reached by the Cliittogong, Manipur Maudalay routes, we Iiave all the conditions for the production of intermittent and remittent fevers of all degrees of severity, and it is from the experience gained by residence in various parts of that country coupled with the ordinary experience of Indian medical officers who have whether

or

that we see conclusions arrived at the object by Dr. O'Connell. At the same time the writings of the numerous skilled observers of Indian3 fevers in past times will be frequently -referred to as regards matters-of-fact. We will leave theory alone as far as possible. Dr. O'Connell's first point, as we understand it, is this:?Formerly enteric fever was un recognised in India, and all cases were returned as remittent. Gradually things have been reversed during the past twenty years, till now it would appear from the report of Sir B. Simpson's Committee that many cases of remittent fever are returned as enteric. There is certainly little doubt that such is really the case, and thatmauy mild cases of remittent fever are returned under the convenient headings of Febricula or S. C. F. But judging from the careful observations and writings of Indian medical officers and the prevalence of undoubted enteric fever at the present time* it is a perfectly open question whether there were many cases of enteric fever unrecognised tweuty years ago, or rather whether enteric fever existed at all for recognition or otherwise. With this question we are not concerned at all, except in so far as the writer uses" it as an Because," argument in favour of his theory. he says, "enteric and remittent fevers were done

duty

reason

?qiflimu wmnnmtipons. malarial fevers. HALL, i.m.s., GRANT, i.m.s.

By Surgeons G. C. A. G.

and

In the Indian Medical Gazette for July 1891 article by Surgeon-Major O'Connell, M.S., on Malarial Fevers, in which the generally received ideas regarding the etiology and causal relations of Intermittent and Remittent Fevers in India are disputed. Dr. O'Connell, whilst admitting that intermittent fever has a directly malarial origin, declines to allow the same for remittent fever and claims for the latter a perfectly different, and, in his present paper, unexplained causation. We venture to think that the reasons advanced by him in favor of this theory are insufficient, and the so-called facta in many cases inaccurate when tested by the touchstone of actual experience. Before replying in detail to the arguments brought forward by Dr. O'Connell we desire to draw attention to the extremely valuable material for the study of these diseases lately made available by the geueral exploration and pacification of Upper Burmah for the past four We know of no district, except, or five years. perhaps, certain parts of Assam, where such absolutely favourable conditions both as regards quantity and quality exist for the study of the relations of intermittent and remittent fevers to each other aud to malaria. Compare with this the following passage from Chever's diseases of India.* " In the present day we hear far less of pernicious Terai fever than we formerly did. Travellers are prepared with quinine against it, the roads are more open and better, transit is quicker, night-journeying at the worst season is avoided. Large tracts of Terai are now under tea cultivation, the European planters being liable to intermittent fever. It may be that the type of the disease has become mitigated ; still, as long as virgin forest remains, men will veuture into it and get remittent fever of grave character, which Indian physicians must be prepared to treat with a full knowledge of the history of Terai fever in its deadliest forms

ia

an

The

italics

are *

ours.

In

Upper Burmah,

Churchill) 1886, p, 192.

to

in

up-country stations, to

clearly distinguished twenty years ago; therefore it is quite possible that the relations of intermittent and remittent fevers are not yet understood." But, we reply it is not proved that enteric and remittent existed undiagnosed side by side twenty years ago, and even if they did, it would not help to prove that intermittent and remittent have a different origin; besides which these two latter fevers have certainly been under careful observation in all their relations for a much longer period. With reference to the relatioe prevalence of enteric and remittent fevers at the military stations from which the army returns are made, it is sufficient to poiut out that the conditions under which the British soldier lives at the present time (including the lowered age average) are just such, speaking in general terms, as are known to favour the occurrence of enteric fever and to lessen the frequency of remittent. On active service, ou the other hand, we find these conditions, with the exception of the a^e not

(which only affects enteric fever), alentirely reversed, and as a result there is a

average most

corresponding change cases

of euteric and

in the relative uumber of

remittent.

45

S?4;

INDIAN MEDICAL GAZETTE.

A residence of several years in India and Upper Burmah lias only strengthened our belief in the intimate relations between intermittent and remittent fevers, as insisted upon by almost every medical officer who has studied the subject, The exact nature of these relations may still be somewhat obscure, but so close do we believe them to be after seeing these fevers in all types and degrees of severity that we wonder how; physicians could ever have separated them into two such distinct classes as they have done. In a thoroughly malarious district it is found impossible to forecaste with certainty the progress of any one case admitted into hospital, i.e%> as to ?whether it will be of a purely intermittent or remittent type or of a mixed form. From this it will be seen that we do not appreciate the difficulty said to be met with in studying the writings of various authors where ague and remittent With many fever are indifferently referred to. authors either term is nsed simply as a synonym for malarial fevers. In much the same way we might (though we do not) complain of the use of ague and intermittent fever as synonymous terms which, of course, strictly speaking, they are not; the former being a symptom more or less pronouncedinintermittent fever but common iii all malarious diseases. He su2

Malarial Fevers.

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