The malarial fevers of Hong-Kong 1894





THE MALARIAL FEVERS

3

OF

HONG-KONG

BY

J. MITFORD ATKINSON, M.B.LOND., M.R.C.S.ENG.,

SUPERINTENDENT, GOVERNMENT CIVIL HOSPITAL, HONG-KONG.

COLONIAL

IBRARY

Reprinted from "THE LANCET," April 28, 1894.

9224 Pamp.

1894

THE MALARIAL FEVERS

OF

HONG-KONG

*BY

J. MITFORD ATKINSON, M.B.LOND., M.R.C.S.ENG.,

SUPERINTENDENT, GOVERNMENT CIVIL HOSPITAL, HONG-KONG.

Reprinted from "THE LANCET, April 28, 1894.

 

RYT5M

THE MALARIAL FEVERS OF HONG-KONG.1

DURING the past six years, as Superintendent of the Government Civil Hospital at Hong-Kong, I have had ample opportunities of studying malarial fevers in that colony. In the summer months, from May to October, we generally have between 300 and 400 cases under treatment.

At the sug- gestion of the Italian Consul there I have gathered together some of the results of my experiences of this disease with the idea that such might prove interesting to the members of this Congress gathered together from all parts of the world in a centre where malaria is not unknown. Undoubtedly it was due to malaria that Hong-Kong derived the unenviable excessively unhealthy reputation it had in the early years of the colony's history, and, although the disease is much less fatal than it used to be, every now and again the colony has been subjected to outbreaks of the severer types of the disease. One such occurred in 1889 after the pheno- menally excessive rainfall in May of that year. Dr. Maclean, formerly Professor of Military Medicine in the Army Medical School at Netley, who was encamped in Hong-Kong before it was ceded to the British Government, states that "at that time the soil was but little disturbed and the troops did not suffer, but when excavations were made at a subsequent period for the construction of the city of Victoria a fatal form of remittent fever appeared, which caused great mortality.

I

In perusing the medical records of the early years of the colony's history I have obtained much valuable information from the annual medical reports of the colonial surgeons. propose giving a few extracts from these reports in order to demonstrate how fatal the disease was then. In 1844, from the colonial surgeon's report, we learn that remittent fever was then the most fatal malady. In 1845 six cases of

1 A paper read at the Eleventh International Medical Congress at Rome, April, 1894.

4

Dr.

death from remittent fever are noted by Dr. Dill, the colonial surgeon. The death-rate that year amongst the European and Portuguese is given as 54 per 1000. Young, in his report for 1846, records sixteen deaths from intermittent and remittent fever and dysentery, in- cluding that of Dr. Dill, the colonial surgeon, owing to whose death it is that these diseases were not differentiated. The death-rate amongst the European and Portuguese com- munity that year is given as 1 in 13 2, or 75 per 1000. In 1847 Dr. Morrison, the colonial surgeon, stated:

"There can be no doubt that the first colonisation of this island was attended with disastrous consequences to our countrymen and soldiers and the ravages of Hong-Kong fever were as fearful as similar visitations have been in other parts of the world."

The year 1848 seems to have been a very fatal one, the death-rate among 963 Europeans being 125, or 129 per 1000. In that year many deaths occurred in the 95th Regiment from what was termed by Dr. Gordon "febris remittens." He states: "The disease was first observed about the first week in May, slightly increasing in June; in July a consider- able increase in the number and severity of the cases took place; this continued during August, but sensibly diminished in September, death generally occurring about the third day, though in many instances it took place a few hours after ad- mission. The fever was of a very malignant and insidious character, the symptoms changing for the worse suddenly and without warning; half an hour prior to his death the patient would become strongly convulsed and his skin intensely hot and dry." He gives a case in point: a colour-sergeant, "a stout, healthy young man, was admitted on the morning of June 17th in the cold stage of inter- mittent fever, and in about six hours had gone through all the stages of the disease. When the intermission occurred quinine was administered; on the 18th he declared himself as feeling quite well and was apyretic, his pulse not even indicating the slightest constitutional irritation. About 11 A M. on the 19th I was called to see him, and found him comatose and convulsed, with lividity, intense heat, and dry- ness of the skin, death closing the scene in a few minutes." This is similar to cases, the notes of which I will give later, which were under treatment in the Government Civil Hospital during 1889. In 1849 ninety-four deaths are stated to have occurred from malarial fever in the 95th Regiment; the death-rate among the civil European population during that year was 64.8 per 1000.

