. When this occurs the liver appears to be of an opaque brown
colour, and on a section being examined with the microscope a large number of black granules are seen surrounding each lobule and mapping it out; these are also found in the small vessels of the liver and in the spleen, and some-times in the capillaries of the brain and kidney. From the above description it will appear that, although
pigment globules
in some cases it is easy to distinguish between an attack of typhoid and one of remittent fever, especially if the case has been seen from the first, or a clear history obtained of as
is the
case
the symptoms, yet if these are not possible^ with most hospital patients, the diagnosis
becomes much
more
difficult,
is to treat all such cases
and the best plan probably of remittent fever by
as cases
.
September 1,
BENGAL NOTES?BY SURGEON-MAJOR F. R.
1879.]
giving large doses of quinine which will often stop the fever and thus decide the diagnosis. If quinine, however, given with all the above precautions in large doses, fails, the disease-is probably typhoid, and will require a differThis would be confirmed by the appearof the rose-red rash or of bleeding from the nose or the bowels, also by the fever lasting more than two weeks, although quinine had been given in large doses. ent treatment. ance
Even after death it is
possible
to determine
by
a
post-
mortem examination whether the
patient died of enteric remittent fever, since, in the former case, there will be well-marked alterations in the small intestines and their mesenteric glands; while in remittent fever these parts or
will be
but the liver will
healthy,
probably
contain
pig-
ment.
Here it may be remarked that some medical men have even the existence of remittent fever, and have thought that this disease was only a modification of typhoid or simple continued fever. But the differences which occur not only in the symptoms but in the postmortem appearances, and the results of treatment with large doses of quinine clearly prove that there is a distinction between these two diseases, and, equally, the doubted
length of time that remittent fever continues properly treated, as well as the frequently fatal
if not results
and the post-mortem appearances indicate that it is entirely different ftom simple continued fever. The closest affinity of remittent fever is certainly with intermittent fever or ague, into which it often passes when under treatment, and from which it is sometimes
developed by the occurrence of a local inflammation or active congestion, particularly of the spleen, liver, or lung. No case of typhoid fever can be brought forward, as none occurred in hospital, but an interesting case of remittent fever
was
treated
as
follows
:?
aged 20 years, was admitted Mayo Hospital on May 6th. He stated that
Latawan,
a
Hindoo male
into the he was a native of Fyzabad in Oude, but had resided in Lahore for six months, employed as a syce ; his previous health had been good, excepting an attack of small-pox and one of fever long ago. He stated that on May 1st, about 5 P. M., he was attacked with fever, and felt cold and trembling. The
fever continued up to his admission into hospital on May 6th. He also suffered from great weakness, slight cough, a feeling of discomfort in the abdomen. No alteration of vision, but slight deafness and a bitter taste in the mouth. The skin visibie ; the
was hot and dry, but there was pulse was quick?90 a minute.
and chest sounds
were
normal.
no
eruption
The heart The abdomen was rather
were loose : motions yellow and semi-fluid ; urine scanty, high-coloured, and Sp.Gr. 1030 ; it contained no albumen.
depressed
;
the bowels
Treatment.?On the 6th of May, a saline mixture was given, and as the temperature was lower on the following morning (May 7th), ten grains of quinine were administered each morning and evening, till May 15th. The temperature, as will be seen in the accompanying chart, diminished somewhat every day under this treatment till on the 16th day the patient left the hospital quite well.
HOGG, A.M.D.
247
This case when admitted into the hospital have been mistaken for typhoid fever, since there
might was
a
high temperature, quick pulse, deafness
and diarrhoea; but the very defin:te commencement, not only the day but the hour of the attack being mentioned?was more like remittent fever, and the subsequent cure by the administration of large doses of quinine, with complete recovery on the 16th day of the disease, proved that it could not be typhoid fever. The absence of eruption and of any disturbance of vision indicated that it was not typhus fever, as well as the fact that there were no other cases, and the long duration of the complaint and its gradual cure by quinine differed from simple continued fever. As is usual in these cases, no clear history could be obtained of the temperature during the first six days, but the temperature after that is shown in the annexed table. 9
Day of disease
Temp.
10
M.
102
101-6 101 100-2
E.
103 6
102!
103*6
39-6
11
I 100-4
12
13
97-6 98
100 101 99-2:99
1G
98'4
1879.J
DIAGNOSIS BETWEEN ENTERIC AND REMITTENT FEVER.
