from the intermittent forms. In these cases the temperature curves are
marked by sharp angles and long tracings between the lowest and
highest records. As cases become more decided in diagnosis, and
consequently represent higher degrees of departure from the
intermittent type, the angles of temperature curves become more obtuse
and exhibit a more or less high average range. The accompanying
temperature diagram (Fig. 23) shows the thermometric record of an
unusually protracted and grave case. The patient was a near relative
of my colleague, Prof. Logan, a leading practitioner of New Orleans,
and the clinical records may be {601} accepted as altogether accurate.
It is somewhat to be regretted that the records of temperature were
not begun at an earlier period, but the gravity of the case was not
manifest until the continued type of fever was found to exist. The
latter part of the diagram illustrates the lapse of the remittent
fever into an intermittent. This is so commonly a mode of cure that
the practitioner watches with solicitude for increasing oscillations
of temperature to announce mitigations of severity in his gravest
cases.
{600} [Illustration: FIG. 23. Temperature chart showing the lapse of a
remittent fever into an intermittent. NOTE.--From the third to the
fifteenth day after attack a half drachm of quinia was given daily.
Observing no good result, it was omitted until the twenty-ninth day,
on which date two doses of eight grains each were administered. On the
morning of the thirty-fourth day eight grains were again given; on the
thirty-fifth day one scruple was given.]
The differential diagnosis of intermittent and remittent fevers may be
looked upon as practically unimportant. All cases so near the
borderline as to make differential diagnosis a question should receive
identical treatment.
There are, however, two other very grave forms of fever which are
liable to give trouble in differentiation from remittent fever. These
are typhoid and yellow fevers. The sanitary protection of communities
exposed to cases of the latter, and also the practical treatment of
the sick, call for early and correct differentiation.
But it is only in the early stages of the pathological processes of
these affections that difficulties of diagnosis are liable to obtain.
The facial expression of patients suffering with remittent is
sufficiently characteristic to afford some diagnostic inferences.
During the pyrexia the face is flushed and the eyes injected, but the
redness is more vivid and the countenance more animated than in either
typhoid or yellow fever. It would not be inaccurate to say that,
however great may be the flushing or other alterations of the
countenance in remittent fever, the natural facial expression is
better preserved than in either of the fevers under comparison with
it. Sallowness of the skin is an early and almost constant event in
remittent fever. It comes on as a secondary manifestation, and appears
in a large ratio of cases to bear some relation to the high
temperature preceding its occurrence. The icteric hue is seldom
intense, indeed very infrequently equalling the orange-yellow of
jaundice resulting from obstruction. There is an exception to this
statement in those cases in which remittent fever attacks a person
already jaundiced. I have seen many cases in which the jaundice
preceded the remittent fever, and became more strongly marked after
its incursion, particularly in those persons who had remained for some
time in a malarial region and suffered repeated attacks. In all cases
of remittent fever it seems reasonable to ascribe the more or less
jaundiced state to one or both of two factors, viz.--the accumulation
of excrementitious material and bile constituents in the blood from
primary derangement of its chemistry; and that excessive activity of
the liver which the malarial poison appears to induce. Whether the
latter mentioned factor results from some action of malaria directly
affecting the nutritive processes of the liver, as it does those of
the spleen, or whether the altered blood-currents during the paroxysms
cause this supposed hypersecretion of bile, we certainly know that to
malaria only can we ascribe those fevers which are marked by such
peculiar symptoms of biliousness or superabundance of bile as to
justify the prefix bilious fever or bilious remittent fever.
The state of the alimentary tract may properly receive notice after
these remarks. In the early stages of remittent fever the tongue may
be moist and large, and covered with a white or lead-colored or
yellowish coat. The edges may be indented with imprints of the teeth.
This is {602} Osborne's malarial tongue, and its appearance is worth
something in diagnosis.
