PART SECOND
INFECTIOUS DISEASES
Fever
Fever is due to various causes, so that a definite statement cannot always be given as to the cause of fever in every disease. Each fever case, like all other disorders, is a law unto itself; different causes are found in different cases. Moreover, often only theories, and not absolute facts, can be given.
Fever may be present when a local disease assumes a constitutional character or when the constitutional character is manifested from the beginning of the disease. Fever may be a systemic disorder or a symptom of disease, and is characterized by an increase of body temperature. Other symptoms are usually present, as an accelerated pulse, disturbances of distribution of the blood, increased catabolism, and disordered secretions.
Etiology.—In infectious diseases fever is due chiefly to the action of various toxic or harmful agents, produced by the disease, upon the fluids of the body and upon the nervous system. Disturbances of the thermogenic centers and nerves of the brain or cord by harmful agents, or by lesions of the anatomical structures affecting these nerves, are sources of fever. Also disturbances of the vasomotor centers (in the medulla and auxiliary centers along the cord) and nerves are causes of fever in many instances. A disturbed or lessened function of the nerves controlling sweating is an important factor. The multiplication of micro-organisms in the body, acting directly on the tissues or by producing toxic substances which affect the nervous system, is a fruitful source of fever. A few cases may be caused by direct affection of the nervous system, as is shown by appearance of fever in epileptic attacks, or by the passage of a catheter into the bladder. In a large number of all cases a demonstrable cause can be found upon careful examination, whether the fever be due to a necrosed mass of tissue, the introduction into the system of decomposed food, infectious diseases, a lesion of some anatomical structure affecting a thermogenic, vasomotor or sweat center, a lesion to the innervation to the heart (vagi and cervical sympathetic) causing a rapid heart, or a lesion to the lymphatic system.
Treatment.—The treatment of fevers in a general way consists principally of thorough inhibition to the posterior spinal nerves of the upper cervical region in order that the center of the vasomotor system in the medulla may be affected, probably by the way of the superior cervical ganglion of the sympathetic. Thus the entire vascular system is equalized, for there is always a disturbance in the distribution of the blood in fever and if the center controlling the nerves that govern the lumen of the blood-vessels can be brought under control, there will result an equalization of the vascular system; if such occurs, health must ensue. Besides the vasomotor nerves to the blood-vessels being affected by this treatment, the nerves governing the lymphatics and the sweat glands will also be controlled. The sweat glands as a rule are rendered active by affecting directly the innervation of the glands, also the glands are controlled indirectly by the blood supply; this aids materially in lessening the temperature of the body. Treatment for a few minutes to the upper posterior cervical region would also affect the thermogenic centers and nerves of the brain reflexly in the same manner as the vasomotor and sweat centers and nerves are affected, thus tending to equalize the mechanism of the thermogenic system. Besides this action on the vasomotor, sweat, and the thermogenic nerves, there is produced an increased exhalation of moisture from the lungs, on account of an increase of vascular area in the lungs through vasomotor action. Also the large vascular area in the abdomen, under control of the splanchnic nerves, becomes constricted. Thus there is brought about a lessening temperature by evaporation, heat radiation, and perspiration; and an increased action of the general nervous system, a stronger cardiac force, an equalization of the vascular system, and a more perfect elimination of toxic properties by the skin, kidneys and lungs; consequently a reduction of the fever.
The foregoing treatment is successful to a limited extent, only in such cases where causative factors of the fever are involving the predominating centers controlling the heat production or dispersion and the vasomotor system directly; for if the lesion that is causing the disorder should be affecting an auxiliary center along the spinal cord instead of the predominating center, as is oftentimes the case, treatment of the predominating center would be useless as far as any permanent benefit is considered; although a temporary effect will be gained by lessening the fever at that point. Consequently, in many cases, the lesion lies within the jurisdiction of auxiliary centers which are situated at various points along the spinal cord. When such is the case, it will be of little benefit to give the cervical treatment. In such instances the lesion to the auxiliary center would have to be removed in order to cure. One cannot depend upon a set rule to reduce a fever; determine the cause, as in any other disease or symptom, and remove it.
In addition to the treatment to the cervical region and along the spinal column, as are indicated upon an examination, attention should be given to the heart’s action. The equilibrium between the accelerator and inhibitory nerves (cervical sympathetic and vagi) should be maintained. The interchange of gases in the lungs should be rendered as nearly normal as possible; this is best accomplished by raising and spreading of the ribs from the second to the seventh dorsals, particularly in the region of the fifth and sixth. Also stimulation of the vagi will aid by increasing the motor power of the lungs. The kidneys and bowels should be kept active so as to favor a rapid elimination of various toxic properties; besides they have control over large vascular areas. Treatment over the ureters will prevent any clogging that might occur in them from a condensation of the urine. Attention, also, should be given the tissues at the fifth lumbar and over the iliac vessels to influence the circulation in the pelvis.
The food of the patient should be liquid—milk, soup, broths, etc., and almost any quantity of water allowed if called for, given little at a time and at frequent intervals. The room should be well lighted, ventilated, clean and kept at an even temperature.
Two points should always be remembered relative to fever:
First—That there are many causes of fever; and in order to reduce the fever the cause must be determined and removed, the same as in any disorder. A definite fever treatment cannot be given any more than a definite constipation treatment; the case must be seen in order to determine the cause.
Second—The reduction of fever is not necessary; the fever should be treated only as a symptom of disease when it exists as such. In fact, fever is beneficial, for it is one of nature’s methods to relieve an over-burdened system from harmful agents, unless the temperature is excessive and continuous and is likely to cause more harm than the primary trouble.
Absolute rest in bed always is of decided benefit in lessening the temperature.
