the physician can possibly encounter. It is nothing less than the
proposition to remove a perverted state of the blood-vessels which is
dependent upon some influence exerted through a nervous apparatus
whose therapeutics and experimental physiology are imperfectly
understood. While a satisfactory solution of this problem will
probably be a remote achievement in medicine, it was long ago
empirically ascertained that certain {608} agents exercised some
degree of control over the cold stage of febrile attacks. For the most
part, these agents are addressed to those perversions of
nerve-function which constitute so important a part of the pathology
of a chill. They are identically the same remedies whose aid we invoke
to allay many other forms of perturbed nervous action. Opium,
chloroform, belladonna, chloral hydrate, and bromide of potassium have
proved more or less valuable, according to the idiosyncrasy of the
patient or the circumstances under which they have been used. I
consider opium the most valuable of these remedies. It should be given
in moderate doses, and preferably combined with chloroform or ammonia,
or, if more expedient to administer per rectum, combined with
solutions of chloral hydrate or bromide of potassium. One-sixth of a
grain of morphia, combined with one-fortieth or one-fiftieth of a
grain of atropia, is an available and useful prescription when given
hypodermically. Rubbing the extremities or the spine, or indeed the
whole surface, with ice, is a mode of practice well worthy of
attention. In the event of inability to procure ice, douches of cold
water, followed by frictions with coarse towels, may be substituted. I
have used nitrite of amyl by inhalation, but its effects are too
transitory to prove serviceable.
Some practitioners speak highly of alcoholic stimulants. My own
experience has not been favorable to their use. Perhaps their benefits
are altogether restricted to those cases in which previously weakened
heart-function existed. But it is important that alcohol be added in
all those cases of pernicious malarial fever, whatever the type may
be, where cardiac stimulation and improvement of nutrition are leading
indications.
I am sure I have often derived benefit from enemas consisting of four
ounces of well-prepared beef essence with a half ounce of whiskey or
brandy and a half ounce of strong infusion of coffee.
The value of the hypodermic syringe in treating congestive chills must
never be lost sight of. The suspension, or even reversal, of normal
systemic currents is made evident by the serous vomiting and purging
attending congestion of the abdominal cavity. Medicine placed in the
stomach under these circumstances is virtually thrown away.
The term comatose is applied to certain cases of pernicious malarial
fever because they present coma as a marked symptom. To appreciate the
propriety of this classification, it must be well understood that the
coma present is not due to cerebral congestion. Further than this one
restriction upon the application of the word there is in its
employment no declaration of any pathological views respecting the
cases it is intended to define. While, therefore, the term is
unquestionably liable to criticism, I suppose its use may still be
admitted, provided it is accompanied by a satisfactorily explicit
account of the symptoms and probable pathological conditions of the
cases included under its caption.
There is a sharp line of distinction between the symptoms and
conjectural pathology of comatose cases and of those of the congestive
form of pernicious fever. The following notes of cases will
sufficiently establish this statement:
C. L., fisherman, aged forty-four, brought into Ward 20, Charity
Hospital, in an insensible condition, November 18, 1875. Temperature
at time of admission 104.8°, pulse 120, respiration 40; able to
swallow liquids placed far back in his mouth. Ordered scruple ij of
quinia in {609} solution, ten grains to be given every fourth hour.
Nov. 19th, patient has taken and retained all the quinia ordered; is
perspiring profusely; temperature 97.8°, pulse 88; more conscious;
takes food and water when offered him. Ordered blue mass, comp. extr.
colocynth., _aa_ gr. v, to be taken at once. To drink through the day
bitartrate potass. oz. j, dissolved in lemonade, until bowels are
moved. Evening temperature 99.3°. Nov. 20th, temperature 98°; patient
placed under convalescent treatment; discharged from hospital Nov.
29th.
