JAN. 4, *919] INFLUENZA AND ITS COMPLICATIONS. MYLD3rnJOwAt 3 tlhan we have to the cause of tllat most baffling of all blood diseases, Addison's anaemia. The progress and the blood picture suggest the liaemolytic type, whicll can be produced experimentally and which is caused by the poisons of the Bothriocephalus. In the profoundly clhangetd metabolism of pregnancy and in the intenisely katabolic metabolism of the Post-parluw states we assume tire production of haemolytic agents-toxins-but, as

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... reuelh remnarks, " tlhe use of the word toxin alitmost coninotes ignorance." Though progressive and often pernicious, tlhe aniaenmia is caused by an agent wlhiclh differ-s in one allimrportant particular from that whiclh causes the anaemia of Addison. Whlen recovery takes place it is permanent, and the woman may escape in subsequent pregnancies. Thlo second patient in my series (wliorii I kneW well) hiad 4n attack of extreme gravity, recovered, bore two children 4nbsequently. and was alive tlhirty years after the attack. Iecovery from the Addisonian form miay last ten, fifteen, or even seventeen (MePhledrai) years. but suclh instances are exceptional, aInd in the cases of reporte(d permanent recovery there is always thio question of mistaken diagnosis. The blood picture may be of value in estimijatingo tlhe outlook. Siguls of active regeneration may be presenit, as in Mrs. A.'s case, ind(icated by blood crises and a large proportion of red cells witli signs of recent formiiation, and the basoplific gratiulation diescrih)ed by Boggs and Morris and by Milne, tioe riito:hOuduiL (Sappington) arid tlhe reticalation described by rlobertson and lBock 12 Tlhe number may rise frotim 1 per cent., the normal, to 20 or 25 per (ent. witi marked bone-nmat-ow stimulation. A hiiglh colour index is the rule in tlhe pregnancy and po8t-pal-tuMfl cases. 'FIre blood condition is uncertain, lhowever, as well slhown in two exceptionally well stuidied cases in Meyer's clinic, reported by Jungermann,i in wlicil thle contrast was striking, tle one withl low colour index and features of an aplastic anaeria, tire othier the chiaracteristic Addisonian picture. Botli were pregniancy cases, and both li-d noriimal deliveries -and recovered corilpletely. Th'e abseuce of platelets is a feature of tle coimmon idiopathic anaemia, contrasting, in, thjis respect, withi tlhe post-laernorrhagic and septic formns. In the liands of skilful students the criteria offer-ed by tile blood examination shiould, as.-a rule, be of great valtie in the prognosis. My individual experiernce is exceptional and miuch more lhopeftil tihani itndicated in tlhe literature, and particularly in works on obstetrics. The seven cases seeii in Montreal qii Piliiadelplhia recovered. I lhave not at hand our larga naterial-froin tle Jolbis Hopkins Hospital; but I do not remhember a fatal pregnancy or post-partuum case. The latet appear to be the mbre fatal, and tlhe cases reported by Elder and Mathews 4 slhow that a fatal termination way follow in spite of the most careful treatmnent. Acute liaernortrhage p0ostparlum may be rapi(dly fatal front reductron in blood volumiie; very large amounts wiay bi lost extending over several days, and yet recovery takes place. The report of Robertson and Bock, just mentionied, coIitains muclh information of value in estimating the blood less in lhaernjorrhage and the mieans of treattment. From what is recorded, and from personal experience, I slhotrld say tle danger of a grave anaemia progressive in character is not great after a fairly profuLse haemorrlhage. Once the bleeding stops, recovry isprogressive and often surprisingly rapid. On tlhe other hand, repeated small losses of blood after abortion or a normal delivery may be followed by an anaemia out of all proportion to the quantity of blood lost. Tlle starting point, indeed, of a few cases of Addison's anaemia appears to be repeated epistaxis or bleedinag piles. The treatment of the cases is that of the severer fornms -fresh-air, rest, food, iron, and arsenic (in which I still have faith); and if the blood count is very low, 20 per cent. of corpuscles and liaemoglobin, transfusion may be employed. Thie newer technique has many advantages, but the results do not, in Addison's anaemia at any rate, appear to be more favourable than those we had with the old Avelinig or Roussel