Hydrotherapy is of immense value in reducing a fever. It is an agent that has been greatly used, and if applied intelligently cannot but be of aid. There is much ignorance in regard to the principles and practice of hydrotherapy, not only among all classes of people, but among well informed practitioners in medicine. The most important function of the skin is as a heat regulator. Knowing this fact, the osteopath treats the vasomotor nerves that control the cutaneous circulation and the nerves that control the excretion of the skin; the nerve supply being from the cerebrospinal and sympathetic nerves. In many difficult and obstinate cases hydrotherapeutic measures should be used to aid the skin in regulating the temperature, as well as to enhance system functions for the same reason that osteopathic manipulations are given. Maintaining an equilibrium in heat production and heat dispersion is necessary in order that the standard of the body temperature may be kept; and the amount of the arterial blood circulating within a tissue determines its temperature.
The principal effect of water as a thermic agent when applied externally is due to the influence of the action of the water upon the cutaneous circulation. Lesser effects would be the mere extraction of heat from the body by evaporation and the equalization of temperatures of two bodies coming into contact. As the body is endowed with compensatory powers, this latter means would apply only to a limited extent. The temperature of the water used is important, as the colder the bath the less effective would its power be in reducing internal temperature. When a cold bath is used there is a driving of the blood away from the surface on account of the contraction of the peripheral vessels; consequently increasing the cutaneous circulation and cooling by radiation is prevented and less heat is lost. A collateral hyperemia occurs in the underlying parts which acts as a protection to the deeper tissues. The cold also inhibits the vasomotor nerves controlling the abdominal splanchnics, and thus a larger amount of blood passes to this immense vascular area. On the other hand, when a warmer bath is used the effect is opposite, and a lowering of the temperature is the result. The cutaneous vessels being dilated, the superficial blood is rapidly replaced by blood from the deeper vessels, thus allowing a cooling of the body to a large degree.
In the various fevers where hydrotherapeutic measures are employed, the object to be gained by such methods is not primarily an anti-thermic one but an anti-febrile reaction; consequently the use of cold water is employed. In mere heat reduction the warmer water would be more effective; but by the aid of the colder water the cause of the increased temperature, as in infectious fevers, is lessened; besides a refreshing and stimulating effect upon the entire system is gained. Thus the aim of the cold bath and friction, is not primarily to subdue the temperature by heat radiation or evaporation, but to correct disturbances governing the formation and the dissipation of heat caused by infectious fevers, and, moreover, to stimulate the nervous system, prevent heart failure, increase the eliminating power of the skin, kidneys and lungs, and to influence the corpuscular and chemical constituents of the blood to a more normal condition.
The full cold bath and friction (Brand Method) is commonly employed in infectious fevers. The half bath, wet pack, or sponging may be used. The modus operandi of each is given under the hydrotherapeutic treatment of typhoid fever.
Typhoid Fever
(Enteric Fever)
In writing of these acute diseases which are self-limiting, it is understood that osteopathy aborts, overcomes symptoms and otherwise changes conditions frequently. When this occurs the case is not typical and it is a typical case which is here described.
Definition.—An acute, infectious disease caused by the bacillus typhosus. It is characterized anatomically by hyperplasia and definite lesions of Peyer’s patches and mesenteric glands, and enlargement of the spleen, and clinically by its slow onset, often diarrhea, abdominal tenderness, tympanites, fever, headache, and rose colored spots on the abdomen.
Osteopathic Etiology and Pathology.—Lesions to the lower dorsal and lumbar regions are always found, which impair the innervation and vascular supply of the intestines and cause defective nutrition. This is the most important predisposing cause, although general lowered vitality from overwork, improper food, unhygienic environment, and insanitary surroundings, are also of great importance. It is possible that one’s vitality may be so lowered that the bacillus of Eberth, if of sufficient numbers or virulency, will find a suitable medium wherein to multiply and grow, and thus the spinal lesions found in these cases are the result of reflex irritation. But the most probable underlying cause is the spinal lesion, and given two individuals with equal likelihood to infection, one with the spinal lesions and the other not, the former within all probability will be the more likely to suffer an attack. The severity and extent of the osteopathic lesion undoubtedly bears a direct ratio to the probability of attack from an infectious disease. Typhoid fever usually occurs between the ages of fifteen and thirty years. Some families are more susceptible than others. The autumn months, especially after a dry, hot summer, favor the disease. One may be reasonably certain that whenever there is a case of typhoid the individual has not been careful as to diet, or drinking water, or some rule of health, and wherever there is an epidemic it can always be traced to insanitary surroundings, the water supply, contaminated garden truck or other food, sewage, etc.; although this does not preclude the probability that the osteopathic lesion or lowered vitality of Peyer’s patches and mesenteric glands from other causes are important and many times primal etiological factors. The specific poison may be so virulent that practically no one escapes and again those of lowered vitality only will succumb to an attack.
The exciting cause is a special micro-organism, the bacillus of Eberth. The contagion may be carried through the air from one person to another, but this is rarely the case. Though the water is the most common mode of conveyance, the bacillus has been found during epidemics in both water and milk. The water may be contaminated by the intestinal discharges which have not been properly disinfected. Extreme cold does not destroy the typhoid germs. Milk may be infected from the milk-can being washed with the contaminated water or the unclean hands of the milker. In fresh milk the germs multiply rapidly. Salads, celery, ice and fruits may be contaminated. Oysters have become infected while being fattened or freshened. It is thought by some that the poison is not eliminated from the sick in a condition capable of transferring disease to a healthy person, but must undergo changes in the soil before it is able to cause the disease in another. Typhoid fever may be caused, however, by direct contact with the stools. Filth, sewers, or cesspools do not directly cause the disease, but they form a suitable medium for the preservation of the typhoid germs.
