In the treatment of chronic malaria and cachexia the principal role is played by residence in a healthy climate, good nourishment, quiet life, moderate exercise, and baths. The remedial treatment is secondary. Frequent examination of the blood is indicated in order to show existing infection. If ameboid parasites are present, quinin must be administered from time to time.
The combating of the anemia by iron and arsenic is also very important. The choice of preparation depends usually on individual circumstances. Nevertheless, we recommend especially Blaud's pills and ferratin, and of the arsenic preparations, Fowler's and Pearson's solutions. They should be given under ordinary precautions.
Under great precaution, especially as regards the liver, alcohol may be given to old malarial patients, though it is usually best avoided.
If the syndrome of progressive pernicious anemia is present, an endeavor should be made to check it by absolute rest, a sea voyage, light massage, arsenic, and milk diet. According to Fayrer and Ewart, iron is badly borne in these cases. In addition, bitters may be employed to encourage the appetite, preferably, tincture of cinchona, cinchona wine, quassia amara, or calumba. Bitters should be administered before meals.
The mineral waters, the saline and alkaline saline, have also been employed with advantage. Carlsbad, Marienbad, Vichy, Wiesbaden, and Kissingen are the most frequently sought health resorts. In cases of severe anemia the waters containing iron and arsenic are to be preferred, as Franzensbad, St. Moritz, Elster, Schwalbach, Levico, Roncegno, La Bourboule, etc.
Critzmann recommends, in cachexia, bone marrow and spleen. In four cases with splenic tumor, edema, etc., he claims to have had good results, which were manifest in two to four weeks. He gave at every meal the following mixture in an uncooked chopped condition:
Beef spleen..................................50 gm.
Bone marrow................................10 gm.
The yolk of one egg.
Hydrotherapy is often very useful in cases exhausted by a severe attack. Too cold water and too brusque measures should be avoided, and lukewarm baths, cool frictions, rainwater douches, etc., be given the preference. Severe, even fatal, malarial relapses have resulted from the application of the cold pencil douche to the splenic region (Fazio, Ascoli). The same is true of massage. Carried out carefully, it .may be of the greatest service in assisting nourishment and improving the general condition; otherwise it may result in injury.
Papinio observed, in three cases of chronic malaria , forty eight hours after massage of the spleen, a renewal of paroxysms and the reappearance of parasites in the blood.
Among the hygienic regulations, residence on the sea must be mentioned first. Cold sea baths may be allowed as an experiment in light grades of anemia; in severe cases they are decidedly con traindicated, though warm sea baths are always to be recommended. High mountain air acts likewise very beneficially, yet excessive exercise, especially exhausting tours, must be avoided.
The nourishment should be mixed, simple, and sufficient. Substances that act as irritants on the intestine and liver, as all kinds of spices and alcohol, are to be eschewed.
When the splenic tumor causes disturbance and pain on account of its size or perisplenitic inflammation, the question of extirpation may be forced on the physician. Before pronouncing for it, every means, like drugs, hydrotherapy, and electricity, should be tried to lessen the size of the tumor. The usual failure is explained by the anatomic structure of the ague cake. The measures that have been recommended are:
As important as this is in lessening the size of the acute splenic tumor, so insignificant is it in the chronic tumor. Berberinum sulphate has been repeatedly recommended. Arzela states that he observed rapid diminution in size after morning doses of 0.5 dissolved in warm water. As associated effects he mentions mild stupor, epistaxis, more rarely diarrhea and vomiting.
Injections, into the parenchyma of the spleen, of quinin, Fowler's solution, phenol (Mosler), quinin (Fazio), ergotin (Messerer), phenocoll (Micheli), and sterilized water (Murri and Boari) have been recommended. The results are variable. We must also add that these injections are by no means without danger. Osier observed one case of internal hemorrhage after puncture of the spleen.
Among external applications we may mention the ice bag, the ether spray (Moscucci), the actual cautery, leeches, sinapisms, and vesicants. In splenic pain these procedures are often quite successful.
Parona recently reported that he employed with good results daily subcutaneous injections of 1.0 of a potassium iodid solution (iodi puri, 0.25; potassii iodati, guaiacoli aa 2.50; glycerini puriss. steril., 25.0).
Cold douches and electricity have also been recommended, though the results leave much to be desired. It must not be forgotten that a too brusque procedure may bring on new paroxysms of fever.
Laveran's suggestion that a dose of quinin be administered previous to a strong douche should not be disregarded.
Fayrer recommends the application, to the splenic region, of an ointment of the red iodid of mercury, while the abdomen is exposed to the sun or a fire. In Bengal the following "spleen mixture" is employed: Pulv. jalapas, rhei, calumbas, zingiberis, potassii tartaric, aa 5j; ferri sulph., gr. xx; tinct. sennas, 5iv; aquas menthas sativas, Sx. Sig.: The tenth part twice daily. Fayrer praises very highly sulphate of iron with quinin.
Splenectomy has been repeatedly done in chronic malaria , sometimes on account of general disturbances produced by the splenic tumor, again, on account of torsion of its pedicle, and frequently with good results. Recently splenopexy has been tried. The chances of splenectomy improve the longer the pedicle and the fewer the adhesions to complicate the operation. After Wyman's experience we must warn about ligation of the splenic artery. The technic of the operation will be found in surgical works.