of the employment agent, and it should not be overestimated.

In summary, the pyramid outline following suggests the plan accepted by the United States Government.**

From the data in this article, the following conclusions may be given in the form of a summary:

Conclusions

1. A new department for the soldiers civil reestablishment has been added to the governments of the warring nations. Military authorities, assisted by philanthropic organizations, take the disabled soldiers and give them physical, spiritual, and industrial training, so that they may become useful citizens.

2. A scale of pay and a pension is allowed to the soldiers while in training, thus providing for the support of dependents. 3. Every one of the allied countries, with the exception of Belgium, has a special institution for the training of the warblinded. Training begins at the base hospitals and is continued until one or other of the following trades are mastered at a special school for the blind: broom-making, mattress-making, basket-making, rug- and carpet-weaving, telephone-operating, various forms of farm work, mat-making, winding of coils for armatures, piano-tuning, salesmanship, massage, stenography, carpentry, and knitting.

4. All of the blinded learn braille and typewriting.

5. Amusements, in the form of gymnasium exercises, table-games, and recreation out of doors, are provided.

6. The men in training are under military control until they are prepared to support themselves.

7. All countries are providing followup work by an after-care committee, who visit them regularly after they have gone into business for themselves.

This new work in education is in an experimental stage. Everything that human mind can conceive is being done by those to whom the work of supervision is entrusted, so that the blinded war-victims will take courage to face the future, with the feeling that much happiness still is in store for them.

Supplementary

Shortly after the completion of this paper, the annual meeting of the American

Medical Association was held in Chicago. A special session was set apart for the discussion of methods as to the best way of carrying out plans for the reconstruction and rehabilitation of our disabled soldiers, sailors, and marines. Addresses were delivered by many celebrated medical men from Europe and by our own equally celebrated medical men. As this is in line with the thoughts expressed in the foregoing article, selections are made from these addresses, for the benefit of the readers of the original paper.

The chairman, Colonel Billings, in speaking of doing something for our disabled men, said: "We want to make them well again; we want to cure them, if we can; and we want to restore them to civil life, that they may take their places in economic life again as capable of earning a living wage or salary as they were before; and, also, to enjoy life as we want them to enjoy it, because they certainly have earned it."

The Surgeon-General of the Army said: "By examining the statistics of the Canadian army, we get a pretty good idea of what we are going to have to do. They save sent over some 350,000 men; they have been at war now about four years. Of the men sent across, they brought back about 10 percent for this reconstruction work."

Recently, Congress has enacted a law that places the disabled soldier within the authority and jurisdiction of the federal

board for vocational education.

In speaking of the war-blinded, Colonel Bordley, on the staff of the Surgeon-General, said:

"The attitude of the blind is not, happiness, but, rather, an attitude of resignation. Strange as it may seem, every great advance in the treatment of the blind has followed in the wake of war, and this war has proved no exception. The surgeongenerals of our Army and Navy have combined forces and together they are going to educate the soldiers, sailors and marines. This education is to be given them in a military training school for the blind, which is to be located on a magnificent estate in Baltimore. This school is to be conducted by the best teachers of the blind in this country. It is to have every appliance that is known and is available in the development of the powers of the blind. When they complete their courses in that

Dr. Wm. E. Robertson has used the mixed vaccines in hundreds of cases, even intravenously, with wonderful results, in the treatment of the disease and its complications.

Thousands of soldiers have been so inoculated in several of the army camps. Thousands of people were successfully inoculated and saved from serious illness in New York City, Chicago, Philadelphia and other places. Among 670 cases in which prophylactic immunization was done by Dr. Napoleon Boston, no cases of the disease occurred.

Prophylactic immunization has been practically demonstrated in many of the large industrial plants in the Philadelphia vicinity which territory was early affected by the epidemic influenza.

was

Some of the employes of the Philadelphia Electric Company who had contracted influenza before the course of prophylactic immunization instituted, were treated with the influenza vaccine, and not one of these died! The initial dose given to patients suffering from influenza was 1 mil in cases which were not serious and 1.5 mil or more in desperate The injections were continued (if necessary) every 24 hours with the same dosage until a favorable prognosis was noted.

cases.

These favorable results prompted other large industrial plants and public institutions including the health boards to employ immediate prophylaxis toward preventing the spread of this influenza epidemic. Notable among these institutions are, the U. S. Steel Corporation, American Steel and Wire Company, of Ohio, Bell Telephone Company, of Pittsburgh, Pa., and others.

Eyre and Lowe, in The Lancet, (Oct. 12, 1918, p. 485-7) report upon vaccines used in 1000 cases for prophylactic purposes. They conclude that (1) There may be no reaction. (2) There may be slight reaction-this is the most likely result and will probably occur during the first 24 hours after inoculation and, apart from a possible tenderness at site of injection, may produce a slight malaise, and stiffness and headache. (3) There may be a severe reaction.