Pathologically, the characteristic lesions in typhoid fever consist of changes in the lymphoid elements of the bowels. These changes are most striking in the solitary glands and Peyer’s patches. The alterations which occur may be divided into four well defined stages: (1) Infiltration—the glands are enlarged from infiltration and there is marked cell proliferation, particularly Peyer’s glands in the jejunum and ileum and to a lesser extent those in the large intestine. The glands become pale and prominent. Occasionally the solitary glands, which are usually deeply imbedded in the submucosa, become prominent also.
Microscopically, the capillary blood-vessels are at first considerably dilated, but later become more or less contracted, giving an anemic appearance to the follicles. The adjacent mucosa and muscularis may become infiltrated. The cells have the character of lymph corpuscles, some of which are larger, epithelioid in character, containing several nuclei. From the eighth to the tenth day this medullary infiltration reaches its height and then undergoes either resolution or necrosis.
(1) Resolution takes place by a granular or fatty infiltration of the cells. This produces pitting of the swollen follicles, which may cause small hemorrhages.
(2) Necrosis.—With all the severe cases of cell infiltration, hyperplasia of lymph follicles reaches a stage where resolution is impossible and necrosis occurs. The necrosis is partly due to the choking of the blood-vessels and partly to the direct action of the bacilli. The necrosis may involve only the superficial layers of the mucosa or it may extend deep into the muscular coat and even perforate the outer or serous coat. Usually, however, this does not extend below the submucosa, mucosa, or muscularis. Not all of the patches necessarily slough, but as a rule it is always more intense toward the ilio-cecal valve.
(3) Ulceration.—The extent and depth of the ulcers depend upon the amount of the necrosis. Large ulcers are sometimes formed, especially in the lower end of the bowel, by the union of several. The edges are swollen and undermined. The base is usually smooth and formed of submucosa. Perforation of the bowel occurs in a small percentage of cases; more commonly the ulcers heal. The perforations may be multiple, but rarely exceed two in number.
(4) Healing.—Cicatrization begins about the fourth week. This granulation tissue covers the floor. It is sometimes formed with connective tissue and a new growth of epithelium results. The gland is ultimately replaced by a depressed scar with a smooth, pigmented surface. The majority of deaths occur before this stage is reached. The gland structure is never regenerated.
The mesenteric glands show intense hyperemia and later become enlarged and softened, but rarely ruptured. The glands at the lower end of the ileum are markedly involved.
The spleen is enlarged, softened, and diffluent. Occasionally rupture occurs. Infarction is not a rare occurrence.
The liver shows parenchymatous and granular degeneration, and the cells are found to contain much fat. Infarction abscesses and acute yellow atrophy occur in rare instances. Diphtheritic inflammation of the gall-bladder sometimes occurs and the bile is thinner and paler than normal.
The kidneys also show parenchymatous degeneration. They are pale in appearance, with slight cloudy swelling. Microscopically, there are seen granular and fatty infiltration of the cells of the convoluted tubules. Rarely, there is acute nephritis which may be hemorrhagic. There may be miliary abscesses in which typhoid bacilli have been found by some observers. Diphtheritic, but more frequently catarrhal, inflammation of the pelvis of the kidney may occur. Catarrh of the bladder is not infrequent and even sometimes diphtheritic inflammation is present. Rarely orchitis is encountered.
Hypostatic congestion of the lungs is not uncommon. Gangrene and hemorrhagic infarction are sometimes present. Lobar pneumonia may be a complication.
In the larynx ulceration is sometimes met with bacilli, however, have not yet been found in these ulcers. Diphtheritis of the pharynx and larynx may occur. Catarrhal or croupous pharyngitis may occur; while swelling of the follicles of the pharynx and base of the tongue is frequently noticed.
Peritonitis is always present in fatal cases in which perforation of the bowel has taken place. The perforation may occur in ulcers from which the sloughs have already separated, or it may be caused by a necrosis of all the coats. Extensive peritonitis may occur without perforation, and is probably due to extension of the inflammation to the peritoneum.
The heart may be affected. Endocarditis is rare, while pericarditis is much more frequent. Myocarditis is frequently met with, the cardiac muscles presenting parenchymatous and rarely hyaline degeneration. The arteries are frequently found to be involved. These conditions (obliterating arteritis and partial arteritis) may affect the smaller vessels, especially those of the heart, but more commonly affect the arteries of the lower extremities. Thrombosis of the veins, especially of the femoral, and more rarely of the cerebral veins and sinuses, occurs.
Granular and hyaline changes in the voluntary muscles may occur. This degeneration does not affect the whole muscle but involves only certain fibres. Regeneration takes place during convalescence.
With the nervous system meningitis is rare. The peripheral nerves are frequently the seat of parenchymatous changes. The ganglia of the trunks of the vagi present an inflammatory change.
The blood presents little change. During the first two weeks the red corpuscles gradually decrease in number until the first week of convalescence, after which they gradually increase in number. There is often a marked decrease in the number of leucocytes. Leucocytosis is absent. The hemoglobin is always reduced.
Symptoms and Course.—The incubation period varies from a few days to two weeks or longer. During this time the patient may feel in his usual health, but more often there is a feeling of languor and indisposition to exertion, loss of appetite, slight coating of the tongue, nausea, headache, chilliness, but seldom a decided rigor, pains in the back or legs and nose-bleeding. Any of these symptoms may be present and last usually from a few days to a week or more. These symptoms increase in severity and the patient takes to his bed. The invasion as a rule is gradual.
