The same reply may be made to Cassoute and Corgier, with regard to the treatment by creosote carbonate, as to Aufrecht in his advocacy of quinine: that the period of observation is too short and the number of cases thus far reported too small to afford a basis for any positive opinion as to results. I do not intend to convey the impression that these remedies are not useful, but only that the claims made as to their specifis effects are as yet unproved.

When we take into consideration that the pathological process is already established in the lungs at the outset of the initial chill, and the absence of evidence to show that we have any agent capable of destroying the specific micro-organism of the disease in doses which would not be toxic to the individual; and, further, that with the exception of malaria, diphtheria, syphilis and possibly acute rheumatism, all other diseases of an infectious nature are self-limited, we are certainly justified in our skepticism as to the specific effect of any drug in the abortion of pneumonia. The statistical evidence which would seem to establish the specific effect of any special drug, should be considered with regard to the extreme variations in the mortality rate, entirely independent of treatment. For example, in selected cases as furnished by strong and previously healthy adults, as in the army in time of peace, the mortality may not exceed 3 per cent, the rate in private practice under some conditions may approach 7 per cent; while in hospital practice-taking its patients from all walks of life, the alcoholic, the aged, and those with impaired vitality from a multitude of causes-the average rate is about 25 per cent. In unsanitary camps, in besieged towns, in prisons, in malarial districts, and under a variety of other unhygienic conditions, irrespective of the most enlightened treatment the rate may be much greater.

As regards treatment by the anti-pneumococcus serum, Dr. James C. Wilson, of Philadelphia, treated thirty-six cases in the German Hospital with a mortality of 28 per cent. Dr. Tyler, of Denver, out of one hundred and sixty-two cases lost 16 per cent. The consensus of opinion seems to be that the serum treatment is unsatisfactory.

So far as the coal tar antipyretics in pneumonia are concerned, in my opinion they should be mentioned only to be condemned. This is contrary to the teachings of some excellent authorities, and to the practice of many. The tendency to death in croupous pneumonia is from cardiac failure due to the action of the pneumo-toxin upon the nerve centers controlling the circulation, and mechanically from the obstructive effects of the pulmonary exudation—overburdening and overdistention of the right ventricle.

Von Jaksch has suggested that in the absence of leucocytosis in severe pneumonia that antipyrine, acetanilid, pilocarpine and neuclein might be useful by increasing the number of leucocytes in the blood. This theoreti

cal claim is the only one, so far as I know, ascribing curative powers to these agents. The most that is usually claimed for them is that they act as palliatives: reducing temperature, promoting diaphoresis, relieving pain, and quieting nervous distress. But the cardiac depression with which the result is accompanied is too positive and serious an evil to be gainsaid, hence my conclusion that the wise physician looking to the recovery of his patient as the chief object to be obtained will avoid these agents.

As to the cognate question, what measures are justifiable for the control of fever, it is contended by some very able authorities that the fever itself is a conservative process, and should be allowed to take its course. There are extremists, on the other hand, who contend that treatment for the fever is treatment for the disease itself, and who resort to the same active means for reducing temperature as in typhoid fever. The conservative physician, while recognizing the value of hydrotherapy, will avoid such active measures as repeated ice poultices to the chest and the cold plunge baths. When the temperature reaches over 103 degrees, cool sponging and applications of cloths to the chest wet in water at a temperature of 80 to 90 degrees are useful. When there are headache and delirium, the ice cap and a bath at 90 to 100 degrees F. are usually sufficient. With embarrassed respiration and failing heart, a warm plunge for two to three minutes at 103 to 105 degrees will often have an excellent effect.

In regard to the use of opiates, many cases will get along without opium. In children we should be especially careful in its administration. I can say of opium in croupous pneumonia what has been said of its use in dysentery: "It has been abused by those who use it, and used by those who abuse it," which is intended to express that opium is indicated in some cases, in some form, or at some time, in spite of the serious objections which have been urged against it. It goes without saying that there are many cases where it is not required; and there are other cases, especially in children, where it should be used with great care or may be positively contraindicated; but in those cases attended by marked pleuritic symptoms-the stitch in the side, severe pain, impaired respirations and shock-there is no agent known to me which will take the place of opium.

