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Show SEe'riox 111.] 1)]81CA91‘1S 01" T1119 ()RGANS ()1‘" 'RESI'IRA'I‘H)N. TABLE \V. Dii-‘i‘t‘si‘. (txxciiicxic or 'ruic Rioiir Lt'xo. C.\.\'1i.-(i'. l". .\ man of Ith‘ years. .l]i.~‘f()l‘f/ uni] Nynzp/o/ns.-lCntered hospital Feb. 247. 1874. Had been sick about nine months. had a severe cruigh. co- pious cxpectoration. and sutfcred from (lyspuira and luemoptysis. About a month ago he contracted acutepneumonia. l'resent symptoms: Percussion. dull sound posteriorly over the whole 01' the right, lung. Auscultation : broncho!ihony. with signs ot' a large cavity about the mid- dle ot' the right scapula. The spiita very copious. of a gray- ish-green color. and so fetid that he had to be isolated. notwithstanding all deodorants used about his person. He died ot'colliquative diarrlnra and exhaustion two days later. Post inm'teni.--'l‘here was found a large gangrenous cavity in the right lung, occupying the lower portion of the portions of the healthy lung, and even several parts of the diseased, to fully ascertain the exact peculiarity and depth of the sounds of healthy portions, to better compare them with those of the diseased parts. Sound-Phcn‘mncna. hy .luscultati'on. \Vhen the liepatized part is at least ofaii extent sufficient to involve ' .) upper lobe, and the upper portion of the right lower lobe. The cavity contained about six ounces of blackish. highly fetid serum. The middle and lower portion ol' the same lower lobe was in a state of gray hepatization. The left lung was congested, and showed a small cavity in the apex. Both lungs were filled with great quantities of miliarv tubercles. i . Figs. 1 and ‘2 show the same lung. Fig. '1 shows the lung covered by the pleura (1).), portions ot'iwhich are perforated (1'. 1).); beneath the pleural coveriugthe dark color of the gangrenous tissue is slightly \'isil)le.i Fig. 2 shows the pleura removed. the ‘avity exposed;(F. (A, gangrenous ex ‘thltioiis, and sphacelous tissue; (11.) exudate between the pleura}; (I). P.) perfo ‘atious; (,P.) pleuracostalis which is adherent to the visee‘al plate; (3.171.) anterior border; (Ii) border; (13.15) posterior border. eat, or great and sudden changes of temperature, were considered the chief agents of croupose pneumonia in all its forms; but, recent very careful olisc vaticns and accurate experiments, made upon animals, have shown that neitln r of those agencies are able to produce a form of inflammation re~ sembliiig either of the named forms of pneumonia with its typical phases. On the other hand, the belief in the infectious nature of one of the larger branches of the bronchus ; farther, when the bronchial branch is neither filled with liquid, solid exudate, or blood coagula, and ot' course filled with air, which freely communicates with the trachea, then the. voice of the patient will consonate piieumonic origin gains more and more ground. Literature on the subject of pneumonia is lately teeming with reports and descriptions ot' many forms of infectious pneumonia, in different parts of the world. with the bronchus and will become audible in the portion of the "'9 find, for instance (in Doercnhcrg, Berlin, Disscrlution) epidemic pneumonia combined with typhus, malaria, diphtheria. The, fever was very high. Very copious haemoptysis. Cerebral symptoms thorax nearest to it, to a greater or lesser extent. bronchophoiiy.) (There will be In this stage there will be heard either the sound of bronchial respiration alone, consonating, rattling, whistling, sibilating, hum- ming noises with the bronchial respiratory sound, single abnormal very severe. (Bunti, (pi'ti'cmir pncuimniiu.) L'itt‘cr, 0n, epidemic pneumonia irilh typhoid type. llr'l'CdOIHNGHII, Zur Lchrc, dcutsch, arch. f. clin. iiictlrzin. 1'01. 25, 580p, describes limits, or several at the same time. All will be the more audible, the deepe‘ and the more rapid the respiratory action will be car- ried on by the patient. It does not necessarily follow that bronchial respiration should always co-exist with bronchophony. For very often, even with the most pronounced broncliophony, there is ing these vessels was infiltrated with colored and colorless corpus- clcs. The pulmonary artery and all its branches contained thrombi, heard only an indefinite respiratory inuriiitin-though never which were filled with bacteria; this was also the case with the vesicular murmurson the other hand, bronchial murmur alone, or with all sorts of abnormal noises, may exist without simultaneous bronchophony. finer bronchi." ll'Ii/ntcr Blyth describes infectious pneumonia, existing in Sep- microscopic examinations of lung tissue in infectious pneumonia: "There were thrombotic coagula in the lymph vessels, containing enormous quantities of bacteria. The parencliyma surround- 111 case the hepatized part is confined to a lesser space than tember, 1875. ll'rz'gly, Grimshani and Moore, in Dublin Journal of Mid, Aug, that mentioned above, or when the bronchial branch is filled with an exudate, which excludes the air altogether, then no cousonance 1875, call that form of epidemic pythogcnir 1)il(‘l(111071‘('a, which they attribute to iniasmata or to a zyinotie origin. takes place in the hepatization. Besides the normal termination, that is resolution and restoration to health, croupose pneumonia may terminate in tuberculosis or gangrene, according as the infiltrated tissue be more or less antemic, and the re-establishment of circulation be retarded. Neither bronchophony, bronchial respiratory murmur, etc, become audible. The voice of the patient is either unheard over the hepatized part or