Page:Tropical Diseases.djvu/424

382 which, in an hour or two, mounts to 104° or 105° F., to be succeeded in a few hours by profuse sweating and a partial remission of fever exactly resembling an attack of ague. For the next two or three days these attacks are repeated, the remission becoming less complete each time. Quinine may be given; but, although the rigors and marked oscillations of temperature are checked, the practitioner is surprised and disappointed to find that the temperature keeps permanently too high, and that the typhoid state is gradually developed. Or it may be that a typhoid fever begins in the usual insidious way, runs its usual course for a week or two, and then, in the middle of what is regarded as an ordinary typhoid, rigors and temperature oscillations and other malarial manifestations show themselves. If quinine is given, these oscillations cease and the typhoid resumes its usual course. Or it may be that it is not until the end of the fever and during convalescence that these malarial symptoms are developed. Several such cases are now on record in which the malaria parasite was found in the blood.

The diagnosis between typhoid and some forms of malarial remittent is often exceedingly difficult, in certain cases almost impossible, without the assistance of the microscope and the serum test. The principal points to be kept in view are, first, the mode of incidence of the disease. In typhoid there is a gradual rise of temperature, a daily gain of a degree or so during several days, the maximum not being attained for five or six days; as against the sharp rigor and sudden rise of temperature through five or six degrees in the first few hours in malarial fever. Secondly, the characters of the gastric symptoms differ. Thus, in malarial remittent there are bilious vomiting and perhaps bilious diarrhœa, tenderness of the liver, epigastrium, and spleen, and an icteric tint of skin and sclerse; in contrast to the abdominal distension, perhaps the iliac tenderness and gurgling, and the peasoup stools of typhoid. Such signs as epistaxis, deafness, and cheek-flushing in typhoid have a certain weight, but skin eruptions in the tropics are of little aid in the diagnosis of such cases. Prickly heat, or its remains, is