tion of weakness, should Phenacetin (5 grains) or acetanilid (3 grains) be resorted to. The alkaline diuretics and diaphoretics may often be of service.

Insomnia and Restlessness.-If the remedies already mentioned for treatment of pain, fever and cough do not control the insomnia and nervousness, whiskey, choralamid, sulphonal, trional or some additional opiate may be tried, in order named.

Heart Stimulants. In the pneumonia of drunkards, and where there is the slightest tendency to cardiac weakness, whiskey or brandy is indicated, at first in half ounce doses every three of four hours, the dose to be increased and continued as the urgency of the case indicates. Should the alcoholic stimulants fail, then strychnia must be used in addition in doses and frequency to meet the needs of the case. For sudden heart failure the hypodermic injection of ether is recommended, or digitalis may be combined with strychnia or given alone. In severe cases of pneu monia or where there is extreme weakness of heart and depression of respiratory forces. Anders recommends the exhibition of the tincture of digitalis in doses of five to fifteen minutes, every threc hours hypodermically. The hypodermic use of the normal saline solution is also often found of marked benefit. However, except in extreme cases, I prefer to use the salt solution by means of high rectal enemas.

Specific Treatment.-There is yet great diversity of opinions on the question of specific remedies in the treatment of insomnia. Andrew H. Smith says: "We may reasonably expect benefit in a considerable proportion of cases from the use of means addressed directly to the germ present in the lungs. The practical question to be solved is, what agent will act most powerfully on the specific organization with least inconvenience of danger to the patient." The salicylates, creosote, chloroform, digitalis, quinine and antipneumonic serum, each have their champions claiming specific action.

Salicylates. Siegel reports seventy-two consecutive cases, many of them most unpromising, treated with sodium salicylates with no deaths. Ingals says that "this is a very remarkable re cord and certainly recommends the treatment most strongly for further trial," and adds that, "apart from the experience of Siegel, it does not appear unlikely that a drug which is capable of producing such decided results in acute rheumatism should be effective against an organism so sensitive as the pneumococcus." Siegel gave two drams daily with no unpleasant symptoms except buzzing in the ears. He claims that the disease was not more than half the usual duration, and that crisis did not occur in any case, the temperature gradually declining from the end of the first day until the third or fourth day, when convalescence was

established. Microscopical examination of the sputa showed a constantly diminishing number of diplococci until they were found to have entirely disappeared with the beginning of conval escence. Other observers report results almost as favorable.

Creosote.-Van Zandt claims that a large percentage of pneu monias are cut short or aborted; that almost all of the rest are mitigated, and the remainder, or a very small percentage, are not affected by creosote. He gives seven and one-half grains of the carbonate of creosote every three hours, in urgent cases, giving the dose more frequently for a few times, and thinks that this rem edy, in pulmonary affections, is one of the greatest life-saving discoveries of the nineteenth century.

Kerr, Robinson, and others advocate the specific action of creosote in the treatment of pneumonia.

On the other hand, neither Anders nor Nothnagel even comments on the use of creosote in the treatment of pneumonia.

Chloroform.-Quoting from Ingals' paper: "Oertel, in 1882, reported decided benefits from the inhalation of chloroform, which he employed mainly in the advanced stages of the disease, about the fifth or sixth day, where there was extensive hepatization with pleuritis which rendered the breathing irregular, frequent, and superficial, and when the expectoration was scanty and viscid, and there were coarse rales over a large area of the lungs, with rapidly increasing cyanosis. The inhalations were repeated as often as five or six times and pushed to commencing narcosis, with most satisfactory results. The respirations became deeper, the pain was relieved, the rales were diminished, expectoration increased, cyanosis became less marked and general betterment ensued. Oertel sums up his experience in the following words: I consider the inhalation of chloroform, when the above indications are present, as a means of treatment in pneumonia that would be difficult to replace by any other."

Digitalis.-Petresco highly extols enormous doses of digitalis. He gives from three to fifty drams of an infusion of the leaves daily, and reports that out of several hundred cases among soldiers he has had a death-rate of only 1.2 to 2.6 per cent. with the crisis commonly occurring on the third day. Nothnagel states, however, in commenting on Petresco's cases, that it must be remembered that these cases were treated in a central military hospital; and further, that to attain such results it is by no means necessary to employ digitalis as a treatment, for in his own mortality statistics he had, in 379 cases of pneumonia in ages ranging from five to twenty, eleven deaths, or a 2.64 per cent. death-rate. These cases were all taken from the civil population, and many were moribund when sent to the hospital. Even more conspicuous are the figures given by Risell. He reports 127 pneumonias

in persons in the second and third decennium of life with only two deaths, or a mortality of 1.8 per cent.

Quinine. Nothnagel says that quinine, when properly used —that is, in accordance with all the symptomatic indications, which in pneumonia are quite numerous-is the most suitable remedy, and that the value of quinine in the treatment of this disease is due less to its antipyretic action than to its specific action on the causes of the disease or their products. According to this author, pallor, marked decubitus, conspicuous weakness, slight apathy, with slight fever, are indications for the use of stimulants; and if in such cases mild delirium is added, the pulse becomes weak, small and frequent, and the disease is at its height, that is to say, on the fifth or sixth day, in some severe cases even earlier, then the hypodermic use of quinine hydrochlorate is strongly advised. He injects seven and one half grains in a half ounce of water once daily for two days. In two years' experience he was but twice required to resort to three injections, and both these cases recovered. For fifteen years prior to beginning the use of quinine he treated 1,461 cases, with an average mortality of 17.4 per cent. From 1895 to 1897 he treated 121 cases with quinine hypodermically with a mortality of only 7.4 per cent.

