Definition:—A chronic condition more or less general in character, which results from the persistence of the malarial Plasmodium within the blood.
The pathological conditions induced from the presence of malaria are probably as persistent as those of any single cause of disease, when chronic changes have been produced in the blood and in the glandular and blood-making organs. A cachexia, when present, is usually the sequel of some of the acute manifestations of malaria which have not been influenced by treatment. It is only found in malarial localities and in these the cachexia may slowly develop without acute primary manifestations.
Symptomatology:—As long as the Plasmodium is not entirely destroyed there is apt to be a recurrence of fever. This may occur regularly, or irregularly remittent, or with periods of complete intermission. The irregular character and recurrence of the fever is the most conspicuous symptom of the cachexia; chills seldom occur, but may precede the fever irregularly for a day or two at a time; the temperature is usually not high at any time, seldom reaching 102° F.; the appearance of the skin is peculiar; it is usually tinged a dirty yellow, or yellowish brown, and is rough, harsh and dry; the sallowness increases, the conjunctivae becomes tinged, and jaundice is finally fairly established. Enlargement of the liver is soon apparent and this sometimes increases to a marked extent, and there is tenderness on pressure over this organ, with a sensation of fulness and occasional little, sharp, cutting pains. Enlargement of the spleen is almost a pathognomonic symptom, it becomes indurated, and often tender, and occasionally the hypertrophy of this organ is excessive. With this the character of the blood changes until the patient becomes profoundly anemic, and this condition induces a further change in the color of the complexion, which may be said to be characteristic of the advanced stage of the disorder. Other blood derangements may follow and there is atonicity of the gastro-intestinal tract, with chronic catarrh of its mucous linings, loss of appetite, and marked malnutrition.
The condition which is called masked-intermittent, which resembles in its symptomatology the condition just described, to my mind should be included in cachexia. However, in masked-intermittent there may be no fever present, or it may recur after long, irregular intervals for a short period only, and when so occurring it may be accompanied with diarrhea or dysentery, with extreme anorexia or there may be severe headache, or erratic attacks of neuralgia. These conditions may all occur independently of any fever, with distinct periodicty. This is especially true of neuralgia. They may be accompanied with marked nervous manifestations, as cerebral hyperemia or convulsions. Another distinct manifestation is that of hematuria, which is usually distinctly periodical in character. This is classed as malarial hematuria. It is much more likely to accompany the pernicious form of the disease, or to occur during a slow and unsatisfactory convalescence from that disease. Other hemorrhages are apt to occur in malarial cachexia, such as bleeding from the nose, from the gums, and hemorrhage into the retina with ecchymoses and petechias
Treatment:—If the specific indications for treatment are closely observed in the acute conditions, chronic manifestations seldom occur. The results of specific treatment are nowhere more satisfactorily manifested than in malarial cachexia. The continued use of aconite over a period of several days, during the continuance of the irregular fever, is of service, and if the indications should not be plainly marked there are no contra-indications. When there is tenderness on pressure or deep soreness, with quick shooting pains, especially if there are evidences of the involvement of any contiguous serous membrane, bryonia must not be omitted. It causes a steady but satisfactory abatement of these symptoms and at the same time exercises a secondary influence upon the functional action of the liver. The underlying congestion, which in these conditions is more or less chronic, and correspondingly intractable, will be met very satisfactorily with belladonna.
A typical case of malarial cachexia was that of a young lady who consulted me, after nearly three years of illness in which she was confined to the bed only on very rare occasions. There was an irregular fever which had suggested the possibility of tubercular infection, in which the intermissions were seldom complete. There was anorexia, extreme lassitude, muscular soreness, and occasional violent headaches. The characteristic appearance of the skin was present, the skin and the extremities were inclined to be cool and there was yellowness of the conjunctivae. The stools were clay-colored, pasty, and floated upon water; there was deep soreness of the liver with occasional shooting pains. The patient implored me not to give her quinin, strychnin, calomel, iron or the bitter tonics, as she had taken them at the advice of several physicians during almost the entire period of her illness, with an aggravation only of the symptoms. She was given bryonia and belladonna for two weeks, with hot applications over the liver, and sodium phosphate in full doses in hot water before meals. The soreness soon abated, the temperature became normal, the skin and the tongue were inclined to clean, and after three weeks she was then given two grains of quinin and one-fourth of a grain of leptandrin every three hours. Later hydrastin and capsicum were added.