5

I think I have gone sufficiently into the early records of the medical history of this colony to show that undoubtedly malarial fever was one of the main causes of the enormous fatality which then prevailed.

ETIOLOGY OF THE DISEASE.

Whatever the specific cause of malaria may be, there is no doubt that in the experience of Hong-Kong, when soil which has long been untouched is upturned either by the process of excavation for building purposes or by natural agencies, then the fever becomes more rife and fatal. According to Tommasi Crudeli 2 three conditions are necessary for the pro- duction of the malarial poison: (1) a temperature of not less than 68° F.; (2) a certain humidity of the soil; and (3) the free action of the air on the soil which contains the ferment. In the summer months, from May to October, these condi- tions exist in Hong-Kong. There can be no doubt that freshly upturned earth is there, as in other parts of the world, a point of considerable importance in relation to the causation of this disease. It may seem superfluous to produce proof in evidence of this, but as some still dissent from this view I will here introduce some facts bearing out this theory. Dr. Young, one of my predecessors at the hospital, wrote to me in 1888 concerning an outbreak of malarial fever at Kowloon Point, which, in his opinion, was caused by the extensive earth-cutting necessitated in the preparation of the site for the new water police-station at Tsim-tsa-tsui. This occurred in

the summer months during the S. W. monsoon, and the houses in which the people were attacked by this fever lay right in the course of the prevailing winds. In 1888, during the time foundations were being made for the new Chinese barracks at our own hospital, we had an outbreak of malarial fever amongst the officers and attendants, which I could only account for by this earth-cutting theory. Out of a staff of forty no less than fifteen were invalided from this cause during one week, in which the earth-cutting and filling in of this space were taking place—a ratio of 34 per cent. Amongst those affected were the superintendent, two European ward masters, two Chinese cooks, and two Chinese attendants. In the same year a similar outbreak occurred at the Lunatic Asylums and Lock Hospital during the time of the earth- cutting, &c., necessitated in preparing the foundations for

2 THE LANCET, Nov. 1st, 1884.

ון

the new administrative block (officers' quarters), the two European attendants and six of the Chinese staff being attacked, and one of the latter succumbing to the disease (remittent fever). Lastly, there is the severe outbreak which occurred in the latter half of 1889 after the great rain-storm in May of that year. That enormous downpour-namely, 33 11 inches from 3 A.M. on the 29th to 5 P. M. on the 30th (thirty-eight hours)—washed down great quantities of alluvial soil from the many landslips on the hillside, and un- doubtedly must have set free the malarial poison to an abnormally great extent. There were no less than nine deaths from remittent fever at the hospital during that year, eight of these occurring after the rain-storm; four of the eight were members of the European police force, men who from the very nature of their calling are more exposed to this poison.

In order to show how exceptional was this mortality in 1889 I give herewith statistics of the malarial fever cases from 1888-92 :—

1888.-Intermittent fever

Remittent fever

-

1889.-Intermittent fever

Remittent fever

1890.-Intermittent fever

Remittent fever

1891.-Intermittent fever

Remittent fever

1892 -Intermittent fever

Remittent fever

::

::

::

::

::

1 :

::

! !

::

: :

::

: :

::

! |

! !

::

::

Number. 340

Deaths.

1

30

2

370

3

384

37

421

325

49

374

276

63

339

4

246

40

286

* | * °*|*

9

9

1

3

मे

4

In my opinion there is no doubt that this excessive rainfall accounted for the severe outbreak which occurred in the latter half of 1889.

There are doubtless many causes necessary for the evolution of the malarial poison; however, almost universal medical

7

testimony points to earth-cutting or the upheaval of alluvial soil, whether by natural agencies or otherwise, as one of these causes. As to the intimate cause of malaria, not- withstanding the researches of Professors Crudeli and Klebs (as described in the Archives of Experimental Pathology in 1879), of Professors Laveran, Marchiafava, and Celli, of Dr. Osler of Philadelphia, and Dr. Vandyke Carter of Bombay, there is much that remains to be ascertained. As far as can be judged at present, the hæmatozoa described by Professor Laveran in 1880 seem to be those most constantly present in malarial blood; but it must not be forgotten, as pointed out by Professor Crookshank at the International Health Con- gress of 1880, that similar hæmatozoa have been found in different animals-viz. frogs, lizards, marsh tortoises, birds, &c. Laveran's hæmatozoon has been observed in birds living in non-marshy districts, and the inoculation of blood containing this hæmatozoon has given only negative results. In 1889 I described certain flagellated corpuscles frequently found in the blood of patients suffering from intermittent fever, and in 1890, in a paper on the Remittent Fevers of Hong-Kong, read before the Hong-Kong and China branch of the British Medical Association, I described and showed what I took to be Laveran's hæmatozoa; these were obtained by double staining with eosine and methyl blue. In my experience, however, these organisms are by no means so definite and constant as some would lead us to suppose, and I cannot help thinking that we must look further ahead before finding the intimate cause of the disease.;