ORIGINAL COMMUNICATIONS. ON THE DIAGNOSIS
BETWEEN ENTERIC
OR TYPHOID FEVER AND REMITTENT OR INTERMITTENT FEVER. By Surgeon-Major T. E. Burton Brown, F. R. C. S.,
Principal, Lahore Medical College. Great difficulty is often experienced in this country in determining whether a case of fever in which remissions occur, but no true intermission, is to be regarded as one of enteric or of remittent fever ; and, as not only the prognosis but the treatment mainly depends on the correct determination of this point, it is of considerable to have distinct ideas as to the mode in which this may be ascertained. In England where remittent fever is a most rare disease, but enteric fever is very common,this difficulty is not met with, and very little is said about this point in onr English test books ; it is not even mentioned in Tanner's or Aitken's Manual, nor even in Ziemsen's Cyclopoedia of
importance
Medicine, but Murcliison writes in his book
on continued fevers as follow : "The diagnosis between enteric and remittent fever is often extremely difficult in countries where both prevail together. The pyrexia of enteric fever is essentially remittent, and cases have occurred in my own practice and been noted by Trousseau and other observers, especially in malarious countries, where it has
put
on
at first an intermittent
type. Moreover, vomiting
and diarrhoea may occur in both diseases, while enlargement of the spleen, cerebral symptoms, and the typhoid state are common to both. The eruption is perhaps the only distinctive mark of enteric fever to be relied on ; and, in every case of remittent fever
ought
complicated with abdominal symptoms, it carefully looked for. The close resemblance
to be
of enteric to remittent fever accounts for the fact that it is only within the last few years that the former malady has been recognised as occurring in India. In other writers on fever the diagnosis between remittent and enteric fevers is not so much noticed, thus it is not mentioned at all by Watson or in Copland's dictionary of medicine. In actual practice in comes a
most
India, however, it frequently beimportant consideration, not only to the pa-
tient and medical attendant but also to the anxious friends and relatives, whether the disease be typhoid fever or A patient suffers from fever which lasts remittent. for several days, being rather less in the morning and
245
it is only on the 4th evening that it reaches in remittent fever the first attack is generally while 104?; more marked, being attended with great prostration, a feeling of cold and shivering followed by great heat of skin and intense fever, the temperature often rising to 104? or 105? on the evening of the first day of the disease,but the attack is not always so decided at first; sometimes it commences more insidiously with slight feverishness, most
cases
some days before the severe attack begins; the other hand in some cases of typhoid fever the patient does not notice or conceals his illness for several days while he is really suffering from a mild attack of typhoid fever, so that the disease is supposed
for
lasting while
on
day of the real atsince it is then alone that he appears to be seriously ill. In many cases too remittent fever suddenly declares itself by closing abruptly or by being changed into intermittent fever with apparently temporary recovery while the intermission lasts ; this frequently occurs at the end to have commenced on the 4th or 5th
tack,
of the first week, especially when the proper treatment employed ; but this recovery is not always the case even in remittent fever, as the disease may continue longer, and then the resemblance to tyyhoid fever is most marked. In both diseases the temperature and pulse are increased, especially in the evening, while on In both there is every morning these are lowered. usually diarrhoea with liquid yellowish stools, and in both this symptom is sometimes absent for a long time. In both affections delirium occurs and gradual exhaushas been
but this usually comes on earlier in remittent fever than in enteric fever. On examining the abdomen there is found in both kinds of fever some amount of swelling and tenderness, but in the case of remittent fever this is usually most marked at the epigastrium, while in
tion,
typhoid fever the right iliac region is more particularly affected, and gurgling accompanies it. In both diseases also the spleen is enlarged and tender on pressure; sometimes it becomes very much increased in size and painful. One great distinction between the two affections is the rose-red eruption, which occurs on the abdomen, of typhoid fever, the spots being small, circular, slightly raised about one line in diameter; they disappear on pressure, but again return when the pressure is removed, and each spot fades permanently after three or four days, but it is replaced by other similar spots in its neighbourhood, so that the eruption continues till the end of the illness by the alternate appearance and fading
anxious, with slight feverishness, headache and a tendency diarrhoea, but very usually he is able to move about and to eat solid food for some days. The temperature
of these spots. When this rash is very distiuct the diagnosis is rendered easy, excepting that in India similar spots may arise from exposure to heat or from the bites of insects ; in the latter case however a minute puncture may often be found in the centre of each spot if it is carefully examined. A more important objection is that the spots rarely appear before the eighth day, and very often not till the end of the second week ; while in remittent fevers it is very important for the treatment to make the diagnosis at an earlier time when this is possible. A still
also is
more
somewhat increased in the evening; in such cases it is often equally necessary and difficult to determine what is the nature of the disease. If the illness has been carefully watched from the very first the diagnosis becomes more easy, for in typhoid fever the invasion is usually very gradual, the patient feels languid and to
ing,
only slightly increased ; at first it rises every evenbut is rather less on the following morning, and in
unfortunate circumstance for the diagnosis by the eruption is, that on a dark skin the spots are often not
THE INDIAN MEDICAL GAZETTE.