Later in the progress of remittent fever the tongue may become dry,
brown, cracked, and difficult of protrusion, but seldom showing the
tremulousness of a typhoid-fever tongue, and differing also from the
yellow-fever tongue in the fact that in this disease the appearance of
the tongue is usually indifferent as a symptom, except that in
advanced stages it is liable to be smeared with blood.
The stomach is irritable from the very beginning of an attack, and the
acts of emesis are generally in striking contrast with those of
typhoid or yellow fever, both in respect to their violence and to the
relative amount of bile they eject.
The bowels are ordinarily costive, and when moved by purgatives the
stools contrast strongly with those of typhoid or yellow fever by
presenting evidences of the bile-coloring principles which attend all
excretions in malarial fever, and are found in the urine, the
perspiration, and occasionally the sputa.
Some unusually violent cases of malarial fever, which may become
remittent, are inaugurated with convulsions, profuse diarrhoea, and
coma.
Before closing the remarks concerning the digestive organs in
remittent fever I should mention that in the long array of cases I
have treated I cannot recall one solitary instance of black vomit. It
is, however, true that I have observed hemorrhage from the bowels in
quite a number of cases. These occurred late in protracted cases, and
were sometimes the cause of death. Whether it be merely a coincidence
I am unable to say, but it is true that the majority of these cases
have been in young females just after the establishment of the
catamenia.
Hemorrhage from the nose is frequent in remittent fever, but I have
never seen a case with general tendency to hemorrhage.
The pulse in remittent fever differs from that of the typhoid or
yellow fevers by being more synochal in character, firmer, and more
resisting to pressure. The longer the duration of the case the less is
this characteristic discernible.
The nervous system shows less ataxia. Delirium may occur in any stage
of the disease, but differs from the delirium of typhoid and yellow
fevers in showing a lessened degree of perversion of the reasoning
faculties. The neuralgias have nothing special.
The urine is acid, high-colored, and scanty. I have never found much
albumen in the urine of a case of remittent fever, unless there was
some other cause to account for its presence. A small amount may be
detected during excessive fever. Blood is a rare constituent.
Mild cases of remittent fever should terminate in recovery in from
five to seven days. Fatal attacks usually end from the fifth to the
tenth day. Many cases pursue a course which lasts from twenty to forty
days. Under proper treatment the usual termination is in recovery,
either directly or by conversion into the intermittent type.
POST-MORTEM APPEARANCES.--When death occurs in remittent fever the
post-mortem changes generally consist of those which are principally
due to chronic malarial toxæmia and those ascribable to the acute
attack.
Under the former division are permanent enlargements of the spleen and
liver, and pigmentary matter in the blood and deposited in various
{603} organs. Under the latter are to be classed hyperæmic or even
inflammatory states of the stomach and intestines, and those
degenerative changes which are the consequence of continuous
hyperpyrexia. The post-mortem changes which are so uniformly found as
to be most often appealed to in the establishment of diagnoses are
enlargements of the liver and spleen. These may be due in part to
hyperplasia and in part to blood-engorgement. The brown or slate color
of an enlarged liver is strongly diagnostic of malarial affections. It
contrasts strongly with the yellow and natural-sized liver of yellow
fever and with the negative liver of typhoid fever.
The skin is generally yellow, sometimes quite intensely icteric, but
seldom showing the ecchymotic extravasations of yellow fever. In
remittent fever we never find the cadaver oozing blood from the nose
and the mouth, nor are the stomach or intestines ever found to contain
black vomit.
TREATMENT.--The indications of treatment in remittent fevers differ
from those of intermittents in two leading essentials.
First. It is a far graver form of fever, and calls for more
promptitude and energy in treatment for its successful management.
Second. The important pathological condition to be combated is the
hyperpyrexia, and not the cold stage, as in intermittents.
But even with a clear realization of the practical importance of these
facts in governing the treatment of remittents, the practitioner must
still exercise care and self-control, lest he shall unconsciously
adopt the doctrine that inflammatory lesions must be present to
occasion such violent pyrexia as often exists. The physician who comes
directly from a case of pneumonia or rheumatic fever and finds a
patient suffering from remittent fever, with temperature higher and
pulse more bounding than those of the patient he has just left, is
pardonable for finding it difficult to realize that these furious
symptoms are not also associated with inflammation.
