CASE 1,-The patient was a man, aged 22 years. Hi previous medical history was unimportant, but he hat recently been drinking rather heavily. He was admitte( to St. George's Infirmary on the second day of his illness He showed the characteristic signs of commencing consoli dation at the base of his left lung, with high temperature dyspncea, and herpes on the lips. In addition, there was a patchy erythematous rash on the palmar and dorsal surface I of the hands and plantar and dorsal surfaces of

more »

... is feet, There were a similar area about two inches square on the lef1 side of his face below the malar prominence and a few smaller ones on the abdomen and back. Except that for thE first five days there was no expectoration, and then that il was white though viscid, the symptoms and physical signs were all those of a severe lobar pneumonia, and by the fifth day of his illness the signs of solid lung had extended upwards as far as the level of the scapular spine. The rash began to fade on the day after admission, first on the hands and feet, but on the fifth day of illness fresh patches appeared on the trunk. Two days later these were also much less distinct, but a few others more punctate in character appeared on the arms and legs. By this time the whole of the left lung except the apex of the upper lobe was involved ; there were, however, no signs of pericarditis and but little of dilatation of the right side of the heart, but much restlessness and delirium. The temperature, hitherto varying from 100° to 103° F., now fell but did not reach normal for 24 hours, but signs of oedema of the right lung appeared and he died on the ninth day of illness. Permission to make a post-mortem examination could not be obtained. CASE 2.-The patient was a man, aged 60 years. He had had fair health up to the commencement of the winter (six months previously), since when he had been troubled with cough and three months ago had an attack of ., influenza" which kept him in bed for three weeks. Since then the cough had been worse and he had been losing flesh, but was able to get about. He was taken acutely ill the day previously to admission to St. George's Infirmary with dyspnoea, tight cough, and blood-stained expectoration. On admission there were slight pyrexia (99 . 20 F.), dyspnae't, cough, and much rusty sputum. There was no herpes. The right lung was affected, showing dulness on percussion in front over the lower portion and behind over the mid-scapular area with a corresponding part in the axilla. Above the note was high pitched and below it was normal. Bronchial breathing and consonating rales were heard over the dull area. The left lung was clear except for a few scattered rules. The area of cardiac dulness was normal but the sounds were rapid and weak. On the following day the lung signs had spread a little upwards and in addition there were a patchy erythematous rash on the hands and wrists and a few faint patches on the legs. There was moderate pyrexia, the evening temperature reaching 100°. A diastolic bruit could now be heard in the aortic area. On the fourth day of illness the rash had faded considerably ; a pleural rub was now heard in the left axillary region. On the following day the patient died suddenly. -Veopsy.—The post-mortem examination showed a lobar pneumonia involving the upper lobe and upper half of the lower lobes of the right lung. At the apex of each lobe it had reached the stage of grey hepatisation, being less advanced in the intervening part of the lung. The rest of the right lung was congested and the left lung was oedematous, with some recent pleurisy over the middle of its lower lobe. There were scars of healed pulmonary tuberculosis at the apices of both upper lobes. The heart was enlarged, slightly fatty, and I there was atheroma of the aorta involving one of the cusps of the aortic valves. The kidneys were slightly granular. The other organs were normal. CASE 3 -The patient was a man, aged 36 years. His previous health was good. He had a rigor and pain in his left side the day before admittance to St. George's Infirmary. On admission his temperature was 103° F. ; there were signs of early. pneumonia as shown by dyspnoea, cough, rusty sputum, and faint friction sound at the base of the left axilla, and on the following day definite signs of pneumonia as shown by bronchial breathing and consonating rales in that area. He was already severely ill on admission, the pulse being rapid and feeble and the urine contained a trace of albumin. The sputum examined two days after admission showed a fair number of pneumococci but no influenza or tubercle bacilli. The pneumonia was of a severe type with moderate pyrexia (the temperature varying from 99'0° to 102 4°) and much toxaemia. By the sixth day of illness bronchial breathing could be heard up to the apex of the lung behind. On the seventh day the temperature fell by crisis with diarrhoea, and sweating. Signs of cardiac dilatation became marked at the same time but the heart improved under treatment, strychnine being pushed to the extent of hypodermic injections of the liquor, five minims every four hours, in addition to moderate doses of digitalis and alcohol. On the day that the temperature reached normal a papular erythematous rash appeared on the legs and back, being most marked on the knees, buttocks, and shoulders, and at the same time a purpuric rash in the left iliac fossa. The rash began to fade on the following day and was gone in another two days. By this time the lung showed signs of " clearing up " and convalescence appeared to be commencing. On the next day, however, there were some reappearance of pyrexia and signs of pneumonic infiltration at the opposite base. In two days the signs had spread up to the level of the spine of the scapula. Jaundice now appeared and by the next day was intense. The inflammation of the lung did not spread much further on this side of the chest and two days later showed signs of subsiding, the temperature never very high, falling by lysis and the jaundice diminishing at the same time. The urine no longer contained albumin, though the chlorides were still deficient. Three days later he developed a left-sided parotitis ; this lasted for some four days, the temperature going up to 103°. The lungs in the meantime were clearing but slowly, the right in particular still showing signs of consolidation over the base. At the end of a week from its commencement the parotitis was well, but two days previously to this he had complained of pain in the hypogastric region and slight tenderness on pressure was noticed there. At first no obvious cause could be found for this, the urine being normal and the bowels satisfactory, but two days later there was a definite sense of resistance on pressure being made a little above the pubes in the middle line. Nothing, however, more definite appeared at the time. The temperature still remained irregular and there were impaired percussion note and diminished air entry at the base of the right lung, and he still had a cough with now a good deal of purulent sputum. The lung was accordingly explored by needle but no pus was found, and a few days later, his condition remaining unimproved, was again explored but without success. Meanwhile a painless swelling had been forming in the hypogastric region where previously had been felt that sense of resistance ; it was exactly in the middle line, not more than two inches in diameter, without heat, redness, or tenderness. A couple of days after the time the lung was explored a second time the swelling began to increase more rapidly in size and then to fluctuate, so the skin having been anaesthetised by hypodermic injections of eucaine and adrenalin it was explored and found to consist of an abscess beneath and between the recti muscles. Several ounces of pus were let out and the cavity was drained. A culture of the pus gave pure pneumococci. After this the temperature began to settle and a week later it was normal. The lung signs slowly cleared up and a fortnight later the right was clear and a few rales only could be heard at the left base on deep breathing, and the patient was well enough to get up. A week later these bad disappeared ; he was up all day and gaining flesh and strength and went out to look for work some three weeks later. These cases are recorded as examples of the rarer complications of lobar pneumonia. Each had an erythematous rash and Case 3 a purpuric rash as well. Case 3 had in addition parotitis and a pneumococcal abscess. Except for the characteristic herpes of the lips skin lesions