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Roland G. (Roland Gideon) Curtin.

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 sequelae. The heart as influenced by the epidemic: with other notes. Notes on the outbreak of influenza an online

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Online LibraryRoland G. (Roland Gideon) CurtinPapers 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 sequelae. The heart as influenced by the epidemic: with other notes. Notes on the outbreak of influenza an → online text (page 4 of 5)
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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.


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Online LibraryRoland G. (Roland Gideon) CurtinPapers 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 sequelae. The heart as influenced by the epidemic: with other notes. Notes on the outbreak of influenza an → online text (page 4 of 5)