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Show DISEAS 5 OF THE ()RGAXS ()F Ix'ISSI'IIIA'I‘IUN. Hi-jm‘iox III.. Tamas. IV. Fig. 1. (Lobular pneumonia tolloiving phlebitis oftlie pulmonary veins"). Mary A. 1).. tyventv-nine vears old; primapa'a, confined .Iiily l2. 18-. duration; artitieial delivery. subsequently. I'arturition of short Considerable litemorrhage Symptoms-Face pale, small. frequent ptilse. Complains of being very feeble; excessive pain iit eontraeted uterus. and increases on the slightest pressure. l'atient in a liigii state of anaemia. 13th. IIypogastrie pain slightly diminished. Less fever. 14th. Flow of 'milk into the mammae. 15. It}. 17th. Excessive perspiration. great thirst : vei'v nervous; painful. headache; inelined to faint. Abdomen not .18. It). 20th. Appears eonsitlerably better. but the pulse continues all the time very frequent. 21st. A return of the liypogastrie and abdominal pain. Some (lizll‘t'lttl‘it; some relief. 23d. Severe pain under the false. ribs. Exploration of thorax does not reveal any pulmonie trouble. 2.3111 July to 3d Aiig.. improves gradually. tth. Sud- denly. severe dyspnoea; eoiigh \vithoiit expeetoration: exeeedingly frequent pulse; very nervous and oppressed. No pain iii the liypogastriiim. 'I‘lioi'at‘it‘ exploration yields little result. Normal sound on peretissioii. Aiiseultation reveals a slight gurgling tone at the base of the lung behind. Heet'et ioii of milk suddenly eheeked. 51h Aug. Faee looks ehanged. expression very anxioiis. Vei'y small and frequent pulse; dry tormenting eoiigh. Some diarrhtea produeed by a eathartie. tith Aug. Has no pain. It'espiration very hurried. No expeetoration. tith. I)ies tinder symptoms of asphyxia. I'os‘f-ium'leni .tu/o/tsa-Xo traee of peritonitis; no apparent lesion of large or small intestine; stomaeli sound. I'terus slightly enlarged. I'terine. ovarian and Iiypogastrie veins like \vhipeords. and full of eompaet adherent and eolorless elots. The external iliae artery. the left eriiral arterv ‘ and some of their branehes. are also distended by the same kind of elots, but not to the extent as the veins. [Si-it"riox III. At the base of the left lung (Fig.2). some small. whitish-green purulent focuses are to be seen t.t.]'. ..»t.l'.) They are siipertieial. and are distinetly visible through the transparent viseeral pleura. In the anterior portion ot'one ot'these. there is a small adherent eseliar. Several other points of the siirfaee of the lung are of a varie- gated reddish eolor. and seem rather eompaet. ()ne of these points (RN) looks like an apopleetie foeiis. The posterior half of the inferior lobes of both lungs are pert'eetly infiltrated yvith serum and pits. and are unfit for respiration. Ineisions here and there into the lungs shoyved hard eoneretions tilting up the branehes of the pulmonary artery (Qt. 1'.) A earet‘iil disseetion of this vessel revealed eolorless bloody elots. slightly adhering to the vaseiilar These elots eoiild be, followed into the tittest yvalls. braiielilets of the artery. It could readily be seen that the eiiibolie oeeliision began in the trunks. and spread into the branehes. The elots in the smaller vessels were red. \vhilst iii the larger and in the trunks they were eolorles-s. \\‘ithin these elots a quantity "1.1"" was titlltltlt('./).ii In ((2521).) the elots are colorless. but eontaiii no pits. Fig. 12 represents a transverse seetion of the same lung. There is to be seen the irregular. spheroidal shaped intlammatory t'oeiises ot'tlie lung t .t. 1,. .t.l/. .t. 11.). yvliieli have not yet reaelied the stage of formation of abseesses. In nearly all of these. a thiek. red layer of indurated tissue surrounds a \vliitish. hard mass- eoniposed of pus. inliltrated into the pulmonary parenehyma. Here and there reddish points of the indurated striieture are pereeptible in the midst of the inliltrated pits. Some of the litt'ltses' present a t‘ttittltlt‘ttt‘t‘lllt‘llt ot‘eol- leetion ot' pits. and the vaseiilar tiit'ts. \vhieh traverse the walls of those l'oeal intiltrations. ean readily be made visible by the use of small foreeps drayving them forward from their position. The inliltrated blood had eompletely eovered the pareiieliymatoiis striietiires \vitli- oiit. ltoyvever. destroying them. The other lung. with the exeeptioii of the pleiiritis. presented the same anatomieal alterations. Sueh appearanees seem distinetly to itidieate that the pits must have formed