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Chronic Malarial Fever.

Synonyms.—Malarial Cachexia; Chronic Ague.

Definition.—A persistent fever of an irregular type, partaking of the nature of both the intermittent and remittent fevers, and characterized by anemia; the skin being either sallow, doughy, and inelastic, or dry and constricted; there is enlargement of the spleen, congestion of the portal circulation, and disordered condition of the digestive apparatus.

Pathology.—Anemia is quite marked, the malarial poison causing a wholesale destruction of the red corpuscles. The viscera, especially the spleen, liver, and kidneys, are dark red, owing to a deposit of the pigment of the blood following the breaking down of the corpuscles.

The spleen is enlarged, sometimes filling the left abdominal cavity. There is congestion of the liver, and the kidneys show extravasation of blood. There may be albuminuria and dropsical effusion. The skin presents a jaundiced appearance.

Symptoms.—The symptoms of chronic malaria are legion; the blood being deranged, nearly every organ and tissue is affected, hence the great variety of symptoms. There is generally disturbance of the circulation. This may result from the enlarged spleen pressing against the diaphragm, and which, by crowding the heart, gives rise to frequent palpitations or irregularity in its beat.

In severe cases, where there is marked congestion of the liver, there will be repeated attacks of asthma, owing to pressure of the liver against the diaphragm, and this in turn against the lungs, thus impeding a free respiration. The tongue is nearly always coated, with a disagreeable taste in the mouth. There is derangement of the stomach, which gives rise to many symptoms of dyspepsia. There may be gastric irritation, of which nausea and retching, are prominent features; here. the tongue is, narrow and elongated, or there is atony, with fullness of tissue, the tongue being broad and full.

The liver being congested in nearly all cases, we have, as a result, an-icteric hue to the skin. The abdomen is enlarged, owing to hypertrophy of the liver and spleen; hence there is great dullness on percussion. There is a dull, aching pain in the loins, and not infrequently dropsy, as a result of impaired function of the kidneys. The skin is usually dry and harsh, although it may be relaxed, cool, and doughy. There is constipation, alternated with diarrhea. Dysentery is not an infrequent complication. With these various symptoms, there is associated the periodicity of malaria.

The nervous system feels the influence of the poison very early, and headache and general myalgia naturally follow.

The chill may occur with the marked regularity ,of the simple intermittent, or it may be erratic, occurring when least expected. Again, there may be an absence of the cold stage, but occasional exacerbations of fever of an irregular type; or the disease may be characterized by periodic neuralgias, such as facial, bronchial, or sciatic. Again, the periodic character may be so slight that, if we are not careful in our examination, we will overlook entirely the true nature of the disease.

Diagnosis.—This is generally easy. The history is of great importance, the patient having resided in a malarial section and having suffered from frequent acute attacks. The cachectic appearance due to the marked anemia; the jaundiced, waxy, or doughy skin; the enlarged spleen, which is characteristic; the congestion of the liver, and the periodical manifestation which a careful study will reveal, point conclusively to the nature of the affection.

Prognosis.—The prognosis will depend to some extent upon the length of time, or the stage of the disease. If the engorgement of the liver and spleen has been followed by more or less degeneration of these organs, or if there is dropsy with Bright's disease, the case is unfavorable, and, while some relief may be promised, a cure is out of the question.

Treatment.—While quinia is a very important agent in malaria, there are few cases of a chronic nature which it will cure. The complication, whatever it may be, must be overcome before it will be of any use, and many cases will be relieved without the administration of a single dose of quinia. If periodicity is the most distinctive feature, the basal lesion, quinia will cure, but in the large majority of instances this is not the case.

The early Eclectics were peculiarly successful in the treatment of this disease, and I can not do better than to reproduce a large part of the treatment as given in "Scudder's Practice." I believe the practitioner will find it the only rational method, and an experience of twenty-five years confirms it.

"Remedies that Influence the Circulation.—I claim that any case of intermittent fever showing increased temperature, increased frequency of pulse, torpor of the organs of excretion, and irritation of the nervous system, should have the sedative before giving quinine, as a part of a good treatment. It is true that persons suffering from ague do not like to wait the slowr actions of remedies: they want it broken at once; yet if they are told that the slower cure is the more rational one, they will take it in preference.

