are principally manifested in persons exposed at points of unusually
abundant evolution. The rule of malarial attacks in temperate
latitudes is, that they require repeated exposure to infection for
their production. The long residence of the poison in the system may
render additional doses possible, until a point of saturation is
reached which occasions paroxysmal explosions. In these cases the
period of incubation is reckoned from the first date of exposure, thus
forming the most striking contrast with the incubative periods of the
cases occurring almost immediately after exposure.
Whether the quiescent period after exposure to malaria be long or
short, attacks are seldom abrupt in their announcement. The symptoms
which usually precede pronounced attacks consist, for the most part,
in some derangement of the functions presided over by the organic
nervous system. Derangement of digestion, vitiated taste, coating of
the tongue, loaded urine, and sallow skin are ordinarily found among
the prodromic symptoms. Next in succession come feelings of malaise,
hot and cold flushes, and those neuralgias which precede and attend
malarial paroxysms.
The symptoms of an ordinary or typical malarial paroxysm are so
characteristic, as to be generally readily interpreted. Creeping,
chilly, {593} sensations over the surface, especially along the spine,
yawning, livid coloration beneath the finger-nails, retreat of blood
from superficial capillaries, and that consequent papillary elevation
which is commonly called goose-skin, comprise the earliest symptoms.
Then decided shiverings with chattering of the teeth come on, and the
patient asks for blankets to be heaped upon him and hot applications
to be made, even though the atmospheric temperature may be decidedly
elevated.
Nausea and vomiting are frequent symptoms, no doubt due to the fact
that the portal system of blood-vessels is so often the seat of
congestion during a chill. No intelligent practitioner can watch a
patient during the cold stage of a malarial paroxysm without realizing
how important the attendant congestion is as a pathological state. It
should first be considered that every chill necessarily implies a
condition of congestion in some part of the system. The blood driven
from the surface and extremities must be accounted for elsewhere; and
the amount of blood which is lost from one part of the circulatory
tree must correspond with that accumulated elsewhere. But in treating
of the pernicious forms of malarial fevers this question will again
receive notice.
In our present state of knowledge we are no more able to explain those
perversions of the normal action of the physical forces of the system
which occasion the phenomena of a chill than we are to explain how the
altered circulation in the first steps of an inflammation is brought
about. The theory which Cullen adopted is quite as explanatory and
consistent as any which has been promulgated since his time. According
to this, a state of spasm of the arterioles and capillaries causes the
chill, while the fever is merely the rebound of functions held in
abeyance during the chill.
After a variable length of time there occurs a change in these
symptoms: the patient begins to remove the blankets which covered him;
the face shows signs of returning circulation; the veins of the whole
surface gradually fill again, apparently beyond their normal state.
But the reaction goes far beyond any normal physiological state. The
face becomes flushed and the eyes injected, and the patient complains
of headache, thirst, dryness and heat of the surface; he will not
permit any covering, and constantly shifts his place in the bed in the
hope that some new position may afford him more comfort. Nausea and
vomiting are commonly present. If the fever runs high, delirium is apt
to occur. The thermometer seldom shows a temperature above 105°, but I
have seen 106.5° recorded in the axilla in the hot stage of a paroxysm
of simple intermittent fever.
The duration of the hot stage is different in different cases.
According to Aitken, the mean duration is three to eight hours.
There is a very old and quite well-supported opinion, that the cold
stage is shorter in the quotidian than in the tertian type, and also
that the hot stage is longer in the former than in the latter. It may
certainly be affirmed that in individual cases of either type there is
no fixed relation between the duration of the chill and that of the
hot stage.
The decline of the hot stage begins by the appearance of a gentle
perspiration, limited at first to the forehead, face, and neck. This
gradually extends itself over the surface and increases in quantity
until the whole body is bathed in a profuse sweat. During this period
the {594} patient's symptoms, both subjective and objective, undergo
wonderful mitigation, and, although this stage is usually short, it
often happens that by the time it is concluded a restoration to
ordinary health seems to have occurred.
The sweating stage terminates a malarial paroxysm. The intermission
now begins, and lasts until the inauguration of another paroxysm. The
intermission is longer or shorter accordingly, first, as the paroxysm
occupies less or more time; and, second, as the interval may affect
it. The interval is that period of time which reaches from the
beginning of one paroxysm to the beginning of another. It therefore
furnishes the basis of classification of simple intermittents into the
following forms: quotidian, tertian, and quartan.
Statistics gathered from a great many sources and relating to many
countries and climates indicate that quotidian intermittents are more
common than tertian. It may then be assumed that the natural type of
intermittents is that form characterized by diurnal paroxysms. It must
be remarked, however, that if any natural law does exist establishing
the quotidian as the typical form of intermittent fevers, it is very
often set aside by unknown influences. In certain epidemics the
tertian cases preponderate, and under all circumstances convertibility
may be witnessed between the various forms.
