In regard to the diagnosis of malarial neuralgia, we must insist that neither the intermittence of the paroxysms nor the result of tinuos Hemicraniam molestam, sinistram capitis partem occupantem, ab octava hora matutina ad quintam usque Vespertinam protensam, quotidise patiebar: Quoad csetera firme valebam, et, cum appetitu integro, muniis solitis fungebar. Quandoquidem autem hunc morbum, antehac in aliis, non obstane trepetita Vense sectione, applicatione Vesicatoriorum, Cucurbitularum, Fotuum, Errhinorum, Masticatoriorum, et exhibitione methodica Catharticorum, Emeticorum, cseterumque idgenus, ad mentem Veterum, Walde Chronicum et contumacem saepius observas sem; atque molestum hoc Symptoma a fermente febrili delitescente subortum esse, suspicatus essem utut nulla febris prsesentis indicia apparerent. Post extractionem unc. XII Sanguinis e brachio sinistro, pulveris febrifugi unc. I spatio biduo de voravi. Postquam Corticis drachm. V absumpsissem, dolorem multo mitiorem, die sequenti (periodice licet et designato tempore recurrentem) passus sum. Penso vero absoluto, die proximo prorsus liberatus sum. Post tres autem hebdomadas recrudescebat dolor (sicuti in febre Cortice curata solet) quern non sine (Chin china jam superare potui, quippe vegetam et genuinam penes me turn temporis non habui. Repetito autem Cortice post duas hebdomadas, prophylaxeos gratia,, huiusque, sine quocumquo alio medicamento exhibito, optima valetudine utor." quinin treatment proves with certainty the existence of malarial infection. It is well known that the most different kinds of pain, whether genuine neuralgias or pain due to other causes, show a pronounced tendency to intermit. I recall only the nightly pains in the bones of syphilitics. A short time ago I saw a woman with a sarcoma of the sternum who suffered from paroxysms of exquisite intermittent pain in the region of the tumor, without any sign of malaria . To what extent a conclusion can be drawn from the region of the pain I leave to the judgment of every intelligent physician.
The parasitologic investigations in relation to this disease are extremely limited in number. Sakhariane found in these cases only a few parasites in the blood; Loeza (Mexico) reports that in several cases he found no parasites at all. Whether in case of a negative finding-provided that the blood examination has been properly carried out-we may still adhere to the diagnosis of malaria appears to me questionable.
These are among the rarest expressions of latent malaria . I find one single positive case in Marchiafava and Bignami. This occurred in a man of middle age, admitted to the Hospital S. Spirito (Ward Baglivi) on September 26, 1899. He was extremely weak, very pale, and complained of headache. He had no fever, the temperature being rather subnormal. The spleen was impalpable. A few hours after he was put to bed he lost consciousness. Examina tion showed a left sided hemiplegia, with simultaneous facial par alysis, hemianalgesia, and abolition of reflexes. The temperature remained subnormal. An accurate investigation had failed to explain the condition, when the blood was found to show the presence of extremely numerous ameboid parasites, the majority of which were non pigmented. Quinin was injected, and two days later the man had recovered, though he still remained very anemic.
In this case the highest temperature during the acute infection occurred during the night from September 25 to 26, and was 37.9° (in the rectum). The cerebral symptoms recovered rapidly and left no trace. The number of red blood corpuscles on September 26 was 1,950,000.
Motor irritative symptoms are likewise very rare. Heidenhain saw in one case twitchings of the left arm and leg occurring with a tertian type; again, a case with twitchings of the masseter in association with frontal neuralgia.
Attacks of vertigo were reported by Triantaphyllides; attacks of anxiety, by Heidenhain.
Relatively more frequent are symptoms of gastro intestinal catarrh. Among Zakhariane's 27 cases, 19 were associated with diarrhea. TriantaphyHides observed 11 cases of chronic diarrhea as the result of latent fever, and in the majority of these the blood examination was positive. A splenic tumor was only four times perceptible.
Bronchitis was observed by the same writer. It usually occurred without a splenic tumor, and always with non pigmented parasites. The bronchitis failed to show any type and changed its location.
Mention has been made of several cases of urticaria in association with ordinary paroxysms; a few have also been reported in connection with latent malaria (Scorczewski, Zeissl, Kaposi, Neumann, Volcker, Brocq, and others).
The reports of herpes zoster as an expression of malaria are not convincing (Masson, Moursou, Girard, Winfield).
Other syndromes described as latent malaria seem only half convincing, as typical anesthesia, convulsions* (sneezing, vomiting, hiccup, coughing, torticollis, tic, chorea, and hysteric convulsions), paralysis of the special senses (as typical amaurosis, amblyopia, anosmia, and deafness), sleeplessness, psychoses,** hemorrhages from different organs, angina pectoris, asthma, edema, intestinal colic, vomiting, discharges of gas from the mouth or anus, coryza, neuralgia of the pharynx, of the testicle, of the urethra, of the uterus, angina, etc.
To demonstrate the relative frequency of the different forms we will quote Zakhariane's statistics. Among 27 cases there were 19 with gastro intestinal symptoms, 2 with palpitations, 2 with angina pectoris, 3 with cephalalgia, 1 with coryza.
As a curiosity, we may add that the older writers, in their credulous way, reported a typical loquacity, even more an intermittent speech in rimed verse, as an expression of latent malaria .
It is contrary to common sense when croupous pneumonias, meningitis, etc., are reckoned among the latent fevers (Tartenson).
To whomsoever is interested in the literature of latent malaria we recommend the works of Morton, Griesinger, Hertz, Bonnet, Duboue (de Pau), Dangerville.
* It is possibly worth while mentioning a case published by Faivre (" Jour, de med. de Bordeaux," September, 1895), and quoted by Laveran, of a soldier with malarial cachexia who manifested very painful cramps in the calves of the legs, associated with fever and sweating. Recovery followed quinin.
** Celsus mentions (Lib. iii, Cap. xviii) the occurrence of intermittent psychoses. He designates the condition phrenitis, and says: " Levatoque accessionis impetu, protinus mens redit."