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 PAPERS ON THE EPIDEMIC OF INFLUENZA 
 FROM 1889 TO 1892: 
 
 RELATION BETWEEN INFLUENZA AND CATARRHAL FEVER. 
 
 THE EPIDEMIC AS SEEN IN PHILADELPHIA FROM 1889 TO 1891. 
 
 THE TREATMENT OF INFLUENZA AND ITS SEQUELS. 
 
 THE HEART AS INFLUENCED BY THE EPIDEMIC: WITH 
 OTHER NOTES. 
 
 iSTOTES ON THE OUTBREAK OF INFLUENZA AND ITS TREAT- 
 MENT DURING THE FALL AND EARLY WINTER OF 1891. 
 
 BY 
 ROLAND G. CURTIN, A.M., M.D., Ph.D., 
 
 LECTURER ON PHYSICAL DIAGNOSIS, UNIVERSITY OF PENNSYLVANIA; CONSULTING PHYSICIAN TO 
 
 RUSH HOSPITAL FOR CONSUMPTIVES, AND ST. TIMOTHY'S HOSPITAL; VISITING PHYSICIAN 
 ; TO PHILADELPHIA AND PRESBYTERIAN HOSPITALS; MEMBER OF THE AMERICAN 
 
 CLIMATOLOGICAL ASSOCIATION, COLLEGE OF PHYSICIANS, ETC.; 
 
 AND 
 
 EDWARD W. WATSON, M.D., 
 
 ilEMBER OP AMERICAN CLIMATOLOGICAL ASSOCIATION; VISITING PHYSICIAN TO THE HOME FOU 
 
 CONSUMPTIVES, AND PENNSYLVANIA INSTITUTION FOR THE BLIND: MEMBER OF 
 
 COLLEGE OF PHYSICIANS, OBSTETRICAL SOCIETY, ETC. 
 
 PHILADELPHIA 
 
 1892. 
 
[Reprinted from THE CLIMATOLOGIST, February, 1892.] 
 
 c ■ 
 
 EPIDEMIOLOGY OF INFLUENZA AND ITS EELA- 
 TIONS TO CATAEEHAL FEVEE. 1 
 
 ByROLAND G. CURTIN, M.D., and EDWARD W.WATSON, M.D., 
 
 PHILADELPHIA. 
 
 The influenza of 1889 and 1890 presents to the medical in- 
 quirer several problems of extreme interest; and, in studying its 
 climatological relations, these necessarily rise into prominence. 
 Whatever may have been its course elsewhere, the first question 
 of importance from our local standpoint must be, When did it 
 first begin in Philadelphia ? Now, to this, almost a universally 
 unanimous answer may be expected, if we inquire of current 
 medical literature and the daily press. All speak in the same 
 voice; all answer, in the late fall and early winter of 1889 ; but 
 we imagine that further thought and a little investigation will 
 somewhat modify this. 
 
 From the summer of 1888 there undoubtedly prevailed in 
 Philadelphia — to go no further than our own immediate locality — 
 a distinct, unique, hitherto unknown catarrhal affection, a fever 
 which seems, so far as medical reports go, to have passed unob- 
 served. Often of long course, characterized by localized but pe- 
 culiar catarrhs of various organs, it became lost in the old nomen- 
 clature of well-recognized diseases. As pulmonary catarrh, it 
 became to the dull-eyed medical attendant only the catarrhal 
 pneumonia known to him of old ; yet he wondered to himself 
 why so often, with the disappearance of all physical signs in 
 the lungs, the fever and the great prostration still persisted. 
 As catarrh of the liver it furnished him with peculiar cases of 
 bilious fever and catarrhal hepatitis, and in the kidneys and 
 bladder he promptly gave it the old names, ticketed it, and men- 
 tally pigeon-holed it in the old receptacles. As a continued fever 
 with abdominal pain, dulness and sometimes diarrhoea, typhoid 
 
 1 Read before the American Climatological Association at Washington, 
 September, 1891. 
 
seemed to him a happy diagnosis; and when that mysterious 
 gland, the pancreas, was sore and painful and all digestion seemed 
 arrested, all capability of taking food gone, visions of abdominal 
 cancer obscured his otherwise serene miud, and the case as it 
 slowly recovered seemed emerging from the jaws of death through 
 his brilliant ministrations. 
 
 When, however, we study this complete disorder, which to 
 the careful observer was wide-spread and prevailed almost 
 throughout the year, we are forced by relentless logic to con- 
 fess that between it and the influenza of the two succeeding 
 years, there was absolutely no difference other than that which 
 is constantly to be met with between the explosive epidemic and 
 the same disorder, less prevalent, endemic, and feebly feeling its 
 way preparatory to a general onslaught on the community. A 
 familiar instance of this may be met with in the difference between 
 sporadic and epidemic cases of cerebro-spinal meningitis. It is 
 also strongly corroborative of this that, in the past year and the 
 late winter, influenza, unlike its history of the preceding year, has 
 tended more and more to return to that form in which it com- 
 menced, and has presented many cases undistinguishable from 
 those before mentioned as occurring in 1888 and its winter, which 
 for want of a better name we must term the " Catarrhal Fever." 
 For a catarrhal fever is well known, has for many years possessed 
 a name and place in text-books, and a study of its symptoms and 
 history as therein described will convince the reader that it is but 
 a feeble imitation and copy of the disorder to which we have 
 alluded as new to the experience of the practitioners of to-day. 
 Yet in the past influenza has acquired the name from the experi- 
 ence of previous epidemics of " Epidemic Catarrhal Fever." 
 
 The first distinct cases of this catarrhal fever were seen by the 
 writers in 1888, in the summer and early fall. They were brought 
 to the city by the returning tide of summer absentees, and were 
 probably contracted at the seashore (the catarrhal region), and at 
 resorts on river sides. Some had so travelled from place to place 
 that it was impossible to locate any actual reception of the disease 
 in any particular locality, but the cases seen were at first all among 
 those who had recently travelled. 
 
 As the warm wet autumn of 1888 progressed, many more cases 
 
appeared. So far as the writers are aware, these were to a large 
 extent among the well-to-do class of the community, but many 
 had not left the city for years. It would have been of interest 
 in this connection to have traced up any possible communication 
 between these and the earlier cases, but this was not done at the 
 time, and later was for obvious reasons impossible. The only ob- 
 servation bearing on the point was in regard to the first case seen 
 in the latter part of August. This patient had remained in Jack- 
 sonville, Florida, until quite late (in the yellow fever year), had 
 then returned to the city, and had subsequently visited the 
 Atlantic coast — Cape May and Atlantic City, and then the 
 Delaware Water Gap, at which latter place she was taken sick 
 and brought back to Philadelphia on August 23d. The case was 
 characterized by hepatic catarrh and some jaundice, urticaria, 
 gastric catarrh, pulmonary catarrh of the peculiar character so 
 well known afterwards in connection with influenza, catarrh of 
 the kidneys and bladder with retention of urine (a very signifi- 
 cant symptom), and the characteristic delirium. After a pro- 
 tracted recovery, which was complete by about October 1 5th 
 [nearly two months], five cases occurred in the square in which 
 this patient resided — all on the same side of the street, and grouped 
 on either side of the house occupied by this lady. The cases were 
 very similar in general character, and in two instances proved 
 fatal, these two being over eighty years of age, and unacquainted 
 with the first case, and had neither of them been out of town for 
 years. This pointed to contagion. An investigation of the after his- 
 tory of the cases of 1888 and 1889, shows that they escaped almost 
 entirely any attack of influenza. Often they alone of whole 
 families in which they lived so escaped, leading us to surmise that 
 the early catarrhal fever was the complete disease, and left on 
 recovery no vulnerable, because no unaffected, organs. A still 
 further observation bearing upon this point is that an investiga- 
 tion of cases of influenza occurring in two succeeding years in the 
 same individual, shows that rarely if ever has the second attack 
 affected exactly the same group of structures as the first. In the 
 numerous cases where many relapses, so-called, occurred, each 
 relapse was a distinct new attack of a new internal organ or sys- 
 tem, or of distinctly new tissues of the organ previously affected. 
 
This was especially noticed of the lungs, and held true wherever 
 a clear account of all the attacks could be obtained. 
 
 In regard to atmospheric causes, we may say that neither heat 
 nor cold in themselves aggravated the disease or the liability to 
 attacks. Changes certainly did, if accompanied by a damp atmo- 
 sphere. East and northeast winds and storms caused the sick list 
 to augment, while sudden dry heat and dry cold caused respec- 
 tively an arrest of the epidemic, and its subsidence. This was 
 true unless there was reckless exposure in an exhausted condition 
 of the nervous system. 
 
 Where did the epidemic originate? Early rumor said in 
 Russia — yet more thorough investigation located it in China; 
 but if we take the case of Russia, where the first cases were said 
 to have been observed in October, 1889, we shall find that in 
 Spain, France, Germany, and in the United States it also was 
 said to have appeared as early, and, as we have pretty well proved 
 above, it existed here for a year or more before that, in this 
 peculiar febrile form. 
 
 A somewhat cursory inquiry has convinced the writers that at 
 least through the Eastern States it was quite common in North 
 America, and as commonly misunderstood. On the continent of 
 Europe something of the same sort seems to have prevailed in 
 France and Germany, and along the shores of the Mediterranean. 
 Especially was it noticed at Malta, where under the name of 
 Malta Fever it received an investigation and report from a par- 
 liamentary committee, being supposed to be an outbreak of the 
 enteric fever prevalent there before certain sanitary work was 
 completed. A perusal of the symptoms and course of this fever, 
 as given in the report alluded to, served to show that it coincided 
 closely with the disorder under notice. We would suggest that 
 thorough and concerted investigation would prove that catarrhal 
 fever occurred in many parts of the world during the spring, 
 summer, and fall of 1888, if not earlier. A very slight com- 
 parison reveals that the influenza of the succeeding year resembled 
 very closely the catarrhal fever we have described — so closely in 
 fact that on comparison the conviction is inevitable that they are 
 one and the same disease, one in the sporadic form, the other 
 epidemic — and, in searching for causes, what more probable than 
 
that the one is the outgrowth of the other ; that a year of mild 
 wet weather in winter allowed the disease to slowly disseminate ; 
 and that, leaving its germs behind it, the succeeding mild and 
 wet summer, fall, and winter allowed them to increase and mature 
 to gigantic proportions? It is impossible to believe that influenza 
 travelled here from abroad after its reported outbreak in Russia 
 and Germany. The Russian authorities report it as spreading in 
 Russia from St. Petersburg, both west and east, from about 
 October 15, 1889. 
 
 In Germany many observers are sure that they frequently met 
 with cases in October. In France and in America the same 
 observation was made. To go no further than the writers' ob- 
 servations, cases were certainly seen, and in considerable numbers, 
 presenting all the marked features of the disease from September 
 1, 1889, onward. Groups of cases, in which the disease ran 
 through whole families, occurred through October and November; 
 and by November, when the press was announcing its spread in 
 Europe and threatening its advent among us, many practitioners 
 found their work already doubled or trebled with cases which 
 corresponded exactly in every minute particular with what after- 
 wards came to be called influenza or " La Grippe." 
 
 Now why, the curious inquirer will ask, did the disease spring 
 into notice so suddenly ? Probably because all over the civilized 
 world the weeks preceding Christmas and the Christmas holidays 
 are marked seasons for crowds to congregate, purchasing, visiting, 
 and attending entertainments, and because the warm and moist 
 atmosphere was universally present throughout the civilized 
 world. It filled the Atlantic with fogs from excessive ice, pre- 
 vailed all over Western Europe and Eastern America, and was 
 evidently the result of changed terrestrial climatic conditions, em- 
 bracing at least three years. It was because the poison was 
 already everywhere, and the bringing together of great numbers 
 of people in contact with cases already suffering, and under con- 
 ditions of moisture and crowding, accounts for its rapid outburst ; 
 and we have sufficient evidence during the last two years that it 
 can lurk in the system, in a latent condition, only requiring 
 proper conditions to develop it. 
 
 Viewed in this light, influenza is shorn of its mysterious 
 
6 
 
 and awesome characteristics, and may be conceived of as an 
 obscure disease spreading slowly over the world, lurking in the 
 guise of other affections, or as developed originally in many 
 places at once from causes brought into activity by wide-spread 
 climatic conditions. Had the summer of 1889 been dry with 
 hot high Minds, had the autumn set in with early and sharp 
 frosts, the disease might have disappeared entirely ; for, whether 
 of local origin in each place or imported from afar, when devel- 
 oped it shows strong evidence of being contagious, either directly 
 or indirectly. Either the contagion is so far-reaching as to be 
 untraceable, or it occurs in some common but unsuspected way, 
 as in cholera or typhoid, or it is a contagion or infection to which 
 the individual exposed is everywhere non-resistant and excess- 
 ively sensitive. We confess that its progress in some respects 
 resembles yellow fever and dengue — diseases which extend from 
 place to person rather than from person to place — but other facts 
 militate against this view. 
 