"A man showing the wrongs that would ordinarily call for sedatives, may have the ague broken by antiperiodics; but it returns again and again, and gives us a chronic case.

"Aconite.—If the patient has a small, frequent pulse—usually small and hard during febrile reaction, small and soft in the intermission, the tissues being somewhat contracted, color not very much changed—I would recommend the administration of aconite, say,—

Tincture Aconite 5-10 drops.
Water 4 ounces. M.
Sig. A teaspoonful every one or two hours.

"Veratrum.—Veratrum does not seem to have as large a field of usefulness as aconite, but still we have an occasional case where it is useful. The pulse is frequent and full, the tissues full, the patient full-blooded. Prescribe it in the usual dose:

Tincture Veratrum 20-30 drops.
Water 4 ounces. M.
Sig. A teaspoonful every one or two hours.

"Lobelia.—Lobelia is used for its influence upon the circulation, as well as an emetic, and it is this first use we wish to study here. There is a sense of precordial oppression, with difficulty in respiration, and a full, oppressed pulse; we give the tincture of the seed in doses just short of nausea. In the olden time an extract of lobelia was combined with black pepper or piperine, as in the following:

Extract of Lobelia 10 grains.
Powdered Black Pepper 2 drachms. M.
Sig. Make three grain pills, and give one every hour.

"Gelsemium.—Though the influence of gelsemium is primarily upon the cerebro-spinal centers, it also influences the circulation, and we may study it here. In the ordinary treatment of ague, many physicians use gelsemium associated with quinine where there is evidence of an excited nervous system. The flushed face, bright eyes, contracted pupils, increased heat of the scalp, restlessness, and irritability, are the common symptoms indicating it.

Gelsemium 20-60 drops.
Water 4 ounces. M.
Sig. A teaspoonful every three hours.

"Belladonna.—Belladonna is the remedy for congestion of the nerve centers, as marked by drowsiness and tendency to coma during the paroxysm of fever. The face is dull, expressionless, the eyes dull, the pupils dilated, and indeed there is want of expression in all parts of the body. In the recent disease, we give belladonna, in such cases, as a preparation for quinine, and in a chronic case, where the symptoms were marked, we would expect it to cure. Usually there is the indication for aconite as well, and we would give the two together, as,—

Tincture Belladonna 10 drops.
Tincture Aconite 5 drops.
Water 4 ounces. M.
Sig. A teaspoonful every one or two hours.

"There are other remedies that might be grouped with these, that we sometimes find useful, but the above must suffice for the present.

"Remedies Influencing the Digestive Apparatus and the Spinal and Sympathetic Nervous System.—I think the lesions of innervation associated with wrongs of the digestive apparatus are more important than the functional wrongs of the organs themselves. We never have a wrong of the stomach, bowels, liver, or spleen, that we have not an equal wrong of innervation from the solar plexus, and sometimes of the spinal cord.

"Emetics.—In the olden time the emetic was a prominent means for the cure of chronic ague, either as preparing the way for antiperiodics or serving instead. Even yet, with our abundant means, we find cases in which the emetic is the shortest way to a cure. The case is well marked, and needs not be mistaken. There is a marked oppression of the nervous system, and oppressed pulse and perspiration, sensations of weight or fullness in the epigastrium, disgust for food, and a tongue broad and heavily coated at the base. In such a case a thorough emetic gives prompt relief.

"Cathartics.—I deprecate the common use of cathartic medicines, and feel confident that many failures, even in the treatment of ague, are due to their injudicious use. Still, if there is evidence of material in the bowels which serves either as a cause of depression or of irritation, it should be removed. Simple constipation is not sufficient to justify their use. The simpler the means, and the milder the action, the better it is for the patient in the ordinary case.

"Podophyllin.—There is a condition of the nervous system, and of the circulation, calling for this remedy, as well as a condition of the digestive apparatus. In the recent disease there is a case in which Podophyllin prepares the way for a cure by quinine. There is oppression of mind, of muscular action, of respiration, of the circulation. The tongue is broad, coated from base to tip, the face is full and expressionless, and there is especially fullness of the veins with evident impairment of venous circulation. Even the old-fashioned emeto-cathartic with podophyllin serves a good purpose here.

"In a chronic case of ague presenting these symptoms, I should give Podophyllin in doses sufficient to obtain its full action.

