Pernicious Intermittent.

Synonyms.—Congestive Intermittent; Congestive Chills; Malignant Intermittent.

Definition.—An intense intermittent, where the paludal poison is so intense as to rapidly break down the blood, resulting in a local or general congestion which early threatens life.

Etiology.—The etiology is the same as that of the other intermittents.

Pathology.—An examination of the blood shows an abundant destruction of the red corpuscles and the presence of black pigment derived from the coloring matter of the broken-down corpuscles. The red corpuscles are sometimes crenated; but as this is often seen in other fevers, it is not characteristic.

The increase in the pigment is the most characteristic lesion of the blood, and is deposited in the tissues and organs of the body; notably the spleen, liver, kidneys, brain, and spinal cord. The lesion of the spleen is characteristic, which consists of hypertrophy and softening, the contents consisting of dark-colored pulp, or black, bloody fluid. There may be thickening of the capsule of the spleen. Infarcts may occur, followed by abscess or gangrene.

The liver is hypertrophied and softened with extravasation of blood; sometimes there is fatty degeneration. The lesions of the kidneys are also similar; viz., congestion followed by degeneration. The lungs, especially the lower lobes, are engorged, and in the severer forms hemorrhagic infarctions are found.

Symptoms.—The symptoms depend upon the type, there being the algid, comatose, hemorrhagic, gastro-enteric, and icteric.

Algid.—This is commonly called congestive chills. It may be preceded by one or more paroxysms of a simple intermittent, or the first chill shows evidences of great congestion. There is marked prostration from the beginning, and the patient, if he attempts to walk, staggers as though under the influence of intoxicants. The early rigors are followed by extreme coldness of the surface; the pulse becomes small and feeble, breathing more or less labored. The eyes are dull and lusterless; the mind becomes early confused, and the patient answers slowly and with difficulty.

The coldness of the surface gradually increases, and the skin, at first contracted, becomes relaxed, and great drops of cold sweat stand upon the face and body, like transparent beads. The face is now blue, the eyes sunken, and the patient is oblivious to his surroundings. The pulse grows more feeble, respiration becomes labored and slow. The patient slips toward the foot of the bed, and death soon terminates the struggle. The temperature during this severe cold stage, strange to say, is very high. One case which I examined registered 108° about one hour before death.

Where not so severe, the cold stage is followed by reaction, which comes up slowly. The heat of the body is gradually restored, the pulse gains in strength, the mind becomes clear, and reaction is fully established. In exceptional cases reaction is very high, with full, bounding pulse and active delirium, which soon gives way to coma.

Comatose.—This, like the preceding form, may be preceded by one or more paroxysms of simple intermittent, to be followed by a reaction, in which the patient early passes into a comatose condition, resembling apoplexy. The face is but slightly flushed and dusky; the pupils are dilated; breathing is labored, and sometimes stertorous; the coma becomes more profound, and may continue for hours, when the skin becomes relaxed, and the patient breaks out with a profuse perspiration; consciousness is regained, and the paroxysm is over; but after a short intermission there may be another exacerbation equal in severity, or more intense, ending fatally.

Hemorrhagic.—In this form the chill is severe and prolonged, and, with reaction, hemorrhage occurs. The urine is scanty and bloody, while the hemorrhage may take place from the uterus, rectum, mouth, or nose. Ecchymotic spots may appear all over the body. The sallowness of the skin assumes a deeper hue, the icteric color being very marked. There is not so much coma in this form; in fact, the patient usually retains consciousness throughout.

Gastro-Enteric and Icteric.—These forms are more a complication of the other three than separate varieties or types. When these complications occur they render the case more grave.

Diagnosis.—The severity of the different types, as recognized by the grave symptoms, the intense congestion and marked depression, the deathlike coldness and the marked coma, render the diagnosis comparatively easy.

Prognosis.—The prognosis must be guarded; if seen early, and active measures be used, many cases may be saved.

Treatment.—This is the most severe form of malarial fever, and the only variety that is apt to prove fatal, and requires not only prompt, but very active and somewhat heroic measures.

Our first object is to bring about reaction and overcome the great congestion. Stimulants externally and by mouth, and hypodermically, will be the order of treatment. Our patient is deathly cold, arid, to determine heat to the surface, we will order blankets to be wrung out of hot mustard or capsicum water, and envelop the patient in them, at the same time directing hot-water bottles, stove-lids, or, if in the country, hot corn, placed about the body to keep up the heat. While the attendant is getting hot water, utilize the time by rubbing the patient briskly with dry mustard; improve every moment, for your patient's life is at stake.

If the tongue be heavily coated, as in all probability it will, administer an emetic of ipecac or lobelia, to which has been added mustard or capsicum. This may be followed by the old compound cajuput mixture every ten or twenty minutes or an infusion of capsicum.

