GANGRENE OF THE LUNGS. 



209 



SYMPTOMS AND COURSE. We have seen that the signs of haemor- 

 rhagic infarction and metastatic deposits in the lungs are very obscure. 

 Even circumscribed gangrene, which develops from hsemorrhagic 

 infarction and metastatic deposits, cannot generally be diagnosed until 

 the gangrenous discharge reaches a bronchus and is ejected. . Then, 

 indeed, the foul odor of the breath, the blackish-gray liquid, and also 

 the very ill-smelling sputa, leave no doubt about the nature of the case. 

 Sometimes the fetid smell of the breath precedes the characteristic 

 expectoration by some days. The sputa, like those of the decomposing 

 contents of a bronchiectatic cavity, soon separate into several layers, 

 a frothy superficial one, a liquid middle stratum, and a thicker sedi- 

 ment. The color of the expectoration is of a dirty blackish or brown- 

 ish color. It contains black, tinder-like masses, and frequently soft 

 cores, containing acicular crystals of fat. In rare cases, it also con- 

 tains fibres of wavy, elastic tissue. Sometimes, physical exploration 

 affords further information. The sound upon percussion is tympanitic, 

 more rarely dull, and in a few instances cavernous sounds may arise. 



Some patients evince the greatest prostration from the beginning ; 

 the countenance is " pinched " and livid, the pulse small and extremely 

 frequent, and the patient soon perishes from asthenic (putrid) fever. 

 Others bear this serious disorder wonderfully well. Their general 

 condition is scarcely changed ; they walk about, are without fever, and 

 the disease goes on for weeks. In these cases haemorrhage may arise 

 at a later period, which may exhaust the patient ; or, after a time, 

 asthenic fever may develop, to which the patient may succumb, after 

 lingering, now better, now worse, for a long time. Should recovery 

 take place (a very rare event indeed), the odor of the sputum dis- 

 appears, it gradually becomes yellow, and at last, if the gangrenous 

 spot be incapsulated and atrophied, it may cease altogether. 



"When diffuse pulmonary gangrene arises from pneumonia, we 

 observe a sudden loss of strength during the progress of the latter 

 disease, with a small irregular pulse, a disturbed countenance, and 

 soon the fetid breath and blackish liquid sputum, with its penetrating 

 odor, are added to the above symptoms. When diffuse gangrene arises 

 independently of pneumonia, it is attended from the outset by signs 

 of extreme adynamia, and by symptoms like those which accompany 

 the entrance of septic matter into the blood, rigors, delirium, stupor, 

 hiccough, etc. The expectoration then often ceases entirely, either 

 because the bronchial mucous membrane itself has become gangrenous 

 and insensible, or else because the patient no longer can respond to 

 any irritation whatever. They now not unfrequently swallow what 

 sputum still reaches the fauces, and thus bring on an obstinate diar- 

 rhoea in lieu of the expectoration 

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