Intermittent Fever.

Synonyms:—Ague; chills and fever; fever and ague.

Definition:—That form of malarial fever in which at regular intervals, a complete disappearance of the fever occurs, the temperature falling to, or slightly below the normal point. All the disease phenomena abate and the patient for a short period is in a nearly normal condition of health, except the consequent prostration.

Symptomatology:—The disease exhibits three phases in each of its entire periods. The first of these is the stage of chill, or the cold stage; the second is the stage of fever, or the hot stage—the stage of reaction; the third is the sweating stage; then follows the period of intermission and cessation of all active phenomena. Preceding the phenomena of ague, often for many days, there are malaise with headache, languor, an indisposition to exercise, and general listlessness. The chill occurs more commonly in the early part of the day, from eight to eleven o'clock. As the time of the chill approaches, the patient yawns and stretches, the nails become purple, the skin becomes pale and cold, and the lips blue as the chilliness occurs. The chill increases to rigor, with thirst, trembling of muscles and chattering of the teeth. In some cases the chill is sudden and very pronounced, in others there is but slight chilliness.

Early in the chill the thermometer will show an increase in temperature, and the pulse becomes rapid, small and usually hard. The skin assumes a dull leaden color and is contracted and roughened. For a time the capillary circulation is very imperfect, the respiration is labored and the secretions deficient. The stage of chill may be of but a few moments duration, or it may be prolonged for three or four hours.

While the temperature is rising, during almost the entire time of the chill the symptoms of reaction are not markedly apparent, until the chill abates. As the coldness disappears, the patient becomes cheerful, the respiration becomes free, the skin becomes warm, and finally hot and burning, and the pulse quickens, but is fuller and of better strength. The patient is inclined to be restless, with some irritation of the nervous system. There is pronounced headache, with flushed face and suffused bright eyes; there is nausea and vomiting and the thirst persists. There is deep muscular soreness and sometimes extreme muscular pain. The secretions are locked, the mouth is dry, the tongue dry and often cracked, the urine scanty and of a dark color, usually without sediment, and the bowels are constipated.

This stage lasts for a longer or shorter period, often inversely as the chill was or was not prolonged. Most commonly the chill has abated and febrile symptoms fully developed before noon. The temperature reaches its height at from three to six o'clock in the afternoon and remains stationary for from two to five hours, when the decline occurs. The fall in temperature is abrupt, occurring soon after midnight. The sweating stage lasts through the remainder of the night.

On the decline of the temperature the pain, restlessness and discomfort abate, perspiration begins and all the secretions are restored. The patient falls into a refreshing sleep and awakens after some hours, somewhat weakened, but otherwise in a normal condition. If the disease persists, the chill occurs sooner each day, the reaction is more marked, the temperature is higher, with each recurrence, and the patient becomes debilitated with disordered functions of the nutritive and blood making organs.

Diagnosis:—The marked intermission is the differential diagnostic feature of this disease. The regularly occurring stages are characteristic. Microscopic blood analysis determines the actual presence of the hematozoon.

Treatment:—During the progress of the active stages of the disease, there is but little that can be done for the existing phenomena, and measures directed to these conditions, at that time, have but little permanent influence, unless the cause is removed and the malarial parasite within the system is destroyed. Heat applied at the onset of the chill—a hot bath or a hot footbath, with hot drinks—is of much benefit, and is gratifying to the patient. The indicated remedies however should not be withheld as the total results depend upon their influence.

It is generally acknowledged that quinin is the typical specific antidote to malaria, and to its periodic manifestations. While this is true, there are some errors of common acceptance concerning this remedy which should be corrected, and much concerning its specific application that is not generally known. These errors are: the belief that it is a harmless remedy; that it is an antipyretic; that its efficacy is in proportion to the size of the dose; and finally that it must be given during the progress of the fever or chill, when there is often but little appropriation of the remedy, often only sufficient to irritate the nervous system.

There is no remedy that has more plainly marked specific indications than quinin, or that will give more excellent results, when given in accordance with its indications. If the skin is moistening or soft, the buccal secretions restored, the tongue moist and clean, or inclined to clean, the temperature normal or declining and below 101° F., quinin will be properly absorbed, and will produce its full desired results. In tests quinin destroys the Plasmodium malariae in the proportion of one part to twenty thousand parts of water. Its influence in the system is correspondingly prompt, if properly administered.