Attempts to cure remittent fevers by an exclusively antiphlogistic
treatment either result fatally or induce long periods of confinement
and suffering before recovery is reached. The great indication is to
secure cinchonism as promptly and completely as possible. Nothing
should divert our attention from this object. The condition of the
patient as it respects fever, delirium, or state of the tongue, should
form no bar to the administration of quinia. There are no
practitioners who have had much experience in treating these grave
forms of malarial fever after this method who are not able to recall
the numerous instances of most astonishing and gratifying amelioration
of symptoms as soon as saturation with quinia was brought about. The
dry tongue becomes moist, the skin is bathed in gentle perspiration,
the delirium ceases, and the patient sinks into a quiet sleep.
The amount of quinia necessary to produce cinchonism must be estimated
for each particular case according to the measure of its severity or
to states of the system more or less favorable to its absorption. It
must be borne in mind, however, that questions concerning the
patient's safety are paramount to those of economy. In the mildest
cases I never trust to a smaller amount than from twenty to thirty
grains. In violent attacks I have administered scruple doses every
fourth hour until a {604} sufficient test had been made of its
capability to arrest or modify the febrile paroxysm. I have never met
with any of those exaggerated physiological effects which some
observers teach us to fear from the exhibition of cinchona
preparations during fever. Certainly, I can declare that no permanent
deafness or other lasting lesion of nerve-function has ever occurred
under my observation. I must also add that I know of no reasons why
remissions afford more favorable conditions for the administration of
quinia, beyond the fact that the system is in a better state for its
absorption and assimilation. The quinia is preferably given in
solution, but may be exhibited in the form of pills, or in powder
suspended in black coffee, or in the thick mucilage of the slippery
elm.
The considerations of treatment which are naturally connected with
those just advocated relate to measures which it may be proper to
associate with the quinia. The answers to the two following questions
comprise all that is necessary to be said on this point--viz.:
Are conditions of the system present which may interfere with the
specific treatment by quinia, and which are not, in themselves,
curable by it?
Are any medicines to be given as succedanea to the specific remedy for
the purpose of rendering its action more sure or prompt?
In regard to the first inquiry, it must be admitted that in quite a
large proportion of cases of remittent fever specific treatment fails
to cure. I suppose that may be a reasonable proposition which holds
that in the majority of these cases the presence of secondary
blood-impurities annuls the ordinary specific effects of cinchona.
These must be gotten rid of by depurative medicines. The intestinal
canal, the skin, and the kidneys are the emunctories through which
elimination must be effected. It is therefore proper for the physician
to endeavor to recognize cases where such impurities exist, and to so
modify his treatment as to remove them. The indications for depurative
treatment are jaundiced skin and eyes, furred tongue, costive bowels,
and scanty, loaded urine. These are more or less positively expressed
symptoms in a large majority of cases. It is therefore proper that in
this large majority of cases of remittent fever depurative treatment
should be conjoined with the specific treatment. In my opinion, no
drugs meet this indication so well as mercurials and saline purges and
diuretics. Calomel or blue mass may be given either simultaneously
with the quinia or in alternate doses.
There are three very important rules to be observed in regard to
cathartics: They should never be carried to such an extent that
absorption of the quinine is interrupted. They should not be given in
such large or repeated doses as to produce prolonged irritation, or it
may be even inflammation, of the alimentary canal. Purgatives should
be used for their depurative effects, and never as antiphologistics.
Opium exercises excellent effects in preventing local irritation or
hypercatharsis, and in relieving derangements of nerve-function and
insomnia. It is preferably given in small doses, combined either with
purgatives or with the quinia.