 Hence the fact of the outbreak of influenza among comfortable 
 classes, these being more brought together than the abject poor at 
 the beginning of the holidav season. In this it would but follow 
 the laws of epidemic outbreaks — as illustrated so vividly in 
 cholera, for cholera undoubtedly exists before the annual gathering 
 of pilgrims at Mecca, the gathering of crowds and the consequent 
 unhygienic conditions fermenting and spreading the poison. If, 
 however, we should desire to trace the epidemic of influenza a 
 little further, and ask from whence it was brought to Russia and 
 Europe, perhaps some light may be gained from a study of 
 Australian medical journals. From these we learn that there was 
 prevailing in 1884 and 1885 in the winter season, which occurs 
 during our summer, a wide-spread and serious epidemic of in- 
 fluenza, presenting (as shown in a careful study of the disease by 
 an Australian physician, which was published early in 1889, be- 
 fore our epidemic was under way) all the symptoms with which 
 we are now so familiar. It appeared in the cold wet season of 
 1884 and 1885, 1886, 1887, 1888, and 1889, and was at the date 
 of the reading of the papers still in existence. Doubts on the 
 subject of identity between the Australian and European epidemics 
 will be entirely dissipated in reading the papers to which we 
 
allude. In " Notes on Typhoid Fever," by G. W. Spring-Thorpe, 
 M.A., M.D., M.R.C.P., London, the discriminative diagnosis be- 
 tween catarrhal fever and typhoid is carefully drawn. Another 
 paper on " The Nervous Substratum of Influenza," by the same 
 writer, both of these being published in the Transactions of the 
 Intercolonial Medical Congress of Australasia, were read at the 
 meeting held January, 1889, and published in the same year, at 
 least eight or ten months before its advent here. From the ex- 
 perience of Australia, as narrated in these articles, we should 
 strongly incline to the opinion that we are yet to have another 
 year or two of the present epidemic, and that another winter will 
 witness some further modifications of its symptoms. Just as the 
 catarrhal fever characterized its first unnoticed year, as the ful- 
 minat type characterized the second, and the nervous and abdo- 
 minal cases predominated in the third, so should we expect in the 
 fourth winter to witness a preponderance of cases characterized by 
 throat symptoms, easily confounded with diphtheria, but with 
 softer and more superficial exudation, or a mingling of these cases 
 with those exhibiting cerebro-spinal symptoms. We say this be- 
 cause in Australian experience the kind of cases which have 
 manifested themselves in the late spring have predominated in the 
 succeeding winter, and we have yet to experience many cases of 
 the two types we anticipate, although there they have occurred. 
 
 Catarrhal fever often seems to have been noticed in past times 
 as a precursor of influenza. An investigation of the literature of 
 past epidemics discloses the observation that catarrhal complaints 
 were frequent for a good while previous to its general onset. 
 From this very fact influenza was called " Epidemic Catarrhal 
 Fever." Stagnation of the atmosphere, absence of winds, preva- 
 lence of damp and warm winds, fogs (in Australia the common 
 name for influenza is " Fog Fever"), continuous rains, all these 
 have been noted, and the interesting question arises, Have these 
 epidemics coincided with two consecutive warm, wet years ? A 
 careful study of what meteorological records the past has left us 
 might throw some light upon the subject. There is, however, 
 reason for thinking that other local epidemics of influenza have 
 occurred after just such local climatic conditions. In the present 
 instance an extremely wide-spread area of epidemic would demand 
 
an equally wide-spread climatic alteration, the cause of which must 
 be looked for in the extreme north or south. 
 
 A brief description of the salient points in this catarrhal fever 
 is as follows : — 
 
 The disease began insidiously as a rule, but sometimes, after 
 unusual exposure, there was an initial chill, which was described 
 by those personally familiar with malaria and dengue as due to 
 one of these diseases. These cases were in the minority, and gen- 
 erally some specially exciting cause for the chill could be discov- 
 ered. Sometimes it began as a mild sore throat, the fever con- 
 tinuing after the subsidence of the local symptoms. The suspi- 
 cion of malaria was sometimes heightened by jaundice and other 
 mild hepatic symptoms, as mental dejection, yellow and furred 
 tongue, slight tenderness over the right hypochondriac region. 
 Often it was noticed that the disease attacked the system seriatim 
 organ after organ. The succession in which the organs were at- 
 tacked was not necessarily the same. Where symptoms of ca- 
 tarrhal pneumonia were present, that disease was suspected as the 
 cause ; where the bowels were affected, typhoid fever was simu- 
 lated, suspected, and perhaps generally diagnosticated, and this 
 suspicion was increased by the appearance in some cases of an 
 eruption on the abdomen, sometimes on the thighs, arms and 
 ankles, and in some rare cases over the whole surface of the skin. 
 This eruption was rarely papular, often acuminate, irregular in 
 margin, generally irregularly ovoid, varying from mere points to 
 a size larger than the rose-colored spots of typhoid fever. They 
 came in crops, occasionally concentric, became very faint on pres- 
 sure, and in the early stage entirely disappeared. This eruption 
 was seen not only in the catarrhal fever, but in diphtheria, in 
 meningitis, after rotheln, and other eruptive and non-eruptive 
 diseases. 
 
 In some cases the attacks of different organs were separated by 
 a period of marked sub-normal temperature. Generally, how- 
 ever, the fever was continuous for from two to five or more weeks. 
 In intestinal catarrh, the abdomen was more or less tympanitic, 
 sometimes painful on pressure, gurgling might be produced at 
 times at any point. The stools were mucous or mucous and bilious, 
 " pea-soup" discharges, or yellow but not ochreous in color. Men- 
 
ingeal complications were more frequent than in any other feb- 
 rile affection, and were the cause of most of the deaths. Heart- 
 failure was almost the only other cause of death noticed ; but the 
 general mortality, considering the severity of the symptoms, was 
 slight. Most of the cases were from ten to twenty-five years ot 
 age ; some few aged and very young were attacked. It was a 
 common remark among physicians later on in the epidemic where 
 catarrhal enteritis was developed, that "the 'Grippe' had run into 
 typhoid fever." 
 
 TEMPERATURE OF CATARRHAL FEVER. 
 
 One of the most striking proofs of the identity of catarrhal fever 
 with acute influenza, is shown by a study of the temperature. Charts 
 of catarrhal fever show that in the vast majority of cases, the ini- 
 tial temperature exactly corresponds to that of the explosive form 
 of influenza ; suddenly rising from a normal or sub-normal to 102° 
 to 104° F. It falls rapidly the next day to a point just above 
 normal (instead of below, as in acute influenza), varying in differ- 
 ent cases, however, and continuing on nearly the same plane, with 
 only moderate variations for two, three, four, or even ten weeks ; 
 finally falling to sub-normal, often as low as 95° or 96° F., and 
 then rising gradually to the normal — this fortelling rapid conva- 
 lescence, with the exception often noted, that a very low sub-nor- 
 mal temperature, suddenly attained, portended a relapse. 
 
 In some cases the fever seemingly aborted from time to 
 time, and returned, like the relapses of influenza. Some cases 
 rarely ran above 100° at any time after the initial rise; while 
 others continued on a higher range, from 100° to 104°. In 
 quite a number of cases, when the temperature was taken day 
 and night, the highest point attained was between twelve and two 
 o'clock in the morning. Quite a number showed on the third 
 day a second rise, which subsided by the fourth day to the 
 second day's temperature. These cases were often diagnosticated 
 as typhoid fever following influenza. 
 
 The Prominent Points in the Differential Diagnosis 
 of Catarrhal Fever. — The small amount of emaciation after 
 prolonged fever and the rapid recovery distinguished it from other 
 
10 
 
 continued fevers of long duration, as also the complete absence 
 of sequelae, resembling in this respect only ephemeral or simple 
 continued fever. The tongue resembled that of almost every other 
 condition from that of low fevers to that of the large, flabby, white 
 tongue of acute indigestion. The almost constant peculiarity was 
 the enlargement of its papillae and its moisture. Sordes were 
 absent. The facial expression was never anxious, but easy, except 
 where marked meningeal complications existed. Sometimes the 
 face was bloated. The flush, which was rare on the cheeks, was 
 slight and never circumscribed. The conjunctivae were frequently 
 congested. The stools were not of the ochreous color of typhoid 
 fever, but were mucous when diarrhoea was present, and darker 
 or lighter in color than true typhoid stools. 
 
 Constipation was frequent, late in the disease it was almost 
 constant. Subsultus was infrequent, and there was no carpho- 
 logia except in meningeal cases. The loss of hair after recovery 
 was slight, when one considered the prolonged high temperature. 
 Similarly the nails showed very little grooving. This undoubtedly 
 was due to the slight impress made by this disease upon nutrition. 
 
 [In recent medical journals we see noticed a disease prevalent 
 in some districts of the South which they call "the sweating 
 fever." Many cases of catarrhal fever would suggest this cog- 
 nomen, and perhaps this is its diagnostic solution.] 
 
[Reprinted from THE CLIMATOLOGIST, March, 1892.] 
 
 EPIDEMIC OF INFLUENZA IN PHILADELPHIA 
 IN 1889, '90, '91. 1 
 
 By ROLAND G. CURTIN, M.D., and EDWARD W. WATSON, M.D., 
 
 PHILADELPHIA. 
 
 This paper is largely based upon 5000 to 6000 cases of influenza 
 seen in private practice, besides man) 7 seen in hospital service, and 
 many severe and unusual cases in consultation. No attempt has 
 been made to arrive at results from mere statistics, but rather 
 from the results of personal observation and generalization. 
 
 Epidemic of Influenza in Philadelphia. — We use the 
 name of Influenza because " La Grippe" was applied to epidemics 
 in which there was a sudden seizure with an almost constant sense 
 of constriction about the throat and chest ; and because " La 
 Grippe" is but a newspaper term. 
 
 The question of the method by which the disease was trans- 
 mitted deserves the first consideration. In almost innumerable 
 instances families were exempt until one member contracted the 
 disorder, after which the whole family rapidly succumbed. In 
 the second year the families exempt during the first were almost 
 universally attacked. The same was true of large groups of 
 individuals engaged in the same locality and occupation. Those 
 brought in contact with affected families, like physicians in active 
 practice, rarely escaped. Isolated communities, schools, reforma- 
 tories, prisons, etc., often escaped entirely, or, if not, suffered 
 generally. The Blind Asylum escaped the first year, and suffered 
 severely and generally the second. A contiguous female reforma- 
 tory was universally affected early in the fall of 1889, and very 
 little, if any, except in newly admitted cases, in the second year. 
 
 1 Read before the American Climatological Association at Washington, 
 September, 1891. 
 
The nurses in the Philadelphia Hospital were simultaneously 
 attacked to the extent of 30 per cent. 
 
 The contagion seems to have spread around the world rapidly 
 by some unknown peculiarity ; but in cases under local observa- 
 tion it did not seem to be far-reaching, but rather depended on 
 personal contact or proximity, aud very slight obstacles prevented 
 its spread — as the wall of a house or the enclosure of a limited 
 space of ground. A family in a block surrounded by cases (in 
 more than one instance), escaped entirely during the first winter, 
 but in the second, a member having contracted it, the whole family 
 succumbed to the influenza. Crowding of the sick, especially in 
 small apartments, seemed to intensify the contagion, and increase 
 the risks of those entering. In close rooms, crowded and poorly 
 ventilated, the disease was more intense and spread more exten- 
 sively and rapidly, and relapsed more frequently. This was 
 noticeably so in the instances of the Pennsylvania Legislature in 
 the Spring of 1891, where sixty members were confined to bed, 
 necessitating adjournment and fumigation of the building; and 
 the Houses of Parliament in London, in 1890 and 1891, were 
 closed for the same reason and fumigated. The immense number 
 of cases made the difficulty of proving direct contagion in any 
 one case much greater, but the proof of the contagion generally 
 seemed as positive as in any other recognized contagious disease. 
 
 Next to the question of contagion is the symptomatology of 
 the disorder. The most important symptoms were undoubtedly 
 those connected with the nervous system, and it is a serious 
 question whether all the symptoms were not due primarily to 
 derangement of that system. Some might consider it more 
 probably a blood disease, in reference to which see our remarks 
 further on. 
 
