whereupon the pulmonary tissues again resume their normal form and functions. Leaving entirely out of consideration the various more or less chronic forms of pneumonia, we still have for discussion, on the one hand, this general affection, which may be called lungfever-with its well-marked clinical course, with its crisis on the eighth day and perfect recovery-and, on the other hand, various local inflammations of the lung structures. Among these are the pneumonitis which usually accompanies pleurisy, and the interstitial form accompanying bronchial inflammation or following the inhalation of irritants. These local forms evidently do not admit of so-called specific treatment, and, in proportion as they are acute and attended by disturbance of circulation and elevation of temperature, they require cardiac sedatives, counter-irritants, cold applications, or ice poultices, and, in fact, the modern antiphlogistic regimen. In plethoric cases, in which the symptoms are urgent, venesection or wet-cupping and leeching, and other reducing measures are not only permissible, but are actually indispensable to the successful result. If these are the forms of pneumonia, and occurring in such cases, that the venerable Hiram Corson encounters in his well-fed and prosperous clientèle, it can easily be understood why he regards the lancet as the sheet-anchor in the treatment of pneumonia. On the other hand, pneumonitis may occur in persons of frail constitution, broken down by exposure and hardships, or reduced by tenement-life in large cities, and it is evident that such patients require a totally different mode of management, including stimulants, digitalis, ammonia, and possibly transfusion of blood.

With regard to those cases in which the lung consolidation is only a part of the general pathological process, and accompanies a self

limited disease, which naturally tends to recovery, it must be admitted that our views of treatment are becoming modified, and there is a growing disposition to look upon the pulmonary condition as merely an incident in the course of the affection, and therefore as not demanding special treatment. It may, indeed, interfere with so much of the respiratory structure as to offer a serious obstruction to proper oxygenation of the hæmoglobin, or it may embarrass the pulmonary circulation so as to dam up the blood in the right cavities of the heart and produce acute dilatation with the possibility of cardiac paralysis from asystole. Therefore, it may become necessary to interfere, with more or less active remedies, and to use measures which will (1) restrict the amount of exudation, (2) stimulate the respiratory centre, (3) increase the power of the heart, and, (4) possibly, relieve an overdistended right heart.

In a given case of acute lobar pneumonia, which begins abruptly, usually after a chill, by fever, frequent cough, pain in one side of the chest, with physical signs corresponding with congestion of the lung (which is frequently soon confirmed by the appearance of blood in the sputum), the first object to be kept in view is to limit the extent of pulmonary involvement. This may be accomplished by keeping the patient in the recumbent posture, in a well-warmed, well-ventilated, and well-lighted room, if possible remote from noises likely to annoy him or disturb his rest. As the rule, the diet should be limited to very light articles of food, and consist principally of milk, but excluding eggs and meat. The temperature is the guide to the form of application to the chest; if it be high, the icebag may be enveloped in flannel and kept on the affected side for half an hour at a time, with half-hour intervals, or less. In patients

with a temperature of say 102° or less, jacket poultices of flaxseed are useful in producing diaphoresis and thus distributing the blood over the periphery of the body, so as to reduce the pulmonary congestion. If there be much pain, dry cups, sinapisms, or turpentine stupes are available. Bandaging of the chest restricts motion of the ribs to some extent and prevents the production of pain on coughing. The action of the skin may be maintained by the use of small doses of Dover's powder, nitrate of potassium, or of acetate of ammonium. If there be much cough and restlessness, Hoffman's anodyne, or spirits of chloroform are good adjuvants to the spirits of Mindererus, and if the urine be scanty, small doses of fresh spirits of nitrous ether are useful. The combined action of the foregoing will tend to restrict the amount of pulmonary exudation; but, inasmuch as absorption is taking place in certain parts of the lung while others are becoming the site of fresh exudation, it is well to keep up the action of the excretory organs so as to carry off the products of the disease and prevent its extension. Purgatives used in moderation are therefore of great assistance, even where it is not deemed necessary to give hydragogues in such doses as "to bleed the patient through his own tissues," abstracting from the circulation in this way a considerable quantity of the serous portion of the blood. The second indication, to stimulate the respiratory centre, may be accomplished by administering belladonna, or its alkaloid, atropine, in small doses where there is danger of respiratory failure, especially about the period of crisis.

The third indication is like the preceding one, and appears under similar conditions. If the heart be failing in power, digitalis, caffeine, strophanthus, sparteine cocaine, ammonia, or alcohol in suitable doses, and especially

strychnine by hypodermic injection, or oxygen by inhalation, may be resorted to. Absolute rest on the part of the patient should be insisted upon; he should not be allowed to move a finger, unnecessarily, until the emergency has passed. When there is evident over-distention of the right cavities and the heart is making ineffectual attempts at contraction, it may become necessary to relieve the engorgement of the right ventricle by tapping with a small aspirating needle, drawing away a couple of ounces of blood. When the emergency is less pressing, general bleeding may be resorted to, taking away sufficient to relax the patient and relieve the high intercardiac tension. In such a case, the pulse is not a guide to the condition of the heart, because the blood has accumulated in the veins and there is relative ischemia in the arteries.

