side; meningeal hemorrhage by contre-coup on the left, involving the arm and motor speech centres. No paralysis of facial muscles could be made out.

On the 26th, she spoke a few words; an occasional slight voluntary movement of the right arm had been observed. June 30th, the child was able to stand on the leg and moved the arm much better. She had been able to walk a few steps. From this on the improvement was steady and rapid. July 10th, all paralytic symptoms had disappeared. The mother claims that the child talks much better than before the accident.

The question in this case would arise, whether it would not be a safe plan to at least elevate the bones of the depressed fracture, and, Is not this fracture, situated in the binauricular line, apt to lead to epilepsy later in life?

That such is not always the case I can prove in a young man twenty-two years of age, who, when five years old, had meningeal hemorrhage, from the effects of which (left-sided hemiplegia) he recovered in the course of six weeks. There is now a very perceptible depression about two inches above and a little anteriorly to the right auditory meatus. He has never shown any sign of epilepsy.

October 15, 1891.-The patient H. T. K. has been hard at work in a brick-yard for a couple of months. He is in his usual health with all his faculties intact, and a steady worker.

THE TREATMENT OF INFLUENZA AND ITS SEQUELÆ.

By EDWARD W. WATSON, M.D., AND ROLAND G. CURTIN, M.D.,

OF PHILADELPHIA.

As far as drugs are concerned, treatment in pure influenza, of the explosive variety, probably has but little effect. Every practitioner possessed his own specific, and the number of such specifics was so great, and their nature so various, that it seems almost certain that few, if any of them, materially shortened the disease. The simple form of influenza was generally a brief, self-limited disorder.

A few of the recommendations found in the papers for grip specifics, and employed by obscure practitioners, and gathered from conversations with men engaged in treating the disease, may be given: Quinine, quinine and whiskey, salol, salicylic acid, salicylate of soda, antipyrine, antifebrin, phenacetin, Dover's powder, camphor, bromides of potassium and sodium, olei santal, ammonium chloride, atropine and belladonna, alkalies, aconite, veratrum viride, jaborandi, boneset, aromatic sulphuric

acid, also oxide of zinc, horseradish, cloves, asafoetida, onions and garlic, and even cutting one's whiskers, if a man.

The simple or explosive form of influenza, exhibited most in the early cases, and occurring less frequently as the epidemic progressed, was best managed and in the most rational way by rest and warmth, with entire quiet of both mind and body. This was far more important than the whole combined pharmacopoeia, but was little heeded when advised. The drugs that seemed to be of use were few. The treatment can best be studied in detail as it adapted itself to the varying symptoms. In the early stage of chill-bed, warmth, warm diluent drinks; as the fever rose, and intense headache and pain in the limbs and sacral region developed, antipyrine certainly afforded relief to all the symptoms and seemed to shorten the dry stage, induce earlier and more profuse perspiration and subsidence of fever; but the next symptom in the natural history of the disease being intense prostration with subnormal temperature and a leaky skin, the depressing element in the drug employed became a serious consideration-the two depressions, that of the drug and that of the disease itself, connecting on the second or third day or later, were sure to increase the difficulty and perhaps danger, and retard recovery. Antifebrin or acetanilide being the most dangerous of this group of remedies in this respect, and antipyrine almost as bad, phenacetine, as the least so, retains its popularity and still remains the best, though not without objection; and in some rare cases they all failed to have any antipyretic effect.

It might be noted in passing that from numerous experiments performed daily by the use of a copyrighted combination, also beginning with "anti," one is led to think whether a considerable amount of this depression may not be obviated by combining any of these drugs with caffein. Salicin, the use of which was begun by one of the writers at the earliest period of the epidemic, and continued pretty steadily until now, presents many strong claims, and comes as near to being a specific as we can get with the drugs now in our possession. The tonic properties of salicin, the large doses in which it can be safely given, and the almost immediate results in most cases in reduction of temperature, diminution of pain, and production of perspiration, quite overcome the drawback of its bitter taste. It seemed, also, that its early use was followed by fewer relapses than the use of other means. Yet, that it was

by no means a specific in the sense in which quinine is a specific in malaria, was proved by certain obstinate cases which took very large doses without any apparent effect, and in the sequelae, other than in pure relapses, attended by the symptoms of the initial attack, its value was doubtful.

Salol was very extensively used in combination with quinine and phenacetine, and was relied on by many practitioners. Salicylates or

salicylic acid also incurred the objection noted above-that of producing secondary depression.

Quinine was very generally employed by the populace as a tonic antipyretic, and also as a preventive, and its previous reputation seemed to warrant its use, but it evidently had but a limited field-that of combating the secondary depression and improving the digestive tone.

Camphor, alone or in combination with quinine and phenacetine, strychnine and other agents, was relied on by some to relieve both pains and fever, in the early stage.

Chloride of ammonium and the bromides were extensively used. Dover's powder seemed the most efficient way in which to give opium, and produced excessive, early, and long-continued sweating. The few cases noted as treated in this way made early recoveries. Opium and morphine were well borne, but proved unsatisfactory. Asafoetida, valerian and the valerianates soothed the excited mental condition in numerous instances and gave relief. Sulphonal was the best hypnotic, in a disease which had insomnia for one of its marked symptoms. Sulphonal and phenacetine in suppository-ten grains of the former to six of the latter-produced sleep and free perspiration in a few hours.