loeally during. and by. the iiillaiii- tiiatory proeess. \\‘itlt tllt‘ itttiltt‘tlteil t'olttlitiolt of the ltlltg‘ tissue. or the loss of portion. bitt also beyond it; and often over the \\‘hole thorax. elastieity will the pereiission sound beeome inoditied. The extent of moditieation will be in aeeordanee with the relative quantity of air to that of the exudate in the organ. The intensity of the inflammation will not determine it. The inliltrated portion will yield more of a tyinpanitie sound so long as it eontains some air: provided the thoraeie \\‘all be not too resistent. This tyinpanitie sound is somewhat miitlled. aml re- mains for some time in this eonditioii until the infiltration t'iilly takes plaee. and then the sound beeonies dull-a peeiiliarity \\‘hieh \vill iiidieate that liepatixation has eoninieneed. This is dtte to the loss of elastieity ot' the liing~tissiie. This tyinpanitie eharaeter is sometimes very persistent. and sometimes speedily disappears, and yields to the dull soitiid. lit-fore siieh a sound appears the lung must be inliltrated to the thielgness of at least an ineh. The adljaeent portion of the lung \\‘liieh is not inliltrated yields a normally elear sound. These abnormal noises (lira/7s) often eover the respiratory mur- Sound-[VaMom utt mt .luxeoh'ut/on. Simple vaseular hypeiamia. \vithoiit intiltration into the tissue. and without aeeiimtilation ot‘ seei'etion in the air passages, does not alter the aiiseiiltatory phenomena. As long as the air passages and the parenehytna are still aeeessible to air. though there be intiltration in the one and aeeiimiilation ot' seei'eta in the other. there will be no other sound manifested than siieh as is heard in broneliial eatarrli, with air passages tilted by liquid seeretion. The kind of Itale depends ( both at the beginning of the intlainination and at the stage of resolution ) on whether the liquid is eontained in the alveola and liner bronehi alone. in the larger bronehi too. or only in the larger bronehi: \\‘hether the intiltrate is very tough: and whether the respiration is aeeelerattal to a greater or lesser extent. In the exudative and in the resolvent st iges of pneumonia. all sorts of rattling. humming. \vhistling and seething sounds. or rather noises tinisnamed murmurs). may be heard singly or (with jointly. They are gt‘3nerally audible not only over the iutlamed Iltlll'gittltlt vesietilai‘ and indetinite. They are as tItitt‘llitwltt‘t'iilily' \\‘hen respiration is eai'ried on slti\\'l(\'irltt':tl'tl simultaneously \\ith the normal. \Very quiet breathing generally dissipates the abliot‘tnal [Ir/tits. NIt/qe of Ill/lt/fliCtIfIiVl/lsr- I)! 1‘1‘Hs‘s/o/I. I'rovided the thiekiiess ot' the hepatixed part ofthe hing. \vhieh lies against the thoraeie wall. is at least an ineh thiek. and its extent. at least three inehes in diameter. the sound emitted by it will be inullled. and the resistanee of that portion of the thorax will be greater than usual. The sound beeomes duller and the pei'eiissing linger meets with so inneh more resistanee. the greater the thiekness the hepatixed portion and the more extensive its area. The tlexibility ol' the thoraeie \\‘all must be taken into aeeoiint. to exaetly aseertain the degree and extent of the hepatixation by pereiission. The more inntIled the sound the greater is the depth of the hepatized portion. When the sound is absolutely dnll. even below the most tlexible portion of the ehest. it may safely be assumed that the \\hole depth of the lung is involved I11 hepatixation, The adjaeent portions of the hepatized part may either be intiltrated. but still eotitaining some air, oi'I/i‘u and normal/Iii distended. or o/omr/m/I/i/ distended, that is. emphysemattitis. The latter eondition exists most frequently near the border of the lobes. I':tt't< remote from the liep:i[i/.etl portions may be normal: emphysemattviis. inliltrated \\ith seriim.or \\ith more eonsistent liquid. btit still eontaining some air. Ati etiiphysetntitotls' portion of the lung bordering on a Itelsttiltal portion \\ill emit a eleai' tyinpaniti‘ sound: \\‘hilst an einphysematons part distant. from the hepaiized \\ill have a somenhat more resonant. but no more tyinpanitie ring than a normal lttitg. lntiltra'ted but still air eontaining portions. situated elosely to the thoi‘aele \vall. emit also a more tyinpanitie sound than a normal part. It is. under all eireiunstanees. best to pereiiss the eori'esponding |
