Remittent Fever.

Synonyms.—Bilious Fever; Estivo-Autumnal Fever; Gastric Fever.

Definition.—One of the divisions of malarial fever in which there is but one revolution of the disease, the hot stage being greatly prolonged and made up of exacerbations and remissions.

Etiology.—The estivo-autumnal parasites already described are the specific micro-organisms that give rise to this form of malaria. The same conditions that favor intermittent fever, predispose to remittent fever.

The severity of the disease depends largely upon climatic conditions, being mild in high and temperate regions, and increases in intensity as we approach the tropics. It prevails more extensively in the fall months, although it is seen during the entire year.

Pathology.—The morbid changes depend largely upon the length of time the disease has existed, and also upon the frequency of reinfection. The pathology does not differ greatly in character from that of intermittent fever, the difference being only in degree.

There is pigmentation of the spleen, liver, and brain, and the blood contains broken-down blood disks or degenerated pigment. The spleen in recent cases is swollen and soft, while in protracted cases, or where there has been frequent infection, it is firm and permanently enlarged.

The liver is dark in color and undergoes similar changes.

The brain is of a dark, almost black, color. Other organs, together with the lymphatic glands and the skin, are deeply pigmented.

Symptoms.—The forming stage is quite variable, and some cases appear suddenly, without any prodromal symptoms; usually, however, there is a more gradual invasion, lasting from two to five or six days.

The first evidence of the disease is a sense of weariness on slight exertion, which, increasing, results in general malaise, loss of appetite, headache, with general aching of the body. The bowels are constipated, the skin dry, and the urine scanty and high-colored. The tongue is coated, there is a bitter taste in the mouth accompanied by nausea, and, as the chill ushers in the disease, vomiting of bilious matter follows.

Occasionally, for twenty-four or forty-eight hours, an intermittent fever precedes the disease.

Cold Stage.—The chill is usually shorter in duration than that of intermittent fever, although, while it lasts, it is quite severe. The nausea which precedes this stage, frequently terminates in vomiting during the chill or as soon as reaction occurs. In the exceptional case, the cold stage can not be recognized from that of the intermittent type.

Hot Stage.—Although the temperature may have been two or three degrees above the normal during the cold stage, with the termination of the chill there is a rapid rise of temperature, often reaching 105° or 106° within ten or twelve hours after the chill. The pulse is full, strong, and bounding; the respiration hurried and uneven; the skin dry, harsh, and constricted; the eyes red and suffused; the face flushed and turgid, and the patient is extremely restless. The tongue is coated with a dirty, yellowish fur; there is tenderness over the epigastrium, and vomiting of bilious material aggravates the patient's suffering. The patient complains of pain in the head, back, and limbs, it being sometimes extremely severe.

The secretions are markedly arrested, the bowels being constipated and the urine scanty, high-colored, and frequently colored with bile. There is restlessness, and, in nervous patients, delirium may ensue, or should there be marked congestion it will be shown by dullness and stupor.

These symptoms continue from ten to twenty hours, when the temperature begins to decline; the pulse is less rapid, loses its full, bounding character, the skin becomes relaxed, and a slight perspiration is noticed about the head, face, and neck; the pain in head and back subsides, the vomiting ceases, and the patient becomes quite comfortable, and frequently drops into a quiet sleep.

This constitutes the period of remission, and usually occurs each day, generally in the morning, although there may be two remissions daily, or they may occur every third or fourth day, resembling a tertian or quartan intermittent.

The time embraced in a remission varies: in one it may be very slight and of short duration, while in another patient it may be quite prolonged, and might even be considered an intermission did not the thermometer show an elevation of temperature.

Following the remission, the temperature again rises with all its accompanying symptoms, and the fever is made up of exacerbations and remissions.

Bilious fever can not be said to run a uniform course. In some, the fever is quite mild, the remission pronounced, and but little, if any, gastric disturbance. In others, as the disease progresses, it loses its remittent character, and merges into a continued fever with typhoid symptoms.

Again, we occasionally meet with cases where there is great congestion of the spleen and liver, and when the remission occurs, there is but little reactive power, the skin becoming relaxed, the patient is bathed with a cold, clammy perspiration, the pulse is small and feeble, the extremities are cold, the breathing shallow and labored, coma appears, and the patient dies during the remission.

Complications.—"Remittent fever is frequently rendered difficult to treat by the existence of some local affection. Irritation of the stomach and duodenum is probably the most frequent complication; the symptoms are, continued nausea and vomiting, tenderness on pressure over the epigastrium, with a feeling, frequently, of insufferable oppression in that region.

"Determination to the brain is also met with in the severer forms of the disease, indicated by symptoms of cerebral excitement, followed by stupor, low delirium, and coma.

"Disease of the liver is also of frequent occurrence in warm climates, most frequently manifested by symptoms of irritation and increased secretion of acrid bile, which produces irritation of the bowels; but sometimes by congestion, the secretion being arrested.

"Various pulmonary affections are met with in this disease, especially bronchitis and pneumonia, of a congestive form."

