(AGUE)
=Definition.=—An infectious disease caused by the hemocytozoon of
Laveran. “It is characterized by paroxysms of intermittent fever of
the quotidian, tertian or quartan type, a continued fever with marked
remissions, a pernicious or rapidly fatal form, and a chronic cachexia
with anemia and enlarged spleen.” (Halbert). The varieties of malarial
fever are: intermittent fever; pernicious intermittent; remittent
fever; malarial cachexia; masked intermittent; malarial hematuria.
=Osteopathic Etiology= and =Pathology=.—Malarial fevers are caused by
a parasite known as the hematozoon of Laveran. Three varieties of the
parasite have been separated, corresponding with the three leading
forms of the affection. The parasite of tertian fever is about as
large as a normal red blood-corpuscle, beginning as a small hyaline
ameba in the red blood-corpuscles. The parasite of quartan fever is
very similar in its appearance to the tertian parasite but smaller;
its ameboid movements are slower and the red blood-corpuscle embracing
it shrinks about the parasite, assuming a deeper greenish color. The
parasite of the estivo-autumnal fevers is still smaller. “If only one
group of parasites exists the paroxysms—quartan intermittent—will occur
every fourth day. Double quartan infection will result in paroxysms
on two successive days with an intermission of one day. Infection by
three groups of parasites will create daily paroxysms—the quotidian
intermittent. Infection by more than three groups is rare.” (Anders).
Only in the earlier stages of development, small hyaline bodies are to
be found in the peripheral circulation; being, in the later stages,
in the blood of certain internal viscera, spleen, and bone marrow,
particularly.
It is an accepted fact among medical observers that to the mosquito,
_anopheles_, is due the spread of malaria and it has been the subject
of much investigation in all parts of the world. The mosquito becomes
infected from biting an individual whose blood contains the malarial
parasite, this is then developed in the mosquito to maturity and later
is transmitted to the next subject bitten. This explanation would show
why certain localities favorable for the breeding of mosquitoes are
particularly given to malarial outbreaks. Low, marshy grounds, banks
of rivers, small ponds, etc., as well as warm weather, are needed to
produce the conditions for the development of the _anopheles_. As
the country has developed the intensity and extent of malaria has
diminished until it is now confined largely to the southern states.
It is practically unknown in the northwest and in the St. Lawrence
basin. Regions which have never had cases, however, have developed them
when the _anopheles_ has appeared. Whiting notes cases in Southern
California, the result of the insect being brought in by ships from
Mexican or Central American ports. In certain regions the _anopheles_
is present but has not apparently come in contact with a malarial
victim, so is incapable of spreading the disease. Also in colder
climates this species is harmless.
By draining the lands and preventing the breeding places, the number of
the pests is reduced, while the screening of houses and care against
exposure to the bites make it possible to live in malarial sections
and not become infected. Naturally the resisting power of a patient
is called into account when bitten by the mosquito. Where it is
epidemic the inhabitants will be found, generally, poorly nourished or
debilitated from climatic or other conditions. This renders infection
easy, for immunity must come from the ability of the blood to combat
the invading parasite.
The =osteopathic predisposing causes= for malaria are usually
interference with the vasomotor nerves to the spleen and liver, as
these two organs are so concerned in maintaining the stability of the
blood tissue. Ligon, of Alabama, notes that most cases have lesions
between the ninth and twelfth dorsal on the right side.
The chief =morbid changes= are clue to the direct effect of the
malarial parasite upon the blood. There are also changes in the
liver, kidneys, and spleen, which changes usually vary with the
duration and intensity of the disease. The disintegration of the red
blood-corpuscles, accumulation of the pigment thus formed, and the
toxin engendered by the malarial parasite are responsible for the
morbid lesions of the disease.
In =pernicious malaria= the blood is more or less hydremic, and the
discs are seen in all stages of destruction. The spleen is enlarged
and soft and the pulp dark from the accumulation of the pigment, and
spontaneous rupture has occurred in a number of cases. The liver is
swollen and turbid; pigmentation occurs, but is generally only visible
by means of the microscope. By the aid of the microscope all the
tissues of the body, even the brain, may be found to be pigmented.
The =spleen= in =chronic malaria= is greatly enlarged, firm, pigmented
and the capsule thickened. The =liver= is enlarged, the color varying
from a slight gray to a deep slate gray, according to the amount of
pigment. The =kidneys= may be enlarged and deeply pigmented, as is also
the mucous membrane of the =stomach= and =intestines=.
