This is characterized by intense epigastric pain ("acerrimus mor sus oris ventriculi"-Torti), which comes on during the paroxysm, usually during the hot stage, and ceases with its termination, though it may occur independently of the fever paroxysm (Colin). The pain sometimes radiates to the spinal column, is often accompanied by vomiting, or, if this is absent, by violent choking sensations. The abdomen is usually contracted and extremely sensitive to pressure. The excruciating pain produces intense restlessness, and the patients turn from side to side, groaning and whimpering. Not rarely the patient's condition is made worse by a tormenting singultus. In addition we frequently see, probably as a secondary effect of shock, cyanosis, lipothymia, etc. The life of the patient may be seriously threatened. Conditions deserving the name of "apparent death" are not rare (Daville).
Torti gives the following description of a paroxysm observed by him:
It occurred in a woman who had suffered repeatedly from tertian fever. With an attack in 1707, the cardialgic symptoms came on. The worst paroxysm ran its course thus: " ... vehemens siquidem per totum principium, augmentum, atque etiam statum accessionis increbuit Cardialgia, vi cujus segra sibi erodi, et mordicari a canibus ajebat orificium stomachi. Ejulabat, dum poterat; sed ssepius intercepta voce deficiebat animo: sicque alternatum ululans, suspiria edens profunda, vomitus inanes tentans, et animo deficiens, subfrigida cum minutis circa frontem sudoribus, cum pulsu exili, et crebro, cum facie, semimortuam referente, oculis caligantibus, et temporibus collapsis, animam jam prope reddere videbatur. Quia vero per brevissima intervalla nonnulla identidem prodebat signa reviviscentise, pulsusque tunc temporis nonnihil resur gebat . . ." (Lib. iy, Cap. i).
We take the following description from Kelsch and Kiener:
Grigno, aged fifty two, day laborer, employed in the cork harvesting. Admitted to La Calle Hospital August 8, 1874. Had his first fever three months before. At the present time, nine days ill. The disease began with a chill, bilious vomiting, and diarrhea. Since then repeated chills at irregular intervals, continued vomiting, and diarrhea.
Status August 9: Facies Hippocratica. Eyes sunken in, injected; cheeks hollow; mouth open, crusted; hands and face cold; cyanosis; incessant jactitation.
Temperature in the axilla, 39.9°; in the rectum, 40.5°; pulse rapid and very small. Patient complains of a burning in the epigastrium. During the night and morning vomited several times. The abdomen is contracted and is very sensitive to pressure. The spleen is enlarged. No stools since admission.
At 3 o'clock: Algor more developed. The extremities ice cold; temperature, 39.5°; in the rectum, 40.3°. Vomiting has ceased. The first clyster of 1.0 quinin sulph. was at once thrown off; the second was retained. Wet cups to the abdomen. Stimulating drinks.
August 10: Continued restlessness. Excruciating internal burning. Tongue dry and rough. Epigastrium contracted and very painful. No vomiting. Two diarrheic evacuations. During the night a profuse sweat. Algor and cyanosis somewhat less than yesterday. Temperature, 37.2°; in the rectum, 39.2°. In the blood, melaniferous leukocytes.
3 o'clock: Restlessness less marked. Dry friction and six leeches to the epigastrhmi caused a diminution of the sensation of internal burning. The nose, forehead, and hands cool; the rest of the body warm. Temperature, 39°; in the rectum, 41.1°.
August 11: Decided improvement. The fever is lower and the distribution of the surface temperature more natural. Temperature in the morning, 38°; evening, 37.4°; in the rectum, 38.6° and 37.9° on each occasion. Restlessness less marked; epigastric pain quieter; tongue still dry; the voice weak; the extremities cool and somewhat cyanotic. No vomiting. One diarrheic stool. The abdomen still contracted, but less painful. Pulse, 92. The urine cloudy, reddish, and larger in amount than on the preceding days, measuring 900 c.c.
August 12: Same condition, with slight improvement. Morning temperature in axilla, 37.2°; in rectum, 37.3°. Evening, 37.4° and 37.3°.
August 13: Apyrexia. Strength not yet returned; the tongue still dry.
Later a left sided pneumonia developed, to which the patient succumbed.
Kelsch and Kiener insist that the excessive employment of emetics and cathartics may produce the cardialgia. Colin considers the so called gastralgic, emetic, dyspneic, pleuritic, pernicious cases as subforms of the cardialgic, which differ from it only in the location of the pain.