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ly and deepened day by day, till the fifth day. The vesicle formed gradually, increasing in quantity till by the eighth day, it was fully distended; thence passing the usual characteristic as to time and subsequent behavior. These observations were taken last October (1882), and up to the present time none of the old symptoms have returned, and the subject has confidence, from his daily experience, that they will not.
I cannot but believe that the trouble that comes from these sources and gives coloring to suspicion and to the formation of "sides" in the matter of vaccination, is because of cases either improperly handled, or because of idiosyncrasy, as alluded to in cases so differently by poison-ivy, poison-sumac, etc., before mentioned in this paper.
Although the human organism is self-regulating as a rule, circumstances being reasonably favorable, yet we are sure to find scattered, it may be, far apart, cases that present decidedly peculiar and obscure symptoms, resulting from cause or causes hat in the majority of cases would have been selflimited. A scratch from a cat, a pin or needle-point piercing the derma, a contused wound, soap upon chapped hands, and numerous other causes, may here and there produce results at once severe and even dangerous to life. We are sometimes told this is because of "bad blood," or other disordered conditions of the system. But it is far from satisfactory; for, on giving the matter a little thought we are unable to reconcile matters in this way, and we are forced to conclude that, as a rule, it must be a resident physical property per se, and not the result of "bad blood," or "derangement of the system;" for the majority so exposed get no unfavorable result from such exposure, though circumstances warrant me in expressing the opinion that cases now and then occur that may manifest a similar train of symptoms to the above, from causes that may have failed many times, and, in fact, always up to some special condition of life, as if a female, the menopause, or if a male, the critical period that seems to come to some, if not all, at a certain age.
In dismissing my subject I remark that I am aware I have not stuck to the text of "self-limited disease," but have rather
alluded to the sequela that often follows disease that should be self-limited; as I do not regard simple gastric disturbances and resultant concomitants as disease, though indeed they are not always self-limited, and may cause the medical man much anxiety. Nevertheless I pass them, as I do the common cold and the many after results; having followed the train of though therein presented, because I have found more to do in this direction, and am aware of imperfections, as I have not aimed at exactness, but rather practicality.
MALARIAL HEMORRHAGIC FEVER-MALARIAL HÆMATURIA.
By J. W. PRUITT, M. D., Russellville, Arkansas.
If we except yellow fever from our category, the malady under consideration must be considered as the most formidable as well as fatal disease of the Southwest, the mortality reaching sometimes as high as thirty-three per cent. All medical authorities that we have consulted, and they are not a few, are silent in regard to it. Only an article now and then, in some medical journal, from a rural practitioner, near the habitat of the disease, constitutes the major part of the literature upon the subject.
Those who long reside near swamps, marshes, and sluggish water-courses, are the most frequent subjects of malarial hæmaturia; indeed the writer has never known or heard of any one being attacked who had not long dwelt in such a region. The disease may be found prevailing at any time, during the summer or early fall-months, but more particularly when there is a mixture of wet and hot weather, or when very hot weather succeeds a long wet spell. Other observers say that they have seen it more often during the cold season.
For a longer or shorter period varying from ten days to as many weeks the patient will be in a condition of general malaise, hardly knowing what is the matter with him, unless
he has seen cases of the disease. Pretty soon appearances of anæmia set in, with a slight cyanotic appearance of skin; the appetite may or may not be somewhat capricious; bowels loose or costive; pain about the region of the kidneys. Sooner or later a well-defined chill sets in of longer or shorter duration, sometimes with feeble reaction.
The history of every case I have ever seen leaves no doubt on my mind that it is the result of chronic malarial poisoning of the blood. I do not propose to discuss the question of malaria in this paper, but for a full exposition of the subject refer the reader to the investigations of Klebs and others in the Roman Campagna, published in the Eclectic Medical Fournal a few years since. I accept the theory of Malaria, till a better one is found, as accounting more perfectly for the phenomena of periodic fevers than any other. That the poisoning is chronic is evidenced by the time the patient complains of feeling unwell, and if he is at all acquainted with the disease he will tell you that he is going to have an attack of "Swamp Fever."
If the vital resistance of the system is great, the outbreak of the disease may be longer in taking place, but if feeble the period will be shorter. But sooner or later the kidneys, skin and other emunctories of the system being exhausted in their efforts to remove the materies morbi from the blood, the final onset of the disease takes place.
