READING NOTICES.

In short, I can say, in 25 years of practice I have never found an equal to Peacock's Bromides for fits and disturbed nerve centres. It possesses a superiority over fits beyond my expectations. I have recommended it for all it is worth in our locality.

Hamilton, Ohio.

M. J. FAIVRE, M.D.

R. RHODES REED, M.R.C.S., Norfolk, England, says: "I have prescribed S. H. Kennedy's Extract Pinus Canadensis as an injection (one part to six) in an obstinate case of chronic gonorrhea, with very satisfactory results. The discharge considerably diminished during the first week, and after a fortnight's use the patient reported himself quite well."

SUCCUS ALTERANS.-Sir:-My experience of "Succus Alterans" was limited to one case of secondary syphilitic roseola, with sore throat, etc., in which it was administered solely, no other remedy being used. The patient had a scrofulous history, hence the reason I selected it. Its administration was attended with the happiest results. The young gentleman made a complete recovery, and has since then (about two years ago) enjoyed excellent health, not having the slightest return of any syphilitic symptoms.

P. J. MACNAMARA,

I am, sir, your obedient servant, (M.D., F.R.C.S., Ireland; L.K.Q.C.P., L.R.C.S., Ireland; Medical Officer, Bruff, etc.)

Adelaide Place, Bruff, Ireland, March 22, 1889.

THE THERAPEUTICS OF HEMOGLOBIN COMPOUND.-The predigestion of foods has done much for the dietary of invalids and convalescents from acute disease or with anæmia and enfeebled digestion. It must be admitted, however, that many cases require frequently in devitalizing diseases some efficient method of rapid nutrition, capable of ready absorption without taxing the digestive functions, to combat the anæmia. This is furnished most naturally by the circulating medium itself-blood containing the elements of nutrition in assimilable form-and a preparation of bullock's blood entitled Hæmoglobin Compound has been prepared which seems to meet the indications admirably. Experiments with this preparation have been in progress by its author, Dr. F. E. Stewart, for ten years past, and Hæmoglobin, as uow marketed by Parke, Davis & Co., is the result. This preparation has many advantages as a nutrient stimulant, and samples of it and literature descriptive of its application will be furnished physicians on request.

NORTH CAROLINA

MEDICAL JOURNAL.

THOMAS F. WOOD, M. D.,

GEO. GILLETT THOMAS, M. D..} Editors.

Number 2. Wilmington, August, 1890.

Vol. 26.

ORIGINAL COMMUNICATIONS.

THE TERMINATIONS OF CROUPOUS PNEUMONIA.

By KARL VON RUCK, M.D., Asheville, N. C.

(Director Sanitarium for Diseases of the Lungs and Throat.)

The terminations of croupous pneumonia were formerly considered to follow the rules of inflammation in general and besides termination in death, older authors recognized termination in resolution, suppuration and abscess, gangrene, and chronic inflammation and induration (Pulmonary Phthisis). So universally were these accepted as the possible terminations of a croupous pneumonia, that if per chance we study any of the older works on the subject, we find no question as to their occurrence, but rather a description

of symptoms and signs, whereby to distinguish them from each

other.

With the more critical research of later years, especially in the field of pathological anatomy, and in the efforts to harmonize the brilliant discoveries in that field with the clinical features of disease, many old theories have been shaken or overthrown, and so it has come that, with the exception of "resolution," all the believed terminations of croupous pneumonia have been taken in doubt or even denied. Resolution being so common and so frequently observed at the bedside, it alone has been granted to be an established fact.

The termination in suppuration and abscess had finally also to be conceded, but critical examination has shown it to be much less frequent than was formerly held, and similar is it with termination in gangrene; it is however not to be denied that most cases with such termination are not typical, and that it is difficult to find cases furnishing unassailable evidence of its occurrence. Having myself notes of a clear case with such an ending, it may be well to place it on record. W. T., age 60, farmer, with good family history as to lung disease, had enjoyed good health from infancy, never had any cough or disease of the respiratory organs. Having felt well as usual, and, after a day of hard labor in the harvest-field, he took a cold bath on the evening of August 7th, 1880, which was followed immediately by severe and prolonged chill, fever, stitch-like pain in the left lower lobe, dyspnea and cough.

Called the following morning, I found the patient suffering very much, and there was short, frequent, dry cough, flushed face, pulse 112, temperature 104.2°, respiration 32. Atheroma of superficial arteries well marked, stomach irritable, rejecting food and drink. The patient was an habitual drinker of large quantities of hard cider, but never to intoxication.

