Part 98

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.

These blended symptoms should not be expected to exhibit the results of a copartnership in which each member exerts equal influence. It is well understood that when two diseases coincide, that one which is more violent or excessive in its morbid process holds so much sway as in some cases almost to extinguish the symptoms of the weaker member of the combination. Consequently, in typho-malarial fever, the typhoid, being the graver of the two forms of disease, ordinarily rules the pathology.

The following notes, accompanied by a temperature chart, will illustrate the clinical course of a case of typho-malarial fever:

J. L., aged thirty years, of French nativity, but a resident of New Orleans for three years, was admitted to Ward 21, Bed 311, Charity Hospital, on the night of December 10, 1881. Had been ill some days with ague. The house-surgeon administered gr. x. of quinia in solution and gtt. xv. of tincture of opium.

The records and temperature date from the 12th of December. During the 11th he took drachm ij sulph. cinch. in solution.

{617} [Illustration: FIG. 24. PART I., showing the temperature-curve from December 12th to 31st, inclusive, during which time the more characteristic typhoid symptoms predominated. PART II., showing the temperature-curve in same case from January 1st to 20th, inclusive, during which the influence of the associated malarial poison was prominent.]

Dec. 13th, tenderness and gurgling in ileo-cæcal region; epistaxis; rose spots on abdomen; deafness and ataxia; no stools since 11th. Ordered

Rx. Acid. Sulphuric. dil., Syr. Aurantii Cort. aa. fl. drachm ij; Tinct. Cinchonæ Co. fl. oz. j. M.

S. Teaspoonful in water every four hours.

Also ordered beef-essence, milk-punch, and milk.

Dec. 13th, two very offensive liquid stools; ataxia greater; skin yellow and countenance dull and listless. Dec. 14th, fresh rose spots; tongue brown and dry; three stools; much jactitation. Dec. 15th, more ataxia; some delirium; pulse 100, weak. Gave gr. iiss quinia in solution, with tincture opium gtt. iii, every two hours. Dec. 16th, pulse 128, weak; delirious. Dec. 17, new rose spots; belly tympanitic; tongue brown, dry; sordes on teeth and lips; eyes injected; very delirious. Treatment continued; nutrition and stimulants given methodically. From 17th to 22d but little change in condition or treatment. Diet and stimulants administered regularly. Dec. 22d, coma vigil; completely delirious. Ordered