Malarial Remittent Fever.

This disease may be, and by some is, regarded rather as a
modification of intermittent than as a distinct disease ; yet, while evi­
dently due to the same cause and occurring under the same circum­
stances, they present so many distinctive features as to justify their
recognition as two distinct diseases.

Remittent fever is also and more popularly designated bilious
fever, or bilious remittent.

Symptoms.—The disease usually begins quite abruptly, with­
out any warning in the shape of previous indisposition on the part
of the patient ; yet there are instances in which the usual premoni­
tory symptoms of malarial fever are present. The paroxysm begins
with a chill, more or less marked. This chill, like that of simple
intermittent fever, usually occurs in the early part of the day, and
not at night. After the chill occurs the usual fever, which does not
subside ordinarily in six or eight hours, as is the case with simple
intermittent fever, but continues twelve, twenty-four, or even forty-
eight hours. At the end of this time — usually during the night —
there is a marked decrease in the intensity of the fever ; the skin
becomes moist, the pains subside, and the patient usually obtains
repose. This aspect of the case differs, however, from the same
stage of intermittent fever, in that the fever in remittent does not
entirely subside. There is, in other words, no complete disappear-
ance of the fever, although it is so much decreased as to render the
patient quite comfortable. In the one case there is complete inter­
mission of the fever, in the other only a remission, hence the differ­
ence in the names. After a remission lasting from two or three
hours to one or two days, a second paroxysm occurs. In * this
second attack the chill may be less severe than in the first, or even
be entirely absent ; the fever is, however, renewed with as much or
more intensity than at the first attack. Thus a series of paroxysms
may follow, separated by intervals or remissions of irregular dura­
tion. After a time these remissions become less marked, so that
the fever finally assumes the continuous form. This fever lasts two
or three weeks, at the end of which time it often assumes the form
of simple intermittent, or it terminates in a condition, to be presently
described, called typho-malarial fever.

Remittent fever presents marked evidences of constitutional dis­
turbances ; nausea and vomiting are almost invariably present, and
are frequently prominent symptoms. The matters ejected from the
stomach are of a greenish or yellowish color ; there is usually much
pain and uneasiness over the region of the stomach, and consider­
able tenderness, on pressure, at the same spot. Jaundice is a not
infrequent symptom.

The name typho-malarial fever is applied to a condition which
is often the continuation of the remittent fever. The remissions
become less marked, the fever, therefore, more continuous ; while
at the same time the patient’s general condition acquires a similarity
to that presented by typhoid fever. There is, however, no reason
for believing that the specific virus of typhoid fever is present in
these cases ; indeed, we know that the inflammation and ulceration
of the intestine, so characteristic of typhoid fever, are lacking in the
so-called typho-malarial fevers. The symptoms so common in
typhoid fever — the general prostration, impairment of mental func­
tion, delirium, stupor, physical debility — are found in several condi­
tions which are not typhoid fever, but which are usually designated
by a name indicating this resemblance to typhoid. Thus we speak
of a typhoid pneumonia, by which we mean not that the patient has
typhoid fever and pneumonia together, but that he is suffering from
pneumonia (inflammation of the lungs), and has sunk into a state of
nervous prostration and physical exhaustion which is so commonly
observed in typhoid fever. So when we say that the patient has
typho-malarial fever, we mean not that he has both typhoid and
malarial fevers, but that he is suffering from malaria poisoning, and
at the same time has sunk into an exhausted condition similar to that
which is usually found during typhoid fever. It is, of course, pos­
sible that an individual should be affected by the one virus while
still suffering from the other, and thus become compelled to endure
the ill effects of both at the same time ; yet such is not necessarily
the case in typho-malarial fever.

As already indicated, the symptoms of typho-malarial fever
present some of the characteristics of typhoid fever, as well as of
malarial poisoning ; the fever no longer presents remission, but has
become continuous ; the mind previously clear is now affected ; there
is active delirium or passive stupor; the face is dark and flushed, the
head hot, the skin dry and harsh, the tongue brown, heavily coated
and deeply fissured ; the teeth are often covered with sordes. This
change of remittent into typho-malarial fever is apt to occur during
the second week of the disease, and can probably always be averted
by proper care and treatment during the first week. This treatment
consists, like that for all forms of malarial poisoning, first and chiefly
in the use of quinine or its equivalent. If this be promptly done by
the method already indicated in speaking of simple intermittent fever,
it is reasonably certain that the disastrous terminations of the disease
can be avoided. Before the use of quinine, remittent fever was a
formidable disease, of which Charles the Fifth, James the First, and
Oliver Cromwell ars oaid to have died. Even after the develop­
ment of unfavorable symptoms of the disease, such as the disappear­
ance of the remission, and the appearance of the typhoid symptoms,
the chief reliance in treatment must still be upon quinine ; it would
be well to administer five grains of this drug every four hours, until
the characteristic effects are produced upon the ears. If the typhoid
symptoms are so prominent as to demand attention, they must be
treated after the manner described in discussing typhoid fever.
Physicians recognize also a disease known as pernicious remit­
tent fever, also called malignant and congestive. This bears to
simple remittent fever the same relation already described as exist­
ing between simple intermittent and pernicious intermittent fever.
The pernicious remittent fever is simply a more intense attack ; in the
severe cases death may occur during the initial chill, before, there­
fore, any remission has occurred.

Remittent fever, when early recognized and properly treated, is
not a a very formidable disease; under circumstances where it is
impossible to procure quinine in sufficient quantities, the disease is
often fatal. Hence it has acquired a reputation for malignity in those
regions where treatment is of necessity unsatisfactory, and is dreaded
in various parts of the world under various names—African fever,
jungle fever, Hungarian fever, and during our late war, Chicka-
hominy fever.

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