The first week dates from the onset of the fever which generally (but by no means in all cases) rises steadily during the first week a degree or a degree and one-half each day, reaching 103 or 104 degrees F. The pulse is quickened to 90 to 110 per minute and is full, of low tension and sometimes dicrotic. There is great thirst, also a coated tongue. The skin is hot and dry and there is rather intense headache. Unless the fever is high there is no delirium. The sleep is disturbed and there may be mental confusion and wandering. Cough with some thoracic oppression is not uncommon at the onset. The abdomen is slightly distended and tender. There may be either constipation or diarrhea. The spleen is somewhat swollen and a rose colored rash appears on the skin of the abdomen and chest.
During the second week the fever remains high and exhibits the continued type, the morning remission being slight. The pulse is accelerated. The headache disappears, but there is marked mental dullness and slowness and there may be a mild delirium at night. The tongue is coated and the lips are dry. The abdomen is tympanitic and tender. Diarrhea replaces constipation. The case may prove fatal during this week from the result of nervous or pulmonary symptoms, hemorrhage, or perforation.
The fever changes in the third week from a continuous to a remittent type. The pulse ranges from 110 to 130. The patient is very weak. Complications may arise, as pulmonary symptoms, feebleness of heart, intestinal hemorrhage, perforation, and peritonitis.
In favorable cases during the fourth week the fever begins to decline and the general and local symptoms gradually disappear. In protracted cases the fourth and fifth weeks may present the symptoms of the third week. Frequently the following aggravated symptoms are added: stupor, delirium, increased weakness, rapid, feeble pulse, and distended abdomen. Heart failure and inflammatory complications increase the danger.
During the fifth and sixth weeks a few cases will show irregular fever. Great care should be taken that complications do not occur.
The fever is the most important and characteristic symptom and from the temperature alone a diagnosis may be made. During these stages of development, which is the first four or five days, the temperature rises steadily; the evening temperature being about a degree or a degree and one-half higher than the morning remissions, reaching 104 or 105 degrees F. at the end of the first week. When the fastigium is reached the fever persists with slight morning remissions. At the end of the second and throughout the third week the temperature becomes more remittent and there may be a difference of three or four degrees between the morning and evening temperature. During the last stage the fever falls by lysis, forming a more or less regular step-like line of descent. The stage lasts from one week to ten days.
When the disease sets in with a severe rigor the fever frequently rises at once to 103 or 104 degrees F. In the lightest forms the fastigium may be almost absent; defervescence setting in upon the first day of the fastigium and in many cases defervescence occurs at the end of the second week and the temperature may fall rapidly, becoming normal in ten or twenty hours. This fall in the temperature may take place without any apparent cause or it may follow an intestinal hemorrhage. The temperature often falls many hours before the blood appears in the evacuations. The occurrence of peritonitis is also marked by a sudden fall in the temperature. Hyperpyrexia in typhoid fever is not very common except just before death.
After the temperature has been normal for several days there may be a sudden rise of the temperature to 102 or 103 degrees F. This may persist for a couple of days and then return rapidly to the normal. These recrudescences, as they are called, are quite common and are caused most frequently by errors in the diet, constipation, excitement or mental emotion. These elevations in the temperature are found most frequently in children and persons of a nervous temperament.
Afebrile Typhoid is of very rare occurrence. The patient has all the characteristic symptoms of typhoid fever with the exception of a fever.
The rash is highly characteristic. It appears about the eighth or tenth day, usually upon the skin of the abdomen or chest, rarely found elsewhere on the body. It consists of a variable number of rose colored spots distinctly elevated, and disappear on pressure. These spots last three or four days and appear in successive crops. Vivid red erythematous eruptions upon the chest and abdomen are commonly seen during the first week of typhoid fever. Urticaria is rarely seen.
Sweating characterizes some cases of typhoid fever, but generally the skin is dry. This may occur with or without chilly sensations or actual rigors. In some cases there may be recurring paroxysms of chills, fever, and sweats and they may be mistaken for intermittent fever. Edema of the skin may occur and is usually due to anemia or cachexia and sometimes to nephritis. Local edema may occur as the result of vascular obstruction, particularly thrombosis of the femoral vein. There is a peculiar musty odor exhaled from the skin in typhoid fever, particularly if the skin has been neglected. In all protracted cases bed-sores are likely to develop. The hair is apt to fall out but is generally renewed. The nails also suffer and ridges can usually be observed upon them.
Intestinal symptoms are very inconstant. Usually there is constipation at the onset and this may persist throughout the disease although a moderate diarrhea may occur throughout the disease. The severity of the diarrhea is due most probably to the degree of the catarrh rather than to the extent of the ulcers. It is probable that the discharges are more frequent when the catarrh involves the large intestine. The number of discharges average, as a rule, from two to four or more daily. The stools are either fluid or of the consistency of jelly, of a grayish-yellow color, alkaline in reaction and are very offensive.
Hemorrhage is a serious symptom, but by no means always fatal. This usually occurs in cases of considerable severity and it generally occurs at the time of the separation of the sloughs during the third week. When it occurs quite early in the disease it is generally the result of hyperemia. It may be so slight as not to be noticed by the eye or it may be from one to three pints. Intestinal hemorrhage, however slight, is always a grave symptom. There may be symptoms of collapse and fall of temperature, or it may occur without any symptoms.
Meteorism is an almost constant symptom, and when excessive adds to the seriousness of the case and corresponds generally with the extent of local lesions. Abdominal tenderness and gurgling upon pressure in the right iliac fossa may be present; pain is generally absent, and when present is usually slight.
Perforation almost invariably causes fatal diffuse peritonitis and is the most serious complication. It may occur at any time but is most common between the second and fourth weeks. It is usually indicated by sudden acute pains in the abdomen and symptoms of collapse. As a rule symptoms of peritonitis appear at once; distension of the abdomen, great tenderness, and rigid abdominal walls. Vomiting, pinched features, and rapid, small pulse shows general collapse of the circulatory system.
