The affected area must be surrounded with ice in bags which are wrapped in towels. If the disease is confined to the front base on one side, one goodsized bag will suffice; but if the exudation extends to the side and back, then at least one more bag must be applied laterally and as far back as possible. If the affection is extensive put on as many ice-bags as are necessary to cover the whole area. Watch the morbid process, for it is very apt to migrate from one spot in the chest to another, and if it does so follow it up with the ice-bag.

The length of time for which cold is to be used must in most cases be decided by the amount of fever which is present. If this falls to or near the normal point and shows a tendency to remain there then the ice may be gradually removed. It is best, however, not to be in too much haste in withdrawing the cold, for frequently before this is off very long the temperature suddenly flies up again. If this takes place, and the temperature remains high after the ice is reapplied for some time, it is a possible indication that the inflammation has invaded a new field, and is not active in the old one. This has happened several times in my experience.

It must always be borne in mind, however, that the ice is not solely employed for the purpose of reducing the fever, but rather with the object of circumventing the exudative process and of hastening resolution in the affected part. There may be very little fever present in some cases of pneumonia, as in the aged, yet the destructive changes are going on in the lungs at a rapid rate. In senile and latent pneumonia the activity with which the ice is employed must be governed entirely by the impression which is made on the pulmonary disintegration. This must be the objective point and not the temperature.

This brings me to say something on the fever in pneumonia as a prognostic sign. Although a temperature of 105° Fahr. is generally regarded more dangerous in the adult than one of 102°, I really believe that this is an error. When the fever is excessive, as when it rises to 107° or 108°, every one admits

that this is almost necessarily fatal; but it must also be granted that a markedly low pneumonic temperature, as for example 95° or 96°, is equally fatal. The safety point, if such there be, lies somewhere between these extremes; and within a certain range I think we can look upon this fever as an indication of the degree of vital resistance which is present in the body. If it remains between 104 or 105°, the prognosis is good, provided other conditions are equal; but if it is either very high or very low it is evidence of serious exhaustion and of vital inadequacy to cope with the destructive forces.

This opinion is partly confirmed by the high authority of Dr. Wilson Fox, when he says, on page 352 (Diseases of the Lungs and Pleura), that "the extent of the pyrexia has a less unfavorable influence on the prognosis than might be expected." Out of a total of 353 cases he shows, on the same page, that the mortality from 107° to 110° was 100 per cent.; from 106° to 107°, 42.8 per cent.; from 105° to 106°, 18 per cent.; from 104° to 105°, 7.4 per cent.; from 103° to 104, 17.6 per cent.; and under 103°, 36.9 per cent.

What, now, is the local action of cold on the pneumonic process? This, I believe, consists in its powerful influence on the pulmonary capillaries and in its ability to resolve the exudate and infiltrate. It is well-known that the most apparent lesion in acute pneumonia is an enormous distention of the pulmonary capillaries, with partial or complete stasis of the blood in these vessels, exudation of fluid constituents of the blood, and proliferation and accumulation of epithelial cells, and diapedesis of white and red blood-cells in the alveoli and bronchioles. Now it is well-known that cold has the power of contracting bloodvessels, and from this action it can be understood why it should be of benefit in pneumonia. But how it can dissolve an exudate or an infiltration is not so clear to me. That it accomplishes this I am firmly convinced. For example, there is a pneumonic area which is wholly devoid of vesicular sounds, and has a flat percussion note and bronchial

breathing, indicating beyond doubt that the process has passed beyond the stage of engorgement and into that of exudation or of infiltration, yet the application of ice to this spot will in a remarkably short time develop a new group of physical signs, such as crepitation, reappearance of the vesicular murmur, diminution of flatness, etc. This has not only been observed by myself over and over again, but is also dwelt on by Dr. Lees, who had an extensive experience in the use of ice in this disease, when he says (Lancet, November 9, 1889, page 894): "In many cases I noticed a striking arrest in the development of the physical signs," and that the ice-bag "distinctly tends to repress the inflammatory process in the lung."

Is the ice treatment applicable in croupous or in acute catarrhal pneumonia, or in both forms of the disease? In my earlier experience I inclined to believe that it was only adapted to the treatment of the croupous variety, but further familiarity with the measure taught me its use in the acute catarrhal form. I have also given it a trial in chronic broncho-pneumonia, and in pulmonary phthisis, but with rather indifferent results, if not with positive harm. in some cases. I must admit, however, that in several cases of this kind it seemed to do exceedingly well. It must be borne in mind, too, that the ice-bag is strongly recommended by the late Dr. Brehmer and by Dr. Detweiler and others in the treatment of chronic lung trouble, and with such excellent testimony in its favor it is very probable that many of us do not yet understand the specific indications for its use.

