ment which I now show you. It will be observed that the edges of the blades which present to the iris are serrated at two points, the one at their extremities, the other a little way back, leaving an interspace which is smooth as in the common iridectomy forceps. When the blades are closed the teeth or serrations fit into one another in such a way that the edge appears quite smooth.

Since my operation, I have seen that Dr. Liebreich, of Paris, meeting with the same difficulties, as every one has who has had much experence in operating, has also invented what he calls a modification of the iridectomy forceps," and publishes an account of the same in the first number of first volume of the Archives of Ophthalmology and Otology. The teeth, as will be observed, are constructed in the same manner as those found at the very end of the ordinary iridectomy or fixation forceps. They are placed at the extremities and also a little way back on the curved edge of the instrument, "so that when the blades lie parallel upon the iris they have the same situation as the teeth of the fixation forceps in the perpendicular or vertical position of the latter." When the instrument is closed the teeth are so concealed that the border of the blades appears perfectly smooth. Both his and mine are, I think, equally well calculated to fulfill the indications for which they were devised.

A CLINICAL LECTURE ON ACUTE PNEUMONIA. By Geo. P. Andrews, M. D., Professor of the Principles and Practice of Medicine in the Detroit Medical College.

GENTLEMEN-I commend the case before you to consideration, because it is an example of a common disease, one which you will meet with early and often in practice, and also one which will be fatal or manageable in proportion as you rightly apprehend its pathology and the rules for treatment.

Pneumonia is a disease frequent and fatal in childhood, frequent. and grave, though not necessarily often fatal, in later life. Much paper and ink has been expended in discussing the treatment proper to be pursued in this affection, one wing, and that until

lately the larger, of the profession, holding that the antiphlogistic, so called, is the one which shows the best record of cures, while, on the contrary, others have claimed that such active measures are unnecessary. With the former, bleeding, tartar emetic and calomel were the sheet anchors; the latter, claiming that the disease is eminently cyclical, running its appointed course and terminating often in convalescence when left to nature's resources, regard medication as important secondarily, needful rather as an aid where nature is inadequate, and especially hold that inasmuch as the disease tends to prostration, often assuming the typhoid form, it is all important that the physician should husband rather than squander the forces of the system. I conceive that the views enunciated last, embody the true theory of the disease. I do not condemn bleeding, tartar emetic or calomel absolutely; there are conditions occurring in which these remedies will be found useful, but they are rare, and when called for must be handled circumspectly or more mischief than good will result, but to the eye quick to catch symptoms and the brain apt to read their lessons, the lancet or the antimonial may offer a resource which will turn the scale between life and death.

To return to the case before us, a young German, 28 years of age, of robust habit and good health hitherto, by trade a carpenter. Having been exposed to wet weather three weeks since, he experienced a chill in the evening; soon after, pain was felt in the base of the right lung, accompanied by frequent respiration and a short, dry cough, with occasional expectoration of tenacious sputum. Considerable fever was present, with rapid pulse. He was treated for four days by a physician in the city, evidently with mercury, as the mercurial fetor of the breath and spongy gums showed. At the time of entering the hospital, two weeks since, the stage of hepatization was established, dullness being marked over the lower lobe, although the height of the attack was reached. Slight fever, increased at night, was observed, pulse 100 to 110, countenance dusky, respiration short-about thirty per minute, pain continuing in the right side, headache, restless nights. Physical examination revealed dullness on percussion over the lower lobe of the right lung; auscultation

rendered apparent bronchial respiration over the area of dullness, although coarse rales heard to a certain extent manifested the commencement of the liquefaction of the exudation. To-day you see a marked improvement in the patient; the dusky hue has disappeared, the respiratory sounds have become more vesicular in their character, the skin is moist and cool, appetite is fair, and the patient daily gains strength; a few days will enable him to return to his work. Now, taking this case as a text, let us go over the ground more minutely and study the history, pathology, symptoms and treatment of acute pneumonia, leaving for another occasion the consideration of the complications and accidents sometimes observed.

Pneumonia, or pneumonitis, is an inflammation seated in the parenchyma of the lung. Following the rule that inflammations are limited to structures anatomically similar, it usually involves the vesicles and bronchioles alone, which form the peripheral terminations to the respiratory tract. The tissue lining these cavities can scarcely be considered as a mucous membrane, inasmuch as it contains no muciparous glands. Its epithelium is of the squamous variety, and the products of inflammation vary materially in their character from those of the bronchi and trachea, which are lined with cylindrical and ciliated epithelium, and supplied liberally with mucous glands. As we shall presently consider, the products of inflammation within the vesicles and bronchioles consist of fibrinous material analogous to the plastic lymph occurring as the result of inflammatory action in the serous membranes, though with this difference, that it does not become organized, and in this it assimilates to the products of mucous inflammations.

