Remarks. Essential Factor in Etiology of Stricture and Its Bearing upon the Question of Radical Cure. On the Value to the Surgeon of Some Recent Methods of Renal Diagnosis. A Possible Aid to the Discovery of the Tubercle Bacillus in Urine. Technique of Prostatectomy.

Pioneer work of a valuable character is in evidence in his investigations regarding the etiologic bearing of urine leakage in urethral stricture; -his recommendation of critical search for the tubercle bacillus in residual urine, rather than from the entire vesical content; his suggestion that in certain forms of prostatic overgrowth the prevesical space be entered, and pressure upon the prostate be induced through the intact vesical wall to facilitate perineal manipulation and excochleation; his advocacy of cystoscopy antecedent to urinary segregation;-and his valuable efforts in establishing upon a firm basis the various forms of, but in particular perineal, prostatectomy.

During a comparatively extended period of time, preceding his death, Dr. Bryson was engaged in making an investigation of the relative values of cryoscopy (both hematocryoscopy and urinocryoscopy), and the methylin blue and phloridzin tests in determining the functional status of the kidney. This valuable mass of material was to have been presented before the Association of Genito-Urinary Surgeons at its session in Washington this month. It is a matter of more than passing regret that the surgical world should be deprived of the fruit of the labors of one of her conscientious sons. Shall we not be permitted the hope that some other gleaner in this field of activity animated by a fraternal and sympathetic spirit may not only be permitted, but encouraged to tabulate and place on record, as a final capsheaf to the memory of our colleague, this the work of his ripened manhood.

And so has drawn to a close the life and the life-work of John Paul Bryson, a man reserved and self-restrained, and yet of a genial and cordial spirit;-an indomitable worker, a true seeker after truth;-a gentleman with the charm and grace of one to the manor born;-a colleague, who in the midst of imperative and endless demands upon his strength, yet found time, and made occasion, to extend the hand of encouragement, of support, of good cheer, of leal comradeship to his fellow-workers;-an unostentatious follower of his Master, who was Himself the Great Physician.

The laws of perspective at times become strangly distorted in this work-a-day world. How often does the man in the far distance loom largely in our vision; while the sterling qualities, the gracious personality and the unquestioned ability of him who sits at meat with us, or daily grasps our hand, are assumed to obtain as a matter of course.

Shall not we, the members of this society,-stimulated by the life and, in particular, the unflagging energy of our late colleague, cheered by his serene and unfaltering spirit, and further animated by the characteristics of gentlemen and seekers after truth,-shall not we in closing up the ranks, gird ourselves anew, be more earnestly painstaking in daily extending a cordial uplift to our fellow-man, and with vision clarified and keen, from this high view-point, strive for the thinking of noble thoughts, the doing of noble deeds, the living of noble lives;-and thus shall we receive our legacy.

Fortnightly's Post-Graduate Course

In this department we will present a series of Practical Papers for the General Practitioner, written expressly for this magazine by the leading Medical Writers of the Twentieth Century.

DISEASES OF THE LUNGS AND PLEURA.

A Series of Papers written expressly for this magazine, by

BY ALBERT ABRAMS, A. M., M. D. (Heidelberg),

SAN FRANCISCO, CAL.

Consulting Physician for Diseases of the Chest, Mt. Zion Hospital and the French Hospital

[CONTINUED FROM PAGE 357.1

ASSOCIATED LESIONS AND PATHOLOGIC PHYSIOLOGY.-The portions of the lung not implicated in the pneumonic process are emphysematous, congested and may be edematous. The large bronchial tubes are congested and contain much secretion. If edema is present, it is most marked at the bases behind (hypostatic congestion). Such congestion predisposes to eventual involvement of the congested lung should the pneumonia spread. The bronchial glands are red, swollen and congested and return to the normal after recovery. Pleurisy usually corresponds to the affected lobe. Extensive pleurisy is rare and serous exudation is uncommon. The heart is implicated as the result of systemic intoxication and mechanic causes. Pericarditis is frequent and endocarditis is more frequent in this affection than in any other acute infection excepting rheumatism. The cavities of the heart are dilated, specially the right and may be filled with ante-mortem white clots, which may extend into the auricles, and for some distance into the pulmonary artery. The clots may be the cause of death from obstruction to the circulation, or. by detachment. The myocardium, kidneys and spleen like in other febrile infections undergo parenchymatous degeneration. Meningitis may occur as well as inflammations of the joints and abscesses in the organs. Fibrinous bronchitis, laryngitis, colitis, gastritis and cystitis may occur.

