a few days it was possible to draw the fingers still straighter, while the wrist was flexed, and the metal splints were straightened accordingly. This method is continued gradually, straightening and lengthening the splints until the fingers are in full extension with the wrist flexed. The splint is now carried up on to the forearm and the wrist gradually extended and then hyperextended, the fingers being kept in extension. The hand is kept in this position until all tendency to flexion is lost, using massage and electricity in the meantime.

Instead of using metal splints for this gradual correction, plaster casts can be used if one is skilled in their use for corrective work. As soon as the hand is hyperextended and remains so without any tendency to relapse, the circulation will be found to improve and the nerves that have escaped destruction will again take up their functions and the hand regain at least in part its normal appearance and use. In cases where the nerves are involved in scar tissue it is necessary to remove this pressure. After the hand becomes straightened it is necessary to continue the massage and appropriate electric currents for many months.

I will report the following cases:

Ruth C., aged 13 years, came to me June, 1908, to have a skiagraph made of her arm. She had fractured it some months previously. On examination I found the typical contracture and paralysis. There was a scar left by the pressure caused by the too tight splinting, about three-quarters of an inch in diameter, on the themar eminence. The radiograph showed all the bones in good condition. Dr. Fell treated this case by gradual splinting and obtained a fairly good result, I believe.

M. J., 5 years old (born January 31, 1905), fell and fractured her left arm August 24, 1909; was admitted to hospital October 12, 1909. History as given by mother:

Splints were applied by a physician about 8:30 p. m. on day of injury, wooden splints and not padded; they were removed the next day at 4:30 p. m. At that time black and blue spots were seen at positions of present scars. Splints were reapplied. Next day removed by another physician, spots had become purple; splints were then padded and reapplied. Six days

after injury the dark colored spots were covered with blood blisters, which opened and became running sores. Mother first noticed contracture of hand one week after injury. Hand remained dark blue and blackish from time of first application of splints for weeks. Splints worn for five weeks. Suffered so much pain for first week that she had to be kept under an opiate. Recurrent hemorrhages from sore at base of thumb. Ulcers about healed November 1, 1909.

On admission to hospital left forearm and hand are almost entirely covered with ulcers, or cicatrices of partially healed ulcers, as can be seen by photographs. In addition to the typical contracture of the paralysis there are contractures and adhesions caused by the scars of the deep pressure sores. The thumb was bound down by a dense hard scar mass. The destruction of tissue had been extensive and deep. No reaction of degeneration areas present. Gradual splinting was started about November 1 and continued for some weeks, at which time the hand could be fully extended with wrist straight. Treatment should have been continued for at least two years, but the parents considered it too much trouble. What the present condition is I do not know, as I have not seen the child since.

THE TREATMENT OF LOBAR PNEUMONIA.

BY DR. J. I. ROE, WILKES-BARRE, PA.

READ MARCH 22, 1911.

Pneumonia was recognized by the very earliest writers in medicine, but until the time of Laennec, in the early part of the last century, it was not separated from pleurisy and the two diseases were described together. Hippocrates speaks of it as "a disease quickly fatal, and characterized by sputa of various colors". "The London Practice of Physic", published in 1792 (5th edition), says that "Peripneumony is an inflammation of the lungs known by a great load and oppression at the breath; a difficult respiration, hot breath, cough, fever, and a florid redness of the countenance". Sir Thomas Watson, in his classical lectures on the practice of medicine first

published in tion of the

1843, defines pneumonia as "an inflammasubstance of the lungs". The infectious nature of the disease was first advocated by Jurgensen in 1872, but the true organisms were not demonstrated until 1883 to 1886 by Friedlander and Fraenkel. Notwithstanding our increased knowledge concerning its etiology, and nature, its prevalence has increased and its mortality has not been materially lessened. It is one of the most fatal of all acute diseases. Hospital statistics show that the mortality ranges from 20 to 40 per cent.-Osler. The mortality in private practice is not so great and is probably somewhat less than 20 per cent., and if the cases occurring in persons over 60-in alcoholics-and in those debilitated by other disease were excluded this estimate would probably fall to 10 per cent. Then, again, it is the cause of the largest number of deaths, in the aggregate, of any other disease. During 1910, in WilkesBarre, it caused 106 out of 932 deaths from natural causes; while the nearest approach was heart disease, 81; kidney disease, 64, and tuberculosis, 61. Last year nearly one-eighth, in 1909 nearly one-seventh, and in 1904 nearly one-sixth of all deaths in Wilkes-Barre were caused by pneumonia, and I presume these figures would hold good for the country at large. Its treatment, therefore, is very important and we cannot too carefully acquaint ourselves with the danger signals which mark its course. Some one has aptly likened it to wading across a treacherous stream, each step taking one into deeper water, rocks, and eddies and unseen depressions on every side, so that fortunate, indeed, is he who keeps his head above water and finds himself safely emerging on the opposite bank.

