The incidence of lobar pneumonia on a major part of the population is therefore diminishing.

2. The returned mortality of the United States for ages above 60 for pneumonia has increased from 21.9 to 22.6 per cent, but the population has, in the same age and same time, increased from 6.2 to 6.6 per cent.

3. The returned mortality of the United States for ages under 15, (about one-third of the total population) shows an apparent rise of mortality for pneumonia. But in former years respiratory troubles of children were often mistaken for affections of the nervous system and so returned, but the correct diagnosis and tabulation can account for the apparent increase of pneumonia.

4. Since 1890 a new cause of infant mortality has come into view, an acute respiratory affection attacking infants of two years old and under. This is commonly returned with a diagnosis of pneumonia, but it is probably due to influenza.

5. The mortality registrations of American cities represent a perversion of statistics which must eventually bring discredit on American mortality registrations. So much for the statistics of the disease.

The treatment of pneumonia is no less interesting than a review of its prevalence and statistics. There is a large class of practitioners and teachers led by distinguished men, such as Osler and Herrick, who frankly state: "We have nothing that will neutralize the poison of the disease.' And as Prebble puts it: "We know nothing that will actually help the patient, let us therefore be content that we do no harm." Personally, I am not in sympathy with such agnostic views in the treatment of the disease under consideration or "the sit-still-and-do-nothing policy" of many other diseases. I believe in certain dependable action of drugs, intelligently administered and in proper dosage But don't be a veterinarian when your patient is not a mule.

But let us consider some of the theories which have been and are in vogue upon which the treatment of pneumonia is based. Here they are: The antiphlogistic theory, the antiseptic theory, the inflammatory theory, the rational theory, the expectant theory. Now we, of this enlightened age, have discovered the one true and only correct theory of its cause and therefore its treatment, the germ theory. We know that

it is the toxemia caused by the pneumococcus lanceolatus.

Fifty years ago all of our standard works were by Englishmen and Scotchmen, with American notes. Their treatment was to bleed, freely and often. Mackintosh states that he has taken 56 oz. at one bleeding and 120 oz. in the first four days. He also states that he has a record where 192 oz. was taken, which he considers too much. Bleeding was followed by brisk cathartics, and that by tartar emetic, usually beginning with 4 to 1⁄2 gr.; it was rapidly pushed to two grains every hour and often one, two, or three drachms were given in 24 hours. In giving tartar emetic in such doses, you drown the patient in his own effusion. Oedema of the lungs is sure to result This was realized in time and reaction followed. Then came mercury as the remedy par excellence, for it arrested the effusion of lymph which tended to spoil the texture of the lungs. It was pushed to salivation and then, if the patient still showed signs of a desire to live, he was blistered and so our "heroic fathers" practiced.

Later, Bennett came forward in advocacy of his antiphlogistic theory, and claimed to save "two out of three cases" by this method. His advice was to 'further all necessary changes which the exudates must undergo to be freely excreted from the economy." A very reasonable theory.

"As Watson was a fair representative of the antiphlogistic plan of treatment 50 years ago, and Bennett of the rational plan 40 years ago, so the elder Flint was the best exponent of the expectant plan 30 years ago, while Bartholow fairly represents the same plan 20 years ago and Loomis 10 years later.

Under the first two plans but few different kinds of drugs were used, while with the expectant plan a great variety was brought into use, and as time passed they constantly increased. Flint followed the usual plan of dividing pneumonia into three distinct stages, and then prescribed a different plan of treatment for each stage, recommending some 12 or 15 different drugs in the five to ten days of the acute stages of the disease."

Coming down to our present time we find Schwartz, of Germany, claiming that iodine is a specific for pneumonia; and so at different times veratrum viride, carbonate of ammonia, digitalis, ergot, salicylate of sodium, benzoate of soda, carbonate of creo

sote and many others have been heralded through the medical press as the long sought specific. Among the latest,and one that has been widely tested and is yet quite favorably spoken of, is carbonate of creosote. While the first 1,100 cases reported as being treated by carbonate of creosote showed only about 5 per cent of deaths, yet Scott and Montgomery report having treated 67 cases in the Pennsylvania hospital with ten deaths, or about 15 per cent. This is a fair showing in a hospital where the general average is 20.4 per cent.