The proposed injection of the blood of a convalescent patient into the veins of a case of acute pneumonia, as proposed recently, is simply another instance of the modern revival of isopathy. It is a therapeutic experiment which is scarcely available outside the walls of a large hospital, in which cases of pneumonia of this particular form are constantly present and at all stages of the disease, and is, in our opinion, of questionable propriety anywhere.

In the form of pneumonia accompanying influenza, persistent dry cupping and the use of stimulants, both cardiac and respiratory, including quinine, strychnine, and the salts of ammonium (especially the chloride), have given the best results.

Finally, in what has been termed the infectious form of pneumonia, a sustaining treatment is considered of the first importance, and the modern antipyretics of the aromatic series (antipyrin, acetanilide, phenacetin, etc.), if employed at all, must be used with great caution

on account of their tendency to produce heart failure. Opium is also a dangerous agent in lobar pneumonia, especially during the stage of congestion; but if it must be used, the safest form is that of small doses of Dover's powder. It is evident, therefore, that Chomel's celebrated maxim, "to treat the patient and not the disease," finds an excellent application in acute pneumonia; and individual peculiarities are not the least among the reasons why a want of agreement should continue to exist as to the "treatment of pneumonia." F. WOODBURY.

Our Library Table.

[All new publications noticed in this department, and all other medical works, may be procured by addressing the Editor of the COLLEGE AND CLINICAL RECORD, 814 N. 16th St., Philadelphia.] NOTES ON THE NEWER REMEDIES, Their Therapeutic Applications, and Modes of Administration. By David Cerna, M. D., PH. D. Small 8vo. Cloth. 177 pages. Price $1.25. W. B. Saunders, Philadelphia, 1893. The new, or rather newer, remedies introduced into practice become so rapidly numerous that it seems necessary to gather them together in such shape that their properties

for good or evil may be made more clearly apparent. Indeed, the only way to study and appreciate them seems to be that in which Dr. Cerna has so ably presented them, and the alphabetical arrangement is doubtless the one best adapted for a glance at their diverse or analogous properties.

TUBERCULOSIS OF BONES AND JOINTS. By N. Senn, M.D., PH.D., Professor of Practice of Surgery in Rush Medical College. 107 Engravings (seven colored). Royal octavo. 520 pages. Extra cloth, $4.00 net; sheep, $5.00 net; half Russia, $5.00 net. Philadelphia. The F. A. Davis Co., Publishers. The author states in his preface that his object in writing this book has been to collect from recent literature the modern ideas on tubercular disease of bones and joints and mingle with them the results of his own experience. The importance of correct diagnosis and early rational treatment is dwelt

upon, and the fact emphasized that the tubercular nature of most of the chronic affections of bones and joints is not as freely accepted or as fully realized as it should be by the mass of the profession. A valuable work of this kind is an important addition and adornment to the literature of surgery and of this particular department.

THE U.S. PHARMACOPŒIA “ 1890," which will be published during 1893, adopts in great measure the Metric System of weights and measures; this will doubtless create much confusion in the minds of physicians and druggists, and lead to many misunderstandings and errors. In order to provide a guide to the proper dosage, etc., Dr. Geo. M. Gould has prepared a complete table of the Official and Unofficial Drugs, with doses in both the metric and English systems, to be published in P. Blakiston, Son & Co.'s Physicians' Visiting List for 1893, together with a short description of the Metric System.

The Messrs. Macmillan & Co. announce that the recently completed edition of Foster's Text-Book of Physiology in four parts is to be supplemented by the issue of an appendix on "The Chemical Basis of the Animal Body,"

by A. Sheridan Lea, Sc. D., F. R. S.

Dr. Lea is Lecturer on Physiology to the University of Cambridge, England.

PAMPHLETS RECEIVED.

'A Long Toilet Pin Accidentally Swallowed and Passed by the Bowel after Four Days.' By Augustus A. Eschner, M. D., Philadelphia. 'Typhoid Fever in the Light of Modern Research; Facts and Doubts about Cholera.' By L. Bremer, M. D., St. Louis, Mo. 'The Curability of Narcotic Inebriety.' By J. B. Mattison, M. D., Brooklyn, N. Y.

'Anal Fissure.' By Lewis H. Adler, Jr., M. D., Philadelphia.

The Treatment of Anal Fissure; or, Irritable Ulcer of the Rectum.' By Lewis H. Adler, Jr.,

M. D.

'Fistula in Ano.' By Lewis H. Adler, Jr., M. D. 'The Operative Treatment of Fistula in Ano.' By Lewis H. Adler, Jr., M. D.

'Chloralamid: The Treatment of Insomnia.' By Joseph Collins, M. D., New York.