"In some cases we do not want the decided action of podophyllin. The ague has been arrested for the time, and we are looking to a radical cure. There is an atonic condition of the stomach, of the intestinal canal, of the organs associated with it, and oppressed innervation from the sympathetic; the patient is dizzy, suffers from dull headache at times, and does not feel like work. In such cases I prescribe Podophyllin with hydrastia in small doses, as the following:

Podophyllin 2 grains.
Phosphate of Hydrastia 10 grains. M.
Sig. Make forty pills; one or two may be given each day midway between meals.

Nux Vomica.—We use nux vomica in the recent disease, where there is nausea, colicky pain in the bowels, pain in the right hypochondrium pointing to the umbilicus, and a yellow sallowness of the skin.

"In some cases of persistent ague these symptoms are very marked, especially the abdominal pain, and an unpleasant color of the surface; then nux vomica may cure when the antiperiodic treatment has failed. In some cases I give it alone, in small doses, as,—

Tinct. Nux Vomica 5 drops.
Water 4 ounces. M.
Sig. A teaspoonful every one or two hours.

"It may be alternated with any other remedy indicated; and even with aconite.

"Alkaline Salts.—There are cases in which the alkaline salts become important remedies, or even curatives. The broad, pallid tongue is the indication, and when present I would never think of treating a case without the use of a salt, usually of soda.

"Sodium Sulphite.—We meet with cases showing distinct indications for this antiseptic salt. The tongue is broad, pallid, and dirty, retrograde metamorphosis is defective, and the tissues look old and inactive. Sulphite of soda will frequently cure these cases, giving it in doses of from ten to twenty grains every three or four hours.

"Acids.—While acids may not be curative alone, they will aid other remedies, or prepare the way for other remedies. The deep-red tongue is the indication, and muriatic or lactic acid is the remedy.

"Uvedalia.—Among the wrongs arising from continued ague, none are so common and characteristic as enlargement of the spleen-ague cake. With this disease of the spleen, the ague will continue to recur despite all antiperiodic treatment. In some cases we will find the liver enlarged, evident engorgement of the mesenteric glands, and sometimes general disease of the lymphatics.

"For these cases uvedalia is undoubtedly the specific. We use the ointment of uvedalia as a local remedy, applied over the enlarged spleen or liver, or even over the entire abdomen. It is well to use heat with the application, covering the part with flannel, and passing a warm iron over it. The application should be thorough and repeated every day. Internally, we give it in doses of from one to twenty drops, three or four times a day.

"Chionanthus.—We have the still more rare case of chronic ague associated with jaundice, and examination does not show incurable structural disease of the liver. The more common case is one of irritation marked by uneasiness in the right hypochondrium, and tenderness on pressure. In one such case a radical cure resulted from the employment of the tincture of chionanthus alone, in doses of ten drops every three hours.

"Tonics.—The advantage of a tonic treatment following the breaking of an ague has long been recognized, and good practitioners always examine the patient with reference to their need of this class of remedies. The bitter tonic improves the appetite, and gives better digestion and blood-making, and increases the power of the tissues to appropriate nutrient material, and in this way increases the resisting power of the body to the disease. Many of these also improve innervation through the sympathetic, and thus strengthen the vegetative functions of the body.

"Restoratives.—Restoratives are also of importance in many of these cases. There is the indication of a special want of some material in the body, and blood-making and nutrition will not go on well without it, or some organ or tissue can not be made without it. Thus there may be the want of phosphorus, of iron, of sulphur, of silica, as well as of soda or an acid, or food. It may be that the administration of a teaspoonful of the compound syrup of the hypophosphites after each meal will be the one thing wanting to restore the resisting power of the body, or a tablespoonful of cod-liver oil may be the thing wanting to give right combustion and a normal temperature.

"The Excretions.—Physicians have also recognized the relation between excretion and the ague: when excretion was deficient or otherwise changed, the ague would continue.

"Our school of physicians has given more attention to the skin, and have placed remedies to increase its activity among the foremost. There are cases, certainly, in which the ague is perpetuated by a wrong of the skin. With a harsh and dry skin, it is almost impossible to effect a cure, as it is also with a soft and relaxed, doughy or inelastic skin.

