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special bacterial agent should always be i.solated. \inong the commoner complications of pneumonia was empyema. In encapsulated empyema follow- ing pneumonia, a positive diagnosis was sometimes ' xtremely difficult. Other means failing to prove the 1 rcsence of pus an exploratory operation should be I'lne. In consequence of the toxtemia or pneumonic -eptich,-iemia, cardiac exhaustion might ensue with- ' lut any marked histological changes in either of the \alves or the myocardium. Viagra Prescription By Phone Acute endocarditis was present in about ten per cent, of the cases of pneu- monia. Viagra Prescription By Phone It differed from other varieties : ( i ) in that three fourths of the cases were ulcerative ; (2) that women showed a higher incidence than men in the proportion of tw-o to one; (3) that Viagra Prescription By Phone the aortic cusps were more commonly involved than the mitral. Pneumococcus endocarditis generally prevented the occurrence of the crisis. Pericarditis was a more frequent complication than endocardi- tis. Meningitis might be associated with endocar- ditis or occur independently as a complication, but this was comparatively rare. It could be diagnosti- I cated only b\- the presence of such features as bradycardia, paralyses, and neurorctinitis, or in the hsence of definite symptoms, by lumbar puncture. We were indebted to Norris for the observation hat acute nephritis probably occurred in about even per cent, of pneumonic infections. The writer had elsewhere shown that chronic nephritis was frequently found at autopsies in cases of pneu- monia (seventy per cent, of the cases at the Phila- delphia Hospital), so that might be regarded as one of the commonest foregoing diseases. Diagnosis of Pneumonia. — Dr. Augustl'S A. EsHXF.K Viagra Prescription By Phone averred that in the majority of cases the diagnosis of pneumonia was easy. With a liistory of exposure to cold, followed by chill, fever, pain in the chest, dyspnoea, rapid, shallow breathing, irri- tative cough, viscid, mucoid. ha?morrhagic sputum. labial herpes, pneumonia would suggest itself, and the diagnosis would be confirmed by ])hysicfal ex- amination. Difficulty in the recognition of pneu- mriii'.-i would ari>-c principally in atypical cases. Error was to be avoided by con.stant vigilance, with frequent physical exploration. .Among the disor- ders from which pneumonia required to be differen- tiated were acute pleurisy, pulmonary tuberculosis, bronchopneumonia, congestion of the lungs, infarc- tion, abscess, gangrene, bronchiectasis, actinomy- cosis, syphilis, malignant disease, pericardial eifu- sion, meningitis, and typhoid fever. Surgical Complications and Their Treatment. — Dr. Ch.\rli£s ['. N.\ss.\u noted that pneumonia was not wholly a medical disease, as generally be- lieved. With enormous effusion, removal by opera- tion was the only proper course. Careful attention should be given to the cardiac condition. In a true empyema the treatment \vas clear: Incision, Viagra Prescription By Phone w-ith or without resection of the rib. and drainage. .Abscess or gangrene of the lung was one of the most difficult propositions confronting the medical man and Viagra Prescription By Phone surgeon. The treatment of either consist- ed in rib resection and the insertion of a drainage tube. There was a sentiment against tapping sup- purative collections in the pericardium, and he be- lieved it was very much safer to make a small rib resection and expose the pericardium, when the needle could be .introduced with comparative safety. In sixteen years he had seen very few cases of ar- thritis complicating pneumonia. It affected Viagra Prescription By Phone chiefly the knee and occurred most frequently in children. Absolute diagnosis rested solely upon bacteriologi- cal examination of the joint fluid. When the pain in pneumonia was referred to the abdomen the pain and tenderness might be as pronounced as in acute abdominal disease. Diagnosis was so difficult that laparotomy might be done. Medical Treatment of Pneumonia. — Dr. Ar- thur Xewlix stated that the mortality of pneumo- nia was maintained at twenty per cent, or over, death or recovery occurring usually, not so much as the result of inefficient or successful treatment, but in direct proportion to the individual's innate power to combat his infection. On account Viagra Prescription By Phone of Viagra Prescription By Phone the constant jM'esence of pneumococcus in the normal individual it behooved us to avoid those things that reduced natural resisting power. Pneumonia pa- tients should be isolated when possible. Two chief ends to be sought were the preservation of the pa- tient's bodily strength and the maintenance of his personal comfort. Local measures such as cupping or strapping were used for the control of pain. The use of baths was not advised in adults, but hot baths in children were frequently of value. Dyspnieaand cyanosis were better controlled by cold air than by any other means. Cold air treatment had met with very good results. Milk remained the staple diet for pneumonia patients. The intestinal tract should be cleansed by calomel and salines. Such expecto- rants as creosote and ammonium chloride were rarely necessary ; respiratory stimulants such as strychnine, atropine, and aromatic s])irits of ammo- nia were useful. Viagra Prescription By Phone They should be administered as occasion indicated. Phlebotomy had its use when the consolidated lung offered a mechanical obstruc- tion to the pulmonary circulation. The circulatory system offered the best f)pportunity for the display of judgment in Viagra Prescription By Phone the administration of drugs. I'^or the cardiac weakness which resulted from fatigue 854 PROCEEDINGS OF SOCIETIES. and toxjemia such stimulants as strychnine, digita- Hs. aromatic Viagra Prescription By Phone spirits of ammonia, caffeine, atropine, and camphor might be used. Of these, strychnine and camphor were probably the best. Alcohol and digitalis were sometimes of use. Although there were objections to alcohol, yet in the aged and to those addicted to the use of the drug it might be used with benefit. Digitalis was better given hypo- dermically and of its preparations preference was given to the fat free standardized tincture. For lowered blood pressure, rapid pulse, and tympani- tes, adrenalin, hypodermically, after the method of Gibson and Forcheimer, might be employed ; its dose was one c. c. of a i to i,ooo solution. Stro- phanthine was a drug that had come into vogue