Another comatose patient was admitted to Ward 19 on the 29th of
October, entirely insensible. He was treated by large doses of quinia
in solution per rectum, and by calomel gr. xx, sodii bicarb. gr. v,
placed upon base of tongue, and caused to be swallowed by a
tablespoonful of water trickled over the powder. As the patient began
to recover it was noticed that his right arm was paralyzed. A history
subsequently obtained showed that the patient was an engineer, and had
been engaged in making some land surveys in a swampy portion of the
State of Louisiana, and had been often obliged to wade or swim across
the bayous and to sleep at night in the open air, sometimes without
any protection from the weather. He had previously enjoyed good
health, and was altogether unable to account for the paralysis of his
arm. During convalescence he was treated with iron, strychnia, and
preparations of cinchona, and by cold douches and frictions to the
paralyzed arm. Convalescence was slow, but he was discharged,
completely recovered, on November 20th.
In typical cases the differential diagnosis between the congestive
form and the comatose is made without difficulty. In a congestive
chill the surface is cold, blue, or livid, the pupils dilated, and the
pulse generally slower than natural and irregular. In the comatose
form the surface is preternaturally warm, of a muddy, semi-jaundiced
hue, and the pulse and temperature both indicate the feverish rather
than the algid state.
The subjects of attacks of the comatose form of malarial fever are for
the most part persons who, having contracted attacks of fever in
malarial regions, continue to reside in the same localities and yet
use no proper medication, either for cure or for prophylaxis. We have
in these cases accumulations of secondary blood-poisons quite
sufficient to greatly impede brain-function, and the additional doses
of the primary toxic agent must exercise more or less influence in
determining the phenomena of the attacks.
Very little need be said of treatment, beyond a recommendation of the
courses pursued in the cases cited. Hypodermic medication must be
resorted to when necessary. Efforts to nourish the patient must never
be relaxed. One must see many of these cases before he can realize how
often they recover, from conditions apparently utterly hopeless, when
promptly treated and properly nourished.
The hemorrhagic form of pernicious malarial fever can scarcely be
regarded as an original type. Malaria is not a hemorrhage-inducing
poison. Indeed, it may be positively stated that malaria never
establishes the hemorrhagic diathesis as a primary effect; and it is
only by changes effected in the human economy by its prolonged
influence that it appears to become capable of doing so. The most
experienced and accurate observers of malarial affections concur in
the opinion that this rule is almost without exception.
{610} The morbid conditions whose concurrence entails upon malarial
fevers a tendency to hemorrhages may be classed together as follows:
First. The blood-changes of chronic malarial toxæmia so alter the
consistency of that fluid as to favor the occurrence of hemorrhage.
Second. The long persistent states of malnutrition in chronic malarial
cachexias produce textural weakening of the vascular walls and
increased liability to their rupture. Third. There should be added to
these one other factor, which is mainly operative during a malarial
paroxysm--namely, the increased blood-pressure put upon the vascular
walls by passive congestions.
Two of these factors, as above enumerated, are more or less general to
the system, being the consequence of general cachectic states. The
third factor acts in a purely dynamical manner in causing hemorrhages,
and must necessarily have its area of influence confined to some
certain portion or portions of the vascular tree, since the
congestions of malarial paroxysms cannot by any possibility be
general. It is an interesting fact that the influence of this
last-mentioned factor is so frequently paramount in producing malarial
hemorrhages. These hemorrhages occur in such immediate relation to
chills that we are forced to the conclusion that while altered blood
and weakened blood-vessels were previously present, yet some increase
of pressure beyond the normal was required to precipitate the
hemorrhage.
More than once in the presence of medical classes I have illustrated
the influence of these various factors, respectively, by showing the
arm of a patient suffering with chronic malarial cachexia, with no
extravasation of blood, but upon which the slightest suction with the
lips would produce exaggerated ecchymoses. This explains the fact that
hemorrhages in malarial fevers are never general, but only manifest
themselves upon those surfaces or into those structures which are the
seats of congestion during the cold stage of an intermittent.
I do most earnestly assert that during a practice of almost half a
century, nearly all of which has been passed in malarious localities,
I have never once seen a malarial-fever patient with a general
hemorrhagic tendency, if yellow fever and other hemorrhage-inducing
diseases could be authoritatively excluded. The medical profession
cannot be too watchful in guarding itself against erroneous entries
upon mortuary records to account for deaths from fevers accompanied by
hemorrhages from multiple surfaces of the body. Such aliases as
hemorrhagic malarial fever, climatic fever, rice fever, hæmatemesic
paludal fever, and many more of the same character, should receive the
severest examination before approval and adoption.
