Among these the chief place is occupied by a disease that imitates the complete syndrome of multiple sclerosis. On account of the rapidity with which this symptom complex comes and goes it is impossible to conceive that its pathologic anatomy is the same as that of genuine "sclerose en plaques." Yet the symptoms are so similar that it is scarcely possible to identify it with Westphal's "pseudosclerosis."
The malarial multiple sclerosis is relatively frequent. There are, even now, a sufficient number of observations, a part of which are based on a positive blood examination, to give this disease a legitimate place in nervous pathology. Among the observers we may mention Boinet and Salebert, Bignami and Bastianelli, Torti and Angelini, and Triantaphyllides. Torti and Angelini observed two cases. Both were in young adults, twenty one and twenty two years of age respectively. In one the first symptom appeared after an irregular malaria lasting three months. The patient was then apyretic, though the blood contained numerous parasites. The sclerosis syndrome developed rapidly-nystagmus, scanning speech, volitional tremor, exaggerated reflexes, etc. On administration of quinin most of the symptoms, together with the parasites, disappeared. Shortly after a relapse occurred, accompanied by the nervous condition. The symptoms, with the exception of the exaggerated reflexes, vanished again on renewed therapy. In the second case the sclerosis syndrome came on after a malaria lasting three months. Malarial parasites were found in the blood. Treatment for three weeks with quinin and arsenic resulted in recovery. Triantaphyllides published four cases, of which three promptly recovered, and the fourth persisted on account of treatment being begun too late.
Canellis reports the case of a man in whom multiple sclerosis developed after repeated attacks of malaria which proved refractory to therapy. According to Torti and Angelini, malarial sclerosis occurs under the following forms: (1) Those in which the syndrome comes and goes with the paroxysm; (2) those occurring after the attack and of variable duration; (3) apparently latent forms without fever.
If the previously quoted uncured case is to be ascribed to malaria , to these three categories must be added a fourth, namely, genuine chronic multiple sclerosis.
Isolated cases of pseudotabes have likewise been seen. The first case of this kind was described by Kahler and Pick as acute ataxia following malaria . After several sharp, typically intermittent quotidian paroxysms there occurred once, in place of the fever paroxysm, a dysarthria accompanied by marked ataxia of all four extremities. The patellar reflexes were abolished; the eyes showed nystagmuslike disturbances of coordination. The pupils were contracted, but reacted to light. The condition lasted only a short time and was followed by complete recovery. Even the patellar reflexes returned. Delweze frequently observed in Jamaica cases of ataxia with visual disturbances which he regarded as malarial. The symptoms came and went intermittently, were equally frequent in men and women, and yielded to specific therapy.
Besides the syndrome of multiple sclerosis, that of paralysis agitans, tetanus, and tetany have been seen after malaria (Boinet). The observations are not yet numerous enough to form a judgment on these cases.
Local asphyxia with symmetric gangrene. Raynaud's own cases showed malaria in their anamneses, though the discoverer did not assume any connection between the two diseases. After Rey and Marroin had published similar observations, Moursou stated that, from his personal experience, he believed that Raynaud's disease could be caused by malaria . Several cases reported since then seem to favor this view.
An especially suggestive and closely investigated case was described by Blanc. This was in a young boy suffering from severe chronic malaria . Algid symptoms appeared, and, during the paroxysms, the cooling and cyanosis of the surface of the body became striking. He later complained of pains in the bones, with formication over the cold, cyanotic toes. In the apyretic intervals the symptoms ameliorated, to become worse with every new paroxysm. Eventually gangrene of the toes set in. In the mean time the patient passed through two attacks of pneumonia. Local asphyxia does not necessarily advance to gangrene. The literature contains quite a number of cases in which it did not occur.
Ischemia of the tongue is described by Berenguier as frequent.
Anomalies of secretion, like excessive secretion of tears, a discharge from the nose, ptyalism, a flow of milk, and a discharge from the urethra have been reported, both accompanying the paroxysms and occurring separately as latent symptoms (Schonlein).
Syndromes probably dependent on a peripheral neuritis are not rare sequelae.
Boinet and Salebert describe cases of evident peripheral origin, though the observers themselves regarded them as medullary. Among these are two of paraplegia with atrophy, lancinating pains, pain in the muscles, anesthesia, and diminution of the tendon reflexes. Another of marked atrophy of the muscles of the buttocks and thigh that developed under violent pain at the close of a long malaria .
Cases belonging to this category were also seen by Combemale, Brault, Catrin, and others. A very beautiful case of polyneuritis of all the extremities in a man with chronic malaria was observed by Metin. Becker described a case of bilateral sciatic neuritis after malaria.
Daville frequently saw, in the New Hebrides, both during the paroxysm and before it, neuritis associated with sharp pains on the dorsum of the foot, about the malleoli, in the hips, in the joints of the hand, and in the elbows. Whether or not these disturbances are identical with the "rheumatic affections" reported by Fayrer from India must be left undecided.
Still less can we express any view in relation to the peculiar affection observed by Grierson, Malcolmson, MacKenna, Waring, Che vers,
Playfair, and others in East India, in Burma, in Tenasserim, Penang, and Singapore, which bears the name, "burning of the feet." Grier son and Waring consider it malarial. The chief symptom consists in excruciating pain, occurring in paroxysms in the soles of the feet and often the palms of the hands. The patients sit on the bed, support their feet on cushions, and endeavor, by turning them inward, to avoid the slightest contact of the soles. The affected parts may be entirely dry, or may show a profuse perspiration. Sometimes, too, the legs are painful, especially over the tibiae.
Heidenhain's peculiar case possibly belongs to this category. This was a woman with duplex quartan who manifested, during every paroxysm, an intensely tormenting itching and burning on the inner surface of both hands, without the slightest perceptible local lesion. The paresthesia ceased every time with the paroxysm.
Neuralgias have been frequently observed during and after malarial fevers in every nerve region, though most commonly in that of the trigeminus. They occur after similar pains have been manifested during the acute paroxysm, as well as when these are wanting. Griesinger observed, among 414 cases of intermittent fever, 13 times trigeminus neuralgia, 7 times general neuralgic pains in the head, once pharyngeal and once intercostal neuralgia. Ver dan reported intercostal neuralgias as very frequent.