 Respiratory Tract or System. — The initial nasal catarrh 
 so associated with the name of influenza as to be popularly 
 synonymous with it, often failed to appear early and was mani- 
 fested later amid other affections of other organs. Inspection of 
 the fauces, however, showed them often reddened on the anterior 
 and posterior half arches, with a dark color like the " port wine 
 stain," but without swelling and very much resembling rheumatic 
 sore throat, and there existed in all these cases a sensation of 
 
tough mucus in the pharynx, requiring frequent and excessive 
 efforts in swallowing and clearing the throat. Violent coryza 
 was seen in about five per cent, of cases as an initial symptom, 
 and appeared in about fifty per cent, in some degree ; often it 
 would yield on the invasion of other organs only to reappear 
 before each relapse. 
 
 The most noticeable feature was a form of bronchitis, of the 
 exact nature of whose pathological condition we are somewhat in 
 doubt, post-mortem investigation very rarely, if ever, offering 
 itself at this stage, so that exclusion and reasoning from the 
 facts in our possession seemed to afford the only means of reach- 
 ing a reliable conclusion. From ordinary bronchitis it differed 
 on superficial observation in its duration, in the character of its 
 expectoration and the pain which attended it, in its rales, in the 
 persistent pharyngeal catarrh which accompanied it, the condi- 
 tion of the tongue (yellow moist fur), its localization in one or 
 other lung or portion of lung, and its rapid shifting from point 
 to point, from one lung to the other, from apex to base. All these 
 peculiarities being generally associated, each case formed a group 
 of anomalous symptoms easy to recognize and difficult to confound 
 with anything else. To these may be added the existence gene- 
 rally in 1889 and 1890 of sharp pain like a pneumonic stitch, 
 and often a plastic pleurisy rapidly disappearing. 
 
 To examine these symptoms seriatim : The duration varied 
 from one week to three months or more, during which its severity 
 rose and fell, and its locality changed until apparently in some cases 
 the whole pulmonary tissue had been submitted to the diseased 
 process piecemeal. The expectoration may be described as gela- 
 tinous, like a semi-opaque wine or gelatine jelly of soft consistence, 
 not as tough or rusty as the gluey sputum of pneumonia — almost 
 brittle or crystalloid ; free, never ropy, and generally of a light 
 yellow tinge ; scarcely at all purulent except during convalescence. 
 In the spring of both '90 and '91, it was often like clear boiled 
 or scalded starch or tapioca. To expectorate this great efforts 
 were required, though the spells of coughing might be infrequent. 
 Exceptionally the sputum was frothy. The sputum early in the 
 epidemic was frequently noticed to be quite black from minute 
 particles resembling soot or coal-dust. The cough was irritative 
 
or explosive, like that resulting from inhalation of pepper-dust 
 or smoke, or like the spasm of whooping-cough. At the Phila- 
 delphia Hospital the children attacked were even isolated under 
 the impression that the latter was the disease from which they 
 suffered. 
 
 The collection and retention of this exudate in the tubes 
 gave rise to rales peculiar in themselves, most noticeable as 
 to their vocal character, and their low pitch, as compared with 
 spasmodic or asthmatic rales. This showed, in the opinion 
 of the writers, dilatation rather than constriction in the lumen 
 of the tubes in which they were formed. There were also more 
 minute rales stimulating the subcrepitant rale, rather coarser, but 
 giving the impression of less moisture in their production. These 
 occupied limited areas, as the lobe of one lung, and were very 
 migratory — more numerous than the fine crackling of phthisis, 
 and resembling closely the full-fledged stage of softening croupous 
 pneumonia with its subcrepitant rales. 
 
 Perhaps the most peculiar condition was that in which the air 
 appeared to go in and out of the tubes readily, but without any 
 rhythmical and normal expansion of the chest, or the auscultatory 
 signs of respiration, the vesicular element being entirely lost ; the 
 patients sometimes dying apparently of apnoea. In one case, the 
 day before death, breathing was at the rate of 66 per minute ; 
 pulse, 74 ; temperature, 99° F., the lungs showing no physical 
 signs of any impediment to the entrance of air, the breath being 
 drawn in and out without apparently performing any function or 
 serving any use, and creating the impression that the bronchioles 
 and air-vesicles were in a continually dilated state. This was a 
 peculiarity of a considerable number of cases in 1889 and 1890. 
 Some cases even showed an effort at forced voluntary expiration. 
 
 Dry crumpling was another physical sign which seemed al- 
 most peculiar to this disease. It was not like that sometimes 
 heard in chronic emphysema — not so coarse, and more migratory 
 — limited generally to areas, suggesting that the condition of the 
 small bronchi supplying them was a factor in its production. 
 
 The symptoms and physical signs, and temperature, often sub- 
 normal, did not always suggest an inflammatory condition of 
 the lung. The mechanism in some marked cases could be eas- 
 
ily accounted for by a condition of the air- tabes and vesicles 
 which might be nervous in origin. The low pitch of the so- 
 norous rales — low in tone as the human voice — as contrasted 
 with the well-known higher pitched rales of bronchial spasm in 
 asthma, suggested the idea that the tubes were enlarged rather 
 than contracted in caliber. The same could be said of the pecu- 
 liar breathing alluded to before, in which there seemed to be no 
 contractile power in the periphery of the lung. The occurrence of 
 phthisis without bacilli as a sequel might lead one to suppose that 
 the conditions were favorable for an inflammatory process, even if 
 it were not already present ; on the other hand, the retained secre- 
 tions in steadily dilated vessels might become after a time a 
 source of irritation, and also the centre of a degenerative area. It 
 was noticed that the chronic asthmatics did not suffer to any 
 great extent when attacked, and many have been relieved of 
 what was before a constant condition, and have remained bet- 
 ter up to the present time. In some cases with these peculiar 
 symptoms there appeared for a short time a faintly and uni- 
 formly pink-tinged mucous expectoration, although it suggested 
 a passive rather than the hemorrhagic condition of croupous 
 pneumonia. Croupous pneumonia itself was exceedingly rare. 
 One of the writers failed to observe a single case in the winter of 
 1889 and 1890 ; the other met with but two. Symptoms of 
 catarrhal pneumonia existed in walking and working cases. 
 True catarrhal pneumonia in children was even rarer than usual. 
 Considering the violence of the cough, it suggests itself to us 
 that the absence of haemoptysis in connection with it might be 
 explained by the cardiac weakness and the consequent reduction 
 of blood-pressure. The similarity of the symptoms to whooping- 
 cough, where hemorrhages from the air-passages are more fre- 
 quent, somewhat sustains the idea. 
 
 Profuse catarrhal discharge from the nose often made patients 
 at night imagine that they had epistaxis. The flow was inter- 
 mittent and associated with pain over the frontal sinuses. 
 
 Latent cases also resembled phthisis, in shortness of breath, 
 nocturnal sweating and cough, expectoration which was not puru- 
 lent, gastric catarrh and dyspepsia, while the diagnostic differ- 
 
6 
 
 ences were physical exploration, no pus in expectoration or ba- 
 cilli, and an absence of emaciation. 
 
 Nervous System. Cerebral Symptoms. — Insomnia existed at 
 some period in almost all cases, and was peculiar and diagnostic. 
 It was like the insomnia of insanity, but existed also in the mora- 
 ine- hours. Its duration varied ; in one case it lasted three 
 months, reappearing for two days between each menstrual period 
 in another it lasted two and a half months, the patient only 
 sleeping when erect in a chair, and while the usual din of daily 
 life prevailed around him. Dread of sleeping was sometimes 
 combined with insomnia ; sometimes sleeplessness was the only 
 symptom of the disorder. 
 
 Delirium was rare in the fever, but when it existed it was rea- 
 sonable, the images being vivid but not annoying, and the patient 
 could be easily roused to take a sane view of things and perceive 
 the absurdity of the situation. In some cases, however, the de- 
 lirium merged gradually into insanity. 
 
 Insanity. — A city magistrate remarked upon the frequency of 
 applications for certificates in the last year, 1891. Insane ideas 
 I were acknowledged by many ; especially a desire to commit sui- 
 cide ; but these were generally controlled by good judgment, and 
 discussed calmly by the patient as aberrations. Fear of going 
 I crazy was excessively frequent. The writers collected in all 38 
 marked cases of temporary and permanent insanity. 
 
 Meningitis. — Meningeal symptoms existed both with and with- 
 out pain. Many cases at first seemed threatened with cerebro- 
 spinal fever, these being most common in the second year. 
 Convulsions were rare, but unconscious attacks at the onset 
 were occasionally met with. In the first year meningitis, when 
 it occurred, was of short duration, and considering the disturb- 
 ance of the nervous system was not severe, but was sometimes 
 fatal. Hemiplegia occurred in one case preceded by a chill ; one 
 case of paralysis of both arms (age 80), lasting 4 months, and 
 followed by recovery ; and one of both legs (age 48), lasting six 
 months and also followed by recovery, were met with. Ver- 
 tigo, frontal or occipital, or passing from one region to the other, 
 was common, Violent headache was generally occipital, at 
 times occipito-frontal, and often continued for months. Cases 
 
 r* 
 
which were left with local or general paralysis were subject as a 
 premonitory symptom to exceptionally violent headache. Among 
 the headaches the so-called uterine headache was probably due 
 to the succussion of violent cough. All these headaches often 
 disappeared soon after rising, or exhibited steady improvement 
 towards evening. The same improvement as day progressed 
 was noticed in the vertigo and unsteady gait with which some 
 cases began their attacks (in the first year), and in relapses these 
 symptoms were often forerunners of a renewed attack. 
 
 Sight was often temporarily lost. There were sometimes weak 
 vision, loss of accommodation, frequently photophobia with con- 
 gested conjunctiva, and localized pain over one or both eyes ; and 
 muscse volitantes. 
 
 Buzzing, rushing and roaring noises in the ears or fine singing 
 or chirping like crickets (not cinchonism) often persisted for 
 weeks or long periods. Sometimes for a short time or perma- 
 nently that modification of this sense was lost Avhich enables us 
 to locate sounds ; noises upstairs seemed from below, or vice versa. 
 
 We noted numbness of the limbs (one or both), sometimes 
 general hyperesthesia ; as also constriction round the waist meet- 
 ing at the epigastrium (this generally came on late in the disease). 
 Sometimes pain and constriction ran from hip to hip across the 
 back and sacrum. A sudden loss of power in the limbs was some- 
 times an initial symptom. As a rule, sensory nerves were affected 
 more frequently than motor. Neuritis was not frequent during 
 the first year (unless in the intercostal s), but was more common in 
 the second. 
 
 True neuralgia was rare. General muscular soreness did 
 occur, but the nerves could often be stretched and pressed with- 
 out increasing pain. Pain in the joints was rare and evanescent. 
 Sometimes joint-pain was stinging without redness or swelling. 
 The scalp was frequently sore to the touch for a long time. Pain 
 " in the bones" was a frequent designation, often in the skin and 
 superficial muscles at the onset. It was also quite general across 
 the sacrum and down the legs, producing uneasiness, so that the 
 patient was continually moving his limbs. Shifting pains were 
 common during the first winter ; often one and then the other of 
 a pair of nerves were aiFected ; and the writers have seen the pain 
 
leave one side and attack the other, and then go back and settle 
 in the first side attacked, especially in the intercostals. The 
 general pains abated during the sweating stage, and returned 
 when the sweating in the head and limbs decreased. 
 
 The generative powers were, as a rule, much weakened. In 
 many cases power was lost for long periods — ten months or a 
 year, and sometimes, it seems, permanently. 
 
 The senses of smell and taste were generally perverted, rarely 
 lost. A fsecal taste and smell were either associated with everything 
 or with some particular articles of food. Some of these derange- 
 ments were so severe as to hint at mental disorder. All noticed by 
 the writers, however, finally recovered. 
 
 Spasmodic affections to which the patient was previously sub- 
 ject were not aggravated, but often arrested or apparently cured, 
 as chronic asthma, hay fever, etc. 
 
 Cramps in the calves, pain and trembling in the legs on stand- 
 ing or walking; creeps or chilliness, general or limited to one 
 place ; travelling chilliness or tickling sensations were constantly 
 met with. A sound or a touch or the brushing of another's 
 clothes past the patient would often excite a creep ; moving the 
 legs in bed would do it. There was no chattering of the teeth. 
 The thrill of coldness was superficial, no evidence existing of co- 
 incident internal congestion of any moment, but the creeps were 
 almost always followed, eventually, by some relapse or exacerba- 
 tion. Alternate creeps and fevers and sweating occurred, and 
 trembling and chills alternated. Pricking in the hands and feet, 
 "cutis anserina," and formication, which at times seemed to indi- 
 cate a renewal of the attack, were also noted. 
 
