Some writers differentiate between subintrant (seu subingrediens) and subcontinued. In this case the name subintrant is applied to that continued or remittent fever which arises by prolongation and anticipation of the paroxysm, the expression being limited to benign fevers. (See Special Part, Div. 1.) This is the benigna continuitas of Torti. The name subcontinua is applied, for instance, by Baccelli, to the continued fevers that arise by the increase of the paroxysms in the course of twenty four hours. Torti understands by subcontinua a fever that was at the same time continuous and malignant. We consider it unnecessary to complicate the matter to such an extent; and, as will be shown later on, it is often impossible to make such differentiations. After several days, remittent, as a rule, goes into intermittent.
In reference to the pure continued, it is only necessary to say that it usually lasts but a few days, and then, by crisis or by becoming remittent or intermittent, proceeds to recovery or death.
We have at our disposal only a very small number of intact curves of remittent and continued fevers, for the reason that these diseases are frequently dangerous from the beginning, and the administration of quinin must be begun as soon as the condition is recognized; thus, in the majority of cases; breaking up the fever.
Any one of the foregoing types of fever may be manifest throughout an attack, though they frequently combine, thereby producing a great variety of fever curves, which may confuse the physician who is accustomed to see only the simple forms, as they occur, for instance, in central and northern Europe.*
The temperature may reach a considerable height (hyperpyrexia) -41° C. (105.8° F.) and over is not rare. Subnormal temperatures are also seen, especially in the algid forms. Gueguen once observed in such a case a temperature of 33.4° C. (92.1° F.).
The fever paroxysm, with its three classic divisions, chill, fever, and sweating, is especially common to malaria ; though in the severe genuine quotidian, remittent, and continued fevers, it may be entirely wanting or be only suggested. This fever paroxysm is not at all peculiar to malaria , since it occurs very frequently in other infections, as ephemera, influenza, sepsis, and at the beginning of all acute infections. Yet in connection with the other symptoms of the disease it often is a characteristic in the diagnosis.
Mild prodromal symptoms, as malaise, headache, yawning, loss of appetite, eructation, etc., usually precede the fever paroxysm by one or more days. The chill usually sets in suddenly, with greater or less violence. Its severity may vary between a light tremor and the most violent shaking and chattering of the teeth, sufficient sometimes to break them. Patients have not always the sensation of cold, and then appear so only from the forcible shaking, though this feeling is usual, and they bury themselves under numerous covers to become warm, and crouch together in order to lessen the general surface of the body. The condition is often rendered worse by headache, nausea, and vomiting. Objectively the pallor of the skin and the coldness of the extremities are striking. Cutis anserina is frequent. The lips are livid, as are, likewise, the nails; the face is anxious; the pulse is small, hard, and rapid; the breathing is superficial, hastened, frequently dyspneic, and disturbed by the impulsive tremors in which the diaphragm also participates. Senac first made the observation that the mouth temperature did not sink during the chill; de Haen discovered the important fact that it was even elevated, and Gavarret showed that this rise began sometimes before the chill. The skin of the patient is not always cold; in fact, it is sometimes warm; yet, as Lorain has shown, the superficial chilling may proceed so far that the mucous membrane of the mouth and of the rectum feel cool.
* For the sake of completeness we will mention several types which were constructed rather than observed by old writers. These are mentioned to day only out of respect for the old names. Among these belong: Amphimerina-continued quotidian; triaeohya (syn. semitertiana, hemitritaeus) = continued + tertian; tetartophya = continued + quartan.
After the chill has passed the patient begins to feel somewhat better, yet this euphoria is transitory and is soon supplanted by a burning heat. This stage is usually more bearable for the patient than the chill. Subjectively, in addition to the feeling of heat, there occur burning sensations in the eyes, thirst, and a throbbing in the head. The face of the patient is flushed, the conjunctivae are injected, the pulse is full, soft, and often markedly dicrotic. During this stage the temperature rises to its acme, frequently reaching 41° C. (105.8° F.). A rapid decline usually follows, during which the third stage appears. The sweating is sometimes trifling; yet more often abundant, so that the patient must change his linen over and over again. It has sometimes a peculiar, sperm like, characteristic odor. At this time the patient feels tired and exhausted, but otherwise in a condition of euphoria. The temperature has in the mean time dropped considerably, and the pulse is often retarded. All three stages may be individually or together abortive. The hot stage is wanting most frequently, and if, at the same time, the chill was slight, the patient may overlook the paroxysm and deny its occurrence, though the thermometer would possibly have shown over 39° C. (102.2° F.).
The assertions, therefore, of the majority of patients, when they are not confirmed by the thermometer, are not to be trusted. Positive results are obtained only by the regular taking of the temperature every two hours.