When hemorrhage does attend malarial fevers, it may occur from one or
another of a variety of surfaces or into shut cavities or in
parenchymatous structures. Some years ago I visited a gentleman who
was suffering from an attack of malarial fever, with hæmaturia. He
made a rapid and, apparently, a complete recovery. Disobeying my
injunctions, he returned to the intensely malarious locality where he
had formerly resided. After a few weeks he was seized with a chill,
followed by apoplectic symptoms, hemorrhage, and death on third day.
It is hardly to be doubted that his death was caused by cerebral
hemorrhage. But, however much in consonance with ascertained facts the
foregoing remarks may appear to be, there are certain points of
pathology connected with {611} malarial hemorrhagic fevers not easy of
explanation. Within the last score of years hæmaturia has been a far
more common form of hemorrhage in malarial fevers than formerly. In
many localities and during certain seasons it has been very prevalent.
In the present state of our knowledge it is not at all possible to
explain why it is that different epidemics of malarial diseases should
give rise to such a diversity of phenomena, so that one epidemic will
be characterized by a peculiar train of symptoms which shall be absent
in another, being there replaced by different symptoms equally
distinctive of the second epidemic. Whatever may be the cause of these
epidemical peculiarities, it must rest in a something which is capable
of acting as a force upon the human system. We must think of that
unknown agency which exercises this force and gives it some peculiar
direction as possessing at least a conventional essentiality. It is
not satisfactory to say that the renal blood-vessels are the first to
give way, because they are accidentally more weakened than other parts
of the vascular system, or accidentally more often the seat of
congestion. When accidents become as numerous as these cases sometimes
are, they acquire the authority of laws.
The following notes of two cases of malarial hemorrhagic fever may be
found of interest:
C. E., aged twenty-six years, was admitted to Ward 19, Charity
Hospital, Nov. 18, 1872. Had been in America more than a year, and for
several months had been working in an intensely malarial district
preparing the bed of a railroad; has had malarial diseases for several
months, and suffered a severe chill the day before admission. A few
hours after admission temp. 103°, pulse 120, respiration 29; effusion
in both thoracic cavities, and very marked in abdominal cavity; lower
lobe of right lung oedematous, legs anasarcous, pitting greatly on
pressure, with several ulcers of long standing. Urine loaded with
albumen and showing under the microscope abundant blood-corpuscles;
considerable jaundice present, which the patient states to have
occurred suddenly. Ordered five grains each of calomel and bicarbonate
of sodium, to be followed after catharsis with ten grains of quinia in
solution every two hours. Nov. 22d, patient has taken and retained one
hundred and eight grains of quinia; secretion of urine abundant; no
blood present, and only a trace of albumen; ordered twenty drops of
tincture of chloride of iron three times daily. Discharged cured
December 12th. The above comprises the whole treatment in this case,
except one important measure, which consisted in determined and
persistent efforts at forced nutrition. Meat essences, milk, eggs, and
milk-punch were given as methodically as drugs.
H. K., fifteen years of age, was admitted to Charity Hospital Sept.
15, 1872; has a history of malarial poisoning for several months; was
considerably jaundiced at time of admission, with anasarcous legs.
Under the administration of a mercurial, followed by quinia and iron,
he improved so greatly that he was discharged from my wards and placed
upon some duty in the hospital. Dec. 19th, at 11 A.M., had a chill
which lasted several hours; this was followed by violent fever, with
rapid but compressible pulse; much jactitation; incessant vomiting of
a greenish-black fluid; urine loaded with blood; and sudden
supervention of intense jaundice. Ordered quinia gr. xij by hypodermic
injection; {612} small doses of calomel and soda to be placed upon the
base of the tongue and washed down with ice-water. Secretion of urine
ceased on the morning of the 20th, followed by death at 11 P.M.
Autopsy showed both kidneys dark-colored and swollen from complete
blood-engorgement.
