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"What a boon it would be to the Med

ALE AND BEEF ical Profession if some reliable Chemist

would bring out an Extract of Malt in combination with a well-digested or peptonized Beef, giving us the elements of Beef and the stimulating and nutritious

MUSCLE portions of Ale."

DR. J. N. LOVE, St. Louis, says:-Since the product has been brought under my notice I have prescribed it in the sick room to one hundred recorded cases. Patients who have suffered from loss of flesh, dependent upon various forms of Dyspepsia, when they partook of the Ale and Beef, "Peptonized," felt much benefited. I have now under my observation three patients, the victims of the dread disease pulmonary consumption, in which the digestive tract is demoralized, and in which it seems impossible to bring to bear any form of nutrition which is not disgusting to the patient. In all these cases the drink is a Godsend. A number suffering from prostration, following serious attacks of the recent epidemic of La Grippe accompanied by loss of appetite and a general feeling of worthlessness, were braced up and greatly benefited immediately after commencing the use of the Ale and Beef, "Peptonized." In half a dozen cases of typhoid fever, in which everything else was distasteful to the patient, the Ale and Beef, "Peptonized," pleased the palate, and nourished and strengthened the patient admirably.

I feel personally under obligations to those who have presented so valuable a product to the medical profession, and many a tired and faded patient will be revived and strengthened by the life-giving drink, Ale and Beef, "Peptonized," which is a happy union, in that it contains mildly stimulating (alcohol in small quantity), gently tonic (a modicum of the active principle of hops), decidedly nutrient (malt and beef) and positive digestive (diastase and peptonoids) propertiesa union which is in harmony with well-known physiological principles, and will in my judgment be indorsed by careful bedside clinicians.

DR. W. F. HUTCHINSON, Providence, R. I., says:-I have used Ale and Beef, "Peptonized," very freely during the past few months and am delighted with the effect obtained. One case was that of a hopeless paralytic, unable to retain any food and steadily failing, for whom I ordered one bottle daily. Her stomach never rejected it and has steadily gained since she commenced using it.

PROF G. A. LEIBIG says:

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DEAR SIRS:-Answering yours of the 8th inst., will say that I have used the Ale and Beef, "Peptonized," in both hospital and private practice, and am much pleased with it. My house surgeons (Drs. F. R. Smiley and Geo. F. Hamel) inform me that it agrees with the stomach in cases where food can not be retained, and this agrees with my own experience. I had one case of a delicate lady with a forming pelvic abscess which involved the ovary. There was constant vomiting and retching. She retained the Ale and Beef, "Peptonized." This, after I had tried a number of things which had failed. She drank it steadily for a month, and it seemed to be, in her case, food, medicine and stimulant, all in one. It is an excellent thing. Keep up the good quality of the preparation and it will readily Very respectfully, WILLIS P. KING, M.D., Ass't Chief Surgeon, Mo. P. Ry.

sell.

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"A careful chemical examination of the Peptonized Ale and Beef shows a much larger per cent. of nitrogenous blood and muscle-making matter over all other malt extracts, and that it is also rich in

Diastase, giving it the power to digest BLOOD MUSCLE

Starch Foods."

PREPARED BY THE ALE BEEF COMPANY, DAYTON, O., U.S.A.

Two full-sized bottles will be sent FREE to any physician who will pay

express charges.

In Corresponding with Advertisers, please mention THE LANCET-CLINIC.

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Original Articles.

NERVOUS AND MENTAL COM.

PLICATIONS OF
LA GRIPPE.

WITH REPORT OF CASES.

Whole Volume LXVII.

ordinary cases of influenza, and, in some epidemics, constitute their most characteristic features. Most prominent of such symptoms are: headache, chiefly frontal; pains, aching or shooting in character, in the back, calves, thighs, arms, eyes, etc., these pains being sometimes almost excruciating, sometimes attended by hyperesthesia;

A Paper read before the Academy of Medi- sleeplessness; and a sense of complete

cine, December 21, 1891,

BY

PHILIP ZENNER, A.M., M.D.,

CINCINNATI.