It is probable that the statistics gathered by the medical staff of
the United States Army during the late Civil War afford the most
valuable data which we possess touching these points, in so far as
they relate to this country. During three years of the war 724,284
cases of intermittent fever were recorded, tabulated as follows:
Quotidian, 370,401 cases, 388 deaths--equivalent to 1047 + deaths per
1,000,000 cases.
Tertian, 318,704 cases, 324 deaths--equivalent to 1007 + deaths per
1,000,000 cases.
Quartan, 35,179 cases, 79 deaths--equivalent to 2245 + deaths per
1,000,000 cases.
It has been remarked by several writers that quartan attacks have a
smaller ratio in the Southern States than in other parts of the Union.
My observations on this point have not been sufficiently well recorded
to make them especially authoritative, but they support such a
conclusion.
The morbid anatomy of malarial fevers is more properly discussed in
treating of the graver forms, since the paroxysms of simple
intermittent do not often occasion death.
TREATMENT.--This must necessarily vary with the stage of the paroxysm
and condition of the patient at the time of the first visit.
Let us suppose this to be the incipiency of the paroxysm, or the early
part of the cold stage. However little the danger to life from the
paroxysm of a simple intermittent attack, the practitioner should not
forget that whatever danger does exist is to be ascribed to damages
suffered during or in consequence of the chill. There are few
exceptions to this rule, and those will be noticed presently. With
this fact in view the practitioner's duties are much simplified. He
should first endeavor to remove any complications present which tend
to aggravate the cold stage. If the chill has come on after a full
meal or after eating indigestible food, the stomach should be promptly
emptied; otherwise the cold stage will {595} be prolonged and rendered
more violent. Large draughts of warm water will frequently produce
sufficient emesis. If this should fail, ipecacuanha may be added. The
warm infusion of eupatorium perfoliatum answers well as an emetic,
producing also a laxative effect. But it is disgusting to the palate,
and sometimes prolongs its action beyond desired results. The effect
of an emetic in abridging a chill by revulsive action are uncertain,
and I avoid resorting to them for this purpose alone in simple
intermittents.
The patient's subjective complaints of suffering should receive a due
degree of attention. Additional blankets and warm applications should
be allowed when solicited. I always discourage hot or heating drinks,
except for the purpose just mentioned. I especially oppose alcoholic
stimulants, because they seldom do any good in mitigating the chill,
oftener aggravating the patient's symptoms during the hot stage,
particularly the headache and vomiting, and sometimes directly
occasioning perplexing perturbations. For example, I have seen
convulsions speedily follow a strong brandy toddy given to shorten a
chill.
While the removal of complications is imperatively indicated, it is
also important to use promptly those means which are designed to
modify and shorten the chill. It is a remarkable fact that all the
agents found to be useful for this purpose are such as directly
influence nervous function. Opium in some form enters into all
prescriptions which I have found efficient in modifying a chill. It is
quite efficacious when given alone, but I think its therapeutic energy
and certainty are increased by the addition of other agents of the
same class. I have often exhibited twenty to thirty drops of
chloroform with an equal quantity of laudanum with excellent results.
The tincture of opium may be combined with aromatic spirit of ammonia,
or with bromide of potassium, or with chloral hydrate. In combination
with either of the latter medicines it may be given by rectal
injection. If the stomach is intolerant, or by preference because of
facility of dosage and quickness of effect, the opiate may be given
hypodermically. For this purpose one-sixth to one-quarter of a grain
of morphia may be given, together with one-sixtieth to one-fortieth of
a grain of atropia. It is rarely necessary to repeat the dose
whichever form may be adopted.
After much experience in these methods of mitigating and abridging the
chills of intermittent fever, I feel entitled to say that, whether the
objects be achieved or not, no injurious consequences ensue.
The conditions of the circulatory and digestive organs are not
favorable for the introduction of quinia or of any preliminary
purgative which may be supposed to be necessary, and I therefore delay
their exhibition. It may be excepted, however, that sometimes a very
obstinately irritable stomach or exceedingly vitiated state of the
fluids can be appropriately met by gr. x to xx of calomel.
The hot stage of a simple intermittent seldom calls for medical
interference on account of excessive temperature. If the headache is
very violent or the vomiting troublesome, a subcutaneous dose of
morphia will bring speedy relief. The existence of high temperature
does not contra-indicate its use.
I am in the habit of giving opium in the following combinations:
Rx. Morphiæ Acet. gr. ss;
Liq. Ammon. Acet. fl. oz. iv. M.
S. Two tablespoonfuls every second hour.
{596} Or, occasionally, the following:
Rx. Sodii Bicarb. gr. xx.
Morphiæ Sulph. gr. i;
Aquæ Lauro-Cerasi,
Aquæ Menth. Pip. _aa._ fl. drachm iv. M.