COMPLICATIONS.-Abscess.-Secondary infection with pyogenic organisms may conduce to lung abscess, or it may be due to the fact that such organisms were primarily present. Sello, in 750 cases, found abscess in 11, i. e., 1.5 per cent. Of these 7 recovered with discharge of the pus either by expectoration or operation and 4 died. Gangrene, is a less common sequel than abscess. The statistics of Sello show, that in 750 cases lung gangrene was present in 3 cases, i. e., 0.4 per cent. Gangrene is likely to occur when the exudation is hemorrhagic, and when the circulation is weak. Induration or interstitial pneumonia is another eventuality which will be described later.

ETIOLOGY-The pneumococcus is the real pathogenic organism of acute pneumonia, although other organisms may cause typical fibrinous

pneumonia. These are the strepto and staphylococci, the bacillus of typhoid fever, the bacillus of influenza and the bacillus coli communis. The atypic course of many pneumonias is certainly dependent on the nature of the micro-organisms present. The two chief organisms identified with this disease are: Bacillus pneumoniae of Friedlaender and the diplococcus pneumoniae of Fraenkel. The latter organism is frequently found in normal persons in the mouth and upper respiratory passages and explains many cases of infection when predisposing factors like cold, fatigue, and systemic depression are present. The organisms of pneumonia are found in complicating peritonitis, pericarditis, meningitis, etc. The organisms never develop primarily in the blood, but gain access to the lungs through the bronchi. The diplococcus of Fraenkel has been found in the blood of patients afflicted with pneumonia, and Silvestrini found them in 15 out of 16 cases. Lobar pneumonia is one of the most widespread and fatal diseases, and its virulency and frequency seems to be on the increase. Pneumonia averages 3 per cent of all diseases peculiar to man, and 6 per cent of all medical diseases. The average mortality is from 1.5 to 2.3 per 1000 persons living. Seasons: pneumonia bears a direct relation to seasons and its frequency is dependent on rapid and marked changes of temperature at a time when the mean temperature is low. According to statistics, the most favorable season for the development of pneumonia are the months of January, February and March, and the months which show the least number of cases, are: July, August and September. The influence of temperature in producing pneumonia has been attempted to be solved experimentally. Thus Lipari, injected into the trachea of animals pneumonic sputum. All the animals remained well, unless they were subjected to cold before the injections were made, and then they contracted pneumonia. He concludes, that cold paralyzes the epithelium of the bronchial tubes which fact invites the elements of infection into the alveoli. Localities exposed to cold winds and dampness favor the disease. Most pneumonias occur during a northeast wind. A high barometer is associated with a diminished frequency of the disease. The disease is more frequent among the urban than among the rural population. While meteorologic conditions influence the prevalence of the disease individual predisposition is the real factor. This factor is made up of many things. Fatigue, overwork and worry are essential predisposing factors. People living in the open air contract pneumonia two and one-half times more often than those working indoors. Occupations which necessitate exposure to the elements are attended with increased prevalence of the disease. The influence of traumatism is an important one and Litten speaks of the frequency of contusion pneumonia after contusion of the thorax with out the latter showing any lesion. He differentiates such pneumonias from traumatic pneumonias following a stab or gun-shot wound. Among 320 cases of pneumonia, Litten traced the cause to a contusion in 4.4 per cent of the cases. A contusion pneumonia usually develops within two days after the accident, and if concussion hemoptysis has occurred, it is soon followed by rusty sputum. Pneumonia has been observed to follow ether anesthesia in 30 out of 12,842 etherizations reported by Anders.

Exposure to cold during anesthesia and infection from the cone were excluded. It is very likely that in such instances, the pneumonia resulting was a deglutition pneumonia, and that during the period of unconsciousness secretions from the mouth and nose were aspirated into the bronchial tree. We know, that, according to Netter, the diplococcus pneumoniae is found in about 20 per cent of normal individuals in the saliva, and its presence has been frequently demonstrated in the nasal secretions. The question of heredity as a predisposing factor was demonstrated by Billard, who found pneumonia six times among seventeen patients who were born in a condition of extreme debility and emaciation. The common occurrence of pneumonia in children seem to indicate an hereditary factor. Pneumonia of all infections is characterized by the fact, that one attack does not establish immunity, on the contrary, it predisposes the individual to subsequent attacks. In v. Grisolle's 174 patients, 94 had recovered from previous pulmonary inflammation which had occurred from 1 to 8 times. Age: it may occur at any age. It is least frequent during the first five years of life when broncho-pneumonias predominate. It is common between the 20th and 40th years of life after which the liability to the diseases lessens until the 60th year, when of all acute diseases, pneumonia claims. the most victims. Sex: Men are more frequently affected than women in the proportion of 2 to 1. When advanced age brings both sexes under the same influence, there is no difference between the sexes. Previous disease, by diminishing the resistance predisposes to the affection. Chronic alcoholism and malaria, the specific fevers, notably measles, typhoid fever, influenza and diphtheria are types of such diseases. Summarizing our knowledge of the etiology, we have essentially this, that the exciting cause of pneumonia is the pneumococcus; that it is a general infection with pulmonary localization and one proof of infection is, that there is no constant relation between the area of pneumonic infiltration and the intensity of the somatic symptoms. In other words, a limited pulmonary lesion may be accompanied by intense symptoms and conversely extensive consolidation by mild symptoms.

