Remittent Fever

The difference in definition between the words remittent and intermittent expresses the clinical distinction between these two forms of fever in a very satisfactory manner.

Remittent fever exhibits oscillations of temperature regulated as to hours of recurrence by laws similar to those which govern the periodic returns of intermittent fever; but there is no complete defervescence of the fever. While the lowest angles of the fever curve approximate the normal body heat more or less closely, they never decline to a standard of apyrexia.

That remittent fever is a malarial disease, produced by a cause identical with that which produces intermittent fever, is well proven by the following facts:

First. Cases occur in close relation with cases of intermittent fever in populations similarly exposed to malaria, and at the same periods of the year.

Second. The two forms of disease are readily convertible, the one with the other.

In non-tropical countries remittent fever cannot be regarded as the natural type of malarial fevers. At least, it may be affirmed that the proportion of cases which begin as remittent attacks is so small that we are warranted in looking upon them as departures from type. In the United States army during the years 1861-66, inclusive, there occurred 286,490 cases of remittent fever. The fatal cases were 3853, being a mortality-rate of 13,450 per 1,000,000 cases. By comparing these statistics with those of intermittent fever recorded in a previous section it will be found that remittent fever is more than twelve times as fatal to life as the simple intermittent forms.

If we accept this view of the pathology of remittent fever, it is of interest to the sanitarian or practitioner to endeavor to arrive at the causes which occasion these departures from type. Some of these are undoubtedly extraneous to the system, and relate wholly to circumstances affecting the malarial poison as a disease-producing agent. Increased quantity of malaria is well understood to enlarge the ratio of remittent cases. There is also strong presumptive evidence supporting the hypothesis that different annual crops of malaria vary in respect to the noxious qualities of this agent. The same presumption relates to all crops produced in certain localities as contrasted with others. Other causes which determine remittent rather than intermittent attacks are personal to patients. They may be classed as follows:

First. Unusual personal receptivity or impressibility to malaria may exist, either because of some constitutional idiosyncrasy or of some state the system at the time of exposure.

Second. Want of timely medical treatment or of proper medical treatment may convert intermittents into remittents.

Third. The rapid occurrence of secondary blood infections, extraordinary in character or amount, may cause the fever to be continuous.

Fourth. The existence of complications, inflammatory in their nature, may change intermittent into remittent attacks.

However various or complex the causes may be which operate to convert intermittent attacks into remittent forms of fever, each one must be supposed to act by disturbing the functions of those centres which preside over the normal physiological and chemical changes of the system.

SYMPTOMS AND DIAGNOSIS.—Attacks of remittent fever are, as a rule, more abrupt in their advent than intermittents. When prodromic symptoms exist, they are similar to those which precede ordinary cases of ague.

The chill is seldom attended by such violent symptoms as the cold stage of intermittents. The duration of the cold stage is also more brief. In a small proportion of cases severe vomiting with large bilious ejections complicate the cold stage. The chill is quickly followed by the hot stage.

The mildest cases of remittent fever are not readily distinguishable from the intermittent forms. In these cases the temperature curves are marked by sharp angles and long tracings between the lowest and highest records. As cases become more decided in diagnosis, and consequently represent higher degrees of departure from the intermittent type, the angles of temperature curves become more obtuse and exhibit a more or less high average range. The accompanying temperature diagram (Fig. 23) shows the thermometric record of an unusually protracted and grave case. The patient was a near relative of my colleague, Prof. Logan, a leading practitioner of New Orleans, and the clinical records may be accepted as altogether accurate. It is somewhat to be regretted that the records of temperature were not begun at an earlier period, but the gravity of the case was not manifest until the continued type of fever was found to exist. The latter part of the diagram illustrates the lapse of the remittent fever into an intermittent. This is so commonly a mode of cure that the practitioner watches with solicitude for increasing oscillations of temperature to announce mitigations of severity in his gravest cases.

FIG. 23.

Temperature chart showing the lapse of a remittent fever into an intermittent.