Bronchitis is almost invariably present as an initial symptom. It is indicated by the existence of sibilant rales. The cough is generally slight.
Hypostatic congestion of the lungs and edema, due to enfeeblement of the cardio-pulmonary circulation, in the latter part of the disease are not infrequent.
The pulse as a rule is not very frequent and is generally not in proportion to the fever until late in the disease; 90 to 120 is the usual range. During the first week it is about 100, full, and frequently dicrotic; later it becomes more rapid, feeble and small. In severe cases during the extreme debility of the third week the pulse may reach 150 or more (the so-called running pulse). During convalescence the pulse occasionally becomes subnormal and bradycardia is met with more frequently than after any other acute fever.
The blood presents definite changes, some of which are important. In cases where there is profuse sweating or copious diarrhea, the red corpuscles may be relatively increased; this is due to the loss of water. In most cases there is little change until the end of the second week. During the third week there is generally a decrease in the number of corpuscles and of the hemoglobin, which is always reduced. Leucocytosis is always absent. The white corpuscles are slightly diminished especially toward the end of convalescence.
During the first week there is generally persistent headache, sometimes neuralgia. There are a few cases in which the effects of the typhoid bacilli or their poison is manifested in the nervous system from the very onset. There are violent headaches, retraction of the head, rigidity, photophobia, twitching of the muscles, rarely convulsions, all indicating meningitis as which it is occasionally diagnosed. It must be remembered however, that all nervous symptoms may occur independently of a lesion of the nervous system.
Delirium may exist from the onset, but it usually is not present until the second or third week and only in the severer cases. As a rule it is most marked at night. It is generally of the low, muttering type, very seldom maniacal. When the patient picks at the bed clothes or grasps at imaginary objects there is indication of danger, as it is a serious symptom. Convulsions are rare.
The urine is diminished in quantity, high specific gravity, and of dark hue. Both urea and uric acid are increased and the chlorids are diminished during the first stages. About the stage of decline the urine becomes light in color and greater in quantity than normal. The specific gravity is lowered, urea and uric acid are diminished, and the chlorids are increased. Febrile albuminuria is very common but of no special significance. Acute nephritis may develop as a complication. Pyuria is not an uncommon complication and post-typhoid pyelitis may also develop.
Malarial fever may be associated with typhoid, especially in malarial districts. Persons with tuberculosis, epilepsy, chorea, and other forms of chronic nervous diseases are liable to typhoid fever. In epilepsy and chorea the movements and fits usually cease during the attack of typhoid fever.
Varieties of Typhoid are numerous and are named with reference to the degree of severity which varies from extreme mildness to extreme severity.
The mild or abortive form is of frequent occurrence. The onset is usually sudden. The symptoms are similar to those of a typical case but much milder and appear earlier than in the usual type. This form runs its course in about two weeks. The fever usually reaches 104 degrees F.
In the severe or grave form there is high fever and the nervous symptoms show a profound intoxication of the system. The grave types are those associated with serious complications or those cases which set in with pneumonia, Bright’s disease, or cerebrospinal symptoms.
In the latent or ambulatory form (walking typhoid) the symptoms are very slight, the patient being hardly sick enough to go to bed. The symptoms may be of this character throughout the attack, and the patient may be able to be up and about. In other cases the first symptoms are very mild, but later they may develop symptoms of the severest type.
The Afebrile form is rare. Hemorrhagic typhoid is a very fatal but rare form. In this type there are cutaneous and mucous hemorrhages.
Diagnosis.—As a general rule typhoid fever is easily recognized. The Widal test should be made. At times the diagnosis may have to be delayed until the distinctive signs appear, especially in those cases which come on with severe headache, delirium, twitching of the muscles, and retraction of the head. In these cases the diagnosis of cerebrospinal meningitis is invariably made, until the appearance of the colored spots on the abdomen, which must decide the diagnosis; cerebrospinal meningitis being a rare disease and typhoid fever with severe nervous symptoms quite frequent, it is more probable that it is typhoid. At least one-half of the cases termed brain fever belong to this class of nervous typhoid.
Prognosis.—A positive prognosis can not be made, as even the mildest cases are liable to have severe complications develop at any stage of the disease. Under osteopathic treatment the prognosis is undoubtedly more favorable than with the treatment of the older schools. If the osteopath can see the case early, the first week, there is always a chance to abort the attack. In all cases there is the probability that the attack will be shortened; this is a common experience. Price of Mississippi, has treated many cases, and invariably when the patient is seen early the attack has been shortened to thirteen or fourteen days, whereas under other treatment the disease runs the usual course. Adsit of Kentucky, White of New York, and the staff of the American School of Osteopathy (Kirksville), as well as many others, have had the same experience. And if the attack cannot be aborted or shortened there is the further probability that the severity will be lessened and complications prevented. The prognosis is always more favorable in winter than in summer, and especially favorable in children. More women die than men, and fat persons stand the disease badly.
Treatment.—Typhoid fever is one of the diseases that practitioners of all the schools are agreed that drug therapeutics avail but little in its treatment. The treatment of the older schools consists of prophylaxis, good nursing, attention to hygienic principles, dieting, and hydrotherapy. All of these have their places and are recognized by the osteopathic school. But the above methods are of the defensive only—allowing the disease to run its usual course and reducing the likelihood of complications. On the other hand the above treatment coupled with osteopathy, not only attacks the ravages of the disease defensively, but of more importance, the disorder is attacked offensively. Herein is where attacks are aborted, or shortened, or severity lessened, or complications prevented. The efficacy of osteopathy is due to the ability of the osteopath to treat disease, not only prophylactically and palliatively, but of more consequence, aggressively.