The more I see of tropical diseases the more convinced do I feel that malarial fevers, dysentery, and beri-beri have one common origin, and will ultimately be shown to have the same cause. The different types of malarial fever met with are: (1) intermittent, with all its varieties quotidian, tertian, quartan, &c.; (2) remittent; (3) mixed type e.g., case of A. W- ; and (4) malignant remittent.

1. The intermittent type.—This is the one most frequently met with, and the least fatal. Referring to the figures already given, we find that in the years 1888-1892 there were 1571 cases under treatment, with but two deaths. In our treatment of these cases, where in the initial paroxysm the temperature does not rise above 103°, after ensuring a free action of the bowels it is found that a combination of anti- pyrin and quinine in the proportion of eight grains of the former to five of the latter is the best, the powder to be given

8

every four hours. When, however, in the initial paroxysm the temperature rises higher-say, to 105° or 106°-we give some antipyretic-by preference phenacetin in ten-grain doses, to be repeated in four hours if the temperature has not fallen, and after this has occurred quinine in five-grain doses every hour. In some of the more severe cases, in which, as the temperature rises, the patient becomes delirious, it has been found necessary to reduce the temperature promptly by the application of external cold. The following is a case in point.

Lui-a-Kan, aged eighteen, a coolie, was admitted at 10 A.M. on Sept. 1st, 1889. On admission he stated that he had felt unwell the previous day; his tempera- ture was 1004° F.; his skin was very dry, and he com- plained of pains in his limbs, headache, and a general feeling of malaise. At 11 A.M. his temperature had risen to 104°, and the following medicine was now given: tincture of jaborandi, twenty minims; antipyrin, twenty grains; diaphoretic mixture to one ounce; to be taken every two hours. At 11.30 A.M. his temperature had

risen to 104-8° and at 12 noon to 106 6°. As the medi- cine did not appear to have any effect, and the tempera- ture was steadily rising, it was thought advisable to ice- pack him.

In two hours his temperature by this means was reduced to 99.6°, the various observations during that time being as follows: 12.15 P.M., 105-6°; 12.30 ℗ M., 105°; 12.45 P.M, 104 2°; 1.0 P.M., 103-8°; 1.15 P.M., 103·2°; 1.30 P.M., 102·8°; 1.45 P.M., 102°; 2.0 P.M., 101; 2.15 PM., 99.6°. As he was now somewhat collapsed he was replaced in bed between blankets, and heat was applied externally, ten grains of quinine being given by the mouth and repeated every two hours, his diet being milk and congee. At 8 P. M. his temperature had risen to 102°, and at 10 P.M. to 103 2o. The following medicine was now given: antipyrin twenty grains, and camphor water one ounce, to be taken every hour, and the result observed. At 11 P.M. his tem- perature had fallen to 102.8, at 1 A. M. (Sept. 2nd) it was 102°, at 3 A.M. 101°, and at 6 A.M. it had fallen to 98′6°. The antipyrin was now discontinued and quinine given as before. That evening it rose again to 104-2° at 8 P.M.; the antipyrin was now substituted, and it rapidly fell. After four doses the temperature had fallen to 99.6° at midnight; the quinine was again ordered, and this time it was given in ten-grain doses every hour during the day. The temperature

9

CHART 1.

