Sequela-Gangrene or abcess of lungs, tachycardia and angina pectoris, chronic gastro-intestinal catarrh, and chronic nephritis or cystitis may also be mentioned. Among the nervous phenomena to be noted are insomnia, neuralgia, migraine, melancholia, mania, meningitis, acute ascending myelitis, locomotor ataxia, peripheral neuritis, organs of special sense; otitis media, mastoid abscess, conjunctivitis, iritis, acute glaucoma and paralysis of accommodation.

The prognosis is good. Almost all fatalities are due to complications. In the very young and very old and chronic cases it becomes a more serious disease than at other periods of life. Mortality usually forms 2 per cent. to 2 per cent. Duration of attack brief though subject to variations. Mild form from two to four days, severe seven to ten days. Duration of epidemic rarely exceeds from four to six weeks. (Treatmentprophylaxis.)

Experience has shown that many drugs which have been advanced for preventive effect, such as quinine, salcin, etc., are devoid of value. The strongest are not immune and those at either extreme of life should be most carefully protected by proper wearing apparel and should not be exposed to unfavorable weather conditions. In this way we may lessen in a measure the number of cases. Inmates of hospitals and prisons have been known to escape the disease. Isolation should be carried out in a hospital and as far as possible in private houses. E. W. White has reported an epidemic of influenza that was successfully abated by street isolation of patients. Disinfection of the catarrhal discharges, particularly the bronchial, is neces

sary.

The Attack-Mild cases may need nothing more than rest in bed and a light diet for a few days. Milk, eggs, rice, gruel, fresh vegetables or stewed prunes. Cooling drinks are to be preferred to hot ones-lemonade and effervescent mineral waters, etc.

Moderate doses of gelsemium, quinine, dovers powder, camphor monobromate every two or three hours. Mild cases need no stimulants. Complications are to be treated as they arise. Insomnia may require trional, sulphonal or opium. Local ca

tarrhal symptoms must be treated according to special indications of each individual case.

Convalescence from influenza requires rigid supervision. The greatest injury to patients comes from going out too early. A good rule is not to allow a patient out until the temperature is normal for several days. Tonics, such as gentian, strychnia and whiskey are usually indicated.

CASE I.-J. W., age 44; good health up to present illness. Came to my office Feb. 8, 1901, complained of great pain in head, back and limbs and said he had been sick for several days but had attended to business. Examination found rapid pulse, temp. 101, diagnosed it a case of influenza, prescribed for him, told him to go home and go to bed; saw him following day, found him resting comfortably in bed; two days later called and he complained of much pain in abdomen, a localized tenderness in region of appendix. I called a consultant who agreed it was a well marked case of appendicitis; operation was considered, but thought best to wait 24 hours; used ice applications, gave divided doses of magnesia sulf.; the pain was relieved and mass soon disappeared; three days later pneumonia of right lung developed; consultation again; diagnosis concurred in; pain very severe in right side and much mucous in lungs; resp. 32 and short; temp. 102.1 F., pulse 120, perspiring freely, much delirium and patient did not recognize nurse or family; about 3 a. m. on 15th, or 6th day of disease went in collapse. Resp. slow, labored, pulseless and a comotose state; nurse gave strych. and whiskey hypodermically. When I arrived found the man very weak; continued stimulants; enema of hot salt solution and whiskey; soon reaction set in; man made slow but good recovery. The case at no time had a temperature above 102.8, pulse not above 120 and yet he had all the delirium and subsultus we find in high temperature of pneumonia and enteric fever. There was no albumen in urine, yet there was retention so he had to be catherised for several days.

Case II. A. S., age 24, single, clerk; at the age of 16 he had a compound fracture of the skull in right occipito parietal

region; there was extensive injury to the bone and quite an extensive portion of bone was removed; made a good recovery; 12 years later had a tumor removed from back of neck at University Hospital by Dr. Ashhurst, which healed and no more trouble until present illness. March 20, 1899, I was called to see patient; found temperature 103, rapid pulse, coated tongue, complained of pain in head, back, limbs, some cough and sneezing. Pronounced it influenza; gave divided doses of mild chloride, gelsemium, phenacetine and quinine, milk diet and remain in bed. In 3 or 4 days the temperature came to normal, pulse slow and full, furred tongue, severe pain in region of mastoid; put on leeches, gave phenacetine and quinine and gelsemium, no result; however the leeching seemed to relieve pain for a time and he seemed to have more serious trouble when he would attempt to walk or stand; complained of vertigo; abdomen rigid; bowels constipated, temperature normal, pulse slow; no remedies seemed to relieve pain except morphia. I diagnosed it abscess of brain and removed him to City Hospital April 6, where he could get more attention. Dr. Fell took charge of case and for a time he seemed to improve, his temperature continued normal or sub normal, pulse slow, and for a time he sat up in a chair; the latter part of May he again. took his bed and about June 5 he began to have some elevation of temperature and died quite suddenly June 8th. I performed an autopsy and found about one ounce of pus in left cerebellum. Dr. Chas. Long reported a case similar to this May, 1896.