There are three periods in the history of acute pneumonia, anatomically considered; first, that of engorgement, during which we find the capillaries of the affected portion of the lung distended with dark blood, nearly in a condition of stasis, and also the commencement of exudation into the intercellular tissue. This period rapidly passes into the second, that of hepatization, wherein the exudation has become fibrinous, filling the vesicles and bronchioles with firm plugs, which are more or less colored

by the presence of blood globules. As the active process of inflammation and the hyperæmia diminishes, the deep red hue of the tissue gradually fades, and as the hæmatin is absorbed. assumes a grayish tint, and the exudation softens. The microscope shows, during the red stage, the presence of a multitude of young cells, which are probably developed from the epithelium of the walls (Niemeyer), together with blood corpuscles, scattered through the amorphous fibrin of the exudate. As the gray stage is developed, we find the cells and fibrin undergoing fatty degeneration. The walls of the vesicles now secrete a fluid material, which tends still further to soften the exudation and promote its absorption and expectoration, by means of which the product of inflammation may be entirely removed without passing into the third stage of purulent infiltration, which occasionally occurs as a sequence of the previous one, and is characterized by a more prolific cell formation, which presents the appearance of pus. Even at this stage, as the lung tissue is still intact, though weakened, recovery may take place.

The physical appearance of the lung in the stage of engorgement, is a deep red, more dense than normal, oedematous and non-elastic. A fresh cut surface exudes a tenacious, viscid, reddish fluid. The stage of hepatization shows the inflamed portion of the lung greatly increased in specific gravity. It sinks in water, is resistant to pressure though very easily torn, and of a granulated appearance, owing to the fibrinous plugs contained. within the vesicles and bronchioles. In the third, or purulent stage, the granulated appearance is lost and the surface is gray or yellowish, and a reddish matter may be freely expressed from a freshly cut surface.

Owing to the amount of lung incapacitated for labor by the disease, an undue amount of blood is crowded into the remaining portion, and where the inflammation is extensive the general hyperæmia may be adequate to produce death. This condition, we shall see further on, constitutes one of the indications for depletion. That portion of pleura contiguous to the inflamed tissue usually participates in the disease, which is then known as pleuro-pneumonia. The right side of the heart, from the obstruc

surcharged with blood, while Tough yellow coagula are of

tion in the lungs, is usually found the left side is abnormally empty. very frequent occurrence in this disease, being found both in the cavities of the heart and the large vessels, from the latter of which long, branchiate polypi may often be drawn (Niemeyer). These coagula, from their appearance, are evidently not post or even ad mortem in their formation, but may have existed for days or weeks, and doubtless, in certain cases, prove the immediate cause of death.

The symptoms ushering in an attack of pneumonia are, first, a rigor, usually but one, wherein the disease differs from the onset of intermittent fever, or septicemia, in which the rigors are repeated; elevation of temperature accompanies the chill, with quickened pulse, soon pain is complained of, usually located at the diseased point; pain may be absent, as in cases where the inflammation is deep seated, not involving the pleura; it is acute and incisive, increased by cough or a deep inspiration; it does not remain constant in intensity for a long period, but varies from time to time; it commonly ceases with the period of extension of the inflammation; the pain is often absent in aged or feeble persons, particularly if the superior portion of the lung is involved. (Niemeyer.)

Cough occurs early, and is one of the most constant attendants of the disease; at first it is short, sharp and dry. The patient represses it as long as possible, and this dread furnishes an aid to diagnosis between pneumonia and bronchitis. The sputum of the stage of engorgement is exceedingly viscid and somewhat frothy. After consolidation is complete, it is tinged with blood and becomes the "rusty" sputum. When resolution is established, the cough either disappears or becomes loose. Accompanying these symptoms are the usual phenomena of pyrexia, pain in the limbs and back, headache, which often continues through the attack, injected countenance, elevation of temperature 103° to 105° F., varying from morning to evening when it is highest, from 1° to 2° F. The pulse ranges from 90 to 120 per minute in ordinary cases, and where it rises to 130 or 150 danger may be apprehended. During the stage of engorgement, the pulse is fre