S. Teaspoonful pro re nata.
I do not limit the use of opiates in the hot stage to old and infirm
subjects, as Dickson suggests, but give them in all cases where
vomiting, headache, or other neuralgias are excessive, or where
unusual restlessness and jactitation are present.
The propriety of giving purgatives as a preliminary measure of
treatment during the hot stage must be determined by symptoms
connected with individual cases. In the majority of cases falling
under my care purgatives are avoided. When regarded necessary, gentle
purgation is solicited by administering bitartrate of potassium in
lemonade or by combining mild mercurial doses with antiperiodics when
these latter are resorted to during the fever. In some cases a very
furred tongue, sallow skin, and costive bowels indicate more active
purgatives, which may be exhibited during the febrile stage.
The most important question which relates to medication during the hot
stage is in respect to the administration of antiperiodics. It may be
safely stated that practitioners of this country were the first to
adopt this method of procedure in malarial fevers. Here it has been
well demonstrated that a competent dose of quinia, given during any
part of the hot stage, is so often followed by the defervescence of
the fever that it would be illogical to attribute the change to any
other cause. Sometimes the remedy fails in producing this result; then
excessive physiological disturbances may follow, and perhaps some
general aggravation of the patient's symptoms.
There are four different circumstances, each of which, in my opinion,
calls for the exhibition of quinia during the hot stage, whether the
fever has reached its maximum point or not:
_First._ If the period which has elapsed since the beginning of the
paroxysm is so considerable that further delay might prevent
sufficient cinchonism to intercept the next accession.
_Second._ When the fever is so excessive that quinia should be given
as an antipyretic.
_Third._ When apprehensions exist that the fever will occasion some
complication or accident.
_Fourth._ When the tongue is clean and the state of the system is
favorable to absorption.
The hot stage is not usually favorable to absorption, and consequently
the economical use of quinia must not be attempted. It should be given
in doses varying from ten to twenty grains, preferably in solution. I
may remark that I have seldom failed in getting good results from the
powder or pills if lemonade or some fluid facile of absorption be
given at the same time. The mixtures previously formulated answer this
purpose very well, and at the same time mitigate the disagreeable
physiological effects of the quinia.
Allusion has been made to certain symptoms occasionally connected
{597} with the hot stage which involve danger. Convulsions are among
the most important of these. They occur most often among children, but
occasionally with adults. They should be met by chloroform, cold to
the head, hypodermic injection of morphia, and cupping or leeching if
the face is flushed, the eyes injected, and the carotids pulsating
forcibly.
The sweating stage may be classed with the intermission in respect to
medication. No time should be lost in securing cinchonism. From the
moment the sweating stage announces itself the fluids of the system
begin to resume their normal physiological functions. Absorption from
the intestinal surfaces is again restored, and remedies may be
administered with confidence in their effects.
The question is now no longer whether antiperiodics should be
administered, but how they shall be given. Many practitioners prefer
exhibiting them in one large dose; others think it better to give them
in repeated small doses. I have usually adopted the latter method.
Beginning with the sweating stage, I give three grains of quinia every
hour or two hours, until eighteen grains have been taken. This would
occupy periods of five to ten hours to complete the doses, ordinarily
quite a sufficient length of time to obtain cinchonism before the
advent of another paroxysm. If the physician elects to give his
antiperiodic in one or two large doses, he should not trust to so
small an amount as eighteen grains. Allowance must be made for the
loss incident to the probable over-taxation of the power to dissolve
and receive a large amount into the circulation.
Purgation should not be induced to a sufficient degree to hurry the
quinia off before absorption takes place. Some practitioners favor the
employment of adjuvants to the quinia. Very few of these have appeared
to me to be of service except opium. A very convenient formula is a
solution of quinia in peppermint-water by addition of dilute sulphuric
acid, in such proportions that fl. drachm j of the solution shall
represent five grains of quinia and seven and a half drops of
laudanum.
But, however we may boast of the efficacy of cinchona as the anceps
remedium for malarial diseases, we are forced to admit that it is not
certainly an immediate cure, and very commonly fails in producing a
permanent curative effect. If we could in all cases discern and remove
the impediments to its immediate or temporarily curative action, its
claims to be regarded as a practical specific would be undeniable. It
is probable that these impediments generally rest upon the fact that
either the remedy does not gain admission to the circulation or that
some complication exists not within the range of its therapeutic
action.
The failure of cinchona to cure a malarial attack in such a permanent
manner that it shall not be liable to return is probably owing to the
incompetent action of the drug because of its transitory stay in the
system as compared with that of the malarial poison. Some objections
apply to this theory, because when the succession of intermittent
attacks is broken by quinia and it is continuously administered
afterward, the paroxysms occasionally recur in spite of its presence
in the system. These objections may be answered by pleading that under
these circumstances secondary blood-poisons precipitate the attacks,
and cinchona should not be expected to cure these conditions.