It may be given as morphine, hypodermically, in -grn. doses with 1-100 grn. of atropine; or in the form of Dover's powder, 5 to 10-grn. doses every three or four hours; or as morphine with tablespoon doses of liquor ammoniæ acetatis at about the same intervals. In addition to its analgesic effects, there is probably no agent known superior to morphine for the control of excessive cough. I have tried heroin in doses of 1-12 grn. and codeine into 3-grn. doses as substitutes; but in my opinion morphine is far superior to anything else in the irritative painful cough of pneumonia.

Of course, it should be discontinued as soon as the symptoms for which it has been prescribed have yielded.

Coming now to speak of cardiac stimulants, these agents, it is now universally recognized, occupy the foremost place in the treatment of pneumonia. The tendency to death being from heart failure, the most important indication is to sustain the heart until the crisis shall have passed. I do not wish to convey the idea that heart stimulants are required in all cases of croupous pneumonia. Many cases will get well without the use of these agents, but in the presence of asthenic conditions and heart weakness, alcohol, strychnine, caffeine, camphor, musk, digitalis, sparteine, ether and strophanthus, occupy a most important place.

Alcohol and strychnine stand at the head of the list, and may be used with a free hand. Unquestionably many cases have been saved by using large doses of these remedies. They should be prescribed for their effects, regardless of the ordinary doses: strychnine in 1-30 to 1-12 grn. doses hypodermically every three or four hours; alcohol in the form of good whisky or brandy, as much sometimes as a pint or quart in the twenty-four hours, as may be demanded. As regards digitalis and its congeners, I do not think that the enormous doses recommended by Petrusco and his followers will stand the test of clinical experience. While they may stimulate the flagging ventricles, they increase resistance of the arteries; and hence if used at all should be given in moderate doses, and their possible evil effects modified by combination with arterio-dilators, nitro-glycerine, amyl nitrite or erythrol tetranitrate. These latter agents are extremely valuable by dilating arteries; enabling us, as it were, to bleed the patient into his own arteries, and thus relieve the overdistended right ventricle. The erythrol tetranitrate may be given in doses of grn. every four to six hours, and is said to be much superior to other agents of this class on account of its more sustained effects.

Speaking now of counter-irritants, it is hardly necessary to say that the enormous blisters formerly used do more harm than good, and should be forbidden. In some instances small fly blisters or dry cups are advantageous for the relief of pain. The same may be said of the turpentine stupes, applied occasionally as may be required.

As to poultices and jackets, it has only been a few years since nearly all the systematic writers recommended these applications; but, in my opinion, they are to a great extent contraindicated, especially where the respiratory powers are very much impaired, as in double pneumonia, in asthenic cases and in children. Here the mechanical effects of heavy poultices bound around the thorax can not fail to be harmful by interference with respiration and the comfort of the patient. Occasionally the application of cold

or hot cloths to the chest may aid in relieving pain and reducing temperature; otherwise they should be discarded.

Certain general measures of treatment are of very great importance. The value of admitting an abundance of fresh air to the bedroom of the patient can hardly be over-estimated. A physician in many instances has to use his authority to secure open doors and windows, against the ignorant prejudice of attendants; he should bear in mind that the life of the patient may depend upon ventilation alone.

Diet. In a disease where asthenic conditions prevail, the nutrition of the patient is of the utmost importance. Bearing this in mind, and the further fact that there is serious impairment of the digestive and assimilative powers, the physician should strive to arrive at a happy medium by the judicious regulation of the diet, avoiding overfeeding, yet maintaining the patient's strength by a sufficiency of easily digested liquid food. There are many cases where it is necessary to employ tact and a knowledge of dietetics in order to secure this result. Especially this is the case when nausea or vomiting are prominent symptoms. Under such circumstances it may be necessary to resort to temporary feeding by the rectum.

