pipes, bedding, as well as certain professional instruments, as the blow-pipe, musical apparatus, etc. The risk in the use of any one article may not be great, but when a syphilitic and non-syphilitic use a variety of things in common, it becomes proportionally greater. I cannot doubt that this form of transmission is common in Cleveland. Although newly arrived, and having but a small clientele, I have already seen two cases. One was a chancre of the lip in a German boy, who was a brass moulders apprentice. It was probably due to the common use of a dipper by the moulders, many such cases occurring in literature. The other case was a chancre on the knuckle, due either to a bite or to striking a syphilitic on the teeth. I know of about seventy such cases in literature.

The time will permit neither the further pursuit of this theme, nor the drawing of conclusions. I trust the paper has been practical and suggestive, and that the dicussion will aid in rounding out the subject.

EPIDEMIC INFLUENZA.*

BY D. S. GARDNER, M. D., MASSILLON, OHIO.

My reason for presenting the subject of Epidemic Influenza to you for discussion to-day, is that medical societies in general devote too little time to matters of interest to the general practitioner. I make this statement with all due deference to the gentlemen pursuing a special calling, yet it is a groove into which all societies seem to be drifting, and no doubt is not only detrimental to the general practitioner in attendance, but in a great measure prevents the attendance of others.

[The writer here presents an exhaustive review of the history of the numerous epidemics of influenza, which we are obliged to omit, owing to limited space, and refer our readers to Dr. Kinsman's article in the last August number.—EDs.]

Most modern writers upon this disease recognize two forms of it, the febrile and the catarrhal.

*Read before the Stark Co. Academy of Medicine at Canton, September 1st, 1891.

The invasion is usually sudden, many being stricken while engaged in their usual employment, with scarcely a moment's warning, while others have experienced premonitory symptoms for several hours preceding the attack.

In the Febrile form, your patient will complain of dizziness, of intense, and I may say, characteristic frontal headache, due to the implication of the frontal sinuses. Occasionally there may be observed in connection with the frontal headache, or without it, occipital headache, which usually is not so severe.

Extreme pain in the lumbar region, elevation of temperature, followed by chills and fever, more or less severe, particularly in the region of the spine, which often may amount to rigors, general aching of the limbs, dyspnoæ, pain in the chest, which is more marked along the lower border of the sternum, melancholy, and depression of spirits, precordial oppression. The appetite is gone and pain in the epigastrium is sometimes present, nausea and occasional vomiting, which may occur spontaneously or be excited by food. The tongue is coated with a moist fur, the pulse is variable, usually weak and sometimes intermittent. The number of beats per minute vary; in some instances falling as low as 40 to 50, in others rising as high as 140 to 160.

The fever is usually remittent in form, the exacerbations occurring at night. The clinical feature which I wish to make the basis of my paper, is the extreme prostration which attends all cases. Indeed, so great is the shock to the nervous system that you have great fears of being able to rally your patient. There seems to be

towards the great

no doubt that the essential shock is directed nerve centers, viz. the cerebro spinal system. But what is its nature? What is the character of the materii morbi, which so completely robs one of all vital energy? Extreme depression of vital force marks the entire course of the disease, and it certainly is the last element which is dispelled. Often for weeks, after all other conditions have subsided, and the patient is enjoying a good nutrition, he still remains unable to attend to his duties.

That the prostration is greater than any discernable lesion would indicate, seems to be obvious. You have all observed the remarkable frequency of relapses, occurring in influenza and also the fact that the relapses are more severe than the original attack. I shall greatly enjoy having the gentlemen of the Academy dwell particularly on this feature of the disease, and hope that some one will be able to answer the question: What is the Pathology of Influenza? If the catarrhal symptoms be present, they will be observed upon the first rise of temperature, by incessant sneezing, increased dryness, redness and swelling of the mucous membrane of the nose, followed by increased secretion. Epistaxis may occur, the throat feels dry and hot, the voice becomes husky, and soon the entire mucous surface of the larynx aud trachea and bronchial tubes are involved. Then follows a troublesome cough, usually more severe at night. At first the bronchial secretions are abundant, consisting of a thin, colorless mucus, which soon assumes a muco-purulent form. Should resolution not occur at this time, either capillary bronchitis or pneumonia results. I have observed no cases of pneumonia as resulting from influenza, and am therefore somewhat sceptical as to its occurrence.

