INFECTION OF THE INTERMEDIATE HOST: VIVAX 
185 
that white infants, 6 weeks old, who were 
infected with P. vivax presented spleens 
reaching to the umbilicus. In infants and 
young children, P. vivax produces a greater 
degree of splenomegaly more rapidly than 
in adults. After the termination of a P. 
vivax infection (whether spontaneous or by 
use of drugs) the size of the spleen de¬ 
creases rapidly and within 6 or 8 weeks it 
may not be palpable at the costal margin, 
even on deep inspiration. Persistently en¬ 
larged spleens in P. vivax malaria are 
occasionally noted and are indicative that 
the patient will have a relapse. 
Malaria cachexia. If we define cachexia 
as a condition of wasting and general ill 
health occurring and persisting for months 
or years after an acute illness, then “ma¬ 
laria cachexia ” in P. vivax malaria, as evi¬ 
denced by observations on paretics under¬ 
going malaria therapy, does not exist. 
Whenever the clinical course is interrupted 
with quinine or when the clinical course 
terminates spontaneously the red cell count 
and the hemoglobin return to normal 
within a month or 6 weeks after cessation 
of the clinical attack. The enlarged spleen, 
the enlargement of which has varied di¬ 
rectly with the severity and length of 
the clinical attack, decreases in size, except 
in a few cases. Other than this transient 
splenic enlargement, there is nothing pres¬ 
ent after an attack of P. vivax malaria as 
described under malaria cachexia. The per¬ 
sistently enlarged spleens found in the field 
are attributable to successive infections 
with different species and different strains 
of plasmodia which bring about a long 
series of clinical attacks. 
Instead of a cachetic condition following 
a P. vivax attack, the opposite condition 
obtains. One of the most outstanding 
effects noted following the use of P. vivax 
malaria for the therapy of paresis is the 
increase in weight after cessation of the 
clinical attack, even when the attack ter¬ 
minates spontaneously and antimalarial 
drugs are not administered. A gain in 
weight of 10 pounds over the weight of 
the patient before malaria therapy was in¬ 
stituted is not unusual, and in a few in¬ 
stances a gain of as much as 20 or even 30 
pounds has been noted. 
From these observations it appears that 
it is extremely unlikely that a cachexia 
due to vivax malaria exists in nature unless 
the disease is complicated by other factors 
which may of themselves produce a cach¬ 
exia, such as intercurrent infections and 
malnutrition. Emaciation, oedema, nephri¬ 
tis or secondary anemia are not present, 
and subjective symptoms such as loss of 
appetite, malaise and lassitude and “a gen¬ 
eral condition of nervous exhaustion” are 
not met with. 
Subjective Symptoms 
Subjective symptoms indicative of an 
impending clinical attack of P. vivax 
malaria are usually experienced before the 
end of the incubation period. The first 
symptoms are vague and may be repre¬ 
sented by insomnia, lassitude, a degree of 
apathy, loss of appetite and a feeling of 
nausea. Some 2 to 12 hours later, head¬ 
ache, pains in the muscles and joints may 
occur as well as a feeling of cold. These 
symptoms last only a few hours and the 
patient feels well, but these same symptoms 
may reappear at approximately the same 
time the next day. This is especially noted 
in the case of the feeling of cold, the first 
chill often occurring at the hour of the 
day at which this sensation was previously 
experienced. 
During the initial stage of continued 
fever the patient may be extremely miser¬ 
able and experience more malaise than at 
any other time during the clinical attack. 
For several days the headaches may be very 
severe and the “rheumatic” pains in the 
muscles and joints be extremely painful. 
The patient is decidedly uncomfortable 
and he has no respite until the first inter¬ 
mission marks the end of the period of 
continued fever. 
During the intervals between the par¬ 
oxysms of the clinical attack subjective 
symptoms may be completely absent. The 
patient may do his work with a certain 
degree of efficiency and even forget that 
he is ill. Just before the next paroxysm 
