1846.]

INTERMITTENT AND REMITTENT FEVERS.

363

had acquired in treating the fevers of India. He tells us how much less successful he had been on some former occasions, when he was in medical charge of native battalions at Seringapatam in 1823, and at Cuddapah in 1826. In the latter instance, out of 955 cases, 20 proved fatal. We must not forget to mention that, at the period alluded to, Quinine had only been lately introduced from Europe, and even the supplies of Cinchona powder were often insufficient to meet the demands. Thus, in one-half of these 955 cases, no bark or quinine was used at all.

There is so much varied and curious information in the following table*—one of several dozens which our author has given in the course of these “Illustrations"—that we have much pleasure in submitting it to our readers as an example of the great pains which Dr. Geddes has expended upon the composition of his elaborate work.

Of the 20 deaths, 17 occurred among the southern Hindoos, and 3 among the Bengalees; while in none of the Mahometans did the disease prove fatal. This was most probably owing in part to the difference of food and greater strength of constitution among the latter, and in part also to the circumstance that they reported themselves more readily sick, and gave a more intelligible statement of their complaints than the poor superstitious Hindoos. The men who suffered were chiefly young recruits; there being but three whose ages amounted to 24 and 25, while thirteen. were only 18 and 20.

In fourteen of the fatal cases, the patients died in a state of delirium or insensibility, supervening upon violent and repeated paroxysms of the fever. In three other individuals, death seemed to be caused by the utter prostration that succeeded to the severe febrile paroxysms, but without the occurrence of any marked cerebral symptoms. In one of the remaining three cases, the patient, who had been affected with vomiting, diarrhoea and slight delirium, sunk just before the expected accession of the cold fit, apparently from a sudden failure of the vital powers. In the remaining two cases death was occasioned, in one by dysentery, and in the other by hectic fever, induced by abscess of the chest. So much for the fatal cases at Cuddapah. With respect to those that occurred at Seringapatam in a battalion of native infantry, 1119 strong, from 15th April 1823, to the 10th March 1824, Dr. Geddes is not able to give a very minute report; but the following are the leading facts. Out of 1503 cases admitted with fever into the hospital, 22 proved fatal.

"In these cases affection of the head was not so prominent as in those above stated. Three individuals only died in delirium or stupor; while another who had suffered from the former affection, eventually sunk by the occurrence of a sloughing ulcer on the loins. In two persons, death took place from the violence of the Fever-one of the cases being attended with cough and much expectoration; five patients died by the supervention of severe Dysentery while in hospital with Fever; and one by the accompaniment of a peculiar disease (Beri-beri) characterised by the lower limbs becoming paralytic, and this ending in dropsy, particularly affecting the cavities of the chest and pericardium. In ten cases the death was occasioned by the result of a chronic state of Fever, or of frequent relapses, in which either a tendency to œdema, or a loose state of the bowels occurred; and frequently both of these symptoms became combined together. By the increase of these disorders, accompanied occasionally by returns of Fever, the patient sunk in an extremely de. bilitated and emaciated condition."-P. 161.

February..
March...
April....

34|| 20
27 25 20

3 1 88 37|| 76 32 75 46

1846.]

TREATMENT OF REMITTENT AND INTERMITTENT FEVERS. 365

In the solitary fatal case, which occurred in the Madras European regiment, the patient died in a state of delirium and stupor after some severe accessions of fever; there had been diarrhoea and occasional vomiting. On dissection the liver was found large and friable; the stomach was filled with a liquid like coffee-grounds; and a few superficial ulcers were observed on the mucous surface of the bowels.

An occasional very troublesome consequence of protracted fever in India is the formation of a peculiar form of Ulcer, that is thus described by our author.

