A system of practical medicine. By American authors. Vol. 3

by Unknown

¹⁰ Gesammte Beiträge zur Pathologie und Physiologie, Zweiter Band, p. 452, etc.

¹¹ Deutsches Archiv für klin. Med., Band ii. pp. 488, etc., "Ueber putride Sputa."

¹² Virchow's Archiv, Band lxxv.; Zeitschrift für klinische Med., Band i. p. 228.

PROGNOSIS in general is unfavorable. Individually, the gravity of the case is determined by the evidence bearing on previous habits and constitution; by the violence of the onset, as shown in prostration, severe pain in the chest, dyspnoea, persistent and violent cough, delirium, feebleness and softness of the pulse; by the variations from the typical standards of croupous, or especially catarrhal, pneumonia, such as greater amount of septic or infectious or typhoidal element, non-typical and low temperatures in the early stages and also in the stage of disintegration; by the amount of the latter as shown in the physical signs of extensive lesion and in the amount of gangrenous sputum; and by the irritant effect of this in producing bronchial catarrh, and consequent catarrhal secretion, which may of itself become an element of danger in a system already much prostrated. Favorable prognosis is allowable when these conditions are being gradually reversed.

PATHOLOGY.—The pathology of gangrene of the lung is scarcely more settled than it was forty years ago, when Stokes¹³ published his eighteen propositions, embodying his experience. Obstruction of vessels and inflammatory exudations are present as important pathological conditions, but of themselves are not pathogenetic of gangrene. Other, as yet unknown, elements of putrefactive agency are present. Leyden and Jaffee's observations and those of Kannenberg have been mentioned¹⁴ as efforts to throw light upon the pathogenesis of gangrene of lung, but how far the bodies described by them precede, coincide, or follow the familiar clinical phenomena are undetermined questions. Filehne,¹⁵ in his experiments to determine the reason of the almost universal absence of elastic fibres in the expectoration of patients with gangrene of lung, comes to the conclusion that there is a ferment which, acting under alkaline conditions, destroys the fibres. The agents of this ferment he does not try to determine. Stokes anticipates the tendency of modern experimental pathology by announcing as an alternative proposition that "a process of putrefactive secretion precedes in many cases the death of lung." The constitutional debility which is so early a symptom prepares the way for such an invasion. In reference to the relation between the septic material and thrombosis in gangrene, Kohler¹⁶ affirms that the septic material produces the fibrin-ferment, and thereby capillary thrombosis. Recklinghausen thinks that a special material capable of exciting coagulation has not yet been found in gangrenous substances, but that there may be several factors, such as anæmia, changes in the vessel-wall, imbibition with foreign substances, etc. Other experiments¹⁷ and views point toward the conclusion that there are substances formed in various diseased conditions which have the power of ferments and of producing coagulation of blood in the lesser circulation.

¹³ Dublin Quarterly Journal Med. Science, Feb. 1, 1850.

¹⁴ Op. cit.

¹⁵ "Sitzungsbericht der Phys. Med. Soc." in Erlangen Schmidt's Jahrbucher, 1877, No. 7.

¹⁶ Recklinghausen's Handbuch der Pathologie, p. 136.

¹⁷ Wooldridge, Du Bois-Reymond, Archiv Centralblatt für med. Wissenschaften, No. 41, vol. xi. 1874, p. 734.