Quinin is best given in broken doses. It should be given only during the decline of the fever, or during the intermissions. In mild cases from two to three grains of the sulphate, given five hours before the expected chill and repeated every two hours, until three doses are given, will modify the anticipated phenomena on that day, and will produce marked amelioration if so repeated on the second day, with the entire abatement of the total phenomena on the third day.

The rationale of giving quinin several hours before the expected chill in malaria is in the fact that the chill takes place when the spores of the plasmodium are poured into the blood stream. The organism develops within the erythrocytes and bursts at sporulation. Quinin given at the proper time before sporulation is in the circulation and ready to promptly kill the parasites.

In severe or protracted cases, and in cases where the evil effects of the disease upon the liver and spleen are apparent, I have made the following combination, with most happy results:

These capsules are to be given, one every two hours until three only are taken, beginning as above specified. This is the extreme quantity of ten grains of quinin within four hours. This anticipates the attack and permits the full antiperiodic effect of the agent, which is assisted in its absorption and is greatly increased in its stimulating influence by the capsicum. I have for a long time made it a routine practice to combine from one-eighth to one-fourth of a grain of capsicum with each grain of quinin and I am sure I obtain better results. The leptandrin acts directly, but mildly, upon the liver.

In long standing cases of this form of fever, where the resultant anemia is pronounced, it is good practice to add iron to the quinin in the capsule. From one to three grains of ferrocyanide of iron in persistent or intractable cases will be found of much service. This remedy has, at once, an antiperiodic, stimulant, tonic and restorative influence.

In the treatment of intermittents, in infants, the best course to adopt is the administration of quinin by inunction. As soon as the decline of the temperature is plainly observed from three to five grains thoroughly incorporated in lard or lanolin should be rubbed into the skin of the axillae, groins, and sides of the abdomen. This may be repeated two or three hours before the expected chill, and the course repeated on each successive day for several days.

When in the treatment of any case, the results of this course are apparent, and the phenomena are modified sufficiently or interrupted entirely, from two to three grains of quinin should be given every two or three hours during the entire twenty-four hours. If the appetite has not returned and the digestion is impaired, the quinin should be combined with hydrastis or berberine. If there is extreme atonicity of the gastro intestinal tract, the capsicum should be continued. If the nervous system be enfeebled or prostrated, one-eighth or one-fourth of a grain of nux vomica should be given with each dose of the quinin.

During the stage of congestion belladonna is a remedy of great efficiency. It may be given in doses only short of its marked physiological action. The old writers advised the use of xanthoxylum, and claimed to obtain excellent results. In its influence it occupies a position as a stimulant between belladonna and capsicum. With the advent of the fever, aconite is usually indicated, and in recent cases it should be given in positive doses, throughout the entire progress of the fever. It is a good plan to continue belladonna with the aconite, but in greatly diminished doses.

In patients especially susceptible to the action of quinin, its effects are obtained, without inducing nervous excitement and finnitus aurium, by prescribing it in conjunction with gelsemium. The physicians of the south claim that they obtain all the favorable results of quinin in malarial disorders, and a minimum of unpleasant manifestations, by this combination.

When an attack of intermittent fever has been brought under control, it is necessary to watch for its recurrence, on the seventh, fourteenth, or twenty-first days from the time of the original attack, and any symptom on these days should be promptly met by the indicated remedies.

Strychnin in full doses in the intermission, acts as an antiperiodic in certain atonic cases. Arsenic is thought by some to exercise a beneficial influence in that class of cases where, though the symptoms are not marked, they are persistent and somewhat intractable to ordinary methods. Good results are claimed, both from persistent large doses and from the use of the homeopathic triturations of arsenic.

The ammonium picrate is an active antiperiodic as well as possessing tonic and restorative properties where there are debilitating and exhausting discharges. It will be found useful in those cases in which quinin cannot be tolerated, or where the remedy has failed to accomplish the desired results. In convalescence, iron in some form is demanded, and the use of other restorative tonics will be found necessary. These should be selected with careful judgment and discrimination.

The Eclectic Practice of Medicine with especial reference to the Treatment of Disease, 1910, was written by Finley Ellingwood, M.D.