EEVIEW TROPICAL MEDICINE, ETC. 67 



need only indicate that at this stage, suspecting this condition, attention would be directed to Fevers— 

 the urine and search made for the tubercle bacillus in the manner to be presently described. coniiimed 



Eeturning again to Sutherland's deductions, we find that 



absence of signs of enlargement of lymijhoid structures, of effusion into serous sacs, and negative results from 

 lumbar puncture, imply that there is not a lymph infection, with the possible exception of infection of the visceral 

 lymphoid tissues or of the deep lymph glands. The three infections most likely to occur in these situations are 

 enteric fever, Malta fever and acute general tuberculosis, and further evidence can be gained as to these by the 

 agglutination and sedimentation tests and by the diazo-reactions, 



(Also possibly by the ophthalmo-reactions. — A. B.) 



A positive diazo-reaetion might imply either enteric fever or acute general tuberculosis, but positive 

 agglutination and sedimentation reactions for enteric and Malta fevers distinctive, under proper conditions, of 

 the technique employed. 



3. Is it a local infection ? 



As a rule there are well-marked symptoms, but in deep-seated afiections the physical signs may be overlooked. 

 These secret local infections are generally associated with the micro-organisms of suppuration, with bacilli of the 

 typhoid, colon or para-colon groups, or with the tubercle bacillus ; and unless borne in mind they will often pass 

 unrecognised. Septic throat infections are liable to be overlooked, and the resulting fever is often attributed to 

 " malaria," simply because the throat was never examined. 



The blood examination usually gives evidence of these infectious, and a leucocytosis or relative increase of the 

 lymphocytes or of the polymorphonuclears in the circulation, with absence of parasites in the peripheral blood, 

 spleen or bowel, is always suggestive. A lymphocytosis points to tuberculosis or to a bowel infection by one of the 

 typhoid or allied groups, and a polymorphonuclearcytosis to a local septic infection. The diazo-reactiou may give 

 evidence about the first two, the agglutination and sedimentation tests about the second, while the finding of 

 peptone or albumose in the urine may indicate the third. A lymphocyte increase is of less value in diagnosing 

 local infections than an increase of the polymorphonuclears, and calls for the diazo-reaetion, the agglutination and 

 sedimentation tests, and the search for tubercles in the chloride with the ojihthalmoscope to clear up the issues. 

 Increase of the polymorphonuclears, on the other hand, is distinctive, for it means local septic infection somewhere, 

 and should send the observer back fi-om the microscope to the patient to look more carefully for it. The 

 conditions which should be examined for, one by one, are : — Oral sepsis, sore throat, appendicitis, abscess of the 

 liver, subphrenic abscess, infective cholangitis, infective endocarditis, phlebitis, empyema, deep-seated pneumonia, 

 abscess of lung, suppurative osteo-myelitis, suppurative periostitis, pyelitis, salpingitis, otitis media, mastoiditis, 

 thrombosis of the lateral sinus, abscess of brain, cerebro-spinal meningitis, etc. With a polymorphonuclear 

 increase in the blood, more thorough clinical examination will generally reveal the local mischief and settle the 

 diagnosis, although the particular infecting microbe may not be determined until the necessary operation is 

 performed. 



If the diazo-reaetion, the serum agglutination and sedimentation tests have given positive reactions and have 

 indicated the nature of the infecting microbe, the diagnosis should be confirmed by microscopic examination of the 

 sputum, fteces and urine, as the case may be, and cultures should be made and animals inoculated if necessary. 

 The infecting micro-organism can generally be distinguished from others by making the agglutination and 

 sedimentation reactions with the patient's blood, due regard being paid to the probability of a mixed infection 

 (symbiosis). 



Having isolated the infecting agent in the above ways, it should be cultivated, or kept in sealed tubes if the 

 former be impossible, and subsequently used for prognostic purposes by testing, from time to time during the 

 illness, the agglutinating power of the patient's blood and its bactericidal and phagocytic powers. 



Apart from the side-room (laboratory) research, valuable information will be obtained from day to day at the 

 bedside by watching the course of the disease, and the effects of treatment. The daily physical examination may 

 reveal some local lesion which at first was not apparent ; the time test may bring out distinctive rashes and show 

 the affection to be one of the eruptive fevers, or may reveal characteristic features which identity the condition ; 

 the fever chart may become typical or the therapeutic quinine test abolish the fever. A consistently slow pulse 

 will point to typhoid, the tdchc ciribrale to typhoid or acute general tuberculosis, and so on through all the 

 established diagnostic criteria. 



If such a method of procedure be followed as a routine in doubtful eases, few will remain over to be returned 

 as Simple Continued Fever, Remittent Fever, etc., terms which now fill the Returns. On the other hand, many 

 slight cases of fever will occur where little or no information is got fi'om the side-room examinations, and where 

 recovery takes place before a scientific diagnosis has been made. In these eases it is hard to .s.ay what the fever 

 should be called, and as they are generally associated with a little gastric, intestinal, bronchial, or uterine catarrh, 

 it is best to return them under those heads. It would be well to regard every case of fever as having its origin 

 and being in some infection or toxic process, i.e. in the reaction of the tissue cells thereto, and it is safer to 

 conclude that heat and " chill " act only as predisposing factors. 



In the above sketch, little has been said about toxic causes of fever as apart fi'om infective causes, but doubtless 

 toxic substances produi.'ed by intestinal and other parasites are capable of causing fever, and in most cases in India 

 a search tor ova in the stools, urine and sputum should be made. There is also the condition called " Fermentation 

 fever," a subject to which Burdon-Sanderson was the first to direct attention, and which arises from the absorption 

 of digestive ferments, fibrin ferment, extracts of fi-esh tissues, etc., and which is seen with gastro-intcstinal 

 disturbance, particularly in children, and after bruises, hfemorrhages, operations and the passage of a sound or 

 catheter. It may also be noted that, as in the case of tuberculin. Professor Krehl has obtained a pyrogenetic 

 albumose from cuhivalions of U. coll comniuiie. 



