Part 94

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.