"They commenced from a trivial sore, such as that of a blister, the friction of a shoe, or the like; and assuming a round form, with raised, thickened, abrupt, or callous edges, and an irregular, unhealthy, and dirty surface, they increased in size with considerable rapidity and much pain. The pus adhered to the surface, and the discharge was a watery or bloody ichor. After extending, occasionally by ulceration, and at other times by sphacelation, the surface began to assume a more equal and clean appearance; the edges became reduced; and granulations forming from the bottom of the ulcer the sore gradually healed. These ulcers occurred at different periods from November to April; and chiefly in men whose health had been broken by frequent returns of Fever, or by long confinement to hospital, from these or other diseases, or by a severe affection of the mouth from mercury.* *"_P. 156.

With respect to the subject of treatment of Remittent and Intermittent Fevers, all we propose to do at present is, to select a few simple memoranda from our author's narrative that may be useful in refreshing the memory of the reader.

Dr. Geddes remarks that, when he first went out to India, the usual practice in Remittent Fever consisted in the exhibition of Calomel pushed to salivation. (( Bloodletting and other remedies were also employed; but without reference to the stage of the disease at which they were applied." The results of such practice were often most injurious. It is not often that this much abused medicine, Mercury, is carried to such an extent in the present day.

In the cold stage, a dose of Opium-one grain combined with eight grains of the pulvis antimonialis-was usually given. When vomiting, purging, or other alvine irregularity was present, a dose of Calomel-from 5 to 20 grains-was associated with the opium. In the hot stage, the great object should be to moderate the violence and shorten the duration of the febrile action. Bloodletting was not often required for this purpose; it was practised in 16 cases only. Local bleeding, by leeches-applied most frequently to the temples, in other cases to the nape of the neck, to the chest or abdomen-was extensively used, and, for the most part, during this stage of the disease. Antimonials were given in frequently-repeated doses.

66

Opium, if not previously exhibited, was given, at this period of the disease, under the same circumstances as in the cold stage; and was combined with calomel, or the antimonial powder, according to the state of the stomach or

* This subject was considered at some length in our last Number, in the review of Dr. Wilson's Medical Notes upon China.

No. 106.

25

bowels at the time of its being used. This remedy was occasionally contra-indicated by severe affection of the head or a plethoric, robust habit of body of the patient, and severe Fever; but, in general-as soothing the patient's feelings, checking various symptoms, and tending to lessen, and thereby shorten, the cold as well as the hot stage of the disease, while it rendered the succeeding portion of it more complete-opium was considered a valuable adjunct in the treatment of many of these cases of Fever; and was generally given where the patient was seen in either of the two first stages of the disease."-P. 173.

The period at which the exhibition of a purgative, when necessary, was found most serviceable, is upon the accession of the sweating stage, so that the operation of the medicine might go along with the decline of the febrile symptoms.* It is to be remembered that purgatives are not required in all cases, and are, therefore, not to be given indiscriminately.† We cannot quite agree with our author in the propriety of the following suggestion; would not the remedy recommended be much more advantageous in the first or cold stage?

"When the patient was first seen at this (the sweating) stage, or decline, of the disease, and the stomach or bowels were not prominently affected, an emetic of Pulvis Ipecacuanha frequently took the place of a purgative at this period; particularly when the admission took place in the evening. The effect of this medicine was to remove indigestible or irritating matter from the stomach, and occasionally to act slightly on the bowels; while its operation also assisted the process of diaphoresis going on at the time. An emetic was thus administered in 495 cases."-P. 175.

As we have already mentioned, the treatment of the Paroxysmal fever of the East Indies is infinitely more easy and more successful since Quinine has been introduced into practice. Its use should, as an almost invariable rule, be commenced whenever the febrile paroxysm has fairly begun to decline, and the skin has become moist. We are not to wait until the pulse falls, nor till any inflammatory and dysenteric, or other affections

* Dr. Sutherland, whose little work on "Mercury in Fevers, &c.," we were obliged, from want of space, to notice so briefly in our number for last April, remarks upon this subject:

"There is, perhaps, no form of fever wherein it is of greater importance to be particular in the time chosen for the administration of calomel or any other remedy. The dose of calomel that would prove highly beneficial, along with a purgative extract, in cleansing the bowels of mal-secretions, if given when half the period of remission is elapsed, would have no purgative effect at all if given in the early stage of an exacerbation; and the same dose given half an hour previous to the expected exacerbation would most probably induce it, and render it more severe, that otherwise the patient might have escaped. Untimely purgatives are often the cause of renewed paroxysms."

