Corine R., age 7, had a typical case of diphtheria of moderate severity. Not deemed serious enough to require antitoxin. The child never seemed very sick, but convalescence was tedious, and attended by great languor. The twelfth day mild throat paralysis appeared, but caused no apprehension until the fifteenth day, when the child complained of the right leg being asleep. Careful examination of the heart showed slight irregularity. This condition kept up several days, the heart action growing worse, and the child complaining bitterly of the abnormal sensation. Great weakness was constant. About the twentieth day she raised up in bed crying, with her leg, and fell back dead, presumably with paralysis of the heart.

CASE 3. Roy S., age 6, was brought in from the country with a most malignant case of diphtheria, with larynx, pharynx, tonsils, fauces and nasal cavities involved with membrane. Horribly offensive bloody discharge dripped from the nose continually, suffocation was threatened, and tracheotomy seemed imminent. Prostration was marked, temperature never very high. Two thousand units of antitoxin was given, quickly followed by fifteen hundred. Great improvement was apparent in a few hours and the danger of suffocation soon passed. During the next few days the membrane loosened up and disappeared by sloughing and constant cleansing with peroxide of hydrogen. The child was critically ill, but everything went along fairly well till the fourteenth day, when difficulty in swallowing was noticed. Having just lost case No. 2 four weeks before, the appearance of paralytic indications were watched in this case with keen anxiety. On the fifteenth day the heart dropped a beat every minute or two. In the afternoon vomiting began and continued for two days and nights, in spite of every effort to relieve him. The heart soon showed great weakness and marked irregularity. The seventeenth day breathing was slightly irregular, and there was a general paretic condition. The eighteenth day vomiting had practically ceased, but the outlook was gloomy. The heart had responded to strychnia and was stronger and more regular, but breathing had become decidedly involved. At an early afternoon

call I found pulse 60, and regular; breathing very bad. During examination patient complained for the first time of his leg being asleep, and cried because of the discomfort. During the next few minutes the pulse dropped down to 50, 40, 30. At this time the diaphragm seemed to become suddenly completely paralyzed, respiration being performed entirely by the chest muscles. The heart slowed up to 20, the pupils suddenly dilated widely, the heart stopped, and efforts at respiration were continued for nearly a minute by the muscles of the upper part of the chest and neck. Strcyhnia and supportive treatment was the main reliance in all three cases Electricity seemed of little avail. Potassium iodide seemed to be beneficial in case No. 2.

Many years ago I had one similar fatal case, but since that time so many simple cases of throat paralysis complicating diphtheria have come under my care, all apparently so trivial and curable that the condition had ceased to give me any concern. With my recent experience, however, and the vivid recollection of my utter helplessness in these cases, I shall watch for this complication with great uneasiness in the future. What the condition is, whether it is a toxic neuritis produced by the Klebs-Loeffler bacillus, or a product of those germs, whether the streptococcus or other germs may play a part in some cases, and whether some cases may be due to brain pressure from effusion or stasis of circulation dependent primarily upon weak heart, I am unable to determine conclusively. The wonderful variation in symptoms would indicate a variety of causes.

I hope a free discussion may throw some light on the causation of this important condition, and that it may also indicate the best treatment.

DISCUSSION.

DR. W. A. HARPER, Austin: I do not like to see this paper go by without some discussion. I have seen similar cases in my own practice, and one just like Dr. Lankford's second case. I believe in these light cases of diphtheria, the physician should keep a sharp lookout and examine the heart, and watch carefully for symptoms of paralysis from day to day, for at least two weeks, that he may be prepared to do something in time. Almost every physician has had some experience with these extremely

light cases, in which the patient does not even go to bed. These are the cases that die unexpectedly; therefore, we should watch them very carefully.

DB. W. B. COLLINS: I want to thank Dr. Lankford for this very interesting and valuable paper. This is a subject which should interest every physician present. I find that he had has some of the same experiences which I, from time to time, have had with this dread malady. Several years ago, we had an epidemic of diphtheria in my town which in the beginning was quite confusing. The cases were nearly all typical, in so much that the local profession were very much divided as to whether it was diphtheria or not. Finally, to remove all doubt, I sent a specimen of the membrane to Dr. A. J. Smith, of Galveston, for microscopical examination. He found the genuine Klebs-Loeffler bacillus. This satisfied me as to the nature of the disease. I treated it after the old orthodox plan.