The Bowels. It is necessary to secure a sufficient intestinal evacuation and is often expedient in malarial countries to begin the treatment by a moderate dose of calomel, say 4 to 5 grains, given in divided doses. Small doses of this remedy are frequently of service also during the progress of the case where a coated tongue, nausea and constipation indicate imperfect elimination and impaired assimilation.

Quinine. In cases complicated by malaria, and all cases occurring in malarial districts, quinine is required. It should be used in sufficient doses to overcome this complication. At the same time, the depressing effect and tendency to produce nausea and interference with the patient's nutrition should be avoided by proper dosages and combination.

Creosote and Its Congeners, Guaiacol Carbonate and Thiocol.-The remarkable results claimed for these remedies in the treatment of croupous pneumonia, first by Corgier and Cassoute, and subsequently by numerous followers,, demand investigation. From statements previously made, it will be understood that I can not subscribe to Van Zandt's conclusions that these agents are capable of cutting short the disease; but that by the exercise of antipyretic, antiseptic and tonic powers these remedies may mitigate and control certain cardinal symptoms, I am not prepared to deny.

Thiocol (guaiacol-sulphonate of potassium), it is claimed, possesses certain decided advantages over any other preparation of guaiacol or of creosote: it is soluble in water, free from odor and taste of guaiacol or of creosote, is non-toxic, non-irritating, and exceedingly assimilable. It may be

administered to adults in doses of 5 to 20 grn. three times daily, in a powder, tablet or solution, in syrup of orange or syrup of cinnamon.

Intravenous or subcutaneous injections of saline solutions, it is claimed by some, are of decided value. A small preliminary bleeding is held to be useful. Oxygen inhalations should be combined with this treatment. The modus operandi of saline transfusion is dilution of toxins, increased elimination, reduction of temperature, and stimulation of cardiac and respiratory functions.

In a discussion which followed the reading of this paper before the West Texas Medical Association at San Antonio, I requested an explanation of the fearful mortality resulting from croupous pneumonia during last winter and spring in certain portions of Texas, which has been variously estimated as from 50 to 75 per cent. Two opinions were given. One was that it was due to malarial complications; the other, offered by Dr. Frank Paschal, was that for inexplicable reasons nearly every case of pneumonia was characterized by profound asthenia during certain seasons, for which malaria was in no way responsible.

The following facts were also brought out in the discussion: That the mortality was far greater in the negro race than in the white; that during the recent war in South Africa, owing to the unhygienic conditions, croupous pneumonia was an exceedingly frequent cause of death, and was attended by an excessive mortality rate.

DR. C. E. CANTRELL, Greenville: In answer to Dr. Smith with reference to patients that have pneumonia and have had malaria previously, I want to say that I have had considerable experience along that line in treating pneumonia. I have found that patients who have had malaria in the summer are more susceptible to pneumonia. Take a man who has had thirty or forty chills, and if he gets pneumonia he is liable to die in spite of all you can do; he generally has acute lobar pneumonia. If you treat a case that has had chills, he has not the blood supply to hold him up, and you had better be more careful than if he had not had the chills.

Dr. J. T. O'Barr, Ledbetter: In regard to giving quinine, I do believe that it is good before expectoration comes on-during the congestive or the stage of engorgement a few large doses of quinine do good.

DR. J. H. MCCRACKEN, Mineral Wells: For acute cold I have ever found quinine beneficial; but I can not recommend its use in pneumonia, if for no other reason than the fact that it excites the nervous system, thereby making the patient nervous and restless and increasing the danger of brain complication. I think you will find that doctors who use quinine and opiates in the treatment of pneumonia get the worst results; however, an occasional dose of opium to produce rest is good practice. In malarial