In my experience, reaction was of no consequence and, if it occurred, was very

arm injected passed off in 24 to 48 hours. The immunity probably lasts from two to six or eight months.

The employment of properly made gauze masks over the face to prevent the transfer of infection to others and to yourself has proved a valuable prophylactic measure. The importance and value of such face masks has been noted and emphasized by George H. Weaver (Chicago), J. A. Capps, Haller and Colwell, A. B. Lyon and B. C. Doust, Hamilton (1905), S. J. Meltzer (1916). Many of the masks used were nothing more than mere camouflage, being made of one, two, or three layers of thin gauze and, hence, absolutely worthless. Masks should be made of good size, of six or seven layers of gauze, or else several layers of gauze with some sterile absorbent cotton between them in sandwich-like

fashion (this latter method was used by me). It is advisable to use a spray of 3 to 5 percent dichloramine-T in chlorcosane on the face masks this is unirritating, does not "wet" or soak the gauze, and is very efficient; repeated spraying should be resorted to. The mask should have an appropriate or suitable mark on the outer side, so that, if the mask is removed for a few minutes, it will always be replaced with the same side out. As these masks are cheap, it would be advisable to change them often, or to use a new one, when the mask worn is temporarily taken off. Doust and Lyon (Jour. A. M. A., Oct. 12, 1918, pp. 1217-1219) conclude that

Liq. Thymolis Comp., (diluted with several parts of warm water), or Liq. Antisepticus Alkalinus Compositus.

Dichloramine-T in chlorcosane, in 3 percent solution, or chlorazene solution, or acroflavine 1:1000 may be used in sprays of nose and throat.

The Treatment of Influenza

The treatment is, principally that 1, by mixed or combined influenza vaccine or combined M. catarrhalis vaccine or by serum from convalescent patients; 2, hygienic and dietetic measures; 3, symptomatic and supportive remedies.

The alkaline treatment, the acute-nephritis treatment, the anticipatory treatment, the expectant watchful treatment, all have their supporters and all have produced good results. Of course, the ideal method would consist of immunizing the patient's family with vaccine or, if it were possible, with an efficient toxin-antitoxin, as in diphtheria, and the use of specific antiserum or antitoxins. Unfortunately, we have no such efficient agents as yet, as we have not been informed by the numerous research men and investigators as to the exact cause of this most contagious and infectious disease-probably the most contagious disease of all infections, when occurring in pandemics of this nature.

In view of the fact, that we have no antitoxin, I started out to use rather large doses of freshly made combined influenza vaccine and combined M. catarrhalis vaccine. The results obtained were most satisfactory and encouraging. Indeed, in some of the cases, the rapid improvement was nothing short of remarkable. There were no ill effects whatsoever and, even when used in young children, temperatures of 105° and 106° F. came down 4, 5 and 6 degrees in 24 hours. I am convinced that such drops in temperature and so remarkably rapid an improvement in many of the cases would certainly not have occurred, had I not used the vaccines promptly and repeatedly where necessary.

It is to be regretted that this vaccine treatment was not given to more patients and their families, prophylactically as well as therapeutically, during the early part of the epidemic. Many lives might have been saved, much illness prevented, and serious complications avoided.

There is no scientific reason for the use of diphtheria antitoxin in this disease and

as a therapeutic measure it is absolutely worthless except, of course, where diphtheria is complicated with an attack of influenza.

The principle of using the serum of patients who have recovered from influenzal pneumonia is rational, and its use has been followed with satisfactory results.

McGuire and Redden have reported the results of the use of such convalescent human serum in the Journal of the American Medical Association (Oct. 19, 1918, p. 1311). They state that all of the deaths in the Naval Hospital (Chelsea, Mass.) were due to the pneumonia complication and none to the influenza as such. The mortality varied from 30 to 60 percent.

Flexner and Lewis (Jour. A. M. A., May 28, 1910) and Amoss and Chesney (Jour. Exper. Med., 1917, xxv. 581) reported valuable and encouraging evidence in the use of convalescent serum from poliomyelitis patients in the treatment of anterior poliomyelitis and it was, therefore, thought advisable by Redden to use the serum of convalescent influenza-pneumonia patients as a curative measure, because of probable antibody content. Out of about 40 patients thus treated, only one died. They used 75 to 125 mils of the serum intravenously. The convalescent serum was obtained within a week after the temperature had dropped to normal. The majority of the patients received a total of about 300 mils. The improvement was noticed in the first 24 hours after its use. Of course, Wassermann tests and compatibility tests of the donors' sera with the recipients' corpuscles were made as soon as new cases appeared in the ward. Further study as to the potency of convalescent serum is advisable.