"In addition to the usual baths for the different conditions of the surface, let me again call attention to the use of fatty inunction and quinine inunction. Frequently this seems to answer the purpose in both cases. Where the skin is harsh and dry, and where it is doughy and inelastic, it is one of our most efficient means of cure, and I usually order a quinine inunction in the proportion of drachms .5 to drachms 1 to the ounce of lard, and have the body thoroughly rubbed with it once or twice daily. Thorough rubbing is the expression, although a large quantity of the ointment need not be used, and if the skin is inclined to be greasy, it may be rubbed clean with soft flannel.

"Potassium Acetate.—Golding Bird placed great stress on obtaining free excretion from the kidneys in these protracted agues; he claimed that cures could be effected by the use of acetate of potash, when all antiperiodics had failed. 1 know by experience that some of these old agues can be cured by the saline diuretics, and possibly can only be cured by them. Take a case where the tissues are inelastic and sodden, and the renewal of tissue is slow, I should give a solution of potassium acetate in preference to all other means. From one to three drachms is divided into doses very largely diluted with water, and given daily, and continued for one or two weeks.

"Specific Remedies.—Physicians recognize other antiperiodics than quinine, but they must concede their inferiority in the ordinary ague. The other alkaloids of the Peruvian bark are now being used to a considerable extent, although, in the main, the only difference between these and quinine is less cost. Other than these I do not know of any remedies that can be classed with quinine as antiperiodics.

"Cuprum.—We occasionally have a case where copper is the remedy par excellence. My first experience with the remedy was so successful that I have ever since been an admirer of its curative power. The patient had been shaking with a regularity which is so characteristic of some of these chronic cases. Quinia had been given in large doses and in small doses, but all to no effect. I found the patient with a sallow, doughy skin, the color of the yellow-green cast that one occasionally sees in chronic ague. The tongue was broad and of the same peculiar yellowish-green order. I prescribed tincture cuprum 20 drops, water 4 ounces, teaspoonful every three hours, and in less than ten days the patient considered himself well, although I had the remedy continued for several days longer, for fear of a relapse.

"Carduus marianus, ceanothus, and grindelia squarrosa are remedies that influence the spleen and liver. (See 'Pernicious Intermittent' for their indications, etc.)

"Arsenic.—Arsenic is in very common use as a remedy for ague, and sometimes exerts a remarkable influence in effecting a cure. But, as ordinarily used, it sometimes exerts a remarkable influence in the opposite direction, which is quite unpleasant for the patient. Some of the patent 'ague cures' contain arsenic; as, for instance—(I will not name them, as the proprietors are very sensitive on the subject.) I have known a preparation of euonymus, quinine, and Fowler's solution of arsenic used successfully, but I can not recommend it.

"When I use arsenic it is in minute doses for its specific effect. Given a chronic case of ague, with soft, feeble pulse, lifeless inelastic skin, and tongue pale, small, and coated with slimy fur, I would think of the arsenic pellets. Take of the medium-sized Homeopathic pellets sufficient to fill an ounce bottle half full, drop on them five drops of Fowler's solution of arsenic, shake them well together, and, when dry, we have the small quantity. Ten of these may be given every three hours. It is well to say that the indications for the large-and small doses of arsenic in the treatment of chronic intermittents are just the opposites of one another.

"Nitric Acid.—Among the positive remedies used in the cure of protracted ague we must not forget nitric acid. The indication is very distinct, a violent coloration of the tongue, and more slightly of any part where the circulation shows free. In the typical case the violet color is transparent, seeming like a glaze on the tongue; it is never a dull, solid color. In these cases I prescribe,—

Nitric Acid 20 drops.
Aqua Dest 2 ounces.
Simple Syrup 2 ounces. M.
Sig. A teaspoonful every three hours.

"Complications.—It may be remarked, in conclusion, that sometimes a complication of functional or structural disease will continue the ague, in the same way that the malarial poison will continue a local disease. Thus I have known an ague continued by amenorrhea, by dysmenorrhea, and by menorrhagia, as I have by disease of kidneys, bladder, urethra, or other structure. It is safe in all cases to take it for granted that this is the fact, and in intractable ague associated with local or functional diseases, to adopt a treatment for their, cure.

"Lastly it may be said, whenever there is a special indication for any remedy, it will prove a remedy in ague, as it would in other diseases. It may be preparatory for the use of the anti-periodics, associated with them, or it may cure alone. This advice is therefore given, to examine each patient carefully with reference to symptoms calling for special remedies, and to use remedies thus indicated."

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.

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