Diagnosis.—The diagnosis is usually not difficult after one or two remissions. Where the remissions are slight, it might be mistaken for typhoid, although an absence of the eruption, and the much less prostration, should enable one to distinguish the one from the other. When complications occur early in the disease, the symptoms may be so masked as to make a correct diagnosis somewhat difficult.

Prognosis.—The prognosis should always be favorable if the patient be seen early in the disease, or unless grave complications arise.

Treatment.—In simple remittent fever, the object of our treatment will be to lessen the fever, establish the secretions, and lengthen the remission, that we may get the full effect of our antiperiodic, quinine. This is usually accomplished early in the disease, and the patient is convalescent in from four to six days.

To accomplish this end, we select aconite or veratrum, according to the condition of the circulation; aconite for the small pulse, veratrum for the full and bounding pulse, and combine with the sedative gelsemium, where the patient is restless and nervous. This modifies the fever and favors the reception of the quinine during the remission. If there is irritability of the stomach, this can be corrected by small closes of aconite and ipecac, rhus tox., or bismuth and mint water.

As the fever begins to subside, and the tongue and skin become moist, we begin the administration of quinia:

Sulphate of Quinia 15 grains.
Phosphate of Hydrastine 10 grains. M.
Sig. Divide into three powders, and give one every two or three hours during the remission.

The sedative may be continued during the remission, but at longer intervals. With the reappearance of the fever the sedative treatment is given as before, and the antiperiodic the following remission. It is noticed that each exacerbation becomes lighter and the remission more marked, the disease early terminating in health. The more severe cases will need additional study and treatment.

Remittent fever is rendered severe by certain complications, but, if recognized early, can be corrected by a selection of the proper remedies. The complications most frequently found are those of the gastro-intestinal tract, the blood, the respiratory tract, and the nervous system.

Wrongs of the Stomach.—Irritability of the stomach is seen in nearly every severe case of bilious fever, and is recognized by the elongated tongue, which is also pointed and reddened at tip and edges, and by tenderness over the epigastrium. There is nausea, with retching, and neither food, drink, nor medicine is retained with comfort, if at all. Our remedies are not readily absorbed, and if quinia is given, it only adds to the general irritability of the stomach and nervous system.

With this condition we administer,—

Aconite 5 drops.
Ipecac 10 drops.
Water 4 ounces. M.
Sig. Teaspoonful every thirty or forty minutes until relief is obtained.

Where the patient is very nervous, and is startled at the slightest provocation, rhus tox. replaces the specific ipecac. A cold pack to the abdomen materially assists the internal medication. If the fever be very high, the wet-sheet pack or frequent sponging of the body will prove very beneficial.

Atony.—A broad, pallid tongue, with a nasty, dirty coating, pitting where the teeth come in contact, tells of atony and more or less sepsis. With this condition, absorption of remedies and food is as impossible as in the opposite condition of irritability. Here the alkalies will be indicated.

If the coating on the tongue be white but not offensive, sodium bicarbonate, a saturated solution, should be given every hour. If the tongue has a nasty, dirty, moist coating, sodium sulphite is very much the better agent, given in the same way; viz., a saturated solution, every one, two, or three hours.

Where the tongue is not coated, but is full, and the tissues look congested and sluggish, echinacea will be the remedy, while the acids will be given where the tongue is dry and the mucous membranes are red, turning to brown as the disease advances.

Irritability of the Nervous System.—This is seen in the flushed face, bright eyes, and contracted pupils. The patient is restless, does not sleep well, which aggravates the disease and uses up the patient's vitality. This is always attended by high fever. The wet-sheet pack, full doses of veratrum and gelsemium will reduce the force of the fever, and, as the tongue becomes moist, administer five to ten grains of King's diaphoretic powder every five or six hours, as the case may need, and the patient will drop into a quiet sleep, that is sure to be followed by improvement.

Where there is great excitation of the cerebro-spinal centers, as shown by the sharp stroke of the pulse, the sudden starting of the patient, aconite and rhus tox. 10 drops each, to water 4 ounces, teaspoon-fill every hour, answers much better than veratrum and gelsemium.

If there be marked congestion, as shown by the dull, dilated pupil and tendency on the part of the patient to doze; if the pulse be oppressed, the tissues full, and the drowsiness passing to stupor, give

Belladonna 10-15 drops.
Water 4 ounces. M.
Sig. A teaspoonful every hour.

This will be followed by good results. As these various complications are overcome, the disease assumes its remittent form and quinine is again administered. Should there be complications of the respiratory tract, such as pneumonia, bronchitis, and kindred lesions, the treatment should be such as given under their respective heads. The same may be said of any other complication that may arise. We meet the condition by appropriate remedies. During convalescence a proper selection of food will be important, and a tonic, nux vomica and hydrastine, will improve the power of the stomach for digestion.

Pernicious Remittent Fever.—This type so closely resembles the pernicious intermittent fevers, that a separate description is unnecessary.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.