Distress in the upper air-passages and the tickling cough call for steam inhalations, and the air of the apartment may be rendered moist by the evaporation of water kept boiling in a broad, shallow vessel. Gargles of potassium chlorate, or potassium chlorate with sumac, exert a soothing influence upon the congested tonsils.

Severe cases call for more energetic measures of treatment. The most prominent indications are the control of the fever; the diminution of the hyperemic fluxion to the mucous tracts; measures of support; the mitigation of pain and the induction of sleep; and, finally, the prevention of the pulmonary congestion, to which the depression leads by enfeeblement of the circulation. The last indication is especially urgent in infants, the very old, and those previously debilitated from any cause.

Inflammatory complications require special treatment or modifications of treatment.

The febrile movement is not, as a rule, high; grave nervous symptoms and serious catarrh may be associated with moderate fever.

An anti-febrile regimen is to be observed. The moderate duration of this fever, as compared with enteric fever, renders it less important that large amounts of fever-food should be given, while the tendency to depression makes it of the utmost importance that the administration of food be systematic and carefully looked after by the medical attendant. The disinclination to take food is so great that it is often with difficulty that a sufficient quantity can be given in the early days of the attack, and it is to be doubted whether benefit follows anything in excess of the most moderate amount. It is necessary to observe regular hours, as in the management of all the low fevers. As soon as convalescence begins the patient should be urged to eat; the quantity of food taken at one time is to be augmented, and the intervals between the meals may be longer.

A favorable action upon the excretory function of the skin and kidneys will result from the moderate drinking of water or of the beverages already spoken of. At least enough fluid should be taken to relieve thirst.

Diaphoretics have been much used, upon the theory that by determination to the skin they correspondingly diminish the tendency to hyperæmia of the affected mucous tracts. Dover's powder, solution of the acetate of ammonia, and other mild diaphoretics are to be selected. Jaborandi should be employed with caution. The wet pack and other hydrotherapeutic measures have been employed to act upon the skin and to effect a direct reduction of temperature in influenza. For old and feeble persons warm packs are employed. A profuse sweating at the onset of the attack is said to occasionally cut it short. Early diaphoresis often brings about a rapid and lasting amelioration of the symptoms. It is to be borne in mind that the fever is rarely excessive, and that sweating is not infrequently a troublesome symptom. In some epidemics it has been a very troublesome one.

General bloodletting is not to be resorted to in influenza. Its danger was apparent to some of the early writers. As has been pointed out, the high mortality of some of the older epidemics is to be explained by the venesections practised at the beginning, and even during the course, of the attack. It has no favorable effect upon the catarrhal processes, and but little upon the subjective symptoms. The fever is not relieved by it; the

nervous depression is increased and the risk of lung-congestion is augmented. Bleeding is not likely to be practised in epidemic catarrhal fever while the present views of its place in therapeutics continue to influence practice. Cautious local bloodletting for the relief of local inflammatory trouble is spoken of in most of the modern books. The occasions for its employment are so rare in the treatment of this disease that even this statement should be henceforth omitted. In influenza, as it is known to medical men of the present from the descriptions of the old and personal experience of the few recent and milder epidemics, bloodletting, either general or local, is clearly uncalled for.

Emetics hold a high historical place. It was of old customary to begin the treatment with a vomit. As late as the epidemic of 1837, Lombard of Geneva believed that they shortened the attack and lessened the intensity of the symptoms when administered at the beginning. In cases attended by early gastric disturbance and nausea they are said to be especially of use. They sometimes set up great irritability of the stomach, with vomiting that it is difficult to control. On the whole, the cases in which an emetic would do good are extremely rare.