perceived as an iiidefinite murmur, and then very muffled. All other hruils are either not at all or but very indistinctly heard. All the above The eminently acute observer Lucncc was the first to describe described sounds may suddenly become audible, and for a time gangrene of the lungs, in his Traitc dc I'auswltalioii, Paris, 1831, and continue to be heard, when a sufficient quantity of cxpectoration has freed the air passages either by coughing or otherwise. The described souiid-phenomena exist in the red, yellow, or gray hepatizations. Even abscesses formed during these stages will not modify the nature ot' the sounds. it holds good to this (lay. He differentiates between a circumscribed and a noii-circumscribed form of gangrene and says: "The first constitutes a dry, black, gangrenous escliar, which is distinctly Clinically different, although anatomically identical with the above described croupose pneumonia, are several forms of the disease, which were formally classified as typhoid pneumonia, bilious pneumonia, but have, at present, received the generic name of usthcnic pneumonia. They all have one character in common, that of asthenia, but differ from each other by a number of groups of symptoms. Lcichtcnstcrn has, in a masterly manner, discussed the subject-nature ot' this asthenia in the 82d lecture of l'volh'mann's collection of clinical lectures. He differentiates primary from sec- ondary, or idiosyncratic. The last befalls very old people, eachectic and aiizeinie individuals, drunkards and very dissipated per- sons. In fact, in all of whom there exists great weakness of the muscular tissue of the heart and general atom]. Primary asthenic pneumonia is characterized : 1. By prodromal symptoms during several days, prior to the manifest attack, resembling those of infectious diseases. 2. As a rule, the attack begins without a chill, or much sensation of chilliness. 3. Scaiit infiltration in the lung tissue, 4. Speedy transition from the red into the gray hepatization. Then purulent intilt ‘ation, with very ready formation 01' abscesses and gangrene of the tissues. 5. The upper lobe is the most frequently affected. 6. Very early prostration, delirium and coma (this form was called typhoid). 7. The fever is usually very high. 8. Inflammation and swelling of the liver and the spleen, also albuminurea are very frequent. ‘J. lctcrus and some vomiting (formerly called bilious pneu- monia. 10. The disease is most frequent in the summer and fall; very seldom in the spring. 11. The rate of mortality is very great. The author considers the peculiar malignity 01' this disease to be due, not so lunch to the intensity of the disease-process as to that of the infection. The typical succession of the histological changes in this form of pneumonia exist, but in a very irregular mode of development. Some stages last longer than usual, others pass imperceptibly or are suddenly arrested by necrobiotic processes. circumscribed. In the second form the tissue is moist, very fragile, ot‘ the consistency of the lung tissue in the first stage ot' inflammation, and varies in color from a whitish-gray to different shades of green. By spots it is perfectly soft and deliquescent. An opac, sanious liquid, exceedingly fetid, oozes from a cut surface. The mortified tissue imperceptibly passes into a zone of inflamed structure, separating it from the healthy portions. The circumscribed form is always confined to small portions of the parcnchyina, and is not much inclined to spread, whilst the non-circumscribed may occupy a whole or a part of a lobe. There are three stages in its develop» inent: 1. The beginning stage of Inortification. 2. The sphacelus. 3. The sloughing and formation 01' cavities. The sputa, from a gangrenous lung, are of a greenish or brownish color, or of several shades of gray, always contain more or less pu‘ and emit an insupportably fetid odor ot' gangrene. 1n the early stages, opac and milky, they turn gradually darker. \VllCIl the tissues begin to heal, the sputa turn yellowish and have an odor of pus, gradually losing its fetor." lle farther very correctly remarks that pulmonary gangrene does not nearly as often originate in inflammation as is usually believed. Dietrich in his work "On Gangrene of (he Lungs, 1850," and Trauhc in his classic "Collection. of Researches," have both clearly dcmoii- strated that by far the greatest number of cases of pulmonic gangrene are due to bronchial dilatations, when the putrid bronchial secretion stagiiates in the finer cavities ot' the air passages and undergoes metamorphosis consisting of either calcification, iiispissation or liquitication. The latter is thrown out by expel-toration as a rery putrid sputum. This sputum serves 2 a very valua- ble diagnostic agent. Trouhe has microscopically examined it and found it derived/from two distinct sources, one from what he termed putrid bronchitis, and the other from genuine ‘11)01‘llll(‘t1il(11‘1 and de*ay of the lung tissuepropcr. "Tho/ntdodm' of the sputum he says, "its dirty yellowish green color, its liquid form, which permits itto separate, after standing for awhile in a vessel, into three distinct layers: the upper yellowish green, opaque, foamy: the middle clearly purulent; the lowest yellow, opaque and resembling a sediment of broken and unbroken pus corpuscles; finally the sott tet1dlumps which it contains, and whichareagglomerations of crystals oi the fatty acids, having a smooth shining surface, characterize it as a one from putrid In'olu-hiiis, or pulmonary yang/rune. ln that from i a gangrenous lung, there are also present particles ot destroyed |