Amongst these are-neuralgic pains; headache; muscular weakness; partial and incomplete paralysis, usually of the lower limbs; and impaired activity, or derangement, of the mind. Senac says, in speaking of the headache: "Patients sometimes declare that the head feels as if it were cleft asunder in the middle." Dr. Mosely says: "Imbecility of mind, as well as of body, is a common consequence of long and obstinate disorders in hot climates; and I have frequently observed that the mind has been greatly impaired after irregular and harassing intermittents; and sometimes a temporary insanity has ensued. This must have been also observed by others; but as far as I know, no person except Sydenham, who was the first that noticed it, has mentioned it as occurring in practice. He says he has often found, when the patients had been extremely debilitated by long continuance of the disease, the doubling of the fits, and repeated evacuations, that they have been seized with a madness, when they began to recover, which went off proportionally as they gathered strength; but that, sometimes, from injudicious evacuations only, it has degenerated into a miserable kind of folly for life." Maillot mentions amongst the effects of the disease noticed amongst the French soldiers in Africa, extreme debility during convalescence, especially in the hot season; and trembling of the muscles, like slight chorea, or like the paralysis of the insane. thinks that neither the type of the fever, nor the intensity of the local irritations, has much influence in the production of these effects.2 Macculloch enumerates a great variety of nervous disturbances and perversions, the result of repeated attacks of marsh fever. Не Another common consequence of long continued periodical fever, or of the chronic lesions to which it gives rise, is an anemic condition of the system. The blood loses its healthy proportion of globules; the gums, lips, and tongue lose their fresh color; and the skin is sallow and pale. [The anemic condition, with a dingy paleness of the skin, and great muscular weakness, was remarkable in the cases of periodic fever, brought to New York from the Isthmus, during the building of the Panama railroad. A few paroxysms of intermittent fever were often sufficient to produce extreme cachexia, and it seems as if the miasm of that region had the force to penetrate far deeper into sources of life, than that produced in more temperate latitudes.] 1 Mosely on Trop. Dis., p. 189. 2 Maillot on Inter., p. 250. CHAPTER VII. MORTALITY AND PROGNOSIS. THE danger attending periodical fever depends very much upon the form which the disease assumes. The purely intermittent and benign variety is never fatal, without some accidental complication. It often entails upon its subjects chronic visceral alterations, which impair the vigor of the system, and which often shorten life, but it is never directly and immediately fatal. The ordinary remittent form is more grave in its character, but still in a very large proportion of instances, it terminates favorably. Of sixty-three cases of periodical fever admitted to the Pennsylvania Hospital, in 1838, 1839, and 1840, six terminated fatally; but three of these belonged to the congestive form, and were received only a short time before death; and in one other case the disease had been greatly aggravated by improper treatment.' Dr. Wilcocks treated one hundred and seventy-one cases of remittent and intermittent fever, in Philadelphia, in 1846, and they all recovered. He does not state the proportion of cases of the two forms. At the hospital of Montluel, of thirteen hundred and fifty-two cases, treated between June, 1822, and December, 1826, one hundred and thirteen terminated fatally. At the military hospital of Bona, in Africa, in twenty-two thousand three hundred and thirty admissions between April, 1832, and March, 1835, there were two thousand five hundred and thirteen deaths, nearly one in nine. Other things being equal, and as a general rule, the gravity and fatality of periodical fever increase as we approach the tropics. "Thus," say MM. Fournier and Begin, "if we examine the endemic diseases of the principal malarious countries, we shall see in Holland, intermittent fevers attacking great numbers of subjects, but generally following a slow march, and giving the physician suffi 1 Am. Journ. of Med. Sci., April, 1842. cient time to combat them. In Hungary, these fevers are more frequently remittent, and complicated with dysentery. The fevers of Italy, in the neighborhood of the Pontine Marshes, have short intermissions, and are frequently complicated with ataxic phenomena." In regard to congestive fever, Maillot makes the following interesting observations and statements. "I do not know," he says, "how the opinion has established itself that pernicious intermittents are readily curable, and that art is almost certain to triumph over them. But, ever since Lautter said that in these diseases the phy. sician is the arbiter of life and death, writers have spoken very lightly of the prognosis of these terrible affections; they have proclaimed their treatment as the triumph of medicine. Certainly, it is a beautiful thing to snatch from an imminent death, to rescue almost from the tomb, a man stricken with a pernicious paroxysm; the danger was so urgent that one has hardly indulged a hope of his patient's recovery, when he is already cured; but deceived by the éclat of similar successes, we have been carried away by our enthusiasm, and have refused to believe in the possibility of reverses, for it has been almost alleged that we had reached mathematical certainty in the treatment of these diseases. But to this enthusiasm, in which we ourselves for a long time participated-to these sanguine anticipations which we should still rejoice to indulge, let us oppose the rigorous impartiality of positive statistical results. In eight hundred and eight-six cases of pernicious fever, observed in 1818 and 1819, at the hospitals of the Holy