4th-Less fever both a. m. and p. m.

sounds unchanged.

Heart area and

5th-Fever diminishing; much brighter. Heart area appears if anything slightly larger, but the sounds are loud and there is no friction. There is still an expiratory moan. The general condition and pulse are very satisfactory; the child appears to be improving in every way and is allowed to be wheeled out of doors for two or three hours.

6th-Fever almost gone, and although respiration is still rapid, yet the child appears very comfortable and the pulse is of good strength at 135. The parents are chiefly disquieted by violent screaming spells, which occur for the most part in the night and cease while the baby is taken out of doors. The color is good, the lungs and abdomen negative, and recovery appears to be progressing rapidly. It is difficult, however, to understand the rapid respiration-dyspnoea seems hardly the word, since there is apparently no air-hunger on the supposition hitherto entertained of a simple serous pericardial effusion.

7th-Great general improvement, out of doors much of the time, and screams much less. Made but one visit today.

8th-Calling at about 6 p. m., I was much alarmed by what appeared to be a condition of sudden collapse, though not noticed by the parents, the nurse having been dismissed the day before. The pulse was hard to count and the face showed a slightly cyanotic pallor; otherwise the child appeared fairly bright and comfortable. Although not quite certain of the gravity of the condition, chiefly because it was so unexpected and apparently unaccountable, a mustard pack was ordered with a great increase of cardiac stimulation. In spite of these measures collapse increased and death occurred in about an hour.

The autopsy, made by Dr. R. W. Arndt, showed as essential lesions small areas of fibrinous pleurisy at both bases without apparent pulmonary involvement, and a pericardial sac full of thick, creamy pus. The amount of pus was not large, possibly 6-8 oz., and the distention was not extreme. The whole parietal and visceral surfaces were covered with a thick corrugated layer of fibrinous deposit. The pus contained only a rod-shaped bacillus, which, though not carefully studied, was probably the specific organism of grip.

The interesting features of this case are:

1. Its probable association with grip, representing a certainly rare complication.

2. The unusual difficulties of diagnosis, occasioned by the absence of other signs than precordial enlargement, giv

ing rise to some doubt even as to the presence of effusion at ail; and especially by the association of suppuration with a falling temperature and apparently progressive improvement.

3. The suddenness with which death may occur in pericardial effusion, due here, unquestionably, since the effusion was not large, to myocardial degeneration and not mechanical interference with the heart.

SOME SURGICAL SEQUELAE OF INFLUENZA.
By LEONARD FREEMAN, M,D.

Denver, Colo.

The most interesting surgical sequelae of la grippe, aside from affections of the ears and the accessory sinuses of the nose, are found in connection with the nerves, joints and bones. They may immediately follow the disease, or may not manifest themselves for weeks or even months. They may be regarded from two points of view-as lesions causing suffering and calling for treatment, or as confusing factors in diagnosis, which may lead to embarrassing and serious mistakes.

Neuritis, for instance, may affect the ilio-hypogastric nerve and simulate an attack of appendicitis. The lowermost intercostal nerves can become involved and give rise to symptoms resembling those of a nephritic or gallstone-colic, or an ulcer of the stomach. In fact, such mistakes have often been made and have lead to useless operative procedures. The true condition may generally be recognized, however, by noting, among other things, the history of the case, the tenderness of the nerve-trunks throughout their course, and the extreme hyperaesthesia of the skin, especially when a fold is pinched between the fingers. The prompt disappearance of pain following a dose of phenacetin or other appropriate treatment is also suggestive.

Stubborn and painful neuralgias, requiring more or less serious operations for their relief, quite often follow influenza, especially in connection with the trifacial nerve, and if casehistories were more thoroughly obtained, the sequence of cause and effect would be recognized more frequently.

Joint and bone lesions are not unusual, and are of considerable interest. Even when the joints are evidently involved, the real seat of the trouble is probably in the adjacent bones, in the majority of instances at least. Almost any portion of the skeleton may be affected, but the most frequent manifestations are in the knee, foot, tibia, hands, ribs and

skull, in the nature of plastic periostitis or osteo-periostitis, resulting, at times, in the production of more or less permanent and tender nodes. Suppuration rarely occurs, and when it does, it is generally due to mixed infection with the ordinary pus-forming micro-organisms.

