The hemorrhages naturally may have a local cause; the hematemesis, for instance, may be the result of thrombosis of the portal vein or of cirrhosis of the liver; hemorrhage from the left nasal cavity, the result of splenic tumor, etc. It has sometimes been affirmed that after such a hemorrhage the spleen diminishes in size.
The overloading of the organs with pigment expresses itself in melanosis of the skin, which is more intense the shorter the time since the last paroxysms. It may reach such a degree that the skin becomes of a bronze color.
The splenic tumor is much more important. It grows, as a rule, in the direction of the umbilicus, more rarely taking a cross position when it lies in the epigastrium. The tumor may extend into the small pelvis and meet its first resistance on the pelvic bones. In this case it manifests no respiratory displacement. It usually produces a feeling of weight in the left half of the abdomen, of which patients frequently complain. It is sometimes the seat of stabbing pain, the result of an intercostal neuralgia or perisplenitis.
According to Laveran, the spleen reaches this immense size only in cases not at all or insufficiently treated with quinin during the acute infection.
Not so frequent as the splenic tumor, yet occurring in a large percentage of cases, is a tumor of the liver. M. E. Colin found, in 61 autopsies, the liver normal in size 18 times, enlarged, 43 times. It is sometimes relatively more enlarged than the spleen.
Occasionally, instead of enlarged, it is decreased in size, apart from any cirrhosis. This is due to simple atrophy of the organ. In addition to these cardinal symptoms there are others which demand a short description.
In every severe case of cachexia the parenchymatous organs suffer tissue changes, with the production of corresponding symptoms. We may mention especially secondary diseases of the liver, as perihepatitis, hypertrophic biliary cirrhosis, atrophic cirrhosis, cholangitis, etc.
The relapses commonly show an intermittent character. They manifest, as a rule, no severe symptoms and no marked elevations of temperature, though there are exceptions, and a relapse may be pernicious and the patient succumb.
They usually occur at long, frequently irregular intervals. The cold stage is but little pronounced or absent. The elevation of temperature usually remains within moderate limits. The sweating is not profuse, though it continues for a long time. Among the dangerous forms L. Colin mentions algid, syncopal, icteric, comatose, apoplectic, subcontinued autumnal pernicious as the most frequent.
The parasitologic investigations in cases of cachexia are as yet too few to judge of a relationship. In a certain number of cases the parasitic infection is undoubtedly continuous. Isolated parasites, especially of the crescent class, are frequently found in the blood, even though not at all times. During a relapse the parasites are quite as numerous as in recent infections. Whether there are cachectics whose organs are entirely free from parasites must be regarded as an open question. A priori this does not seem impossible-in fact, it seems to a certain degree probable.
In addition to the paroxysms of fever the result of relapses we see feverish conditions that cannot be regarded as due to the malarial infection, on account of their behavior to quinin. Moreover, frequently no local disease can be found, and we are obliged to speak of symptomatic fever. Undoubtedly a great part of these fevers are dependent on organic anatomic processes, as, for instance, the connective tissue formations in the liver and spleen, the phlebitides, thrombi formations, etc.
The mouth is frequently the seat of gangrene, the gums especially showing an inclination to necrosis. From there the gangrene not rarely spreads to the lips and cheeks. The jaw bones are laid bare. Gangrene of the soft palate and of the tonsils at the close of apparently mild anginas is frequently observed.
The gastro intestinal tract is regularly the seat of symptoms, even though these are not characteristic. Loss of appetite, a feeling of compression in the stomach after meals, an inclination to constipation, more seldom to diarrhea, are common symptoms. Dudon frequently observed attacks of intense colic (colique seche) associated with contracted or tympanitic abdomen.
Catarrh of the respiratory tract is very common. This may become dangerous by extension to the fine bronchioles, by the production of bronchopneumonia, etc. When this last occurs, it not rarely terminates in gangrene.
The nervous system likewise participates, as mentioned under anemia and hydremia. In addition to the symptoms considered there, we see attacks of vertigo, fainting, paralysis of the bladder, a trembling gait, and trembling of the hands or of the whole body. Laveran saw this last disappear on the administration of quinin.
According to Mouneret, hemeralopia is not infrequent. Sulzer observed chronic optic neuritis, melanosis of the papilla, retinal hemorrhages, and changes in the vitreous humor.
Gangrenous processes of the severest kind may occur about the genito urinary apparatus. Gangrene of the penis, especially in association with chancre, and gangrene of the labia, extending to the mons veneris, the thigh, or the perineum, is not infrequent.
The urine is usually increased, but may be diminished in quantity. It frequently contains urobilin. When nephritis or amyloid disease complicates, it is rich in albumin. Hemoglobinuria and hematuria are not rare.
The mixed infections to which the unresisting organism of the cachectic readily succumbs are many. We will devote more space to them in the section on Complications, and will mention here only the most frequent and, therefore, the most characteristic: Scorbutus, gangrene, pneumonia, cirrhosis of the liver, nephritis, phlegmon, to which we may add, as a sequela, amyloid degeneration.