Spirit, and Saint John in Lateran, at Rome, there were five hundred and forty-five recoveries, and three hundred and forty-one deaths—one death in two and a quarter. In five hundred and eighty-one cases of periodical fever, observed by M. Nepple, fourteen belonged to the pernicious form; six of these terminated fatally. Antonini and Monard, in thirty-nine comatose or apoplectic cases, had nine `deaths; in eighty-six encephalitic cases, they had only eight deaths-unquestionably the most favorable result on record, if they include in this category only cases of the delirious variety. The following is the result of my own experience. I have notes of one hundred and eighty-six cases, belonging to the comatose delirious, and algid varieties, occurring between the first of June, 1834, and the first of March, 1835, thirty-eight of which, about Dict. des Sci. Méd., art. Marais. one fifth, terminated fatally. Seventy-seven comatose cases furnished fourteen deaths, one in five and a half; sixty-one delirious cases furnished twelve deaths, one in five; and forty-eight algid cases furnished twelve deaths, one in four. The mortality varied. with the type in the following manner. Sixty cases of the quotidian type furnished fifteen deaths, one in four; thirty of these were of the comatose form, and gave six deaths, one in five; twenty-one were of the delirious form, and gave five deaths, one in four; and nine were of the algid form, and gave two deaths, one in four and a half. Twenty-seven cases of the tertian type furnished six deaths, one in six, nearly; nine of these were of the comatose form, and gave two deaths, one in four and a half; fourteen were of the delirious form, and gave three deaths, one in five, nearly; four were of the algid form, and gave one death, one in four. Ninety-nine cases of the remittent and pseudo-continued type, furnished nineteen deaths, one in five, nearly; thirty-eight of these were of the comatose form, and gave six deaths, one in six, nearly; twenty-six were of the delirious form, and gave four deaths, one in six, nearly; thirty-five were of the algid form, and gave nine deaths, one in four. "Such is the mean rate of mortality that has attended pernicious fevers at Bona. In localities where the malarious poison is less powerful, it is probable that more favorable results may be looked for; but otherwise, I have reason to believe, from the researches which I have made, that proportions much more encouraging than those just indicated have never been obtained, unless it may have been accidentally. "If now we endeavor to ascertain the modes in which death takes place in periodical fever, we shall find that in the acute forms, the patient is either carried off suddenly, during a paroxysm, or that the paroxysms are prolonged and run into each other, the visceral congestions becoming fixed and being followed by inflammation, and complicated frequently with a typhoid condition. When death does not happen in either of the foregoing modes; when relapses have followed each other in rapid succession; especially when the disease has been neglected, and the irritations feebly combated, there then supervene chronic affections of the digestive tube, engorgements of the abdominal viscera, intractable diarrhoeas, dropsical effusions, etc. "Amongst three thousand seven hundred and sixty-five patients received into the military hospitals of Bona, in the space of fourteen months, there were one hundred and thirty-five deaths, occurring in the following modes. Fifteen hundred and eighty-two cases of the quotidian type furnished forty deaths, one in forty, nearly; of these patients, eight died in a delirious paroxysm; eight, in a comatose paroxysm; three, in an algid paroxysm; one, with jaundice; five, in a typhoid condition; thirteen, with chronic diarrhoea or dysentery; one, with acute dysentery; and one, anemic. Seven hundred and thirty cases of the tertian type furnished twelve deaths, one in sixty-one, nearly; of these patients, three died in a delirious paroxysm; two, in a comatose paroxysm; one in an algid paroxysm; three, with chronic diarrhoea or dysentery; and one each with chronic bronchitis, chronic pneumonia, and marasmus. The quartan type furnished no death. One double tertian had a fatal issue, after six weeks' duration. Seventy-nine cases of the remittent type furnished two deaths, one in a delirious and one in a comatose paroxysm. Thirteen hundred and thirty-two cases of a continued or pseudo-continued type furnished eighty deaths, one in sixteen and a half, nearly; of these patients, five died in a delirious parox. ysm; seven, in a comatose paroxysm; ten, in an algid paroxysm; thirty-one, with chronic diarrhoea or dysentery; three, with acute dysentery; three, with typhoid affections; three, with chronic pneumonia; six, with acute follicular colitis; two, with chronic bronchitis: two, with chronic affections of the heart; and one each, with acute gastro-colitis, encephalitis, encephalic irritation followed by paralysis, apoplexy, acute bronchitis, acute carditis, and maras mus. "To sum up these details, death took place during the paroxysm, in fifty-one cases; in a typhoid condition, in eight cases; from diseases such as occur in non-malarious regions, in fifteen cases; from chronic affections, in sixty-one cases, forty-seven of which were chronic diarrhoeas or dysenteries."" In another place Maillot says: "The prognosis in pernicious fever is always very grave. The principal varieties—the delirious, the comatose, and the algid-give nearly the same mortality. When, notwithstanding large sanguineous depletions, the coma continues profound, and the pulse remains strong and full, although the patient may be bathed in sweat, we have reason to fear a fatal issue. Death may be equally apprehended, if the persistence of the coma is accompanied by a rapid, feeble, small and vibrating pulse. There are comatose cases where the trismus is so strong 1 Traité des Fièvres Intermittentes. Par F. G. Maillot, p. 277, et seq. |