IS THERE A CONTINUED FEVER OTHER THAN

MALARIAL OR TYPHOID?

BY J. W. PALMER, M.D., AILEY.

So much has been said and written on this subject, no doubt a great many of you feel that it is threadbare; but the fact is, the last word has not been said, nor will be for some time.

I have nothing new to add to the subject, and will not speak of it from a pathological or etiological standpoint, but from a bedside study.

The Georgia State Board of Health, having decided to locate a station in the southern part of the State to investigate and see if they could discover what this third fever was, and I, having an unusual amount of continued fever in my practice for the past eight months, have felt that I might provoke a discussion of the subject, if nothing

more.

What is fever? We mean by fever an abnormal elevation of the temperature of the body with more or less pronounced functional derangement of all the organs of the body, lasting for some time, or repeated at certain intervals, and not produced by external heat or violent muscular exercise. This abnormal elevation of temperature is supposed to be caused either by direct action of microorganisms upon the nervous centers, to which they are carried by the blood, or by the action of a poison, which they develop in the body. Wood claims that the inhibitory center is so depressed and benumbed by these or

ganisms that it does not exert its normal influence upon the system, and, consequently, tissue change goes on at a rate which results in more heat than normal; at the same time, the vasomotor and other heat dissipation centers are so benumbed by them that they are not called into action by their normal stimulus.

Fever is classified as continued, remittent and intermittent, according to the character of the temperature range in either case.

Now, in regard to there being a continued fever other than typhoid or malarial, I don't believe there is. My knowledge of the subject, based on my experience with continued fever, and from what I have read on the subject, forces me to represent the negative side of the question.

Since last June I have tabulated only forty-eight cases of continued fever, of which thirty-six were typhoid and the remainder were malarial. I kept close tab with all these cases, and not in a single instance did I not satisfy myself as to the fact that it was typhoid or malarial, and not a new fever.

From a clinical standpoint, I believe all these questioned cases of continued fever are a variety of mild, uncomplicated cases of typhoid fever, except occasionally it is malarial. I live near malarial districts, and I have noticed that this continued fever seldom occurs much in localities where remittent fever prevails. In my tabulated typhoid cases there were a few families through which the fever went, and scarcely any of the members escaped. Some members of these families had typical cases of typhoid, while the majority had mild atypical cases, affording me a good opportunity to study these atypical cases of typhoid, which I could exclude from malarial or some unknown continued fever.

I will mention a few of these cases of atypical typhoid that occurred in families where some of the members of the family preceded them with malignant cases of typhoid.

Case No. 1.-Boy, twelve years old, white, had a continued fever for twenty-three days, ranging from 100 to 1032 degrees, with no symptoms whatever of typhoid fever, except the rose-colored spots on the abdomen. Had I seen this boy first in the family, and those rose-colored spots absent, I would have been inclined to call it malarial, or this unknown fever.

Case No. 2.-White, age fifty years, female; ran temperature from 100 to 1021⁄2 degrees for only fourteen. days, but seemed very sick during this period, and especially suffered from severe pain in hepatic region; had no symptoms of typhoid, other than continued fever. Quinine had no effect, and malarial plasmodium in the blood was found wanting. Had I seen this case elsewhere I would not have called it typhoid fever.

Case No. 3-Colored boy, age sixteen years; came to my office apparently very sick to be out; had temperature 1011⁄2 degrees, feeble pulse and a severe bronchial cough. I could not tell at that time whether he had consumption, malarial or typhoid fever, but, giving a history of being sick only ten days, and having a sister who had been down for two months with fever, I placed him on typhoid treatment. This boy never went to bed, but in ten more days was able to do light work. I later treated four more members of the family for typhoid fever. Had it not been for the typhoid history in the family, I would have never known for certain that this boy had typhoid fever.

I could report several more cases similar to these, but will report a few cases that occurred sporadically that were proved typhoid by complications.

Case No. 4.-Woman, white, age twenty-five years, married, had two children. Had smallpox eighteen months prior; had convulsions at birth of last child, ten months ago. Also had psoriasis. When I saw her she had continued fever, with no symptoms of typhoid whatever; temperature ranging from 100 to 102 degrees. Her symptoms were so mild I could not keep her in bed. On the twentieth day she began to have intestinal hemorrhages, and continued until the twenty-third day, when she died.

Case No. 5.-Colored man, age twenty-five years; came to my office with continued fever, and other symptoms of malarial. Other members of the family had done likewise, and, with malarial treatment, fever had yielded in few days. I placed this case on similar treatment and told him to go to bed, and if not better in few days to send for me. I heard nothing more, until eight days later he returned to my office, saying he was better, but not well. I then saw he had something more than malarial, and told him to stay in bed, and I saw him every day for a week, at the end of which, during my absence, he had a fatal intestinal hemorrhage. This case never showed any symptoms of typhoid, only by exclusion, as quinine had no effect, and I could not find any malarial plasmodium in the blood.

Case No. 6.-Woman, white, married, age twentytwo years, one child; had a continued fever for twentyeight days, with temperature ranging from 101 to 103 degrees, with no symptoms of typhoid. I was treating this case for autumnal malarial, as it is claimed that quinine has no effect on this form of malarial, and it is usually very difficult to find the malaria plasmodium in the blood. After the twenty-eighth day this case began to

have repeated, profuse intestinal hemorrhages for three days, after which she made an uneventful recovery.

I could report other similar cases, but this sufficeth to show had it not been for the previous history in the first cases, and the typhoid complications in the last, I would never have felt fully satisfied as to the kind of fever I was dealing with, but would have been inclined to believe it malarial, or this unknown third fever in question. Hence, this leads me to believe that all these cases thought to be a third fever, when brought down to a correct diagnosis, will be proven typhoid. These last cases I reported should also impress us with the importance of having all suspected cases of typhoid to go to bed at once, because I believe had these cases staid in bed from beginning of fever they would now be living.

When this continued fever long ago was called typhomalarial, it was thought they then had a third fever, and even now, when we are doubtful about our diagnosis, as a catch-all, we call it typho-malarial, so whichever one it turns out to be, we will say that element predominated, and make ourselves safe. There is no such fever as a combination of typhoid and malarial. Professor Osler claims the only way to have both of these fevers at the same time is, while suffering with malarial you may at the same time have the typhoid bacilli in your system, which may begin to develop typhoid while you still have some malarial; that they are two distinct germs, one bearing no relation to the other whatever, and there is no such thing as these germs uniting and producing a third fever known as typho-malarial. There is no such disease as typho-malarial fever, because the cases called typho-malarial are nothing but simple uncomplicated cases of typhoid fever of a mild form; they are only a clinical variety of typhoid fever, because it must be remembered that uncomplicated ty