DAY of MONTH

| ST

2ND

3RD

4TH

5 TH

ΤΗ

DAY of

DISEASE 2ND

3RD

4TH

5TH

6TH

MIE MIE

ME

M: E

M:E

106°

105°

104°

103°

102°

101°

100

99°

98°

10

that evening did not rise above normal. As the temperature was normal on the morning of the 3rd ten-grain doses of quinine three times a day were ordered, a pint of beef-tea being added to his diet with one pound of rice. On the 4th the quinine was reduced to five-grain doses thrice daily, and he was discharged cured on the 7th. Remarks: This was a case of intermittent fever, with the paroxysm more marked than is usually the case. During the year we have had many such cases; as a rule, however, the température does not rise above 105°, when, if antipyrin be administered, it almost immediately begins to fall, profuse perspiration setting in. If we find antipyrin has not this effect we invariably now ice-pack these cases. This patient had no return of the fever. I have been able to keep him under observation since that time, as he was soon after engaged as a hospital servant. An extended trial has been made of the three antipyretics— antipyrin, antifebrin, and phenacetin-and of these I have found phenacetin to be the safest; it never depresses the heart and invariably induces free diaphoresis. Occasionally one meets with cases in which a mottled erythematous rash similar to that met with in rötheln occurs after phenacetin has been given. In some cases in which phenacetin has not lowered the temperature I have found antipyrin in two hourly doses of twenty grains each to prove effectual. One must, however, watch the effect of antipyrin, as it is very depress- ing to the heart.

It is very difficult in some cases to distinguish between intermittent fever and the so-called "ardent fever"; in the latter the head symptoms are, as a rule, more marked. It is always better to watch these cases for twenty-four or forty- eight hours before making a diagnosis.

2. Remittent fever.-These cases are much more protracted than the intermittent ones. At the onset the patient is much more prostrated; the stomach symptoms-nausea and vomit- ing-are always present. The chief difference is in the tem- perature the fever, instead of intermitting, remits. The treatment is much the same as in intermittent fever. The patient must be kept in bed, his diet should be light and easily assimilable, and when the remission occurs quinine should be given in the same way; if it is not retained by the stomach it should be given hypodermically, the solution of the acid hydrobromate of quinine (1 in 6) being the best.

J. L aged thirty-five, was admitted to the hospital

P

11

on June 18th, 1890, at 8.30 A.M.

*C

On admission the patient stated that the fever had commenced the day previous (the 17th) about 10 A.M. From his account the attack was a typically aguish " one. His temperature on admission was 99° F. He was placed on low diet, with two pints of milk daily with soda and ice, and was ordered ten grains of quinine every half-hour. Notwithstanding this, his tem- perature gradually rose, and at 6.20 P. M. it registered 103 4°. Two minims of tincture of aconite were now ordered every ten minutes. At 8.40 P.M. his temperature had risen to 104°, and twenty grains of antipyrin were given; at 10.10 P.M. it had fallen to 102.8°, and ten more grains of antipyrin were now ordered, but as this made him vomit the aconite was recommenced. At 12 (midnight) his temperature was 105°. Twenty grains of antipyrin were again given, and this brought his temperature down to 103° in half an hour. The aconite was continued during the night when he was awake. On the 19th, at 7 A. M., the temperature was 103.6°. As it was still 103° at 10 A.M., twenty grains of antipyrin were given. At 11.30 A. M. the temperature was 105-4°. The patient was now placed in a bath, the temperature of the water being 96°; he was kept in for an hour, the temperature of the water in the meantime being reduced to 80°. At 12.30 P.M. his temperature was 102.2°, and at 12.40 P.M. it was 100-8°. He was kept in the bath until 1 P.M., by which time his temperature had fallen to 98.6°. After being taken out of the bath he slept for an hour. At 2 P.M. ten grains of quinine were given hypodermically; he now slept until 3.40 P.M., when his temperature was found to be 101°. As his skin was now dry, the following mixture was ordered: tincture of aconite, two minims; diaphoretic mixture, two drachms; water to half an ounce; to be given every fifteen minutes. Notwithstanding this, his temperature gradually rose, as will be seen from the following observations: 4.30 P.M., 102°; 6 P.M., 103°; 7 P.M., 104°; 8 P.M., 105.6°; 9 P.M., 105.6°; 9.40 P.M., 106°; 10.25 P.M., 107°; 11 P.M., 108°. As the patient was now delirious he was ice-packed. At 11.54 P.M. his temperature had fallen to 105°; he became sensible and was conscious of what was transpiring around him. The ice-packing was continued, and at 12.15 A. M. his tem- perature had fallen to 101°. Sixty minims of the hypodermic solution of the acid hydrobromate of quinine (ten grains) were now injected, and at 12.30 A.M. his temperature had fallen to 99-8°. The ice-packing was now discontinued, and he was replaced in bed. Ten grains more of the acid

CHART

DAY of MONTH

18th

19th

20

DAY of DISEASE

2 ND

3 RD

4

107°

106°

Σ

105°

104°

103°

102°

101°

100°

99°

98°

E

10.15 A.M

Σ

GRADUATED BATH

ICE PACKING

M

....

F

1

!

!

E

*

1.

14

hydrobromate of quinine were injected. At 1.15 A.M. his temperature was 99o, and another ten grains of the quinine were injected. He now slept for a few hours, and as, on awaking at 4.30 A.M., his temperature was found to be 101.8° and the skin dry, the aconite and diaphoretic mix- ture was now given every half-hour. Profuse perspiration set in; but his temperature rose slightly and at 5.30 A.M. was 102 4°. Distressing vomiting now commenced, and at 6 A.M. a mustard plaster was applied to the epigastrium. This controlled the vomiting; but the temperature still con- tinued to rise, and at 7.30 A.M. it was 104°. Wet sheets were now applied, the aconite still being given. At 9.20 A.M. his temperature was 103.6°, and at 10.30 A. M. 102.8°. By 1.30 P.M. it had fallen to 101°, when sixty minims of the hypodermic solution of the acid hydrobromate of quinine were injected. At 4 P.M. his temperature was 100.6°. At 5.30 P.M. another ten grains were injected, the wet sheet still being applied. At 7.15 P.M. his temperature was 101°, and at 10.30 P.M., it having fallen to 99°, ten grains more of the quinine were injected. He now slept until 2 A.M. (the 21st), when his temperature was 100°, and the wet sheet was continued. He slept on and off during the night. At 5.40 A.M. his temperature was 100°. On this day it did not rise above 101 2° (6 P.M.). At 11.30 A.M. ten grains of the acid hydrobromate of quinine were injected, and a similar injection was given at 10 P.M. On the 22nd his temperature fell to 99.6° (7.5 A.M.), and five grains of quinine in the form of a pill were now ordered to be given every hour. As at 3P.M. his temperature had risen to 102·4° this was discontinued, and the aconite mixture was substi- tuted. At 8 P.M his temperature had fallen to 101·8°, and at 11 P.M. it was 100°. Ten grains of quinine were now injected hypodermically, and during that night his temperature did not rise above 100°. On the 23rd, at 6 A. M., the temperature registered 99°. Ten grains of quinine were injected hypo- dermically, and a five-grain quinine pill was ordered every hour.

On

The wet sheet was discontinued in the morning, it having been applied continuously for seventy-six hours. this day the highest temperature was 100-4°. In the evening, as the patient was suffering from retention, his urine was drawn off. On the 24th the urine had to be drawn off again in the morning. The quinine pill was still given every hour, excepting when the patient was asleep. temperature only rose above 100° at 6 P.M., when it was 100.2°. From this date he continued to improve, the

His

15

retention continuing until the 26th inst., after which he passed his urine normally. On the 25th the following medi- cine was ordered in addition to the quinine pill: liquor strychniæ, four minims; chloroform water and aqua pura, of each half an ounce; thrice daily. On the 26th the quinine pill was reduced to once every two hours, and on the 27th to once every four hours. On this latter date he was placed on half diet, and a mutton chop was added to his diet on the 29th. He was discharged cured on July 7th. Remarks: This is a typical case of the most severe form of what is termed "Hong-Kong fever." The type is really that of unusually malignant remittent fever; the onset is very sudden, and the tendency is for the fever paroxsym to be excessive-i.e., the temperature rises as high as 107° or 108° and can only be reduced by the application of external cold by the use of the graduated bath, the wet sheet, or "ice packing" in the extreme cases. There is generally distressing bilious vomiting, and the nervous system is much more affected than in the milder cases of malarial fever. In this case the fever was reduced in the first instance by the graduated bath; however, this reduction was only temporary, and the tem- perature that day rose again. No active measures were taken for some time, with the hope that the crisis marked by profuse perspiration would set in. Tincture of aconite in small doses frequently repeated in a diaphoretic mixture were given with the object of promoting this. However, as this did not occur, it was found useless to delay matters any more, and with the temperature registering (in the axilla) 108° ice packing was commenced. By this means, in an hour and a half, the patient's temperature was reduced by 8.2°. The hydrobromate of quinine was then injected hypodermically, as much as thirty grains being injected during the following hour. A rise above 104° occurred that day, but this was controlled by the continuous application of the wet sheet for seventy-six hours. In several of these severe cases retention has been met with; in this case it occurred on June 23rd (seventh day of illness). Great care is taken to use a fresh solution of the hydrobromate of quinine (1 in 6), and the syringe is provided with a platinum needle. In this case there was slight stiffness of some of the muscles of the forearm, which disappeared in a short time and was evidently due to the direct irritation of the muscle fibres by the hypo- dermic solution. The places selected for the injections are the calves of the legs, the shoulders (deltoid muscles), or the

16

muscles of the forearm. I attach to this a temperature chart of the case.

(See Chart 2.)

3. Mixed intermittent and remittent.-As a good example of this mixed type the following case may be given.

A. W, aged twenty-two, a sailor, was admitted on Aug. 5th, 1889, at 10.45 A. M. On admission the patient stated that he had been feeling unwell for the last two days; his temperature was 103 2° F., and the following was pre- scribed tincture of aconite, four minims, and diaphoretic mixture, one ounce, to be taken every four hours. He was placed on low diet, and milk and soda-water was ordered. His temperature rose that evening to 105 6°. The medicine was continued every four hours; during the night profuse perspiration set in, and the next morning (the 6th) at 6 A.M. his temperature had fallen to 98.4°. A five-grain dose of quinine was then administered; at 9 A.M. his temperature was 98.5°. Ten grains of quinine were now ordered every two hours, and his temperature that day rose only to 99° (8 P.M.). The next morning his temperature rose to 99 6o, and in the evening at 8 P.M. it was 101°. The quinine was now discontinued, and the aconite mixture given every four hours. The next morning the temperature fell to 99°. The quinine was again given every two hours in ten-grain doses; that evening the temperature rose to 100°. The next morning (the 8th) it was down to 97 8°. The quinine was given as before A mutton chop was ordered, and the highest temperature recorded that day was 98.5°. On the following day it was normal, and as the patient felt quite well he was discharged from the hospital at his own request. (See Chart 3.) This patient was readmitted on Aug. 28th at 7 50 A. M. with a temperature of 105°. He said he had been well since his discharge from the hospital until the previous day, when the fever came on again.

The following pre- scription was ordered, as his skin was very dry: antipyrin, fifteen grains; tincture of jaborandi, thirty minims phoretic mixture, to one ounce, to be taken every two hours, with low diet and milk-and-soda-water. At 8 P.M. his tem- perature had fallen to 101 6°. At 12 (midnight) it was 102°. On Aug. 29th, at 6.30 A.M., the temperature was 102.8°. As his bowels had not been opened for the previous twenty-four hours the following powder was ordered: calomel, four grains; quinine, five grains; compound powder of rhubarb, to fifteen grains, the medicine to be taken as before.

dia-

17

At midday the temperature was 105°; at 2.15 P.M. it was 106.2°. The patient now vomited everything, so the

DAY of MONTH

DAY of DISEASE

CHART 3.

56 7 8

9

10

2ND

3RD

4TH

5TH

6TH

7TH

لنا

E

M

.3

ไป

E

M E

Σ

E M.E M.E

Fo

M

105°

104°

103°

102°

101°

100°

99°

98°

97°

medicine was discontinued. was 108°, and at 3.45 P.M.

At 3 P.M. his temperature it had risen to 108.2°.

As

:

18

His

the patient was now comatose and his skin very dry, ice packing was at once commenced, he being placed on a mackintosh sheet covered with a sheet dipped in ice-cold water which was changed every few minutes, and ice was packed all over his body. At 4.15 P.M. his temperature had fallen to 104 2°. Twenty minims of the acid hydrobromate solution of quinine (1 in 6) were now injected hypodermically, ice packing being continued, for the next few hours. temperature was as follows:-4.50 P.M., 103°; 5 15 P.M., 102°; 5.45 P.M., 100°; 6.30 P.M., 99°. The ice packing was now discontinued, and as he was slightly collapsed hot water bottles were applied, and brandy was administered internally. At 6.45 P. M. his temperature was 98 2°. Ten grains of quinine were now ordered every two hours, which was retained. At 9 P.M. the temperature was 101.4°. On the 30th, at 6.45 A.M., the temperature was 101 6°; at 9 A. M. it was 102 4°. He was given the following: antipyrin, fifteen grains; water, to one ounce, every two hours. That evening the temperature rose to 102.8° and fell during the night to 100.8°. On the 31st the temperature in the morning was 102 6o, and at 8 P.M. it was 103°. During the night it fell to 100°. Eight grains of quinine were now given every two hours in place of the antipyrin. As the temperature rose next morn- ing (Sept. 1st) to 103° the antipyrin was substituted. That evening the temperature fell to 101°, and registered 100·4° at 8 A.M. On the 2nd it only rose to 101 4°; on this day two doses of antipyrin were given, and the temperature again fell. One pint of chicken broth was now added to his diet. The after-course of the case will be seen from Chart 4. By the 10th the temperature bad fallen to normal, and fish diet was now given. It took the patient some time to regain his strength. On the 12th full diet was given, and the following medicine was prescribed: Easton's syrup, half a drachm; water to one ounce; thrice daily. was discharged cured on Sept. 20th. Remarks: The first attack was evidently one of intermittent fever, the second being of the remittent type. In these severe cases I am firmly of opinion that the only way to combat the fever is by the application of external cold and administering quinine hypodermically as soon as the temperature falls, it being useless to give it by the mouth, as the stomach will not retain anything.

He

4. The malignant remittent fevers.—In these the patient at the onset seems to be quite overcome by the virulence of the

DAY of

CHART 4.

MONTH 28th 29th 30th 31st

1st

2nd 3rd

DAY of

DISEASE 2ND 3RD

4TH

5TH

6TH

7TH

8TH

MEME

ME

M E M.E

ME ME

;

108°

107°

106°

105°

104°

103°

102°

101°

100°

99°

98°

--

20

poison. Their clinical history reminds one forcibly of the severe remittent fevers which are recorded as occurring in the early years of the colony's history. The clinical history of these cases of malignant remittent fever is as follows. The premonitory symptoms are the same as in all febrile disorders-namely, pains in the back and limbs, a feeling of lassitude, tenderness about the joints, nausea, and headache. As a rule these are of very short duration, lasting only for a few hours, the onset of the fever paroxysm being very sudden and generally accompanied by distressing bilious vomiting. The patient at the first appears to be quite prostrated, the countenance is pinched and flushed, the tongue is generally foul and dry, the bowels are constipated, and the patient complains chiefly of headache and distressing vomiting. On taking his temperature it will generally be found to be as high as 102° to 105°; as a rule he is very restless and anxious. In this condition the patient will remain for three or four hours, or perhaps longer; then, as a rule, the urgent symptoms will to some extent subside, the temperature will fall two or three degrees, the skin becomes more moist, and the vomiting either ceases or becomes much less. This is the remission. In some cases, however, where the patient is more severely attacked by the disease, no remission occurs, but the tem- perature will gradually, but surely, rise, despite every means taken to lower it; the skin remains dry and hot, the vomiting continues, rapid respiration sets in, the patient soon becomes delirious, the delirium passes on to coma, and death occurs in a few hours. This was the case with a police-constable admitted on June 6th at 950 P.M. He had been on duty that evening near the bridge over the Kennedy-road and, feeling ill, came into the hospital His temperature on admission was 105°; antipyrin was given, and by 11 P.M. the temperature had fallen to 104.5°; however, it soon rapidly rose from this point Notwithstanding that he was wet- packed and antipyrin administered, but not retained, the temperature continued rising, the patient soon became delirious, coma supervened, and he died at 2 35 A.M. next morning, his temperature just before death being 107.8°; after death it registered 110° in the rectum. On admission to hospital this patient simply complained of distressing pains in the limbs, accompanied by vomiting. He had been in the force for only some five months, and it is undoubtedly the case that newcomers seem to be more liable to this malignant type of the disease. The only case of severe remittent fever that ended fatally in the Government Civil Hospital in 1890

21

amongst Europeans was that of a gentleman who had been in the colony for only a few months, and this was his first attack of fever. He was not smitten down quite so suddenly, but he succumbed after a week's severe illness.

In cases where remission occurs it will last for from two to ten hours, and then the exacerbation supervenes, the tem- perature probably rising some two or three degrees higher than in the initial attack. The urine is acid, high-coloured, and generally contains a trace of albumen. As the tempera- ture rises, during the exacerbation all the symptoms become more severe. As a rule, drugs are now quite useless as the stomach rejects everything; the patient soon becomes delirious, and unless active measures are taken to lower the temperature coma sets in and death in a short time occurs.

The duration of the fever is from a few hours to as many weeks. Maclean states that "death is rare before the eighth day," but in some of the cases I have named death has occurred in a few hours apparently.