That nervous disturbances of various kinds may occur with infectious diseases is well known. Those attendant upon or subsequent to typhoid fever and diphtheria are most familiar. Recent experience has shown us that such dis turbances are frequently found with influenza. In fact, historical research has revealed that the visitations of this pandemic disease have always been marked by the attending nervous complications. Kirn, (') who has made a careful study of historical and recent epidemics, states that no other acute infectious disease has so frequently nervous symptoms; and Althaus (2) says that, as an etiological factor of all kinds and forms of nervous disease, influenza stands facile princips among all infectious diseases.

Doubtless the frequency of such symptoms is due to the almost univeral spread of the disease, and to its occurrence in individuals specially predisposed to nervous troubles, a subject of which we will have occasion to speak more fully hereafter.

Nervous symptoms are common in

1 Sammlung klin. Vorträge, Neue Folge, No. 23.

2 Boston Med. and Surg. Jour., December 10, 1891.

prostration, mental and physical. As symptoms of the same order, but occurring less commonly, may be mentioned: vertigo, peræsthesia of various kinds, and neuralgia, especially supra-orbital. The frequency and severity of these symptoms vary in different epidemics and different localities. Of 140 cases of influenza in the Morning Side Asylum a sense of prostration was present in 93 per cent.; frontal headache in 88 per cent.; pains in the back and limbs in 84 per cent.; vertigo in 81 per cent.; unrefreshing sleep in 59 per cent.

Most of these symptoms may occur in the invasion or during the febrile period of the disease. Others, notably the neuralgias, occur more frequently in the post-febrile period, while the feeling of fatigue and incapacity to do may linger several weeks after the acute disease has passed away.

But many nervous symptoms appear which are not so common, even very rare, so that they are not so well known as those just mentioned. Sometimes there are symptoms indicating irritation of the brain or meninges: hyperæsthesia of the special senses; in children, convulsions; in adults a tendency to stupor or somnolency, or other mental symptoms of which we will speak farther on.

It would occupy too much space to mention all the nervous manifestations which have been noted as complications

The post-febrile psychoses may begin a few days or a few weeks after the fever has subsided.

or sequellæ of influenza. I will merely | have passed away, and may pass into mention some of the more prominent. the form of post-febrile insanity. As inflammatory complications we may Usually there is partial or complete note: cerebral and spinal meningitis, amnesia of the attack. myelitis, polioencephalitis, poliomyeli tis, multiple neuritis and optic neuritis. As paralytic manifestations: hemiplegia, aphasia, paralysis of the muscles of the Kirn, () who collected seventy-one eyes, of the soft palate and other mono- cases of mental disease occurring with plegias, and optic atrophy. As general influenza, divides the post-febrile psynervous disturbances: angina pectoris, choses into four groups: The first, acute glycosuria, Graves' disease, epilepsy asthenic form, of rapid development, and chorea. Of many of these diseases with many hallucinations, rapid speech only single instances have been re- and movements, anxious, sometimes corded; none of them are common com- exalted mood, and general weakness plications. Much more commonly hys- and anæmia. The second, melancholia, terical disturbances are observed, and either simple, or combined with hypostill more frequently some forms of chondriasis. The third, mania. neurasthenia. The latter are dis- fourth, pseudo-influenza psychoses, tinguished by their mental cast, a feel- cases of general paralysis, paring of incapacity in thought and action, anoia, alcoholic delirium, etc., where a tendency to melancholia and hypo- the disease probably developed indechondriasis, which may run into well-dependently of the influenza, and the marked insanity. This leads us to the consideration of the mental disorders which complicate influenza.

The psychic symptoms, on account of the varied pictures presented, furnish a more complex subject for study, and are more difficult of classification and definition. They may occur during the febrile period of the disease, or in the post-febrile or convalescent stage. Mental symptoms may even occur with the invasion of the disease. Pick (3) reported a case beginning with violent delirium, which disappeared on the second day, when the symptoms of influenza became manifest.

