will tax to the utmost the resources of the young physician, both as regards his skill in early diagnosis and his judgment in therapeutics and general management, namely, infantile febrile influenza. The symptoms of influenza are varied and depend largely upon the organ of selection. of the toxins produced by the bacillus of Pfeiffer, together with various local alterations of their functional process. Both the constitutional infection and the local symptoms are capable of such wide expression that there will frequently be such a clashing of symptoms, apparently diverse in their significance, that you will often be confused and uncertain in making an early diagnosis. The case I show you is a baby 14 months old, which we have had under our care for twelve days. When the child was first admitted to the ward, it had a temperature of 105°. There was a slight coryza present, but no evidence of bronchitis or pulmonary involvement. The child was restless, yet in a stuporous condition. Digestion not impaired. My first prescription was a bath, prolonged for six minutes, at a temperature of 95°, gradually cooled down to 90°. While the child was in the bath we applied cold cloths to the head, and kept up friction to the body during the five or six minutes in which the child was immersed. result of this bath, the temperature dropped from 105° to 99°. In the course of two hours, however, it again rose to 103°. Immediately after the bath we started with intestinal irrigation. We first injected into the rectum 1 tablespoonful of glycerine with 2 tablespoonfuls of warm water. In five or ten minutes peristalsis was induced and a thorough evacuation of the bowels resulted. In half an hour we followed this up with a high or colon irrigation of 1 quart of tepid water in which 1 drachm of bicarbonate of soda has been dissolved. This solution was allowed to flow into the bowel by gravity, the bag of the fountain

As a

syringe being elevated about eighteen inches above the buttocks. This dislodged some fæcal matter long retained, and which would eventually prolong in autointoxication. We next sterilized the nose and throat with a spray of weak Dobell's solution, followed by an oily mentholated spray. To get the gastro-intestinal tract in a more normal condition and to antagonize the influenzal poisoning, we prescribed the following powders :--

R Hydrarg. chloridi mitis, gr. j. Phenacetini, 5ss.

Sodii bicarb.,

Sacchari lactatis, of each, gr. xij.
M. ft. chart. no. xij.

Sig. One powder every two hours for four doses.

We also used suppository containing 1 grain bisulphate of quinine three times a day.

The coal-tar products must be used with great caution in young children, but phenacetin appears to have little or no depressing influence upon the circulation in moderate doses, especially if antidoted by quiniæ. At the end of one hour after giving this prescription the temperature dropped to 100°, and three hours later it again rose, this time to 106°, and during the greater part of the twelve days that the child has been under our care the temperature has hovered around 105°. The child was sponged every three hours if temperature reached 102°, with ice-bag to head and hot-water bag to feet. Gentlemen, it is most surprising that a child of this tender age should survive such a high temperature for so long as has been the case with this child. The temperature has now, at the end of twelve days, dropped to normal, and remains there. The only compli cation we find present in this case is a few

aphthous patches on the buccal mucous

membrane. There has been no severe respiratory disturbance at any time. It is quite evident that the child has been suffering from the febrile type of influenza, which is very frequent in young children. The poison did not become localized in any of the larger organs, but took the form of a general febrile infection. The temperature has been controlled mainly by means of baths and quiniæ. When the temperature was above 103° we gave pack baths, and when above 101° sponge baths, not forgetting ice-bag to head and hot-water bag to feet. We also used ice suppositories in the rectum when the temperature was very high. We found ice suppositories acted very promptly in reducing the fever, and the child did not seem to mind them as much as it did the disturbance of the baths. While we were combating the fever in this case we, of course, had to keep up careful nutrition. We found that milk, in any form, acted as a poison to the child during fever and seemed to complicate the disturbance, and so for a time we gave the following:

R Whey, iv.
Lime water,

Cream, of each, 3j.

In the course of a few days we found that this also disagreed, and at the end of the third day we abandoned it and alternated with three foods which you will find very valuable in the management of young children who are critically ill. These three foods are albumin water, using the white of 1 egg to a pint of water, well shaken; juice of half an orange slightly sweetened, gum water, made by adding 1 drachm of gum arabic, 1 drachm of sugar, and 1 teaspoonful of brandy to 1 pint of boiling water; toast water, made by breaking up two slices of well-toasted bread in 1 pint of boiling water and adding 1 drachm each of brandy and sugar. For the last nine days

this child has lived on these three foods alternately, and has not apparently lost in vigor, while it has lost some in weight.

This, gentlemen, constitutes a very brief outline of how you should handle a severe infection of influenza in a child of this tender age. There is no disease which overwhelms the child so thoroughly and so quickly as influenzal poisoning, and you must meet all the indications very promptly. After the temperature dropped, in this case, we resorted to cardiac stimulants, giving 1 drachm of the following every three hours:

R Strychninæ sulphatis, gr. 1/3.
Elixiris lactopeptin, fiij.