Purgatives were formerly regarded as important in the treatment. This view no longer prevails. In case of constipation gentle purgation, ex indicatione symptomaticâ, is a necessary part of the proper management of the case. For this purpose the laxative mineral waters, as Friederichshalle, Hunyadi, Pullna, are excellent. Castor oil may be given, and calomel is in some cases, and particularly in childhood, of great service. Simple enemata of warm water or soap and water will often suffice. The tendency in some cases to exhausting and troublesome diarrhoea, and the fact that diarrhoea occurs spontaneously some time in the course of most cases, should inspire caution in the use of purgatives. Repeated purgation during the progress of the attack is not only useless-it is also positively injurious.

In the severe cases quinine is to be given early and in full doses. It exerts at the same time a powerful influence upon the temperature, upon the tendency to local hyperæmias, and upon the nervous symptoms, and in particular the headache. Rawlins,' as early as 1833, found that excellent results followed its administration, the effect being the better the earlier it was given. It has even been lauded as a specific for influenza. The mineral acids may be given with a view to realizing their tonic effects.

For the most part, the foregoing measures, directed against the fever, will exert a favorable influence upon the catarrhal processes. Expectorants are of advantage; ipecac is useful. The preparations of antimony are inadmissible by reason of their tendency to depress. Ammonium chloride is indicated in the earlier stages of the bronchitis. Among recent drugs, yerba santa (Eryodiction glutinosum) and the oil of eucalyptus are of use in mitigating the symptoms in epidemic catarrh, as they do in certain forms of simple sporadic catarrh.

The peculiar dry, racking cough so often present in the early days of the attack should be relieved. It is not useful in removing bronchial accumulations, being, as has been shown, in most instances out of proportion to the lesions of the bronchial mucous membrane; on the other

1 London Medical Gazette, May, 1833.

hand, it tends to increase the hyperæmia of the upper air-passages by the mechanical violence of the cough-paroxysms. Further, it is distressing and exhausting, and contributes to the muscular and nervous prostration. Benefit will be derived from keeping the air of the apartment moist, and from the occasional inhalation of the steam from hot water, either used alone or poured upon the compound tincture of benzoin, a pint to the teaspoonful, or upon paregoric, a pint to the tablespoonful, in a proper vessel or inhaler.

No drugs are more potent to this end than opium and its derivatives, and in particular morphia and codeia. The hypodermic use of the morphia salts, judiciously resorted to, constitutes our most valuable therapeutic resource in fulfilling the threefold indication of relieving cough, alleviating both the head-pain and the pains in the extremities, and in procuring sleep. The old-time dread of opium in influenza was not well founded. The administration of this drug in moderate doses is attended with advantages that far outweigh any danger of increasing the tightness across the chest and retarding expectoration. It is necessary to observe the same caution in giving it to infants and aged persons in influenza that is necessary under other circumstances. The influence of carbolic acid in restraining cough makes it a useful addition to soothing draughts in this disease.

The substernal and other chest-pains may be combated with sinapisms, turpentine stupes, repeated inunctions of fatty substances containing extract of belladonna, and the like. Pleurodynic stitches call for similar measures; a long strip of machine-spread belladonna plaster, about five centimetres (two inches) in width, applied very firmly to the side of the chest from the spine in a direction downward and forward parallel with the ribs, and reaching to the median line in front, affords great relief to the lateral chest-pains.

The control of the debility must be regarded as the most important indication in old and feeble persons. Wine, spirits, milk-punch, ammonia, spirits of chloroform, are to be used, not in accordance with fixed rules, but as occasion may require. In many cases wine or whiskey will be indicated from the beginning, the quantity being determined rather by the effect upon the circulation and the general condition of the case than by rule. Women and others unaccustomed to the use of alcoholic drinks often take wine and brandy in considerable quantities, with striking benefit and without flushing or other evidences of its disagreeing.

Chloral is inadmissible as a hypnotic by reason of its depressing effect upon the heart. Paraldehyde may be used, or the bromides in connection with opium if the latter alone is not well borne.

Diarrhoea must be managed in accordance with general principles. If slight, it does not require special treatment. It is apt to occur at one period or another in the course of most cases, and not infrequently marks the beginning of convalescence. Colic may be treated with warm fomentations and carminatives; if it be due to constipation, mild laxatives are to be combined with them.

