The disease begins quite suddenly (prodromal symptoms are very rare) with a chill, which frequently develops into a rigor.
Coincidentally with this chill the temperature rises abruptly (more rarely the rise in the temperature is gradual) to 39° or 40° C. or even higher.
Together with this acute onset the other symptoms of the affection appear; they are: severe headache, especially in the frontal region and in the orbits; intense pain in the back, lumbar pains, and especially very characteristic pains in the joints, particularly the knee joint, making movement an impossibility (hence the name, "abou rekabe," compare Nomenclature), besides pains in numerous other joints, as of the foot, fingers, hands, and shoulders. Dengue sometimes attacks the limbs so suddenly and painfully that the patient cannot even complete a movement already commenced, so that if kneeling in church, - he is unable to arise, or if attacked in the street, he is unable to drag himself home. "Some patients are so stiff from the onset of the affection that they have to be fed. But others, the milder cases, are not compelled to take to bed at all and are able to carry on their usual occupations" (de Brun).
Severe pains in the muscles and a general hyperesthesia of the skin, so that every movement is painful, are frequently noted.
Very characteristic and constant are the gastric symptoms: complete anorexia, a thickly coated tongue (de Brun, Apery, von
During), frequently a fetid odor of the mouth, a foul taste, and a tormenting thirst.
Occasionally,-according to von During but rarely, and according to other observers frequently,-even in this first stadium febrile, a fleeting exanthem ("rash," "eruption premonitoire") appears, which is hardly more than a vasomotor erythema of the skin, especially on the face, where it also may appear in a macular form. The face is reddened, the eyelids are swollen, the conjunctiva is injected, there is photophobia, the pharynx is reddened, the nasal passages are occluded, and even "coryza" has been observed (Smyrna report, von During); but all these symptoms, which remind us of influenza, play a minor role when compared with the pains in the joints, the gastric symptoms, and the fever, and the strong contrast to influenza lies in the fact that the occurrence of a laryngotracheitis (Hong-Kong, 1895) or a bronchitis (von During) is extremely rare.
Very great prostration is always present, and is frequently quite out of proportion to the mildness of the fever and other symptoms.
This first stadium febrile usually lasts three days ("three day fever"). Occasionally, upon the first or second day, but regularly, in the typical cases, upon the third or fourth day, the temperature falls to normal, occasionally by lysis, at other times by crisis, accompanied, in the latter case especially, with profuse perspiration. This really ends the " stadium febrile." It is now that the pathognomonic rash appears and marks the second stage of the disease, the " stadium exanthematis, s. afebrile, subfebrile." Before entering on a description of this stage, some of the more important symptoms may be mentioned more in detail.
The fever rises, as already remarked, after the initial chill, rapidly and considerably, reaching 40° C. and over. Von During once observed a temperature of 41.7° C. Very frequently this initial rise of temperature is the highest reached during the whole course of the fever. In mild cases the pyrexia is of but a few hours' duration, and lasts one, two, or, most frequently, in the fully developed cases, three days. In both of the latter cases a progressive, gradual fall of the temperature from day to day is the rule. Only rarely is the three- and four day fever maintained at a high level (Floras).
If, with the appearance of the rash on the fourth day, a fresh rise of temperature occurs, or if, on the sixth to the eighth day, a relapse, with or without rash, comes on, the temperature curve naturally assumes the frequently noted recurrent type. The temperature curve of dengue is remarkably like that of influenza, but in the latter illness the fever plays a far greater part. The fall in temperature on the third or fourth day is generally accompanied by a profuse and, as is stated, very fetid perspiration (Smyrna medical report, de Brun). On the other hand, according to von During, the temperature usually falls "without perspiration." But in another place this author speaks of the fetid perspiration occurring toward the termination of the febrile period, and continuing for some time as a symptom of prostration. The onset with high fever frequently causes convulsions in children, and in adults occasionally dizziness and faintness, epileptiform attacks (Shaughter), coma lasting sometimes for a day, but especially delirium, which in the Hong-Kong epidemic of 1895 was frequently observed. Also "maniacal attacks with suicidal tendencies" are mentioned in these initial febrile stages (Mordtmann). The initial delirium and psychoses, rare in dengue, and more frequent in influenza, disappear with the fall of temperature and the appearance of the rash.
There is a considerable difference in the descriptions of the highly characteristic articular pains (especially of the knees) by the physicians of the older and more recent epidemics. The older authors, and among the modern ones Engel-Bey, speak of true articular effusion, of "acute multiple swelling of the joints" quite analogous to rheumatic polyarthritis. These descriptions were naturally used by A. Hirsch and Zulzer. On the other hand, in the later epidemics, de Brun in Smyrna, Mordtmann and von During in Constantinople, and Skottowe in the Fiji Islands, never saw inflammation or swelling of the joints; only von During speaks of very rare periarticular swellings. According to these authors, there are intra articular, periarticular, and muscular pains only, which cause the stiffness and the difficulty of movement in the joints. Yet these violent articular pains probably have their origin in hyperemic or inflammatory processes at or in the joints, as indicated by a few postmortem examinations ("serous infiltration in the vicinity of individual joints, reddening of the crucial ligaments of the knee joints," quoted from A. Hirsch).
To the already described symptoms in the digestive organs, viz., the pathognomonic anorexia and the thickly coated tongue, may be added nausea, which occurs frequently, and vomiting occasionally. Constipation is the rule. Diarrhea is rare, perhaps principally caused by the purgation method of treatment of dengue, practised in the Orient. Bloody diarrhea, dysenteric manifestations, intestinal hemorrhages, and choleraic diarrhea, such as have been mentioned for influenza, occur only exceptionally in dengue (Mordtmann, von During).
According to de Brun, icterus is occasionally present, and von During also mentions it once. In the yellow fever districts of the American tropics the icterus of dengue is said not to be rare (?).
The "pulse" corresponds to the bodily temperature. It is of interest that cle Brun has repeatedly observed " marked slowing of the pulse," analogous, therefore, to our observations concerning bradycardia in influenza.
Enlargement of the spleen has, up to now, never been noticed in dengue; its absence is expressly emphasized by von During and Sand with.
Albuminuria is just mentioned by von During, and undoubtedly, like in influenza, is only a passing temporary manifestation. There is nowhere any mention of nephritis as a sequel. Nowhere have I found herpes mentioned.