The correction of the spinal lesions in typhoid fever is of first importance. This treatment effects a tendency toward equalized circulation of the intestines. The vasomotor nerves are disturbed by the above lesions which in turn produces stasis in Peyer’s patches and the mesenteric glands. Reversely some of the spinal lesions may be due to reflex stimuli, for “Kirk ... states that muscular contractions produced by reflex activity are often more sustained than those produced by direct stimulation of the motor nerves themselves.”[51]
Prophylactic treatment is very essential, for typhoid fever as a rule is a preventable affection. Modern hygienic and sanitary resources enable a community to reduce the number of cases to a minimum. The number of cases in a locality depends almost directly upon the condition of the water supply and drainage. Care should always be taken in regard to the source of drinking water and milk. During an epidemic the water should be boiled for half an hour before being used. The patient should be isolated. In hospitals they should have special wards; in families a special apartment should be given them. Hygienic principles should be followed as in other infectious diseases.
The methods of disinfection must be rigid to prevent the spread of an infection. The excreta (stools, urine, vomitus, and sputum) are to be received into a bed-pan or any appropriate receptacle containing half a pint of carbolic acid (one to twenty). Three or four pints of the carbolic acid (one to twenty) should then be added to the bed-pan and the contents mixed carefully before emptying. All utensils used in handling the excreta are to be carefully disinfected by the same material, and dried. After every stool the nates of the patient should be cleansed by a cloth compress, wet with a solution of carbolic acid (one to forty) and the cloth burned. The sick room should be thoroughly ventilated each day. All utensils used about the patient in feeding should be boiled in water immediately after using. The bed and body linen is to be changed as soon as soiled and these, with all changed bath towels, blankets and rubber sheets, should be received in a sheet rinsed in carbolic acid (one to forty) and placed where they may be soaked in the solution for four or five hours. The clothes are to be boiled for half an hour. The rubber blanket is to be washed in the solution, dried and aired.
The General Management, careful nursing and a regulated diet, is of paramount importance in the treatment of typhoid fever. The patient should be placed in bed as soon as the disease is determined and there remain until the end of the attack. The room should be well ventilated and have a sunny exposure if possible. The single woven wire bed with soft hair mattress and two folds of blankets is best. A rubber cloth should be placed smoothly under the sheet. When a good nurse cannot be had, the attending osteopath should write out directions regarding diet, bed linen, and utensils, and the disinfection of the excreta.
A liquid diet should be administered. Milk is most commonly used; care being taken that it is thoroughly digested. If milk is not borne well by the patient, other foods, as whey, sour milk, buttermilk, and broths may be substituted. Give food that is easily digested and which leaves but little residue. When milk is used alone, three pints at least may be given to an adult in the course of twenty-four hours; and it should always be diluted, preferably with plain water. Beef juice, mutton or chicken broth may also be used when milk is not agreeable. Albumin water, prepared by straining the white of eggs through a cloth and adding an equal amount of water, is an excellent food. Well strained, thin barley gruel is considered by many an excellent food for typhoid fever patients. Cases not able to take nourishment into the stomach, on account of vomiting and other causes, should be fed rectally to support life. Do not force feeding to an unwarranted degree.
Recently a number of new diets have received commendation. These include the “high calory” diet, which includes three pints of milk with one of cream, two to eight ounces of milk sugar, eggs, butter; sometimes cereals, toast, potato, and other soft foods are given. A full sugar diet, as of candy alone, is based upon the immediate absorption of sugar, its value as a source of energy, and the fact that a plentiful carbohydrate supply lessens the danger of acidosis.[52]
The best drink for fever patients is pure, cold water and they should be encouraged to drink freely of it. Barley water, ice tea, lemonade, or even moderate quantities of coffee or cocoa, may be given.
By Osteopathic Treatment many cases of typhoid fever may be aborted, if treated correctly, during the first week. If the stage of necrosis of Peyer’s patches has set in, one can either lessen the severity of the attack or, at least, shorten the usual course. During the stage of infiltration, treatment to the intestinal splanchnics (chiefly from the ninth to twelfth dorsal, the innervation to the jejunum and ileum) and careful treatment over the abdomen is indicated. This treatment will tend to lessen the intestinal catarrh and diminish the infiltration and cell proliferation of the lymphoid elements of the intestines, and thus produce unfavorable the conditions for the bacillus of Eberth. In other words, increase the tone and activity of the intestines so that the micro-organisms of typhoid fever will not find the proper tissue-soil in order to grow and multiply.
All cases of typhoid fever present lesions in the dorsal or lumbar spine and this is really the great predisposing cause of typhoid fever. Correcting these lesions is absolutely necessary in order to abort the disease. Some patients may have such a lowered vitality to begin with that the recuperative powers of the body cannot be rendered forceful enough in a short time to combat the effects of the micro-organism. Carefully raising the cecum is very effective (A. T. Still), but this must be done with the greatest of caution and judgment. Dr. Still considers a posterior condition of the third, fourth and fifth lumbars as typical in typhoid and that it inhibits the lymphatics to the intestines.
R. L. Price has had excellent success in shortening the usual typhoid course. His first treatment is to thoroughly empty the bowels by enemata. This is followed by spinal, liver and splenic treatment, and a liquid diet.
E. C. White has also treated a large number of typhoid cases with marked success. He prefers to employ the Brand method (and it must be properly used) from the start. He is, also, a thorough advocate of the spinal treatment. In cases of constipation give a very light treatment over the left iliac fossa. With all patients observe careful dieting. White believes that many lesions of the spine arise from reflex irritations during acute attacks. Careful, frequent attention to the spine is demanded.