Besides being useful in croupous pneumonia and in acute catarrhal pneumonia, it also has excellent effects in the capillary bronchitis of infants, and in the catarrhal pneumonia which follows measles, diphtheria and scarlet-fever.

It is also desirable in this connection to say something regarding the heart in this disease. From the tenor of much that is said and written on pneumonia at the present time, one receives the impression that more is to be feared from cardiac than from pulmonary fail

ure.

That the heart's function is impaired no one will, I think, deny, Indeed, this could not be otherwise, for the heart and lungs have a common nerve supply, are bound closely together by the pulmonary blood-current, and whatever invalidates one must also affect the other; but I believe that the doctrine that pneumonia becomes fatal because the heart is unequal to the work of forcing the blood through the engorged lungs, and all that we are required to do is to stimulate and to goad this organ, unmindful of what is going on in the lungs, is as imaginary in its conception as it is fatal in its practice. The pulmonary circulation is undoubtedly obstructed, and there is no question but that the heart chafes, frets, and becomes seriously embarrassed. Dr. Wilson Fox (op. cit., p. 285) says that "one of the most important consequences of pneumonia on the circulation is the occasional occurrence of thrombosis in the pulmonary vessels leading to the affected part. This event, caused in all probability by the retarded circulation in the lung, is not uncommon and may, extending to the larger branches of the pulmonary artery, be a source of immediate danger from sudden death, and may also, in great probability, retard the process of resolution and the subsequent convalescence." But is this any reason why we should whip up this organ in the hope that it may perform an impossible task, and stand by and do nothing to alleviate the blockade in front? Is this sound sense or physiological reasoning? No. We must discard this cart-before-the-horse theory, and make strenuous efforts to remove the difficulty in the lung, and in this way liberate the heart from its entangled situation. To accomplish this very end there is no measure more efficacious than ice, and besides removing the engorgment and even the exudation in the affected lung, it also acts as a powerful stimulant to the heart's function. Indeed, it is chiefly for its serviceable influence on the heart that the ice-bag is recommended in chronic lung diseases by Dr. Brehmer and others.

In conclusion, I beg to say that the

external application of cold in typhoid fever has reduced the death-rate from this disease to almost nothing, and I am sure it is not too much to presume that the same remedy, although differently applied, will do the same in the case of pneumonia. My opinion is based on what I have seen in my own practice and in that of others. In my collective report of fifty cases from various sources (see Medical News, June 24, 1893) there were two deaths. Since the publication of this list I received abstracts of seventeen other cases treated by Dr. Jackson of Brockville, Ontario, together with seven cases collected by myself, without a death, neither the histories of which,

POTT'S DISEASE IN CHILDREN.-Pott's disease in children is so often recognized so late in its course that all hope for improvement is futile. The early symptoms and signs which should always be looked for are laid down by Dr. Dillon Brown in the Archives of Pediatrics in the following list of different points:

1. The pain, general disability and sickness are out of proportion to the apparent amount of spinal disease.

2. The onset is alarming and the progress of the disease is more rapid than in tubercular caries-the paralysis being an early symptom and the deformity appearing even in a few weeks after the beginning of the symptoms.

3. The local pain is intense; and the peripheral pains, the deformity, the extreme spinal disability and the paralysis, including incontinence of urine and feces, rapidly grow worse in spite of rest in bed and instrumental support.

4. Secondary disease soon appears, rapid emaciation and marked cachexia are seen, and the patient does not live more than six or eight months.

Whether a vertebral caries is due to syphilis or to tuberculosis is of immense importance as regards prognosis and treatment. In both diseases the symptoms are almost identical, and the diagnosis must be based upon the history, the presence or absence of other evidences of syphilis, and the result of treatment. In tuberculosis there is more likely to be an evening rise in tempera

nor those of Dr. Jackson, had I time to write out since receiving the kind invitation from your board of directors to prepare a paper for this evening-making in all seventy-four cases of pneumonia treated with cold applications, and two deaths; or a death-rate of 2.70 per cent.

