It should be observed that after the 14th of December the patient's bowels were rather costive, and the stools occasionally moulded and very dark in color. On the forty-fifth day after admission the patient had a severe chill, followed by a rise of temperature to 104°. This yielded to competent doses of sulphate of cinchonidia.
This was a typical case of typho-malarial fever. The blended symptoms, as well as those special to each disease, are sufficiently exhibited in the clinical account. The presence of typhoid fever was established by the rose spots and the marked nervous symptoms. The typhoid process seems to have been unusually mild in so far as evidence of bowel lesions were made manifest.
The history of the patient before admission, the color of his skin and stools, and the temperature curves gave abundant proofs of the malarial element in the pathology of the case.
Perhaps nothing need be added on the subject of diagnosis. I may, however, remark that I am very cautious in asserting the diagnosis of typho-malarial cases unless the nervous symptoms, positively-marked bowel symptoms, or rose spots are present to vindicate such a decision. The presence of malarial poison may be determined with less difficulty from the previous history of the case and its special symptoms in the early stages of an attack. But if the morbid processes of the typhoid poison are violent, there are likely to be stages of the disease when it is not possible to detect symptoms which indicate the presence of malaria. On the other hand, it is unquestionably true that the typhoid condition, as it is termed, which so often complicates malarial fevers, can very generally be differentiated from true typhoid fever. While certain cases, or even epidemics, of malarial fevers are attended by remarkable adynamia, often manifesting itself from the very incipiency of attacks, it differs widely from that utter nervous ataxia which characterizes typhoid fever. Again, the adynamia of malarial attacks is generally ascribable to some cause not essential to those affections. Imperfect reaction from a chill, long persistent hyperpyrexia, diarrhoea or vomiting, or chronic paludal cachexia, or, it may be, some epidemic influence, may produce it. The ataxia of typhoid fever is part of its morbid process.
Woodward's statistics show that 49,871 cases of fever diagnosed as typho-malarial occurred among the white forces of the United States during the late Civil War. Of this number, 4059 proved fatal, a mortality-rate of 8.13 + per cent. Among the colored troops 7529 cases occurred, with 1301 deaths, a mortality-rate of 17.27. Statistics borrowed from the same excellent authority give the number of cases of unmixed typhoid fever (or fever classed as typhoid without reference to any complication) as 75,368 among the white troops, with 27,056 deaths, a mortality-rate of 35.89. Among the colored troops 4094 cases occurred, and 2280 died, a mortality-rate of 55.68. These figures show very singular comparative results. They prove that typhoid fever as an uncomplicated malady, was four and a half times as fatal among the whites as the same disease when in combination with malarial poison. Among the colored troops typhoid fever was three and a half times more fatal than typho-malarial fever.
It is highly probable that inaccuracies exist in statistics gathered in the confusion of a great civil war, but I am not prepared to say that the conclusions they point to are incorrect. When an acute inflammation is complicated by malaria, its prognosis is rendered more grave. This, no doubt, is due in part to degradations of the fluids of the system by the malarial poison, and in part to the revulsions of circulation during paroxysms. But it does not follow from this fact that the presence of malaria in the blood, or its effects upon that fluid, exercise an unhappy influence upon diseases due to other specific poisons. It may, on the contrary, be ascertained in the future that it modifies the typhoid process, so as to deprive it of some of its most dangerous features.
Further investigations are required to determine the facts in regard to these questions. But it may be premised that if such a conclusion shall ever be reached, it will influence our expectations of cure rather than our practice. If the malarial poison is capable of modifying the toxic effects of the typhoid poison, it must do so in the very formative stages of that affection, if not in its incubative period, so that, having accomplished all the good it is capable of effecting, we may proceed at once to rid ourselves of its presence.
In entering upon the treatment of two diseases compounded in the same patient, if one should ordinarily be amenable to specific treatment, it must certainly be wise practice to endeavor to simplify the case by subtracting that one from its composition. This is more especially true if the treatment does not affect the course of the other disease in any injurious manner. It is therefore proper to begin the treatment of a case of typho-malarial fever by administering large doses of quinia. A scruple may be given every fourth hour, until its effects in eliminating symptoms ascribable to malaria, and also as an antipyretic, have been sufficiently tested. In the early stages of typho-malarial attacks the febrile exacerbations conform to those laws of periodicity which govern uncomplicated malarial fevers. After the first week, or when the typhoid process has become well established, periodic returns of the fever are less plainly observable. It is possible that in some cases in which the typhoid process manifests itself with great severity the temperature curves may be very characteristic of that disease. I am satisfied that the indications for giving quinia to eliminate the malarial element must be based upon the fever curves which mark the case. Perhaps a more frequent application of the thermometer would often exhibit malarial periodicity where it may otherwise remain unsuspected. I know this to be very often the case in pneumonia complicated by a malarial fever.
Whether thorough cinchonism in the early progress of the attack rids the case of symptoms due to malaria or not, only a very few days are likely to elapse before oscillations of temperature call for its repetition.
The typhoid processes require very much the same measures which are applicable in uncomplicated cases of that disease. The stools of the early stages of attacks should not be checked unless excessive, and mercurials and laxatives should be more freely used than in simple typhoid fever. The effects of the malarial fever and of the hyperpyrexia of typhoid fever, when combined, must almost necessarily entail more accumulation of excrementitious material in the blood than would occur either disease existing separately. On this account eliminating treatment is an important indication. When it becomes necessary to check the diarrhoea because excessive or on account of failing strength, diuretics subsequently prove serviceable. Effervescing solutions of potassium or ammonium, lemonade, Apollinaris water, iced tea, strawberry, mulberry, or raspberry juice, are grateful beverages and increase renal activity. The mineral acids may be given during the ulcerative periods of the disease. Insomnia must be relieved by opiates, chloral hydrate, or other hypnotics.