mon and are undoubtedly of importance in connection with the weakened heart's action and with the albuminuria which may develop. The spleen often shows acute enlargement due to congestion, with more or less hyperplasia. In the ganglion cells chromatolysis is described. The blood shows in the great majority of cases a leucocytosis. Belonging to the second variety of changes are to be noted pericarditis which occurs particularly in cases of double-sided pneumonia with much purulent pleural exudate. Also endocarditis and meningitis, inflammation of the joints, etc. as well as serous or seropurulent infiltration of the tissues in the mediastinum and of the connective tissue of the thorax and neck. These may be shown to be due to the local action of the same exciting cause that is accountable for the pneumonia.

In describing the microscopic constituents of the exudate in the air spaces in pneumonia all reference to the presence of bacteria was intentionally omitted. As their presence in or absence from the lung or other tissue is directly connected with the question of the etiology of the disease a brief discussion of that point may be here given. The pneumoccocus of Fränkel may frequently be found in large numbers in the solidified lung. They are said to be found more plentifully in the early stages than later. Others state that when the expdate is very cellular they are more liable to be found in numbers than when it is chiefly fibrinous. The causal connection between the pneumococcus and the disease is now quite generally accepted, many authors adding, however, that the disease may be caused by other bacteria as well. A few, and even those who speak with considerable authority, doubt that the pneumococcus is the specific cause of the disease. As indicating the proof that exists that the diplococcus pneumoniae appears to be the specific exciting cause of acute lobar pneumonia, I shall quote from the report given by Pearce (Boston Medical & Surgical Journal, Dec. 2, 1897.) of the results of the post-mortem

bacteriological examination of one hundred and twentyone fatal cases of the disease, made at the Pathological Laboratory of the Boston City Hospital. The work was done under the supervision of Drs. Councilman and Mallory. I have chosen this report because it shows the frequency with which the pneumococcus may be found in the disease by careful workers using the most approv ed methods for its detection. The results are confirmed by those of other competent observers working under similar conditions. In this series of one hundred and twenty-one cases the pneumococcus was obtained from the solidified lung in one hundred and ten cases, in eighty-four of which it was the only micro-organism present. In the remaining cases it was most frequently associated with the common pus organisms, rarely with the diphtheria bacillus or other bacteria. Of the remaining eleven cases in which it was not obtained from the lung, no lung cultures were made in four, in two others the cultures from the lung were lost, and in two others they were sterile, but in each of these eight the pneumococcus was obtained either from the pleural exudate or from other organs of the body. In each of these cases it seemed probable that the presence of the organism in the other parts of the body was secondary to its growth in the lung. Including these eight cases the pneumococcus was found in one hundred and eighteen of the one hundred and twenty-one cases, or 97.5 per cent. The other three cases were both macroscopically and microscopically, true lobar pneumonia. In two of them there was a sufficient number of pus organisms to readily overgrow the pneumococci if these were present. The third was a case well along in the third stage in which the staphylococcus albus was alone present. In every case in which cultures were made from the pleural or pericardial exudate, fifteen of the latter, it was found present. In abscess of the pneumonic lung it was present in all of the three cases examined, twice being alone. Also in two

cases of acute meningitis and three of acute endocarditis accompanying or following lobar pneumonia it was present in pure cultures. This was also true in one case of acute fibrinous peritonitis.

The question of systemic infection was also studied by Pearce. Cultures made from the heart's blood showed the pneumococcus fifty-six times in this series; from the liver, forty-four times; from the spleen, forty-seven times; from the kidney, fifty-one times. In eighteen cases all four of these organs gave a growth of it; in eighteen others three of them; in twenty-one others two of them; and at least one organ in twenty-four other cases. In conformity with this systemic infection is the presence of the pneumococcus in the blood during life. Until quite recently the demonstration of it in the circulating blood was considered of most unfavorable prognostic significance. It is now known to be present in the blood in the great majority of cases, probably in all, and can be obtained by withdrawing 5 to 10 c. c. of blood and planting on appropriate media.

The following conclusions given by Pearce seem justified: The pneumococcus is almost universally present in true lobar pneumonia and its complications. It's presence in pure culture in the majority of cases indicates its etiological relation. General infection in fatal cases is quite frequent and therefore of considerable importance both from a bacteriological and from a clinical point of view.

THE MANAGEMENT OF PNEUMONIA.

OLIVER T. OSBORNE, M.A,. M.D.,

NEW HAVEN,

Pneumonia, second only in importance to tuberculosis, has begun to compete with the latter in claiming the attention of municipal boards of health. Certainly dur ing the last ten years the number of reported deaths from pneumonia has greatly increased in most of our large cities. This reported increase, however, is not an absolute one, as with the ever-advancing education of the people along insurance lines many certificates are handed in for pneumonia which really should be for consumption. Also, many deaths of children are now reported as due to broncho-pneumonia which were previously reported as deaths from bronchitis or capillary bronchitis, and statisticians compute broncho-pneumonia with pneumonia.

However, the fact that pneumonia is the most fatal of all acute infections is my excuse for considering a subject which is so well understood. We can, perhaps, not have too frequent discussions of a disease that so many times baffles us all, hence in making a few sugges tions I may be pardoned for reciting many well-known truths.

In considering inflammation of the lung we should not forget that it has two distinct systems of circulation; that derived from the pulmonary arteries carrying venous blood to the air-vesicles and returning the aerated blood through the pulmonary veins; and that coming through the bronchial arteries from the aorta carrying ar terial blood and nutrition to the lung tissue, a weak right side of the heart impairing one circulation and a weak left

side of the heart impairing the other. Also, a weak right ventricle will allow a profuse bloody or prune-juice exudate and expectoration, while a weak left ventricle may be one cause of the lack of resolution in a pneumonic lung.

Pneumonia is an infection, and often causes a temperature out of all proportion to the amount of lung involved, or may cause irritation of the brain out of all proportion to the local manifestations. The germ that causes this disease may migrate to different paris of the body and cause trouble in different parts, and such secondary infections are frequent.

Probably, ordinarily, only the toxins of the pneumococci enter the blood and cause the later symptoms of toxemia. If the pneumococci themselves enter the blood various complications occur, such as empyema, perhaps from the extension of the infection, endocarditis, middle ear or mastoid inflammation, or a joint complication. The crisis of pneumonia may be due to the pneumococci themselves producing enough of their own toxins to inhibit their further growth somewhat like the ferment of the tubercle bacilli, or it may be due to a sufficient amount of antitoxin formed in the blood to combat their growth or their toxins. In normal cases this occurs at the eighth, ninth or tenth day. If such crisis does not occur it is probably because other fresh foci of pneumococci have started new fresh toxins or because the leucocytosis is not sufficient or an antitoxin is not produced in sufficient amount. The toxin formed by the pneumococci seems to be a decided depressant to the heart, vying, perhaps, with the depressant action of the diphtheria bacilli.

Although there cannot be a real pneumonia without the micrococcus lanceolatus of Fränkel or Sternberg, we recognize a streptococcus pneumonia, which is the variety that develops upon la grippe, or influenza. Traumatism does not produce true pneumonia.