Pernicious Intermittent Fever.
Synonyms:—Congestive chill; pernicious malarial fever; malignant malarial fever; congestive intermittent fever.
Definition:—A sudden, profound, general congestion accompanied with a violent chill and rapid, serious, often fatal prostration exhibiting the phenomena of surgical shock. Relieved by active measures it is apt to recur at the same hour on the second or third day.
Symptomatology:—In one typical case thoroughly studied by the author in an extremely malarial location on the Vermilion river bottoms in Illinois, there were malarial symptoms for several days preceding the attack, with distinct periodical manifestations occurring the same hour on which the congestion occurred at this time. The attack had almost no premonitory symptoms, the onset being abrupt. Within an hour there was marked pulmonary, hepatic, splenic and renal congestion, with some symptoms of cerebral congestion. The heart and respiratory functions failed rapidly, the pulse soon becoming small, thready, easily compressible and very rapid. The temperature was pronouncedly subnormal. There was a sensation as of the coldness of death. This was the only complaint made.
In the reaction which was induced by the most active measures, the temperature did not reach an extremely high point. There was extreme prostration, from which the patient was a long time in recovering.
In some cases there is great distress at first; the patient then becomes lethargic and sensibility is diminished; the skin is damp and very cold, dusky in color, at times almost purple; the pulse is at first full, large and slow, until the prostration is marked, then it increases rapidly and becomes small, weak, thready and easily compressed.
There are three forms of the disease. The Algid form is that described above, with the addition, in some cases, of nausea, vomiting and purging. In the Comatose form the congestion expends, its force upon the brain. There is at first abrupt delirium, followed by deep coma. The constitutional symptoms are as above described, but usually in a modified form. The patient may not rally. In some cases there is a reaction after the first attack, to be followed by a more severe attack, from which the patient is not likely to recover.
In the Hemorrhagic form there will be severe, exhausting, hemorrhages from the mucous surfaces, especially from those of the kidneys and intestinal canal. There is apt to be sudden and severe jaundice.
There are a variety of manifestations in the various cases of this disease; usually there is a besotted expression to the countenance and the patient is careless of the outcome. The deathly coldness comes on early, with loss of muscular control. The tongue is broad and flabby, and is protruded with difficulty. The patient experiences great distress in breathing, and the respiration is short and feeble. Later the intellect becomes confused; he lies upon his back, and slips down into the bed. There is muttering delirium, the pulse becomes weak and intermittent and flutters; the lips are drawn tightly across the teeth, the face assumes a dull leaden hue, the pupils are widely dilated, and the patient dies without reaction.
These congestive phenomena, in a less severe form, are apt to occur during the progress of severe, protracted fevers, which are complicated with malaria, in the latter stages, at regular intervals. This complication has caused the death of patients that could have been restored but for this invasion.
Treatment:—The condition must be promptly recognized. There must be no temporizing or experimenting in the treatment. If possible, the patient should be put at once into a hot bath, the temperature increased to the limit of endurance and sustained at that point until there are signs of a reaction. Atropin and strychnin may be given hypodermically, and other direct stimulants. The patient should be rubbed and flagellated under the water. It is a good plan to add both mustard and salt to the water in the bath in an extreme case, or a hot flush of the physiological salt solution may be given. In the case above referred to, the writer was called in unprepared, while passing the house, a log cabin in the woods. Availing himself of means at hand, a string of red peppers was thrown into a kettle of boiling water, from this, flannel blankets were wrung, cooled to a bearable point and wrapped around the patient, stripped of all clothes. Dry blankets enclosed these, and they were changed when cool. An infusion of the peppers was given internally, with diluted alcohol and tincture of belladonna. The treatment was continued for nearly two hours before reaction began.
Quinin is an important remedy as soon as the reaction has occurred fully, provided the temperature is not high. If there is any case in which large doses are permissible, it is in this first intermission. Our older writers advised the use of from ten to thirty grains at a dose at this time. I am convinced that from five to ten grains, combined with one grain of capsicum, will accomplish equally good results as the larger dose alone, with no danger of untoward effects.
The patient must be closely watched during the entire period of convalescence. The physician must be on the alert for a return of the attack on the second or third day, and again seven and fourteen days later, which must be anticipated by antiperiodics and stimulants.