tion of the lungs. There is an exudation of the alveolæ, but it is not an inflammation of the lung substance. I further wish to say that it is open to doubt as to whether pneumonia is essentially the intoxication of the toxin of the pneumococcus, or whether it is an intoxication of retained metabolic substances in the system, to-wit: leukomain intoxication. It is an intoxication primarily and prominently, and perhaps more so than any other disease. The prognosis of pneumonia, in my opinion, depends altogether upon the integrity of the system of the patient. If the patient is an alcoholic, nephritic, or is surcharged with adipose tissue or with fatty tissue of the heart, pneumonia is often a dangerous and fatal disease. If the system is sound to the bottom,-if the vital organs are sound, pneumonia is not a dangerous disease. In regard to treatment, it is symptomatic, and it is personal, and it depends altogether upon the judgment of the doctor as to what system of treatment can and ought to be inaugurated, and to what extent it ought to be carried. It is a matter of judgment. The doctor is the engineer that is running the disease; that is, running the machinery; he is adding more fuel and more water as his judgment dictates. He controls the lever of the system that carries the patient through the disease, and I claim there is no disease in which the physician can apply more skillful and conscientious and withal effective treatment in the control of the issue than in pneumonia.

DR. C. H. MAYO (Rochester): I would like to say a word or two upon pneumonia from the surgeon's point of view. The lung has the largest lymphatic system in proportion to any organ of the body, and any infection touching the lung lymphatics produces a chill. The next thing is the enormous congestion and effusion. The bulk of this must be absorbed through the lymphatic system. Children under the age of puberty have more than an older person, so in children we have enormous absorption and an extreme degree of sickness, and possibly there may be evidences of pneumonia developing only as late as the third or fourth day of sickness because of the activity of the lymphatics. Alcoholism produces a sclerosis of the tissue and a gradual disappearance of the lymphatic system, and in chronic alcoholism this produces an additional danger to middle age or advanced life. If this congestion is extreme it may cause exudations to the pleura, and the pneumoncoccus is possible with empyema as a result. A new system of treatment has been advanced lately by one of the men who has originated so many new things, and that is Dr. Alex. H. Ferguson, of Chicago. He has made clear by observation in a case of mistaken diagnosis where he believed he had a case of empyema present when it was a case of pneumonia, by putting a finger in the lung, then putting in a packing of gauze when he had an enormous escape of serum. He depleted this congestion by opening the

This has happened

lymphatics, with consequent escape of serum. in three cases. So when congestion is extreme, rather than let these cases go on to death, in the worst cases, there is a possibility of this line of treatment being carried out by draining the lung which the lymphatic system is unable to take care of. Another thing: there may be a question of operations for appendicitis being made upon children in some cases because of this latent condition of pneumonia not being discovered the first few days. In pneumonia of the lower right lobe producing a tenderness over the right rectus, we have the rigidity and tenderness which the best surgeons say we find as indicating operation for appendicitis, and in the case of children we must be on the lookout for pneumonia in the lower right lobe. (Applause.)

DR. J. G. CROSs (Minneapolis): The papers of Drs. Conley and McGaughey have brought out the essential facts in pneumonia. The particular thing that I would emphasize is that pneumonia is a general infection, and not a local infection, for the reason that investigation has shown that there is an infection of the blood stream in many, if not in all, cases. The fever and the condition of the lungs are not in the typical cases the most dangerous conditions in pneumonia, but it is the general toxemia that is most to be feared. Sudden death in pneumonia is not by any means uncommon, and when it occurs it is probable that it is caused more often by degeneracy of the heart muscle than by embolism, as has been suggested. It should not be lost sight of that in the pathological study of pneumonia the pneumococcus of Fränkel is not the only cause, but it may be caused by the streptococcus or other organisms. In many instances these latter cases cannot be told from true pneumococcus lobar pneumonia. They may complicate the other forms. Dr. McGaughey's point that venesection often does good, but that it must be done early, finds corroboration in the pathology of the disease. Early in the disease, before cloudy swelling of the heart takes place, venesection may be done, but if depressants are used in the state in which the heart degenerates, when cloudy swelling of the muscle fibres has taken place, or we have acute myocarditis, then venesection and depressants can only still further weaken the resistance of the patient. The direct action of the bacteria, it seems to me, is the most important feature in pneumonia, and combating of the weakness of the heart is, of course, recognized by every practitioner to be the most important part of treatment. I cannot help feeling in this matter that the physician who feels that he has some particular means by which he has cured or aborted or helped shorten the course of pneumonia, does more good than he who has no faith in any such means, because he observes his cases more carefully, he sees them often, is able to direct treatment to the

heart weakness, and really does more good by his very confidence than he who has no faith in what he can do.

