pletely and the use of tobacco reduced to a minimum. As a rule the three regular meals should be replaced by more frequent ones consisting of smaller amounts of easily digested food with a minimum amount of meat. Whatever causes flatulence should be avoided. When headache, insomnia and nervous symptoms are troublesome it is of advantage to place the patient on an exclusive milk diet for a time.

Hydrotherapy-Warm tub bath (temp. 98 to 100°) once or twice daily. Massage of muscles is beneficial because depletion of the veins may follow giving relief to overfilling of arteries. Either sodium or potassium iodide may be used and are the best medicinal effects. The best effects are obtained when they are used in small doses and continued over a long period of time. For insomnia, warm milk and hot foot bath at bed time. Care must be taken in administration of heart stimulants. Usually

a sedative is better and safer.

In hemorrhage the head should be high with plenty of pillows and the body placed in a half reclining position. Cold may be placed to head to cause contraction of the cerebral vessels and heat to the lower extremities to dilate the blood vessels and lessen the blood pressure in the brain.

sure.

If the case is one of embolic obstruction our desire is to increase the intracranial blood presFor the embolism already being there and beyond the hope of immediately removal, it is an object to check its progress and further development by suddenly making it stationary. To do this the head of the patient should be placed as low as possible, instead of a cardiac sedative a stimulant acts more favorably, such as digitalis or ammonia. The head should be to one side, the nurse should keep the tongue forward and keep the mouth swabbed out. Venesection is not to be recommended unless the pulse is strong and full and the heart in good condition and the patient robust. About ten ounces of blood may be withdrawn. The heart action is however, usually weakened in apoplexy and to weaken it still more, deprives it of its natural stimulus and is not to be recommended. Venesection should never be employed in embolism.

It is a very difficult matter to carry out treatment of these kind of cases outside of an institution especially when mental symptoms are prominent, such as delirium, persecution, mental confusion and extreme irritability. Many of them get along much better and are more contented when among strangers than when in their own homes.

Hot milk, hydrotherapy and simple hypnotics when carefully used are effectual in controlling restlessness and much more satisfactory than indiscriminate use of sedatives.

DISCUSSION.

Dr. Harvey: Not in position to comment on the paper, but wishes to express his appreciation of its excellence. It shows a great amount of experience and ability.

Dr. Fulkerson: Circulatory disturbances of the brain do not come within the scope of the opthalmologist, but wishes to urge the early examination of the eye in this class of cases. Has been surprised to find how early and how easily the changes can be found in the eye. Opthalmoscopic examination will render a great deal of service in many of these cases and the general man should familiarize himself with the use of the opthalmoscope.

Dr. Jackson: The essayist has observed a large series of these cases and his experience is of great value. Asks what proportion of these cases die of paralytic symptoms. Janeway states that only a small per cent. die with apoplectic symptoms, but rather a large per cent. die from cardiac causes. Would expect from a series such as just reported, that a larger percentage would have terminal cerebral symptoms.

Dr. Penoyer: An article in Clinical Medicine emphasizes the point brought out by Dr. Fulkerson on the importance of the opthalmoscopic examination. Patients having arterio-sclerosis often have a low blood pressure. Arterio-sclerosis may involve only certain regions of the arterial system. Abbott has worked up the subject of hypotension and says that there is a class of arteriosclerosis in which the renal changes may not be marked. We should examine the condition of the blood vessels and along with this consider the findings of the opthalmoscope. Many cases become cardiac cases.

way.

Dr. Gregg: Agrees with Dr. Fulkerson that a very important thing is the examination of the fundus of the eye. Do not get as clear a conception of the condition of the brain in any other Examine for the tortuosity of the blood vessels, etc. Does not believe the percentage of arteriosclerotic patients who died of stroke to be very high, probably noť over 10 per cent., some other lingering disease usually carries them off, such as cardiac disease, pneumonia, etc. Arteriosclerosis may bring on an exhaustion, and it is hard to tell what really did cause their terminal symptoms. The complete rest is not satisfactory in all cases and should be modified according to the case. There should be lessening of responsibility but not absolute inactivity in early

cases.