Serum Treatment.-Goldsborough reviews the cases of pneumonia treated by anti-pneumonic and anti-diphtheritic sera re ported in the literature. Four hundred and forty-seven cases were treated with a percentage of deaths of 15.7, which, when compared with the average hospital death rates of 25 to 35 per cent., as determined by Osler, would appear to justify or even, as Goldsborough expresses it, to almost make it obligatory upon the hospital physician to employ it in conjunction with hygienic and symptomatic treatment. Sixty-one cases were treated with antidiphtheritic serum with nine deaths, or slightly less than 15 per

cent.

The most noticeable effect of the serum is the marked cessation of cough and expectoration.

Nammack says that, in his practice at Bellevue Hospital, he has never been able to convince himself that the serum treatment had any value, and many other clinicians who have employed the serum are sceptical as to its therapeutic efficiency. However, there seems to be little doubt but that the Klemperer brothers have demonstrated that anti-streptococcus serum has a certain protective power in rendering animals, and, to a more limited degree, humans immune to pneumonia.

General Conclusions.-This is not, as you will perceive, a paper pregnant with original ideas. I have endeavored rather to present a view of some of the recent literature on this subject. In several instances I have thought it advisable to quote more or less extensively from various authors, believing their words to be better than mine.

My studies on the treatment of pneumonia lead me to make the following conclusions:

1. Pneumonia is a self-limited disease and is practically uninfluenced by treatment.

2. There is a wide range of deviation or variation in the mortality rate in different years, seasons and locations, and in different classes of people of the same age and environments.

3. The laity must be educated as to the dangers and methods of contracting pneumonia, and how to avoid it.

4. Rest, fresh air, appropriate nourishment, with ample protection for the chest, are of first importance in the treatment of a case of pneumonia.

5. No method of treatment has yet been recommended that can be accepted as a specific remedy.

6. Serum therapy would seem to hold out the most promise of giving us a specific treatment for pneumonia.-North-West Medicine, July, 1903.

QUEBEC COLLEGE OF PHYSICIANS AND SURGEONS

THE College of Physicians and Surgeons of the Province of Quebec has issued the following formalities, to be complied with in order to be admitted to the study and practice of medicine, surgery and obstetrics in that Province:

I. ADMISSION TO STUDY.

1. The Bachelors in Arts, Sciences or in Letters of a Candian or English University will be admitted on presentation of their diploma, the taking of the oath before one of the Secretaries of the College and the payment of the fee ($20) at least eight days before the meeting of the Provincial Board of Medicine; or else, at their option, they may take the oath before a justice of the peace or a commissioner of the Superior Court in their own locality, according to a form of affidavit, that can be obtained by them from one of the Secretaries. They must then address the said affidavit, with their diploma, their certificate of good morals and their fee to one of the Secretaries, at least ten days before the date of the meeting of the Board.

2. Those who are not bachelors must pass, before the examiners of the Board, a satisfactory examination upon all matters forming a classical course of studies.

3. The Board may admit any candidate having passed an examination, equivalent to the examination required in this Province, before an authorized College or a licensing Board in any other Province or British possession, provided however, that the same privilege be granted there to students from this Province.

II. ADMISSION TO PRACTICE.

Shall be admitted to the practice of medicine, surgery and obstetrics in this Province:

1. Those who having been regularly admitted to study shall have followed during four years regular medical lectures in one of the universities of this Province and passed satisfactory examination in presence of the assessors of the College or before the Board of examiners.

2. Those who having followed a regular and complete course of Medical studies in any University of England or France shall have obtained the diploma of Doctor in medicine from said University.

3. Those whose names are entered upon the medical register of England under the Imperial Act of 1886 (49-50 Vict1, chap. 48) or under any act amending the same.

4. The physicians of the other provinces of Canada, the British Colonies and foreign countries may be admitted, provided they pass the preliminary examination, study medicine during one year in one of the Universities of this Province and pass a satisfactory medical examination before the Board.

III.-MIDWIVES.

Any woman wishing to practise obstetrics in this Province must furnish:

1. A certificate of regular presence at not less than fifty lessons given by a French or English-speaking physician connected with a lying-in hospital.

2. A certificate of regular service, during at least six months, in a lying-in hospital.

3. A certificate showing that she has attended at not less than twelve births.

4. A certificate showing that she enjoys a good reputation and is able to read and write.

GENERAL INFORMATION.

The Provincial Board of Medicine meets twice a year; the first Wednesday of July, in Montreal, and the last Wednesday of September, in Quebec.

The committee on credentials and the committee interested with the professional examination meet the day before or on the day fixed by public notice, at nine o'clock in the forenoon.

All the candidates for the license must present themselves before the committee on credentials, on the appointed day, with their certificate of matriculation, their diploma from the University and their certificate of good morals.

Those who have no diploma must pass before the committee