R. W. Connor observes that the kidneys and liver are most noticeably
involved, vasomotor obstructions the rule, the spleen in the majority
of cases shows engorgement and that special attention to these centers
will give the best results. He invariably finds spinal lesions from
the seventh dorsal to the first and second lumbar, most frequently the
eighth, ninth and tenth dorsals. A lowered vitality predisposes to
infection from the bite of the mosquito.
=Symptoms.=—=Intermittent Fever.=—This form is what is known as fever
and ague, in which chills, fever and sweat follow each other. The
period of incubation varies from six to fifteen days, but it may be
months after exposure before the first paroxysms set in. The paroxysm
is usually preceded by a feeling of uneasiness and discomfort,
sometimes by nausea or headache. The paroxysm consists of three stages,
cold, heat and sweating.
In the =cold stage= the chill usually begins gradually; it is generally
intense, the teeth chatter and the body shakes violently. The skin is
cool and pale, the lips are blue, the face is pinched and the patient
looks very cold. During the chill the temperature rises rapidly.
Nausea, vomiting and headache are common. The pulse is frequent, small
and hard. The urine is increased in quantity and of low specific
gravity. The chill lasts from a few minutes to a couple of hours.
The =hot stage= succeeds the chill. The skin gradually loses its
coldness and becomes hot. The face is flushed, there is great thirst,
the mouth is dry, and the tongue is coated. Usually at the termination
of the chill the temperature has reached its maximum level, from 104
to 106 degrees F. The pulse is full, and there may be a throbbing
headache. The duration of this stage is from half an hour to three or
four hours. During the =sweating stage= drops of perspiration appear
upon the face; the perspiration soon becomes profuse, extending all
over the body. The temperature soon falls, the headache disappears and
in a couple of hours the paroxysm is over.
The entire duration of the paroxysm is from eight to twelve hours;
the patient usually feeling perfectly well between the paroxysms.
The spleen is enlarged. If the paroxysms of fever occur daily at the
same hour they are called =quotidian= intermittent fever; if every
other day they are known as =tertian= intermittent; and if every
third day they are called =quartan= intermittent. If there are two
paroxysms in the same day the term =double quotidian= is used; if the
paroxysms occur a couple of hours later each successive day they are
called “=retarding=;” if a couple of hours earlier they are named
“=anticipating=.”
=Remittent Fever.=—(Estivo-Autumnal Fever).—This is characterized by a
continued fever with paroxysmal exacerbations and remissions. It occurs
especially in warm and tropical climates. In temperate climates it
usually occurs in the late summer and fall. It is also termed bilious
remittent fever on account of the intensity of the gastro-intestinal
manifestation. The estivo-autumnal parasite is the exciting cause.
It is very often preceded by malaise, headache, nausea and vomiting.
The onset is usually gradual and the chill may be wholly absent. As a
rule, however, a chill generally occurs at the onset, but it is less
severe than that of intermittent fever. After the chill the temperature
rises rapidly to 102 or 104 degrees F. or even higher. The pulse is
full, rising to 100 or 120. There is violent headache, flushed face,
pains in the limbs and loins, nausea and vomiting, and delirium when
the temperature is very high. The urine is scanty or even suppressed,
slightly albuminous, sometimes bloody, high colored, and deposits a
sediment of urates. Jaundice is not infrequent; the spleen is enlarged
and herpes labialis is quite common. After six to twenty-four hours
the symptoms abate and slight sweating occurs. The temperature usually
drops to 100 degrees F., the headache disappears and vomiting ceases;
this is followed by a new exacerbation of fever at the end of about
twelve hours, generally without the chill; and this hot stage is in
turn again followed by the remission. These attacks may last three or
four weeks.
=Pernicious Malarial Fever.=—This is rare in temperate climates and
is always associated with the estivo-autumnal parasite. The principal
types are the cerebral and algid.
The =cerebral type= usually begins with a severe chill; sometimes,
however, the chill is absent. The patient is violently seized with
grave cerebral symptoms, as acute delirium or sudden coma. The comatose
condition lasts from twelve to twenty-four hours when consciousness
usually returns, the primary paroxysm rarely proving fatal; it is,
however, often followed in a short time by fatal relapse.
The =Algid= variety is characterized by intense prostration and extreme
coolness of the surface with the internal temperature high. The gastric
symptoms are extreme nausea and vomiting. The pulse is feeble; the
breathing frequent and shallow. There is intense thirst. The voice is
feeble and indistinct. The mind is clear. The urine is suppressed. In
this type the parasites gain entrance to the gastro-intestinal mucosa,
sometimes forming distinct thromboses of the smaller vessels. This form
may be confused with yellow fever.