A NOTE ON THE TREATMENT OF INFLUENZAL PNEUMONIA BY IN

TRAVENOUS INJECTION

OF NON SPECIFIC
PROTEIN.

THEODORE LOUIS SQUIER, M.D.

(From the Department of Internal Medicine, University of Michigan.)

In spite of the fact that many articles have already appeared concerning the excellent results following non specific protein therapy in influenzal pneumonia we feel that its value can not be over emphasized. To attempt a detailed discussion of the merits of such treatment would lead us beyond the scope of this paper. We wish merely to present four cases, the first two of which were treated with the idea in mind of combating the infection by supplying additional specific immune bodies as such. The apparent failure of this treatment in the second case led to the successful use of non specific protein in this and the two subsequent cases.

CASE 1. The patient, a nurse, entered the ward Oct. 29th with symptoms of influenza. Her temperature, pulse and respiration remained normal subsequent to her admission and as she felt well and there were no physical signs discovered she was discharged on the 31st. On the day following her discharge she re-entered the ward with a temperature of 101.5 degrees. Her symptoms increased in severity but with no definite abnormal lung signs until Nov. 4th when her temperature rose to 104 degrees and her respirations increased to 30. A few crackling rales were heard at the left base and a definite area of consolidation was found in the left lower back. She complained of general aching, was nauseated and vomited frequently. On the following day she raised blood streaked sputum, had a great deal of pain in her left side and coughed considerably. The nausea continued and on Nov. 6th she was irrational at times. Her condition became progressively worse until on the 8th her temperature dropped to 101 deg.. but the pulse increased in rapidity, cyanosis was marked and her respirations were of the rattling, bubbling character which had proved of ominous import in preceding cases. She was at this time given an intravenous injection of 450 cc. of citrated blood (homologous) from a patient who had recently recovered from influenzal pneumonia. The transfusion was preceded by the withdrawal of 250 ce. of blood. Forty-five minutes later she had a severe chill lasting half an hour. Her temperature rose to 105.2 degrees and then fell

by crisis, as shown on the chart, to normal, and there was a coincident fall in the pulse and respiration. The change in her general condition was remarkable. After the reaction she became perfectly rational, was very comfortable, and except for a post critical rise to 100 degrees on the following day her temperature thenceforth remained normal.

CASE 2. The patient, E. B., a nurse who had just cared for a fatal pneumonia case, entered the ward Nov. 1st with a temperature of 100.4 degrees. On the 8th her respirations rose to 32 and the temperature to 104. On examination there was slight dullness in the right lower back. A chest X-ray confirmed the diagnosis of early pneumonia. She was then given intravenously 300 cc. of citrated blood from a recovered case of influenzal pneumonia. The transfusion was preceded by the withdrawal of 200 cc. of blood. There was no reaction whatsoever and the temperature, pulse, respirations and general condition remained unchanged.

On the assumption that the blood used might possibly have contained fewer immune bodies than did that which was used in the preceding. patient, transfusion was repeated on the following day. This time 300 cc. of blood obtained from the same patient whose blood had produced such excellent results in the first case was injected, 250 cc. of blood having first been withdrawn from the patient. Again there was no reaction and again there was no change in the temperature, pulse, respiration or general physical condition of the patient.

We were led to the conclusion that either the remarkable improvement following transfusion in the first patient was due to a natural crisis coincident with the transfusion or else it was due to the reaction, since transfusion with the same immune blood when no reaction followed caused no improvement. Therefore on the following day, Nov. 10th, the patient was given one billion typhoid bacilli intravenously. Onehalf hour later she had a severe chill which lasted twenty minutes. Her temperature rose to 105.8 degrees and then fell, in the course of the next six hours, to normal, with a corresponding drop in the pulse and respiration. On the 11th and 12th there was an afternoon rise in temperature to 101.2 degrees and 101.8 degrees respectively. On the 13th her temperature was normal and it remained so until on the 19th when she began to run a septic temperature which was demonstrated by X-ray to