PnooNosis.—The prognosis of this dis ease is generally favorable. The compli cations mentioned above render the out look more grave.
—The treatment is mainly symptomatic.
The treatment of glandular fever is symptomatic. The use of small doses of calomel at the outset has, according to different observers, been of particular benefit. Small doses of salophen person ally employed have seemed to relieve the pain and the general malaise. The ad ministration of iron is necessary during convalescence. Locally belladonna oint ment in conjunction with lanolin may be employed. A. E. Roussel (Med. and Surg. Reporter, Apr. 17, '97).
Terminal Infections. — It may seem paradoxical, says Osler, but there is truth in the statement that persons rarely die of the disease with which they suffer. Sec ondary infections, or, in hospital par lance, terminal infections, carry off many of the incurable cases. Flexner, of Phila delphia (Tour. Exp. "Med., i, '96), has ana lyzed 255 cases of chronic cardiac and renal disease in which complete bacterio logical examinations were made at au topsy. Excluding tuberculous infection, 213 gave positive and 42 negative results.
The infections may be general or local. The latter are very common and are found in a large percentage of all cases of chronic nephritis, arteriosclerosis, car diac disease, hepatic cirrhosis, and other chronic disorders. The most frequent le sions are affections of the serous mem branes (acute pleurisy, peritonitis, or pericarditis), meningitis, and endocar ditis. Osler advances the opinion that it is perhaps safe to say that the majority of cases of advanced arteriosclerosis and of Bright's disease succumb to these in tercurrent infections. Of the infective agents, Osier mentions the streptococcus pyogenes as perhaps the most common, but the pneumococcus, staphylococcus aureus, the bacillus proteus, the gonococ cus, the gas bacillus, and the bacillus pyocyaneus are also met with.
In connection with the terminal form of acute miliary tuberculosis, Osler notes the great number of cases of arteriosclero sis of chronic heart disease, of Bright's disease, and especially of cirrhosis of the liver, in which death is determined by an acute tuberculosis of the peritoneum or pleura.
Flexner has found that the general ter minal infections are less common. Of 85 cases of chronic renal disease in which he found micro-organisms at autopsy, 33 exhibited general infections; of 48 cases of chronic cardiac disease, in 14 the dis tribution of bacteria was general. He found the blood-serum of persons suffer ing from advanced chronic disease to be less destructive to the staphylococcus aureus than normal human serum. Other diseases in which general terminal infec tion may occur are Hodgkin's disease (pseudoleukmmia),leukmmia, and chronic tuberculosis.
Finally, Osler observes that the ter minal enterocolitis so frequently met with in chronic disorders is probably of the same nature.
Malta, Mediterranean, or Undulant disease, called by various names, is an endemic fever characterized by an irregular course, undulatory py rexial relapses, profuse sweats, rheumatic pains, arthritis, and an enlarged spleen (Osler). The disease is met with at Malta,
and in the countries bordering on the Mediterranean. In Gibralter it is known as rock fever, and in Italy and Sicily as Neapolitan fever. It is probably also met with in India and China. Our knowledge of this disease is almost entirely owed to the labors and reports of Marston, Bruce, Hughes, Durham, and other army-sur geons stationed at Malta and Gibraltar.
SYMPTOMS.—The period of incubation is from six to ten days. "Clinically the fever has a peculiarly irregular tempera ture-curve, consisting of intermittent waves or undulations of pyrexia, of a dis tinctly-remittent character. These py rexial waves, or undulations, last, as a rule, from one to three weeks, with an apyrexial interval, or period of temporary abatement of pyrexial intensity between, lasting for two or more days. In rare eases the remissions may become so marked as to give an almost intermittent character to the febrile curve, clearly distinguishable, however, from the parox ysms of paludic infection. This pyrexial condition is usually much prolonged, hav ing an uncertain duration, lasting for even six months or more. Unlike palu dism, its course is not affected by the ad ministration of quinine or arsenic. Its course is often irregular and even erratic in nature. This pyrexia is usually accom panied by obstinate constipation, pro gressive anemia, and debility. It is often complicated with and followed by neu ralgic symptoms referred to the periph eral or central nervous system, arthritic effusions, painful inflammatory condi tions of certain fibrous structures, of a localized nature, or swelling of the tes ticles." (Hughes.) Three distinct types of the disease are recognized by Hughes: A malignant type, in which the disease may prove fatal within a week or ten days; an un dulatory type (the common form), in which the fever is marked by intermittent waves, or undulations, of variable length, separated by periods of apyrexia and ab sence of symptoms, the duration of this undulatory form being from three months (the average time) to two years, the patient suffering a series of relapses; finally, the intermittent type, in which the patient may have daily fever toward evening, without any special complica tions, and may do well and be able to go about his work, and yet, at any time, the other serious features of the disease may develop.
DIAGNOSIS.—This fever must be dif ferentiated from typhoid fever and from malaria. A close study of the tempera ture-curve and the characteristic symp toms will facilitate the diagnosis. More over, the absence of specific action of quinine and arsenic and the absence of the Plasmodium malarice in the blood distinguish it further from malaria.