NOTE.—From the third to the fifteenth day after attack a half drachm of quinia was given daily. Observing no good result, it was omitted until the twenty-ninth day, on which date two doses of eight grains each were administered. On the morning of the thirty-fourth day eight grains were again given; on the thirty-fifth day one scruple was given.

The differential diagnosis of intermittent and remittent fevers may be looked upon as practically unimportant. All cases so near the borderline as to make differential diagnosis a question should receive identical treatment.

There are, however, two other very grave forms of fever which are liable to give trouble in differentiation from remittent fever. These are typhoid and yellow fevers. The sanitary protection of communities exposed to cases of the latter, and also the practical treatment of the sick, call for early and correct differentiation.

But it is only in the early stages of the pathological processes of these affections that difficulties of diagnosis are liable to obtain. The facial expression of patients suffering with remittent is sufficiently characteristic to afford some diagnostic inferences. During the pyrexia the face is flushed and the eyes injected, but the redness is more vivid and the countenance more animated than in either typhoid or yellow fever. It would not be inaccurate to say that, however great may be the flushing or other alterations of the countenance in remittent fever, the natural facial expression is better preserved than in either of the fevers under comparison with it. Sallowness of the skin is an early and almost constant event in remittent fever. It comes on as a secondary manifestation, and appears in a large ratio of cases to bear some relation to the high temperature preceding its occurrence. The icteric hue is seldom intense, indeed very infrequently equalling the orange-yellow of jaundice resulting from obstruction. There is an exception to this statement in those cases in which remittent fever attacks a person already jaundiced. I have seen many cases in which the jaundice preceded the remittent fever, and became more strongly marked after its incursion, particularly in those persons who had remained for some time in a malarial region and suffered repeated attacks. In all cases of remittent fever it seems reasonable to ascribe the more or less jaundiced state to one or both of two factors, viz.—the accumulation of excrementitious material and bile constituents in the blood from primary derangement of its chemistry; and that excessive activity of the liver which the malarial poison appears to induce. Whether the latter mentioned factor results from some action of malaria directly affecting the nutritive processes of the liver, as it does those of the spleen, or whether the altered blood-currents during the paroxysms cause this supposed hypersecretion of bile, we certainly know that to malaria only can we ascribe those fevers which are marked by such peculiar symptoms of biliousness or superabundance of bile as to justify the prefix bilious fever or bilious remittent fever.

The state of the alimentary tract may properly receive notice after these remarks. In the early stages of remittent fever the tongue may be moist and large, and covered with a white or lead-colored or yellowish coat. The edges may be indented with imprints of the teeth. This is Osborne's malarial tongue, and its appearance is worth something in diagnosis.

Later in the progress of remittent fever the tongue may become dry, brown, cracked, and difficult of protrusion, but seldom showing the tremulousness of a typhoid-fever tongue, and differing also from the yellow-fever tongue in the fact that in this disease the appearance of the tongue is usually indifferent as a symptom, except that in advanced stages it is liable to be smeared with blood.

The stomach is irritable from the very beginning of an attack, and the acts of emesis are generally in striking contrast with those of typhoid or yellow fever, both in respect to their violence and to the relative amount of bile they eject.

The bowels are ordinarily costive, and when moved by purgatives the stools contrast strongly with those of typhoid or yellow fever by presenting evidences of the bile-coloring principles which attend all excretions in malarial fever, and are found in the urine, the perspiration, and occasionally the sputa.

Some unusually violent cases of malarial fever, which may become remittent, are inaugurated with convulsions, profuse diarrhoea, and coma.

Before closing the remarks concerning the digestive organs in remittent fever I should mention that in the long array of cases I have treated I cannot recall one solitary instance of black vomit. It is, however, true that I have observed hemorrhage from the bowels in quite a number of cases. These occurred late in protracted cases, and were sometimes the cause of death. Whether it be merely a coincidence I am unable to say, but it is true that the majority of these cases have been in young females just after the establishment of the catamenia.

Hemorrhage from the nose is frequent in remittent fever, but I have never seen a case with general tendency to hemorrhage.