Bartholow tells us that Flint once claimed that large doses of quinine, 20 to 40 grain doses, would abort pneumonia. But Flint's dose was homeopathic in size compared to that advocated by Dr. Gilbrath, of Cananae, Mexico, who in a recent article in the Journal of the American Medical Association, after detailing the history, examination and diagnosis of his cases, of which there were 50 "consecutive ones without a death," he gives the following as his routine treatment The man was hard to arouse but 75 grains of quinine were administered. One hour later 40 grains more were administered; five hours after the initial dose 40 grains more. With this the well-meaning doctor gives 15 drops of tinct. of chloride of iron every three hours and ends his article in this style: "This treatment may seem aggressive to some, but I believe the future will record many larger doses. The most prominent feature that recommends. my treatment of pneumonia is the absence of cardiac depression and the early resolution that invariably follows." But note this closing sentence: "The giving of quinine during the stage of resolution must be carefully watched, as small doses, of from 5 to 10 grains, will frequently produce cinchonism."

Dock, of Ann Arbor, advocates the use of the ice bag for the relief of pain, the cold bath for high temperature, rectal enema for tympanites. Hypodermoclysis Hypodermoclysis for failing heart action, and oxygen for paralysis of respiratory centers, marked by dyspnoea and cyanosis.

Dr. Solis Cohen, of Philadelphia, gives the following as the cause of heart failure in pneumonia. Excessive fever, 105 or 6; tympanites, general want of nourishment and deficient oxygenation; and adds, such contributive causes are best met either by general measures or by symptomatic means

directed to the removal of the special symptoms or conditions.

For the early stages of hepatization he advocates infusion of digitalis. For sudden collapse he advises the use of suprarenaline given in 1-20 grain tablet triturate on the tongue every two minutes until reaction is accomplished. Or camphor in doses of 20 to 30 minims in sterile olive oil may be given hypodermically; but he relies particularly upon the injection of tinct. of musk in five to ten drop doses for quick and sustained action. Antipyretics and hypnotics are condemned. For the elimination of urine, saline colon injections are urged.

The treatment by alkaloids as followed by Abbott is worthy of note. His endeavor is to prevent or at least limit each stage in its development. To quote him: "We were taught that the first step in a pneumonia consisted in dilatation of the pulmonary capillaries; then came diapedesis of white cells, possibly rupture of vessels and effusion of blood with exudation of red and white cells, fibrin, bacteria, epithelium, etc.

If the first step is not taken there can be no second. If the primary dilatation of the capillaries is relieved, the subsequent phases of the process must wait. Hence we relax the spasmodic contraction of the cutaneous. and central vessels by giving sedatives like aconitine and veratrine, as our fathers did by giving antimony, while we restore tone to the paretic walls of the pulmonary capillaries by the use of strychnine and digitalin. By employing both principles at once we accomplish both indications, and thus obtain a more direct and powerful action than when either one of these therapeutic forces is put in operation without the other.

This is most conveniently accomplished by using small and closely repeated doses of the above agents combined in accordance with the particular indications of each case. Thus we may administer aconitine amorphous, gr. 1-134, and digitalin Germanic, gr. 1-67, every ten, twenty, thirty or sixty minutes until the pulse and the other symptoms show that the desired impression has been made upon the circulation, then less frequently so as to keep up the desired effect. If the pulse is unusually hard and the elimination deficient, as in what is known as sthenic pneumonia, we add to the above veratrine, gr. 1-134; while if the heart is weak and the symptoms denote the asthenic type of the malady, we add strych

nine arsenate, gr. 1-134, to each dose. As the type changes from sthenic to asthenic, or vice versa, we change from one to the other of these triad combinations and back again. This enables us to pursue the same general plan throughout, but gives a flexibility to our therapy that has no parallel elsewhere."

He secures and maintains antisepsis of the bowel by the following medication: "One-sixth grain of calomel (or one-sixth

antitoxic qualities, and their anti-infectious properties have not been proven.

6. Further investigation into the subject with a view to discovering an efficacious serum are strongly advised and encouraged.

INDICATIONS FOR PREMATURE DELIVERY.

(Read at annual meeting of State Medical Association, June, 1906.)

Other antiseptic agents may do as well as the sulphocarbolates; the principle is the thing, but so far, in the writer's experience, no other has given as good results at so moderate a cost.”

The profession has waited long for "a Moses to lead them to the promised land" where serum therapy would give them hope of giving their patients a foot-hold in Canaan, and at times we have thought we were in sight of the goal, but in a recent article Dr. Anders, of Philadelphia, gives the following conclusions regarding the serum treatment of pneumonia :

I. A sufficiently extensive trial of the antipneumococcal sera has been made to determine with a reasonable degree of accuracy their efficiency, and the results as a whole fail to carry conviction.

