Part 99

Rx. Liq. Morphiæ Sulph., Tinct. Digitalis aa. fl. drachm iij; Spts. Æther. Nitrosi fl. drachm ij; Liq. Potass. Citrat. fl. oz. iij. M.

S. Tablespoonful every three hours.

As the oscillations of temperature became more marked, quinia was resorted to, apparently with good effect. The patient was discharged from the hospital Feb. 8, 1882.

It should be observed that after the 14th of December the patient's bowels were rather costive, and the stools occasionally moulded and very {616} dark in color. On the forty-fifth day after admission the patient had a severe chill, followed by a rise of temperature to 104°. This yielded to competent doses of sulphate of cinchonidia.

This was a typical case of typho-malarial fever. The blended symptoms, as well as those special to each disease, are sufficiently exhibited in the clinical account. The presence of typhoid fever was established by the rose spots and the marked nervous symptoms. The typhoid process seems to have been unusually mild in so far as evidence of bowel lesions were made manifest.

The history of the patient before admission, the color of his skin and stools, and the temperature curves gave abundant proofs of the malarial element in the pathology of the case.

Perhaps nothing need be added on the subject of diagnosis. I may, however, remark that I am very cautious in asserting the diagnosis of typho-malarial cases unless the nervous symptoms, positively-marked bowel symptoms, or rose spots are present to vindicate such a decision. The presence of malarial poison may be determined with less difficulty from the previous history of the case and its special symptoms in the early stages of an attack. But if the morbid processes of the typhoid poison are violent, there are likely to be stages of the disease when it is not possible to detect symptoms which indicate the presence of malaria. On the other hand, it is unquestionably true that the typhoid condition, as it is termed, which so often complicates malarial fevers, can very generally be differentiated from true typhoid fever. While certain cases, or even epidemics, of malarial fevers are attended by remarkable adynamia, often manifesting itself from the very incipiency of attacks, it differs widely from that utter nervous ataxia which characterizes typhoid fever. Again, the adynamia of malarial attacks is generally ascribable to some cause not essential to those affections. Imperfect reaction from a chill, long persistent hyperpyrexia, diarrhoea or vomiting, or chronic paludal cachexia, or, it may be, some epidemic influence, may produce it. The ataxia of typhoid fever is part of its morbid process.

Woodward's statistics show that 49,871 cases of fever diagnosed as typho-malarial occurred among the white forces of the United States during the late Civil War. Of this number, 4059 proved fatal, a mortality-rate of 8.13 + per cent. Among the colored troops 7529 cases occurred, with 1301 deaths, a mortality-rate of 17.27. Statistics borrowed from the same excellent authority give the number of cases of unmixed typhoid fever (or fever classed as typhoid without reference to any complication) as 75,368 among the white troops, with 27,056 deaths, a mortality-rate of 35.89. Among the colored troops 4094 cases occurred, and 2280 died, a mortality-rate of 55.68. These figures show very singular comparative results. They prove that typhoid fever as an uncomplicated malady, was four and a half times as fatal among the whites as the same disease when in combination with malarial poison. Among the colored troops typhoid fever was three and a half times more fatal than typho-malarial fever.

It is highly probable that inaccuracies exist in statistics gathered in the confusion of a great civil war, but I am not prepared to say that the conclusions they point to are incorrect. When an acute inflammation is complicated by malaria, its prognosis is rendered more grave. This, no doubt, {618} is due in part to degradations of the fluids of the system by the malarial poison, and in part to the revulsions of circulation during paroxysms. But it does not follow from this fact that the presence of malaria in the blood, or its effects upon that fluid, exercise an unhappy influence upon diseases due to other specific poisons. It may, on the contrary, be ascertained in the future that it modifies the typhoid process, so as to deprive it of some of its most dangerous features.

Further investigations are required to determine the facts in regard to these questions. But it may be premised that if such a conclusion shall ever be reached, it will influence our expectations of cure rather than our practice. If the malarial poison is capable of modifying the toxic effects of the typhoid poison, it must do so in the very formative stages of that affection, if not in its incubative period, so that, having accomplished all the good it is capable of effecting, we may proceed at once to rid ourselves of its presence.

In entering upon the treatment of two diseases compounded in the same patient, if one should ordinarily be amenable to specific treatment, it must certainly be wise practice to endeavor to simplify the case by subtracting that one from its composition. This is more especially true if the treatment does not affect the course of the other disease in any injurious manner. It is therefore proper to begin the treatment of a case of typho-malarial fever by administering large doses of quinia. A scruple may be given every fourth hour, until its effects in eliminating symptoms ascribable to malaria, and also as an antipyretic, have been sufficiently tested. In the early stages of typho-malarial attacks the febrile exacerbations conform to those laws of periodicity which govern uncomplicated malarial fevers. After the first week, or when the typhoid process has become well established, periodic returns of the fever are less plainly observable. It is possible that in some cases in which the typhoid process manifests itself with great severity the temperature curves may be very characteristic of that disease. I am satisfied that the indications for giving quinia to eliminate the malarial element must be based upon the fever curves which mark the case. Perhaps a more frequent application of the thermometer would often exhibit malarial periodicity where it may otherwise remain unsuspected. I know this to be very often the case in pneumonia complicated by a malarial fever.