So-called "influenza-knee," described in detail by Franke, is not uncommon. It is accompanied by swelling of the joint and characterized by especial tenderness over the internal condyle of the femur.

Pain and tenderness in the heel and sole of the foot arise from periostitis and from inflammatory thickening of the plantar fascia, which sometimes develops exquisitely painful nodes within its substance. Tenderness of the heads of the metatarsals may simulate Morton's disease, while true metatarsalgia can arise from inflammation of the external plantar nerve. The tarsal bones may also become involved, causing swelling of the tarsus with difficult locomotion, which may early be confused with beginning flat-foot.

The anterior aspect of the tibia may be the seat of tender and painful spots and periosteal thickenings, which are easily confused with those arising from syphilis.

Spinal periostitis can cause pain and rigidity, accompanied, at times, by perplexing and disturbing neuralgias from involvement of the spinal nerve-roots, the pain being referred to the areas of distribution of the nerves.

The hands are not uncommonly attacked, giving rise to swollen joints and tender nodes upon the fingers. Inflammations of the tendon-sheaths, muscles and bursae in various localities also occur, as well as a form of non-suppurative orchitis closely resembling that of gonorrheal origin. Periosteal lesions, sometimes causing multiple nodes, may also appear upon the ribs and the skull.

It will be noted, from the foregoing, that the bone-lesions of influenza closely resemble those of typhoid fever.

Many observations go to show that appendicitis not infrequently follows influenza, which is readily understood when we consider the manner in which the mucous membrane of the entire gastro-intestinal tract is involved.

All sorts of abscesses in various regions are apt to succeed la grippe, possibly due to the specific bacillus alone, but more often to a mixed infection, which is also true of suppurative affections of the pleura, pericardium, cerebral meninges and joints.

Although they do not come strictly under the head of surgery, it is proper that I should refer to the various characteristic skin- lesions, such as petechiae and more extensive

extravasations of blood beneath the skin and mucosae; also angio-neurotic swellings and erythematous areas, and herpetic eruptions along the courses of nerves.

I have recently seen a case, in consultation, which so aptly illustrates many of the points just enumerated that I venture to describe it here, although the diagnosis is rather uncertain, as the bacillus of influenza was not demonstrated. Some two weeks ago a man about 35 years of age contracted a severe "cold" which enervated him profoundly. Among other symptoms of influenza he experienced severe muscular cramps, and his hands and feet "went to sleep" frequently and had to be rubbed energetically to restore their normal sensation. He had previously been in his usual health, his diet and habits being those of an ordinary individual. At the end of a week his knees swelled and became exquisitely painful and tender over the internal coudyles, this being accompanied by pain in the heels and along the tibiae and followed by swelling of the joints of both hands. Somewhat later a severe pain manifested itself in the left iliac region within the distribution of the ilio-hypogastric nerve, and a tender and painful swelling occurred over the left lower ribs anteriorly, with marked hyperaesthesia of the skin. Meantime, petechiae and even large extravasations of blood appeared on the skin of the extremities and trunk, and especially the eyelids and forehead, the eyes being swollen completely shut. Extravasations also occurred within the mucous membrane of the mouth and pharynx, and mucus streaked with blood was expectorated from the trachea.

The bone and nerve-lesions of influenza often respond promptly to treatment, but occasionally a stubborn case is encountered which resists all efforts for weeks or even months. Violent methods are usually contra-indicated, such as massage, passive motion, or voluntary exercise. It may even be advisable to confine the patient to bed. The best results seem to be obtained by rest, hydropathic measures, and the administration of those drugs most efficacious in the treatment of influenza. Operations are not often required, and one should be more than careful to avoid operating uselessly upon the strength of a mistaken diagnosis. Occasionally, however, nerves may be excised or stretched to great advantage, as is done in the various forms of intractable neuralgias, and pus should of course always be evacuated as expeditiously as possible.