Intravenous injections of hexamethylenamine were used by Loeper and Grosdidier in doses of 1.5 to 2 Gm. (Bull. Soc. Méd. des Hôp. Paris, May 31, 1918, xiii., No. 19.) It is harmless, according to these men, and, of 15 pneumonia patients, all were improved and cured; in 5 cases the disease was aborted, defervescence occurring the following day. It would seem to me, however, that the frequent presence of albumin and casts in the urine of these influenza-pneumonia patients, would surelv. contraindicate the free use of urotropin. I did use, at the beginning of the attack, a capsule called by me "Urotropin Comp.

Capsules" and consisting of phenacetin grs. 11⁄2; acetylsalicylic acid, grs. 3, and urotropin grs. 3-one being taken every two hours. This relieved the pain and aching. Where the kidneys were affected or where the patients were not seen early in the attack, the urotropin was not used.

Another favorite prescription I used was, caffeine citrate, grs. 2; cinchonidine sulphate: grs. 2 to 3; and acetylsalicylic acid, grs. 3 to 5.

I did not use quinine sulphate, quinine and urea hydrochloride, nor Dover's powder, nor a great many other drugs employed by many physicians. I used small doses only, of aspirin, phenacetin, urotropin, and other pain alleviating preparations-these were stopped at the end of 36 to 48 hours, or sooner if the patient felt relieved. For the cough, I found nothing better than codeine, in doses of gr. 1/8 to 14, and citrate of sodium or citrate of potassium in doses of grs. 5 to 10, every two hours. Mistura glycyrrhizæ composita was used occasionally, however, the tartar emetic contained in this preparation is depressant and this must not be forgotten, especially in our weak, enfeebled sweating patients. My patients received tincture of nux vomica in fairly large doses or strychnine sulphate in doses of gr. 1/20 to 1/30, frequently repeated. Digitalis did not seem to act so well, and failed utterly in some of my urgent, seriously sick cases. Digipuratum was the digitalis preparation mostly used and, in a few cases, seemed to help over the crises, where the ordinary tinctures failed.

Weaver, of New Orleans, says that, in an adult, 40 to 60 grs. of citrate of sodium, every three hours, should be continued day and night until the lungs are entirely cleared. He states further that if the citrate is discontinued before complete resolution, there will be an immediate relapse. He has treated 36 cases of pneumonia with this method thus far, and the rapid recovery has resulted in each instance. (New Orleans Med. & Surg. Jour., Oct., 1918.) In cases of relapse, recovery again occurs under the influence of the citrate. This, in his opinion, is absolutely proof that the citrate is responsibility for the recovery by lysis.

Drs. Brown and Sweet, of El Paso, Texas, report the use of whole citrated blood in the treatment of influenza pneu

monia. They think that the corpuscles are also valuable as probably containing some of the antibodies and they have, therefore, used citrated-blood transfusion. (Jour. .4. M. A., Nov. 9, 1918.)

Dr. F. J. Kalteyer recommends the use of stimulating remedies, in an anticipatory manner. He prefers digalen. Some physicians used camphor in oil hypodermically in the cyanosed patients, along with oxygen. I doubt whether either one of these measures does much good in the cyanosis occurring in this epidemic-pandemic disease.

Dobbyn advises applying ice-bags to axilla, neck, groin (over Scarpa's triangle), and popliteal spaces where the great blood vessels are subcutaneous or nearly so-a reduction of 3o may be obtained in 14 of an hour.

Dr. Boston treated all his cases as cases of acute nephritis. Some physicians gave very little in the way of drugs. Dr. M. Н. Fussell thinks he got just as good results with rest in bed, fresh air, and plenty of good nourishing food, provided these patients went to bed immediately on the very first appearance of the slightest symptoms, such as, coryza, or headache, or chilliness, or cough. He tried this with the nurses of a large hospital.

However, in general practice, we always found our patients very sick when we were called in, and treatment was necessary and urgent in many of the cases. The expectant watchful treatment would have failed utterly in the large majority of the cases of epidemic influenza-pneumonitis.

Nearly all my patients received the alkaline treatment, consisting of citrate of sodium and citrate of potassium by mouth, and bicarbonate of sodium and saline solution by rectum. The bowels were kept open by administration of mild salines or fractional doses of calomel with bicarbonate of soda. Rest in bed, of course, was the first and most important treatment insisted upon by me. The patient was kept in bed, where possible, for several days after the temperature dropped to normal. I believe that, if it had been possible to keep all the patients in bed for five or six days after complete recovery, and if these same patients had taken to bed immediately on the first appearance of the symptoms of the disease, the mortality and incidentally the morbidity rates, would have