 Localized pains in the first year were most common in the inter- 
 costals ; the side affected with pain w T as usually the side showing 
 the peculiar bronchial physical signs. This pain simulated pleuritic 
 or pneumonic stitches, but if pleurisy existed it was only with 
 limited plastic effusion. Pain in the brachial nerve was very 
 frequent. It often slowly descended from the shoulder and fol- 
 lowed the course of either radial or ulnar — generally on the right 
 side — and exhibited painful spots or pain on pressure over its 
 course. Pain in the hypochondrium — generally the right, and 
 from the right shoulder to the ilium — was frequent. Creeping 
 
pain in the epigastrium and region of the pancreas, apparently 
 accompanying peristaltic movements and excited by swallowing, 
 was noticed. The pain was generally that of irritation rather 
 than inflammatory. In the sciatic nerve there were all grades of 
 disturbance from numbness to well-marked sciatica, and these 
 pains also travelled slowly down to the leg, foot, ankle, and heel, 
 and in the latter locality occasionally persisted about the tendo 
 Achillis and ball of the heel for some time. 
 
 The prostration and exhaustion deserve special mention. Some- 
 times there was at the onset sudden prostration, the patient, but 
 the moment before a well man, becoming at once incapacitated 
 for any movement. Often the mental prostration was less, but 
 continued longer, in convalescence. For months after apparent 
 recovery fatigue or exposure would bring on exhaustion or " good- 
 for-nothingness ;" in fact, the relapses seemed due more to ner- 
 vous conditions than to the condition of the blood. Mental effort 
 or emotion was sufficient to cause this condition to appear and 
 reappear. Sustained thought was often utterly impossible. Some- 
 times it w T as extreme general fatigue, although no work had been 
 done. In the second year all these symptoms were more marked 
 and protracted. 
 
 The peculiarity of this exhaustion and weakness was evidently 
 in the patient's absolute unconsciousness of it till he made trial of 
 himself. At rest he felt capable of exertion, and often as well and 
 strong as ever. The attempt to rise from bed failed at its edge, 
 where he would sit quite done out ; or, if a walking case, he would 
 decide to go a few squares only to find, after walking a short dis- 
 tance, that he was obliged to rest on some door-step, utterly unable 
 to go any further. To a certain extent the same was true of the 
 heart and lungs ; heart-beat and respiration might be nearly nor- 
 mal at rest, but in effort there was a sudden slowing down of 
 the heart, with embarrassed respiration, and further effort was 
 sometimes fatal. 
 
 To us these symptoms seem to point to a more or less complete 
 interruption of those channels through which the economy is 
 enabled to summon up all its nerve-force to any particular place 
 required. There is no proof that the general amount of nerve- 
 force was less, but it was distributed, and for practical purposes 
 
JO 
 
 could only be massed slowly when and where required. A short 
 rest gathered and stored up enough for a little more effort, and so 
 on ; or, to use another illustration, the reservoir of nerve-force 
 filled too slowly, and there was only enough in it to keep the 
 organs going on the lowest possible scale — sudden and general 
 demand exhausting it. 
 
 Alimentary System. — The tongue was moist always, and 
 this was true in all diseases and conditions of a low type during 
 the prevalence of the epidemic up to the present time. Thirst 
 and hunger were both remarkably rare. Thirst was absent even 
 when the temperature was exceedingly high, due perhaps to the 
 moist condition of the tongue and throat. The taste, as well as 
 sense of smell, was sometimes perverted. (See Nervous Symptoms.) 
 The tongue, on examination, was sometimes white and flabby, 
 large and indented ; sometimes with creamy fur, and in a few 
 cases a bilious-yellow ; when white it was generally studded with 
 red papillae and had a tendency to flake off, leaving a moist, raw, 
 smooth, very red surface, and this indicated very slow convales- 
 cence. In the pharynx extreme pain on swallowing, without 
 redness or swelling, was a not uncommon symptom. 
 
 Nausea was met with in quite a number of cases, but as a rule 
 the stomach retained what it received. 
 
 The appetite was exceedingly variable. In the abdominal form 
 there was absolutely none, but there was an utter unwillingness 
 to eat. In other forms the appetite was often excellent, and food 
 was taken and assimilated. Pain in the region of the stomach 
 seemed to be really situated in the surrounding organs rather than 
 in the stomach itself. 
 
 In the intestines the most pronounced condition seemed relaxa- 
 tion and want of tone. Passive distension was common, but no 
 tension of the abdominal walls was present. Gurgling was present 
 in limited, but shifting areas ; when in the right iliac fossa it gave 
 rise to a suspicion of enteric fever ; when associated with diarrhoea 
 it increased the suspicion — but it could be found at times to cover 
 the whole abdominal area. Peristaltic action seemed weakened 
 or lost. This loss of power extended to the rectum, as shown 
 sometimes by constipation with inability to expel the contents of 
 the bowels except after frequent efforts and in small masses. One 
 
11 
 
 long; case of diarrhoea was noticed, but most of the attacks were 
 short ; often slight provocation induced it, and generally it was 
 worse at night, probably from indigestion, the food taken during 
 the day proving irritant. Constipation was the rule when diar- 
 rhoea was not present. 
 
 Heart Symptoms. — Pericardial distress, exhaustion, slow 
 pulse even in fever, were noted. Marked cardiac failure in some 
 cases occurred weeks after the attacks, with no other symptom, 
 lasted a few days, and was followed by recovery. 
 
 Inflammation of the heart was rare. JNo endocarditis was met 
 with except when associated with a complicating articular rheu- 
 matism ; three cases of pericarditis were seen. The heart was 
 often irregular, slow, and feeble with soft slow pulse, and when 
 evidences of heart-failure occurred, there was rarely even much 
 bluish tinge of the surface. Heart-failure caused most of the 
 deaths in the earlier part of the first year's epidemic. 
 
 The symptoms indicated want of nerve-power rather than 
 impaired heart muscles, since recovery was often so rapid. Not 
 many accelerated hearts were noticed. Cases affected with organic 
 disease of the heart seldom had heart-failure, in fact cases did not 
 succumb at their weak point. In so-called pneumonia, heart 
 failure was more common than the condition of the air-cells 
 seemed to warrant. 
 
 Blood and Circulatory System. — Hemorrhages were not 
 infrequent and occurred early as a rule. Epistaxis was rare except 
 when associated with aggravated nasal catarrh, being then slight in 
 amount and generally mere streaks of blood mingled with mucus. 
 Pulmonary hemorrhage was limited almost entirely to the early 
 stages of bronchial cases and to a few cases of pneumonia. Pink- 
 tinged mucus rather than large amounts of blood was the rule. 
 Hsematemesis was exceedingly rare ; three cases were noticed, all 
 in women, suggesting sexual causes. From the bowels also hemor- 
 rhage was uncommon except when associated with an apparent 
 typhoid fever ; in these, assuming them to be typhoid, it was more 
 frequent than usual, and occurred too early to be due to sloughing 
 of the glands. This early hemorrhage, also, when associated with 
 mucous stools and constitutional symptoms, was confounded early 
 in the disease with entero-colitis. 
 
12 
 
 From the urinary tract hemorrhage was noticed in a considera- 
 ble number of cases; in all the blood was changed, sometimes 
 smoky and often in flocculi, black and altered. This condition 
 was accompanied by pain in the region of one or both kidneys, in 
 a small number of cases. In cases of purpura the hemorrhage 
 seemed to us to be accounted for by a vaso-motor paralysis or 
 leakage. Acute simple anaemia was frequently observed late, 
 often gradually increasing, but not accompanied by dropsy or 
 other extreme symptoms. This anaemia could not be accounted 
 for by imperfect nourishment, since in marked cases the digestion 
 was not impaired to any great extent. 
 
 The late spring and early summer of 1890 witnessed an out- 
 break of dysentery, mild in type and easily controlled. 
 
 The influenzal poison, whatever its nature, exhibits in pro- 
 tracted cases a likeness to malarial poisoning in symptoms and 
 length of duration, in temperature range, and in long and short 
 relapses. The disappearance of malaria in its presence would 
 argue that the poison was, like the paludal, of a blood type, fol- 
 lowing the same course and affecting the same structures ; a 
 blood parasite in fact deteriorating that fluid, and especially 
 manifesting its toxic force upon the nervous system. This is a 
 possible hypothesis. 
 
 A similar resemblance following; somewhat different lines allies 
 this disease (influenza) with relapsing fever — undoubtedly a dis- 
 ease produced by a micro-organism in the blood. The tendency 
 to relapse, the profuse sweats which terminated the paroxysms, 
 and the sub-normal temperature following the exacerbations, 
 seemed to support this view. 
 
 In its tendency to produce sodden and dangerous heart failure 
 we again see a resemblance to two other blood diseases — diph- 
 theria and relapsing fever ; but the paralyses, cardiac included, of 
 diphtheria are much more prolonged and more likely to depend 
 upon an actual change in nerve structure. 
 
 Affections of other Organs not already Enume- 
 rated. — Hepatic jaundice was rare ; hepatic tenderness was 
 common, but not marked ; the stools were rarely bilious ; the 
 vomited matter was rarely bilious, even when retching was severe 
 and prolonged. Three cases of marked catarrhal jaundice only 
 
13 
 
 were noted. The liver was not found perceptibly enlarged in 
 many cases. The milder cases were of two kinds, either with 
 arrested or retained secretions. Bitter taste in the mouth was 
 often complained of, and this as often rapidly disappeared. 
 
 Renal. — In the urine a slight ring with nitric acid resembling 
 albumin was common, but without clouding when heated. Early 
 in the epidemic there was often a dark mahogany-colored or 
 smoky urine. When the kidneys were painful, it was at first 
 sometimes scanty and dark with blood ; or frequently passed, 
 copious and limpid, but becoming darker. Either frequent 
 micturition or retention was noticed. The cases of limpid urine 
 often became dark and smoky in a few days. Flocculent brown 
 blood was often noticed in these cases, and in almost all the urine 
 was not perfectly clear at some stage ; a fine, sparkling dust ap- 
 peared disseminated through it. A number of cases gradually 
 developed chronic parenchymatous nephritis. A number of in- 
 stances of urethritis with a clear transparent discharge, or some- 
 times one of milky whiteness, were seen. 
 
 Explosive cough produced, especially in women, involuntary- 
 urination. Dribbling of urine in children and old persons was 
 without apparent special cause. Uric acid deposits were occa- 
 sionally noticed at the crisis. 
 
 The pancreas seemed to be affected, though obscurely; and 
 where gastric pains were prolonged and anorexia most marked, 
 tenderness could be elicited in the region of that organ, and at 
 times a doughy feeling was noticed. The pain was in thrills in 
 these cases and at frequent intervals. 
 
 Abortion was very rare, as was also puerperal fever. Pregnant 
 women escaped or had light attacks. 
 
 In the first year, 1889 and 1890, typhoid fever was rare, and 
 catarrhal fever was confounded with it. Typhlitis, during the 
 winter and spring of 1891, was notably more common than 
 usual. 
 
 Skijst Affections. — Erythema at the onset was of frequent 
 occurrence, as is usual in ordinary influenzas, lasting from 12 to 24 
 hours. The occurrence of sudamina was frequent and associated 
 with the more protracted and sweating cases. Prickly heat, lichen 
 tropicus (closely allied to sudamina), was very common, and 
 
14 
 
 occurred earlier than the latter. Acute dermatitis and varieties 
 of this, simulating the symptoms of rubeola, scarlatina, and 
 roseola, occurred in many cases. Purpura was rare. Of purpura 
 rheumatica two cases were seen, and of erythema nodosum fifteen 
 or more in one institution, associated with rather severer pain 
 than usual. Herpes zoster was observed in six of our cases ; 
 herpes labialis was rare, differing in this respect from malarial 
 fever. Two other physicians report eleven cases of herpes zoster. 
 Dermatitis herpetiformis was so frequent that five cases came to 
 the knoAvledge of the writers in one day. General and local 
 pruritus were common. Prickly heat was frequently followed by 
 boils. Erysipelas was exceedingly rare ; roughness of the legs 
 and forearms often passed into a distinct eczematous eruption. 
 Prurigo in the second and third years seemed more frequent than 
 usual. 
 