246
visible, particularly if the skin is dirty, as is the with most natives who come to hospital. The diagnosis of remittent from enteric fever may be In confirmed by the other symptoms which occur. remittent fever jaundice is a common symptom, but it is
at all
a
case
succeeded
in enteric fever ; the liver also is more often affected in remittent fever. On the other hand haemorrhage from the bowels often occurs in typhoid fever, but only rarely in remittent, and even then it usually takes the form of meloena, being of a dark colour, while the blood in enteric fever has generally an arterial character. The
rare
urine also more often contains albumen in typhoid fever than in remittent. Perforation of the intestine with subsequent peritonitis also occurs in enteric fevers in some cases, but not in remittent fever, and tympanitis is more excessive in the former affection, and often enables one to distinguish it from disease of the brain, in which there is no distension but rather retraction of the abdominal parietes. In remittent fever also the distension of the abdomen is seldom very great, as it may be in typhoid fever. The same state of exhaustion may occur in either disecise, attended with great prostration, black, dry tongue, quick, feeble or irregular pulse, and low muttering delirium called the typhoid state, and death may happen similarly in both diseases ; but in typhoid fever there is usually more tympanitis, and more often death is preceded by htemorrhage from the bowels and other changes already described. Temperature.?During the course of the diseases also differences occur in the temperatures of the skin ; thus the temperature in typhoid fever generally rises slowly during the first week, but falls a little every morning ; it is nearly at the same high level during the second week, and it often varies considerably in the 3rd and 4th weeks,
rising
and
sinking irregularly, but usually
remaining
high till the
4th week. In remittent fever there is sudden ris?, followed by a high temperature for one, two or more days, and then a remission succeeded by another sudden rise ; at length the elevations and
usually
a
depressions
occur
more
rapidly,
and
become
may
intermittent. Causes.?A difference also occurs between the causes of enteric and remittent fever. The latter is only
produced by exposure generally epidemic, and
to malaria, while the former is is believed to be caused by frecal contamination of the water or air. Unfortunately in India both causes are very prevalent, and in most cases of fever in India it will be found that the patient has been exposed at once to malaria and to the
of absorption of the cause of typhoid fever. In fact the only way in which an appreciation of the cause can affect the diagnosis here is when the fever attacks about the same time more than one member of a family where it is probable that there has been some
probability
contamination of the
typhoid
drinking
water which has
produced
fever.
The most important means of diagnosing these diseases is by the results of treatment. In remittent fever if large doses of quinine are given the fever will be in most cases cut short, but this is not the case with
typhoid
fever ; in this disease the
quinine only
causes
[September 1,
187&
temporary depression of temperature, which is again
by an increase of feverishness. In remittent fever, however, it is often necessary to employ some preliminary treatment before giving the quinine, particularly if the liver is congested and the bowels confined, in which case acholagogue purgative must first be given ; or if the spleen is enlarged and tender, it is better to use counter-irritants to the spleen first ; if there are any dysenteric symptoms, Ipecacuanha should first be given, and if there is much cough, expectorants should be used together with these remedies ; quinine should be given in some form either in solution or in pills, and in most cases it will be necessary to give it in doses of from 20 to 30 grains to an adult. In some cases it may be advantageously combined with opium and aromatic stimulants, a3 in Warburg's tincture, which is really a mixture o! quinine, aromatics and opium, and which has often proved of great service in the cure of malarious fever. Under this plan of treatment remittent fever is generally cured between the Gth and 10th days, but typhoid fever would continue for many days longer, though it mights be diminished for a time by the action of the quinine. Lastly, the post-mortem appearances differ greatly in " remittent and in enteric" fever. In both there is hypostatic congestion of the under part of the body with congestion of the larger veins, and an enlarged and congested condition of the spleen ; but in enteric fever the principal lesion is situated in the small intestines, especially at the lower part of the ileum, where the agminated glands or Peyer's patches are very much altered ; at first there swollen condition of the glands, which and contain a peculiar deposit called the gested deposit, but afterwards the mucous membrane
is only
a
are con-
typhoid covering
glands sloughs off, leaving minute ulcers correspondto each gland ; these gradually unite into a large oval ulcer with its long diameter parallel to the axis of the bowel. It has irregularly excavated borders, and often extends deeply intothe muscular coat of the intestine, or sometimes reaches to the peritoneum, It occasionally lays open a small vessel, thus causing htemorrhage. The mesenteric glands corresponding to this part of the intestine are swollen and congested, and contain a similar typhoid deposit to that in Peyer'a glands. In the
ing
remittent fever these lesions do not occur, but in many cases there is congestion of the liver, and very often a deposit of pigment granules in the interior of the liver. When this occurs the liver appears to be of an opaque brown
colour, and on a section being examined with the microscope a large number of black granules are seen surrounding each lobule and mapping it out; these are also found in the small vessels of the liver and in the spleen, and some-times in the capillaries of the brain and kidney. From the above description it will appear that, although
pigment globules
in some cases it is easy to distinguish between an attack of typhoid and one of remittent fever, especially if the case has been seen from the first, or a clear history obtained of as
is the
case
the symptoms, yet if these are not possible^ with most hospital patients, the diagnosis
becomes much
more
difficult,
is to treat all such cases
and the best plan probably of remittent fever by
as cases
.