The mental symptoms of the febrile period are more likely to appear on the second or third day of the disease. They are mostly like those of the ordinary delirium of fever, a semiconscious, dream-like state, and a sense of restlessness, indicated by tossing about, screaming, singing, etc. There is usually disturbed sleep, and often the indications of hallucinations and delusions, and perhaps, of an anxious, depressed mental state. The delirium may be only of a few hours or a few days' duration, but frequently it lasts a few weeks after all other symptoms

3 Neurolog. Centralblatt, 1890, p. 100.

The

relation to the latter was only apparent. He places 14 per cent. of his cases in the first group, 30 in the second, and 7 in the third.

Introsinski (5) collected 124 cases. According to his classification, 28 of these were cases of acute delirium, 38 melancholia, 15 delirium tremens, and 15 mania.

It is readily seen from these figures that the predominant form of these post febrile psychoses is melancholia. This mental type is present even in the neurasthenic cases. The mental and physical exhaustion and insomnia, so commonly found with and after attacks of influenza, perhaps aid the development of this special type of mental disease.

But classifications of the kind indi cated are only partly accurate. The cases represent all gradations of the diseases mentioned and many cannot be properly classified with any of them. Cases in which, on account of the blunted condition of consciousness, or the presence of many hallucinations, a state of mental confusion is the prominent one, or those presenting the ordinary features of febrile delirium, occur

Loc. cit.

5 Neurolog. Centralblatt, 1891, p. 119.

not uncommonly, and, in general, are | of shorter duration than those where the anxious mood, settled melancholy and quiet demeanor indicate the presence of pronounced melancholia, or where the cheerful mood, exalted manner, quick speech and action reveal well-marked

mania.

We must now devote ourselves to a brief study of the pathogenesis of these nervous manifestations. Among the assigned causes for the mental symptoms of infectious fevers are hightened temperature, increased oxydation from the more rapid flow of blood, and the effects of visceral diseases: for instance, uremia with renal disease; impeded circulation, and, perhaps, oedema of the brain with heart or lung disease, and the possibility of embolism with the former, or disturbed oxygenation of the blood with the latter. As causes of the post-febrile nervous disturbances may be mentioned, the increase of waste products in the blood, anemia of the brain and impaired nutrition from prolonged and exhausting fever, oedema,

etc.

Such factors may account, in large part, for the febrile and post-febrile. nervous manifestations of most infectious fevers, but, probably, play a rather unimportant rôle in influenza, where the fever is, usually, neither high nor of long duration. Here we must seek for a cause in the direct intoxicating effect of the poison of the disease. Just what that poison is we do not know, though, not improbably, it is a chemical product allied to the ptomaines. For the early symptoms, severe headache, pains in the muscles, great physical and mental prostration, and the invasion of delirium we can scarcely find any other explanation. To an even higher degree this seems to be

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play-the presence of a predisposition to nervous disorder. The same is largely true of the post-febrile disturbances of other infectious fevers, notably typhoid. Kirn examined the histories of 72 cases of influenzal psychoses, and found in 22 cases of febrile psychoses only 5 with a predisposition to nervous disease, while of 50 post-febrile cases, 37 had such a predisposition. This predisposition was either hereditary or congenital, or acquired as the result of head injuries in childhood, chronic diseases, anæmia, or the like.

So we may conclude, the chief cause of the febrile manifestations is what Kirn terms the toxin of influenza; of the post-febrile manifestations a prior constitutional condition. In the latter instance, the toxin is the less important factor, but it still acts as the exciting cause, so that in its absence the disease might never have appeared. The special form of the nervous disease is doubtless shaped by the constitutional condition. What has just been said of the etiology of the mental symptoms holds good for the other nervous disturbances.