As to treatment in the milder cases of remittent fever it is our custom to first of all open the bowels with some aperient, a modification of Livingstone's powder being pre- ferred-viz., four grains of calomel, five grains of quinine, with compound powder of rhubarb or jalap added to make one drachm. After that has been given, according to the temperature either phenacetin or antipyrin is prescribed, the former being in mild cases administered every four hours in doses of four grains to ten grains, and the latter in twenty- grain doses repeated hourly for the first two hours; if the temperature has not fallen by this time two further hourly doses of ten grains each are given. As a rule antipyrin will lower the temperature. When the remission occurs quinine is given in five-grain doses hourly until the temperature rises to 101° or 102°; after that it is useless to give it, as the stomach nearly always rejects the drug. In the severer cases, where antipyrin and phenacetin prove useless, as soon as the temperature rises to 106°, which it will do very rapidly even in the first exacerbation, ice packing is applied; by this I mean that the patient is placed on a mackintosh sheet, covered with a sheet dipped in ice-cold water, ice being packed all over his body, and an ice-bag applied to his head. It is simply marvellous to see the beneficial effect of such treatment in these severe cases. A patient who previously to it is violently delirious soon begins to calm down, and as the temperature falls he regains con- sciousness, his pulse becomes quieter and less rapid, and

22

all fears of a sudden fatal termination are at an end. (See notes on L- -'s case.) In an hour the tem- perature has by this means been reduced by 10°. Having effected this, the patient is replaced in bed, and the hypo- dermic solution of the acid hydrobromate of quinine is injected, the favourite sites being either the deltoid or the

OCT

NOV

SEPT

DEC.

AUG

JAN.

160°F.

JULY

FEB.

Opases

MÅR.

JUNE

APRIL

MAY

Black line: monthly number of malarial fever cases. Dots and strokes: mean monthly temperature. Dotted line monthly rainfalls.

muscles of the calf. During the ice packing the patient should be carefully watched, as symptoms of collapse may set in, when stimulants should be administered. The patient generally falls into a short sleep and has some hours' respite; the temperature, however, frequently rises again. When the next exacerbation occurs a wet sheet applied over the body

1

23

will often suffice to control the fever (as in L- -'s case). Morphia has been found very useful, as it calms the mental anxiety, induces sleep, and probably acts—as is supposed by many-as an antiperiodic.

There is another variety described by some- -the so-called "Typho-malarial fever."" There is, as far as I can ascertain, no such disease as a hybrid of enteric fever and malaria, or a transformation of malaria into enteric fever. The disease, as Duncan so well says, to which this name has been applied by writers, is either a severe form of remittent fever with marked nervous prostration, or else enteric fever occurring in a patient who has previously suffered from malaria, and in which the latent malarial poison is raised into activity and considerably modifies the existing disease. This is seen every day in malarial patients with surgical injuries; the fever consequent on such injuries often takes an inter- mittent or remittent type, and unless this is borne in mind grave errors in diagnosis if not in treatment may take place.

The diazo reaction is very useful in distinguishing between these cases and typhoid fever. It is much more marked in the latter. There is a pinkish colouration in cases of remittent fever, but it is quite a different tint from that met with in enteric fever.

""

In conclusion I would refer to the diagram comparing the rainfall, temperature, and number of cases of malarial fever occurring; and, although it is not possible as yet to make out any constants, yet it is to be seen that a sudden rise in the rainfall is followed in a short time by an increase in the number of malarial fever cases admitted.

In 1891 notes were kept of the hours of duty of the police who were admitted to the hospital suffering from this disease. From this it will be seen that 138 out of 173, or a ratio of 79.7 per cent., contracted the fever when on night duty. This, of course, simply bears out the view that the hours between sunset and sunrise are those in which the malarial poison is most rife.

PRINTED BY GOOD & CO., 11, BURLEIGH STREET, STRAND, W.C.


本網站純為個人分享網站,不涉商業運作,如有版權持有人認為本站侵害你的知識版權,請來信告知(contact@histsyn.com),我們會盡快移除相關內容。

This website is purely for personal sharing and does not involve commercial operations. If any copyright holder believes that this site infringes on your intellectual property rights, please email us at contact@histsyn.com, and we will remove the relevant content as soon as possible.

文本純以 OCR 產出,僅供快速參考搜尋之用,切勿作正規研究引用。

The text is purely generated by OCR, and is only for quick reference and search purposes. Do not use it for formal research citations.


如未能 buy us a coffee,點擊一下 Google 廣告,也能協助我們長遠維持伺服器運作,甚至升級效能!

If you can't buy us a coffee, click on the Google ad, which can also help us maintain the server operation in the long run, and even upgrade the performance!