Tremor of the paralyzed extremities has probably been observed oftenest (Vespal). Choreic symptoms were observed by Maillot and Ouradou; tetany (?), by Wilckes.
Boinet and Salebert describe an interesting case of athetosis observed in a soldier in Tongking. After a series of malarial paroxysms a sensation of numbness in the right hand arose, followed by tormenting formication over both hands and all the fingers. Ten days after the last malarial paroxysm a new one with coma occurred. Two clays later the right hand showed a typical athetosis. Sensation was diminished in the region of the ulnar nerve, but was little disturbed in that of the radial. The hand was powerless and could grasp no object. Sensibility of the forearm was fully preserved. The condition remained stationary.
Maillot describes a case in which, after a comatose double tertian, contracture of the right arm occurred. The contracture forced the arm tightly against the breast. Verdan frequently observed in Wargla (Algeria) contracture of the extremities during the paroxysms.
Paraplegias of the lower extremities are comparatively the most frequent, and are often associated with disturbances of sensation, and sometimes, too, with paralysis of the bladder and the rectum. In some cases atrophy of the muscles has followed. Whether actual disease of the spinal cord, rather than a peripheral neuritis, played the role in these cases cannot be determined.
Csillag observed a series of pure paraplegias which developed during a severe subcontinued malaria , and persisted only a few days after the acute infection. Sensation was preserved. Ataxia was seen once; again, rectal paralysis. The patellar reflexes were diminished. Laveran, too, observed a case of paraplegia without disturbances of sensation and without bladder or rectal symptoms. Moreover, in this case the parasites were demonstrated in the blood, though we must add that the patient was also syphilitic. The paraplegia persisted in spite of quinin, mercury, and the iodids.
Much more rare are cases of successive paralysis in all four extremities. Maillot observed one case.* A tremor of the upper extremities was first noticed, followed by paralysis; later the same in the lower extremities. Sensation was gradually lost. Secessus in voluntarii, paralysis of respiration, death. The autopsy showed the spinal pia and the cord, especially in the region of the cervical enlargement, markedly injected, and, at the level of the lower dorsal segment, a red softening, six to eight lines in diameter.
Two highly interesting cases of rapidly increasing paralysis with fatal termination were observed by Range in Benin.
The following is an abstract of one of these casesf:
L. M., aged twenty one, twelve months resident in Benin, was admitted to the hospital at Porto Novo July 23 on account of blackwater fever. Previous to this he had had fever paroxysms every three months. He ascribes this last affection to exhausting work in the sun.
July 23: Temperature, morning, 39.6°; evening, 40.3°; bilious vomiting; pathognomonic urine; restless. Injection of quinin hydro brom.
July 24: Temperature, 38° and 38.3°. Persistent vomiting. Considerable urine of a malaga color. General condition pretty satisfactory. Two injections of quinin.
July 25: Evident improvement. Temperature, 37° and 37.4°. Vomiting still continues. Urine clear, copious. Diarrheic stools. Two injections of quinin.
July 26: Temperature, 37.6° and 37.9°. Urine clear; vomiting less frequent.
July 27: Temperature, 38.4° and 37°. The vomiting, again more frequent, is exhausting the patient. Two quinin injections.
July 28: Temperature, 37.5° and 37.3°. Vomiting has ceased, but in its place singultus. Urine clear. One injection of quinin.
July 29: Temperature, 36.8° and 37.2°. The singultus has ceased, and the vomiting has set in again, yet the general condition is improved. The patient has an appetite. Quinin sulph. in pills.
July 30: Temperature, 38.8° and 37°; general condition improved.
Up to August 3 there was no change. At the afternoon visit he complained that he could not feel his legs. These were insensible to every irritation. The upper part of the thigh and the rump had retained slight sensibility. The patient was massaged, and a warm bottle was put to the feet. The temperature was normal; pulse quiet and rhythmic.
When we saw the patient again at 4.30 p. m. the anesthesia had progressed, and, further, the patient could not now move his legs. Both sphincters opened involuntarily. The paralysis rapidly advanced in spite of every effort, affecting the buttocks, the upper extremities, the neck, and finally interfering with respiration. The intercostal muscles and the diaphragm struggled against the paralysis, but in vain. The patient died at 5.30 p. m.
The second case progressed in an analogous way, as likewise a third case, observed by Dr. Mesnard.
Isolated cases of paralysis of the bladder with retention of urine during the acute infection are not rare. This may occur without pyrexia-in other words, latently (Marion).
The diagnosis of spinal disease as the result of malaria is often difficult in regions where beri beri is simultaneously endemic. Especially cases with paraplegia may lead to error. If the girdle pain frequent to beri beri, and never, so far, described in malarial paraplegia, is absent, or if the paraplegia quickly recovers under quinin, the diagnosis of malarial paraplegia is easy. Yet if pain and atrophy exist, it may be very difficult to make a diagnosis. It is impossible here to go into further details.
We have already described (p. 291) a case of Marchiafava and Bignami's with bulbar symptoms. These writers mention also in the same publication that they have several times seen similar bulbar cases, and that they always continue a longer time than the cerebral. Orlancli observed in five cases transitory bulbar symptoms following the paroxysms.