fails to control either temperature or nervous symptoms, tepid sponging should be tried before resorting to cold.

2. LOCAL APPLICATIONS.

The quilted pneumonia jacket was used in six cases with recovery, and in six cases with death. No reason is recorded in any instance for its use, and no benefit is noted as a result of its use in any case. In three cases it was removed because it hampered the movements of respiration. The jacket seems to have no advantage over a light woollen shirt, which opens along the side of the chest to permit ready examination.

Poultices have been used in a few instances. In many cases they are uncomfortable, and in nearly all instances they are a mechanical hindrance to respiration, as shown by an increased rate of respiration following their use.

Counter-irritation by means of the ice-bag or thin mustard paste is of value in the few cases in which pleuritic pain requires attention. Beyond the relief of pain they furnish a mechanical embarrassment to respiration.

3. MEASURES FOR THE RELIEF OF CARDIO-VASCULAR DISTRESS.

Bleeding was used in two cases of extreme cyanosis with dilated right heart. It was repeated in each case and was of value in relieving the immediate distress in each instance. Both cases, however, terminated fatally, because the mechanical cause of the cardiac distress persisted.

Strychnine and whiskey were used separately or together in 57 cases; five cases are recorded in which the use of strychnine was discontinued because of muscular twitchings, with cessation of twitching in each case.

Whiskey, on the other hand, is perhaps of greatest value, because of its action as a cerebral sedative, soothing the restlessness of the little sufferer after the manner of the "night cap" in the insomnia of old age, and so providing the mental quiet necessary to physical rest.

4. MEASURES DIRECTED TO THE RELIEF OF RESPIRATORY DISTRESS.

Some interference with the function of respiration, shown by cyanosis, increased respiratory rate, or shallow respiratory excursion, is, according to our records, much the most important indication for treatment.

Expectorants were used in nine cases with recovery and in thirteen cases with death. Four instances are recorded of their being discontinued because of gastric disturbance. No record is found of any benefit to be ascribed to their use.

Steam inhalations have proven of value only in those cases where laryngitis or tracheitis were a feature. So far, no apparatus for the administration of steam has been used here, which has not the disadvantage of interfering with the circulation of sufficient fresh air.

Belladonna or atropine was used in nine cases, as follows: In two cases in extremis; no result.

In one case of excessive secretion of mucus; no result.

In two cases as a respiratory stimulant; two cases report improvement, one case is negative.

In three cases as an antispasmodic in cough with a good result in each case.

Oxygen was used in nineteen cases, ten of which were fatal, while nine cases recovered. The results of its use are recorded as follows:

In two cases without effect.

In four cases it was administered in extremis without effect. In thirteen cases improvement is noted in the lessening of cyanosis and diminution of respiration rate.

In nine cases with recovery the severity of the cases is shown by the average maximum temperature, pulse, and respiration, viz: Average maximum temperature, 104; pulse, 163; respiration, 64.

These rates are above the average severity as shown by a comparison with the table above.

It appears therefore that of all the means used for the treatment of broncho-pneumonia in this hospital, none have been more uniformly useful than inhalation of oxygen. I believe that in broncho-pneumonia the greatest need of the little patient is a plentiful supply of oxygen, whether we consider his need from the standpoint of limiting the bacterial growth, mitigating the effect of the toxins, stimulating the individual immunity, guarding against cardiac disability, or preventing respiratory failure. Most other therapeutic measures may be safely neglected in order to provide a plentiful supply of fresh air, and when fresh air is inadequate inhalation of oxygen will save more lives than drugs or local applications.

Toronto, June S. 1908.

INFLUENZA AND ITS TREATMENT.

BY G. C. H. MEIER, M.D., NEW YORK CITY, NY.

Since the first severe epidemic of la grippe in the United States in 1889, which resulted in a large number of deaths, mostly due to pneumonia, there have been frequent repetitions, but it seems that the virulence of the disease has decreased or that a degree of tolerance has developed. The last occurrence during November and December, 1907, was especially mild; only in exceptional cases were acute nervous symptoms noted, and severe bronchitis, pneumonia and pleurisy were of comparatively rare occurrence.

As I have observed it, la grippe usually begins with slight chilly sensations, pain in the limbs or entire body and marked pain between the eyes. In most cases there is also present some coryza, with much sneezing and teasing, dry cough. The appetite is lost, the bowels are constipated, and there is a marked feeling of malaise and debility. The fever is usually characterized by slight fluctuation and rarely reaches a higher point than 103 F. when no complications are present.

A diagnostic feature is the marked prostration of the vital powers, even when the attack is of mild character. It generally takes the patient two to three weeks to recuperate, and often its exhausting effect persists for months. The complications and sequelae of la grippe, of which pneumonia is the most common and most serious, are numerous, and include inflammations of all the serous and mucous membranes of the body, constituting the chief risk in the debilitated, the aged, and those suffering from previous diseases.

In the chronic form a general neurasthenia, with mental depression, a peculiar irritability of temper, and sometimes hallucinations, is present.