The best methods of practice I know of to prevent a recurrence of
{598} intermittent fever after having interrupted the succession of
attacks are, first, to continue the cinchona for at least forty-eight
hours, giving at least three three-grain doses a day. After this no
medicine need be given except such as may be required to correct
chronic toxæmic states of the system or to act as blood-restoratives
until such time as prodromes of another paroxysm may exhibit
themselves. At the instant when these manifest themselves ten to
fifteen grains of quinia in solution should be taken. In order that no
loss of time should occur in applying this method, I always advise
patients to keep a solution of quinia within immediate reach. The
following prescription has sometimes appeared to effect a permanent
exemption from recurrence of paroxysms:
Rx. Ferri Redacti gr. xl;
Acid. Arseniosi gr. j;
Quiniæ Sulph. gr. xl;
Ol. Pip. Nigr. gtt. x. M.
Ft. pil. No. xx.
S. One pill three times daily.
It seems sometimes to occur that intermittent attacks so impress the
nervous system that they become, like epilepsy, more liable to recur
because of an established habit. I have known chills to occur when the
ears were ringing with quinia. Strychnia fails to arrest them; arsenic
has more value, but frequently fails. Pure nitric acid, properly
diluted, in doses of six to ten drops, given every four to six hours
without regard to the stage of the paroxysm, succeeds more often than
any medication I have ever resorted to.
Before dismissing the subject of the treatment of simple intermittent
fever it may be proper to mention that I have made trials of cure by
carbolic acid, administered by mouth and subcutaneously, and also of
the sulphites, with no results worthy of recommendation.
Remittent Fever.
The difference in definition between the words remittent and
intermittent expresses the clinical distinction between these two
forms of fever in a very satisfactory manner.
Remittent fever exhibits oscillations of temperature regulated as to
hours of recurrence by laws similar to those which govern the periodic
returns of intermittent fever; but there is no complete defervescence
of the fever. While the lowest angles of the fever curve approximate
the normal body heat more or less closely, they never decline to a
standard of apyrexia.
That remittent fever is a malarial disease, produced by a cause
identical with that which produces intermittent fever, is well proven
by the following facts:
First. Cases occur in close relation with cases of intermittent fever
in populations similarly exposed to malaria, and at the same periods
of the year.
Second. The two forms of disease are readily convertible, the one with
the other.
In non-tropical countries remittent fever cannot be regarded as the
{599} natural type of malarial fevers. At least, it may be affirmed
that the proportion of cases which begin as remittent attacks is so
small that we are warranted in looking upon them as departures from
type. In the United States army during the years 1861-66, inclusive,
there occurred 286,490 cases of remittent fever. The fatal cases were
3853, being a mortality-rate of 13,450 per 1,000,000 cases. By
comparing these statistics with those of intermittent fever recorded
in a previous section it will be found that remittent fever is more
than twelve times as fatal to life as the simple intermittent forms.
If we accept this view of the pathology of remittent fever, it is of
interest to the sanitarian or practitioner to endeavor to arrive at
the causes which occasion these departures from type. Some of these
are undoubtedly extraneous to the system, and relate wholly to
circumstances affecting the malarial poison as a disease-producing
agent. Increased quantity of malaria is well understood to enlarge the
ratio of remittent cases. There is also strong presumptive evidence
supporting the hypothesis that different annual crops of malaria vary
in respect to the noxious qualities of this agent. The same
presumption relates to all crops produced in certain localities as
contrasted with others. Other causes which determine remittent rather
than intermittent attacks are personal to patients. They may be
classed as follows:
First. Unusual personal receptivity or impressibility to malaria may
exist, either because of some constitutional idiosyncrasy or of some
state the system at the time of exposure.
Second. Want of timely medical treatment or of proper medical
treatment may convert intermittents into remittents.
Third. The rapid occurrence of secondary blood infections,
extraordinary in character or amount, may cause the fever to be
continuous.
Fourth. The existence of complications, inflammatory in their nature,
may change intermittent into remittent attacks.
However various or complex the causes may be which operate to convert
intermittent attacks into remittent forms of fever, each one must be
supposed to act by disturbing the functions of those centres which
preside over the normal physiological and chemical changes of the
system.
SYMPTOMS AND DIAGNOSIS.--Attacks of remittent fever are, as a rule,
more abrupt in their advent than intermittents. When prodromic
symptoms exist, they are similar to those which precede ordinary cases
of ague.
The chill is seldom attended by such violent symptoms as the cold
stage of intermittents. The duration of the cold stage is also more
brief. In a small proportion of cases severe vomiting with large
bilious ejections complicate the cold stage. The chill is quickly
followed by the hot stage.