The diagnosis of obscure pyrexia.

The task of diagnosis in a patient with pyrexia of uncertain origin demands a close alliance between clinician and pathologist-an alliance based on a full understanding of each other's powers and limitations. On the one hand the clinician must have a sound knowledge of the tests which he asks the pathologist to carry out; on the other, the pathologist must not be used merely as a sort of penny in the slot machine to deliver an answer of yes or no to such questions as, ' Has this patient typhoid fever ? ' Ephemeral fevers, so common, yet to which so frequently no diagnostic label can be assigned, are outside the scope of this paper, as are also the common exanthemata. The importance of an accurate history. A careful history of the illness, especially of its onset, is of the first importance. For example, in typhoid fever the onset is usually gradual, but frequently the classical ingravescent fever with gastrointestinal symptoms does not occur and the presenting symptoms may be bronchial. Again, previous illnesses may afford a clue to the present condition, which may be a relapse, a complication, or a sequel of either a recent or a long-standing illness. Has the patient been abroad, particularly in the period directly preceding the illness ? If so, the type of fever common to the foreign parts visited must be kept in mind. Are other members of the family, or fellow workers similarly affected ? If the latter, Weil's disease should be considered as an. industrial hazard; in this country minor epidemics have been reported among sewer labourers, coal miners, bargemen, fish workers, and tripe makers and it is important to realize that more than half the cases are not jaundiced. Usually the disease has an abrupt febrile onset followed by marked prostration, muscular pains, evidence of nephritis without oedema, frequently meningismus and marked injection of the episcleral vessels of the conjunctivae' and haemorrhages from various sites, most commonly the nose. Particular attention must be paid to symptoms which cannot be attributed to the pyrexia per se, e.g., cough, dyspnoea, dysuria, or diarrhoea, which may give a direct clue to the particular organ which is diseased. Clinical Examination