The sputum showed Type IV pneumococcus. The blood culture was negative.
FIG. XXX. AUTOPSY NO. 169 (LEFT) AND AUTOPSY NO. 97 (RIGHT). THIS CONTRAST IN THE EXTENT OF INFLAMMATORY INVOLVEMENT BETWEEN NEIGHBORING LOBULES IS FREQUENTLY ENCOUNTERED.
FIG. XXXIII. GANGRENE OF THE LUNG.
The autopsy was held four hours after death. The body was markedly emaciated. The peritoneal cavity and its contents appeared normal, though the liver was low. The right pleural cavity contained 150 c.c. of slightly cloudy, yellow fluid. The left was free from fluid. Both lungs were bound to the chest wall by silvery grey, translucent adhesions which were broken with slight difficulty. The right lung was heavy, voluminous, retained its shape on removal, and was consolidated throughout. Thick, creamy pus exuded from the cut trachea. For the most part, the lung was covered by a recently organized exudate several millimeters thick in which delicate blood vessels could sometimes be made out. Beneath the pleura of the lower three-fourths of the lung, were numerous, irregularly rounded, slightly elevated, opaque, greenish-yellow areas resembling conglomerate tubercles. These gave the lung a shotty or nodular feeling. In the lowest lobe several of these areas had fused and softened to form semifluctuant areas several centimeters in diameter. On section the lower two-thirds of the lung was studded with areas corresponding to those seen on the surface, which in many instances had broken down and formed irregular cavities filled by thick, green pus (Fig. [LI]). Between the green areas delicate strands of new-formed fibrous tissue could be made out in all parts of the lung. The bronchial mucosa was injected, the walls were irregularly thickened and dilated and they opened into the ragged cavities noted above. New-formed fibrous tissue was prominent along the bronchi. One chalky white, old, encapsulated, tuberculous focus was found near the apex of the left lung.
Microscopically, there were two distinct processes found in the sections taken from various parts of the lung: an early miliary and exudative tuberculosis, and a necrotizing and organizing bronchopneumonia. Often the two processes were side by side, but sharply demarcated, in the same section. In others, they might be so intermingled that they could not be differentiated. The bronchi were filled with pus and often could be seen opening into large abscess cavities. The proliferation of the bronchial epithelium, as noted elsewhere, also was a striking feature in these sections. The pleural exudate was undergoing organization.
Streptococcus hemolyticus was found in the cultures of the lung, blood, pleural fluid, and bronchi. In addition, the bronchi and abscess cavities also showed Type IV pneumococcus and Staphylococcus albus.
Summary.
In this series of ninety-five cases, two examples of activation of an old tuberculous focus by the acute respiratory process were encountered. In both the pulmonary tubercular process was acute and played an important rôle in the fatal outcome.