Part 96

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.

The cure of a congestive chill is one of the most difficult problems 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.