The most common summer and autumn fevers in some malarial regions (the coasts of the Mediterranean Sea, Africa, Madagascar, India, etc.) are those associated with more or less pronounced icterus and gastric disturbances. As mentioned on page 262, these frequently run a favorable course, though often, too, they manifest acutely dangerous symptoms, which, if recovery takes place, may leave behind lasting chronic disease. It is these severe cases which we intend to discuss here.
Natives and the acclimatized, as well as new arrivals, may prove victims. According to some authorities, the not yet acclimatized, especially those who have just arrived in the tropics, are attacked the most frequently.
The disease is usually ushered in with prodromes, which consist in general weakness, pain in the loins and limbs, loss of appetite, ana coated tongue. The temperature is, even at this stage, often somewhat elevated.
In other cases a few mild intermittent fever paroxysms may precede, and again the prodromes may be entirely wanting.
The attack itself seldom begins with a chill, and the "first stage" limits itself either to a chilliness or is absent. The patients complain principally of headache, frequently radiating from the eyeball, excruciating pain in the loins and in the limbs, loss of appetite, vomiting, and prostration. The face is usually flushed and turgid; the conjunctivae are injected, and photophobia is frequent.
* It is possible that the observation of Frerichs applies to it. See the section on Intestinal Complications.
The type of fever is variable, the malignant tertian type being most common. Less often we see from the beginning short, sharp, intermittent quotidian or ordinary tertian paroxysms. In many cases where the fever began with a remittent type we see later, usually under the influence of quinin treatment, a pure intermittent. Moreover, the reverse is not rare, namely, the appearance of a subcontinued type, after several sharp, intermittent quotidian or tertian paroxysms. The remissions are often only suggested, lasting not more than two or three hours, though in other cases we see intervals of thirty six hours' duration without a paroxysm.
According to Fayrer, the first paroxysm is usually the longest, while the succeeding ones are more severe and come on without a chill.
The remittent or continued fever may extend over six or seven days, even when quinin is employed, though, as a rule, it goes over into remittent in a shorter time. The sweating stage is only suggested or is absent.
The gastro intestinal tract manifests the most striking symptoms. These consist in anorexia, epigastric pain, ructus, pyrosis, and vomiting. The epigastric pain is of varying intensity: it is usually pretty severe, sometimes occurs as frightful paroxysms of cardialgia, and rarely is entirely absent. The epigastric sensitiveness is sometimes so great that the patient Cannot bear the weight of the bed clothes.
Vomiting is one of the most constant symptoms. Fluctuating between vomiting and nausea, it is a dreadful torment. The attacks of vomiting are more frequent at the beginning. They often continue day and night. The vomit is greenish from the biliary coloring matter as long as hydrochloric acid continues in the stomach; later it becomes brownish yellow and finally bloody, coffee ground like, as the end approaches.
Constipation is frequent, though profuse diarrhea is not rare, so that from this and the vomiting the suspicion of cholera may arise. The stools, too, contain considerable bile, and are in the beginning dark brown; later, clear yellow. In the very severe cases the stools become bloody antemortem. Singultus frequently occurs as a preagonic symptom.
Icterus is one of the most important symptoms. It is usually seen from the beginning, and even suggested during the prodromal period. In the majority of cases it is limited to the sclera, though it may become very extensive.
As shown in the section on Pathogenesis, this is a polycholic icterus, due to the increased destruction of the red blood corpuscles. The bilious vomiting and the bile in the stools are also to be included under the polycholic symptoms.
A bronchitis increasing with every paroxysm is frequently seen from the beginning. Delirium, stupor, carphologia, show the participation of the nervous system. Hemorrhages, like epistaxis, hemat emesis, are occasionally observed.
Micturition is usually undisturbed, yet sometimes there are strangury and sensations of burning. The amount of urine is variable: with profuse diarrhea and frequent vomiting it is often very slight. The urine is dark in color; it contains urobilin in large amounts; more rarely, in addition, bilirubin. Albumin in considerable quantities is frequent.
The blood shows a rapid impoverishment of erythrocytes. Whether hemoglobinemia exists in these cases has not been investigated; yet the marked destruction of blood corpuscles and the polycholia make it probable that it does exist at the beginning or before the beginning of the paroxysm.
As a result of the hydremia the patient develops, in the course of the disease, or more commonly during convalescence, an edema that may be general or limited to the ankles.
Under the exhaustion produced by the hemolysis, vomiting, diarrhea, and the impossibility of administering nourishment, the general condition sinks rapidly. The adynamia and algor especially become threatening, and coma is not infrequently added, to which the patient succumbs. Sometimes, especially in Hindus and negroes, pneumonia and bronchitic complications occur to render the condition worse. Symptoms of a hemorrhagic diathesis, in the form of epistaxis, melanemia, hematemesis, petechias, etc., favored probably by the hydremia and icterus, may likewise appear.
The duration of the disease, when uninfluenced by quinin, is usually about ten to twelve days (Kelsch and Kiener), though severe cases may be fatal, in spite of quinin treatment, during the first days or in the course of the first week.