Irritative symptoms of slight intensity and well localized are not uncommon during the comatose attack. We mentioned before that trismus and deviation of the eyes were often observed. It happens quite as frequently that the extremities show, either singly or altogether, a transitory slight rigidity, or even a few clonic twitchings.
Rarely these motor irritative symptoms are so marked as to dominate the disease picture.
Under these circumstances conditions arise which recall epilepsy, hysteria, uremia, and tetanus.
Epileptic convulsions (epileptic pernicious) as a direct expression of malarial infection occur very rarely. They are seen most frequently in small children, who seem to manifest a general tendency to replace the initial chill of various infections by eclamptic convulsions. The infantile eclamptic convulsions, therefore, are not so difficult to understand. When they occur, though in an adult, we should first think of the possibility of the patient being an epileptic or hysteric in whom the convulsion was provoked by the malarial paroxysm. Marchiafava and Bignami observed such a convulsion in a malarial patient. On examination of the blood showing parasites of the first group, they came to the conclusion that it was a case of malaria in an epileptic individual. When the patient awoke from the postepileptic stupor, he assured them that he had suffered from convulsions for a long time.
A patient with quotidian intermittent was admitted to the hospital in Daya (Algeria). The day after entrance (9 a. m.) he was unconscious, had general convulsions, subnormal temperature, and was pulseless. Recovery after the application of artificial heat. On the evening visit slight stupor, tongue red and dry, skin warm, pulse hard and frequent. 1 gm. quinin sulphate.
The next day a new paroxysm. " I had scarcely moved away from the bed," writes Laveran, "when a cry from the patient brought me back. I found him cold, pulseless, shaken by general convulsions, during which urine and feces were passed involuntarily. In vain I employed excitants; in a few minutes D. was a corpse.
Abelin observed, in Gabun, a pernicious case with two epileptic attacks in the course of'one day. Recovery followed quinin.
Several cases of tetanic pernicious are to be found in the literature, though in a well developed form it is at most a rarity (see Perinelle's thesis).
We take the following case from Marchiafava and Bignami:
M. F., aged twenty, had malaria last year; no manifestation this year until July 30, when he had a paroxysm.
July 31: In the morning he went on foot to his working place. About midday he was found in a comatose condition by a cousin and was transported by him to the hospital; a physician on the spot had administered, in the mean while, an injection of quinin.
Admitted to hospital 6 p. m. : Patient in deep coma. Trismus (it was impossible even by great force to open the mouth). The arms contracted, the forearms extended pronated, the hands and fingers flexed. The tetanic contractions subsided occasionally to recur unexpectedly. Compression of the vessels and nerves of the extremities called forth no paroxysm during the relaxation. No opisthotonos. The lower extremities contracted in extension, the feet in plantar flexion and slight varus position; the contractions became occasionally less marked, but never ceased.
Abdomen contracted. Respiration of costal type (180 a minute) and rattling. During inspiration the abdomen is drawn in. Pulse 120, soft. Right heart dilated. The eyes turned upward and outward; pupils dilated and react to light.
Now and then paroxysms occur during which the stiffness of the gluteal muscles increases and the pelvis is elevated. The penis in half erection. The patellar reflexes increased; skin reflex normal.
Temperature, 8.30 p. m., 39.7° C. (103.5° F.)-3.0 quinin bimuriat.; 9.00 p. m., 38.3° C. (101° F.) (after cold pack); 12.00 m., 39.8° C. (103.6° F.); August 1, 2.00 a. m., 40° C. (104° F.); 2.30 a. m., exitus.
The blood examination of July 31, 6 p. m., showed only a few endo globular organisms with central pigment and a few melaniferous leukocytes.
Autopsy.*-Dura mater tense; meninges very hyperemia; the central gray matter very melanotic; no hemorrhages. Spleen quite soft, melanotic; the Malpighian bodies non pigmented and conspicuous. Liver soft; slight melanosis.
Microscopically the brain capillaries were found filled "with erythrocytes, every one of which contained a parasite with concentrated pigment. Few of these parasites free. The blood taken from a cerebral artery and vein contained only a few parasites.
There was in this case one single generation of quotidian parasites. It is worth remarking that after a mild attack the day previously the second attack led to a fatal termination under the severest pernicious symptoms.
Motor irritation may manifest itself also in the form of a tremor. Sometimes both forms of motor excitement go hand in hand-as, for instance, Schellong's case,f in which rigidity of the neck and of the upper extremities was observed in association with tremor of the head and arm.