Severe cases of influenza demand the careful attention of the physician, who must be on the alert to detect the inflammatory lung complications which so often lead up to the fatal issue as early as possible. Their treatment must be regulated by the circumstances of the case, the nature

of the particular complication, the age of the patient, and so on, in accordance with general therapeutical indications.

Finally, all measures, of whatever kind, that tend to depress the general nervous system or the functional activity of the respiration, and especially the heart-power, are to be sedulously avoided in the management of influenza. During the convalescence unfavorable influences of the weather are to be guarded against. It is important to warn the patient that a severe attack of influenza renders him liable for some time afterward to pulmonary disorders. The sequels, and in particular those implicating the respiratory tract, are to be appropriately treated. After severe cases a course of tonics is commonly of advantage, and a change of climate often necessary to re-establish the health.

As bearing on what is stated in the foregoing pages on the causation of influenza, reference may be made to the investigations of Seifert,' who claims to have found in the mucus expectorated by patients with influenza numbers of a peculiar micrococcus. It is evident, however, that no conclusions can be based upon these observations until the results have been subjected to careful examination in other epidemics.

Volkmann's klinische Vorträge, No. 240, June 20, 1884.

DENGUE.

BY H. D. SCHMIDT, M. D.

SYNONYMS.-Break-bone fever, Dandy fever.

HISTORY.-The history of this disease dates only from the second half of the last century, though it appears very probable that previous to this time dengue existed in the tropical regions of Africa and Asia, whence it was carried to Europe and America.

In Spain the disease has been known since 1764, when, up to 1768, it prevailed in Cadiz and Seville under the name of la piadosa or la pantomina. In 1780 it appeared in the form of an epidemic in Philadelphia, where it was first noticed and described by Rush under the name of bilious remitting fever, commonly called break-bone fever on account of the violent pains attending it. Next it prevailed in Calcutta in 1824, and two years afterward it made its first appearance on the southern coast of the United States, in Charleston and Savannah, where it prevailed to 1827. Toward the close of 1827 another dengue epidemic broke out in the West Indies, whence the disease proceeded to the American continent, reaching New Orleans in the spring, and visiting Charleston and Savannah in the summer and autumn of 1828.2 In 1844 it showed itself in Mobile, and in 1848 in Natchez, whilst in 1850 it reappeared along the Southern seacoast, particularly in Charleston, from which it proceeded even to inland towns, such as Augusta, Ga.3 In 1865 dengue appeared in Teneriffe and other Canary Islands, whilst at the same time and through the years 1866 and 1867 it prevailed in Andalusia and in some other Spanish provinces."

One of the most extensive epidemics of dengue prevailed from July, 1870, to January, 1871, in Zanzibar," on the East Coast of Africa, whence it extended to Aden in Arabia and Port Said in Egypt. In December, 1871, the disease appeared simultaneously at Bombay and Calcutta, to which place it had been carried by transport-ships from Aden. Proceeding from Bombay in a northern direction along the railroad, it spread

1R. H. Poggio, La calentura roja observada in sus apariciones epidemicas de los anos 1865 y 1867, Madrid (reported in Virchow und Hirsch's Jahresbericht für das Jahr 1871, vol. ii. p. 200). "G. B. Wood, Practice of Medicine, 4th ed., vol. i. p. 444. S. H. Dickson, Elements of Medicine, 2d. ed., p. 747.

R. H. Poggio, Virchow und Hirsch's Jahresbericht für das Jahr 1871, vol. ii. p. 200.

5 J. Christie, "Remarks on Kidniga Pepo, a peculiar form of exanthematous disease epidemic in Zanzibar, East Coast of Africa, from July, 1870, to January, 1871," Brit. Med. Journal, July 1, 1872, p. 577 (reported in Virchow und Hirsch's Jahresbericht für das Jahr 1872, vol. ii. p. 203).

Virchow und Hirsch's Jahresbericht für das Jahr 1873, vol. ii. p. 208.