Although pneumonia was suspected, physical evidence could not be made out, until the second day, when the characteristic expectoration also appeared. Consolidation seemed complete on the sixth day, extending over the whole of the left lower lobe. To this time the case had followed the usual course, but there was no crisis, the temperature gradually declining from the seventh to the fourteenth day, when it was normal in the morning, without, however, the occurrence of the looked-for amelioration in the general condition of the patient. The consolidation continued unchanged as did the

bronchial respiration, but below the angle of scapula bubbling râles were noted; the expectoration lost its bloody character, became muco-purulent and profuse. This state continued until the sixteenth day, when the temperature became subnormal (96.5° F.) for a number of hours in the forenoon, followed by evening fever, and the same temperature curves were noted to the nineteenth day. Meanwhile the patient became more and more exhausted, despite the most careful feeding, use of stimulants, etc., the expectoration had now changed to a dirty gray color, was profuse and very offensive. The microscope revealed fragments of lung-tissue, crystals of fatty acids, pus-cells and blood pigment; the fever became again continuous with maximas of 102° to 103°; on the twenty-second day a cavity with gurgling was made out below the lower angle of the left scapula, the rest of the lung involved remained consolidated, râles appeared throughout and also in the upper lobe. For several days the patient had now irregular chills, heart-failure, with colliquative diarrhoea set in on the twenty-eighth, and the patient died on the thirtieth day.

Autopsy twelve hours after death showed the right lung and left upper lobe structurally intact, there was catarrh of the bronchi, and emphysema along the anterior border, the left lower lobe in a state of hepatisation, with a central cavity as large as a man's fist, with necrotic walls filled with greenish bloody horribly offensive pus and débris, and a large fragment of lung-tissue still slightly attached. The rest of this lobe was friable, and exuded a greenish purulent, and, in some sections, a bloody fluid from its cut surface, the pleura adherent. The pulmonary and bronchial arteries showed atheromatous changes in both lungs. The alveoli contained pus and cast-off epithelial cells, fibrinous plugs and blood pigment. The heart was flabby, the muscular fibres in a state of fatty degeneration, the coronary arteries atheromatous. The chest only, was

examined.

That this case was one of primary croupous pneumonia seems beyond a reasonabie doubt in view of the clinical symptoms, course of the disease and the autopsy; and it is interesting to observe, that the conditions favoring the occurrence of gangrene were all present and very apparent. Thus Cohnheim says, that previous vascular changes favor the occurrence of gangrene. Rindfleisch speaks of an

exudation containing much blood as prone to lead to such a result. The patient had been a drinker, was much reduced by his inability to take nourishment in the early part of his disease, the feeble circulation became even more depressed on the cessation of fever and the subsequent occurrence of subnormal temperature, all favoring compression of the nutrient vessels by the exudate, and final stasis and death of the tissue under such conditions became a necessary consequence.

The termination in chronic inflammation and induration is a question of greatest interest and has often been debated. Considering, however, the strictly superficial process of pathological changes in a croupous pneumonia, in which everything is favorable for repair, on one hand, and the deep-seated lesions of a chronic pneumonia on the other hand, it is difficult to so explain the origin of the latter. Abscess or gangrene may be accounted for as local and circumscribed results due to the action of pathological germs and the cutting off of certain areas from the nutritive blood supply, and in the light of pathology of the present day, it is extremely probable that the heretofore observed chronic inflammation and induration following pneumonia of a croupous nature, were in fact true tubercular processes, owing their origin to the infection with the characteristic bacillus of Koch. Prior to Koch's discovery no strict differential diagnosis was possible, since the clinical symptoms of non-bacillary phthisis, or chronic pneumonia, and those of pulmonary tuberculosis are so identical that only the microscopic demonstration of the presence or continued absence of the characteristic germs, enables us to correctly diagnosticate the nature of the pathological process.

Aside from the possibility that latent tubercular deposits may have existed prior to the occurrence of the pneumonia, patients suffering, or slowly convalescing from the latter, are predisposed subjects to tubercular infection for the time being, by reason of the imparement of nutrition in general and of the affected lung in particular, and having paid particular attention to the subject, since we have a sure means of differential diagnosis, I have not observed a chronic pneumonia to follow the acute croupous form, but in three instances have seen croupous pneumonia followed by pulmonary tuberculosis, and it would seem very desirable that the cases of croupous pneumonia terminating in phthisis should be closely