The mortality was, as you may suppose, very great. I believe that under the old "drug" plan of treatment, it is one of the most treacherous diseases in all the nomenclature of medicine. I recall several patients which I had dismissed, believing them convalescent, and would be suddenly recalled to witness a death, either from paralysis of respiration, heart failure, or both. Up to this time, i. e., Dr. Smith's report, I had never used antitoxin. Owing to the fact that the profession at that time were very much divided, and my clientelle strenuously opposing experimentation, and, I might confess, to a lack of moral courage on my part, I had not employed this great boon to suffering humanity. Necessity, however, drove me to it, and the results of its use have been most gratifying.

Now, in conclusion, I want to warn you to look with a suspicious eye upon all forms of inflammatory throat trouble. Antitoxin within itself is entirely harmless. Use it early and persistently, and I feel sure you will be rewarded with a minimum death rate. I regard it as the remedy par excellence in treating diphtheria.

DR. C. W. GODDARD, Holland: I desire to make mention of two cases that my partner, Dr. Crosthwait, saw last year with another physician. Both boys, ages 5 and 7 years; both taken with typical diphtheria. The ordinary lines of treatment, together with diphtheritic antitoxin were administered; the exudate\disappeared from tonsils and fauces, temperature became normal, pulse improved to nearly normal conditions; al indications were that convalescence was well established, when, at the end of the second week in one case, and two days later in the other, symptoms of heart paralysis developed, which gradually increased, causing death in both cases two days after its development.

MALTA FEVER.

CHAS. F. MASON, U. S. A.,

SAN ANTONIO, TEXAS.

I wish to call your attention tonight to a case of Malta fever I have recently had under treatment at the post, the first, I believe, ever reported in Texas, and one of about a dozen in the United States, all imported.

The first case was reported in Philadelphia, in 1898, by Musser and Sailer, in the person of an officer recently returned from Porto Rico. The second case reported among United States soldiers was also a patient of mine in the General Hospital at San Juan, Porto Rico, and was reported by my pathologist, Assistant Surgeon Walter Cox, U. S. Army. Before giving you a history of the present case I will refresh your memory by a brief resume of this, to us, rare disease.

The disease is variously known about the Mediterranean, which was supposed for a time to be its only habitat, as Malta fever, Mediterranean fever, Rock fever, Neapolitan fever and undulant fever. Now we know that it prevails also in the West and East Indies, in India, China and the Philippines, and is probably much more widely distributed than is generally supposed.

It is a specific, infectious fever, endemic or epidemic at times, due to the micrococcus melitensis of Bruce, characterized by a longcontinued, undulatory fever, with remissions or intermissions, enlarged spleen, profuse sweats, arthritis, neuralgia, and sometimes orchitis. Other features are constipation, anæmia, low mortality (2 per cent) and tedious relapses.

The disease is not contagious; it occurs especially in the summer, earlier than typhoid. The micrococcus is not found in the blood during life, but is abundant in the spleen; it gives a characteristic

agglutination with the blood of sufferers from the disease and is even more sensitive in this respect than the bacillus typhosus.

The infection seems to be a place infection, and is favored by unsanitary conditions; but whether it is water or air borne, or both, is not determined. A number of instances of accidental laboratory infection have occurred.

The incubation period is generally about five to ten days, though it may be as long as seventeen days. One attack usually confers immunity.

The symptoms are not especially distinctive in themselves: headache, loss of appetite, constipation, fleeting swellings of the joints, obstinate neuralgias, night sweats; the sign that usually catches the attention is the temperature curve; waves of fever lasting one to three weeks, and followed by an intermission or remission of two or three days, and this continued for weeks, months, even as long as two years; the patient, though weak and anæmic, does not look seriously sick. Quinine has no effect. Examination of the blood is negative for the plasmodium and for the Widal reaction, but is positive with the micrococcus melitensis.

The treatment is symptomatic.

I will now describe my latest case:

Sergeant Frank J. Reiner, Company E, 4th Infantry, was transferred to this post December 14, 1902, for observation and treatment. He came from Fort Ringgold, Texas, with a diagnosis of "chronic malarial fever, malarial cachexia, complications: chronic muscular rheumatism."

Upon admission he was anæmic, with an enlarged spleen, and complained of marked sciatica and pains in the right shoulder; constipated. He gave a history of what he called "rheumatism and malaria," with fever more or less constant for several months.

His blood was examined repeatedly (always with negative results) for the plasmodium, and for the agglutination tests with the typhoid and para-colon bacilli. Finally, recalling my Porto Rican experience, I had his blood tested with the micrococcus melitensis with positive results, thus clinching the diagnosis.