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and ipecacuanha treatment. We would almost say that, if a case of acute dysentery does not improve in 48 hours under the latter treatment, it is combined with malaria and requires quinine either by mouth or by enema.
Case 7.-A case of chronic dysentery from Manila was extremely obstinate and resisted all treat- ment until the blood was examined and parasites found. Quinine, given as above, soon cured the case and the patient left for America looking and feeling very well after six months of this trouble- some complaint.
TYPHOID FEver.
The combination of malaria with this disease is most interesting to tropical practitioners. Without a post mortem examination our diagnosis in some of these cases may be called in question but they were all seen several times by other medical men who agreed with the diagnosis in every case and if they were not typhoid it would be difficult to explain the long continued fever. Of the 10 cases examined all showed malaria. The effect of the malaria on the chart was various.
In some cases for several days the temperature intermitted regularly and markedly until, apparently, the ma- laria dropped out and the typhoid element had free play; in others, however, notwithstanding quinine, there was no intermission and the chart from the beginning was very suggestive of typhoid. We have not found much assistance from Widal's reaction, which in most of our cases has given a negative result-as late as the 16th and 20th day in two fatal cases. Our only dictum on this subject is that held by most other practitioners-if after thorough treatment by quinine for 10 days, the temperature does not fall in the absence of any symptom to account for the continued rise, the case is in all probability typhoid and purgatives should be withheld. Typhoid is held to be a more fatal disease in the tropics than in temperate climates but why this is so is not quite clear, unless the malarial element, which is present in the greater number of cases, has something to do with the high rate of mortality. The previous treatment of the malaria tends, we think, to keep the typhoid temperature lower than it would otherwise be. Our rate of mortality was 30%.
Case 8.-A Police Constable who had been doing duty at Tai O-a fairly malarial spot-up to May 9th, returned on that day to the Central Police Station. On May 25th he was admitted to hospital suffering from fish poisoning as the result of eating raw oysters. On June 1st he was attacked with fever and the malignant parasite was found in his blood. In spite of quinine the fever continued and on the 18th day a slight hemorrhage from the bowels occurred. The diagnosis was now altered to typhoid and the quinine discontinued. The temperature fell to normal on the 29th day of the illness and he is now progressing favourably.
In some of these combined cases the blood examination gives information or relieves one's mind regarding a relapse.
Case 9. A Policeman with malaria and typhoid, On the 18th day the temperature fell to normal and continued so for 12 days when it suddenly rose to 105. An examination of the blood showed the return of the malignant parasite and under quinine the fever ceased in a day or two and the patient left for Japan on leave.
Case 10.-A very bad case of malaria and enteric. After the temperature had been normal for 8 days it suddenly rose. No malaria was found and the case was treated as a relapse which it turned out to be and lasted 14 days. Patient recovered slowly and left the hospital on the 62nd day of the illness.
PLAGUE.
Up to date 8 cases have passed through the hospital, all being admitted as malaria and parasites being found in each case. It is very desirable to keep these cases out of a general hospital, as it entails such a lot of extra disinfection and there is always a risk-though small-of some of the other patients or the staff contracting the disease. We do not, however, see how this can always be managed. We were both on the alert throughout the plague epidemic and yet failed to detect some of these cases until they had been some time in hospital. We have not been very successful in finding the plague bacillus in the blood in these cases until the case was far advanced. Professor KITASATO states that it is rare to get them in the early stage and if present there may be only one in a whole slide. Detecting it under these conditions must be due to good luck. The invention, by some bacteriologist, of a double stain, similar to Gabett's for tubercle bacilli-one of the most useful ever invented-would be a great boon. The agglutination test, as improved by Professor KLEIN, we have not employed as it requires a good deal of time and skill in preparing the media. Its use in these cases will no doubt be settled in next epidemic by the Government bacteriologist. Cases of plague are so interesting that we need not apologise for detailing one or two.
Cases 11 and 12.-Were of interest as both presented the point of inoculation, one on the finger and one on the thigh and from the bleb in each case, plague bacilli were easily found. Both showed malaria as well and only slipped into hospital owing to the absence of the medical officer and were after an hour or two transferred to Kennedy Town Hospital.