This is the most common form of pernicious malaria associated with gastro intestinal symptoms. In tropical as well as subtropical regions it is exceedingly frequent; in the malarial regions of the temperate zone, at least in our day, it follows in frequency the cerebral forms. It is especially this form that leads to errors in diagnosis in tropical countries, in that it imitates the picture of cholera morbus. This syndrome occurs so frequently that we are scarcely surprised to find an investigator like Fayrer come to the conclusion that cholera, dysentery, and malaria are closely associated etiolog ically. Davidson also insists that the relations between cholera and malaria are too manifest to be questioned, though these are of such a complicated nature that they cannot be reduced to any definite rule.
The situation is further complicated by the fact that malaria and cholera are frequently endemic in the same place, on account of which choleraic pernicious is readily mistaken for true cholera, in the same way as a case of arsenic poisoning may pass unrecognized during a cholera epidemic.
In order to show the importance of this question in India the following passage is quoted from Sir Joseph Fayrer's work:
"Ancient Hindu authors, observes Mr. Andochurn Kastogiri, a learned Bengali physician and graduate of Calcutta, mention symptoms of cholera as being prominent in a certain type of fever called jewar atishar, literally, 'fever with excessive diarrhea,' and he remarks: Tt has been observed that both may break out simultaneously, or one follow in the track of the other. In practice mixed attacks of cholera and fever are frequently seen.' An attack beginning with symptoms of fever may end with cholera, or vice versa. And even recently such an epidemic was devastating Amritsar in the Panjab. A report says: 'Choleraic fever is still raging in Amritsar. Business is at a standstill, and nine tenths of the shops have been closed. A correspondent describes the appearance of the place as a city of the dead. He adds that not a single European has escaped an attack, and that the railway, post, and telegraph officers are working under great difficulties, owing to sickness among the employees.'
" A telegram from Lahore, dated October 4, ran thus: ' Two thousand, two hundred and sixty five persons died at Amritsar during the eleven days ending with the first hist. One half of these were children. The heavy mortality is almost wholly owing to choleraic fever, which still prevails in many towns in the Panjab. Considering that the Amritsar medical and municipal staff is greatly overworked, and that natives are always reluctant to give information of deaths, the foregoing figures must be below the mark.'
" The fever here referred to is described to me by the medical officers who witnessed it,-Dr. Duke, of Amritsar, and Dr. Ross, now of Delhi,- who have sent me the following information:
"Dr. Duke says: 'since my arrival here on November 9, 1881, the fever has offered no special aspect; it has not been of a choleraic t}rpe.
The symptoms have been those of malarial fever. Our hospital medical wards are filled with pale, anemic men, with dropsy, enlarged spleen, diarrhea, and dysentery, supervening on fever and starvation; for, as the Kashmeeris were attacked with fever, their looms were stopped, and they earned no food. Neither typhus nor typhoid has been observed, nor have any cases of fever with a rash been observed in the city. The death rate has fallen to 50 per 1000, only 10 or 15 per 1000 above the usual state of Amristar, which has 150,000 inhabitants. I will send you notes on any cases of typhoid or other special fever that may hereafter come under my notice.'
"Dr. Ross says: 'My opinion is that the fever was a special type, which appears in cholera }rears, and resembles relapsing fever very closely. The course and progress of the disease were distinct from ordinary malarious fevers, and neither typhus nor typhoid existed. Some 12,000 people died in two months or thereabouts; the fever that existed in the jail and civil stations was quite distinct! I send extracts from notes I sent to the Surgeon-General bearing on the epidemic, but have no records of cases.
" 'The rainfall here in 1881 is reported to have been rather more than twice the average fall of the last fifteen years. It fell principally over the cit}" and around the outskirts of the city. Average rainfall at Amritsar during the past fifteen years was 24.9 inches; the rainfall of 1881 was 52.2. At Tarantaran, a station 15 miles from Amritsar, 68.5 were registered, this being the maximum rainfall.
" 'The heavy rainfall, which commenced in June, caused immense collections of water over a tract of canal irrigated ground to the north and northeast of the city of Amritsar; the two natural drainage channels, the Gumtala Nulla and the city ditch, being quite inadequate to carry off the water. The consequence was that the water level rose to an unprecedented height, bubbling up like miniature geysers; all the wells became thoroughly polluted, and the water tasted distinctly brackish.
" 'Fever in the city did not appear in an epidemic form until September; it was preceded by cholera about the beginning of August, of an extremely fatal type, and, later on, when masked by fever, there was some difficulty in recognizing it in time.
"'The fever, which prevailed with its utmost force in September and the early part of October, appeared to be of the relapsing fever species, but with some affinity to cholera. There were the rigors, fearfully severe, headache, insomnia, disordered bowels (often constipated), fever, suppression of urine, with death from coma frequently within a few hours after seizure, but then the rice water evacuations and vomit of cholera appeared in very many instances during the course of an attack of the fever.