have turpentine stupes applied to the back of the chest, especially on the left side.

There are so many cases of this malady in the hospital that, in one clinic, I could hardly exhaust them. But I will show you one more case, which is of great therapeutic interest.

Case 3. This man is twenty-six years of age, and has been in the hospital since December 26th. When admitted his temperature was 100°, pulse 88, and respiration 34 per minute. His eyes were injected and his tongue coated. His heart's action was weak, and there was noticed reduplication of the first sound and a faint systolic mitral murmur. The man was very weak. The lungs were normal, with the exception of a few mucous râles. His symptoms were those of such prostration that he was thought to be in the socalled typhoid condition, and the opinion was entertained that it might possibly be a case of latent typhoid fever. Indeed, he was so drowsy that we could not get any account of his illness, and this added much to the difficulty. Watching the man, we found that there was not the least evidence of typhoid fever. There were no spots, no diarrhoea, and the splenic dulness extended only slightly below the margin of the ribs. The peculiarity of this case is that while, almost from the beginning, the temperature has been between 98° and 99°, and the pulse extremely feeble, he was dull, his pupils somewhat dilated, and he was extremely delirious. He could not sleep at night, and the only sleep obtained was by the use of small doses of chloral. This, with the prostrated condition, suggested the possibility of typhoid fever. As his mental condition improved, it became clear that this was not the case. He told us that he had had symptoms of coryza, pain in the bones, and all the symptoms of the prevailing epidemic.

Let us see what his condition is to-day. He, too, has a weak first sound, but not so weak as in the preceding case. He has a compressible pulse, moderately weak. The lungs are clearer. He has had no cough since admission and the mind is clear. I think that this is an undoubted case of influenza.

What I desire particularly to call your attention to is the violent and persistent delirium which was present, and the manner in which it was relieved. When I first saw the man I was struck with the sluggish, dilated pupil; the feeble pulse and the extreme delirium, with a temperature which was normal or slightly subnormal. It at

once occurred to me that here was a case of delirium from inanition. This I have seen more than once at the end of an attack of typhoid fever, or any other depressing disorder interfering with nutrition, such as cancer of the stomach, where the brain is disturbed because it does not get a proper amount of stimulus of blood. I had the man placed on liberal supply of food given at short intervals and associated with stimulants, and in twenty-four hours the delirium had passed away. It was clearly a case of delirium from inanition. Do not misunderstand me. Do not suppose that this is a specific delirium. As I have said, I have seen this delirium in other typhoid conditions, using this term in a wide sense, as a result of the brain being illy supplied with its proper stimulation of blood. The man is now convalescent, and simply requires a chalybeate tonic. We shall give him 5 grains of tartrate of iron and potassium three times daily. The stimulation with a liberal supply of food will be continued.

Leaving these cases, I shall make some general remarks upon this disease, to which, for some absurd reason, we have applied the French name "la grippe," which means nothing so far as the disease is concerned. Influenza or catarrhal fever, as is illustrated by these cases and many others that I have lately seen, almost invariably begins acutely. Nearly all of the cases that I have met with started suddenly in persons previously in good health. One case came under my notice where a physician was so abruptly seized with pain in the back that he had to lie down on a bed, and with difficulty could leave the house. In other instances, not quite so marked, the severity of the pain in the back has been great and has been the first manifestation of the disease. The pain is often referred to the middle of the back in the dorsal region, and it is quite commonly observed that starting in this position it spreads downward into the legs. As described to me, the pain is at times sharp, with a dull pain persisting. The patient is never free from pain, which occasionally rises into acute exacerbations. While many of the cases begin with pain in the back, they soon have pain in the bones followed by headache and moderate fever, and then there are or are not catarrhal symptoms.

I have partly traced the development of the disease in these patients; let us now pay some attention to the character of the fever with which these painful sensations soon become associated. In the

majority of instances the fever is moderate and lasts about three or four days. The fever is at its height in from twenty-four to thirtysix hours; then it slowly subsides, and the temperature may go below normal. In one case it passed to 96°, and there was profuse sweating, something like a crisis taking place. During the period of highest temperature lasting thirty-six or possibly forty-eight hours, there is only the ordinary variation of about one degree between the morning and evening temperatures. There is really a slight continued fever, and not a fever with remissions and exacerbations as in malarial fever. As a rule, the temperature does not exceed 103°; but, by way of variety, I have in this epidemic encountered a few cases in which the temperature at the onset unexpectedly shot up to 105°, and the next day went down to about 100°, and then the case ran the ordinary course, terminating in recovery. In two of these cases bloody sputum or pure blood was at first expectorated.

With the fever we have the ordinary concomitants; high colored urine of a high specific gravity, without albumin. In one of the cases before you there is a trace of albumin in the urine, but as the man is of rather intemperate habits, it is a question whether it does not belong to the individual rather than to the disease.