The pulse in remittent fever differs from that of the typhoid or yellow fevers by being more synochal in character, firmer, and more resisting to pressure. The longer the duration of the case the less is this characteristic discernible.

The nervous system shows less ataxia. Delirium may occur in any stage of the disease, but differs from the delirium of typhoid and yellow fevers in showing a lessened degree of perversion of the reasoning faculties. The neuralgias have nothing special.

The urine is acid, high-colored, and scanty. I have never found much albumen in the urine of a case of remittent fever, unless there was some other cause to account for its presence. A small amount may be detected during excessive fever. Blood is a rare constituent.

Mild cases of remittent fever should terminate in recovery in from five to seven days. Fatal attacks usually end from the fifth to the tenth day. Many cases pursue a course which lasts from twenty to forty days. Under proper treatment the usual termination is in recovery, either directly or by conversion into the intermittent type.

POST-MORTEM APPEARANCES.—When death occurs in remittent fever the post-mortem changes generally consist of those which are principally due to chronic malarial toxæmia and those ascribable to the acute attack.

Under the former division are permanent enlargements of the spleen and liver, and pigmentary matter in the blood and deposited in various organs. Under the latter are to be classed hyperæmic or even inflammatory states of the stomach and intestines, and those degenerative changes which are the consequence of continuous hyperpyrexia. The post-mortem changes which are so uniformly found as to be most often appealed to in the establishment of diagnoses are enlargements of the liver and spleen. These may be due in part to hyperplasia and in part to blood-engorgement. The brown or slate color of an enlarged liver is strongly diagnostic of malarial affections. It contrasts strongly with the yellow and natural-sized liver of yellow fever and with the negative liver of typhoid fever.

The skin is generally yellow, sometimes quite intensely icteric, but seldom showing the ecchymotic extravasations of yellow fever. In remittent fever we never find the cadaver oozing blood from the nose and the mouth, nor are the stomach or intestines ever found to contain black vomit.

TREATMENT.—The indications of treatment in remittent fevers differ from those of intermittents in two leading essentials.

First. It is a far graver form of fever, and calls for more promptitude and energy in treatment for its successful management.

Second. The important pathological condition to be combated is the hyperpyrexia, and not the cold stage, as in intermittents.

But even with a clear realization of the practical importance of these facts in governing the treatment of remittents, the practitioner must still exercise care and self-control, lest he shall unconsciously adopt the doctrine that inflammatory lesions must be present to occasion such violent pyrexia as often exists. The physician who comes directly from a case of pneumonia or rheumatic fever and finds a patient suffering from remittent fever, with temperature higher and pulse more bounding than those of the patient he has just left, is pardonable for finding it difficult to realize that these furious symptoms are not also associated with inflammation.

Attempts to cure remittent fevers by an exclusively antiphlogistic treatment either result fatally or induce long periods of confinement and suffering before recovery is reached. The great indication is to secure cinchonism as promptly and completely as possible. Nothing should divert our attention from this object. The condition of the patient as it respects fever, delirium, or state of the tongue, should form no bar to the administration of quinia. There are no practitioners who have had much experience in treating these grave forms of malarial fever after this method who are not able to recall the numerous instances of most astonishing and gratifying amelioration of symptoms as soon as saturation with quinia was brought about. The dry tongue becomes moist, the skin is bathed in gentle perspiration, the delirium ceases, and the patient sinks into a quiet sleep.

The amount of quinia necessary to produce cinchonism must be estimated for each particular case according to the measure of its severity or to states of the system more or less favorable to its absorption. It must be borne in mind, however, that questions concerning the patient's safety are paramount to those of economy. In the mildest cases I never trust to a smaller amount than from twenty to thirty grains. In violent attacks I have administered scruple doses every fourth hour until a sufficient test had been made of its capability to arrest or modify the febrile paroxysm. I have never met with any of those exaggerated physiological effects which some observers teach us to fear from the exhibition of cinchona preparations during fever. Certainly, I can declare that no permanent deafness or other lasting lesion of nerve-function has ever occurred under my observation. I must also add that I know of no reasons why remissions afford more favorable conditions for the administration of quinia, beyond the fact that the system is in a better state for its absorption and assimilation. The quinia is preferably given in solution, but may be exhibited in the form of pills, or in powder suspended in black coffee, or in the thick mucilage of the slippery elm.