=Malarial Cachexia.=—This is a chronic condition which often occurs in
cases that have not been properly treated or in persons that live in
malarial districts and are constantly exposed to the infection. The two
most striking symptoms of this condition are anemia and an enlarged
spleen or “ague cake.” There is fever at intervals, but chills rarely
occur. The skin is of a dirty yellow color. The spleen is greatly
enlarged and the blood is profoundly anemic. There is debility, and
frequent sweating, and the hands and feet are cold. The digestion may
be deranged and there may be slight jaundice. Sometimes there is edema
of the feet and even dropsy occurs. Hemorrhages of the various mucous
surfaces are common. Paraplegia and orchitis are rare symptoms. These
cases usually do well under proper treatment, and if the patient can be
moved from the malarial district.
=Masked Intermittent.=—Malarial neuralgia most frequently involves
the supraorbital branch of the trigeminus; also the occipital, the
intercostals, sciatic and brachial nerves may be affected. Such forms
of malaria are called “masked malaria.” In this form there is no fever
and as a rule it is very hard to diagnose. A blood analysis should be
made to confirm the diagnosis. In some cases one or more stages in the
paroxysm of intermittent fever is omitted; this is especially true with
the chill, in which case it is termed “dumb ague.” Malarial cachexia is
also sometimes called “dumb ague” and both are found among the older
inhabitants of malarial districts. Persons living in malarial districts
are sometimes affected with constipation, headache, loss of appetite,
nausea, vomiting and a languid feeling; this is called “latent
intermittent fever.” Frequently “bilious attacks” are of a malarial
origin.
=Malarial Hematuria.=—Hemorrhages may occur from the mucous membrane in
all severe and persistent types of malarial infection. It is a frequent
symptom of the pernicious variety. The parasites destroy the red
blood-corpuscles; this is the cause of the hemoglobinuria. Prostration
and anemia are marked. In =blackwater fever=, a tropical disorder,
acute hemolysis, is the cause of the hemoglobinuria.
=Diagnosis.=—This is usually easy. The characteristic stages of the
paroxysms, the periodicity, residence in malarial districts and the
alterations in the blood will usually remove every doubt as to the
diagnosis.
=Typhoid Fever= may simulate malarial fever, but a careful analysis of
symptoms and blood examination will differentiate.
=Prognosis.=—This is almost always favorable under early and persistent
treatment. The unfavorable symptoms are uremia, hemorrhage and marked
jaundice.
=Treatment.=—Attention should first be given to =prophylactic
measures=. Environment, isolation of the patient, and destruction of
the mosquito are important considerations. Cases of malarial fever
present distinct lesions in the vertebræ and ribs corresponding to
the vasomotor nerve supply of the spleen and liver. The most common
lesion found is a marked lateral deviation between the ninth and tenth
dorsal vertebræ and a consequent downward displacement of the tenth
ribs. A disturbance will always be found in the region of the eighth
to the eleventh dorsal vertebra, inclusive, or in the corresponding
ribs on either side. These lesions undoubtedly derange the vasomotor
nerves to the spleen and liver; thus permitting a weakness or lowered
resistance of the system, especially of the blood. The blood resisting
powers are lessened, probably on account of the spleen being affected,
as it is an elaborating gland of the blood; and the liver’s action is
somewhat dependent upon the action of the spleen; besides, the liver is
a secretory and excretory organ.
The principal =osteopathic treatment= given in cases of malarial fever
is correction of these subdislocations, and thorough treatment to the
liver and spleen directly. Ligon observes that when the case does not
respond quickly to treatment it is very liable to be of considerable
duration, although in the majority of cases the disease is controlled
from the third to seventh day; the most constant lesions found are from
the eighth to tenth dorsal and also the fourth lumbar.
During the =chilly stage= thorough treatment of the vasomotor nerves in
the upper cervical, the upper dorsal, the lower dorsal and the lumbar
regions is indicated; this treatment is given to equalize the vascular
system.
During the =hot stage= the same treatment as in the chilly stage should
be given to control the vascular system; besides a thorough treatment
of the spleen and liver is necessary. Sponging the body with water will
be of some aid in reducing the temperature.
During the =sweat stage= thorough inhibition at the superior cervical
ganglion to control the sweat center of the medulla, and treatment at
the upper dorsal and first lumbar to control auxiliary sweat centers
are indicated.
The bowels should be kept active. When in a comatose form and when
internal temperature is high, place the patient in a bath. In chronic
cases, change of climate with thorough systematic treatment will
usually result in recovery.