You can administer this in gum water, with a little water. When the heart begins to strengthen under this treatment you can increase the intervals of administration to every four hours, and finally twice a day..

Now that the temperature has reached normal and the active symptoms have subsided, you must not expect a rapid convalescence. Unfortunately, this is not the case. You know that the alimentary canal. is an especially vulnerable part of the body, and from the aphthous patches in the mouth we may infer that the lymph nodes. and solitary glands in the intestine are saturated with the influenzal poison, and will constitute a source of reinfection for a long time if the vitality remains low. This is one of the characteristic features of the disease, that after the subsidence of the acute stage there is apt to be a recurrence of a new type of the same disorder; relapses are frequent. The child should be protected, if possible, from reinfection, by removal to healthy environments. The complications of influenza are more serious and far-reaching in their effects in young children than smallpox or diphtheria, although it will take a long time to educate the public up to a proper appreciation of this fact.

first twenty-four hours; hence, an early

INJURIES OF THE LIVER AND

institution of the proper treatment of these

cases.

The indications for treatment in the

PORT OF A CASE.

BY M. P. WARMUTH, A.B., M.D., Lecturer on Surgery and Demonstrator of Operative Surgery, Medico-Chirurgical College; Assistant Surgeon to the Medico-Chirurgical Hospital and Philadelphia General Hospital.

INJURIES of the liver may be of any degree, from a slight tear in the capsule to the complete destruction of one or both. lobes. In this article I shall only speak of those injuries that are of sufficient gravity to cause death, primarily from hæmorrhage, or subsequently, by the development of sepsis, unless relieved by surgical intervention.

The causes of injuries to the liver are stab-wounds, gunshot wounds, blows upon the abdomen over the region of the liver, and "crushes." These injuries are conveniently divided into "subcutaneous" and "open" varieties. Kehr further divides the subcutaneous variety as follows:

1. Rupture of hepatic tissue combined with tears in the capsule.

2. Separation of the capsule with subcapsular hæmatoma.

3. Central rupture which often gives rise to separate or united hæmatomata which may develop into cysts or abscesses.

In the "open variety" there is a wound of the abdominal wall communicating with the liver injury, which is often complicated with an injury to some of the adjacent

organs.

It is necessary to remember that injuries. of the liver may be multiple as well as single, and that hæmorrhage is in proportion to the extent of the injury. Elder has shown that all patients who die of hæmorrhage from wounds of the liver do so in the

it is the recognized practice in all penetrating wounds of the abdomen, whether stab or gunshot, to explore at once to control hæmorrhage, to repair any damage done to other organs, to remove any foreign mate-. rial that may have been carried within the abdominal cavity, and to institute the best methods for the prevention of sepsis.

In the "subcutaneous" variety the indication is by no means so clear. In these cases the only diagnosis possible is that of internal hæmorrhage. We may suspect an injury to the liver if the force or blow has been applied over the region of this organ. I distinctly recall seeing a patient several years ago who had received a violent blow upon the abdomen, and complained of severe pain in the left inguinal region. There was no evidence of any external injury, not even a bruise. He presented all the symptoms of severe internal hæmorrhage and was operated upon at once by Dr. Laplace, to whose service at the MedicoChirurgical Hospital he was admitted. The liver was completely shattered, fragments being found throughout the entire abdominal cavity. Therefore, with the history of a blow upon the abdomen, the absence of any external evidence of injury should not obscure the diagnosis of the real condition.

The symptoms most to be relied upon

are:

1. Shock which continues, and shows little tendency to react.

2. Pulse rapid and feeble. 3. Pallor.

4. Increasing pain and tenderness. 5. Rigidity of the abdominal muscles. 6. Dullness over the right iliac fossæ. If the surgeon should conclude that internal hæmorrhage is taking place, al

though all the typical symptoms are not present, he should not delay operation, for in these cases delay is frequently more harmful than an exploratory incision.

The object of surgical intervention in these cases is for the purpose of control ing hæmorrhage and preventing sepsis. The incision to be adopted must depend, to a great degree, upon the fancy of the operator and the site of the injury. The incisions for gall-bladder operations are the ones most commonly used. In the "open" variety the original wound may be enlarged or a new incision made, according to the necessities of the case.

After exposure of the liver and the location of the injury the following methods are ordinarily recommended for controlling hæmorrhage:—

1. Suture.

2. Tampon of gauze.

3. Thermo-cautery. 4. Steam.

The larger vessels may be ligatured as their coats are sufficiently strong to bear the ligature, or they may be ligated en masse by passing a suture through and through the entire liver. For this work Kousnetzoff recommends a thick or coarse suture material on account of the great friability of the liver. He also devised a needle patterned after the Hagerdorn, but with a blunt point and no cutting edges. This or some modification is undoubtedly the best needle for this work.