The considerations of treatment which are naturally connected with those just advocated relate to measures which it may be proper to associate with the quinia. The answers to the two following questions comprise all that is necessary to be said on this point—viz.:

Are conditions of the system present which may interfere with the specific treatment by quinia, and which are not, in themselves, curable by it?

Are any medicines to be given as succedanea to the specific remedy for the purpose of rendering its action more sure or prompt?

In regard to the first inquiry, it must be admitted that in quite a large proportion of cases of remittent fever specific treatment fails to cure. I suppose that may be a reasonable proposition which holds that in the majority of these cases the presence of secondary blood-impurities annuls the ordinary specific effects of cinchona. These must be gotten rid of by depurative medicines. The intestinal canal, the skin, and the kidneys are the emunctories through which elimination must be effected. It is therefore proper for the physician to endeavor to recognize cases where such impurities exist, and to so modify his treatment as to remove them. The indications for depurative treatment are jaundiced skin and eyes, furred tongue, costive bowels, and scanty, loaded urine. These are more or less positively expressed symptoms in a large majority of cases. It is therefore proper that in this large majority of cases of remittent fever depurative treatment should be conjoined with the specific treatment. In my opinion, no drugs meet this indication so well as mercurials and saline purges and diuretics. Calomel or blue mass may be given either simultaneously with the quinia or in alternate doses.

There are three very important rules to be observed in regard to cathartics: They should never be carried to such an extent that absorption of the quinine is interrupted. They should not be given in such large or repeated doses as to produce prolonged irritation, or it may be even inflammation, of the alimentary canal. Purgatives should be used for their depurative effects, and never as antiphologistics.

Opium exercises excellent effects in preventing local irritation or hypercatharsis, and in relieving derangements of nerve-function and insomnia. It is preferably given in small doses, combined either with purgatives or with the quinia.

I have found bitartrate of potassium the most grateful and efficient saline for depurative action. I have generally given it in lemonade in such amounts as to secure a gentle aperient and diuretic effect. I hold strongly to a conviction that all drugs as soluble as this facilitate the absorption of those less soluble—as, for example, of quinia.

If the first efforts to break the febrile paroxysms fail, it is better to discontinue the quinia and place the patient under symptomatic treatment, and await conditions of the system more favorable for its repetition. Of course the high temperature is generally the symptom requiring most care and attention.

Vomiting is one of the troublesome symptoms of remittent fever. As internal medication minute doses of morphia, dry upon the tongue or in solution in cherry-laurel water, or in combination with eight or ten drops of chloroform, are generally efficacious. Swallowing pellets of ice or frequently taking iced effervescing mixtures are good measures of treatment. Occasionally, a mild emetic, such as warm chamomile infusion, or warm water alone, will arrest the vomiting temporarily. It is doubtful, however, whether this relief is secured by the ejection of any offending matter from the stomach. It is more than probable that the forced dilatation of the stomach has arrested the spasms, for filling this viscus with cold drinks to repletion will often effect the same result.

Of all applications to the epigastrium, a cold wet towel occasionally sprinkled with chloroform is the best.

A tympanitic or tender abdomen requires stupes wrung from warm water. They may be dashed with turpentine at first, and afterward consist of warm water with whiskey. I have occasionally given two or three doses of turpentine emulsion with benefit, but from much observation I am forced to protest against the turpentine treatment, as it is called, which is to give twenty drops of turpentine every two to four hours as a curative agent.

Hemorrhage from the bowels must be met by hæmostatic treatment—preferably, in my experience, by the use of five grains of gallic acid in half an ounce of camphor-water every two hours, of morphia subcutaneously, and of cold cloths over the bowels. As in all diseases liable to cause death from exhaustion, careful attention must be paid to the nutriment, and stimulants must be administered as required.