On the subject of those black tarry evacuations so frequently observed in cases of protracted Remittent Fever, Dr. Parkes says that, judging from the results of necroscopic examinations, the liver will generally be found much enlarged and congested, while the mucous surface of the bowels is but little affected. "The black stools probably came from the minute structure of the liver, and passed at once into the common duct without entering the gall-bladder. The black, coffee-grounds-like matter, which I have seen vomited in dysentery, comes evidently from the dark striated vessels occupying the bottom of sloughing ulcers in the colon."

1846.]

CONTINUED AND EPHEMERAL FEVERS.

367

that may happen to be present, be removed; for its use is by no means incompatible with that of depletory and other such remedies as may be required to relieve these complaints. By preventing the tendency to the recurrence of the febrile paroxysms, the quinine serves to facilitate and promote very materially the removal of any accidental morbid phenomena that are complicated with the primary disease.* The usual dose of the quinine was three grains, given every two or three hours. From a scruple to a drachm and a half was required to effect a cure. The average stay in the hospital was about six days. Nearly three-fourths of the patients, 883, were discharged by the sixth day; 226 by the eighth; and the remaining 88 were there for a longer time. The quinine seemed to produce Vertigo and Tinnitus Aurium in some cases; in two or three instances these symptoms were followed by a certain degree of deafness. Occasionally its use in the fluid form was followed by diarrhoea and intestinal

uneasiness.

Continued and Ephemeral Fevers.—We have not much to say upon this head.

"Continued Fever," Dr. Geddes observes, "in its form of a contagious disorder, as usually seen in Great Britain, has not been met with in the course of the author's experience in the East. It is true that, in certain instances of violent remittent, the symptoms, as have been above described, occasionally put on a typhoid appearance; and, in some cases afterwards to be alluded to, the disease has occasionally assumed the chief features of a Continued Fever; but in neither case was there any cause to believe in the presence of infection; while the history of the attack in the one instance, and the presence of certain symptoms in the other, showed that the febrile disorder was not originally of a continued nature, or if so, it was not a purely idiopathic disease."-P. 195.

Not a few of the cases of ephemeral or apparently Continued Fever were owing to the effects of intoxication, or of direct exposure to the sun's rays. In some instances, erysipelas or a furuncular eruption appeared upon the subsidence of the febrile symptoms. What is usually called a stroke of the sun (coup-de-soleil) is an attack of ephemeral or continued fever, accompanied with symptoms of cerebral congestion, which, it is well known, may terminate in stupor and death. Three fatal cases of this description occurred in our author's practice. In the more fortunate cases, a paralytic weakness of one side or of one extremity was sometimes left behind. Venæsection and purgatives were generally required. The abuse of spirituous liquors will occasion the same sort of apoplectiform attacks, which exposure to the intense rays of the sun is apt to produce.

* Dr. Parkes remarks that "the combination of Calomel and Quinine appears decidedly useful in Remittent Fever, in reducing the bulk of the liver and spleen." He says that the combination of the quinine with the mercurial has appeared, on several occasions, to accelerate the occurrence of ptyalism; and that, when this effect had ceased, it was re-induced by the use of quinine.

Nine pounds, four ounces and a half in all were used in the treatment of 1200 cases. It would appear, however, that the Cinchona in powder was given at the same time; for we read, in one part, that this in powder "was generally employed, from motives of economy, in the last two days of the patient's stay in hospital, when the force of the disease had been fully checked by the Quinine."