The prognosis of the nervous manifestations is generally favorable. The febrile delirium may be only of a few hours' duration, occasionally lasts a few weeks, and very rarely runs a chronic course. The post-febrile psychoses may be of only one or two weeks' duration, or even shorter, but have an average duration of six or eight weeks, and sometimes continue for months. Rarely cases do not manifest any tendency to recovery. Occasionally a fatal termination ensues from exhaustion. Suicide sometimes abruptly terminates the clinical history.

In the non-mental cases the prognosis is also generally favorable, though the duration is quite variable. Some cases, especially those with inflammatory diseases of the nervous centres, terminate fatally.

The field gone over in this paper is so large that it will be impossible to say everything satisfactorily on the subject of treatment. In general it may be said that a building up treatment is frequently called for, especially in the

post-febrile cases. Helweg (") speaks of]
antifebrin as beneficial in both the L. Dine, of Minster, O.:
nervous and mental complications of
influenza.

For the history I am indebted to Dr. C.

A few words on the effects of la grippe on those already suffering with nervous diseases. A very few cases have been reported as favorably influenced. Metz (') reports a case of paranoia or chronic delusional insanity, which was entirely cured by an attack of influenza, and Helweg (8) reports two cases of dementia, one improved, the other cured. The latter author found hyperæmia of the brain in a number of autopsies of influenza cases, and he supposes this condition-hyperæmialead to a cure where there had, previously, been too little blood in the brain. I can find no other reports of favorable effects of this disease. On the other hand, there are many reports of injuries, even disastrous effects, and this is not only true of cases of insanity, but also in some instances of neurasthenia, myelitis, locomotor ataxia, etc. Nevertheless, in most instances, for example as observed in insane asylums, influenza had little or no effect on the existing nervous disease.

REPORT OF CASES.

I wish, in conclusion, to add the report of a few cases. I have selected such as appear to me most interesting, and which represent different types of disease. But as almost all the cases seen by me were those that ran a chronic course, they represent, rather the class of cases which fall into the hand of the specialist than those most commonly seen by the general practitioner.

For the sake of brevity I will only report so much of each case as to make the constitutional condition and the character of the nervous disturbance easily discernible.

Extensive paralysis has been very rarely seen after influenza. I shall, therefore, first report a case of this kind, though I was only consulted by letter and did not see the patient in person.

6 Neurolog. Centralblatt, 1890, p. 746.
7 Loc. cit., p. 764.
8 Loc. cit.

Mrs. M., aged fifty-two, usually in excellent health, was attacked with la grippe in February, 1890. She did not entirely recover from the disease, a cough and weakness and tired feeling remaining, but, apparently, some months elapsed before distinct nervous symptoms were manifested. Then the weakness and tired feeling increased in degree, and a sense of numbness, beginning in the toes, extended slowly up the extremities, involving the latter entirely and reaching as far as the lumbar region on the back. At a later period the hands and arms also became involved. Her strength diminished so that she could walk very little, and became finally bedridden. The cutaneous sensibility was blunted, so that light contact with the skin was not perceived, and only firm pressure was felt. Muscular sense was also impaired, so that she was sometimes not aware of the position of the limbs. Either on account of ataxia or loss of sensibility she would stagger in walking, and sometimes drop her needle while sewing. The electrical muscular contractility was not lost, but appeared to be more difficult to obtain over the affected, than over the unaffected, parts. The knee jerks seemed excessive. The bladder and rectum performed their functions well. The pupils, vision, in fact all the cranial nerves, were, so far as known, normal.

Her condition got gradually worse. The last two months of her life she suffered with spasmodic contractions of the muscles and severe pains in the feet and legs, and these parts became very oedematous. Bed sores developed and she died of exhaustion in November,

1891.

It is difficult to determine from the symptoms whether we have here a multiple neuritis or myelitis. The predominence of the sensory symptoms and the course of the disease inclines me to a diagnoses of the latter disease.

The next case I shall report is of the type most commonly seen by the specialist as the sequela of influenza. one of neurasthenia :

Mrs. H., aged forty.

It is

Several mem

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