The treatment of hemorrhagic malarial fevers may be included under the
following indications:
First, to secure cinchonism as early as possible;
Second, to arrest the extravasation of blood;
Third, to sustain the patient's strength, and to preserve the systemic
fluids at as near a healthy standard as may be possible.
The first-mentioned indication is certainly the first in importance.
If the hemorrhage originates during a chill, or exhibits degrees of
aggravation in such close relation to the cold stage of malarial
paroxysms as to point to a relation of cause and effect, then that
course of treatment which breaks the recurrence of paroxysms will at
the same time mitigate the hemorrhage, if, in truth, it should fail to
stop it entirely. Quinia should be given in large doses by the mouth
or rectum, or both, or subcutaneously if demanded by the urgency of
the symptoms. I have generally used carefully prepared solutions of
the sulphate for hypodermic injections, but many practitioners prefer
solutions of the hydrobromate for this mode of exhibition. I have
never witnessed any symptoms following the administration of cinchona
salts which justified a belief that they increased the hemorrhage. My
rule of practice has invariably been to endeavor to prevent the
occurrence of another paroxysm, without regard to this very
questionable charge.
In regard to the second indication, it may be stated that patients are
not likely to die from actual loss of blood in any form of hemorrhagic
malarial fever. The blood which is poured out on free surfaces and
escapes by some outlet is seldom so much as to endanger life, but the
hemorrhagic process is likely to involve deeper-seated vessels. This
is especially true in malarial hæmaturia. Hemorrhages into the stroma
of the kidneys, the Malpighian tufts, and the uriniferous tubules
arrest urinary secretion, and thus entail death. In order to prevent
these results hæmostatics should be resorted to as often as attendant
circumstances will permit. Generally these are such as to admit of the
use of hæmostatics without prejudicing the effects of other remedies.
In my experience ergot in combination with gallic acid and dilute
sulphuric acid has been very efficient. The following prescription has
been usually given:
Rx. Ext. Ergot. Fluid. fl. drachm iv;
Acid. Gallic. gr. xl;
Acid. Sulphuric. dil. fl. drachm j;
Syr. Zingiber. fl. drachm iij;
Aquæ q. s ad fl. oz. ij. M.
S. Dessertspoonful every four hours, diluted with water.
Some practitioners place a very high estimate upon the hæmostatic
effects of turpentine. This is undoubtedly a most valuable and
accessible remedy. Dr. Schnell of Plaquemine Parish, La., has found
the tincture of chloride of iron the best hæmostatic. He places fl.
drachm ij in fl. oz. iv of water, and directs a dessertspoonful every
hour as long as the hemorrhage continues. In a great majority of cases
of malarial hæmaturia occurring under my observation solutions of
bitartrate of potassium have {613} been given with great apparent
benefit. Its action is certainly not that of a direct hæmostatic, but
by setting up currents through the kidneys, and perhaps by some
solvent power over exudations in the uriniferous tubules, it has acted
as a renal deobstructive.
In the arrest of renal secretion diuretics, cupping over the lumbar
region, and large injections of warm water into the bowels may be
resorted to. Some practitioners state that they have found buchu
beneficial.
The third indication involves a twofold duty. One relates to judicious
and vigilant attention to the patient's nutrition; the other relates
to such measures for depuration as may be called for in each
particular case.
It must be admitted that there is a degree of antagonism in the
measures of practice proper to effect these two purposes, which
renders their coincident exercise a difficult practical question. In
many cases of hemorrhagic malarial fever a competent supply of
properly prepared foods is sufficient. In other cases--and this is
especially true of malarial hæmaturia--depurative medication becomes
paramount. A person suffering under the effects of chronic malarial
poisoning is seized with a chill; this is followed by bloody urine,
and in the course of four or five hours intense jaundice appears.
Incessant vomiting, delirium, and jactitation also occur. The
experienced physician is at once brought to the conclusion that he has
to deal with a case of blood-poisoning bearing a close resemblance in
symptoms to uræmia. To render this conclusion still more absolute, he
has only to recall the suddenness of the occurrence of the jaundice
and to inquire what has occasioned it. Its appearance is too rapid to
permit us to ascribe it to obstruction. It is altogether improbable
that it is due to sudden hypersecretion in such pathological states of
the system as are present. If, however, we account for it by saying
that the addition of a new toxic constituent, urea and its congeners,
to an already profoundly poisoned fluid suddenly arrests those
processes which dispose of bile in physiological conditions of the
system, it seems to me that we adopt the most rational theory. It is
then jaundice from lack of consumption. The mere probability of truth
in this theory will impress the practitioner with the great importance
of eliminant practice in these conditions.
Calomel has been the medicine to which I have principally trusted. I
give it merely as a depurative, and not as an alterative. Doses of
from two to ten grains may be repeated at suitable intervals until
catharsis has been produced. Bitartrate of potassium, Seidlitz
powders, or solutions of citrate of magnesia may be also administered
if indicated. After purgation the vomiting is mitigated, if not
altogether relieved. On this account, and because of bettered states
of the system for absorption and assimilation, the way is now clear to
the physician. He can ply his antiperiodics, his properly prepared
sustenance, and his alcoholic stimulants according to the exigencies
of each particular case.
The following propositions may seem not inappropriate in closing this
section:
1st. Attacks of pernicious malarial fever are attended by more danger
to life or subsequent health than simple attacks; therefore more
prompt and energetic efforts should be made to cut them short by
cinchonism.
2d. The blood depravations of pernicious malarial fevers far exceed
those of simple cases; and therefore it becomes a leading indication
of treatment to correct faulty conditions of this fluid as early as
possible. {614} In endeavoring to secure this end assimilable foods,
stimulants, and depurants must have a shifting scale of value
according to the exigencies of each particular case.
3d. The complications of attacks of pernicious fever are far more
important than those of simple forms; and therefore symptomatic
treatment is often urgently required.
4th. Attacks of pernicious fever may be greatly diminished in number
by properly directed treatment of chronic malarial toxæmia, and
especially also by the removal of persons suffering under this
cachexia to non-malarious localities.
Typho-Malarial Fever.
The prefix typho- is properly applicable to a class of malarial fevers
which are complicated by the specific poison which produces typhoid
fever.
This term was introduced into medical nomenclature by Surgeon J. J.
Woodward of the United States Army. His classical paper on this
subject has been published in the _Transactions_ of the International
Medical Congress at Philadelphia in 1876. The following extract from
the proceedings of this congress will show the interpretation of this
term by Woodward:
"On motion of Dr. Woodward, seconded by Dr. Pepper, the following was
adopted as expressing the opinion of the section: Typho-malarial fever
is not a specific or distinct type of disease, but the term may be
conveniently applied to the compound forms of fever which result from
the combined influence of the causes of the malarious fevers and of
typhoid fever."
It follows, therefore, that the term should be so restricted as to
define a disease compounded of the two pathological factors which when
acting separately produce either typhoid or malarial fever.
When understood in this sense, and carefully employed, the term
appears to me unobjectionable. Perhaps, indeed, it may be a convenient
addition to medical nomenclature. If such a name had not been
introduced, we would be forced to speak of these cases of compound
disease as complications. As it is customary to regard the minor or
less important affection as the complicating disorder, we would often
have confusion in determining whether the case should be typhoid fever
complicated by malaria or malarial fever complicated by typhoid. This
term leaves all questions of precedence or predominance in abeyance.
There are no facts, however, which support a conclusion that the
malarial poison is capable of forming combinations with the particular
poisons of other specific fevers and give birth to a new special
poison, which may be perpetuated by successive generations, and thus
produce epidemics of a new but compound disease.
The importance of a proper use of the term typho-malarial implies
co-ordinate care in diagnosing the true nature of the malady it should
define.
It may be said, in brief, that the diagnosis of typho-malarial fever
must rest upon the blending of the symptomatic phenomena peculiar
{615} to each one of the two fevers which enter into combination. In
other words, if the differential diagnosis between the two diseases
when they are distinct is made by contrasting the symptoms peculiar to
each, the compound disease is to be recognized by more or less
positive combinations of these symptoms.