I have found bitartrate of potassium the most grateful and efficient
saline for depurative action. I have generally given it in lemonade in
such amounts as to secure a gentle aperient and diuretic effect. I
hold strongly to a conviction that all drugs as soluble as this
facilitate the absorption of those less soluble--as, for example, of
quinia.
{605} If the first efforts to break the febrile paroxysms fail, it is
better to discontinue the quinia and place the patient under
symptomatic treatment, and await conditions of the system more
favorable for its repetition. Of course the high temperature is
generally the symptom requiring most care and attention.
Vomiting is one of the troublesome symptoms of remittent fever. As
internal medication minute doses of morphia, dry upon the tongue or in
solution in cherry-laurel water, or in combination with eight or ten
drops of chloroform, are generally efficacious. Swallowing pellets of
ice or frequently taking iced effervescing mixtures are good measures
of treatment. Occasionally, a mild emetic, such as warm chamomile
infusion, or warm water alone, will arrest the vomiting temporarily.
It is doubtful, however, whether this relief is secured by the
ejection of any offending matter from the stomach. It is more than
probable that the forced dilatation of the stomach has arrested the
spasms, for filling this viscus with cold drinks to repletion will
often effect the same result.
Of all applications to the epigastrium, a cold wet towel occasionally
sprinkled with chloroform is the best.
A tympanitic or tender abdomen requires stupes wrung from warm water.
They may be dashed with turpentine at first, and afterward consist of
warm water with whiskey. I have occasionally given two or three doses
of turpentine emulsion with benefit, but from much observation I am
forced to protest against the turpentine treatment, as it is called,
which is to give twenty drops of turpentine every two to four hours as
a curative agent.
Hemorrhage from the bowels must be met by hæmostatic
treatment--preferably, in my experience, by the use of five grains of
gallic acid in half an ounce of camphor-water every two hours, of
morphia subcutaneously, and of cold cloths over the bowels. As in all
diseases liable to cause death from exhaustion, careful attention must
be paid to the nutriment, and stimulants must be administered as
required.
Pernicious Malarial Fever.
Certain departures from the ordinary types of malarial fever are
termed pernicious, because of their great tendency to inflict more
than usual systemic damage and danger to life upon those who suffer
such attacks. The word pernicious is used in its common English sense
of being hurtful or injurious.
It is entirely unnecessary to enter upon a discussion respecting the
propriety of employing this adjective to designate a class of cases of
disease which are primarily due to the same poison which produces
simple intermittent attacks. The extreme hurtfulness and danger of the
attacks to be described in this section, and the awful suddenness with
which they often occasion death, form striking contrasts with the more
typical forms of malarial fever, and appear fully to justify the use
of the qualifying adjective pernicious.
While all these various departures from type to be grouped under the
term pernicious possess the quality ascribed to them, they
nevertheless differ so widely in their modes of inflicting injury that
it seems desirable to arrange them under distinct sub-classifications.
{606} Some cases of pernicious malarial fever preserve the periodicity
of simple attacks sufficiently well to enable one to classify them as
intermittent or remittent in form. But more commonly it is impossible
to determine this classification, and for practical purposes it is
unimportant to attempt to make any such distinction.
The classification which appears to me most true to nature is the
following:
First. The algid or congestive form;
Second. The comatose form;
Third. The hemorrhagic form.
The algid or congestive form occurs more frequently than either of the
others. Its perniciousness is due to an aggravation or sheer
exaggeration of the cold stage of an intermittent attack.
The following brief clinical histories of two cases will serve to
illustrate the symptomatic phenomena of this form of pernicious
malarial fever:
M. S., aged fourteen, had accompanied his father to a malarious
locality in the country, and had remained with him during September
and a portion of October. Shortly after his return I was asked to
visit him because of some unusual symptoms attending a chill. I found
him in a stupor, from which he was with difficulty aroused
sufficiently to be able to swallow a dose of quinia combined with
laudanum. His face was pallid and inexpressive; the skin cool and
moist; extremities shrunken and cold; pulse small, easily obliterated
by pressure, and irregular; tongue large and moist; and pupils rather
dilated.
