and are of different sizes, ranging from the size of a pea or small marble to that of a hen's egg. When cut through, they show a circumscribed surface, in strong contrast with the surrounding tissue. They are evidently composed mainly of deposited and coagulated blood. As the different lobules have no direct communication with each other when the masses become large, they are evidently formed by the engorgement of several lobules in proximity.

Sometimes there are but few small masses or nuclei. The disease consists mainly in the existence of one large diffused mass, occupying nearly the whole of one tube, but having limits obscurely defined, the color gradually deepening in the course from the border to the centre. In this case, the central portion is obviously formed almost solely of a black clot of blood; while, at a distance from the centre, the sanguineous deposit is more diffused and intermingled with the pulmonary tissue.

DIAGNOSIS.-The symptoms of pulmonary apoplexy are not constant. Among those which more generally appear, are dyspnoea, a sense of tightness or a dull pain in the chest, a cough, and hæmoptysis. The blood expectorated may be a mere tinging of the sputa, or a little pure blood raised in coughing. Often, however, in this disease, there is little, sometimes no hæmoptysis, the effused blood coagulating and remaining undisturbed in its place of deposit.

Among the physical signs is feebleness or absence of the vesicular sound over the part affected. If the disease is extensive, the sound will be almost entirely wanting in the lung. At the same time, the respiration may partake decidedly of the shrill bronchial character, especially towards the root of the lungs. In one remarkable case which came under my treatment, the airpassages of the right lung were so completely blocked up, that no sound of respiration whatever was heard, except over the largest bronchi, and the superior lobe. Of course, what sound there was, was of the shrill bronchial character. When sufficient hemorrhage takes place, or blood is found in sufficient quantity in the medium-sized bronchi, the sub-crepitant rale is heard; and, in the largest bronchi the mucous is also heard, if there is sufficient

liquid there to produce it. These rales, of course, have the peculiar character given them by the thinness of the liquid.

If the disease is slight, there will be, on percussion, a slight dullness only; but, in graver cases, the dullness will be considerable. In the unusual case to which I have just alluded, there was dullness amounting almost to flatness, all over the lower half or more of the lung, anteriorly, posteriorly, and laterally. Indeed, the percussion was hardly normal on any portion of the right side of the thorax. This case commenced suddenly in the night, after exposing the chest and taking cold the previous evening. There was, at first, a slight hæmoptysis, but hardly enough to create the sub-crepitant rale; and some febrile symptoms lasted for a few days. In one year, symptoms of tuberculous disease developed themselves; and in six months more the patient died of phthisis. Whether this disease, in its incipient state, was there in the first place, cannot be known. Possibly latent and incipient tubercles might have assisted in producing the pulmonary apoplexy.

PROGNOSIS. The prognosis, in the case of pulmonary apoplexy, is not very favorable. The disease supposes an antecedent serious affection of some sort, or perhaps a complication of affections. By its irritation, also, and its disturbance of the function of respiration, it almost necessarily leads to other ill results.

TREATMENT.—If there is hæmoptysis, that is to be arrested, as described in the treatment of congestion. If febrile action is excited, that should be treated as in other cases. But, in regard to the removal of the coagulated blood, remedial means can accomplish but little. Simple expectorants and demulcents to relieve the air passages and allay irritation, may prove palliative. If there are complications of other diseases, they should receive proper attention, and so should the general health of the patient.

CHAPTER IX.

PULMONARY GANGRENE.

I use the phrase pulmonary gangrene, in accordance with common professional usage. Pulmonary mortification, however, would be a more appropriate designation, as the phrase is not intended to be limited to a partial destruction of the parts, but simply to an entire loss of vitality and sloughing.

PATHOLOGY.-Pulmonary gangrene may occur either as a primary or a secondary affection. When it is primary, it results from a reduced state of the blood, in which the vitality or nutrition of the part is not sustained. As a secondary affection, it occurs some→ times in asthenic pneumonitis. In the primary form, the diseased part is, at first, infiltrated with a thin serous liquid which is an exudation dependent on the incipient gangrene. In the secondary form, the tissue in the beginning, is hard and congested, and situated in the midst of an inflamed portion of the parenchyma. This difference of anatomical character in the part affected, at the outset of the disease, is essentially all that distinguishes the primary form from the secondary. They soon assume essentially the same appearance.

