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of a certain type that succeeding cases will assume the same type. This holds good of even such unusual forms as the renal and hepatic with jaundice, and the laryngeal form. The fact itself points apparently to a different means of entrance of the poison into the system in the different varieties of influenza.

The contagion of influenza has been doubted by some observers, but we think without good reason. Contagious and infectious would best describe it, like scarlet fever or smallpox, but with a power of reaching further than either, and not, as the public seem to think, and the profession did, that it is purely an aërial poison not emanating from a sick individual but travelling independently of persons.

The subject of the treatment of the sequela of influenza is a very large one. The numerous affections appearing in the wake of the original influenzal attack require special treatment in each case, symptomatic and general.

To give a general but brief outline of such treatment we must enumerate, as far as possible, the sequelæ generally met with, and the complications most frequently seen of influenza with preëxisting disease. The sequelae of influenza were like the contents of Pandora's box-only no "hope" was left behind. The ordinary sequelæ were bronchitis, pneumonia, and local catarrhs, meningitis, neuralgia, neuritis, paralysis, heart weakness, general nervous prostration, insomnia, obstinate dyspepsia, diarrhoea, diphtheria, anæmia.

Anæmia, phthisis, chronic bronchitis and asthma, Bright's disease, and valvular disease of the heart were often complicated by influenza.

The best remedies for pain were mustard plasters, blisters, and dry heat. For neuralgic pains of short duration, these remedies were generally followed by a cure. Persistent pain (neuritis) is treated on general principles.

Myalgia Injections of atropine or cold water hypodermatically, rest in bed with relief of pressure, and rubbing with stimulating embrocations, generally spirit of camphor alone, or lin. chloroformi; the latter in violent headache were also very useful.

For bronchitis Ammonium chloride when expectoration was free quebracho and olei santal, with menthol or olei menth. pip. when cough was dry with asthmatic râles. Whiskey and glycerin-a popular remedy -allayed the tickling cough, and when combined with quebracho caused freer expectoration.

For pneumonia: Counter-irritation and the usual treatment, avoiding depressing measures as much as possible, with free stimulation. In the later stages of pulmonary catarrh, atropine with ammonium iodide were used with great success.

Local catarrhs: Violent coryza can be alleviated by menthol, with

liquid vaseline, cocaine in 4 per cent. solution, and by the snuff of bismuth, pulv. acacia, cocaine and morphine acetate.

Gastric catarrhs: By hot water, hot infusion of hydrastis canadensis, gtt. x, fluid extract, to one ounce of hot water; by cocaine in gr. doses every hour; and by withdrawal of food, with rectal feeding. Catarrh of the bladder-of which several very severe cases were seenwhile resisting ordinary means, usually yielded promptly to a combination of antipyrine gr. ij, morphine gr. , atropine gr., every four hours and the use of the catheter when retention occurred. Urethral catarrhs were very obstinate-occurring under circumstances and at ages when suspicion of gonorrhoea was impossible-and slowly subsided apparently regardless of treatment.

Meningitis was, in some respects, the most serious and fatal sequel; this was especially true in the spring of 1890. Its treatment was by the bromides, by ergotine and belladonna per rectum, and counter-irritation to the occiput. Allied to it was the peculiar sleep, which in the aged often occurred just when the lung symptoms seemed about to yieldand too often ended in death. This was the most frequent manner of death among the aged in the fall of 1891.

In paralysis: Strychnine gave the best results, with hypophosphites. Electricity in the early period increased the pain-the nervous system was already exhausted by over-stimulation.

The treatment of neuritis was unsatisfactory; it progressed slowly, the pain travelling from centre to periphery of nerve. Blisters and iodine, local stimulating applications, and hypodermatics were employed with varying success.

In heart weakness: Digitalis, strophanthus, cactus, at times seemed effective; caffeine was undoubtedly so.

For insomnia: Sulphonal was the best and safest hypnotic. (Somnal, theoretically, should be the best drug.) Ammonium bromide, in excited mental states, at times restored mental equilibrium.

The obstinate dyspepsia occurring especially after the abdominal attacks, seemed due to impaired muscular tone of the stomach. When an apeptic condition existed pepsin was indicated, and gave a certain amount of relief. Generally mild stomachic stimulants were beneficial. Mineral acids and ordinary bitter infusions were worse than useless, irritating the stomach and increasing distress. Alcohol in the shape of brandy or whiskey, taken with pounded ice, was as useful as anything.

General nervous prostration often extended over long periods without any discoverable local cause; it was always worth while, however, to examine the urine with care. Sometimes a catarrhal nephritis, sometimes a faulty digestion or hepatic inaction seemed to underlie the general condition in latent form. These cases, by enforced rest and attention to local complications, gradually recovered. These cases and nervous

cases generally, were very disappointing when sent to the seashore during convalescence.

Sweating: This was sometimes exceedingly profuse and very hard to control, owing to the vaso-motor paresis. The best remedies were atropine and alcohol in proper quantity. Oxide of zine and aromatic sulphuric acid were sometimes of use. In some cases the side on which the patients were lying, in bed, would be dry while the upper side would be bathed in perspiration and cool; on a reversal of position the dry side would become moist, and the previously moist side dry; this suggests that the stimulation of a certain amount of heat might control the relaxed vessels.

