Remittent Fever.
Synonyms:—Bilious fever; bilious remittent fever; estivo-autumnal fever; continued malarial fever; typho-malarial fever.
Definition:—A common form of malarial fever in which the periodical phenomena are similar to those of intermittent fever, but in which, after the onset, the temperature remits only, at a given time each day but does not at any time during its continuance make a complete intermission or reach the normal point.
Etiology:—The specific cause is a malarial parasite peculiar to autumnal fevers, called the estivo-autumnal parasite. The pre-disposing causes are the same as those of malarial conditions in general. It is more active in its development in hot climates. It is milder in its manifestations in temperate climates.
Symptomatology:—The prodromata are much the same as those of ague, with loss of appetite and marked gastric disturbance, usually. The chill is short at the onset, though often severe, the fever will last during the entire cycle, but abates usually after midnight, when there is a mild sweating stage. The temperature which reaches 105 degrees or more at its height, declines to perhaps 100 or 100.5 degrees in the mild cases, and to 101.5 or 102 degrees in the sfevere cases, in the early morning. The remission will continue through the morning hours. At a little before noon there is usually a feeling or depression, followed by slight chilliness and a sudden rise of the temperature which reaches its highest point usually between four and eight o'clock in the evening and remains nearly stationary until after midnight. While the fever is increasing, or high and stationary, there is severe or bursting headache, often nausea and vomiting, with restlessness, and ultimately mild delirium. There is marked soreness on pressure in the epigastrium with a sensation of oppression and distress. The spleen becomes enlarged and tender, and there are often sharp, shooting pains in the region of the liver.
As the disease increases in severity the remissions become shorter and less marked, and the chill is not distinct. As the fever abates the chill disapears, and the remissions are distinctly marked, and prolonged. In extreme or fatal cases the remissions disappear entirely and there is present a high continued fever with all its attendant phenomena and often extreme typhoid development. In the mild cases,—those terminating favorably by resolution—the increasedly marked remission finally becomes a complete intermission, which is prolonged on each successive day, until the fever no longer appears. As the intermission is prolonged, the fever which follows is correspondingly milder, the temperature reaching three, two and a half or two degrees above normal for a period, perhaps, of two or three hours only. During the active stage, the tongue and mouth becomes dry, the lips are dry and cracked, herpes labialis appear early and persist, and if the fever is prolonged there are sordes and other evidences of blood infection and depravation.
The tendency of all cases which have not been aggravated by the preliminary treatment, is toward a termination on the fourteenth day. Cases that are actively physicked, especially with mercury, may abate in three weeks but the usual course is five or seven weeks, if they recover.
Diagnosis:—The character of the remissions will suggest the character of the fever, and its treatment. The diagnosis is confirmed by the presence of the characteristic parasite in the blood, on microscopic examination.
Prognosis:—The tendency of this disorder in cooler climates is toward recovery. In hot climates the disease is more severe but is amenable to treatment, and the prognosis is good if gastro-intestinal irritants are not used in any form. They will almost invariably complicate the case, as these organs are in a condition of greatly increased sensitiveness.
Treatment:—The use of aconite and belladonna at the onset of this fever will be attended with excellent results in nearly all cases. Five drops of specific aconite and ten drops of specific belladonna in four ounces of water may be given in teaspoonful doses every half hour during the height of the fever and every hour or two during its remission. This course will usually be indicated by the character of the fever and the tendency to chilliness. If there is dulness of the mind, with listlessness, dull eyes and dilated pupils, irresponsive to light, delirium will be apt to follow soon, and belladonna must not be omitted. The aconite may be combined with gelsemium if there is much nervous excitement at any time with bright, sharp eyes. With hyoscyamus, if there is extreme restlessness, with some acute delirium and sleeplessness; with small doses of jaborandi, if the secretions are greatly reduced, the mouth and tongue persistently dry, and the skin very dry during the period of high fever.
