quently large and full, but later it loses power and is small and compressible, owing in some cases to the intensity of the tissue destruction which is progressing as shown by the high temperature, but more frequently to the lack of blood in the left heart from obstruction in the lungs; while the right side and the venous system are overloaded, as shown in the dusky hue of the surface. In the face it is so characteristic as often to suffice for the diagnosis at a glance. Aside from the venous congestion, a circumscribed dusky red spot very generally appears upon one or both cheeks, where single usually upon the the affected side.

The tongue is coated with a white fur, anorexia is complete, and thirst is complained of. Slight jaundice is occasionally observed, to be referred to the venous obstruction in the lungs, reacting upon the hepatic circulation.

A singular phenomenon is presented in the urine, in the complete disappearance of the chlorides from that fluid during the aggression of the disease. It is also scanty, of high color and specific gravity, and showing in the increased quantity of urea the waste of the nitrogenous tissues. Coincident with the decline of the inflammation the chlorides again appear, as shown by the nitrate of silver test.

cence.

A very remarkable feature of pneumonia is the suddenness with which the active symptoms moderate, a few hours often sufficing to change the condition of the patient from that of acute suffering and apparent danger, to comfort and rapid convalesThis change may occur, though rarely, as early as the third day, usually not before the fifth or seventh. In unfavorable cases, convalescence does not become established at the end of the first week, but after a slight remission the diseased action continues to extend; exhaustion soon appears and typhoid symptoms supervene; or, if the stage of purulent infiltration succeeds that of hepatization, a similar series of symptoms manifest themselves. To distinguish between these two conditions, physical examination is necessary.

Favorable convalescence from pneumonia is often wonderfully rapid, the exudation being absorbed in a few days, possibly without cough or expectoration, though as a rule both exist. Recovery

from the stage of purulent infiltration often takes place, though much prolonged by the exhausted state of the system. Cases of this kind are often mistaken for tuberculosis, but the history of the disease and the location of the deposit, as well as the appearance of the patient, should suffice to determine the diagnosis.

Death may occur during the stage of engorgement or hepatization, from general hyperemia with accompanying cedema of both lungs-the pressure upon the capillaries being adequate to impair their capacity to a fatal degree. It is very rare that the inflammatory action is sufficiently extensive to involve death in either the first or second stage; in the latter it often occurs from exhaustion, attendant upon the extensive retrograde tissue metamorphosis, without counterbalancing nutritive processes. Thus innervation fails and death follows by asthenia.

Pneumonia may terminate in abscess of the lungs or gangrene. The former will be suspected when the sputum of the third stage changes from gray to yellow, and the expectoration becomes suddenly profuse, accompanied by severe rigors. The microscope. will reveal elastic fibres in the ejected matter, and percussion the presence of a cavity. Gangrene manifests itself by most profound collapse, attended by a horribly foetid breath and the expectoration of a blackish, putrid matter.

Physical Signs.-Inspection shows no change in the thorax at rest; during respiration we observe the muscular action to be suspended over the diseased portion of the lung-in the early stage, from fear of pain, subsequently, when consolidation has rendered the lung impervious.

Palpation reveals at once during engorgement, and at times in the stage of hepatization, increased pectoral fremitus, depending upon diminution of the elasticity of the lungs, and consequently increased power of transmission by the tissues, of vibrations. If, however, the lung is extensively and densely infiltrated, the fremitus may be entirely destroyed over that portion of the lung.

Percussion during the first stage gives a more tympanitic sound than the normal vesicular resonance, higher in pitch also. As hepatization supervenes the sound becomes more and more flat

and dull, until complete solidification extinguishes the resonance over so much surface as is involved in the disease. It will be borne in mind that the tympanitic sound of the stomach and duodenum may be propagated to a certain extent through the intervening tissues.