September 1,
BENGAL NOTES?BY SURGEON-MAJOR F. R.
1879.]
giving large doses of quinine which will often stop the fever and thus decide the diagnosis. If quinine, however, given with all the above precautions in large doses, fails, the disease-is probably typhoid, and will require a differThis would be confirmed by the appearof the rose-red rash or of bleeding from the nose or the bowels, also by the fever lasting more than two weeks, although quinine had been given in large doses. ent treatment. ance
Even after death it is
possible
to determine
by
a
post-
mortem examination whether the
patient died of enteric remittent fever, since, in the former case, there will be well-marked alterations in the small intestines and their mesenteric glands; while in remittent fever these parts or
will be
but the liver will
healthy,
probably
contain
pig-
ment.
Here it may be remarked that some medical men have even the existence of remittent fever, and have thought that this disease was only a modification of typhoid or simple continued fever. But the differences which occur not only in the symptoms but in the postmortem appearances, and the results of treatment with large doses of quinine clearly prove that there is a distinction between these two diseases, and, equally, the doubted
length of time that remittent fever continues properly treated, as well as the frequently fatal
if not results
and the post-mortem appearances indicate that it is entirely different ftom simple continued fever. The closest affinity of remittent fever is certainly with intermittent fever or ague, into which it often passes when under treatment, and from which it is sometimes
developed by the occurrence of a local inflammation or active congestion, particularly of the spleen, liver, or lung. No case of typhoid fever can be brought forward, as none occurred in hospital, but an interesting case of remittent fever
was
treated
as
follows
:?
aged 20 years, was admitted Mayo Hospital on May 6th. He stated that
Latawan,
a
Hindoo male
into the he was a native of Fyzabad in Oude, but had resided in Lahore for six months, employed as a syce ; his previous health had been good, excepting an attack of small-pox and one of fever long ago. He stated that on May 1st, about 5 P. M., he was attacked with fever, and felt cold and trembling. The
fever continued up to his admission into hospital on May 6th. He also suffered from great weakness, slight cough, a feeling of discomfort in the abdomen. No alteration of vision, but slight deafness and a bitter taste in the mouth. The skin visibie ; the
was hot and dry, but there was pulse was quick?90 a minute.
and chest sounds
were
normal.
no
eruption
The heart The abdomen was rather
were loose : motions yellow and semi-fluid ; urine scanty, high-coloured, and Sp.Gr. 1030 ; it contained no albumen.
depressed
;
the bowels
Treatment.?On the 6th of May, a saline mixture was given, and as the temperature was lower on the following morning (May 7th), ten grains of quinine were administered each morning and evening, till May 15th. The temperature, as will be seen in the accompanying chart, diminished somewhat every day under this treatment till on the 16th day the patient left the hospital quite well.
HOGG, A.M.D.
247
This case when admitted into the hospital have been mistaken for typhoid fever, since there
might was
a
high temperature, quick pulse, deafness
and diarrhoea; but the very defin:te commencement, not only the day but the hour of the attack being mentioned?was more like remittent fever, and the subsequent cure by the administration of large doses of quinine, with complete recovery on the 16th day of the disease, proved that it could not be typhoid fever. The absence of eruption and of any disturbance of vision indicated that it was not typhus fever, as well as the fact that there were no other cases, and the long duration of the complaint and its gradual cure by quinine differed from simple continued fever. As is usual in these cases, no clear history could be obtained of the temperature during the first six days, but the temperature after that is shown in the annexed table. 9
Day of disease
Temp.
10
M.
102
101-6 101 100-2
E.
103 6
102!
103*6
39-6
11
I 100-4
12
13
97-6 98
100 101 99-2:99
1G
98'4