Alcohol, in the second stage, given in proper quantities, was beneficial, but in too large doses increased the vascular relaxation and favored perspiration. It was useful in all stages, except the earliest, when it increased the headache and pain. Drunkards, as a rule, were free from influenza, probably because alcohol fortified the system against that exhaustion and depression which favored its onset, and in the actual exhaustion which followed the initial fever, and in the recurring periods of depression throughout the oftentimes long course of the disease, the medical attendant would have been utterly at a loss for any stimulant that would stimulate but for its use. Ammonia and other traditional stimulants did not give the same relief. Tinct. cinchoni. comp. in full doses, or other bitter tinctures, were employed with some success, where the bitter principle contained in them, if given alone, did little or no good. Extract of malt in the later stages was of great benefit.

Boneset in the form of tea, combined with heavy coverings and warmth to the feet after the manner of ancient domestic practice, claimed some success, but was often rejected by the stomach.

Exhaustion during convalescence was best treated by the phosphorus compounds. Where the syrup of the hypophosphites was obnoxious, a substitute suggested by one of the writers to his chemist-a tablet containing its ingredients-was largely used and with excellent effects, the ingredients being hypophosphites of strychnine, quinine, and iron and alkalies (pil. hypophosphit. cum quiniæ co.).

Opiates which, as said above, failed generally to benefit the initial discomforts, failed also to exhibit their usual sopo rific effects even when

given in largely increased doses; they stopped neither cough nor pain, but often seemed to aggravate both. This might have been from excessive elimination through the increased secretion (catarrhal) of the emunctories, or from a diminished power of absorption due to the catarrhal condition of all the mucous surfaces. The relief afforded in the cough-so general after the first stages were passed-by atropine or oil of sandal, was either from arresting excessive secretion or from a sedative effect upon the nerve centres, or both.

Atropine seemed to be rapidly absorbed, and to be efficient in very small doses; in fact it was poorly borne, one-five-hundredth grain four times a day having often a decided effect in the adult. Oil of sandal may have acted by diminishing secretion, but in whatever way it produced its effect, that effect was quite certain and well marked in the majority of obstinate coughs. The old-time expectorants generally aggravated matters, and were almost universally abandoned. They may have intensified the already existing catarrhal condition.

Chloride of ammonium was the only old expectorant extensively used throughout the epidemic. By some it was claimed as the best remedy for influenza in all its various varieties. In its use, however, even in carefully selected cases it was disappointing; perhaps the benefit, where derived, came from its property as a stimulant.

A number of active practitioners at a medical society, being questioned as to what, in their opinion, was the most nearly specific treatment for the disease in its simple form, gave the following answers derived from their own personal experience: Phenacetine, 2 grains every two hours; antipyrine and digitalis, the latter to prevent depression of the heart; Dover's powder with quinine; antipyrine or acetanilide; phenacetine in doses of 7 grains each at intervals; acetanilide or phenacetine with strophanthus; pilocarpine gr. hypodermatically to break up the initial fever-this, the gentleman advocating it said, produced almost immediate ptyalism and profuse perspiration-which he followed by tinct. gelsemium gtt. ij every two hours until the pains were quieted.

In theory, ergot and the bromides should have the effect of diminishing secretion by acting on the capillaries; but the combination has not, to the writers' knowledge, been generally tried, and, like other means, might prove quite inefficient, owing to the active morbific process not being overpowered by the drug.

Phenacetine seems, of all remedies, to possess the most evidence in its favor, as most safe and active; if too long continued into the stage of subnormal temperature and exhaustion, it too would prove unsafe. In the ofttimes protracted catarrh of the lungs following the first stage, when the chest would be filled with sonorous and sibilant râles-simulating asthma-a pill containing phenacetine gr. jss, atrop. gr. to sto strychn. gr., and quinine gr. j (or if thoracic pain was a prominent

symptom, camphor in gr. j doses instead of quinine) given four times a day, and kept up steadily, gave very evident and satisfactory results; the râles disappeared, and the power of the lung to expel its secretion seemed markedly increased.

A very important question in the treatment was in regard to going out of doors. Patients were almost universally eager to get out and utterly careless of admonition. How soon an influenza patient was fit to encounter the outside air was, in every case, a very serious question. Caution urged one way, the patient's inclination another. One element in going out was generally forgotten—the fatigue of going, a thing entirely separate and distinct from the atmospheric effects of outdoor air. Probably in good weather, riding, if the patient be properly protected, is safer than walking, the element of fatigue being partly eliminated. Generally speaking, it is well to wait until all lung symptoms have entirely disappeared, until expectoration is but a trifle and cough only occasional, the sweating and chilliness gone, and the feeling of fatigue, and then choose the best and brightest day for a very short exposure the first time; night air is injurious for a long time after apparent

recovery.

As for air and temperature in the sick-room, it can only be said that the room should be kept as fresh as possible, not over 70° or below 68°, and with as little draughts permitted as can be. In our late warm winters, to keep the temperature as low as this without freely admitting the outside air through open windows has been often quite impossible. The patient, however, should be well shielded by screens and curtains from direct currents of cold air.

Mingled with the cases generally known and recognized as influenza, have been many with obscure abdominal symptoms due to catarrhs other than pulmonary, the treatment of which deserves especial notice. The cases referred to presented the same initial general symptoms, but nausea speedily appeared, and in many everything, no matter how bland, was at once rejected. Here cocaine in gr. doses every hour, given in a teaspoonful of cold water, gave the most direct results; if the bowels were loaded, it could be combined with fractional doses of calomel. Externally, rubefacients and heat; for food, milk heated to 180° and slightly salted, given in small quantities frequently, or alternated with beef-tea; if these were rejected, champagne could be given, or brandy and soda, by the stomach; all other feeding was necessarily rectal. The most successful nutrient enemata were animal broths beaten up with the yolk of an egg and a small quantity of brandy or whiskey, and given in quantities of half a pint every four or six hours. After a few days the stomach gradually but surely regained its power.

These abnormal attacks are extremely prone to occur in whole families; in fact, it is a pretty sure thing when the first case in a family occurs