DR. W. F. COвв (Lyle): I have been very much interested in the papers just read on the subject of pneumonia, and especially interested in the mode of treatment that has been given. But there is one thing that has been barely touched upon, and that is the use of cold water. I believe in the use of cold water in pneumonia, in certain stages and under certain conditions, just as much as I believe in the use of it in the treatment of typhoid fever. Take a patient with a high temperature, restless and delirious, and put him in a pack of cold water or use baths of cold water, and you will find he will get quicker relief than he would with any kind of an opiate. An opiate is all right in its place. It is indicated in cases of pleuro-pneumonia where there is severe pain, giving relief and comfort to the patient. Cold water has a place and an important one in the treatment of many acute diseases, and in pneumonia I believe it is one of the best agencies we have, when there is restlessness, delirium, and high temperature.

DR. A. T. CONLEY (Essayist): I have only a few words to add. I did not understand Dr. Cobb as to whether he would use cold water as a bath, a pack, or in what form he would use it. I have almost invariably used the ice-pack, and it relieves the pleuritic pain the best of anything I have found. If fever is running high I generally use the ice-pack to the head. I believe the most important point in our consideration of pneumonia is the point only touched upon,-that is prevention. I believe we are agreed that pneumonia is increasing, regardless of the statistics that Dr. McGaughey doubts. I fully believe that pneumonia is rapidly increasing, and I believe it is due to contagion. I had this demonstrated in my practice this winter. I have had only ten cases since January, and five of them were in one family. All had pneumonia, one after another. I think when we shall treat pneumonia as we do other contagious diseases, and use more precaution than we are now using or to the same extent or in the same way as in other contagious diseases, we shall probably see it diminish. I believe in the contagious principle, and I believe we must pay more attention to that feature or pneumonia will continue to be our greatest foe.

DR. J. B. MCGAUGHEY (Esayist): In expressing doubt of statistics I did not express it as to the number of cases that exist. It was mainly in regard to deaths. In modern times where a family desires to keep its record as clean as possible from certain diseases, such as consumption and alcoholism, there is a very strong disposition to throw the responsibility upon pneumonia. There is one point that was brought up by Dr. Mayo in connection with symptoms of appendicitis in certain cases of pneumonia in the right

lower lobe of the lung in children, of which I wish to speak. That is a very important point. In the first case of the kind I ever saw I fortunately postponed operation for a few hours. At that time I had never had my attention called to that condition, but in those few hours I found a well developed case of pneumonia of the right lower lobe. We often have rigid muscles and vomiting, and the mistake is in many instances excusable.

PROSTATECTOMY AND ITS RESULTS

ARCHIBALD MACLAREN, M. D.

St. Paul

The first evidence of hypertrophy of the prostate is, in some cases, an acute attack of retention. I can recall three such cases which were brought on either by exposure to cold or alcoholic excess, in men who had given little or no previous evidence of the disease. One case temporarily recovered following rest in bed, and suprapubic aspiration, which was repeated every twelve hours for two days. He was then lost sight of.

The second case occurred several years ago in the country. His family physician made very persistent and heroic efforts at catheterization, spending several hours at night in a vain attempt to pass a catheter. Toward morning he emptied the bladder by using a trocar above the symphysis. The patient had a severe chill during the night and when I first saw him his temperature was 104 degrees and he looked very badly. This man came to St. Paul on the morning train and I operated upon him the next noon, opened the bladder by a suprapubic section, and put in a drain. The median lobe of the prostate was engorged, edematous, and about the size of a small hen's egg. On account of the man's bad physical condition the prostate was not disturbed. He rapidly failed, developed septic meningitis, and died on the fourth day following, in spite of the bladder drainage. I have always regretted that I did not make a perineal section on this man; perhaps this might have helped by opening up a septic pocket in the perineum.

The third case was like the second in its early history; acute retention, efforts at catheterization, followed by suprapubic aspiration. When he reached the hospital he had a