Paralyses are much rarer than the motor irritative symptoms, yet a number have been observed, and they are consequently of pathologic diagnostic interest.
These paralyses must, on clinical and etiologic grounds, be divided into groups, depending on whether they occur with the paroxysm, or substitute it, or appear first after it has passed; depending further on whether they disappear with the paroxysm or continue a longer or shorter time after it.
* Here given in abstract.
We will discuss especially the paralyses which come and go with the paroxysms, and classify those that substitute the paroxysms with the latent forms; those that continue after the paroxysms, with the complications and sequela?.
The most frequent form of malarial paralysis is hemiplegia, and, according to Landouzy, this is ordinarily associated with aphasia; among 12 malaria hemiplegia cases which he collected from the literature, 8 were associated with aphasia. Monoplegias and paralysis of individual cerebral nerves are less common.
The paralysis usually occurs during coma, but may develop while the cerebrum is active. On account of the small number of these cases it is impossible to name any type of fever as predominating. It may be quotidian, tertian, or subcontinued.
There are a few cases reported, and these are the most interesting ones, in which the paralysis appeared and disappeared with repeated paroxysms, in which there was, therefore, an actual intermittent paralysis.
The diagnosis of malarial paralysis depends on the proper appreciation of the accompanying symptoms, as the chill, fever, splenic tumor, etc., though the positive result of a blood examination is the only absolute criterion.
It must not be forgotten that in predisposed persons hysterical paralysis, as well as hystero epileptic attacks, may occur with the malarial paroxysm. In such cases the anamnesis is of importance. The following cases may serve as examples of malarial paralysis:
Boisseau observed in Val de Grace a man who became infected in Cochin China. During the paroxysm he manifested cephalalgia and a pure motor aphasia without any other paralysis. This lasted seven hours and then completely disappeared. Consciousness was preserved throughout. Altogether the patient had three such attacks (type not mentioned).
Macario observed a woman who manifested, on four successive days, in addition to the fever, the following condition: Horripilation over the entire body, followed by paralysis of all the body muscles, even to difficult movements of the tongue. Speech became almost unintelligible, swallowing difficult, and, in addition, there was paralysis of sensation. No headache. The attack lasted three hours. Recovery followed the administration of quinin. Marchiafava and Bignami describe the following case:
B. V. has been suffering from fever for two days. Three days before his admission to the hospital he walked and talked well. He was brought to the hospital in a very low condition and received at once injections of quinin (August 29, 1890).
August 29: Morning: Quite prostrated; stuporous; speaks slowly and scanningly; answers questions in a tired sort of way; pretty evident facial paralysis on the left; the tongue is deviated to the left; the pupils are equal; muscle strength of both sides the same; no disturbance of sensation; superficial and deep reflexes normal; bladder full. In the blood a few non pigmented parasites, many pigmented macrophages. Injection of 1.50 quinin bimuriate.
August 30: Morning visit: Dysarthria; deviation of the tongue continues; some stupor; bladder full (catheterized); temperature subfebrile.
August 31: Facial paralysis. Deviation of the tongue, continued dysarthria. The voice has a nasal tone. Paralysis of the soft palate. The patient staggers in walking. During the night involuntary urination. In the blood only melaniferous leukocytes. Apyretic.
September 1: Again fever (38.6°). Injection of 1.0 quinin bimuriat. In the blood a few melaniferous leukocytes.
September 2: After another fever paroxysm which occurred during the night the bulbar symptoms became worse. Secessus involuntarii. Expression of face stupid. In the blood only pigmented leukocytes.
After further injections with quinin, rapid improvement. The nervous symptoms are gradually disappearing, yet there are some remains of the dysarthria in the form of a suggestion of scanning speech.
September 20: Exit.
The prognosis of malarial paralysis is generally good, since it usually passes with the paroxysm. Yet the character of the paralysis cannot be recognized from the beginning. A paralysis the result of hemorrhage may occur during an attack of malaria and produce the same symptoms as one due to a thrombosis by parasites, or to the action of a toxin. The latter may entirely disappear with the paroxysm; the former usually continues a longer or shorter time, and sometimes indefinitely. The prognosis as to the outcome of the paralysis may be forced into the background by the vital prognosis, when the other symptoms are of such a nature that a fatal termination is to be feared.