haps, the drug being excreted in considerable quantities by the lungs, gives an opportunity for some specific action, or makes a less favorable soil for the development of the bacilli. In my hands it has never been hard on the stomach, as claimed by some of its opponents. It is often given in such a manner that none of it is in suspension, making the dosage very irregular. I usually give from three to six minims, prepared, first, by adding three to four parts of glycerine, warming and mixing thoroughly, after which, further dilute with some of the simple expectorants. In support of this treatment, I beg to quote from Andrew H. Smith, M. D., New York, the following:

"A very interesting paper is communicated to the Medical and Surgical Report of the Presbyterian Hospital for 1904, by Drs. G. A. Tuttle and H. S. Carter, entitled, "Data Regarding Acute Lobar Pneumonia." The paper is based upon the reports of six hundred cases treated in the hospital during the six years previous to February, 1903.

The mortality in uncomplicated cases was 22.8 per cent.; in complicated cases, almost 36 per cent., and when in connection with other diseases, 47 per cent. One hundred and one cases, thirty of which were complicated, received 10 minims of creosotal every two hours during the whole course of the disease, in addition to the usual symtomatic treatment. According to the ratio in other cases, the thirty complicated cases should have given twelve deaths, and the seventy-one uncomplicated cases sixteen deaths, making twenty-seven deaths in all. The actual number of deaths was sixteen. Of the sixteen deaths, nine were in complicated cases and seven in uncomplicated. The mortality in the uncomplicated cases was, therefore, 7 per cent., as against the general mortality in uncomplicated cases of 22.8 per cent.

It is important to begin the treatment at an early stage of the discase, so that the first exudate poured into the air cells may be impregnated with the drug and rendered an unfavorable culture-medium for the germs. It is evident that once the cell is packed full with fibrin the plug will be but little affected thereafter by any remedial agent contained in the blood. But this early institution of the treatment is usually precluded in hospital and in consultation practice. In family practice, there is a natural hesitancy in using a treatment with which one is unfamiliar. From these circumstances, it results

that the conditions are seldom favorable to the fullest success of the treatment. Nor will this be otherwise so long as dogmatic denial of the efficiency of any specific rules the day.

Incidentally, the creosotal has a decided effect in preventing the formation of gas in the stomach and intestines, with all the discomfort and danger attending abdominal distention.

For myself, individually, should I be attacked by pneumonia, I wish to be treated by a physician who believes in the use of creosotal, and will employ it with a liberal hand.

Fourth, Local Applications: I don't use them except in bronchial pneumonia in children, where the cotton-batting jacket is used, which I regard as very valuable; and, in cases where a severe localized pleuritic pain is present, an ice bag over the painful area gives much relief.. The blistering and ice-jacket I regard as bad practice.

SPECIAL REMEDIES.

First, Diaphoretics: A moist condition of the skin is more to be desired than a dry, hard and glistening appearance. I use to correct this condition, hat mustard baths. I have had good results, especially in cases of children, who, having been seized suddenly with an initial chill, followed by high fever and often convulsions, an active diaphorisis was produced. A mustard bath gives a quick flushing of the skin, reflexly stimulates the heart and respiration, and also lessens internal congestion.

Second, Expectorants: The creosote, as given under general remedies, is about the only expectorant I use. If a comprehensive statement is to be made in regard to the employment of expectorants in pneumonia, it had best be said that they are contra-indicated. Many patients do well whose expectoration is trifling. Perhaps not more than a few drachms. throughout the attack, and the symptom is of no prognostic importance one way or the other. Expectorants are prone to disorder the stomach and interefere with proper assimilation of food. There are but few theoretical grounds for their use; first, rid the system of toxic material from the pneumonia. area of the lung proper; and second, to rid the bronchi of tenacious secretion, which might render the breathing in the normal lung more difficult. In regard to the first of these factors: During the period of consolidation there is but little material capable of expectoration from the solidified lung. With regard to the second factor: In those cases in which there is a copious tenacious, bronchial secretion, it may be well

to aid its removal with some of the ammonium compounds, such as the chloride and carbonate, given in syrup of wild cherry.

Antipyretics. Phenacetin, as recommended by some to have very little depressing effect on the circulation, has not been free from danger in my hands. I used in one-half grain doses every two hours in a child six years old, who, having had pneumonia about twenty-four hours, registered a temperature of 106 F. After giving three doses, the child became cyamotic, so phenacetin had to be discontinued. A similar experience shortly afterwards shook my faith in the drug, and now when antipyretics are indicated, I use nothing but the ice-cap to the head. Unless hyperpyrexia exists, the temperature needs no special attention.

Stimulants. Under this head we place alcohol and strychnine and normal salt solution. There are few cases that require stimulation from the beginning. I have given alcohol in small doses from the beginning, mainly to lessen the toxic effect of the poisons on the nervous system, but the size of the dose is such as to admit considerable increase, if necessary. In case of an adept I would always give alcohol throughout the course of the disease, for in so doing delirium tremens, that dreaded complication, is apt to be overcome.