The disease manifests itself in two forms, the sthenic and asthenic. The latter is much more frequently encountered than the former, owing perhaps to the system being debilitated by the longer-continued depressing effects of the morbid material in the blood. Fortunately this disease is somewhat rare, not occurring as often as might be supposed. For example, in the course of one season, from one to a dozen cases may be encountered, and then several years may elapse before another case is seen in the same region. It is said to be encountered more frequently in some localities than others. The district south of Memphis, bounded by Nonconnah creek, Horn Lake, and the Mississippi river, is a region where it is said to be frequently found.
In the sthenic form the symptoms do not materially differ from the asthenic, only in their severity. The patient may be up and about, only feeling a slight aching in the bones, with chilly sensations for a few days; when suddenly the disease makes its onset, as manifested by a chill of greater or less severity. This is succeeded by the hot stage, that lasts ten or twelve hours, with pain in the head and back, the pulse full and bounding, the tongue full, sodden, and only slightly coated, or it may be covered with a dark-brown fur. The bowels are generally costive; the eyes may or may not be at this stage slightly tinged with yellow. The hot stage is succeeded by the stage of remission, which is generally of short duration. So far the symptoms detailed are those of a severe attack of remittent fever; but at about the second or third rise of the fever hemorrhage from the kidneys sets in, together with a general icteric condition of the skin requiring only a few hours for its full development. The hemorrhage may be slight, or quite profuse, amounting in some cases to one-half the quantity of urine and blood discharged at one time.
In the asthenic form the symptoms are not so active, while those of vital depression are profound; also the prodromal stage is of longer duration. The patient may be up and about several weeks before he takes to bed, feeling bad and dull, and out of health, presenting an anæmic, slightly cyanotic appearance. Finally a chill supervenes, followed by slight reaction; patient dull and listless; the vital depression marked; bowels costive or loose; pulse quick, small, and easily compressed; tongue sodden, moist, with a slight dirty, yellowishbrown coat; skin cyanotic. On the second or third day hemorrhage, generally of a passive character, sets in from the kidneys, together with the peculiar icteric appearance of the skin, which may pass into a deep bronze, as the disease progresses; the dullness and coma become more profound, the vital depression deepens, until finally the patient sinks into the arms of death. But if the case is to terminate favorably, the hemorrhage after the second or third day of its duration gradually diminishes, the skin clears up, secretion is restored, but the patient is as weak and helpless as an infant, and his convalescence will have to be managed with great care.
No post-mortem appearances that we are aware of have ever been reported, but one would suppose, from the symptoms and course of the disease that there would be found the kidneys in a state of congestion with rupture of their bloodvessels, congestion of liver and spleen, the blood dark and loaded with carbon, and general congestion of the capillary blood-vessels.
Diagnosis.-The only disease this is likely to be taken for is yellow fever; but as that disease always prevails as an epidemic, together with watery, inflamed eyes, and absence as a rule of hemorrhage from the kidneys, these will serve as sufficient marks of distinction.
Prognosis.-This must be guarded in bad cases; in mild ones it may be regarded as favorable.
Treatment. In the sthenic form we begin the treatment with the special sedatives. Thus, if the pulse is full, hard, and bounding, we prescribe Veratri Virid tinc. gtts. xx to zss.; Aqua ad. ziv. Mix. S. Teaspoonful every half-hour or hour till the circulation is brought to as near a normal standard as possible.
To the above, if there should be determination of blood to the brain, as shown by a flushed face, contracted pupils, restlessness, etc.; we add tincture of Gelsemium, zj. to zij. If there is dullness and hebetude, we add tincture of Belladonna gtts. x. to xx. If the stroke of pulse is sharp and quick, small and corded, we substitute tincture of Aconite for that of Veratrum. In connection with this we use hot mustard pediluvia, and the alkaline sponge-bath to the entire surface every two or three hours. Should the hemorrhage set in early, before the sedatives have their desired effect, nothing that can be done will have much effect in controlling it, but as soon as sedation is established and the skin begins to assume the peculiar icteric hue, we then prescribe the following: Specific Tincture o Chionanthus, zvi.; specif. tinct. of Rhus aromatica ziij. Mix. S. Forty to sixty drops every three hours. This has a wonderful effect in clearing up the skin and abating the hemorrhage. Do not waste time with small doses of the tinctures of Chionanthus and Rhus, if you expect to accomplish anything good for your patient. It is the worst kind of nonsense.