I believe the condition which we observe is that of capillary bronchitis. When this supervenes, the dyspnoæ becomes greater, the respirations more accelerated, the pulse more feeble and rapid, the secretions more purulent, thick and tenacious, and more difficult of expectoration.

You have all witnessed the sight of a patient suffering from capillary bronchitis making violent and long continued efforts at coughing, and often when completely exhausted, you would see his efforts rewarded by spitting upon a napkin a small particle of putty like expectoration. I have noticed what appeared to me to be a diaphragmatic pleurisy, but have failed to observe pleurisy in any other location of the chest.

In mild cases, influenza reaches its height on the second or third day, when it begins to gradually subside. In graver cases, that is,

in those where the pulmonary complications are the marked feature, the convalescence does not begin before the tenth or twelfth day. In ordinary cases occurring in persons previously in health, the prognosis is not unfavorable; but, when it occurs in the young or very old, or where persons have been out of health, and especially where there has been a previous disease of the lungs, the majority of the cases prove fatal.

The treatment of influenza should in all cases begin by placing the patient in bed, and insisting upon his remaining there for not less than from ten days to two weeks. Absolute rest and quietude are the greatest factors in the management of the disease, and I believe that the majority of cases will tend to spontaneous recovery when treated in this manner.

When the headache is intense, I prefer antikamnia in five or six grain doses, repeated once in two or three hours. I also give calomel in small doses, say from one-twentieth or one-tenth of a grain once in about two hours, until five or six are taken. I treat the fever with rest and stimulants, but never with quinine. I believe that quinine produces increased cerebral congestion, and in several cases that I have seen, has caused acute delirium. After the febrile stage has passed, and when the patient is in need of tonics, I then administer quinine in one or two grain doses, three times daily.

Should the catarrhal symptoms supervene, they should be treated with inhalation of steam, dry, hot applications to the chest, and expectorants, avoiding opium in the early stages of the disease, especially should there be much dyspnoæ. Of the expectorants, ammonia and ipecac stand first. If there be much dyspnoe, with danger of suffocation, brandy and ammonia with valerian and the etherial tincture of lobelia must be freely used. Tartar emetic is contraindicated because of its depressing effect. In the later stages, if expectoration is profuse, senega, serpentaria with stimulants freely administered seem to be very useful. Counter irritation to the chest should be discouraged until the

chest symptoms begin to assume a chronic form.

When the cough

persists, and we feel it is doing injury as a mechanical agent to the lungs, it should be stopped. Conium and henbane should at first be resorted to, but should these fail, opium must be administered; either the substance of the drug or one of its derivatives, the best of which I believe to be the muriate of morphiæ. The heart should be continually watched, particularly in the aged and feeble. Should it show a disposition to failure, caffeine in one grain doses or inhalations of the nitrite of amyl should be resorted to. During convalescence, iron, quinine, arsenic and strychnia, the preparations of malt and cod liver oil should be given, together with a very nutritious diet, and the free use of beer and wine. Milk and Seltzer water should be given in large quantities.

Especial attention should be directed to the surface of the body. during convalescence, as the skin is very sensitive. It should be sponged daily with brandy and hot water, quickly and thoroughly dried, after which the body should be warmly clothed.

I shall not dwell upon the complications arising from influenza, as it would extend my paper beyond its latitude. Suffice it to say that they must be treated as independent conditions.

1

cases of apex catarrh. It will help a large proportion of cases of early phthisis, but in confirmed phthisis it does little good. In the dispensary, we give creasote in a solution of alcohol and glycerine. Our solution is made as follows: