children, those under the age of three years, in the cases where the disease is well up in the larynx, where none of the pultaceous deposit exists found in the lower respiratory track, and in a large number of cases where parents will not yield to a cutting operation.

I cannot believe that these two operations are to be regarded as rivals, applicable to the same classes of cases. I prefer to consider them help-mates, each meeting the individual cases for which it is best suited.

ADDENDA.

Since writing the above, the proceedings of the last Congress of German Surgeons have come to hand. At this meeting, Thiersch, of Leipsic, presented the subject of intubation. He exhibited the table of Dillon Brown containing the 806 cases, upon which Sprengel's criticism is based.

During the past ten years 697 tracheotomies have been performed at the Leipsic clinic, of which 24.5 per cent. recovered. During the first three months of this year intubation was given a trial. Thirty-one children were intubated, of which seventeen subsequently required tracheotomy. The cutting operation was performed in eleven for respiratory difficulties; of these, seven had slowly-increasing dyspnoea, and four were threatened with suffocation from sudden plugging of the tube with membrane. In the remaining six the trouble was with deglutition. None of the seventeen recovered; nine died of pneumonia, one each of septic diphtheria, nephritis and pulmonary gangrene, and five of several of these conditions combined.

Of the remaining fourteen, while the dyspnoea was relieved in each case, eleven died; three of pneumonia, three of septic diphtheria, two of nephritis, and three of a combination of these causes. Three recovered; one after the canula, filled with tube casts, had twice been coughed out, and two who had repeatedly cast off thin shreds of membrane. Thiersch refers to the absence of irritation in many cases where, without difficulty, the tubes were worn for six days and longer.

As in Dillon Brown's table no mention is made of slowlyincreasing dyspnoea after intubation, and of only five instances of

asphyxia from membranous collections, Thiersch argues that we must have a milder variety of diphtheria in America than they encounter in Leipsic.

In his summary the writer says that in Leipsic the most brilliant success of intubation was in its primary results. He considers it a substitute for tracheotomy when the membranous formations and swelling are moderate. It is applicable without professional assistance; the consent of parents is more easily gained; there is no hemorrhage, wound infection, tracheal granulations and stenosis; and no marked injury from the canula was observed. Yet it is possible to bruise the mucus membrane and excite infection when the introduction or removal of the tube is difficult. The great danger of sudden suffocation indicates the need of constant medical attendance. When the epiglottis or tracheal mucus membrane is swolien, intubation is useless. Broncho-pneumonia, and even inanition, are frequent results of the difficulty of swallowing. The future of intubation in laryngeal diphtheria in Germany will depend upon increasing the lumen of the tube, the facilities offered for its immediate removal when suffocation threatens, and overcoming the impediment to deglutition.

Rehn, of Frankfort, also contributed an article upon intubation. While, he says, O'Dwyer has presented a muchimproved method, intubation cannot displace tracheotomy. After considering the details of its application he argues that, because of their need of skillful after-treatment, intubated patients can be cared for properly only at a hospital. Of his fourteen cases only one was able to swallow soft foods. The others strangled so that he was obliged to resort to nutrient enemata, the esophageal tube, and even to remove the intubation tube in some cases whenever food was given.

Both Thiersch and Rehn appreciate the conscientious work O'Dwyer has performed, the desirability of a bloodless substitute for tracheotomy, and trust that, as the profession acquaints itself with the subject of intubation, its present objectionable features and difficulties may be surmounted.

115 NORTH SALINA STREET.

MALARIAL PARALYSIS.*

BY ARTHUR W. HURD, A. M., M. D.,

Second Assistant Physician to the Buffalo State Asylum for the Insane.

Various paralyses of supposed malarial origin have been on record for some years, but the cases are so few in number, and some so questionable, that any new matter throwing light on this important subject, is of value. The mere fact that profound paralysis may result from malarial infection, seems fairly well established, but in the matter of differential diagnosis, clinical history, and pathology, much remains to be done. As yet, it appears to be a rare disease, but if it should be learned by closer observation that infantile paralysis is sometimes a malarial manifestation, and curable by anti-periodic remedies, to what importance does this subject then attain ? Some works on nervous diseases do not treat of this subject at all, while others give but a few lines. Of recent years, Dr. Gibney, of New York, has given especial attention to this subject, all of his cases being those of children.

