_Hôtel Dieu._
_Cases of Gangrene of the Lungs._
Some interesting cases of gangrenous suppuration of the lungs were
published by Dr. Chambers, about eighteen months ago, in which he
particularly pointed out the horrible fœtor of the breath as a
diagnostic mark of the disease. The following cases which recently
occurred at the Hôtel Dieu are good illustrations of more extensive
destruction of the lung by a similar disease.
CASE I.--A man, aged 32, of good constitution, laboured under
bronchitis for some weeks, to which he paid little attention,
when he was suddenly seized with pain in left side, dyspnœa,
considerable cough, and a rigor, followed by fever. He was admitted
into the Hôtel Dieu next day. Crepitation was perceptible over the
whole extent of the left lung, posteriorly, and reaching to the
site of the pain in the side, which was increased by percussion;
great oppression, with frequent cough, and expectoration of
violet-red colour, mixed with mucus; pulse frequent and small;
constant chilliness; cheeks flushed.
Next day the symptoms remained unabated, and _fœtor of the breath_
was observed. Two days after it is stated that the expectoration
maintained the same appearance, but _was now fœtid_; the breath
was, however, still more offensive, and during the fits of coughing
particularly so. In the evening the breath is said to have become
_gangrenous_.
21.--The cough was small, difficult, and painful, producing an
expectoration of violet-coloured matter, approaching to chocolate,
_with a characteristic odour_.
22 to 25.--Expectoration and breath emit an _intolerable stench_.
On the latter day the patient died.
_Examination._--The body not emaciated. Strong adhesions of the
left lung to pleura costalis. At its posterior part a large
gangrenous layer, occupying the two superior thirds of the lung,
covered at some points by a false membrane. The lower third, and
the parts round the gangrenous portion, in different degrees of
inflammation, and hepatised; the putrid mass was in great part
black or violet-coloured, containing fragments of the pulmonary
texture; the smell gangrenous, but less so than that of the breath
during life; pus might be squeezed from the adjacent part of the
lung.
CASE II.--A man, aged 55, enjoyed good health till the beginning
of May, at which time he experienced pain in the left side of
the thorax after exposure to cold. During the next few days the
cough was frequent, and the expectoration tinged with blood. A
rigor now came on, followed by a distinct exacerbation of fever,
and he came to the Hôtel Dieu. At this time he presented symptoms
of inflammation of the lungs, and was bled with relief; he left
the hospital in twelve days, being sufficiently well to resume
his occupation. Scarcely had he done this, however, when he had a
relapse, accompanied by great lassitude, oppression of breathing,
and frequent cough. At the end of a week he returned. He was now at
the twenty-first day of the attack. His skin was yellowish; face
pale or of leaden hue, and greatly altered; his cough frequent,
with abundant expectoration of matter like chocolate, with small
specks resembling pus, and little bodies about the size of peas,
which appeared to be portions of the lung. This putrid mass exhaled
a _gangrenous odour_, and the expired air was impregnated in a
high degree with an equally disgusting smell, which surrounded the
patient's bed with a contaminated atmosphere. Percussion gave a
clear sound over the whole extent of the chest; auscultation did
not discover the pulmonary expansion on the right side. The pulse
was weak, but not frequent; the patient was in a state of extreme
prostration. Next day the odour of the breath and expectoration
was, if possible, more dreadful. He lingered two days longer,
during which time the fœtid smell somewhat diminished, and the
proportion of pus in the expectoration increased.
_Examination._--The left lung had contracted firm adhesions,
particularly above and behind. It was torn in attempting to
remove it, and there issued from the middle and posterior part a
large quantity of dark-coloured matter, similar to what had been
expectorated. An incision was made along the back part of the
lung, and laid open a large cavity, occupying all the extent of
the pulmonary organ, and still in part filled with the same kind
of dark putrid matter. On washing out the cavity it was perceived
that it was lined with a smooth and white membrane, to which were
still adherent, at some points, dark filamentous shreds; these
were removed by the least touch, and left the surface smooth
beneath. The boundary was formed by a false membrane, about a line
in thickness, which separated the mortified from the sound parts.
The lung was reduced to a kind of bag, the parietes of which were
on an average about an inch thick. In the upper part of the lung,
which was hepatized, an incision discovered a number of smaller
tubercles, which in the centre were in a crude state; and at one
point several had suppurated, forming a cavity large enough to
contain a nut.
[The Editors of the _Journal Hebdomadaire_, from which these cases
are abridged, add, in a note, that although the fœtor of the
expectoration, such as above described, is usually dependent on
gangrene of the lungs, yet that this is not invariably the case.
In confirmation of this assertion they refer to three instances
of fœtid expectoration--in the first, the patient is still alive;
in the second, there was chronic bronchitis, with considerable
dilatation of numerous bronchi; and in the third, bronchitis with
some appearances of chronic pneumonia. Laënnec gives a case of
dilatation of the bronchi, with remarkably fœtid expectoration.
The argument derived from the first patient having survived we
consider to be altogether erroneous, as patients more frequently
recover from this than other forms of purulent expectoration.--ED.]