For closing up these injuries, Frank, of Chicago, recommends a continuous suture, first, deep down to the depths of the injury or wound, and the next a superficial suture only through the capsule, continuing in this manner until the wound is closed. The abdominal wound is then closed without drainage.

Not long since I had occasion to adopt Frank's method and was well pleased with

result. The report of the case is as follows:

J. M., age 33, white, admitted to the Medico Chirurgical Hospital suffering from a stab wound of the abdomen. The wound commenced about one inch below the ensiform cartilage and continued parallel with the right costal border for one and one-half inches. The wound was bleeding freely when the patient was admitted. His pulse was rapid and feeble; his pallor was extreme; but being under the influence. of liquor, the patient's answers to questions were unreliable. He was operated upon immediately after admission, by extending the wound downward to the border of the rectus, then parallel with its fibers to near the umbilicus. The abdomen was filled with blood, and as soon as this was removed a cut about one and one-half inches long was seen upon the superior surface of the liver near the inner border of the right lobe, and extending almost through the entire thickness. By using Frank's continuous suture method the bleeding was quickly and easily controlled. The abdomen was closed with exception of a small gauze drain which led down to the liver wound. During the operation one quart of normal saline solution was administered intravenously, and the patient's condition was much better than when the operation began. While recovering from the anæsthesia the patient began to manifest symptoms of delirium tremens. His delirium grew more violent and he finally died of sheer exhaustion eight hours after the operation. At the post-mortem the abdomen was free from blood and the sutures were in situ, absolutely controlling hæmorrhage. While the patient died, I was able to control the hæmorrhage, and accomplished what I intended, and believe, in a normal patient, this method will soon change an almost fatal prognosis into a most favorable one.

863 North Twentieth Street.

THE DANGER OF VENEREAL DISEASES AND A STEP TOWARD THEIR PROPHYLAXIS.

BY S. LEON GANS, M.D., Demonstrator of Genito-Urinary Diseases in the Medico-Chirurgical College; Assistant Genito-Urinary Surgeon to Medico-Chirurgical Hospital and Surgeon to the Out-Patient Department of Same.

DURING a period of a few months this, as does other cities, spends a large amount of money in its effort to stamp out smallpox, scarlet fever, diphtheria, and other contagious diseases. Every year money. and time is expended in an honest effort to arrive at a proper prophylaxis of tuberculosis, while during the same period a larger amount is spent in contracting, propagating, and distributing gonorrhoea. The consumptive is surrounded by all kinds and forms of precaution to protect others; the smallpox victim is presented with two large, yellow danger signals and four police officers in twenty-four hours to call public attention to them. Compare this condition of affairs to the man with "only a clap," so diagnosed by some medical man with a knowing smile and small regard for this dangerous malady.

This yellow danger signal is all the more of a menace to the community because concealed; he has no officer of the law, or no elaborately printed card to proclaim to the public that he is a walking source of infection. The former unfortunate and his family are subjected to annoyance, discomfort, and expense, for the patient having contracted a disease insontium our gonorrhoeal protegé is allowed perfect freedom for having contracted a disease in a manner which might be called elective.

The argument immediately set forth. would be that the former group is the more dangerous type of disease. From a standpoint of mortality directly due to the disease this is correct, but surely a face marked with pits, a deaf ear, or a temporary paral

ysis, is no worse than a face minus two eyes due to the gonorrhoeal process. Smallpox spends its fury on the patient, though it may be and is often transmitted, but gonorrhoea will be spread among a large number of innocent persons in a non-venereal as well as a venereal manner.

When we look at the number of useless joints, blind eyes, and chronic invalids due. to diseased prostate glands, kidneys, etc., we are considering the damage done the patient.

Consult the gynæcologist and ask him the causative factor in the majority of "pus tube" cases among young married women and others. Look over our case books and we will be horror-stricken to find the large number of endometritis cases, pelvic abscesses, and post-partum sepsis due to this "only a clap" in a husband who had thought himself perfectly well or. far worse perhaps, had been pronounced cured by some medical adviser. Consult the ophthalmologist and hear of the cases of ophthalmia neonatorum which have destroyed the eyes of innocent children. Inquire carefully into your cases of ulcerative endocarditis; make post-mortems of deaths caused by inflammations of other serous membranes peritoneum, meninges of brain and spinal cord; now and then a suicide from sexual neuræsthenia, impotence, etc. then and only then will we realize the ravages of a gonorrhoeal infection.

Let us acknowledge the power of this dreaded disease. What can be done to prevent it? If all our efforts as to the contagious diseases are correct, and they surely are, we might at least take advantage of every possible chance to prevent gonorrhoea. It is claimed that to license the houses of prostitution is to encourage or at least sanction immorality. Be that as it may, it is of questionable usefulness on other grounds. Noeggorath states that all prostitutes have gonorrhoea in some form, but does not venture an expression