Diarrhoea was best controlled by rest, proper diet, milk and broth, and as remedies bismuth, with or without opium, or bismuth with cocaine; when gastric pain existed especially cocaine; when internal pain, opium and spirits of chloroform. The short attacks often ended in diarrhoea, and after it all other symptoms, engorged lungs, etc., disappeared at once, but induced diarrhoea did not seem to have the same beneficial effect.

Diphtheria as a complication was exceedingly rare, until the fall of 1891. So much so as to lead to the belief that the two diseases were antagonistic. In the early fall of 1891, however, in Philadelphia the reported deaths from diphtheria increased greatly above the average, though mostly in the outlying wards it seemed in the cases seen by the writers to have followed rather than preceded the influenza, in one case appearing during the progress of an influenzal bronchitis, in a man aged seventy-six, in the second week of the disease.

Anæmia: In some cases of acute anæmia after influenza, the bloodcount ran down from 3,500,000 to 4,500,000 to the c.mm., and hæmoglobin was below 50 per cent. Iron was disappointing as a remedy, the hypophosphite excepted where combined with the other hypophosphites.

Phthisis undoubtedly developed from influenza. The catarrhal condition remained and caused a breaking down of the lung tissue. These cases while presenting the physical signs of phthisis and terminating finally in death, showed during life, on examination of the sputum, no bacilli. In the fall of 1891 in the Philadelphia Hospital the sputa of 14 cases of phthisis, examined (often several times and by different methods) for bacilli, showed them abundant in 4, few in 6, absent in 4 cases. In the fall of 1890, after most of old cases of phthisis had died, 12 out of 28 cases were found free from bacilli, and invariably with histories dating from an influenzal attack.

Many chronic catarrhal cases also, when the lungs were involved, resembled and were mistaken for phthisis. Cough, diarrhoea, nightsweats, anæmia, dyspepsia, and fever were present, with physical signs

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which agreed with phthisis in all but dulness on percussion, which was absent.

The differential symptoms were: an almost non-purulent sputum, absence of emaciation, and at last a sudden disappearance of fever and all physical signs, with rapid recovery. (These cases may have formed the basis for the claims of some recent remarkable specifics for phthisis.)

FOSSA PRÆNASALIS.1

BY THOMAS DWIGHT, M.D., LL.D.,

PARKMAN PROFESSOR OF ANATOMY AT HARVARD UNIVERSITY.

THE purpose of this paper, besides the description of a specimen, is (1) to attempt to prove that two quite different conditions are described by this name; (2) that the fossa pranasalis proper is not at all a simian feature, but that, while it occasionally reaches its greatest development in man, the nearest approach to it is not in the ape, but in the seal; (3) to discuss its significance.

2

The subject may well be introduced by a passage from Topinard's paper, "Du Prognathisme alvéolo-sous-nasale: " "But the anterior border of the nose is not always simple, with a sharp crest. In the first degree it becomes dull; in a second it becomes thickly rounded, measuring in diameter from 1 to 4 mm.; in the third degree it is decomposed into two lips bounding a little triangle, which, joining that of the opposite side, forms a lozenge-shaped surface. Of these two lips, continuous with the side of the nose, the anterior bounds the nasal fossa in front; the other forms the anterior border of the anterior palatine canal. So far, the line separating the nasal fosse and the subnasal region is clear. Now the difficulties begin." He then points out that there is occasionally a middle transverse line between the two others, and that sometimes its importance increases so that it seems to form the limit between the nose and the face. Then, again, the lozenge-shaped surface is divided

1 This paper was to have been read at the meeting of the Association of American Anatomists during the Congress held at Washington in September, 1891. Its title appeared on the programme of the meeting, but I was unexpectedly prevented from attending. An article entitled " Ueber die onto- und philo-genetische Bedeutung der verschiedenen Formen der Apertura pyriformis," by Dr. Mingazzini, of Rome, appeared in the Archiv für Anthropologie, Bd. xx. Heft 3, which was published in October, 1891. As in some respects my views are the same as those of Dr. Mingazzini, I wish to state that, though not quite in shape for publication, my paper was originally in all essentials what it is now.

2 Revue d'Anthropologie, tome i., 1872.

into two, of which the posterior-about one-third of the whole-looks backward toward the nasal fossa, while the anterior two-thirds slant downward on the face. The anterior lip practically disappears, though traces of it may be seen running downward in various ways. This is what he calls the double vertical gutter. "Of this," he continues, "I distinguish two degrees-one in which the inclination is moderate and traces of the anterior lip still visible; the other in which these traces join quite below the nasal spine, or are lost in the direction of the spacebetween the two middle incisors, or between the middle and the lateral one. In this case the line of demarcation between the nasal fossæ and the subnasal surface has disappeared; they to some extent form but one, and recall a similar disposition in many apes."

"Two other striking varieties are still to be mentioned. I have met them only in the lowest types of the Melanesians. The anterior and middle lips of the above-mentioned slanting surface remain strongly marked, and are separated by a deep depression-as it were, a digital one-which is elongated from above downward, measuring sometimes as much as a centimetre in length; or it may be developed crosswise, decomposing the nose into two stories-two true steps."

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The two last-mentioned variations seem practically one. They constitute the true fossa pranasalis, differing essentially from the vertical or

1 This term is sometimes used to denote all curly-haired inhabitants of the South Sea Islands. Vide Ranke: Der Mensch.

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