Whether thorough cinchonism in the early progress of the attack rids the case of symptoms due to malaria or not, only a very few days are likely to elapse before oscillations of temperature call for its repetition.

The typhoid processes require very much the same measures which are applicable in uncomplicated cases of that disease. The stools of the early stages of attacks should not be checked unless excessive, and mercurials and laxatives should be more freely used than in simple typhoid fever. The effects of the malarial fever and of the hyperpyrexia of typhoid fever, when combined, must almost necessarily entail more accumulation of excrementitious material in the blood than would occur either disease existing separately. On this account eliminating treatment is an important indication. When it becomes necessary to check the diarrhoea because excessive or on account of failing strength, diuretics subsequently prove serviceable. Effervescing solutions of potassium or ammonium, lemonade, Apollinaris water, iced tea, strawberry, mulberry, or raspberry juice, are {619} grateful beverages and increase renal activity. The mineral acids may be given during the ulcerative periods of the disease. Insomnia must be relieved by opiates, chloral hydrate, or other hypnotics.

Tympanites should be met by warm stupes, large enemas of warm water with fl. drachm j tincture of asafoetida or fl. oz. j of whiskey. Small doses of turpentine in emulsion are often beneficial.

In the early progress of cases the diet should consist of farinaceous foods, with milk and the pulps or juices of fresh fruits, given either cooked or in their natural state as the physician may determine for each patient. Methodical and forced nutrition becomes necessary at more or less early periods in different cases.

The stools and all ejecta of the sick should be disinfected and disposed of with the same care and for the same purpose as those of unmixed typhoid fever.

{620}

PAROTITIS.

BY JOHN M. KEATING, M.D.

The term parotitis is applied to a condition of painful enlargement of one or both parotid glands, inflammatory in nature, acute in its course, and usually subsiding by resolution, but sometimes ending in suppuration. The different methods of termination, together with certain etiological distinctions, form the basis of a division of the affection into two sub-classes--namely, 1, idiopathic parotitis; and 2, symptomatic or metastatic parotitis. These demand separate consideration.

I. Idiopathic Parotitis.

Idiopathic parotitis, parotitis epidemica, or mumps, as it is variously named, is an acute contagious inflammation of one or both parotid glands, which usually appears but once in a lifetime, and which, although by no means limited to children, is commonly met with between the second year and the age of puberty. In certain exceptional cases the disease affects the submaxillary glands alone.

NATURE.--The undoubted contagiousness of mumps, with the fact of its frequently occurring in extended epidemics, entitles it to a place among the zymotic diseases, from which it differs, however, in the marked disproportion between the local and constitutional symptoms, the former being well developed, the latter but slight or altogether absent.

ETIOLOGY.--While it is more than probable that, like the other diseases of the zymotic class, mumps is due to a contagium that finds its way into the body in the inspired air or with the food or drink, nothing is known of the nature of this infecting principle.

The predisposing agencies are better understood. Age is one of these, the greater number of cases occurring, as already stated, between the second and the fifteenth year. Infants at the breast are almost entirely exempt, and so, too, are individuals advanced in years. In extended epidemics it is not unusual to meet with cases in adults, but it will generally be found on careful examination that these patients have escaped the disease during childhood. Sex exerts some influence, a much larger percentage of males being attacked than females. Epidemics appear more frequently in the spring and fall than at the other seasons of the year, so that cold and dampness of the atmosphere must be looked upon as predisposing causes. Mumps bears a peculiar relation to measles, scarlet fever, and diphtheria, epidemics being apt to occur directly before, during, or immediately after the prevalence of either of these affections, especially {621} the first. The popular idea of mutual protection is entirely without foundation.

Certain peculiarities are presented by the disease in its mode of occurrence and in the duration and intensity of its epidemics. Thus, some localities are visited annually, others only at intervals of thirty years or more; again, one epidemic may last but a few weeks and affect a small number of individuals, while another extends over months and attacks all the children and many of the adults in the affected region.

ANATOMICAL APPEARANCES.--The exact pathological lesion in mumps is obscure, since the trifling nature of the disease and the almost invariable termination in recovery afford no opportunity for post-mortem investigation. According to Foerster, who seems to have made examinations in cases where mumps occurred as one of the accidental complications of other and fatal diseases, the affected gland at first becomes hyperæmic, and is then the seat of serous exudation. It is reddened, swollen, and on section presents a uniform flesh-like, moist appearance, in place of the ordinary granular aspect. The tumor is often greatly increased in size by a simultaneous serous infiltration of the periglandular connective tissue, and occasionally this tissue alone is involved, the gland itself being entirely free from lesion. The great point in favor of this view of the pathology is the rapid and complete subsidence of the parotid swelling by resolution--a termination to be expected only when the inflammatory process stops short of suppuration or fibrinous exudation.

Virchow regards all cases of parotitis as the result of an extension of a more or less malignant catarrh originally affecting the gland-ducts. This is undoubtedly true in some cases, but that it is far from being the rule is proved by the infrequency of parotitis as a secondary complication of catarrhal affections of the mucous membrane of the mouth.