 Sweating accompanied the whole disease, alternating with 
 chilliness, the sweating accompanying the fever and persisting 
 for a long time, especially in the limbs at night, its disappearance 
 being a good sign of recovery. Two cases of alopecia areata, 
 following attacks of influenza, were seen by one of the writers. 
 
 Extensive loss of hair was infrequent, but slight aud gradual 
 loss in many instances continued for a year or more. Scarlatiua, 
 rubeola, erythema, cerebral and cerebro-spinal meningitis, ery- 
 sipelas, and typhoid and typhus fevers were all confounded with 
 influenza, and vice versa. There was no tendency to bed-sores 
 even in long-continued cases. 
 
 Tempekatube. — During the first year the temperature was 
 high, 101° to 105° ; in the second year not so high. Subnormal tem- 
 perature followed light attacks after twelve to twenty-four hours 
 of elevation, and resumed the normal a few hours afterwards. 
 Patients often went to their usual avocations with high tempera- 
 ture while unconscious of any fever ; but one of the writers took 
 in his office the temperature of five such cases in one day, and 
 found in two cases 103°, in one 101.5°, and another 100.3°, and 
 in a fifth case 104.4°. This condition in which the patient was 
 not aware of his own fever was probably due to the marked mois- 
 ture of the skin, and the absence of thirst, the latter being probably 
 due to the moisture of the throat and its free catarrhal secretion. 
 
15 
 
 In a few of the cases the temperature was subnormal through- 
 out the attack. One physician had a temperature of 97° to 98° 
 for two months continuously until complete recovery of strength. 
 It was quite impossible to judge of the temperature by the hand. 
 
 In some cases the temperature remained elevated and the 
 patients suffered a continuous fever, lasting sometimes for weeks ; 
 and these were generally diagnosticated as " typhoid fever ;" but in 
 many of these cases, when carefully observed by the writers, they 
 presented all the characteristics of catarrhal fever alluded to 
 before, and were wanting in the characteristic symptoms and 
 sequela? of true typhoid. 
 
 The face was rarely flushed for any length of time, and, if so 
 at all, it was not limited to the upper part of the cheek. The 
 physiognomy did not indicate suffering or distress, nor show, 
 while quiet, any appearance of prostration. 
 
 Relapses. — The relapses seemed to occur most generally in 
 persons in active middle life, those who were most exposed to 
 cold, dampness, anxiety, and fatigue. Children and the aged, 
 more carefully watched and protected, were less liable to relapse. 
 Causes producing chilliness or over-exertion would singly bring 
 on a recurrence of the attack. Internal organs as a rule did not 
 suffer a second time, but the disease would either extend further 
 in the same structure or attack an entirely different organ. Small 
 chills, creeps, or formication, generally indicated an extension in 
 an organ already suffering ; more defined chills an attack in 
 another organ. In the short explosive attacks of 1889 and 
 1890, those cases which were at once confined to bed and kept 
 there until sweating ceased — five to seven days — did not suffer 
 relapse, and had no subsequent trouble ; whereas those who 
 undertook to withstand it and worked through the first few 
 days almost always succumbed and suffered severely. The num- 
 ber of relapses varied from one to as high as seven distinct and 
 well-marked ones, gradually growing lighter unless produced by 
 some gross indiscretion ; some occurred at long intervals, even 
 seven weeks. In relapses all the general symptoms recurred as 
 above described. 
 
 These remarks concerning relapses do not include subsequent 
 attacks, since in succeeding years or epidemics close on each other, 
 
16 
 
 the liability to attacks remains ; in fact those once susceptible seem 
 always susceptible. 
 
 The most severe and protracted cases were generally in the 
 educated classes, where occupation involves responsibility and the 
 interests of others; while the laborer, as usual, readily gave up his 
 work, though most dependent on it, having less at heart the interest 
 of his employer than the clerk, bookkeeper, and overworked 
 public servant. Those who gave up early recovered most com- 
 pletely, and so were less subject to relapses. Drunkards strangely 
 escaped severe attacks. 
 
 The influenza type seemed to be stamped upon all diseases, 
 modified them, and caused confusion in diagnosis. 
 
 Epidemic in 1890 and 1891. — Grip-cold in 1891 consisted 
 principally in headaches, frontal and occipital, followed by sore 
 throat lasting from three to five days, and this followed by mus- 
 cular pains in all the limbs. There were very few deaths during 
 the second year in comparison with the first ; but the deaths 
 were mostly from protracted attacks, and a complicating menin- 
 gitis. All through the period there was still a disposition to 
 heart failure, but principally where it took the form of continued 
 fever and pneumonia. In the first year very little croupous 
 pneumonia occurred ; in the second it was more frequent. 
 
 In the second year languor and exhaustion, or a " good-for- 
 nothing" feeling, with loss of appetite, was associated with a dry, 
 hacking cough, much less marked than the year before. 
 
 Of typhlitis and rheumatism there were seen eight cases each 
 in the second year, and eight cases of pleurisy with effusion. 
 
 It was noticed in 1891 that rheumatism was not associated 
 with the usual sour odor, but a decomposed filthy odor like that 
 noticed in influenza itself took its place. 
 
 Antagonisms. — Influenza cannot be a filth disease, as its 
 initial outbreak was among the wealthy rather than the poor. 
 The whole group of diseases characterized by squalid surround- 
 ings fled before its onset, and hid themselves somewhere. Good 
 plumbing gave no immunity, sewer-gas offered no invitation. 
 Abominably drained houses escaped the first year, were over- 
 hauled and put in good order in the summer only to be filled 
 with obstinate cases during the second year. Many instances of 
 houses with very insanitary surroundings whose inmates have 
 
17 
 
 entirely escaped both years are known to the writers. Over- 
 crowding, wherever the contagion had taken hold, obviously 
 intensified the disease and assisted its spread. Diphtheria and 
 diphtheritic tonsillitis, quinsy, follicular tonsillitis, which were 
 universally prevalent in the fall of 1889 and 1890, vanished 
 mysteriously and suddenly with the influenzal outbreak. Scarlet 
 fever, for years allied to diphtheria, almost forming a hybrid with 
 it, suddenly, though diminished in frequency, rehabilitated itself 
 as simple, uncomplicated, and with throats free from patches ; 
 but all the patchy throats returued with renewed force in early 
 summer. Measles was rare, whooping-cough rarer. Malaria, by 
 which we mean that condition characterized by remittent and 
 intermittent fevers, as well as the various neuralgias, amenable to 
 quinine, disappeared. Arsenic and cinchona seemed to have no 
 field, though the public took large quantities of the latter on its 
 own responsibility. 
 
 Dyspeptics escaped or had digestive trouble only. 
 
 Asthma was relieved, postponed, or apparently cured. Hay- 
 fever was arrested at once by the influenzal attack, and in several 
 cases has not appeared this year at the usual time. 
 
 People did not succumb in their notably weak spots. The 
 cases of valvular disease did not have heart-failure ; nor did those 
 with irregular or the slow hearts. Nasal catarrhal cases had no 
 specially bad catarrh when attacked. The permanently insane 
 were not aggravated ; the periodically insane did not specially re- 
 lapse into insanity when attacked in the first year. 
 
 Gout seemed to flourish. No gouty person in the experience 
 of the writers failed to have an attack of gout during or after 
 one of influenza. Pseudo-membranous enteritis was brought on 
 in new cases and in those who had already suffered. 
 
 Collated Paealyses (Involuntaey). — In what light are 
 we to regard the persistent occurrence of innumerable paralyses of 
 involuntary muscles ? The list is too full to be accidental — bron- 
 chial, vesicular, ocular, intercostal, cardiac, gastric, biliary, hepatic, 
 vascular, vesical (probably renal too), intestinal, and rectal. These 
 occur at once to the mind, and do they not indicate some disorder, 
 some disarrangement, some alteration or possession of the nerve- 
 centres and nerve-trunks concerned in the vital processes of the 
 economy ? 
 2 
 
18 
 
 To specially, but hastily, examine these : The bronchial, with 
 its relaxed and unchanging calibre of the bronchi, bronchioles and 
 air-vesicles, the difficulty of expectoration, the rales without ex- 
 cessive secretion, the necessity for supplemental spasmodic cough 
 to clear the lungs, the abnormal chest resonance, have all but one 
 signification, and were often preceded by intense thoracic pain. 
 
 The weakened accommodation showed a similar condition in 
 the eyes. The intercostals at times were totally unresponsive, and 
 breathing wholly diaphragmatic. The cardiac symptoms showed 
 as in an illustrated diagram the effect of the action of some influ- 
 ence upon the various supplies of nervous force. The stomach 
 rejected everything or retained everything without permitting it 
 to pass down, or the bowels showed in particular regions stasis of 
 peristalsis or passive distension, with ineffectual pain, denoting the 
 effort of some remaining fibres to propel their contents, only to 
 fail and allow it to recede. 
 
 The rectum and colon were the seat of persistent expulsion or 
 retention ; attacks of tenesmus often occurred without a trace of 
 mucus or of blood, or there was torpor, so that no agent seemed 
 to reach their impaired irritability. The liver suffered in two 
 ways — impaired secretion and impaired excretion — and one variety 
 might be succeeded by the other; tenderness, however, always 
 preceded the latter. Vesical trouble was generally in the form of 
 retention — the urine would be normal or even excessive in quan- 
 tity, but the power of expelling it suddenly lost for one or two 
 weeks. This occurred so frequently that it became diagnostic in 
 some obscure cases. It was seen in all ages, as early as 10 months, 
 as late as 86 years of age ; and in cases that succumbed as well as 
 in cases that recovered. It followed either the pulmonary or the 
 renal attack. Lastly, when we consider the insomnia, the hsema- 
 turia, and the hepatic tenderness followed by icterus, we may 
 readily suspect a vaso-motor paralysis whose extent we have not 
 begun to trace, and whose influence has a strong bearing on this 
 whole question of the modus operandi of the influenzal poison and 
 its manifestation. The paralyses and atonic conditions of motor 
 nerve fibres which followed attacks can be studied with great 
 profit. The sensory nerves were much more actively excited than 
 the motor, as shown by the pains. 
 
Extracted from 
 The American Journal of the Medical Sciences for February, 1892. 
 
 THE TREATMENT OF INFLUENZA AND ITS SEQUELAE. 
 By Edward W. Watson, M.D., axd Roland G. Curtis, M.D., 
 
 OF PHILADELPHIA. 
 
 As far as drugs are concerned, treatment in pure influenza, of the ex- 
 plosive variety, probably has but little effect. Every practitioner pos- 
 sessed his own specific, and the number of such specifics was so great, 
 and their nature so various, that it seems almost certain that few, if 
 any of them, materially shortened the disease. The simple form of in- 
 fluenza was generally a brief, self-limited disorder. 
 
 A few of the recommendations found in the papers for grip specifics, 
 and employed by obscure practitioners, and gathered from conversa- 
 tions with men engaged in treating the disease, may be given : Quinine, 
 quinine and whiskey, salol, salicylic acid, salicylate of soda, antipyrine, 
 antifebrin, phenacetin, Dover's powder, camphor, bromides of potassium 
 and sodium, olei santal, ammonium chloride, atropine and belladonna, 
 alkalies, aconite, veratrum viride, jaborandi, boneset, aromatic sulphuric 
 acid, also oxide of zinc, horseradish, cloves, asafoetida, onions and garlic, 
 and even cutting one's whiskers, if a man. 
 
 The simple or explosive form of influenza, exhibited most in the 
 early cases, and occurring less frequently as the epidemic progressed, 
 was best managed and in the most rational way by rest and warmth, 
 with entire quiet of both mind and body. This was far more important 
 than the whole combined pharmacopoeia, but was little heeded when 
 advised. The drugs that seemed to be of use were few. The treatment 
 can best be studied in detail as it adapted itself to the varying symp- 
 toms. In the early stage of chill — bed, warmth, warm diluent drinks; 
 as the fever rose, and intense headache and pain in the limbs and sacral 
 region developed, antipyrine certainly afforded relief to all the symp- 
 toms and seemed to shorten the dry stage, induce earlier and more pro- 
 fuse perspiration and subsidence of fever ; but the next symptom in the 
 natural history of the disease being intense prostration with subnormal 
 temperature and a leaky skin, the depressing element in the drug em- 
 ployed became a serious consideration — the two depressions, that of the 
 drug and that of the disease itself, connecting on the second or third day 
 or later, were sure to increase the difficulty and perhaps danger, and retard 
 recovery. Antifebrin or acetanilide being the most dangerous of this 
 group of remedies in this respect, and antipyrine almost as bad, phena- 
 
2 WATSON", CURTIN, INFLUENZA. 
 
 cetine, as the least so, retains its popularity and still remains the best, 
 though not without objection ; and in some rare cases they all failed to 
 have any antipyretic effect. 
 