In the treatment of this malady we know of no specific that will positively cut short the disease, but must rely on the indicated remedies, according to the existing symptoms. A solution of carbolic acid, 1 to 5 per cent., a teaspoonful every two hours, according to age, has been found to greatly modify the symptoms. Dr. Dessau treated 3,000 cases in this manner with satisfactory results. Oil of cassia (Ceylon) has been employed for 16 years by Dr. Ross in doses of 10 to 12 drops every two hours until the temperature becomes normal, and then three times a day for 3 days in 1-2 glass

ful of water; he claims exceedingly good results therefrom. I particularly insist, in all cases at the beginning of treatment, on a good calomel purge, usually 10 grains at a dose, placed dry on the tongue and washed down with a swallow of water. This need only rarely be followed by a saline cathartic, as usually it produces from 3 to 4 fluid stools within 6 to 8 hours after its administration. Cold applications to the head by means of ice-water cloths, renewed every 2 to 3 minutes for an hour at a time, are often very beneficial in lowering the temperature one or two degrees and in mitigating the headache. These applications are more certain to do this than an ice-bag, which in private practice is rarely retained on the patient's head long enough for the cold to penetrate to the deeper parts, and being usually placed on the top of the head the hair prevents in a great measure the cold from reaching the cerebral blood vessels. A thorough disinfection of the nasal and post-nasal spaces by douches or sprays will tend to arrest further infection from the bacilli lodged in these cavities. As the patient has little inclination for food, he should not be urged to take other nourishment than milk and seltzer or koumiss in small quantities for the thirst. Medication will be more effective, as in all acute diseases, when the digestive system is not overtaxed by broths, soups and other nourishment. After the bowels have been thoroughly emptied 10 to 15 grains of novaspirin every 3 hours will speedily modify the pain in the limbs and the headache, at the same time reducing the fever without producing depression. Although I have found that aspirin, when not given in excessive doses, was well tolerated by many patients, there were some who complained of gastric disturbances after its use. Since resorting to novaspirin I have encountered no instances of such an idiosyncrasy. The drug, however, has a somewhat milder analgesic power than aspirin, and in neuralgic cases it is necessary to use it in larger doses, and these in my experience were always well tolerated by the stomach. Its beneficial effect in influenza is seen by a rapid lowering of the temperature and an alleviation or disappearance of the pains between the eyes and in the limbs, which as a rule are such a disturbing symptom of la grippe. The disagreeable sweating which occasionally follows the taking of large doses of aspirin in some persons is not observed under the use of novaspirin. Its action on the heart also seems to be nil. Thus, it seems to me, that we have in novaspirin a remedy which combines with the good qualities of aspirin a lack of some of the disadvantages of the latter.

I report here a few cases of influenza occurring in my practice illustrating my present mode of treatment.

Case 1. G. M., aged 18, a school girl, was taken with slight chilly sensations and some headache and malaise on November 19th, 1907. Temperature 102; pulse 120; slight nausea. The patient was put to bed; 10 grains of calomel were administered, cold cloths were ordered to be applied to the forehead and changed every few minutes for an hour at a time. No food to be taken. November 20. Had vomited once during the night, quite restless, little sleep; now complains of pain in the limbs and back. Temperature 101 1-2; pulse 118. Bowels had moved three times toward morning. Ordered novaspirin, grains 15, every two hours, until more comfortable, then every three hours. Cold cloths to the head continued. November 21. Temperature 100; pulse 105. Slept several hours during the night; pain in the limbs greatly diminished and headache gone. The dose of novaspirin was reduced to 10 grains three times a day for another week, when patient was put on triple arsenates for a week. Recovery uneventful.

Case 2. D. P., aged 32, stock broker, was seized on November 15th with an attack of sneezing, coryza, and a severe pain between the eyes. Had chilly sensations and a dry, teasing cough. Complains of general malaise and pains in the limbs and back. Temperature 103; pulse 120. He was ordered to bed and given a nasal douche (Seiler's tablets) to be used every 3 hours. A dose of calomel, grains 10, was administered dry on the tongue. The cough was treated with codein, grain 1-4, every 2 hours. November 16. Cough somewhat better, nose more comfortable, but patient complains greatly of pain in his limbs and of severe headache. Bowels had moved twice. I now ordered novaspirin, grains 20, every 2 hours. No food, except milk and seltzer for thirst. November 17. Temperature 100; pulse 100. Pains greatly relieved; cough looser and less troublesome. Continued novaspirin, grains 10, every three hours. November 19. Temperature 99; pulse 100. Had some sleep during the night. Feels quite comfortable, but very weak. I prescribed syr. hypoph. co., a teaspoonful in a goblet of cold water, 3 times daily, before meals, and novaspirin twice a day; also ordered a laxative. November 21. Appetite returning, had a good night. Discontinued novaspirin.

Case 3. H. F., aged 45, housewife, was seized with vomiting. during the night, chilly sensations and pain all over the body, also some headache. Temperature 102; pulse 110. Prescribed the usual dose of calomel and also novaspirin, grains 10, every 2 hours. No food. Mustard leaf to pit of stomach and cold to the head. December 17. Bowels moved once only. Ordered a dose of Rochelle salts. Pain in body much better, though some aching is still pres