MODES OF INFECTION.-Epidemic Pneumonia.-The specific organism is found in man during health on various mucous membranes. Should pneumonia develop, we are constrained to suppose one of two things: Either the pneumococcus has undergone virulent modification, or the conditions of the host have changed. The occurrence of pneumonia in epidemic form may be traced, as a rule, to sanitary defects. The so-called house pneumonia, in which the affection recurs in the same habitation may be referred to the same cause. It is difficult in these cases to segregate pneumonia as an independent affection occurring during the prevalence of typhoid fever. The latter affection may be confined to the lungs, the intestines escaping as Gerhardt has attempted to show. Cases of direct infection are to be found in the literature. Pneumococci have been demonstrated in the milk of nursing women with pneumonia. Cases are recorded where infection has also occurred in utero, the mothers suffering from pneumonia. The incubation of pneumonia is stated to be two or

three days, but this is a problem too difficult for solution at the present time.

GENERAL SYMPTOMATOLOGY.-In adults, the onset of the disease is sudden with a violent chill and elevation of temperature. In children, convulsions may be the initial symptom and in youth, emesis. The facies is flushed, the pulse and respiration accelerated. With these signs, the usual "stitch in the side" is experienced. Pneumonia complicating any of the infectious diseases or psychoses may be characterized by no evidence other than elevation of already existing fever, and unless the lungs are examined the affection remains unrecognized. A cough usually attends the earlier signs, and it may not be until the second day, that the characteristic "rusty sputum" is in evidence. Death rarely occurs in the first two days of atypic pneumonia, and its occurrence postulates the assumption that the affection is produced by some other kind of infection.

SPECIAL SYMPTOMATOLOGY.-Onset. The onset of the disease is not always sudden. Thus in old age, the disease begins acutely in only onehalf the cases. In other instances, an attack of bronchitis, general malaise, or headache, precedes the onset. The onset by chill is present in by far the majority of cases (60-80 per cent), and lasts usually from twenty to thirty minutes. The chill, however, may last nine hours, or even longer. The chill may be absent when the affection occurs at night or during the summer months, and its absence is frequently noted in children. The chill may be supplanted by slight shiverings. Pneumonia commences most frequently during the early afternoon or evening.

Temperature. This very rapidly, even in a few hours, reaches 103 deg. or 104 deg. F. A typic temperature chart permits of analysis in three directions: 1, the rise; 2, the continued fever; 3, the fall. The rise is rapid and usually reaches its maximum in twelve hours. In rare instances, this temperature may be attained within three hours, or as in a case reported by Quinquard, within fifteen minutes. In atypic pneumonias, the rise is usually very gradual. The continued fever remains the same level for several days, and the difference between morning is rarely greater than one degree. The daily oscillations may amount to even 2.7 deg. F., and these marked remissions have no unfavorable significance. Before the actual fall in temperature, there may be a drop of several degrees (pseudo-crisis), but may attain the same level after 36 hours, after which the actual crisis may occur. A marked rise in temperature (perturbatio critica) may precede the crisis. Severe nervous symptoms preceding death may occasion a very rapid rise in temperature and Lebert, has noted an enormous rise in temperature immediately after death. The continued fever serves only as an index to the severity of the disease in a general way insomuch as pronounced toxic symptoms may accompany a low and mild symptoms a high temperature. Fox has shown that a temperature above 106 deg. F. occurred in 4.6 per cent of. all cases between 103 deg. and 106 deg. F. in 84 per cent, and between 104 deg. and 105 deg. F. in 40 per cent of the cases. Cases have been reported in which there has been no rise in temperature (apyretic pneumonia). The temperature in the axilla may be higher on the affected than on the unaffected side.