There is anorexia and alimentary tract disturbances. A very important feature of malarial cachexia may be the occurrence of haemorrhages, particularly serious being those from the retinal vessels.
It is probable that hookworm infection has frequently been confused with the anaemia of malarial cachexia as in both of these conditions we may have a high-grade anaemia with swelling about the ankles, palpitation of the heart and shortness of breath. Some authorities have recently called attention to splenic enlargement in hookworm disease, but this is not generally accepted. There may be also ascites in malaria. Urobilinuria is an important sign in malaria where other causes for red cell destruction are excluded.
The Sequelae of Malaria.—The anaemia and other manifestations of malarial cachexia have been described above. The enlarged spleen not only is a source of danger from rupture but it may cause sensations of pain or tension. The skin of those with chronic malaria tends to ulcerate from slight wounds and phagedenic lesions may occur. There may be various disorders of the nervous system varying from mental confusion or lack of mental concentration to melancholia. Neuritis and possibly peripheral neuritis may have origin in repeated attacks of malignant tertian malaria. Ulceration of the cornea is the most frequent of the ocular sequelae although even this is rare. It only occurs after many relapses. It is painful, heals slowly and tends to recur with relapses. Iritis may accompany it. Abortions are frequent unless the malaria is adequately treated.
Symptoms in Detail
General Appearance.—In the cold stage of the benign infections the face is pinched and blue to become decidedly flushed when the hot stage sets in. In malarial cachexia there is an earthy color with the pigmentation more marked about the face and knuckles. In the algid forms of pernicious malaria the skin is pale, cold and clammy, in a measure simulating cholera. Herpes labialis is very common in the benign infections, but less so in the malignant tertian ones. Jaundice is a feature of bilious remittent fever.
The Temperature.—Even in the cold stage the temperature is steadily rising and may have reached 105°F. or higher by the time of onset of the hot stage. It remains elevated during the four to six hours of the hot stage and then falls rapidly to normal during the sweating stage. The paroxysm tends to occur in the forenoon or early afternoon. In 793 typical paroxysms Stott found only 37% to occur before noon. Intermittent fever curves are characteristic of benign infections. In malignant tertian a prolonged hot stage (fifteen to thirty-six hours) is a marked feature. The onset also is more gradual and the fever tends only to remit or may remain continuous over several days, but even with such a chart there are apt to be indications of slight rises every other day.
In the hyperpyrexial form of cerebral perniciousness the temperature may rise to 112°F. and the case resemble sun stroke. In the algid forms the axillary and rectal temperatures are usually elevated.
The Circulatory System.—The pulse is small, rapid and of high tension in the cold stage to become full and bounding in the hot stage. A cardiac type of perniciousness in which the right heart dilates has been referred to.
The Alimentary Tract.—Nausea and vomiting are common manifestations of malarial paroxysms and in bilious remittent fever the bilious vomiting is an especially distressing feature.