683 ACUTE INFECTIOUS DISEASES 



tent malarial fever among the exotic diseases and pass it by, but I 

 shall follow the excellent description of Griesinger in my short ac- 

 count of it, as I have but little knowledge of the affection from per- 

 sonal observation. 



The dependence of remittent fever on malarial infection is shown, 

 first, by its exclusive occurrence in places where we know, from the 

 quality of the soil and climate, and from the occurrence of numerous 

 cases of intermittent, that there is an intense malaria ; secondly, from 

 the many cases where remittent fever becomes intermittent. "We do 

 not know whether the change of symptoms be due to a modification 

 of the poison, and, if so, in what this modification consists. The more 

 severe the cases of intermittent, the more frequent are the remittent 

 cases. 



ANATOMICAL APPEARANCES. As regards the melanaemia, the post- 

 mortem appearances of remittent fever correspond with those of per- 

 nicious intermittent. At least, in almost all places where remittent 

 fever is endemic, in the rare cases of autopsy it has been noticed that 

 the cortical substance of the brain is of a dark, ashy hue, and the 

 spleen and liver are blackish. Besides these changes, which are not 

 constant, traces of more or less severe icterus are often found, some- 

 times with, again without, obstruction of the gall-ducts ; as well as the 

 remains of catarrhal and diphtheritic inflammation of the intestines, 

 and, more rarely, haemorrhages into the stomach, haemorrhagic infarc- 

 tions in the lungs, or lobular pneumonia. 



SYMPTOMS AND COURSE. Griesinger distinguishes three forms of 

 remittent fever. According to him, the first and mildest form begins 

 with a sudden feeling of severe illness, high fever, and foul stomach. 

 These are soon accompanied by enlargement of the spleen, mild jaun- 

 dice, irregularity of the bowels, discoloration of the faeces, and herpes 

 labialis. The depression of the patient, the pain in the head and 

 limbs, the dizziness, noise in the ears, and not unfrequent bronchitis, 

 remind us of a commencing typhus ; but from the first the fever shows 

 a decided remittent character. Irregular exacerbations, which subse- 

 quently become regular, and usually have a quotidian type, are fol- 

 lowed by distinct remissions. These gradually pass into perfect inter- 

 missions, the patient sweats freely, and feels well; the remittent 

 becomes a simple intermittent. In other cases, even without this 

 change, the disease terminates in recovery, by a gradual decrease of 

 the symptoms ; it lasts from a few days to three weeks. 



In the severer form the fever is very high, the remissions are well 

 marked only at first ; the disease reminds us of a severe typhus ; the 

 patients become stupid and delirious ; the tongue grows dry, and the 

 spleen is enlarged. Generally, also, but not always, there is icterus ; 