Sometimes the disease occupies a large portion of the lung; and sometimes it is quite limited. Like pneumonitis, it generally begins in the lower half of the lung. The color of the part that has perished, is mostly a dirty olive color or greenish brown. The part becomes moist and of the consistence of an engorged lung, or softer. Sometimes, it is even diffluent.

Sometimes the disease of pulmonary gangrene has been divided into three stages. The first embraces the period in which the mortification is just fully established; the second, that in which the tissue begins to break down; and the third, that during which a cavity exists. After the explanation which I have elsewhere given of the nature of mortification, the pathology of pulmonary gangrene needs no further illustration, except to say, that, recov

ery takes place from the third stage only; and, when it begins, a

line of separation and a kind of membrane forms between the healthy and the mortified tissue. As the gangrenous portion sloughs, this membrane becomes a kind of lining to the cavity; and, while the cavity communicates with the bronchi, the membrane gives origin to the formation of pus; and, though delicate as a serous membrane, it has rather the character of a mucous. After the communication is closed, the membrane assumes a character more distinctly serous; and then the cavity is gradually obliterated by the formation of areolar tissue within the cyst, or else it remains, without closing, during the individual's life. After a cure of the gangrene, the portion of the lung which has been involved in the disease, is liable to remain for a long time, more or less dense, and to receive somewhat less than the normal proportion of air.

As a cavity is forming, the bronchial tubes resist the destructive. process longer than the areolar tissue; but the blood vessels generally hold out long after the bronchi have yielded. On a post mortem examination, they are frequently seen traversing the cavity. At length, however, they too are destroyed; and, sometimes, their destruction gives rise to hemorrhage, though generally, they do not slough, till after the blood has ceased to circulate in them.

The immediate cause of primary pulmonary gangrene, is, doubtless, the influence of vitiated and poorly vitalized blood. In the secondary affection, too, there must be substantially the same condition. The remote or ultimate causes are intemperate habits, neglect of nutritious and wholesome diet, and all such circumstances as tend to diminish vitality or break down the general health of the patient.

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DIAGNOSIS. The general signs of pulmonary gangrene are fever, with a small, frequent, irritable, and sometimes exceedingly feeble pulse; loss of appetite from the nauseating character of the gangrenous liquid which is swallowed; sometimes diarrhoea from the effect of the same liquid; dyspuca often extreme; and a peculiar pale or lead colored condition of the whole skin of the patient.

The more local signs of this disease, are cough, expectoration, and fetor of breath. The cough, at first, resembles that of ordi

nary bronchitis, but becomes more loose and paroxysmal, with the progress of the disease. The paroxysms are caused by an accumulation of fluid in the bronchi, inducing an effort to throw it off;

and hence, as soon as the object is gained, the effort ceases, until a new accumulation renders another effort necessary. These paroxysms of coughing, are sometimes very disturbing.

The sputa in the second stage begin to contain gangrenous matter; and, during the third stage, they remain about the same, until that matter is all discharged. They consist of a thin fetid liquid which not unfrequently is stained with blood that flows from sphacelated vessels. This liquid is pathognomonic of the disease. If the case proceeds to a fatal termination, the sputa increase in quantity, while the patient is gradually sinking. Dr. Gerhard says, "there are two principal varieties of the gangrenous sputa. One consists of a dark thin liquid which sometimes resembles tobacco juice or the infusion of licorice, occasionally containing small pieces of black gangrenous lung. The other consists of a grayish-yellow pasty fluid which is probably a mixture of pus and gangrenous liquid. The latter occurs most frequently in cases following pneumonia. Both, however, are extremely fetid, though the odor differs slightly."

The fetor of the breath is peculiar, and it begins to appear even in the first stage of the disease. It is greater, however, in the second and the third stages, in which the sloughing process is going on. This fetor, as well as the sputa, is pathognomonic of the affection; and the former is sometimes so extreme, as to render the room of the patient scarcely endurable.

The physical signs, previous to the third stage, are very limited. The thin serous liquid which exudes, in primary gangrene, from the affected portion of the lung, may be sufficient to give a subcrepitant and a mucous rale, as it passes through the tubes; but if the disease be limited to a small space, and that deep-seated in the lung, the healthy sounds of respiration will be heard as usual. If the disease be extensive, the current of air in the air passages being prevented, the respiratory sounds at the part will be suppressed. Percussion generally maintains about the normal resonance, though the pulmonary tissue, infiltrated with serosity, may yield a considerable degree of dullness.