September 1, 1879.J DIAGNOSIS BETWEEN ENTERIC AND REMITTENT FEVER. 245 most cases it is only on the 4th evening that it reaches ORIGINAL COMMUNICATIONS. 104?; while in remittent fever the first attack is generally more marked, being attended with great prostration, a feel- ON THE DIAGNOSIS BETWEEN ENTERIC ing of cold and shivering followed by great heat of skin OR TYPHOID FEVER AND REMITTENT and intense fever, the temperature often rising to 104? or 105? on the evening of the first day of the disease,but OR INTERMITTENT FEVER. the attack is not always so decided at first; sometimes it E. C. By Surgeon-Major T. Burton Brown, F. R. S., commences more insidiously with slight feverishness, Principal, Lahore Medical College. lasting for some days before the severe attack begins; while on the other hand in some cases of typhoid fever Great difficulty is often experienced in this country in the does not notice or conceals his illness for determining whether a case of fever in which remissions patient several while he is really suffering from a mild occur, but no true intermission, is to be regarded as one days of so that the disease is or attack typhoid fever, supposed of enteric of remittent fever ; and, as not only the to have commenced on the 4th or 5th day of the real at- prognosis but the treatment mainly depends on the cor- since it is then alone that he appears to be seriously rect determination of this point, it is of considerable tack, ill. In cases too remittent fever suddenly declares importance to have distinct ideas as to the mode in many itself or into inter- which this may be ascertained. by closing abruptly by being changed mittent fever with temporary recovery while In England where remittent fever is a most rare dis- apparently the intermission lasts ; this occurs at the end ease, but enteric fever is very common,this difficulty is not frequently of the first week, especially when the proper treatment met with, and very little is said about this point in onr has been employed ; but this recovery is not always the English test books ; it is not even mentioned in Tanner's case even in remittent as the disease continue or Aitken's Manual, nor even in Ziemsen's Cyclopoedia of fever, may and then the resemblance to fever is Medicine, but Murcliison writes in his book on continued longer, tyyhoid most marked. In both diseases the temperature and fevers as follow : "The diagnosis between enteric and are in the while on remittent fever is often extremely difficult in countries pulse increased, especially evening, these are lowered. In both there is where both prevail together. The pyrexia of enteric fever every morning diarrhoea with liquid stools, and in is essentially remittent, and cases have occurred in my usually yellowish both this symptom is sometimes absent for a long time. own practice and been noted by Trousseau and other In both affections delirium occurs and gradual exhaus- observers, especially in malarious countries, where it has tion, but this usually comes on earlier in remittent fever put on at first an intermittent type. Moreover, vomiting than in enteric fever. On examining the abdomen there and diarrhoea may occur in both diseases, while enlarge- is found in both kinds of fever some amount of swelling ment of the spleen, cerebral symptoms, and the typhoid and but in the case of remittent fever this state are common to both. tenderness, is most marked at the epigastrium, while in The eruption is perhaps the only distinctive mark of usually fever the right iliac region is more particularly enteric fever to be relied on ; and, in every case of remit- typhoid and accompanies it. tent fever complicated with abdominal symptoms, it affected, gurgling In both diseases also the is and tender ought to be carefully looked for. The close resemblance spleen enlarged on sometimes it becomes much increased of enteric to remittent fever accounts for the fact that pressure; very in size and it is only within the last few years that the former painful. One distinction between the two affections is malady has been recognised as occurring in India. In great the rose-red which occurs on the other writers on fever the diagnosis between remittent eruption, abdomen, of the and enteric fevers is not so much noticed, thus it is typhoid fever, spots being small, circular, slightly raised about one line in on not mentioned at all by Watson or in Copland's diction- diameter; they disappear pressure, but again return when the is ary of medicine. pressure removed, and each fades after three or four In actual practice in India, however, it frequently be- spot permanently but it is replaced other similar spots in its comes a most important consideration, not only to the pa- days, by so that the continues till the tient and medical attendant but also to the anxious friends neighbourhood, eruption end of the illness the alternate and and relatives, whether the disease be typhoid fever or by appearance fading remittent. A patient suffers from fever which lasts of these spots. this rash is distiuct the is for several days, being rather less in the morning and When very diagnosis that in India similar somewhat increased in the evening; in such cases it is rendered easy, excepting spots may arise from to heat or from the bites of insects often equally necessary and difficult to determine what exposure ; case however a minute is the nature of the disease. If the illness has been in the latter puncture may often be found in the centre of each spot if it is carefully watched from the very first the diagnosis carefully examined. A more important is that the becomes more easy, for in typhoid fever the invasion objection spots before the eighth day, and very often not is usually very gradual, the patient feels languid and rarely appear till the end of the second week ; while in remittent fevers anxious, with slight feverishness, headache and a tendency it is for the treatment to make the to diarrhoea, but very usually he is able to move about very important at an earlier time when this is and to eat solid food for some days. The temperature diagnosis possible. A still more unfortunate circumstance for the the also is only slightly increased ; at first it rises every even- diagnosis by that on a dark skin the are ing, but is rather less on the following morning, and in eruption is, spots often not 246 THE INDIAN MEDICAL GAZETTE. [September 1, 187& as is the at all visible, particularly if the skin is dirty, a temporary depression of temperature, which is again case with most natives who come to hospital. succeeded by an increase of feverishness. In remittent The of fever be diagnosis remittent from enteric may fever, however, it is often necessary to employ some confirmed by the other symptoms which occur. In preliminary treatment before giving the quinine, parti- remittent fever jaundice is a common symptom, but it is cularly if the liver is congested and the bowels confined, rare in enteric fever is more often affected ; the liver also in which case acholagogue purgative must first be given ; in remittent from fever. On the other hand haemorrhage or if the spleen is enlarged and tender, it is better to use the bowels occurs but often in typhoid fever, only rarely counter-irritants to the spleen first ; if there are any dy- even the form of in remittent, and then it usually takes senteric symptoms, Ipecacuanha should first be given, and a while the blood in meloena, being of dark colour, if there is much cough, expectorants should be used to- enteric fever has an arterial character. The generally gether with these remedies ; quinine should be given in fever urine also more often contains albumen in typhoid some form either in solution or in pills, and in most cases than in remittent. Perforation of the intestine with it will be necessary to give it in doses of from 20 to 30 also occurs in enteric fevers in subsequent peritonitis grains to an adult. In some cases it may be advantage- some but not in and is cases, remittent fever, tympanitis ously combined with opium and aromatic stimulants, a3 more excessive in the former and often enables affection, in Warburg's tincture, which is really a mixture o! one to it from disease of the in which distinguish brain, quinine, aromatics and opium, and which has often there is no distension but rather retraction of the proved of great service in the cure of malarious fever. abdominal In remittent fever also the parietes. Under this plan of treatment remittent fever is generally distension of the abdomen is seldom as it very great, cured between the Gth and 10th days, but typhoid fever may be in fever. The same state of exhaustion typhoid would continue for many days longer, though it mights occur in either attended with may disecise, great pros- be diminished for a time by the action of the quinine. feeble or tration, black, dry tongue, quick, irregular pulse, Lastly, the post-mortem appearances differ greatly in and low " muttering delirium called the typhoid state, remittent and in enteric" fever. In both there is hypo- and death in both diseases but may happen similarly ; static congestion of the under part of the body with con- in fever there is more and typhoid usually tympanitis, gestion of the larger veins, and an enlarged and congest- more often death is from the preceded by htemorrhage ed condition of the spleen ; but in enteric fever the prin- bowels and other described.