cent mucous membranes. Through the lacrimal canal they extend to the ocular conjunctiva, where they give rise to redness and swelling, to increased secretion of tears, and to photophobia. The mucous membrane of the frontal sinuses becomes inflamed with especial frequency. The patients complain, in consequence, of intense pain on either side of the root of the nose, and pressure in this situation evokes tenderness. Pain in the superior maxilla, above the upper teeth, is suggestive of inflammation of the mucous membrane lining the antrum of Highmore. Frequently, roaring in the ears, impairment of hearing, and pulsatile pain in the ear are present-phenomena that are dependent upon extension of the inflammatory process along the Eustachian tube into the tympanic cavity. Suppuration and rupture of the pus externally through the tympanic membrane often occur. The pharyngeal mucous membrane, likewise, does not escape. A sense of burning and of tickling in the pharynx, and pain in swallowing, are indicative of inflammation of the pharynx, and inspection of the pharyngeal structures will disclose redness, swelling, and increased secretion. The general condition suffers in marked degree in many cases. The patients are prostrated, feel excessively weak, as if they had been attacked by an especially grave disease, and not rarely become pallid with remarkable rapidity. With gradual subsidence of the fever and of the catarrhal symptoms recovery slowly sets in, and if the disease pursues an uncomplicated course it generally terminates in from seven to fourteen days, although occasionally it may occupy only from two to four days. Complications, however, occur with extraordinary frequency, and especially the influenza-epidemics of the last decade have been justly notorious and feared on account of the frequent occurrence of serious complications. Inflammatory complications occur with especial frequency, in the causation of which particularly streptococci and pneumoniacocci take part, in addition to influenza-bacilli. Other complications, particularly certain nervous disturbances, are probably dependent upon the action of bacterial poisons (toxins) of the influenza-bacilli. Among all the inflammatory complications pneumonia is most frequently observed, at times resembling bronchopneumonia, at other times rather fibrinous pneumonia, and occasionally being converted into abscess and gangrene of the lung. The latter condition I have observed to rupture into the pleura and to give rise to putrid pyopneumothorax. Also pleuritis and pericarditis, less commonly myocarditis and endocarditis occur. Occasionally marked gastro-enteritic symptoms are present, such as persistent and frequent vomiting and profuse diarrhea. At times the stools contain blood. Often nervous symptoms are prominent-headache, vertigo, coma, delirium, even marked psychopathy, occasionally signs of encephalitis and cerebral abscess. Palpitation of the heart, and irregularity in the action of the heart, are also among the nervous complications. Troublesome neuralgia is especially disagreeable, at times being confined to a single nerve, or jumping from one nerve to another. Inflammatory processes in the peripheral nerves at times give rise to peripheral paralysis. The organs of special sense are often involved, especially inflammation of the eye and the ear occurring, and also paralysis of the ocular muscles. Arterial thrombi occasionally form rapidly in the blood-vessels, and they may cause gangrene of one or another extremity, and terminate fatally from septicemia. Among the sequelae protracted pallor, vertigo, irritability, and sleeplessness especially are to be mentioned. The complications that have been named may in part become sequelae. The abdominal variety of influenza is characterized especially by severe vomiting or profuse diarrhea, or both together. In women hemorrhages from the genitalia occur not rarely, and abortion often take place in pregnant women. In the nervous variety of influenza all of those disturbances may occur that have already been mentioned as complications of bronchitic influenza. A bacteriologic diagnosis is not possible during life. The recognition depends essentially upon whether gastro-enteritic or nervous symptoms are present during the prevalence of an epidemic of influenza without other discoverable cause. Prognosis.-Uncomplicated influenza is readily recovered from by young and robust individuals, but is a serious disease for the debilitated, and especially for the aged, in whom death readily results from exhaustion. The prognosis depends essentially upon the nature of the complications, and, as these vary with the character of the epidemic, the latter will also determine the gravity of the prognosis. Anatomic Alterations.-Distinctive anatomic lesions are not known. The mucous membrane of the air-passages is the seat of redness and swelling. The spleen is generally soft and diffluent (infection-spleen). The kidneys are hyperemic. Influenza-bacilli have been demonstrated in the brain in cases of cerebral influenza. They have been found, also, in the intestine, in the spaces of the follicles of Lieberkühn, as well as between the epithelial cells and in the basement-membrane. The remaining alterations in the intestines are suggestive of cholera. Treatment. No specific treatment for influenza is known. Generally the patients are so distressed by individual symptoms that symptomatic treatment must be instituted, and expectant treatment cannot be followed. In cases of bronchitic influenza the air of the sick-room should be kept moist by spraying a 3 per cent. solution of carbolic acid thrice daily; or, during the winter, by keeping in the chimney or upon the stove a vessel containing water to which 5 c.c. of creosote have been added. As a beverage warm infusions may be recommended, as, for instance, pectoral speciesone tablespoonful to a cup of hot water several times daily. Severe irritative cough should be relieved by means of mild narcotics, as, for instance: Or, B Powdered ipecac and opium, R Bitter-almond water, Morphin hydrochlorate, Dose: 10 drops thrice daily. 0.3 (44 grains). 