The stomach is very torpid, however, and remedies are but slowly absorbed, so we give strychnia, one-twentieth grain, hypodermically, or a five per cent solution of camphor and ether. As the system begins to respond to the action of the stimulants, we will administer subcutaneously ten, twenty, or thirty grains of the bisulphate of quinia, and repeat in an hour or two till reaction is fully established. It is always better in these extreme cases to give quinia hypodermically, owing to the slow action of the absorbents.

During the intermission, quinia in somewhat larger doses than in simple intermittent will be given. The nasty, dirty, pasty coating on the tongue, in nearly all cases, shows not only acidity, but sepsis. It calls for sulphite of soda; of a saturated solution we will give a tablespoonful every two or three hours. If there be capillary congestion, which will be shown by dull and dilated pupils, belladonna will be called for, and with this we may combine successfully nux vomica:

From the favorable reports of subcutaneous injections of saline solutions in the stage of collapse in cholera, and from what we have seen of its benefit in surgical collapse, I would suggest its use in the cold stage of this fever.

In the comatose form, the medication should be active. Jaborandi or pilocarpin should be given to establish diaphoresis, reduce the temperature, and overcome congestion; as in the other form, quinia in twenty or thirty grain doses will be used hypodermically.

For congestion of the liver and the spleen, which occurs in all pernicious intermittents, we think of chionanthus and polymnia uvedalia. One drachm of the former and two drachms of the latter to four ounces of water, teaspoonful every one or two hours. Where febrile reaction is intense and delirium active, give,—

Where there is gastric irritation and persistent vomiting, it is well to wash out the stomach by having the patient drink freely of warm water, to which a little ipecac or lobelia has been added.

Wrongs of the Liver and Spleen.—Enlargement of the spleen and congestion of the portal circulation are among the chief characteristics of this disease, and remedies looking to a correction of these wrongs will early be called for. Fortunately these remedies may be combined or alternated with any of the above treatment.

Polymnia Uvedalia.—Where the spleen is enlarged with engorgement of the liver and mesenteric glands, and there is but little or no pain, and the tissues are doughy, uvedalia internally and locally will be the specific. One or two drachms to water four ounces, teaspoonful every three hours. For the external use, either a hot infusion or the ointment may be used, care being taken to rub it in with brisk friction.

Chionanthus.—Where the engorgement of the liver is followed by jaundice, and there is tenderness in right hypochondriac region, chionanthus in five or ten drop doses will effect a cure.

Ceanothus.—This is an agent that acts nicely where there is puffiness of the face, doughy skin, and pain in spleen and liver; two to five drops of ceanothus in water every two or three hours will prove beneficial.

Carduus Marianus.—Those who have read Burnet's little book on "Diseases of the Liver" will prescribe carduus for the big spleen; if the patient is despondent, bordering on melancholy, the indication for its use will be still more pronounced.

Grindelia Squarrosa.—Dr. Webster speaks very highly of this remedy with enlargement of spleen with dyspeptic symptoms of long standing, while Professor Bundy declares that for these enlarged spleens there is a "Balm in Gilead," and that this is found in grindelia squarrosa.

Chelidonium.—Where there is enlargement of the liver, and the skin is of a bronze color, the tongue thick and full and of the same yellowish-green tinge, two drops of chelidonium every three hours will give good results. These remedies are somewhat similar in their action, and two or three may be combined, or two may be given one day and two others the following day, in this way getting the benefit of the entire group.

Excretions from the Skin.—There is a relation between excretion and ague, and remedies that increase the function of the skin, kidneys, and bowels, will prove curative to the disease. There are cases where the ague is perpetuated by the wrong of the skin; if harsh and dry, the proper bath is to be commended. If doughy, or leathery and inelastic, quinine inunction is invaluable.

To be rubbed into groin, axilla, and over abdomen every three or four hours, using considerable friction.

Kidneys.—Where the tissues are full, puffiness under the eyes, broad, thick, full tongue, scanty secretion of the kidneys, acetate of potassium is our best agent. Place half an ounce in four ounces of water, and give teaspoonful every three or four hours, the patient drinking freely of water after each dose.

Cuprum.—Where the skin is of a greenish hue, and the tongue of the same color, the blood is of poor quality and a blood-maker is needed, cuprum will prove curative. One of my first cases of chronic ague, nearly twenty years ago, yielded to the small dose of tincture of copper after all other agents had failed.

Arsenic.—Where the tongue is small, pale, and slimy, and of a bluish cast, and where the pulse is small and feeble, the skin lifeless and inelastic, the small dose of Fowler's solution will be found effective. There may be some structural complications that will need to be corrected before a cure can be effected. An old metritis, giving rise to dysmenorrhea, or menorrhagia, or to an amenorrhea, will continue indefinitely the periodic disease, as will wrongs of the rectum or urethra, and in all these persistent malarias a careful examination must be made, that the offending part may be corrected. The convalescent period must be carefully watched, and any symptoms of a recurrence be met by the judicious use of quinia.

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