DISCUSSION.

DR. L. H. TAYLOR.-Those of us who were practicing medicine twelve years ago will recall, I think, that the cases of Grip in the first epidemic the winter of 1889-90, were of a severer type than any we have had since. Patients complained of an excruciating headache and great depression. And while it may be true, as Dr. James says, that much of the depression in Grip cases comes from the use of coal tar products, it was nevertheless the fact that in many of these earlier cases great depression was a marked symptom before any medicine was given. I recall, too, that in the earlier months of 1890 there

were many cases of acute ear trouble frequently involving the mastoid that came as a direct sequel of the Grip. Mastoid disease has been far more prevalent in the past ten years than it was previously and no doubt there have been more mastoid operations performed since the beginning of 1890 than there were in all the preceding years of the nineteenth century. It may be said that there are more surgeons performing this operation and recognizing the disease. This is true and accounts in part for the great activity in this line of surgical work, but the disease itself is more prevalent and I believe it due largely to the prevalence of Grip.

DR. W. G. WEAVER. On two points I am distinctly in accord with Dr. James concerning the treatment of influenza. First, on the importance of I know of

no disease in which there is a greater prostration in the beginning than in influenza. There is evidently in this disease a high grade of toxemia resulting from the specific germ. This should impress upon us the importance of early and sufficiently prolonged rest. Where absolute rest is secured nearly all the patients make a good recovery but where it is impossible to confine the patient to bed or even to the house and frequent relapses occur, the distressing after effects are common. In the second place, I fully agree with Dr. James on the injurious consequences resulting from the use of the coal tar preparations. The many cases of weak and dilated heart following influenza are doubtless due to two factors-the lack of sufficient rest and the injudicious use of the coal tar preparations. In many of these cases strychnia should be used early and hypodermically and afterwards continued for some time in full doses three times a day. I believe where this practice is carried out, joined with proper rest in bed and in the house, very few cases of weak heart will be encountered. We should never lose sight of the fact that we are not dealing in this disease with an ordinary cold, but with a toxemia, which, in many cases, is profound.

PURPURA HAEMORRHAGICA.

REPORTED BY DR. R. L. WADHAMS,

MARCH 19, 1902.

M. R., American, carpenter by trade, aged twenty-four years; family history, rheumatism; otherwise negative. Previous personal history good.

February 18th, 1900, felt a little ill, had a dull headache, but was able to work.

February 21st, his nose began to bleed, not profusely but steadily. It bled seven hours.

February 23d, his nose bled three hours.

February 26th, his nose bled four hours, making fourteen hours in all. From then until March 3d he had numerous small hemorrhages from his nose and mouth.

March 3d he had a very profuse hemorrhage from his nose, controlled with difficulty by packing.

On the first day of these attacks, February 21st, an eruption appeared extending over the greater part of his body and limbs. It was hemorrhagic in character.

On February 25th, he had an attack of facial paralysis on the right side. This was slight and nearly disappeared in a week.

March 4th, patient first came under my observation, he was a large, muscular, well-built man. He was very weak and pale. He could hardly walk on account of weakness. His nose had been bleeding for some hours and still continued to do so. Bleeding could only be controlled by firm gauze packing. There were hemorrhages into the conjunctiva. During the afternoon he vomited large amounts of both fresh and decomposed blood. Pulse 128 and weak. Temperature 99.6. Respirations, 28.

March 5th, weakness increased, otherwise his condition was about the same.

March 6th, the hemorrhage persisted, and the eruption had increased in amount and was deeper in color. Pulse was 156. Temperature, 102. Respirations, 40. Toward the latter part of the afternoon he became unconscious, developed symptoms of cerebral hemorrhage, had cheyne-stokes respiration and died.