Strychnine. This is our most valuable drug in tiding our patient over the crisis, and should be reserved until symptoms indicate the approach of this critical period. It has been my observation that patients who require active stimulants early in the attack, reach the crisis in such a condition that it becomes. less effectual, and, often, when stimulants are given in heroic doses, the pulse reacts for a few minutes, but to keep them up, it is necessary to repeat the dose frequently. In a typical case, where strychnine is not given until the advent of the crisis, it should then be given hypodermically from twenty-four to forty-eight hours, when the patient is ordinarily transposed from the dreadful state of anxiety to one of comparative ease and composure, then our stimulants can be administered by mouth, the dose being gradually decreased. Normal salt solution is very valuable in toxic cases, since it dilutes the toxines and promotes their excretion. It is also valuable in cases in which the urine is scanty, and where the patient cannot be induced to take a sufficient amount of water to keep the kidneys well flushed.

Quinine. I mention this not because I have had any experience with it in pneumonia, but because a good deal is being

said in the journals on quinine in pneumonia. Dr. Galbraith, of New Mexico, reports fifty consecutive cases without a death (Journal of American Medical Association, January 28th, 1905.) His report does not strike me as being conclusive, and I shall be unwilling to adopt his heroic measures until he can furnish us another series in which blood examinations are made to exclude malaria.

General Hygiene and Care of the Patient. That this phase of our duty should be left for secondary consideration is a mistake we ought never make. It is of the utmost importance that the comfort and hygiene of our patients should be properly looked afer. Överzeal in the treatment of pneumonia is to be criticised. This includes over-stimulation of the heart, the too free administration of expectorants, and above all, incessant annoyance by talking and noisy visitors, and in no case where it is possible to avoid it, should the sick room become the sitting room for the family. The room should be ventilated so as to admit fresh air without draft. The general person should be kept clean and free from the lavish of all sorts of local applications which come in as panaceas from the neighborhood. The diet should be liquid and nutritiousmilk, broth, egg-albumen, beef juice and palatable gruels. Over-feeding is to be avoided; it causes disturbance of the digestion, giving rise to tympanites, which encumbers the action of both heart and lungs. The use of the bed-pan is imperative, for the danger of heart-failure is greatly augmented by the patient getting up and sitting in an upright position.

In the foregoing remarks I have attended to statistics but very little. I began to collect some data on treatment and rate of mortality from some of our hospitals, but found so few changes from former records that are familiar to all, that I concluded not to present them in this paper. I desire to thank Dr. Clark, of the State Prison Hospital, for a report he furnished me. For the class of patients with whom he has to deal, his death rate is low, and I commend his method to any who may have an opportunity to investigate. In my practice during the past two years, 45 cases have been treated in the manner outlined in the paper-four cases were fatal. Two of these cases were children, ages three and eleven months respectively. One was an alcoholic, the pneumonia developing during a severe attack of delirium tremens. The fourth was a severe case of toxic variety in a woman about fifty. There

is much more that could be said on the treatment of pneumonia, but since we are so prone to do too much, my remarks have been restricted to the more important measures, and in closing, I will emphasize certain points.

First, the importance of not crowding an over-taxed heart with too much stimulation.

Second, the uselessness, as a rule, of expectorants.

Third, the importance of aiding digestion.

Fourth, the uselessness of general applications.

Fifth, the necessity of giving the patient proper intervals of rest-sleep.

DISCUSSION.

Dr. W. M. Wilkerson: I only desire to make a few remarks. I want to begin by saying and emphasizing the point that it is useless for us to talk about treating pneumonia; it is not a disease to be cured, it is a disease that patients frequently recover from in spite of our treatment, and, as a doctor has well said, "the less we treat it the better for the patient." There are cardinal points that should be remembered: First, that the disease is going to run a natural course-that it is going on to recovery or death; the second is, that we should, as the doctor has said, husband the strength of our patient, particularly his heart. And just here I want to add that the condition of the heart-the pulse-is of far more importance than the temperature; watch the pulse. Notwithstanding how high the temperature may be, the pulse may remain in a very satisfactory condition. Do not begin, as he says, the use of stimulants too early; reserve them until later in the disease when the crisis is imminent, otherwise you will have to attempt to stimulate an already over-worked organ. So, with reference to medicine, I have very little to say; I think, perhaps, creosote carbonate is as good as anything; whether this is any good I am not sure. I know in the great hospitals a number of treatments are used. One physician, during his term of service, will use a certain line of treatment, and another during his term will use another line, and all will have about the same results. I would like to say something about the use of ice. Dr. Guice, I believe, referred to the use of the ice bag. I think that is a very important agent in many cases of pneumonia, with high temperature, and a rapid, irregular, feeble pulse. I am sure that I have seen life saved by the timely use or application of a large ice poultice over the