My second visit was at 12 M., one hour and a half later than the
first. Patient was found in a deep stupor; surface cold; extremities
and face shrunken and blue; pulse barely perceptible; large liquid and
offensive stools occasionally escaped from the bowels without the
consciousness of the patient. Death at 3 o'clock P.M.
Miss H., living in a malarious situation, complained about noon of
September 19th of great cerebral fulness and unaccountable sleepiness
and debility. She retired to her room, and after a few hours' sleep
resumed her household occupations. On the 20th similar symptoms
manifested themselves, but earlier in the day. She again slept for
some hours, but complained of great prostration after the sleep. On
the 21st, about 10 A.M., she complained of a return of the stupor, and
while retiring to her room requested that I should be called if she
did not awake in a better condition. At 1 P.M. she was found
profoundly comatose, with cold extremities and surface and bathed in
perspiration. When I reached her residence at 3 P.M. she had expired.
There is a common belief among non-professional people that the third
congestive chill is necessarily fatal. There is no foundation for this
opinion, except in the fact that when congestive chills are waxing in
their perniciousness the subject is seldom able to survive the third
recurrence if the second or first should not prove fatal.
It is difficult to account for the pathological dissimilarity between
the simple and congestive types of malarial fevers. If we say that
congestive chills are produced by an intensification of those causes
which produce and govern an ordinary chill, we make an explanation
which, however unsatisfactory, represents very nearly the full extent
of our knowledge on this point.
{607} It cannot be admitted that alterations of quantity or quality of
the malarial poison exercise the sole influence in determining the
occurrence of congestive cases. All experienced practitioners
understand that certain constitutional conditions may pervert simple
chills into congestive forms by producing prolongation or aggravation
of the states of congestion always present in ordinary chills.
Weakened cardiac function, from whatever cause, may be reckoned among
these conditions. In these cases the feeble vis a tergo yields readily
to those perturbations of vaso-motor influence which occasion passive
blood-accumulations in the small veins and capillaries. I may say
further, in speaking of the influence of the vaso-motor nerves in
governing the phenomena of a chill, that we know that in congestive
chills the cerebro-spinal system is much less the seat of symptomatic
phenomena than in simple attacks. On the other hand, the organic
system is far more profoundly affected.
However we may account for the perversions of normal circulation
underlying and producing congestive chills, the great degree of injury
they are liable to inflict is so well understood as to awaken the most
serious apprehensions whenever we are called upon to treat them.
Congestion, however occasioned, may destroy life through abolishment
of function by the sheer physical change of infarction, or, again,
through those inevitable consequences which arrested circulation
entails upon the blood. Blood-stasis is followed by separation of its
constituents, and its disqualification as a circulatory fluid in a
degree proportionate to the duration of the stoppage, and probably
also to the actual extent of the passive engorgement. Thence result
the formation of coagula in the congested vessels and deposits of
pigmentary matter. If partial reaction should occur, portions of this
blood-débris may be floated to various parts of the circulatory
system, and give rise to greater or less important alterations of
function.
Among the white soldiers of the United States army from May 1, 1861,
to June 20, 1866, 13,673 cases were diagnosed as congestive
intermittent fever. Of this number, 3370 died, being a mortality-rate
of 23.91 per cent. The aggregate number of malarial cases returned was
1,255,623. It would therefore appear that 1 case in not quite 372 was
congestive in its type, or 1.08 per cent. The late Dr. Cook of
Washington, La., estimated 2 per cent. of his malarial cases to be of
the congestive type. It can scarcely be doubted that the ratio of
congestive attacks is greater in the more southern belts of latitude
than in the middle or northern parts of the United States. Chronic
malarial toxæmia and the enervating effects of long-continued heat
upon the circulation must occasion an increased proportion of such
attacks, but my own observations show slightly more than 1 per cent.
of the cases treated in the Charity Hospital to have been of the
congestive form.