Auscultation is of the greatest importance, as by means of it our diagnosis may usually be made certain. During the stage of engorgement, until consolidation occurs, the crepitant rale is almost pathognomonic; and it is very generally present. Even after solidification has occurred at the base, as long as the inflammatory process is extending the line of engorgement may be traced by the crepitant rale. This is the finest rale described. It is variously likened to the crackling of salt in the fire, or of hairs rubbed between the fingers near the ear. It arises in the bronchioles and vesicles, and is probably caused by the separation of the walls of these cavities, which adhere by means of the viscid secretion lining them. The inspired air entering forces the cavities open with a click. After the exudation has filled a number of the air cells, the vesicular murmur is lost, and becomes progressively broncho-vesicular, bronchial, or even tubal, where the solidification is very extensive. This latter sound depends upon the fact that the solid tissue is a better conductor than the normal lung, where these sounds are broken up and dispersed by the infinite number of minute rustling cavities intervening. Bronchophony is present, and is particularly noticeable in children. Rarely, pectoriloquy and gophony are observed. Frequently the case does not come under observation until the second stage is established; then we are able to make out our diagnosis positively from the presence of bronchial respiration, bronchophony and whispering bronchophony. During the period of resolution the rales become gradually coarser and more moist as liquefaction progresses, and with the process of absorption the vesicular character reappears, and ultimately the morbid sounds are lost. In making physical examination it is important that it should be thorough, and extend over various parts of the thorax. The disease may be exceedingly limited in extent, or the usual characters may be modified by coexisting circumstances. So

important is physical examination in pneumonia, that in many cases a positive diagnosis cannot otherwise be made out, particularly when the subjects are feeble or where the disease is secondary. The symptoms may be so slight or so much obscured. as to be overlooked, when the application of the ear to the chest will reveal at once grave disease.

The Prognosis, of course, depends, usually, upon the extent of lung tissue involved-double pneumonia is most dreaded. The amount of febrile reaction, which is the gauge of tissue metamorphosis, is the element of greatest importance, as, necessarily, fatal exhaustion will appear when waste has gone forward to a degree sufficient to paralyze the powers of the nerve centres. A temperature above 105° F., with a pulse above 120 per minute, indicates danger. Pneumonia is peculiarly fatal to old people. and drunkards, the proportion of deaths being nearly threefourths (Niemeyer). As a complication of other diseases the prognosis is grave.

Dangerous symptoms are seen in the thin, dark red expectoration (prune juice), very free and liquid sputa, absence of expectoration, accompanied by gurgling in the chest; the latter indicates paralysis of the bronchi, cedema of the lung, and death. Delirium is not necessarily a grave symptom, but when occurring late in the disease shows exhaustion of the vital forces.

Treatment. And here, gentlemen, we touch debatable ground, but my suggestions upon this will be very brief and simple. Above all things remember that the disease is self-limited; a simple, uncomplicated attack occurring in a previously healthy person, will usually run a favorable course if left to nature's powers. Beware, then, that in your anxiety to expedite a cure you do not hinder, by over-officiousness. The best guide you can have in treatment is a thorough understanding of the pathology of the disease; then make out your diagnosis accurately, and the proper treatment will suggest itself almost intuitively. The tendency is to asthenia. Avoid, then, depressing measures, unless by means of them you ward off greater dangers than you incur by their use. Strict attention should be paid to alimentation, nourishment being administered early in the disease. First on

the list I place milk, to which I know of none equal. The various liquid preparations of fresh meat come next. In severe cases a little nourishment, often repeated, will do more good than larger quantities at longer periods.

Bleeding will be necessary rarely. 1st. In cases where the amount of engorgement is so great as to produce impending suffocation by pressure upon the pulmonary capillaries, as indicated by a puffy, livid, anxious face, and labored and very rapid respiration; bleed at once with a full stream until relief is obtained, and your patient will bless the lancet as long as he lives. 2d. During the stage of hepatization, asthenia may be so marked as to produce partial paralysis of the nerve fibrils supplying the capillaries. The condition is similar to the one mentioned above, though from a different cause; oedema of the lung occurs, the pulse is small and frequent, respirations forty to fifty per minute, prolabia livid, and death imminent from passive venous congestion; here also you will bleed as a last resort, and it may be with benefit to your patient. I met with a case of this kind early in my experience, in an old, feeble man, who had been sick for two weeks and the purulent stage established: death was imminent, my counsel advised bleeding, which was performed, and to our mutual surprise the patient rallied from that hour and recovered; this, however, is an extreme case, and the only one in which I have seen it necessary to bleed.

The only fatal cases of pneumonia that I have met with have been in young children, and two or three where the disease was intercurrent with phthisis. Local depletion by means of leeches or wet cups is not open to the same objections as general bleeding, and may be employed where the febrile action is intense, with severe pain and short respiration; the application of the wet, or even the dry, cups, will be accompanied usually by great relief.

Niemeyer and Smoler recommend the use of cold compresses, renewed every five or ten minutes during the active stage of the disease; though disagreeable at first, great relief to the distressing symptoms is experienced in a few hours, and it is claimed. that the further course of the disease is very favorably modified