Malarial Pernicious Intermittent Fever. 

The ordinary intermittent fever, just described, is rarely attended
with any immediate danger, to life; if there be ultimately any serious
effects from the disease, those effects are traceable rather to the im­
poverishment of the blood and the enlargement of the spleen, than
to the immediate features of the disease. But there are forms of
malarial disease which occur in the same districts where the ordinary
intermittent fever is experienced, that are distinguished by the over­
whelming violence of their onset, which sometimes prove fatal
within a few hours. These forms are variously designated as per-
niciousy malignant and congestive. In the South and West this
variety is commonly termed congestive chills. This pernicious form
of the disease occurs at certain periods in malarial regions, particu-
larly in the lower portion of the Mississippi valley and in some parts
of the banks of the great lakes.

It is extremely important to be able to recognize the malig­
nant character of this disease, more especially since it may be
developed in the course of a simple intermittent fever; that is, after
the patient has had one or more paroxysms of the ordinary variety.
For if anything can be done, it must be done early. It is said that
in the cases of ordinary intermittent, which gradually develop a
malignant character, the different features of the paroxysms are not
plainly marked ; that is, the cold stage is not accompanied by any
pronounced chill, nor the hot stage with so much fever. Indeed,
the patient may pursue his avocation in the intervals between the
paroxysms, and be thrown entirely off his guard, until the malig­
nant character of the disease suddenly manifests itself.

Symptoms.—The symptoms of this affection vary within wide
limits. Unlike the ordinary intermittent, the first paroxysm of the
pernicious variety may occur in the night, as well as by day ; or, as
has been remarked, the malignant feature of the paroxysm may be
unexpectedly developed after the patient has had several paroxysms
of the ordinary variety. Then the skin suddenly becomes extremely
pale and shrunken ; there is usually a cold, clammy perspiration; the
countenance betrays extreme anxiety, which is indicated also by
the nervous restlessness of the patient. In the worst cases, the mind
is at once affected ; the patient becomes either unconscious, and lies
in a state of stupor, or he becomes wildly delirious, has convulsions,
and then passes into a state of unconsciousness. In this state the
breathing is slow and snoring — stertorous, as it is technically
called. If the patient retain consciousness, he complains of intense
thirst and a sensation of extreme internal heat, though his skin, par­
ticularly that of the extremities, is cold and corpse-like. Usually
there is violent vomiting and purging, the matter discharged being
thin, watery and often tinged with blood. The malignant paroxysm
does not always present the same stages of the ordinary attack. It
may be that after this profound chill a febrile reaction will occur,
in which case the fever is apt to be intense. Oftener, however, the
reaction from the cold stage is but partial; the patient’s skin and
extremities become warmer, and he lies in a state of profound pros­
tration, without developing the usual symptoms of the hot stage. In
a large number of cases, indeed, death occurs either during the
cold stage, or before the febrile reaction has been completely estab­
lished. If he survive the first six or eight hours, the chances for
life depend largely upon the probabilities of escaping subsequent
paroxysms. In some cases, especially if proper treatment be
promptly employed, but one such paroxysm occurs; if subsequent
attacks are experienced, they resemble more the ordinary simple
intermittent paroxysms. If a second malignant attack follow, as it
may on the succeeding day, the chances of the exhausted patient
for surviving are correspondingly diminished, and a third attack is
almost invariably fatal.

Cause.—So far as we are at present aware, the pernicious or
malignant form of intermittent fever differs from the ordinary simple
variety in intensity rather than in kind. The same difference is
familiar to us in other infectious diseases; thus we recognize a
malignant form of scarlet fever in which the patient is overwhelmed
in a few hours by the violence of the attack, though he may have
contracted the disease from an individual suffering with the ordinary
form of scarlatina. So, too, we recognize a malignant form of small­
pox, which may be contracted by contagion from simple small­pox.
Inasmuch as pernicious intermittent fever occurs in the same locali­
ties as the simple variety, and since it often begins apparently as a
simple intermittent fever, and its features are merely those of the
simple variety intensified, it seems but reasonable to assume that
the pernicious variety of intermittent fever is merely a more intense
exhibition of the ordinary intermittent virus.

Treatment.— As already indicated, the treatment of perni­
cious intermittent fever is a matter of vital importance, since without
it, a very considerable majority of the cases would doubtless prove
fatal ; as it is, the mortality is probably not greater than one case in
eight.

Much can be done in the way of preventing pernicious fever by
interrupting the paroxysms before they assume the malignant chai-
acter. During the seasons when malignant cases are prevalent, no
time should be lost in arresting every case of intermittent fever, no
matter how simple and light the attack may seem. When the features
of the pernicious attack are developed there are two objects to be ac­
complished by treatment: one, to bring the patient under the influence
of quinine as soon as possible; the other, to induce reaction from the
chill. The latter, it is evident, requires immediate attention ; it is
useless to attempt the administration of quinine while the patient
lies in a state of profound collapse, which usually characterizes the
cold stage \ for medicines introduced into the stomach will not be
absorbed, and even if inserted under the skin by means of a small
syringe, the circulation is so feeble that but little effect could be
hoped for. The measures best adapted for promoting reaction vary
somewhat with the features of the case, but always include stimula­
tion of the skin and of the circulation. Heat may be applied best
of all by putting the patient bodily into a hot bath ; if this be
impracticable, hot bottles or flat-irons may be applied to the feet and
along the spine. The skin of the trunk and its extremities may be
vigorously rubbed with alcohol or brandy containing a little red
pepper ; if there be much vomiting or purging, a mustard plaster
should be applied over the stomach, or indeed over the entire
abdomen. In all such cases it is to be remembered that mustard
blisters, and although blisters would probably not be formed so long
as the patient remains in the collapsed state, yet it must not be for­
gotten, in the excitement of the moment, that the plasters should be
removed when the patient reacts from the chill. These measures
will also serve to stimulate the circulation, which is one of the
objects of the treatment ; this can be furthered by the administra­
tion of alcoholic stimulants in some form—brandy or whisky may
be given; hartshorn may be applied to the nostrils ; if a physician
be in attendance, he will doubtless inject ether or alcohol under the
skin. If the mental symptoms have been prominent from the
beginning, especially if the patient have been unconscious and
stupid, a full dose of calomel—say five grains—may be given at
once. It was in just these cases that the old practice of bleeding
from the arm celebrated its triumphs ; yet in the revulsion which
has followed the abuse of that practice of bleeding, medical men
would to­day scarcely practice or advise this measure. So soon as the
signs of returning heat and strength are manifested, it is desirable to
avoid pushing the stimulation, since the result will be to intensify
the fever that usually follows.

The second object of treatment is to bring the patient under the
influence of quinine, with the hope of preventing a repetition of the
chill, which would otherwise occur on the succeeding day. Five to
ten grains of quinine should be given at once and repeated every
three hours until the usual evidences of its effects — roaring in the
ears — occur. In these cases there should be no trifling with any of
the usual substitutes for quinine, though these may answer well
enough the simple intermittent, for it should be remembered that
unless the patient can be saturated with this drug at once, he will
probably succumb to an attack on the succeeding day. Promptness
and boldness are indispensable for the successful treatment of this
malignant disease ; yet it must be borne in mind, that it is possible to
do damage by excess of quinine, as has been shown by the induction
of long-continued or permanent deafness and blindness.

In addition to the free use of quinine, it may be well to keep
the patient in bed for the next two or three days, especially during
the hours when a recurrence of the paroxysm may be expected.
During these hours the patient should be kept warm by artificial
heat—hot bottles and similar measures — and by hot drinks. A dose
of laudanum, say twenty drops, will be also efficient.

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