Another peculiarity about the disease is the occurrence of catarrhal symptoms in the eyes and nose with cough, which is frequently laryngeal rather than bronchial. These catarrhal symptoms are, however, often absent. Some of the worst cases that I have seen have had no catarrhal symptoms whatever in the eyes, throat or anywhere else. When the catarrhal symptoms are present they are more apt to involve the eyes, nose, throat and larynx, than the bronchial tubes, although a fair proportion of cases have catarrhal bronchial râles, and some have even congestion of the lungs, as illustrated by the cases before you. In a few instances epistaxis comes on, and with the occurrence of high fever and debility you are irresistibly made to think of beginning typhoid.

One of the most singular features of the present epidemic is the prevalence of the nervous symptoms. As I have stated, I have passed through other epidemics of catarrhal fever, but this one seems to be stamped by the prominence of the nervous symptoms. These are shown by the violent headache, the severe pain all over the body, the pain in the spine travelling downward, and also by

what I have seen in quite a number of cases, hyperæsthesia or general sensitiveness of the surface. This is something more than what might be attributed to the efforts of coughing. Then, too, in some of the cases, there is delirium, not simply the delirium of inanition, as occurred in one of the cases before you, but a delirium with violent headache, this delirium sometimes taking strange forms. In one case, that of a most refined lady, who, when well, would hardly recognize an oath, when she became delirious from an attack of influenza, swore at her doctor every time he entered the room. I have been told of instances in which patients have lost their minds from the violence of the headache and the delirium. Besides the delirium there are in some cases convulsions. About a week ago I was called by Dr. Rosenthal to see a young man who, while in perfect health, was seized with violent headache, severe pain in the back, pain in the limbs, slight catarrhal symptoms, considerable congestion of the lungs, but no pneumonia. Almost from the onset he had spasms in the arms.

The spasms were most marked in the left arm, although the right was also affected. He was very restless and slightly delirious, but not markedly so. His temperature, almost from the beginning, was 97°. I found him with pupils somewhat dilated and head slightly rigid, and the presence of cerebro-spinal fever at once suggested itself; but further investigation showed that this was not the case. There was no eruption; the spasms were limited to the arms; there was congestion of the lungs; and, above all, there was no fever, the temperature remaining about 97°. The only thing that gave any relief from the spasms was chloral. Notwithstanding the fact that atropine and opium were used hypodermically this patient gradually sank under the violence of the disease. I know of one case in which paralysis of the lower extremities has followed influenza. It is slowly yielding and the patient will recover. This case had a marked history of a preceding attack of influenza. I know of several others in which convulsions occurred. The kind of cases I have just mentioned have probably given rise to the idea with some that cerebro-spinal fever and influenza are the same disease. The prostrating influence of the malady on the nervous system is also shown by the fact that patients often stagger on getting out of bed. A prominent lawyer whom I recently attended, thinking that, as he was compelled to remain in the house, it would be a good time to

get up his work, sent for his papers, but a few minutes' attempt cured him of this idea and he was glad to lie down. This debility remains for a long time and is often associated with considerable sweating. The pains often remain, and do not necessarily pass away on the subsidence of the rather short fever. In some cases profuse and persistent sweating is also very common during convalescence, and the patient looks anæmic and miserable. I have seen the kneejerk absent at the height of the malady, but in the majority it is preserved. Cramps in both calves and shoulders, as well as in the chest muscles, have been reported to me by a physician as happening after the febrile stage had passed.

The main complication of ordinary catarrhal fever is, as you know, pneumonia, or what is called pneumonia. Looking over the records of boards of health of different cities, it will be found that the deaths from pneumouia have nearly doubled. What is called pneumonia must therefore be set down as one of the chief complications. You notice that I say "what is called pneumonia." A great many of these cases are simply heavily congested lungs, with great debility, the lungs seeming to collapse. There does not seem to be a true process of pneumonic exudation. While in many cases there is slight dulness on percussion, yet it is not absolute, and the high-pitched bronchial breathing of croupous pneumonia is found in only a few instances. There is no consolidation. This has been the characteristic in most of the cases that we call pneumonia. It is probably proper to speak of these cases as pneumonia, but I want you to bear in mind the difference between this condition and ordinary croupous pneumonia.

Let me call attention to another peculiarity that I have noticed in a large number of instances. A great many persons when seized, and often during the height of the attack, complain of violent pain in the left side, but I have not found any friction sounds, save in one instance, and this may have been accidental. There is want of expansion of the lower part of the lung, usually on the left side, associated with this violent and persistent pain, which makes the patient think that he has pneumonia or some other grave condition of the lung.

We know nothing of the cause of this disease. It is epidemic, and I think myself that it is feebly contagious. It would be an admirable thing if some of our over-filled treasury could flow into