If, at the onset of this disease, the chill is very severe and prolonged, and the fever is markedly high, with extreme constitutional and nervous disturbance, in patients who have previously been robust and vigorous, a half dram of the fluid extract of jaborandi at one dose, or the hypodermic injection of one-eighth or one-fourth of a grain of pilocarpine will sometimes produce a complete revolution in the symptoms and abruptly abort the disease. I have had this experience and have met others who were enthusiastic at its success. The patient should be kept warmly covered in bed during the sweating stage unless it be too severe. It should not be prolonged to produce exhaustion. If, after two or three hours, the temperature falls to 100 degrees or below, three grains of quinin and one-half grain of capsicum may be given every three hours until the time for the paroxysm on the following day is past. The subsequent treatment will then be adjusted to the indications.
It is seldom, however, that this course can be adopted with impunity.
At the onset of the fever, if the tongue is broad and thick, and coated with a white or dirty white fur, some alkaline preparation must be administered. The soluble citrate of magnesium, the calcined magnesium, or small doses of magnesium sulphate will be beneficial if the bowels have not moved normally. Full doses of the syrup of rhubarb and potassium compound every three or four hours for the first day or two will sometimes be of much more benefit than any other agent.
Bryonia indications are usually present after the third day. These are high fever, with soreness on pressure over gastric or abdominal areas, with acute shooting pains. The aconite may be omitted when this agent is given, unless its indications are too plainly apparent, in which case the remedies may be given in conjunction, but in small dosage. In many cases it is advisable to continue very small doses of aconite throughout the continuance of the fever.
If the mucous membranes become red, the tongue red and pointed, or red at the tip and edges, with a brown coat in the center, baptisia may be added with good results, or the rhus toxicodendron indications may appear. Hydrochloric acid is of service at this time. It may be given in the water the patient drinks, from five to ten drops at a time, four times daily.
After the second week, if the symptoms continue severe and show signs of developing typhoid, the rigid course advised for that fever should be adopted in the treatment of this. This is especially true if the remissions are shortened, or show signs of ultimate effacement, and the period of high temperature is increased in each twenty-four hours.
Toward the end of the first week in mild cases, or the end of the second week in favorable, well managed cases, the period of remission becomes more marked on each successive day until there will be from four to eight hours of remission with a temperature at 100.5 degrees or below. If the condition of the secretions is favorable and the irritability of the stomach has abated, the tongue moist and inclined to clean, quinin may be given early in the remission. I usually give one dose of perhaps three grains of the bisulphate the first day, and if it be well absorbed and there is no gastric or nervous irritability from its use, with no increase of the temperature, I would give two doses, two or three hours apart, on the second day, the first given early in the remission. With favorable results from this, the same course should be repeated on the following day. As the remission becomes more marked, and an ultimate fall of the temperature to the normal occurs, two and one-half grains of quinine should be given every three hours until the hour when an increase of the temperature above 101 degrees is anticipated. If the course is favorable the remedy can soon be continued throughout the twenty-four hours.
The restorative treatment during convalescence will be readily suggested by the indications. Quinin, with small doses of nux vomica and hydrastis canadensis are usually sufficient. If the redness of the tongue and mucous membranes continue, with the general weakness, I have had excellent results from ten drop doses of a mixture of equal parts of the tincture of iron and dilute phosphoric acid every two or three hours in water. This gives us a quickly absorbable form of nascent phosphate of iron which is of great benefit. It may be given in alternation with the quinin and nux.
Intestinal antiseptics may be demanded. These are the sulphite or the sulphocarbolate of sodium, baptisia, and echinacea. I have given hydrogen peroxid in the drinking water continuously, with excellent results. The care of these patients should be a modified form of that advised for typhoid cases, unless the disease assumes that type, when there should be no modification, but the. extreme course advised for typhoid, with prohibition of food, must be adopted. Food should be largely withheld for the first few days until the stomach irritation is allayed. Fruit juices in cold water may be drunk, ad libitum. These may be made from jellies, diluted. Later, buttermilk, whey, a raw egg, and ultimately, if progressing favorably, milk may be administered, with toast.