apparatus. REFRUENOES. Tnp following observations were made during a severo epidernic of iifluIenza amtiongst patients of thie 3rd and 4tlh Scottish Genieral H-lospitals a few weeks ago. rTle miajority of cases were amongst Aniericau troops, antd1 miost of the patients were ill on arrival at Glasgow by transport. Otlhers were ahlongst Britislh troops, arid tlherc was no essenitial differenice between the twvo groups of ! ases excel)t that pneueiionuia was sniore frequent amionDgst the formner. At the outset we were struck bv the prevalence of nmixed inifections, as hmas been found by variou>s observers elsewhere, anid we lhave enideavoured to trace tlhe part played by tlhe various orgauisms concerned, as regards botlh thle conmplications whichl occuirred and thje iimanner in wlhichl a fatal result took place. 'T'lie facts recorded refer chiefly to the results of post-mortent examnations, and we jbriig tlhemn forward, as it is desirable to lhave as mnanty records as possible of tlhe featureb of the epidemic in diffetrent localities. 'T'o) sl)eak generally, we miiav say tlhat tlle syml)toIns were essentially tlose of severe influenza, wvithi a prepondlerance of puilmonary affectionis, wlichi may be rouglhly classitied und(ier the hjeadings; of bronchlitis attended wIth Imarked irritation, bronclh-opuenmiiiionia, aind lohar pneum-lonia. Amnougst the pneumoniia cases tlhe mlortality was very lhiglh. 'the epidetnic was essentially asssociated with the presence of the Bacillus influenzae (Pfeiffer). Owing to la k of sufficienit timle At our (lisposal we were lunable to undertake so extensive ani examinationi of sputa as we would hiave wislhed, bult tthe organisui could ustually boe found; vrthout difficulty, and. was often presenit in enormnous nrubers. Inl a smuall proportion, of cases it could not be foumid, but witlh regard to these latter it IImust be recognized that, wlilst tlhe microscopic picture is often clharacteristic, the identification of the organism by microscopic f*wt'ans, wlhen it is scanty, is impossible; and, of course, it is in suCh1 cses that the isolation by culture is attended by special difficulty. In over a dozen cases wlere tlhe organism was present in conisiderable nuimbers it was cuiltivated fromr tlhe sputumn witlhout difficulty, and in many I instances tlhe number of colonies obtained exceeded thoso of othier organistnis. Cultiures were obtainied also at postmiortem exanminations fromn the brouclhial mlucosa, thie pneumonic patchles, abscesses, etc.; in fact, fromii all the lesioIIs withi wlicih it was found associated. Thje clharacters of thle bacihli--4soted agreed in all essentials witlh tlhose described by Pfeiffer and recently. by C. J. Martin, and it is accordingly unnecessary to say anythiug under thjis lheading. Blood cultures were mnade in fifteen severe cases, but with iegative result in all as regards the influenza bacillus. In five of thiose cases pure cultures of the pneuirnococcus were obtained, to wlichl furtlher reference is made below. The medlium which we used thiroughout was a mixture of (delibrinate(d bumana blood and trypagar, in the proportion of about one to eight; and we have not yet made any systematic( examination of other media recommended. The agar being melted, and its temperature being brouglht to 550 C., the bloo(d is added and mixed, and the mixture is poured into small Petri (lishles. For inoculation, a drop or two of bouillon or sterile saline solution is placed on the surface of the medium. This is inoculated from the sputum or other material, and then sprea(l over the surface in the usual way with a bent glass rod. Ciolonies on this medium remain small, blut appear to come up in large numbers; they are practically invisible by transmittetd liglht. there being no alteration of the medium around, but are readily distinguishted oni examination with a len's by obliquely reflected light. Oni this medium, however, the bacilli undergo inivolution at an early stage, and we do not regard the medium as an optimium onie. For staining the bacilli hi sections we found Giemsa's stain most suitable. The ordinary solution is diluted with fifteen parts of water, and the sections are stainedl overnlight. T'he process of dehydration Withl alcohol gives thle nlecessary differen3tiationl. -.Poeat omortemz examsinations were performned ins 26 cases, and1 in all1 a pneutmonic lesion 'van pre.sent. In 17 th]e