 It might be noted in passing that from numerous experiments per- 
 formed daily by the use of a copyrighted combination, also beginning 
 with "anti," one is led to think whether a considerable amount of this 
 depression may not be obviated by combining any of these drugs with 
 caffein. Salicin, the use of which was begun by one of the writers at 
 the earliest period of the epidemic, and continued pretty steadily until 
 now, presents many strong claims, and comes as near to being a specific 
 as we can get with the drugs now in our possession. The tonic proper- 
 ties of salicin, the large doses in which it can be safely given, and the 
 almost immediate results in most cases in reduction of temperature, 
 diminution of pain, and production of perspiration, quite overcome the 
 drawback of its bitter taste. It seemed, also, that its early use was fol- 
 lowed by fewer relapses than the use of other means. Yet, that it was 
 by no means a specific in the sense in which quinine is a specific in 
 malaria, was proved by certain obstinate cases which took very large 
 doses without any apparent effect, and in the sequelse, other than in 
 pure relapses, attended by the symptoms of the initial attack, its value 
 was doubtful. 
 
 Salol was very extensively used in combination with quinine and 
 phenacetine, and was relied on by many practitioners. Salicylates or 
 salicylic acid also incurred the objection noted above — that of producing 
 secondary depression. 
 
 Quinine was very generally employed by the populace as a tonic an- 
 tipyretic, and also as a preventive, and its previous reputation seemed 
 to warrant its use, but it evidently had but a limited field — that of com- 
 bating the secondary depression and improving the digestive tone. 
 
 Camphor, alone or in combination with quinine and phenacetine, 
 strychnine and other agents, was relied on by some to relieve both pains 
 and fever, in the early stage. 
 
 Chloride of ammonium and the bromides were extensively used. 
 Dover's powder seemed the most efficient way in which to give opium, 
 and produced excessive, early, and long-continued sweating. The few 
 cases noted as treated in this way made early recoveries. Opium and 
 morphine were well borne, but proved unsatisfactory. Asafoetida, vale- 
 rian and the valerianates soothed the excited mental condition in numer- 
 ous instances and gave relief. Sulphonal was the best hypnotic, in a 
 disease which had insomnia for one of its marked symptoms. Sulphonal 
 and phenacetine in suppository — ten grains of the former to six of the 
 latter — produced sleep and free perspiration in a few hours. 
 
 Alcohol, in the second stage, given in proper quantities, was beneficial, 
 but in too large. doses increased the vascular relaxation and favored per- 
 
WATSON, CUETIN, INFLUENZA. 3 
 
 spiration. It was useful in all stages, except the earliest, when it in- 
 creased the headache and pain. Drunkards, as a rule, were free from 
 influenza, probably because alcohol fortified the system against that ex- 
 haustion and depression which favored its onset, and in the actual ex- 
 haustion which followed the initial fever, and in the recurring periods 
 of depression throughout the oftentimes long course of the disease, the 
 medical attendant would have been utterly at a loss for any stimulant 
 that would stimulate but for its use. Ammonia and other traditional 
 stimulants did not give the same relief. Tinct. cinchoni. comp. in full 
 doses, or other bitter tinctures, were employed with some success, where 
 the bitter principle contained in them, if given alone, did little or no 
 good. Extract of malt in the later stages was of great benefit. 
 
 Boneset in the form of tea, combined with heavy coverings and warmth 
 to the feet after the manner of ancient domestic practice, claimed some 
 success, but was often rejected by the stomach. 
 
 Exhaustion during convalescence was best treated by the phosphorus 
 compounds. Where the syrup of the hypophosphites was obnoxious, a 
 substitute suggested by one of the writers to his chemist — a tablet con- 
 taining its ingredients — was largely used and with excellent effects, 
 the ingredients being hypophosphites of strychnine, quinine, and iron 
 and alkalies (pil. hypophosphit. cum quinia? co.). 
 
 Opiates which, as said above, failed generally to benefit the initial 
 discomforts, failed also to exhibit their usual soporific effects even when 
 given in largely increased doses ; they stopped neither cough nor pain, 
 but often seemed to aggravate both. This might have been from exces- 
 sive elimination through the increased secretion (catarrhal) of the 
 emunctories, or from a diminished power of absorption due to the 
 catarrhal condition of all the mucous surfaces. The relief afforded in 
 the cough — so general after the first stages were passed — by atropine or oil 
 of sandal, was either from arresting excessive secretion or from a 
 sedative effect upon the nerve centres, or both. 
 
 Atropine seemed to be rapidly absorbed, and to be efficient in very 
 small doses ; in fact it was poorly borne, one-five-hundredth grain four 
 times a day having often a decided effect in the adult. Oil of sandal 
 may have acted by diminishing secretion, but in whatever way it pro- 
 duced its effect, that effect was quite certain and well marked in the 
 majority of obstinate coughs. The old-time expectorants generally 
 aggravated matters, and were almost universally abandoned. They may 
 have intensified the already existing catarrhal condition. 
 
 Chloride of ammonium was the only old expectorant extensively used 
 throughout the epidemic. By some it was claimed as the best remedy 
 for influenza in all its various varieties. In its use, however, even 
 in carefully selected cases it was disappointing ; perhaps the benefit, 
 where derived, came from its property as a stimulant. 
 
4 WATSON, CURTIN, INFLUENZA. 
 
 A number of active practitioners at a medical society, being ques- 
 tioned as to what, in their opinion, was the most nearly specific treatment 
 for the disease in its simple form, gave the following answers derived 
 from their own personal experience : Phenacetine, 21 grains every two 
 hours ; antipyrine and digitalis, the latter to prevent depression of the 
 heart ; Dover's powder with quinine ; antipyrine or acetanilide ; phena- 
 cetine in doses of 1\ grains each at intervals ; acetanilide or phenacetine 
 with strophantus ; pilocarpine gr. \ hypodermatically to break up the 
 initial fever — this, the gentleman advocating it said, produced almost 
 immediate ptyalism and profuse perspiration — which he followed by 
 tinct. gelsemium gtt. ij every two hours until the pains were quieted. 
 
 In theory, ergot and the bromides should have the effect of diminish- 
 ing secretion by acting on the capillaries ; but the combination has not, 
 to the writers' knowledge, been generally tried, and, like other means, 
 might prove quite inefficient, owing to the active morbific process not 
 being overpowered by the drug. 
 
 Phenacetine seems, of all remedies, to possess the most evidence in its 
 favor, as most safe and active ; if too long continued into the stage of 
 subnormal temperature and exhaustion, it too would prove unsafe. In 
 the ofttimes protracted catarrh of the lungs following the first stage, 
 when the chest would be filled with sonorous and sibilant rales : — simu- 
 lating asthma — a pill containing phenacetine gr. jss, atrop. gr. 4^-5— 3-^ -q, 
 strychn. gr. y^, and quinine gr. j (or if thoracic pain was a prominent 
 symptom, camphor in gr. j doses instead of quinine) given four times a 
 day, and kept up steadily, gave very evident and satisfactory results ; 
 the rales disappeared, and the power of the lung to expel its secretion 
 seemed markedly increased. 
 
 A very important question in the treatment was in regard to going 
 out of doors. Patients were almost universally eager to get out and 
 utterly careless of admonition. How soon an influenza patient was fit 
 to encounter the outside air was, in every case, a very serious question. 
 Caution urged one way, the patient's inclination another. One element 
 in going out was generally forgotten — the fatigue of going, a thing en- 
 tirely separate and distinct from the atmospheric effects of outdoor air. 
 Probably in good weather, riding, if the patient be properly protected, 
 is safer than walking, the element of fatigue being partly eliminated. 
 Generally speaking, it is well to wait until all lung symptoms have 
 entirely disappeared, until expectoration is but a trifle and cough only 
 occasional, the sweating and chilliness gone, and the feeling of fatigue, 
 and then choose the best and brightest day for a very short exposure 
 the first time; night air is injurious for a long time after apparent 
 recovery. 
 
 As for air and temperature in the sick-room, it can only be said that 
 the room should be kept as fresh as possible, not over 70° or below 68°, 
 
WATSON", CURTIN, INFLUENZA. O 
 
 and with as little draughts permitted as can be. In our late warm 
 winters, to keep the temperature as low as this without freely admitting 
 the outside air through open windows has been often quite impossible. 
 The patient, however, should be well shielded by screens and curtains 
 from direct currents of cold air. 
 
 Mingled with the cases generally known and recognized as influenza, 
 have been many with obscure abdominal symptoms due to catarrhs other 
 than pulmonary, the treatment of which deserves especial notice. The 
 cases referred to presented the same initial general symptoms, but 
 nausea speedily appeared, and in many everything, no matter how bland, 
 was at once rejected. Here cocaine in gr. -£% doses every hour, given in a 
 teaspoonful of cold water, gave the most direct results ; if the bowels were 
 loaded, it could be combined with fractional doses of calomel. Exter- 
 nally, rubefacients and heat ; for food, milk heated to 180° and slightly 
 salted, given in small quantities frequently, or alternated with beef-tea ; 
 if these were rejected, champagne could be given, or brandy and soda, 
 by the stomach ; all other feeding was necessarily rectal. The most 
 successful nutrient enemata were animal broths beaten up with the yolk 
 of an egg and a small quantity of brandy or whiskey, and given in 
 quantities of half a pint every four or six hours. After a few days the 
 stomach gradually but surely regained its power. 
 
 These abnormal attacks are extremely prone to occur in whole fami- 
 lies ; in fact, it is a pretty sure thing when the first case in a family occurs 
 of a certain type that succeeding cases will assume the same type. 
 This holds good of even such unusual forms as the renal and hepatic 
 with jaundice, and the laryngeal form. The fact itself points appar- 
 ently to a different means of entrance of the poison into the system in 
 the different varieties of influenza. 
 
 The contagion of influenza has been doubted by some observers, but 
 we think without good reason. Contagious and infectious would best 
 describe it, like scarlet fever or smallpox, but with a power of reaching 
 further than either, and not, as the public seem to think, and the profes- 
 sion did, that it is purely an aerial poison not emanating from a sick 
 individual but travelling independently of persons. 
 
 The subject of the treatment of the sequela? of influenza is a very 
 large one. The numerous affections appearing in the wake of the origi- 
 nal influenzal attack require special treatment in each case, symptom- 
 atic and general. 
 
 To give a general but brief outline of such treatment we must enu- 
 merate, as far as possible, the sequelae generally met with, and the com- 
 plications most frequently seen of influenza with preexisting disease. 
 The sequela? of influenza were like the contents of Pandora's box — only 
 no " hope " was left behind. The ordinary sequela? were bronchitis, pneu- 
 monia, and local catarrhs, meningitis, neuralgia, neuritis, paralysis, heart 
 
6 WATSON, CUKTIN, INFLUENZA. 
 
 weakness, general nervous prostration, insomnia, obstinate dyspepsia, 
 diarrhoea, diphtheria, ansemia. 
 
 Anaemia, phthisis, chronic bronchitis and asthma, Bright's disease, and 
 valvular disease of the heart were often complicated by influenza. 
 
 The best remedies for pain were mustard plasters, blisters, and dry 
 heat. For neuralgic pains of short duration, these remedies were 
 generally followed by a cure. Persistent pain (neuritis) is treated on 
 general principles. 
 
 Myalgia : Injections of atropine or cold water hypodermatically, rest 
 in bed with relief of pressure, and rubbing with stimulating embrocations, 
 generally spirit of camphor alone, or lin. chloroformi ; the latter in 
 violent headache were also very useful. 
 
 For bronchitis : Ammonium chloride when expectoration was free ; 
 quebracho and olei santal, with menthol or olei menth. pip. when cough 
 was dry with asthmatic rales. Whiskey and glycerin — a popular remedy 
 — allayed the tickling cough, and when combined with quebracho caused 
 freer expectoration. 
 
 For pneumonia : Counter-irritation and the usual treatment, avoiding 
 depressing measures as much as possible, with free stimulation. In the 
 later stages of pulmonary catarrh, atropine with ammonium iodide were 
 used with great success. 
 
 Local catarrhs : Violent coryza can be alleviated by menthol, with 
 liquid vaseline, cocaine in 4 per cent, solution, and by the snuff of bis- 
 muth, pulv. acacise, cocaine and morphine acetate. 
 
