abdominal and the perineal muscles may be so profoundly paralysed that, when cough is attempted, at most a husky expiration is produced, whilst the belly is bulged forwards and the perineum shot downwards by the sudden contraction of the muscles of expiration. In practically all cases of over a fortnight's standing the knee-jerk and tendo-Achillis reflex are absent; at the very commencement of the disease these deep reflexes are exaggerated, gradually disappearing as symptoms develop, not to reappear for months, perhaps, after the patient is well in all other respects.
Erroneous diagnoses.— The novice in tropical medicine will be greatly puzzled for a time over these cases. I have seen them called cardiac disease, locomotor ataxia, muscular rheumatism, progressive muscular atrophy, ascending spinal paralysis, and have over and over again seen them relegated to that refuge for ignorance— malaria, and called " malarial rheumatism," or " malarial paralysis, "or, more pedantically, "malarial paraplegia," or "malarial neuritis. "*[1]
If the visitor has the curiosity to examine the blood of these patients, possibly in a proportion of them he will find microfilariæ; very likely he will then think that the cases are forms of filariasis, and he may construct theories to explain how the filaria produces the symptoms. Or, if he examine the fæces, very probably in over 50 per cent, of the cases, or, in some countries, in nearly all the cases, he will find ova of ankylostomes and, probably, those of the whipworm and the roundworm also. On this evidence he may conclude that these are cases of ankylostomiasis or other form of helminthiasis. He had better, however, not commit himself to such a diagnosis until he has ascertained how it fares with the rest of the population as regards these parasites; for he will find
- ↑ * Dr. Strachan has described (Practitioner, 1897, p. 477) a form of multiple peripheral neuritis which he calls "malarial." The disease is endemic, and very common in Jamaica. It differs from beriberi inasmuch as it is not attended with œdema, is frequently attended with implication of the cranial nerves and is rarely fatal. We have no accounts of any similar disease from other tropical countries. Probably, therefore, Dr. Strachan's neuritis is not malarial, but depends on some cause peculiar, so far as known, to Jamaica. The subject requires further study.