Hildreth, relative to abdominal and spinal treatment, writes as follows: “In the abdominal treatment of typhoid fever, too much care cannot be exercised; or in the spinal treatment, too much judgment used in giving just the right kind of manipulation. There can be no question relative to the seat of the disease, and consequently there should be no trouble in knowing where or how to affect the nerves to control the same. That Peyer’s patches or the right iliac region is always involved, we all know. The spinal treatment should be applied from the eighth dorsal to the first lumbar inclusive; this affects all the lesser splanchnics and thus controls the circulation of the entire bowel. And this treatment should be given, according to the symptoms indicated, in each and every case. If the patient is constipated, then the treatment should be more of a stimulative character, but if diarrhea is present, as is commonly the case, the treatment should be an inhibitory one. In the above I always finish with a very careful treatment of the floating ribs on the left side; this affects the lesser splanchnic nerves. In all cases I always carefully treat the lower two or three lumbar vertebræ, which directly affects the hypogastric plexus of nerves, and thus controls the circulation to the lower bowel.
“In all cases I always treat the bowels directly, more or less, but this treatment must be given with the very greatest care and the best judgment, always governed by the condition of the bowel. By no means manipulate the bowel, but just lay your hands flat on the abdomen, and with the most gentle pressure inhibit the peripheral nerves, thus either quieting an excited peristalsis or equalizing a disturbed circulation. And with this treatment remember that the two specific points in typhoid fever are the lower dorsal and lower lumbar nerves.
“The above treatment is used, of course, in connection with all the other necessary treatments, such as dieting, nursing, sponging, relieving the headaches, etc. I am unalterably opposed to ice-packs for the bowels in typhoid, for the reason it is too much of a shock. Cold cloths are good and much better than ice, and should always be used instead of ice.”
After the disease has become thoroughly established always make it a point during each visit to examine the entire length of the spinal column carefully and readjust any tissue, whether it be vertebra, rib, or muscle, that may be found disordered. The bowels are to be watched carefully and if constipated, they should be moved with a light enema. Great care must be taken not to treat the abdomen roughly, if at all, after the first week. The treatment might be very injurious to the structures diseased. A light treatment over the liver and kidneys each time is a wise precaution. The heart’s action, should be watched carefully. In addition to the hydrotherapeutic treatment, the general fever treatment should be employed. The patient should usually be seen twice a day.
Abdominal pain is best relieved by light treatment over the abdomen and by thorough treatment of the lower dorsal or lumbar region. Applications of hot water will be helpful.
Meteorism can be relieved by raising the lower ribs and by direct treatment to the abdomen. A change of diet may be beneficial. When gas is in the large bowel an enema may be given to remove it.
Diarrhea and constipation are best controlled by the usual treatment given the spine in such cases, and over the abdomen and the liver. Light enemata may be given for constipation. The stools should be examined when diarrhea occurs, as the presence of curds may cause the aggravation.
Hemorrhage from the bowels demands absolute rest. It is probably better to have the patient use the draw sheet for the evacuation. Immediate and thorough treatment must be given to the spinal column in the region of the intestinal nerves to the diseased area, so that existing lesions may be corrected and the vascular area of the mesentery equalized. Ice should be given freely and an ice pack placed over the abdomen. Food should be restricted for ten or twelve hours. If the peristalsis of the intestines is increased, an effort should be made to control it through the vagi and splanchnic nerves.
In perforation hot applications, rest and thorough treatment of the innervation to the peritoneum are of value, but immediate operation is usually advisable.
Insomnia is best relieved by attention to the cervical region. Relaxation of the muscles in this region and a quieting treatment to the posterior occipital nerves, coupled with cold sponge baths, will usually induce sleep.
In delirium attention to the circulation of the brain, by careful treatment of the vasomotor system, and the Brand method of baths will relieve this distressing symptom.
During convalescence the patient should be restricted from any mental or physical exercise for a week or ten days and then should move about with care. Solid food should not be given for ten days or two weeks. If the temperature has been normal for ten days, it is then safe to allow such food as eggs, milk puddings, and milk toast. If diarrhea should persist, being due to ulceration, the diet should be restricted and the patient confined to the bed. If constipation is troublesome relieve it by enemata.
There are several beneficial effects obtained by hydrotherapeutic measures that should receive careful consideration. Probably it is of the least significance to lower the temperature; other beneficial effects being of greater importance. When the baths are systematically carried out, (1) there is obtained a general improvement of the nervous system, the mind is rendered clear, muscular twitchings are lessened, sleep is induced and the heart’s action strengthened; (2) the respiration is stimulated, thus diminishing the liability of lung complications; (3) the activity of the renal function is increased, consequently allowing more rapid elimination of toxic matter; (4) reduction of the temperature, and overcoming ill effects of high fever.
A cold water bath, or what is generally termed the Brand method, is commonly employed. The following plan is usually followed. When the temperature is above 102.5 degrees F., rectally, a bath of 70 degrees F. is wheeled to the patient’s bedside and he is placed into it for ten or fifteen minutes. The patient should be lowered into the bath by means of a sheet. Enough water is used to cover the body and neck of the patient. The head is sponged and the limbs and trunk are rubbed thoroughly during the entire procedure. When the patient is taken out he is wrapped in a dry sheet and covered with a blanket. This procedure is gone through with every three hours if the case is severe, otherwise once every seven or eight hours will be sufficient.
The luke-warm bath is occasionally used in private practice when one is unable to use the Brand method. A bath of 90 degrees F. is employed, which is gradually cooled ten or twelve degrees, after the patient has been placed in it, by pouring cold water on the patient. This bath is found very helpful. Also in private practice the cold pack is found satisfactory. The patient is wrapped in a sheet wrung out of water at 65 degrees F. and cold water is sprinkled over him. Whenever there is objection to any of these methods the body may be sponged off with tepid or cold water when the temperature rises above 102.5 degrees F., rectally. One limb should be taken at a time and then the trunk, occupying altogether some twenty or thirty minutes.