The earliest recorded example of intermittent paralysis was made known by Romberg, and I quote his description of it.

"A woman, sixty-four years of age, after being quite well the day before, was suddenly attacked with paralysis of the lower extremities and of the sphincters. Sensibility was unchanged, consciousness clear, the temperature cool, pulse eighty degrees, small and empty; no pain in the spinal cord. The next day there was an astonishing change in the condition, the patient could walk again and void urine voluntarily, and only complained of weakness in the legs. The following morning there was paraplegia again, which had set in at the same hour as it had done two days before. A third paroxysm was awaited, which also set in at the appointed time, although without paralysis of the sphincters. Quinine affected a rapid cure.

There has been under my charge at the Asylum a case whose history warrants a diagnosis of malarial paraplegia; at least, it appears that the foundations for this conclusion are as strong as are those on which unquestioned diagnoses are made constantly.

* Read before the Physicians' Club.

This patient was brought into the office by two men; he could not walk, feet dragged, and he appeared quite helpless. His mental condition was one of dementia. He was easily confused on questioning; could not remember events without great effort, and then imperfectly; complained of pain in the head; inability to concentrate his attention on any subject; showed loss of sensibility in limbs, but no paralysis of bladder or rectum; is twenty-eight years old, and of muscular development.

From his mother, and later from himself, was obtained this history: He was very well up to two and a-half years ago. He then went to live in Rockland county, a malarial district, and became infected. He kept at work for months, however, taking large quantities of quinine. Said that ordinarily his paroxysms were every second day, but that at times they had occurred every seven days, and at one period every fourteen days. Getting no better, he went to Massachusetts in July, 1887, and there suffered severely, being confined to bed. Had paroxysms every second day, and was attended by a physician. One day, during a paroxysm, he suddenly became unconscious, and, it is said, remained in this condition about forty-eight hours. When he regained consciousness, he was found to be paraplegic; he had diminished sensation in limbs; urine and fæces were passed involuntarily. He himself remembers but little of the occurrences at this time. He was taken to the Asylum at Tewksbury, was given quinine again, and got somewhat better, but after a few months, progress being stationary, he was brought home to Hornellsville, thence here in December. He gave no history of syphilis. He was put on anti-malarial treatment, together with tonics, and improvement soon began. In about four weeks he could walk well, with but little uncertainty of gait and without assistance. His mental condition also improved, though more slowly, and his progress has been steady since. He has for several months been on parole, helping about the stable and grounds; shows no trace of paraplegia, and is to-day one of the most active runners in a foot-ball team. Twice since his improvement he has complained of pain in the back (but no

paralysis), with general malaise, and each time relief has followed a re-administration of the original remedy.

His mental condition would have permitted discharge, but the pain in the back, which returned, led him to think that he is not entirely over his malarial trouble, and he stays voluntarily until he shall be entirely well.

We have in this case a young man previously healthy, who, two years ago, was attacked with ague, suffered with it some months, and in a paroxysm, without previous nervous or mental symptoms, becomes paraplegic.

ses.

In the cases cited by Romberg, Gibney and Ziemssen, the fact that relief followed quinine promptly, is properly given as a strong argument in favor of the malarial origin of these paraly If a facial neuralgia disappears promptly under quinine, the average medical mind is convinced that the neuralgia was malarial. Is it because paralysis, one affection of the nervous system, is less common and more unusual than neuralgia, another affection of the nervous system, that the argument which convinces in one, is considered insufficient in the other? This argument cannot be advanced in support of the malarial origin of the paraplegia in the case just cited. He was not given quinine, but decoction of lemon, of the anti-periodic qualities of which much was said in the journals about one year ago, especially in old and obstinate cases of malarial infection. Good results in several instances previously, led to its trial here. Three pints of water, into which one lemon has been sliced, is boiled down to one pint, strained, allowed to stand over night, and given, unsweetened, to the patient before breakfast the following morning.

This was also given the patient on the two occasions when his sensations led him to think he was to have a return of his old malarial trouble, and his experience of so many months made him pretty familiar with them. It is important to note that he had taken quinine in large quantities for a long time, and was completely cinchonized once. At the time of its administration, he said his paraplegia improved to the extent of being able to