As has been stated, these fevers present an extraordinary variety of symptoms, in that there is scarcely a system of organs which does not occasionally participate and in a conspicuous way. These symptoms may be the result of the accumulation of parasites in the organs, or of the (hypothetic) intense poison. In the latter case the disease is given a peculiar stamp, which, to the inexperienced, may not at all recall malaria .
We will discuss, first, those cases which show no preponderating participation of any organ and no severe general symptoms; in other words, the simple forms of this infection.
In the milder malarial regions infected with the crescent forming parasites these simple forms constitute the great majority of cases, and even in the severest malarial regions,-e. g., East and West Africa, -where the cases of the true pernicious variety occur in immense numbers, the simple forms are not uncommon.
The mild fevers of this class have many features in common with those of ordinary intermittent fever (tertian and quartan). But this is true only in the minority of cases. In the first place, the cold stage, which occurs so prominently in almost every case of the ordinary variety, is in these often very rudimentary and not rarely entirely wanting. According to Thayer and Hewetson's statistics, a chill or chilly sensations were found in 71.4 per cent, of cases of the latter: in 97.2 per cent, of cases of the former. As a consequence, the patient frequently fails to realize his elevated temperature, and has no support on which to base the actual beginning of the paroxysm. The sweating stage, is less commonly absent, even though it is not so regular as in the intermittent fevers of the first group.
The disease usually begins suddenly, though sometimes with vague prodromal symptoms. The first symptoms often consist in headache, a tired feeling in the limbs, sciatic pains, and absolute anorexia, frequently associated with vomiting. The patient appears in the majority of cases anemic, with somewhat of a subicteric discoloration. The lips are dry; the tongue, thickly coated.
The sensorium is often unaffected, and the patient gives then the impression of a hectic consumptive; sometimes a mild stupor or slight delirium exists. During the short apyrexia the patient is not restored to that complete euphoria that we see in fevers of the first group. Though patients of the latter class feel somewhat weak and in need of rest, they are otherwise well and manifest a good appetite and good spirits; while the patients under consideration, even during the interval, are severely depressed, if not prostrated, incapable of physical or mental work, and complain of painful sensations in the limbs and head.
As to the type of fever, we need only say that it manifests the same variations in the light forms as in the severe; in other words, it is not a criterion of the other symptoms. The tumor of the spleen is evident, even in the first days of the disease. The anemia progresses more rapidly than in fevers of the first group.
In many cases severe symptoms are manifested by the gastrointestinal tract. These cases are described under the special name gastrobilious, bilious remittent, or jungle fever. Little known in Europe, this form is the most frequent expression of malarial infection in tropical and subtropical regions. It is recognized on all coasts of the Mediterranean Sea, especially Italy, Sicily, Algeria, Egypt, Greece; it is especially frequent in India, in the United States of North America, particularly in the southwestern parts of the Union (Wood), and is wide spread in Mexico, Brazil, and in the Antilles. It is likewise very frequent on the east and west coasts of Africa as well as in Madagascar.
Since we will return to the description of the severe bilious fever in the section on Pernicious Fevers, we will content ourselves here with a short description of the milder symptoms. They are as follows:
The loss of appetite is absolute and is frequently associated with a decided distaste for every kind of nourishment. The patient is tormented by a nauseating taste, and the tongue is thickly coated and swollen. In addition there is vomiting. The vomit is at first greenish, later yellowish, and finally almost pure bilious, when no more hydrochloric acidv remains in the stomach. The vomiting is extremely tormenting and frequently uncontrollable, ceasing only with the intermission or remission of the fever.
The epigastrium is often distended and sensitive to pressure. There may be slight meteorism. There may be either constipation or diarrhea. In the latter case the stools are dark and rich in bile pigment; rarely the opposite. From the beginning there is a subicteric discoloration, which may increase to intense jaundice.
The urine is dark, concentrated, and contains considerable urobilin when jaundice exists. Bilirubin may be found; likewise albumin. The other symptoms are the same as have been described for the ordinary fevers of this group.
The prognosis is good, though it must be remembered that severe complications can never be excluded. When the case is left to itself, we occasionally see spontaneous cure, in five to ten days, though it is always advisable to push from the beginning the specific and symptomatic treatment.