10.0 (2 fluidrams); Resort to expectorants will also have to be made frequently. Subcutaneous injections of pilocarpin hydrochlorate (0.3:10.0— 4 grains 2 fluidrams; half a syringeful-8 minims-subeutaneously) have been lauded. For the relief of neuralgia and other nervous disturbances sodium salicylate, phenacetin, antipyrin (1.0-15 grains-thrice daily) especially are to be recommended. Also, in the presence of slight fever rest in bed is to be advised. The patient should avoid going out into the open air too early, as relapses readily occur under such circumstances. As a prophylactic measure isolation of the patient should, so far as possible, be secured and the sputum rendered innocuous by its reception into a 5 per cent. solution of carbolic acid. V. INFECTIOUS DISEASES ATTENDED WITH LOCAL ALTERATIONS IN THE DIGESTIVE ORGANS. EPIDEMIC PAROTITIS. Etiology.-Epidemic parotitis is known also as mumps, and is an infectious disease that occurs in epidemic distribution most frequently in the autumn or the spring. The infectious agent has not yet been discovered. In all probability it gains entrance through the mouth into the duct of Stenon, and from here into the parotid gland. The small caliber of the duct of Stenon in infants has been assumed to be the cause for the infrequency with which the disease appears in them. Infection generally occurs through personal association. It has been observed in educational institutions that almost all of the pupils are attacked by mumps if at the close of the vacation one of the pupils returns from home with parotitis. In children schools and public playgrounds are the principal channels through which infection takes place, and not rarely epidemics are confined to a single school. Symptoms. The period of incubation for epidemic parotitis may be as long as twenty-one days, although frequently it is less. Prodromes often are wholly wanting. Occasionally the disease sets in with chilliness and slight elevation of temperature. In other instances, however, the general condition remains unaffected and local changes in the parotid gland appear earliest. These begin at first in one gland, according to some most frequently in the left, and then in the course of one or two days they make their appearance also in the other gland. In the latter, however, they may be so ill developed as to be overlooked altogether on superficial examination. The first symptoms generally consist in a sense of tension, or even in slight pain in the affected parotid gland. The involved region becomes enlarged almost to the size of a fist, and above, and feels hard and often also somewhat hot. The overlying skin is tense, glistening, and smooth, and more often pale than red in consequence of compression of the vessels, The swelling, in correspondence with the situation of the parotid gland, occupies the region bet teen the mastoid proces, the maar arch, and the angle of the lower jaw: but it extende aleo partion larly in the submaxillary region into the négwbornood. patient is in great degree emvermoed in de preeding die somer jan, and if marked enlargement of the part 4 2.54 present gon both sides he will war through his teeth, and le cop who difay cagane of the ty solid and quid fed. In consecetect often aci the head are head is geeth.. relax the 2 Among the complications inflammation of the testicle-orchitisis the most frequent and the most important, although this occurs only in virile males. It is almost always unilateral, and is attended with a sense of heaviness, pain, and swelling in the affected organ. At times the swelling of the parotid has been observed to subside, while orchitis developed, and to become more active after the orchitis had gotten well. Occasionally orchitis is followed by atrophy of the testicle, in consequence of which, if it be bilateral, sterility in the male may result. In women swelling and tenderness of the breasts, or of the ovaries, and the formation of a hematoma of the labia have been observed. Suppuration occurs but rarely in the diseased parotid gland, and it may be attended with rupture of the pus externally or with burrowing abscesses, with erosion of the large blood-vessels of the neck, even with burrowing and secondary suppuration in the pleural or the pericardial cavity, or in the mediastinum, together with its various dangers, or with general septicemia. At times disease of the ear occurs, particularly of the labyrinth, which may induce vertigo, vomiting, impairment of hearing, or deafness. Of the sequelae of epidemic parotitis some have already been mentioned as occurring as complications. Occasionally the inflamed parotid gland is not wholly restored to its normal size, but remains enlarged and indurated. Either ptyalism or diminution in the secretion of saliva may also occur. Pressure upon the expansion of the facial nerve is occasionally attended with peripheral facial palsy. Diagnosis. The recognition of epidemic parotitis is easy on account of the distinctive local alterations. It is distinguished from secondary and metastatic parotitis occurring in the sequence of a number of infectious diseases, in the first place, by the circumstance that it occurs as an independent disease, and, further, that it but rarely gives rise to suppuration. Prognosis. Epidemic parotitis is a benign disorder, which scarcely ever terminates fatally. Anatomic Alterations.--Little of a definite nature is known with regard to the anatomic alterations, as few opportunities are afforded for study. It is assumed that catarrhal inflammation of the excretory ducts and the acini of the gland arising through the salivary duets is present. Treatment.-As no specific remedy is known, the treatment is restricted to symptomatic, and especially antiphlogistic measures. The swollen portion of the face is rubbed with warm olive-oil, and is covered with absorbent cotton. The mouth is rinsed after each meal with a solution of aluminum acetate (1.0: 200). The diet should be liquid, with a preference for milk. Even if the disease pursue an afebrile course the patient will do well at least to remain in his room. If orchitis develop, the inflamed testicle should be |