When nervous phenomena are present in this condition and the indications for quinin are present, it may be given with gelsemium with excellent advantage. The influence of both remedies is apparently heightened by combination. Prof. Locke advised an infusion of eupatorium perfoliatum, when in this condition there is sluggishness of every function with no reaction following even distinct remissions of the fever, with little if any perspiration, and extreme aching of the muscles and bones. He advised that the infusion be given in three ounce doses every half hour, beginning at the time the fever would increase. This after a few doses would induce perspiration and perhaps vomiting. The patient was then to be put to bed and a mild perspiration sustained for perhaps three or four hours. In any malarial condition where there is intermittent headache or severe irregular browache, this remedy will exercise a specific influence.
In the above form of ague, Dr. Pruitt succeeded admirably in the use of an infusion of the husks of common field corn—maize. He continued the remedy during all stages of the disorder. It controls the persistent temperature, quiets irritability, and restores the functional activity of the stomach, regulates the action of the liver, and also the kidneys, and reduces enlargement of the spleen.
The old writers placed much confidence in the action of uvedalia in malaria, where the spleen was enlarged. Scudder advised an ointment for free external use, and twenty drops of the tincture, three or four times daily, was given internally. It is specific in congestion and chronic hypertrophy of the ductless glands, especially efficient if there be a full, sodden, inelastic, flabby condition of the tissues of the body.
A woman forty-three years of age, from protracted ague, developed extreme jaundice, with enlargement of the liver, anorexia, constipation with clay-colored feces, and great debility with ultimate emaciation, being reduced from one hundred and forty-five pounds in weight to ninety-three pounds. Edema of the feet and limbs appeared, soon followed by general anasarca. The anemia was extreme. The patient was given small doses, every three hours, of chionanthus, iris versicolor and apocynum in an elixir of hydrastis canadensis. The chionanthus for the hepatic congestion and jaundice, the iris to arouse the liver to normal functional operation, to stimulate the intestinal glandular organs and to enforce the chionanthus; the apocynum for the dropsy and to increase the power of the heart; the hydrastis as a tonic, both to the nervous system and to the stomach and appropriative organs. While I do not usually approve of combinations, these four remedies work in perfect harmony, with the indications here present, operating like a single remedy. After three or four weeks with this combination this patient had a syrup of the glycerophosphates and strychnin, with the hydrastis elixir. This completed the cure.
In gastro-intestinal disorders which accompany chronic malarial manifestations, Dr. John Fearn advises the use of alstonia constricta. It has cured for him atonic dyspepsia, lienteric diarrhea and dysentery. It relieves gastric and intestinal pain and antagonizes all the malarial processes. King cured obstinate cases of tertian fever with this remedy alone.
Other remedies which will be indicated for the hepatic and splenic complications of malarial poisoning, and which should be studied with reference to their adaptation to certain intractable phenomena in severe cases, are podophyllum, leptandra, iris, chelidonium, helonias, ceanothus, sodium phosphate and magnesium. These are certainly preferable to mercury when their specific application is thoroughly understood.
Holmes, of Florida, has observed the action of boldo—peumus boldus—in these obscure liver and splenic disorders, and claims an influence not obtained by any other remedy or combination of remedies. He claims that it relieves the toxemia, of whatever character, favors the resumption of the normal functional action of the liver and spleen, without increasing intestinal peristalsis. In five cases in which he used it with perfect results there was pain in one or two cases, resembling that of gall stone, and tenderness in the right hypochondrium, extending to the epigastric region. The skin was yellow, the urine scanty and dark, the tongue heavily coated in the center, the tip and edges red. The patients were dull, indisposed to exercise, sleepy, the pulse was about 95 and the temperature about 100° F. There was nausea and vomiting. In one of the cases the symptoms increased in severity and the temperature at times reached 105° F. Boldo was given in dram doses of the fluid extract every four hours, with apparent improvement from the first, and ultimate recovery in all the cases.