Reference to the older writers shows that in early days, from the time of Hippocrates down to nearly the middle of the last century, heroic treatment was in vogue. One or two quotations may be interesting. Hippocrates advises that "The inner vein of the arm be opened on the side affected, and blood abstracted according to the habit, age, and color of the patient, and the season of the year, and that largely and boldly". (Our lamented friend, Dr. Hakes, would say Amen! to that.)

The London Practice, 1792, says: "We should be very cir

cumspect in this disease and not disturb nature", and then goes on to advise "bleeding, and that repeatedly, from a large orifice, cupping with sacrification, blisters, leeches and hot formentations". An old couplet slightly paraphrased would run like this:

"I blisters, bleeds and sweats 'em,

And if they die, God lets 'em."

The reproach of Van Helmont, "that a bloody Moloch presides in the chairs of medicine", was certainly true of this time. But when the change came the pendulum undoubtedly swung far to the other extreme and bleeding, as Gross well said, became "a lost art".

in

It is not the purpose of this paper to take up the general treatment of pneumonia, except to refer briefly to some of the salient points in its proper management. I do not believe any routine treatment; each case must be an individual case and must be treated accordingly. I have no confidence in the published statistics regarding the results of treatment by this or that specific plan, one series by digitalis, another by salicylates, another by creasote, and still another by camphorated oil. All of these drugs may be useful but no one should be used in a routine way. Sir Thomas Watson, that pastmaster in the use of fine English, gives expression to his opinion on this subject in the following gem of choice English diction: "Each individual case requires its own special study, speaks its own proper language, furnishes its own peculiar indications, and reads its own lessons."

"All pneumonia patients may be divided into three groups, those doomed to death by the malignancy of the infection, those that are but slightly ill by reason of a mild infection, and those who are between the two extremes and need careful medical aid to accomplish their recovery." As Hare has aptly said: "The physician must be the watchman all the time, and the therapeutist only when treatment is actually needed.”

We must not forget in the first place that pneumonia is an infectious disease and must use every possible means to prevent the spread of the infection.

I suppose it is doubtful if a true pneumonia can be aborted,

but I have seen so many cases, especially in children, where high temperature, rapid respiration, fast bounding pulse and short dry cough indicated a beginning pneumonia, that have become normal in from twelve to twenty-four hours, under the administration of drop doses of Norwood's Tincture of Verat. Viride with active hydrotherapeutic measures, that I have still great faith in its use in proper cases.

Should we ever have any real specific treatment for pneumonia it will doubtless come to us through the development of serum-therapy. Experience so far with antipneumococcic serum has not been sufficiently productive of beneficial results to warrant its general administration, still the results are somewhat encouraging.

The fresh air treatment is most important. "It stimulates the heart and respiration; it supplies requisite oxygen, relieves 'air hunger', promotes sleep, quiets restlessness, and aids digestion". Thanks to the general educational campaign in favor of fresh air both in health and disease there is now much less prejudice against its use than was formerly the case, and it is not difficult to carry it out quite thoroughly in private practice. All the windows should be wide open, regardless of weather conditions, care being taken by attendants to protect themselves by extra wraps. There is no danger of the patients "catching" anything worse than they already have. Jurgensen long since pointed out that "fever patients cannot catch cold". In private residences, if it is possible to have connecting rooms, one for the patient and one for the nurses, it makes it more comfortable for the latter. In institutions where these patients can be cared for in protected porches the results have been excellent. Northrup pointedly says, regarding the value of fresh air in pneumonia: "Do not make the patient breath five times when three will accomplish the same effect. Give him air, fresh air, in unlimited amounts and constantly."

Next in importance I would place hydrotherapy. Some of the older members of this Society will remember my advocacy of this treatment in a paper which I read before the Society some ten or twelve years ago, and I am glad to know that its general use has grown in favor until I believe at the present