 Gastric catarrhs : By hot water, hot infusion of hydrastis canadensis, 
 gtt. x, fluid extract, to one ounce of hot water ; by cocaine in gr. -^j 
 doses every hour ; and by withdrawal of food, with rectal feeding. 
 Catarrh of the bladder — of which several very severe cases were seen — 
 while resisting ordinary means, usually yielded promptly to a combina- , 
 tion of antipyrine gr. ij, morphine gr. \, atropine gr. ^o, every four hours 
 and the use of the catheter when retention occurred. Urethral catarrhs 
 were very obstinate — occurring under circumstances and at ages when 
 suspicion of gonorrhoea was impossible — and slowly subsided apparently 
 regardless of treatment. 
 
 Meningitis was, in some respects, the most serious and fatal sequel ; 
 this was especially true in the spring of 1890. Its treatment was by the 
 bromides, by ergotine and belladonna per rectum, and counter -irritation 
 to the occiput. Allied to it was the peculiar sleep, which in the aged 
 often occurred just when the lung symptoms seemed about to yield — 
 and too often ended in death. This was the most frequent manner of 
 death among the aged in the fall of 1891. 
 
 In paralysis : Strychnine gave the best results, with hypophosphites. 
 Electricity in the early period increased the pain — the nervous system 
 was already exhausted by over-stimulation. 
 
"WATSON", CUETIN, INFLUENZA. 7 
 
 The treatment of neuritis was unsatisfactory ; it progressed slowly, the 
 pain travelling from centre to periphery of nerve. Blisters and iodine, 
 local stimulating applications, and hypodermatics were employed with 
 varying success. 
 
 In heart weakness : Digitalis, strophanthus, cactus, at times seemed 
 effective; caffeine was undoubtedly so. 
 
 For insomnia : Sulphonal was the best and safest hypnotic. (Somnal, 
 theoretically, should be the best drug.) Ammonium bromide, in excited 
 mental states, at times restored mental equilibrium. 
 
 The obstinate dyspepsia occurring especially after the abdominal at- 
 tacks, seemed due to impaired muscular tone of the stomach. When an 
 apeptic condition existed pepsin was indicated, and gave a certain 
 amount of relief. Generally mild stomachic stimulants were beneficial. 
 Mineral acids and ordinary bitter infusions were worse than useless, irri- 
 tating the stomach and increasing distress. Alcohol in the shape of 
 brandy or whiskey, taken with pounded ice, was as useful as anything. 
 
 General nervous prostration often extended over long periods without 
 any discoverable local cause ; it was always worth while, however, to ex- 
 amine the urine with care. Sometimes a catarrhal nephritis, sometimes 
 a faulty digestion or hepatic inaction seemed to underlie the general con- 
 dition in latent form. These cases, by enforced rest and attention to 
 local complications, gradually recovered. These cases and nervous 
 cases generally, were very disappointing when sent to the seashore 
 during convalescence. 
 
 Sweating : This was sometimes exceedingly profuse and very hard to 
 control, owing to the vaso-motor paresis. The best remedies were atro- 
 pine and alcohol in proper quantity. Oxide of zinc and aromatic 
 sulphuric acid were sometimes of use. In some cases the side on which 
 the patients were lying, in bed, would be dry while the upper side would 
 be bathed in perspiration and cool; on a reversal of position the dry side 
 would become moist, and the previously moist side dry ; this suggests 
 that the stimulation of a certain amount of heat might control the 
 relaxed vessels. 
 
 Diarrhoea was best controlled by rest, proper diet, milk and broth, 
 and as remedies bismuth, with or without opium, or bismuth with 
 cocaine ; when gastric pain existed especially cocaine ; when internal 
 pain, opium and spirits of chloroform. The short attacks often ended 
 in diarrhoea, and after it all other symptoms, engorged lungs, etc., disap- 
 peared at once, but induced diarrhoea did not seem to have the same bene- 
 ficial effect. 
 
 Diphtheria as a complication was exceedingly rare, until the fall of 
 1891. So much so as to lead to the belief that the two diseases were 
 antagonistic. In the early fall of 1891, however, in Philadelphia the 
 reported deaths from diphtheria increased greatly above the average, 
 
8 WATSON, CURTIN, INFLUENZA. 
 
 though mostly in the outlying wards it seemed in the cases seen by the 
 writers to have followed rather than preceded the influenza, in one case 
 appearing during the progress of an influenzal bronchitis, in a man aged 
 seventy-six, in the second week of the disease. 
 
 Anaemia : In some cases of acute anaemia after influenza, the blood- 
 count ran down from 3,500,000 to 4,500,000 to the c.mm., and haemo- 
 globin was below 50 per cent. Iron was disappointing as a remedy, 
 the hypophosphite excepted where combined with the other hypophos- 
 phites. 
 
 Phthisis undoubtedly developed from influenza. The catarrhal con- 
 dition remained and caused a breaking down of the lung tissue. These 
 cases while presenting the physical signs of phthisis and terminating 
 finally in death, showed during life, on examination of the sputum, no 
 bacilli. In the fall of 1891 in the Philadelphia Hospital the sputa of 
 14 cases of phthisis, examined (often several times and by different 
 methods) for bacilli, showed them abundant in 4, few in 6, absent in 4 
 cases. In the fall of 1890, after most of old cases of phthisis had died, 12 
 out of 28 cases were found free from bacilli, and invariably with histories 
 dating from an influenzal attack. 
 
 Many chronic catarrhal cases also, when the lungs were involved, 
 resembled and were mistaken for phthisis. Cough, diarrhoea, night- 
 sweats, anaemia, dyspepsia, and fever were present, with physical signs 
 which agreed with phthisis in all but dulness on percussion, which was 
 absent. 
 
 The differential symptoms were: an almost non-purulent sputum, ab- 
 sence of emaciation, and at last a sudden disappearance of fever and all 
 physical signs, with rapid recovery. (These cases may have formed the 
 basis for the claims of some recent remarkable specifics for phthisis.) 
 
[Reprinted from the Transactions of the Philadelphia County Medical Society.] 
 
 THE EFFECT OF THE INFLUENZAL POISON UPON 
 
 THE HEART IN THE EPIDEMIC OF INFLUENZA, 
 
 FROM 1889 TO 1892; WITH SOME 
 
 ADDITIONAL NOTES. 
 
 By EOLAND G. CUBTIN, M.D., 
 
 AND 
 
 EDWAED W. WATSON, M.D. 
 [Bead January 13, 1892.] 
 
 This paper is an embodiment of the joint observations of the 
 writers during the last two years. The heart symptoms in the two 
 epidemics differed rather in degree than in kind. In the first out- 
 burst in 1889-90 the heart played an important part in the mor- 
 tality, and much less so in the second explosion in the winter of 
 1891-92. 
 
 Early in the attack of 1889 and 1890, four cases of acute peri- 
 carditis were brought to the writers' knowledge, and none have 
 since been observed. 
 
 Fatal heart-failure was quite a frequent association of the early 
 catarrhal fever and the catarrhal pneumonia of influenza of the 
 winter of 1891 (January, February, March, and April). It was a 
 weak heart, with blueness of the lips and extremities, which last 
 were bathed in a cool sweat, followed generally by death. 
 
 In the epidemic of 1889 and 1890 several 'cases were seen of 
 irregular and rapid or slowed heart, with blueness of the skin, in 
 patients who had had attacks of the epidemic weeks before, and had 
 apparently recovered. These all yielded promptly to treatment. 
 
 In the latter part of 1891, although the general fatality was as 
 great as in 1889 and 1890, heart-failure was a rare cause of death. 
 But in the winter of 1889 and 1890 deaths were largely, first, from 
 heart-failure ; and, second, from meningeal complications. During 
 
2 CURTIN AND WATSON, 
 
 the last few months, however, we have seen a great many of the 
 severer cases of influenza (many of which died), and according to 
 our observations, the heart was quite strong, seeming to be one of the 
 last organs to give way. The method of death in the majority of 
 these cases seemed to be as follows : The patient was first affected by 
 influenzal pneumonia, with a deepening hebetude, from which, how- 
 ever, he could be aroused until the last ; the heart maintaining a 
 regular, strong action, and the pulse quite full and strong, at about 
 85 to 95, only giving way a short time before death. The condi- 
 tion causing death seemed to be one of general nervous exhaustion, 
 rather than one of pulmonary or cardiac weakness. Sometimes, 
 instead of the hebetude, as before stated, there was an un natural 
 brightness preceding death. In these cases the heart performed its 
 work well up to the moment of dissolution. 
 
 In the winter of 1891 and 1892 there have also been observed a 
 number of cases of irregular and intermittent heart, unassociated 
 with symptoms of heart-failure. This condition was often associated 
 with a want of synchronous action between the two sides of the 
 heart. The action of the heart in these cases was occasionally very 
 much accelerated, but more frequently slowed. On listening over 
 the heart the sounds were quite sharp, even the first being heard 
 quite plainly. The pulse, although altered as before mentioned, was 
 not a weak one. These conditions of the heart above spoken of 
 were sometimes found with attacks of so-called pneumonia, and in 
 two cases the pulmonary conditions suddenly disappeared, seemingly 
 being supplanted by the cardiac condition, suggesting the nervous 
 origin of both. In one case we saw the pneumonic phase of the 
 disease replaced by the disturbed condition of the heart, and this 
 action of the heart again replaced by delirium. 
 
 In another case the pulmonary catarrh was immediately sup- 
 planted by active delirium, and this again supplanted by an active 
 catarrhal diarrhoea. We should say that the condition of the heart 
 found associated with and following the influenza was due to an 
 affection of the inhibitory nerves of the heart. There was no special 
 disposition to endocardial inflammation during the last two years. 
 In fact, it would seem to be, so far as our experience goes, less 
 frequent during that time. 
 
 Angina pectoris and anginose symptoms have been observed very 
 frequently during the last year and a half, one of the writers having 
 seen sixteen cases within that time. These seemed to be generally in 
 men, and unassociated with organic disease. The angina often alter- 
 
EFFECT OF INFLUENZA POISON UPON THE HEART. 3 
 
 nated with attacks of asthma. Some of these were well-marked cases 
 of angina pectoris ; in others the pain was decided over the region of 
 the heart, and was associated with a heavy, tired, aching sensation in 
 one or both arms. Confinement to bed, careful diet, nervous seda- 
 tives, heart tonics, and counter-irritation generally afforded relief. 
 Some of the cases lasted one or two months. 
 
 Dr. Juergensen has stated that the heart is almost the only source 
 of danger in influenza. According to our experience, in the first 
 epidemic more deaths occurred from meningeal symptoms than from 
 heart- failure, and the cases in which the heart was affected were 
 rarely old heart cases, or aged persons. 
 
 The heart was little complained of by the patient in the course of 
 the disease, except in cases with anginal symptoms, the other condi- 
 tions producing very little anxiety or distress. 
 
 In the first outburst the poison seemed to overpower the heart ; in 
 the second it seemed to simply disturb the organ ; in the anginose 
 cases it was a nervous irritation, producing a neuralgic condition. 
 
 The treatment for heart-failure, according to our experience, was 
 as follows : First in importance was alcohol. Next to alcohol, 
 citrate of caffeine was the best stimulant to the heart, being- also a 
 stimulant to the respiratory centre in lung cases, and a stimulant to 
 the kidneys in addition to its heart-tonic properties, and thus more 
 completely filled the indications than any other one remedy. It was 
 also prompt and efficient in cases of irregularity of the heart. Cactus 
 grandiflora added greatly to the efficiency of the caffeine as a simple 
 heart tonic, well borne by the stomach, and incapable of doing harm. 
 Digitalis and strophanthus were found to be of benefit in small doses 
 where the stomach tolerated them, and when the pulmonary circula- 
 tion was not obstructed. We have not been impressed with the 
 efficacy of large doses, or long-continued use of smaller doses of 
 strychnine by the mouth, or by hypodermatic injection. It seems 
 to us to expend the force rather than to increase its amount. 
 
 "While our therapeutic resources are, at least in theory, equal to all 
 demands made by rapidly acting hearts, and while with digitalis, 
 strophanthus, convalleria, sparteine, cactus grandiflora, adonis majalis, 
 etc., we can reasonably expect to reduce such a heart to a normal 
 beat, and increase and improve its tone, we have actually no reliable 
 means for increasing the rapidity of a slow heart, such as we find 
 so frequently in the course of influenza. The reserve strength of the 
 heart being so diminished, it seems probable that, even if we pos- 
 sessed such a drug, it might under the circumstances prove disastrous. 
 