Now the death-rate from pneumonia, when treated according to the current methods, is variously estimated from 20 to 30 per cent., hence the results from cold-water treatment are at least ten times better than those which are obtained by other methods.*

*In addition to the ice, most of the patients received quinine, acetate of ammonia mixture, digitalis, morphine occasionally, a nutritious diet, etc.

ture, and the pus and debris may contain tubercle bacilli. Syphilis is suggested by nocturnal pains, and the involvement with chronic disease of some other joint or joints or some other part of the spine.

HOW INVALIDS SHOULD TRAVEL.Dr. Edward Ruxton of Southern California asks, in the Southern California Practitioner, how invalids should travel to this part of the country. Southern California being the Mecca for consumptives, Dr. Ruxton had seen many cases arriving in an exhausted condition from the east and many dying on the way or immediately after arrival, from fatigue of the trip. He thinks consumptive patients are with benefit sent to a warm, equable climate, but he is of the opinion that eastern physicians should tell their patients how to make the long trip in safety and he gives the following good advice:

Come the route that has the least change of altitude.

Come in easy stages, the journey occupying weeks or months.

Come to that particular locality that seems best suited to the individual case; one county may and does have within its confines every variety of climate.

Come determined to get well, not relying upon climate solely, but using all appropriate means.

And having come and got better, let well enough alone, and stay.

SOCIETY REPORTS.

PHILADELPHIA COUNTY

MEDICAL SOCIETY.

STATED MEETING HELD SEPTEMBER 26, 1894.

Dr. Thomas J. Mays read a paper on ICE COLD APPLICATIONS IN ACUTE RHEUMATISM. (See page 8.)

Dr. Alfred Stengel: I disagree entirely from Dr. Mays as regards the heart in pneumonia. I have seen a considerable deal of pneumonia clinically, but a great deal more pathologically. I have not made a post-mortem in pneumonia in which I did not find some cardiac thrombosis. I have seen the thrombosis of such a character that it was difficult to imagine how any circulation could be carried on during the last moments of life. Of course, in some cases it is difficult to determine whether the thrombi are ante-mortem or post-mortem, but in most cases the manifestly antemortem character of the thrombi shows that the heart must have been seriously embarrassed. It is certainly the opinion of most authorities that the heart is seriously embarrassed, and post-mortem. experiences would indicate the same thing.

Dr. J. M. Anders: I was somewhat astonished to hear the reader of the paper take the position that the fever in pneumonia was in all probability the result of the localized inflammation. The localized inflammation may, to some extent, show the degree of infection, but its presence does not prove that this is not an infectious disease. I should incline to the view that the temperature is an indication of the severity of the type of infection, and not of the severity of the local inflammation.

I am always glad to hear a paper on the use of cold. Cold, whether locally or generally applied, can have but one effect in this disease, and that favorable. If applied locally, as suggested, it would undoubtedly mitigate to some extent the local inflammation, but it could not in an acute infectious disease control to any extent the course of the ailment. I do not believe that there is anything

that will entirely control the course and symptoms of pneumonia, simply because it is an acute, infectious, self-limited disease. The local use of cold cannot meet all the indications in a case of pneumonia. It is well enough in a mild case, where the respiration is ordinarily good, the temperature only moderately high, and there are no nervous symptoms, but in a severe case the cold or tepid bath meets many more indications and is more efficacious. One of the reasons for the bad respiration is the presence of pain, hence this should be gotten rid of early. The local application of cold does not influence the respiration of a patient suffering with pneumonia, in my experience; whereas the cool or tepid bath stimulates to deeper respiration and assists expectoration. Its effect on the nervous system cannot be over-estimated. I shall not go into the subject in detail. It is scarcely necessary; but it is bad practice, I think, to rely upon the local use of cold, which meets but a single indication, when we have at hand the cool or tepid bath, which meets so many and such as are of vastly more importance than the mere combating of local inflammation to the welfare of the patient.

Dr. B. F. Stahl: I am interested in the use of cold in the treatment of pneumonia, and especially so after considerable experience with application of baths in the treatment of typhoid during the past few months. I recognize that the general application of cold or cool water is productive of rest and of better respiration and it has a general tranquilizing influence by its reduction of temperature. I am led to anticipate that its application in pneumonia will be advantageous. I freely admit, however, that I have had no direct experience in the use of local application of cold in pneumonia. I am ready to try it in any case where it may be applied generally or in the form of a bath, and I believe that we may expect decided advantages from its use.

Dr. Lawrence Wolff: I have had some experience with the use of cold in pneumonia. A couple of years ago I employed the cold bath in the treatment