Tete[53], of Louisiana, makes the following interesting statement: “A
specific osteopathic treatment given within an hour before the expected
chill is a specific cure for malaria.” He follows this up by treating
on the third, fifth, seventh, fourteenth, and twenty-first days, on
account of the tendency of the return of an attack on those days. His
observation of the value of treatment just before the attack is borne
out by a report by Teall[54] where the case was cured in one treatment,
but the lesion was as high as the fourth dorsal. N. Chapman confirms
this as being her experience in many cases. The spleen has been
observed by Bandel to become engorged and upon emptying there would
follow a rise of temperature of one fourth to half a degree. This has
also been spoken of by Tucker as the “splenic wave.” Ligon makes the
statement that where the osteopathic lesion (the predisposing cause)
has been of long standing prior to the attack, and as a consequence
hard to correct, it is difficult to shorten the malarial attack.
This would emphasize the point that the essential treatment must be a
thoroughly readjustive one, and that stimulatory and inhibitory work
can only palliate. This is borne out by several practitioners who
have had considerable experience. Very satisfactory results follow
adjustment of the seventh to tenth dorsals.
Quinine has been accepted by medical authorities as a specific for
malaria. It is supposed to act directly upon the intracorpuscular
hematozoa. That it is not infallible is shown by the numerous cases
which come to the osteopath, suffering from both the disease and the
quinine. And even drug authorities state that other treatment is also
required. It has remained for Dr. Still to demonstrate that excellent
results follow osteopathic treatment in malaria. Frequently a single
treatment has been sufficient to free and regulate the body fluids and
forces so that the parasite was rendered inert, and this treatment
was directed chiefly to the fourth and twelfth dorsals. Whereas the
osteopath recognizes and appreciates the importance of micro-organisms
as exciting and determining factors in many diseases, still he values
them as secondary factors only and relies primarily upon removing
the predisposing and true etiologic factors, so that nature’s forces
may not be obstructed and thus predominate. Osteopathic etiology and
pathology has shown so conclusively, in a large number of cases, that
the existence of micro-organisms is dependent upon devitalized tissue,
whether the tissue is a local one or a circulating one, as the blood;
and just so soon as the anatomical is adjusted the physiological will
function and antitoxic and antimicrobic substances are secreted.
“When the patient has the quartan parasite, as soon as the temperature
begins to fall I give him from two to six ounces of red meat juice,
extracted from rare beefsteak, sometimes as much as five pounds in the
first twenty-four hours following the chill. In almost all cases of
quartan malaria the blood is built up sufficiently by the time they
reach the second cycle to pass without the paroxysm, or chill. By the
time for the third cycle, which is the seventh day, I always have
built up the patient’s resistance so as to enable him to pass by this
cycle without any symptoms of malaria whatever. In cases of double or
triple I find the same treatment causes about the same results. I do
not give any other diet, except dry toast if they eat the beef instead
of taking the juice. If they can take the steak I prefer their taking
it, but almost all cases prefer the juice. * * * The treatment for the
tertian type of malaria is practically the same as the treatment for
the quartan.
“The estivo-autumnal type of malaria differs from the quartan and
tertian types; first, in that the paroxysms are, as a rule, much more
irregular; second, they are much longer in duration; third, the chills
are more frequently absent; fourth, the fever is often irregular,
intermittent, remittent, or continuous in character. This type very
often takes the form of blackwater or hemoglobinuric type with
hemorrhagic symptoms, with hemorrhage from nose, gums, and bowels. The
first thing to do in a case of hemorrhagic malaria is to put an ice
bag on the abdomen, which will tend to control the hemorrhage from the
kidneys. Give the patient all the red beef juice you can get him to
take, provided he has not developed a very sick stomach; if so, give
him high saline enemas and in one-half hour give him four ounces red
beef juice per rectum. Repeat the feeding per rectum in four hours. As
soon as he can retain anything on stomach give him all the juice he can
take comfortably. Treat the liver thoroughly—at least three times in
the first twenty-four hours. At the end of thirty-six hours the yellow
cast will be very much lighter, which is a sure sign that the patient
is getting better. Watch the urine closely. The third day there may
occur a suppression. If so, give strong stimulation to the renal plexus
through the abdomen, and be sure there is a thorough relaxation of the
dorsal and lumbar muscles.
“It is an established fact that people in the malarial districts eat
very little beef. I find that ninety-nine per cent of the cases of
malaria never eat it, or when they on rare occasion do, it has been so
overcooked that all the blood-building substances have been destroyed.
The beef raw would be better in my opinion; although, the possible
chance of getting a tape-worm or animal parasite is so considerable
that I would advise that the beef should be heated to 250 degrees.”—E.
C. ARMSTRONG, Clinical Osteopathy.