4 CURTIN AND WATSON, 
 
 The heart itself, unimpaired in muscular tone, simply lacks innerva- 
 tion from its centre supply, and does its best under the circumstances. 
 The actual indications seem to be to keep the patient free from all 
 bodily or mental excitement, and stimulate general nutrition until 
 the disease yields, rather than exhaust the centres still more by ill- 
 timed and ill-judged local stimulation. This is the secret of the 
 beneficial action of alcohol, acting as a stimulant to produce nerve- 
 force rather than creating a local excitement, which would use up 
 still more rapidly the deficient supply, and which would bring about 
 a condition incompatible with life. 
 
 One proof that the weakness of the heart was of nervous origin 
 was the rapidity with which it presented itself and the rapid recovery. 
 A possible element in heart weakness met with late in the disease was 
 the anaemia, which interfered with the nutrition of the heart muscle. 
 Such a condition of the blood was frequently observed as a sequel. 
 
 Sulphonal was the most safe and satisfactory drug for combating 
 the insomnia, being well borne even by comparatively weak hearts. 
 
 In addition to the consideration of the influence of influenza upon 
 the heart, some interesting and apparently new points in connection 
 Avith the disease may be of interest. 
 
 In a paper by the writers, read at the International Congress in 
 Washington, in September, 1891, a brief allusion was made to the 
 fact that the sexual power in the male was impaired often, and in 
 some cases apparently lost. In this connection some observations 
 made by Adolphe Bloch, of Paris, are of interest. The number of 
 births in every department of France was less in 1890 than in 1889 
 — very considerably less. In one department, for instance, over 
 3500 less, both legitimate and illegitimate. It occurred to the 
 observer that this might be explained by the epidemic. If so, as the 
 disease raged mostly in December, 1889, and January, 1890, the 
 effects should be shown in diminished births in September and 
 October, 1890 — which was the case. The statistics gathered by him 
 show very conclusively that, in his own words : " The grippe was 
 largely responsible for the extraordinary and unusual diminution in 
 natality in 1890. Now this responsibility is capable of explanation 
 in several ways : Sexual impairment in the male, in the female also, 
 or in both, or impaired health — generally, distraction of mind from 
 anxiety and increased labor — or the actual diminutiou of the child- 
 procreating and* child-bearing members of the community by death." 
 
 The child in utero was probably also influenced. One of the 
 writers has seen incidentally four cases which seemingly support this 
 
EFFECT OF INFLUENZA POISON UPON THE HEART. 5 
 
 view. In the first case, a lady from the West, who had a severe and 
 dangerous attack of grippe about midway in her pregnancy, after an 
 easy labor, was delivered of a child apparently in good health, as all 
 her previous children had been. When about six weeks old the left 
 femur became painful, hot, and tender; later the limb began to swell, 
 and there was considerable induration and enlargement about the 
 whole shaft of the femur. Dr. D. Hayes Agnew examined the case, 
 and decided that it was a general periostitis ; under treatment the 
 swelling, pain, and heat subsided. In the second, a child about two 
 months old, whose mother had suffered severely in the epidemic two 
 months before its birth, exhibited, one month after birth, swellings 
 at the ends of the long bones ; these tumefactions soon ran into 
 abscesses, and the child recovered without any involvement of the 
 joints. In the third, a mother had the grippe one month before 
 delivery ; the child was born weak and puny, and, one week after 
 birth, the abdomen and neck were the seat of an eruption of large 
 pustules rapidly developing, and rapidly subsiding as the condition 
 of the child improved, but has since developed a number of abscesses. 
 In the fourth, a woman — whose first husband had infected her with 
 syphilis, and to whom she had many years before borne one syphilitic 
 child and afterward one healthy one, and who had subsequently 
 married again and borne to her second husband two healthy children 
 — after an attack of influenza during pregnancy, had a child which 
 was puny and soon showed distinct evidences of syphilis, and died 
 in less than two weeks after birth. 
 
 A number of children have been observed — born after maternal 
 influenza — very small, thin, and puny, and in several cases their 
 slow rate of growth and their small size as contrasted with previous 
 children have been a source of great anxiety. 
 
 The delirium and insanity of influenza were peculiar. They were 
 subjective rather than objective, suicidal rather than homicidal. 
 The patient's head was of plaster-of-Paris, and not some other per- 
 son's head ; his was the body sawn asunder and kept apart. It was 
 always his brain that had slipped out of place, and not another's ; 
 or his calvarium that was " hind-side before." Few worried about 
 the affairs of others ; others were always striving to wrong them. 
 Were the thoughts fastened on pecuniary matters, they alone were to 
 be considered. It was all self. The victims of mania were non- 
 combative, unless resisted, unless restrained from efforts to injure 
 themselves — then they became furious. No fears for the comfort and 
 safety of the living interfered with suicidal desires. 
 
6 EFFECT OF INFLUENZA POISON UPON THE HEART. 
 
 This desire to die — so universal, so unusual — was not produced by 
 pain, but by failure in the mainspring of life. The subconsciousness 
 perceived, but the brain of the sufferer only dimly and mistily knew 
 what the world at large yet fails to kuow — how vitally the system 
 was wounded ; how nearly a deadly blow was struck at it by the 
 influenza. If we were for a moment to imagine the malign force of 
 the disease doubled, who can tell what devastation it would work ? 
 Let the slow heart beat a little slower ; let the respiration be a little 
 more feeble ; let the power of retention and assimilation of food be 
 still more diminished, and what result could follow but widespread 
 death, and a recognition by the survivors of a pestilence equalling 
 the frightful epidemics recorded of past ages. 
 
Reprinted from the Therapeutic Gazette, January, z8gs. 
 
 NOTES ON THE OUTBREAK OF IN- 
 FLUENZA, AND ITS TREATMENT, 
 DURING THE FALL AND 
 EARLY WINTER OF 
 
 1891. 
 
 By Roland G. Curtin, M.D., and Edward W. 
 Watson, M.D. 
 
 IN the article by the writers, read last Sep- 
 tember before the Climatological Asso- 
 ciation in Washington, the present outbreak 
 of influenza was prophesied from a study of 
 the Australian epidemics, ranging between 
 the years 1885 and 1890. The object of this 
 brief article is to supplement the papers 
 already written on this subject. The epidemic 
 outbreak of this fall presents some points of 
 divergence from those of the two previous 
 winters, though agreeing with them in having 
 timed its outbreak at a period when — as 
 alluded to in the paper above mentioned — 
 a general intermingling of the populace 
 takes place, due to the almost universal shop- 
 ping and other opportunities for dissem- 
 inating the disease which precede the holi- 
 day season. 
 
 A renewal of the epidemic in its explosive 
 form occurred about December 1, although 
 cases were met with through the summer and 
 fall in steadily increasing numbers. Cerebro- 
 spinal symptoms seemed to predominate, and 
 
the disease was less frank in its onset ; in fact, 
 three cases of true spotted fever were known 
 to have occurred in Philadelphia. Contin- 
 ued catarrhal fevers occurred, though not so 
 marked or protracted as in the year pre- 
 ceding the outbreak of 1889. 
 
 Occipital headache and cervical headache 
 were almost constant symptoms. When 
 serious meningeal symptoms were present, 
 they often immediately subsided with the oc- 
 currence of catarrhal diarrhoea, bronchial 
 asthma, or more serious pulmonary disease. 
 A number of cases of meningitis in children 
 were observed which had followed directly on 
 very slight blows on the head, two of them 
 proving fatal. 
 
 With the first of December cases increased 
 rapidly in number, and took on a more frank 
 type, resembling the outbreak of the fall of 
 1889, but in a lighter form, except in those 
 after middle life, and in cases of relapse. The 
 disease travelled over pretty much the same 
 ground, as remarked by a rural practitioner ; 
 chills, amounting in some cases to rigors, 
 at the onset, were more marked than in 
 1889. 
 
 A condition of chilliness, with a disposition 
 to perspiration, often exists for days or weeks 
 before the real outbreak, which is generally 
 directly induced in these cases by severe ex- 
 posure or exposure coupled with exhaustion. 
 Sometimes chills and consecutive fever as- 
 sumed an intermittent or remittent type. 
 The fever generally has taken a lower range 
 than in the preceding winters, rarely going 
 above 102 F., while before it was often 
 103.5 to 104.5 F. 
 
A true conjunctivitis has often occurred, 
 and readily subsided without treatment. 
 Coryza is not so marked as in 1889. Sore 
 throat is almost universal, the only visible 
 signs of which is a redness back of the anterior 
 half -arches and an enlargement of the tonsils 
 and cervical glands. 
 
 Croupal laryngitis has been very common 
 where the air-passages were affected, in chil- 
 dren resembling sometimes spasmodic laryn- 
 gitis, with a shrill laryngeal cough, and more 
 rarely with a muffled cough, suggestive of 
 cedematous laryngitis. 
 
 In the lungs, bronchitis is the principal 
 symptom, varying but little from that of the 
 preceding year, except in its lighter type. 
 Hemorrhages, both from the nose and bron- 
 chial tubes, is more common, and has gener- 
 ally foretold a speedy subsidence of the pul- 
 monary symptoms. Croupous pneumonia has 
 been exceedingly rare. The explanation of 
 this may be found in the general catarrhal 
 condition of the air-vesicles, which excites 
 free secretion, thus preventing solidifica- 
 tion. 
 
 The catarrhal pneumonia which followed 
 the peculiar conditions alluded to in our earlier 
 articles, was frequent, but by no means so 
 severe as in the first winter, old people very 
 frequently recovering. Almost all the cases 
 of pneumonia were in patients beyond middle 
 life. 
 
 The marked redness of the eyes in the 
 common so-called " grip cold," with general 
 muscular and cutaneous soreness, has been 
 followed, after some days, by the onset of 
 rigors and fever. With these symptoms there 
 
has been a sense of oppression over the 
 chest, and great pain in the head, occipital or, 
 rarely, frontal, and in the limbs. The dura- 
 tion of the initial fever seemed longer than 
 in similar mild cases in 1889. 
 
 The abdominal forms furnished a large 
 number of cases. Diarrhoea is a frequent 
 symptom, and a violent serous diarrhoea gen- 
 erally portends an early and rapid recovery, 
 even where serious symptoms exist. The 
 other abdominal cases of this year consist 
 chiefly of a short period of pain or nausea, 
 followed by some prostration, or a reversion 
 to bronchitis. Infants and young children suf- 
 fered this fall much more frequently than be- 
 fore, but with mild attacks followed by rapid 
 recoveries. 
 
 Treatment. — For the first time since 1889, 
 a recurrence to old therapeutic measures has 
 been of service. The fever mixtures of an- 
 tiquity seem at least to allay fever, induce 
 quiet and sleep, produce perspiration, and 
 hasten recovery. The standard saline and 
 other fever mixtures seemed to be again 
 efficacious. 
 
 For the initial symptoms, salicin still seems 
 to be the best and safest remedy, both as a 
 tonic and an antipyretic, in doses of from 10 
 to 30 grains. Each dose will often be fol- 
 lowed by marked relief, and the occurrence 
 of perspiration, with a fall in temperature. 
 No remedy seems to show the same direct re- 
 sults, unless it be antipyrin or phenacetin, 
 which are decidedly more unsafe, though not 
 so unsafe as in the preceding years, since the 
 tendency to dangerous heart- failure seems now 
 much more rare. Salicin may be combined 
 
5 
 with small doses of phenacetin, antipyrin, or 
 sodium salicylate. 
 
 The formula most agreeable is, — 
 
 R Salicin, ^iii ; 
 
 Sodii salicyl., _^ss; vel Phenacetin, gr. xvi; 
 
 Syrup, acaciae, f^vii; 
 
 Aquae, f^ix; 
 
 Olei gaultherise, gtt. xv. 
 Sig. — Teaspoonful every hour or two. M. 
 
 For the delirium and insomnia, sulphonal 
 is the best and most efficacious soporific. 
 
 Ammonium iodide, in 2-grain doses every 
 hour, until iodism is produced, hastens re- 
 covery in the later stages of pulmonary catarrh 
 and asthma. 
 
 Ammonium chloride has proved more useful 
 this year than heretofore. 
 
 Nausea is best controlled by cocaine, in 
 doses of Jj grain every two hours in solution. 
 In severe cases feeding by the stomach must 
 be withdrawn and rectal feeding employed, 
 champagne and plain soda-water from the 
 siphon being given to quiet the stomach and 
 allay thirst. 
 
 Catarrhal jaundice has been frequently ob- 
 served, generally in children, and treated by 
 small doses of calomel and sodium phosphate, 
 with speedy recovery. 
 
 In any case with bilious vomiting, 2 grains 
 of bicarbonate of sodium and ^ grain of 
 calomel may be employed until some action 
 of the bowels has been produced. 
 
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