French writers mention the frequent occurrence of a colic resembling lead colic (colique seche ou colique nerveuse des pays chauds). The abdomen is contracted, and the patient complains of continuous violent pain, yet these are the only symptoms of lead poisoning. When this dry colic is conspicuous, the physician may overlook the hemoglobinuria and fall into serious error. Moursou's opinion that all cases of colique seche are to be attributed to lead poisoning is, even from his own descriptions, far fetched.
Micturition is ordinarily not disturbed, yet sometimes there is a burning in the urethra. Corre several times observed priapism. The amount of urine passed at one time is usually about normal. Occasionally tenesmus ad matulam is present. The icterus in these cases is usually of a light grade.
After four to six hours the symptoms disappear under a simultaneous fall of temperature, which is often associated with an outbreak of sweating. The urine may show again a normal color six hours after the beginning of the paroxysm.
One single paroxysm usually constitutes the sum total in these mild cases, yet sometimes, after regular or irregular intervals, one or two more paroxysms similar to the first occur.
When these symptoms increase in intensity and duration and are accompanied by symptoms of prostration and adynamia, the disease picture assumes a very ominous character and we speak of a severe form. This, too, begins with a chill, intense headache, precordial anxiety, dyspnea, etc. These opening symptoms are exceedingly distressing, and from them the severe course may be conjectured.
The most distressing condition to the patient is a continued nausea and an inconquerable vomiting of bile. In addition there is a profuse diarrhea, characterized by yellowish brown or brownish red stools, so that the dejections may be easily confused with the urine (Berenger-Feraud). An especially distressing singultus (of grave prognostic import) frequently comes on, which may continue day and night without relief. The thirst brought on by the fever and the great loss of fluid from the body are almost as intolerable and cannot be alleviated on account of the constant vomiting.
The tongue is covered by a thick, dirty, sometimes black coating, the result of the bilious vomiting.
The abdomen is usually tense and painful. The pain radiates from the epigastrium and the right hypochondrium to the lumbar region, or is limited to the latter.
The icterus becomes rapidly marked and may reach the highest grade. If the disease lasts a long time, it gradually decreases and gives way to a dirty leaden hue. It sometimes lasts two or three weeks.
According to Berenger-Feraud, epistaxis is frequent, but this has not been confirmed by others. Petechias are sometimes observed. The urine in these cases is blood red, and, as a rule, considerably diminished in quantity, amounting often to not more than 50 c.c. in the twenty four hours. Complete anuria for several days is not rare. In these cases uremia is added to the other symptoms, which, as a result, frequently become worse (vomiting, singultus, diarrhea, etc.). .
The general condition of the patient is very serious. At the beginning of the disease, a tormenting anxiety and restlessness appear to distress the patient through days, and prevent sleep at night.
Later the symptoms of deep prostration and adynamia predominate.
The pulse is hastened; the tension, at the beginning increased, sinks suddenly. The condition may eventually assume the whole symptom complex of syncopal algid pernicious.
The severe symptoms continue for several days to two weeks, with more or less evident remissions. These remissions may be absent, and then the condition becomes so much the more serious. [We have summarized earlier the results of blood examinations by recent observers.-Ed.]
According to Bastianelli, the parasitologic findings in the blood vary. We may find developmental stages of the small ameboid parasites or organisms of the crescent order, or only melaniferous leukocytes. Again, there are cases in which the blood examination is entirely negative, and the anatomic investigation alone shows the signs of a previous infection by the endothelial, perilobular, and perivascular melanosis. We will discuss these latter cases under Postmalarial Hemoglobinuria.
As to the cases showing positive results in the blood examination, Bignami and Bastianelli found once the coincidence of the hemoglobinuria with the sporulation of the parasites. From this they thought it possible that the act of sporulation and the destruction of the blood corpuscles might be associated. When the hemoglobinuria persists, though only forms of the crescent order are present, and even the spleen contains no ameboid parasites, it is possible that the destruction of the blood corpuscles caused by the small parasites previously present continues, for reasons that we do not understand, analogously to the temperature movements not rarely observed with crescents alone. Bastianelli proposed to designate the first cases as "accessual," the second as " post accessual," hemoglobinuria.
Shadow corpuscles are sometimes, but not often, found free or inclosed in leukocytes. The infected red blood corpuscles are usually not distinguishable from those of other forms of malaria , and it is only rare to find them prematurely decolorized. Bignami and Bastianelli believe that the parasites in these latter die as a result of the decolorization, and that spontaneous cure may occur in this way. A. Plehn also expresses a similar view. Unfortunately, the phenomenon of decolorization is too seldom to act as a premise for extensive conclusions.
As regards the negative blood examination in blackwater fever, little is proved, as we have seen, when the blood is not examined at the beginning of the disease, and still less when the patient has previously taken quinin.