2. An efficient serum or one that will cut short the pneumonic process is yet to be produced. Although according to clinicians, the sera available at present have a restricted field of usefulness.

some

3. Recent observers have employed the serum in massive doses from the commencement of the disease without gratifying results.

4. The practical results of the use of the antipneumococcus serum, as shown by the mortality percentage, does not warrant its general introduction.

5. The sera thus far found possess no

The course of pregnancy may be arrested artificially at any time in the interest of either mother or child. The subject divides itself naturally into two parts. First, if gestation is interrupted before the fetus has become viable, that is prior to the one hundred and eightieth day, it is called the "induction of abortion:" and second, if after the child has attained viability but before the period of full term, or two hundred and eighty days, it is termed the "induction of premature labor." The date of fetal viability is therefore the line of division between these two operations.

The operation for induction of abortiondates back to the earliest antiquity and more or less accurate directions for its performance are to be found in the oldest writings upon medicine. The practice of inducing abortion became so extensive in ancient Rome that we may find it repeatedly referred to by secular writers of that day as a matter of common occurrence. With the rise of the Christian era, however, it came to be considered as criminal, except when undertaken for the express purpose of saving the life of the mother. The line of distinction between criminal and therapeutic abortion has in later times been very closely drawn.

The induction of abortion is a procedure that should be undertaken with great reluctance. However, if in the course of pregnancy some pathological conditions arise as a direct consequence of gestation, or if a woman suffering from disease is made much worse by the existence of pregnancy and her life is distinctly endangered thereby, it is not only justifiable but it is the duty of the physician to terminate the pregnancy and thus save the life of his pa

tient instead of sacrificing the life of both mother and child.

The most frequent condition demanding artificial interference will probably be pathological vomiting. When all the remedies for relief of this condition have been carefully and conscientiously tried with no avail, when alimentation per rectum has been continued for a week or ten days and no improvement in the patient's condition is noted, and it becomes evident that she is in danger of death if the pregnancy continues, the uterus should be emptied.

Death of the embryo is another condition calling for active interference. If it can be demonstrated that the fetus is dead, its removal is imperative. It is well to remember, however, that the signs of fetal death are sometimes difficult to elicit, and a certain diagnosis can only be made after an extended observation, unless the amnion has ruptured and putrefactive changes in the fetal body have become manifest.

Albuminuria and degeneration of the kidneys are conditions demanding prompt and careful attention. If untoward symptoms arise, such as persistent head-ache, progressive oedema, steady or rapid increase in the amount of albumen, sudden diminution in the amount of urine, tube casts in large amount, and failing vision, in spite of careful and thorough hygienic, dietetic, and medicinal treatment, abortion should be induced.

Hemorrhage from the uterine cavity, due either to placenta praevia or from the detachment of a placenta normally situated, may be so excessive or so long continued as to demand prompt evacuation of the uterine contents.

The advent of certain diseased conditions within the uterine cavity, as cystic degeneration of the chorion, or acute hydramnios in which the fluid has accumulated in such amount or so rapidly as to produce alarming symptoms, demands that the uterus be promptly emptied.

Certain displacements as prolapse, anteflexion, and retroflexion of the pregnant uterus, resisting all efforts at reposition and threatening to Secome incarcerated, demand the termination of pregnancy.

In the course of gestation acute mania and melancholia or chorea or possibly a general pruritus may arise and show such grave symptoms that termination of the pregnant condition must be considered.

If organic heart lesions exist in which the compensation is weakened or broken, or if there be disease of the blood such as pernicious anaemia or leucocythaemia, abortion is indicated at an early period.

In addition to the indications for abortion above mentioned, there are special indications for the interruption of pregnancy after the child has become viable; the most important of these is a contracted pelvis, in which case the patient should be allowed to choose for herself between a premature delivery and Caesarean section at term. The next in importance is placenta praevia in which active measures are always indicated.

In the case of advanced tuberculosis in a pregnant woman, it may be necessary to secure delivery before the fatal termination of the disease which is evidently close at hand, or to save her the strain of the last month of pregnancy and secure her an easy delivery.

Lastly, labor may be induced at term or shortly thereafter in a patient showing a disposition to a prolonged pregnancy.

