THE RELATION SHIP BETWEEN "PYREXIA

OF UNCERTAIN ORIGIN" AND ENTEKIC FEVER.

By D. M. TAYLOR, m.b.,

LIEUT., I.M.S.

I read with much interest an article in the \ticrust number of the Indian Medical Gazette, bv Captain James Husband, i.m.s., and Lieutenant H V Hodge, on certain obscure cases of pyrexia which they had had under observation. T propose to place on record a very interesting series of cases which I had in my charge between January and March ] 912.

r ? i ?

. Some of these cases gave a clinical picture resembling a typical attack of enteric ; others a mild or less typical form ; but in alU\ idal s reaction was persistently negative, an undoubted case of enteric with a marked positive reaction died in hospital at the commencement of the series ; three of the cases resemble enteric so closely that no other diagnosis is possible in spite of the negative reaction ; while two others resemble a mild enteric or paratyphoid infection, and are similar, I imagine, in many respects to some of these cases referred to in the above quoted article. The cases have an important beirinff on two questions and fall naturally under one or other of two headings, viz. m Enteric fever giving a negative reaction. (2) Pyrexia of uncertain oiigin. The case of enteric fever which gave a positive

reaction was admitted on January 14th and died on January 28th, 1912. The reaction was posi- tive in dilutions even of 1 in 160.

Qase /?The first case of this series, admitted on January 2nd, had twenty-one days pyrexia, six days intermission, and a lelapse of twenty-one days which appears to have been brought on by his eating some swTeetmeat^ given him by a friend (sic). The pulse was relatively slow throughout. There were very marked rlionchi all over the chest, sometimes very moist in character, but unaccompanied by other physical signs. It was noted that the amount of the rales appeared to increase concomitantly with an exacerbation of fever and vice versa. The spleen was not enlarged and there was no rash nor diarrhoea. The patient became lethargic, drowsy, and ancemic, but was

398 THE INDIAN MEDICAL GAZETTE. [Oct., 1912.

remarkably free from delirium. Widal's reaction

was negative on tlie 21st day of the disease and

again on the 40th day in dilutions even of 1 ? 20.

Reactions for paratyphoid A. & B. were also

negative on the same days. Blood was repeatedly negative for malaria.

Case 11?Admitted January 14th, had a temper- ature curve closely resembling enteric, a relatively slow pulse and marked signs of bronchitis which closely resembled the previous case. Both these cases for a time were regarded as broncho-

pneumonia, but this diagnosis was soon given up. There was no enlarged spleen nor diarrhoea. ^The

patient complained very little about his chest condition and had little cough. There was a

certain amount of prostration but only slight deli- rium. Widal was negative (including paratyphoid A. & B.) in dilutions of 1 in 20 on the 9th and 35th day. Blood was negative for malaria

throughout. The tongue in this case was moist and clean.

Case III?Was interesting from the fact that he was a brother of No. I and had nursed him in his illness. He was admitted one month after

his brother became convalescent and was possibly a case of direct infection. He had fever for

45 days ; bronchitis, which was less severe than in above cases ; a relatively slow pulse : no

enlarged spleen, nor eruption. He appeared better than one would expect during such a

prolonged attack of fever and had no delirium. He had at times a tendency to diarrhoea. Widal was negative on the 6th and 28th day ; a blood culture on bile salt agar taken on the 6th day showed no growth ; reaction for micrococcus melitensis was negative on the 28th day ; and malaria was negative throughout.

Case IV?Admitted January 26th, had sixteen days fever with physical signs of bronchitis and a relatively slow pulse. He was never very ill. Widal was negative on the 17th day, including paratyphoid group. Malaria was negative on the 92nd day and quinine was tried without effect.

Case V?Had thirteen days fever and possibly a day or two more before admission. His chart shows large undulations. His pulse was rela-

tively slow, spleen was not enlarged. He had

practically no symptoms apart from the pyrexia and appeared remarkably well. WTidal (including paratyphoid group) was negative on the 8th day. A blood culture on the same day gave no growth, malaria was negative and quinine had no effect.

These two last cases appear to me to link

together this series with those cases described

by Captain Husband and Lieut. Hodge, and

suggest an enteric origin in most of these cases.

The cases all made a good recovery and have had no sequela3. A sixth case may be briefly referred to.

He died soon after I arrived in the station, and 1 only saw him once or twice. The date of his death, the 14th January, corres-

ponds with the commencement of the above series and suggests a connection with it, He

had intermittent pyrexia for 22 days. His blood was negative for malaria and his liver normal to

percussion. On the 13th day pain set in round the umbilicus with nausea. The pain later in the disease became severe and the vomiting incessant and the abdomen full and tympanitic. He died on the 28th day of the disease. His case is

interesting as being one of obscure pyrexia occurring at this time, but differs considerably from the other cases referred to. We have had six cases occurring apparently

in epidemic form, in conjunction with one case

with a positive Widal ; three of the cases resemble

typical enteric so closely that no other diagnosis seems possible ; two suggest mild or paratyphoid infections, while the case, which may not have

any connection with the others, has little resem- blance to enteric and had it occurred sporadically, would scarcely have suggested such a diagnosis. In these cases Widal was repeatedly and absolutely negative. As a series they suggest that enteric fever may not only occur in mild and atypical forms, but also that in these forms Widal's reaction may be negative. They further suggest that there is a possibility of a particular type of typhoid infection which does not react to the

present Widal test, and that these cases, especially when sporadic and atypical, account for many obscure cases of fever in India which are returned

as " Pyrexia of uncertain origin."

THE RELATIONSHIP BETWEEN "PYREXIA OF UNCERTAIN ORIGIN"

AND ENTERIC FEVER.

By Lieut. D. M. TAYLOR, m.b., i.m.s

CASE I. CASE I.

CASE II. CASE II. CASE IV. CASE IV.

THE RELATIONSHIP BETWEEN "PYREXIA OP UNCERTAIN ORIGIN"

AND ENTERIC FEVER.

By Lieut. D. M. TAYLOR, m.b., i.m.s.

CASE III. CASE III.

OASB V. CASE V. CASE VI. CASE VI.