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It appears from this that it is very important to make an early diagnosis of the local disease and general condition of the patient. By so doing, we are enabled to eliminate some very injurious complications, and often to save the patient's life. For, when the disease has progressed to the dangerous point, there is no time to deal with the collateral troubles. The congestive stage may be distinguished, if not posi- tively at least with considerable certainty, from simple pul- monary congestion by the occurrence of a more marked chill, by a higher temperature, by the sense of pain or un- easiness being usually confined to one side, and by the uni- lateral situation of the physical How Much Does Levitra Cost At Costco signs. If the diagnosis is not positive, the course of treatment should be arranged as if it were, for it corresponds pretty closely to the treatment of ordinary pulmonic congestion. If the patient can bear it, measures should at once be taken to move the bowels and to keep them considerably relaxed. By this means we secure, to some extent, a redistribution of blood, lessen the inhibitory effect of the irritation of the splanchnic plexuses upon the pulmonary vaso-motor mechanism, and help to re- establish the normal equilibrium between the circulations How Much Does Levitra Cost At Costco in the various parts of the body. At the same time, if the di- gestive organs require any further treatment, it should be attended to. The most important measure in this direction is to make the diet such that it can be very easily digested and assimi- lated. The temptation to cram food into an asthenic pa- tient should be resisted, as these are the very ones where digestion is apt to be inadequate. The diet should be fluid, and given frequently in small quantities. It is unnecessary for me, before such an audience as this, to go into the de- tails of feeding. If blood-letting is ever to be resorted to, it should be in this stage of the disease before any exhaustion occurs, and while the vessels of the pulmonary system are yet capable of contracting to their normal caliber. In high livers, and those who make blood rapidly, it might be of great service. Alcoholic stimulants should not be administered in this stage unless the patient has been accustomed to their free use. The simple fact that a man has been accustomed to drink occasionally, or moderately, does not call for any ex- hibition of alcohol in this stage of the disease. But it should not be withheld from those who have become so accustomed to its stimulating action How Much Does Levitra Cost At Costco that they become re- laxed and depressed when not under its influence. To them it should be given in regular doses, the same as the other medicine, and care should How Much Does Levitra Cost At Costco be taken to limit the amount to that quantity nectissary to bring the pulse up to the usual physiological standard. Anything in excess of this is posi- tively injurious. The vascular system should be treated in accordance with the constitution and needs of the patient ; some require arterial sedatives and some arterial excitants. Another important matter to be attended to as early as possible in every case of pneumonia is counter-irritation over the chest, anteriorly and posteriori}'. This is done for the How Much Does Levitra Cost At Costco purpose of combating the tendency to bronchitis. By adopting the course indicated in the first stage of the disease, we take the preliminary steps toward obviating the three great dangers of the How Much Does Levitra Cost At Costco stage of hepatization — \\z., the excessive accumulation of mucus in the bronchial tubes, col- lateral congestion and oedema from failure of the heart, and exhaustion. In the stage of hepatization the most important function of the diagnostician is not to simply ascertain the existence of the disease, but to investigate the factors which make toward recovery or death. First of all he should ascertain, as nearly as possible, the extent of the hepatization, for, when this is very considerable, not only is the patient in danger on account of the amount of lung-tissue rendered useless for respiratory purposes, but for the still graver rea- son that, other things being equal, the danger from collateral hyperemia increases in a rapidly augmenting ratio with the increase of the hepatized area. If the hepatization is ex- tensive, the prognosis is better when it is unilateral, even though the entire lung is involved, which must, however, How Much Does Levitra Cost At Costco be extremely rare, than when it invades both sides. It is, furthermore, important to ascertain the amount of the co- incident bronchitis, as this may also exert a material influ- ence upon the fate of the patient. We should remember that bronchitis of any extent is not a necessary accompani- ment of pneumonia, and it should be eliminated from the case, if possible, or at any rate kept at a minimum. Then the heart should be investigated in order to ascer- tain its strength and competence to accomplish the in- creased labor which it will have to perform during the next few days or How Much Does Levitra Cost At Costco weeks. Nothing is of greater importance to the welfare of a pneumonic than to have a strong, efficient heart. Even an hypertrophied heart, if not associated with mitral disease, or with only some slight lesion, as an inex- tensive aortic stenosis, may prove advantageous. I remember once being taken by a fellow-practitioner to see a laboring man — a 'longshoreman, I believe — who had a croupous pneumonia involving almost the entire right lung, yet throughout the disease he sat in a chair, and even walked a little about the room. He made a good recovery. There was no marked collateral congestion or oedema on the other side. The doctor and I attributed the extraordi- nary result to the fact that the man had a simple cardiac hypertrophy, due, apparently, to heavy muscular work, which carried the apex out to the mammillary line. The digestive apparatus should be closely observed- in order that it may, if possible, be kept in condition to supply the body with sufficient nourishment to carry it through the disease. If hepatization has already occurred, it is, of course, impossible to reopen the vesicular structure ; we must wait for this to occur in the natural course of the dis- ease. It may be possible, however, in the early stages, to considerably limit the amount of hepatization, and, after it has occurred, to prevent its extension. This may be done July 24, 1886.J WESTBROOK : DIAGNOSIS AND TREATMENT OF DISEASES OF THE CHEST. 91 by prompt and careful attention to the digestive apparatus, by counter-irritation, and such other measures as diminish pulmonary congestion. From my observation of its action, I am inclined to think that the salicylate of sodium has, be- sides its action upon the liver and mucous glands, and its antipyretic effect, some direct action upon the inflamed