In any of the conditions and indications above referred to the question is one of such moment that it should never be decided by the attending physician on his own responsibility alone, no matter what may be his skill or experience. There should always be a consultation so that the responsibility may be shared, and the physician be free from criticism, and the unwarranted claims so frequently brought forth for damages.

CATARACTOUS FAMILIES.

John L. Dickey, A. M. M. D., Wheeling, W. Va.

(Read at meeting of West Virginia Medical Association, June, 1906.)

The ordinary observer, and the stockbreeder, as well as the medical man, know that marks and physical peculiarities and tendencies to certain diseases, also mental and moral traits, are apt to run in families and are transmitted from one generation to another, either directly or by atavism.

In fiction, which is generally founded on the best proven facts, Anthony Hope's "Prisoner of Zenda” illustrates well by the plot of the story the recurrence of physical peculiarities by the cropping out in succes

sive generations of the Rassendyll family the long, sharp, straight nose and the dark red hair that distinguished the race of one of the ancestors.

Every one of us, no doubt, knows a family that is distinguished by prematurely gray hair, and this peculiar aberration of one of the vital processes may manifest itself not only in one, but in several generations; in fact, back to the time when the memory of man runneth not to the contrary.

The eye, probably more than any other feature, shows in families as a hereditary peculiarity. The brown eye, or the blue or gray; the myopic or the hyperopic, or the astigmatic eye may readily be followed through several generations.

Would it not be natural, then, to expect cataracts to be hereditary? Would it not be as natural to find a whole family with opaque lenses as with prematurely gray hair? I think it would; and to prove my contention, wish to report at least four families which I have run across in my practice that were cataractous families, or families with a hereditary tendency to opaque lenses.

The first family was one in which the mother had been blind with soft cataract at the age of forty. She was operated on successfully. On November 6th, 1884, I removed a hard cataract from the eye of one of the daughters, aged thirty-eight. I used cocaine as an anaesthetic. It was the first time on record, I believe, that cocaine was used as an anaesthetic in cataract extraction.

On February 5th, 1885, I operated on the other eye of the same patient. The result was perfect, vision of 20-20 being secured in each eye with the proper glass. In 1892 I removed a hard cataract from the eye of another daughter, aged forty-seven. The result was perfect vision. In 1895 I operated on the third daughter who had been blind for twenty years with capsular cataract. She had been living in Missouri during that time and had lost one eye entirely from an operation that proved unsuccessful. She came back home to have the remaining eye operated on. The dense, opaque capsule was largely removed, and the result was perfect. She was able, with the proper glass, to read small pica print. After her twenty years of blindness she had not forgotten in the least how to read. The remaining daughter of the family is about sixty-five years old and still has good

eyes and normal vision. Of the two sons in the family nothing definite could be learned, as they had gone away from home early in life. One of them served through the Civil war, and they heard at home he had gone blind.

The second family that seemed to be cataractous was that of a man aged sixtyseven on whom I operated for a ripe cataract in 1898. His father had cataract in both eyes, well-matured, when he died at the age of sixty-eight. An older sister of my patient had been blind from cataract and had been operated on when about fifty years old. Another sister, aged about sixty, had a mature cataract in the right eye at the time. The male cousins, sons of his father's brother, had cataract in both eyes when about sixty years old.

The third case of possible hereditary cataract was that of a man aged forty-four years whom I operated on in 1899. He was totally blind from double cataract, and I removed a hard, fully matured lens from the right eye, in which the vision had begun to fail two years before. His brother had gone blind from the same cause when about forty years old, and had been successfully operated on. His father and mother were living at seventy with good vision, but his father's sister had double cataract when seventy years of age.

In 1904 I removed a mature cataract from an old gentleman of seventy-four. His sister, aged eighty-two, had been blind in one eye from cataract for several years, and had one eye operated on a year before her death. A sister of his father had also been blind from double cataract for several years before her death at seventy-seven.

Dr. G. N. Brazeau, of Fond du Lac, Wisconsin, at my suggestion, having read my report of this last case in the Association Journal, sent a report of a family in his practice which was published in the Journal in July, 1904. In the family he reports the mother, aged sixty-four, a son aged thirty-six, a daughter aged thirty-two, and a grandson aged ten, are all afflicted with partial cataracts.

Dr. Edward Nettleship, of London, the eminent occulist who operated on Gladstone for cataract, has written about hereditary cataract, and asserts that Americans have reported no cases of the kind. Dr. Casey Wood, of Chicago, wrote an excellent paper on the subject recently that he read