The Great War brought the subject of typhoid vaccination before the world with emphasis but its results are not, as yet, in shape so an unbiased opinion can be formed. The army medical department will tell us that it was an unqualified success but we do know that there were serious outbreaks among inoculated troops who were living under most hygienic surroundings in America. There were, also, outbreaks among protected troops in France to the extent that the medical authorities felt called upon to warn all medical officers that vaccination should not be considered as protecting against unsanitary surroundings and that great precaution must be observed, the same as under non-vaccination conditions. This does not imply implicit confidence.
It is, also, a historical fact that the Japanese army, during the Russo-Japanese war had as low a rate of typhoid without vaccination as can, probably, be shown with it in this war. At that time they depended entirely upon pure water and sanitation.
See reports of typhoid fever in A. O. A. Case Reports as follows: C. M. T. Hulett, Series I, p. 7, J. H. Wilson, Series III, p. 3, F. E. and H. P. Moore, and F. A. and E. S. Cave, Series IV, pp. 4 and 5.
In paratyphoid fever, an acute infectious disease caused by the paratyphoid bacillus, the treatment is the same as for typhoid fever. It is milder and similar to typhoid fever.
Typhus Fever
Definition.—An acute, infectious disease; characterized by sudden invasion, high fever, marked nervous symptoms, a peculiar maculated and petechial eruption and a termination by crisis about the fourteenth day.
Etiology and Pathology.—Typhus fever is becoming less frequent than formerly and is rarely seen in this country. It was very destructive during the Great War, particularly in the Balkan states. Filth, over-crowding, famine, intemperance and bad food are the predisposing causes. Typhus fever is highly contagious and is transmitted by the pediculus corporis (cootie) as was first discovered by the American Red Cross workers in Serbia. Probably infection may come by contact and fomites. The specific organism is the bacillus typhi exanthematici (Platz).
Pathologically, there are no constant lesions. There is a general hyperplasia of the lymph follicles, but no ulceration. The blood is dark, thin and lessened in fibrin. Hypostatic congestion of the lungs and bronchial catarrh are frequently met with. The liver, kidneys and spleen are found to be somewhat enlarged and softened. The petechial rash remains after death.
Symptoms.—The incubation period is about twelve days. The onset is usually sudden, ushered in by chills. The temperature quickly rises to 104 or 105 degrees F. There is headache, pains in the muscles, especially of the back, and early, profound prostration. The pulse is at first full and strong, 100 to 140, but soon becomes weak and frequent. There may be distressing vomiting. The face is flushed, the eyes injected, the expression stupid, and there is generally low, muttering delirium. The tongue is furred and white, soon becoming dry. The bowels are constipated and the urine is usually scanty and of high specific gravity. There is great thirst. Conjunctiva injected; pupils contracted; early prostration.
The eruption appears about the fifth or seventh day. It first makes its appearance upon the abdomen and chest. It rapidly extends all over the body with the exception of the face. The eruption is of two kinds—rose spots, which disappear upon pressure, and those which become hemorrhagic (petechial); pressure has no effect upon them. During the second week the symptoms are increased. The tongue is dry, brown and fissured, and sordes appear on the teeth. Retention of the urine, due to paralysis of the bladder, is common. The breathing becomes more rapid and the heart’s action more feeble; the patient may die from exhaustion. This ushers in the typhoid state with low, muttering delirium, ataxic symptoms, subsultus, tremors, and maybe bronchial symptoms. In favorable cases the crisis occurs at the end of the second week. Patient sinks into a sound sleep, the temperature falls rapidly, there is profuse sweating and a critical diarrhea but the patient now gains rapidly.
Convalescence is usually rapid; relapses rarely occur. The urine is scanty, high colored and frequently albuminous. Bed-sores are common. The temperature continues high, reaching 106 degrees F., or more, with slight nocturnal remissions. In fatal cases the fever often rises to 108 or 109 degrees F. just before death.
Diagnosis.—The sudden onset, frequent chills, early profound prostration, character of the rash, history of exposure to the poison and unhygienic surroundings decide the diagnosis. During an epidemic there is usually no doubt, but in sporadic cases the diagnosis is sometimes extremely difficult.
Prognosis.—This is usually grave, but the mortality rate is being greatly reduced in consequence of the better sanitary arrangements.
Treatment.—Typhus fever is highly contagious and great care should be taken in controlling the disease. Isolation, disinfection and extermination is imperative. So far as known none of the osteopaths have had experience in the treating of typhus fever osteopathically, but there is no reason why the disease should not be treated with the same success as is met with by osteopathic treatment in other diseases. It is claimed that the disease should be treated in the open air, in tents, as the recovery of the patient and the safety of the attendants are greatly favored.
For high temperature, besides the treatment given to remove any disorder that may be found, the general fever treatment is indicated, and hydrotherapy would also be of aid—sponging the surface of the body, or the use of the bath. Asthenia is wherein the greatest danger lies, and a stimulating treatment along the spine and to the heart should be given; although correction of the primary trouble may be sufficient. Hydrotherapeutic measures, the systematic use of the cold bath, would be of service the same as in typhoid fever.
Headache and delirium which are apt to arise, caused by too much blood in the head, may be relieved by treatment of the cervical spine. Also cold applied to the head will aid. The bowels should be watched carefully; treat the splanchnics thoroughly and the intestines and liver directly. Nourish the patient as in typhoid fever by nutritious liquids—milk, broths, etc.
Although typhus is now a comparatively rare disease, an outline has been given to emphasize what correction of unhygienic conditions and insanitary surroundings will accomplish. It is particularly a disease of filth.
Malarial Fever
(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.