By this we understand a very malignant, frequently fatal expression of malaria , the chief symptom of which consists in an extraordinary cooling of the surface of the body during the hot stage. This is very probably the result of a vascular paralysis in the internal organs, producing a threatening diminution of blood pressure and a stasis that proclaims itself in the form of a general cyanosis.
The disease picture is as follows: During the hot stage, in fact, usually at its beginning,* the arterial tension sinks unexpectedly; the pulse becomes easily compressible and eventually disappears. The eyes are sunken and surrounded by a black ring; the pupils dilated. The face is wrinkled and presents a Hippocratic expression. The sensorium is unaffected. The lips are cyanotic; likewise the tongue, which also becomes cold. The surface of the skin is unpleasantly cool; in fact, feels like marble, and is covered with a cold sweat. The pulse is increased in frequency; the breathing is superficial and hastened. The rectal temperature is usually elevated; the axillary, about 38°.
The subjective complaints of the patient are limited, as a rule, to a feeling of extreme fatigue in all the limbs, though he sometimes also complains of a burning internal heat. It is remarkable that the patients do not feel the coldness of the body surface. They never complain of cold, and differentiate the algor from the chill. In the latter case the skin temperature is objectively little or not at all below the normal, yet the patients complain of cold; while in the algid stage the skin is ice cold and the patient complains either not at all or of an internal burning. The patients are usually uninterested and do not suspect the danger hanging over them. The condition may be fatal in a few hours, and may be protracted twelve hours or even longer.
The prognosis is decidedly unfavorable, though some cases of recovery have been reported.
The condition occurs in intermittent as well as subcontinued fevers, though we must add the algor itself never intermits. When it once appears, it terminates either in recovery or death.
The algor is frequently secondary to severe participation of the gastro intestinal tract (further details later), though it occurs, too, as an independent symptom. In the latter case it is in all probability the result of the action of the toxin on the vasomotor centers. Proceeding from this assumption, we will consider the pure algid formunder the cerebral pernicious fevers. Laveran observed the following case of algid pernicious:
* According to Torti, the algor occurs in the cold stage and is nothing else than its prolongation ". . . cum Frigus quoddam mortiferum incipienti Paroxysmo jungitur quod non, ut assolet in Benignis, paulatim evanescit, ut illud sensim calor excipiat; sed protrahitur, et protrahitur," etc.
B., aged twenty three, soldier, was brought into the hospital at Con stantine, July 27, 1882, 11 p. m. He had been employed as a gardener, and had suffered from fever several times. He appeared at the hospital on July 27, on account of a recurrence which, at the time, showed nothing at all suspicious of perniciousness. The battalion physician ordered 1 gm. quinin sulphate in pills. The same evening his condition became suddenly worse and he was brought at once to the hospital. On admission he was extremely weak, yet in possession of his senses. He sighed deeply from time to time, but when asked how he felt, complained only of weakness and prostration. The extremities were cold, the pulse quite rapid, and impalpable in the radial artery. It was 120 in the carotids. The heart beat was rapid and feeble; respirations hurried, but deep.
The rump was warm to the feel. The temperature was not taken. Pupils were dilated. Secessus involuntarii urinarum. Subcutaneous injection of 1.50 quinin; frictions, sinapisms, warm drinks. The algor progressed rapidly.
July 28, 3.30 a. m. : The death agony. Half an hour later the end.
The autopsy showed the signs of a severe malaria . In the blood of the organs enormous numbers of parasites were found.
Closely connected with the algid form, though rarer, the syncopal likewise depends on a diminution of blood pressure. The patient falls into a deep faint on the slightest effort, as, for instance, the act of sitting him up straight, or, as Torti mentions, of turning him from one side to the other, or even a personal attempt on his own part to raise his hand.
These patients also show the subjective and objective symptoms of extreme weakness; the pulse is small, easily compressible, rapid; the forehead and neck are covered with a light sweat.
Torti affirms that the intermission after such a paroxysm may be quite bearable, yet woe to the physician who believes himself in security and omits the necessary medication. The next attack may prove fatal, and the reproach which Hippocrates once made be applicable: "Medicus non intellexit; puella mortua est."
This belongs also to the group of algid forms. It is characterized by symptoms of collapse, and, in addition, an excessive secretion of sweat, from which it receives its name. The profuse perspiration occurs sometimes at the beginning of the warm stage, and may then give rise to the error that the paroxysm was short; or it may appear at the close of the paroxysm.
Torti, who passed through a severe attack of diaphoretic pernicious fever himself, describes the condition in the following words:
" Fraudulentior est ea febris, quae nullo prsecedente pravitatis indicio Aegrum invadit more solito cum horroro, rigore, et frigore cui succedit calor, et statim sudor aliquantulum praecox, qui equidem februm videtur primo aspectu alleviare, sed revera post ilium potius intenditur febris, quam remittitur; immo eo fortior videtur fieri, quo copiosior est sudor. At ille not est terminus occulta? fraudis, hinc enim potius longitudo morbi significatur, quam mors. Quod pejus est, frigefit paulatim sudor, et in diaphoreticum sensim degenerat. Sudat perpetuo segrotans, et deffluit undequaque frigido sudor perfusus; sicque perpetuo algens, et sudans sicut cera liquatur, dissolvitur et deficit. Pulsus celer est, minutus, ac debilis, respiratio fit anhelesa, et frequens, dissipantur spiritus, et viryus universaliter languet. Mens sola lucidissima est, et sentit homo, se paulatim mori. Nisi autem hoc ilia ipsa accessione succedat, in proxime futuram tantum protrahitur" (Lib. iii, Cap. i).