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serves the attention of the surgeon. I mean that variety of Pneumonia, which occurs in connection with, or as a consequence of, surgical operations and injuries, and which is not dependent upon the absorption of pus.
In a Table* appended to this paper, will be found an account of the condition of the lungs in sixtytwo cases of death after surgical operations and injuries. Before proceeding to the analysis of this, it may be necessary, in order to avoid all misconception, to point out those circumstances that have been considered to serve as distinctive signs between Pneumonia, properly so called, and mere passive congestion of the lungs.
The anatomical characters of the first stage of inflammation of the lungs, more especially when that disease assumes an asthenic type, are in all respects similar to those of mere passive congestion of those organs. The lungs, in both cases, being heavy from sanguineous engorgement, presenting externally a livid violet hue, mottled with spots of a dark red, or purple colour, and preserving the impression of the finger, as if edematous. When pressed upon, they will be found to be more compact and solid than natural, scarcely crepitating. When cut into, a frothy, spumous, reddish fluid
* I may mention that the cases contained in this Table have been calculated indiscriminately, and not selected, from the records of University College Hospital, that very many of them fell under my own observation, and that all deaths occasioned by burns, which are attended by peculiar lesions, have been omitted. exudes in considerable quantity, and the pulmonary tissue will, at the same time, be found to be altered in its consistence, breaking down readily under even moderate pressure of the finger into a grumous pulpy mass. This friability of the tissue of the lung has been, by many, supposed only to occur in those congestions of that organ which were of an inflammatory nature, but it has been proved by the observations of Andral, and others, to be of no value as a diagnostic mark in distinguishing these from the mechanical engorgement that frequently supervenes but a few hours before death, and which, when it occurs, is probably the immediate cause of that fatal event. In order, therefore, to avoid all source of fallacy by confounding together these two conditions, that so closely resemble one another in their anatomical character, though differing so materially in their essential nature, I have comprised under the term Pneumonia, only those cases in which either one lung alone was affected, or else, in which some other possible sign of inflammatory action was manifested in the cavity of the thorax beyond a merely congested or softened condition of these organs, such as solidification of their tissue, whether hepatization or splenization of it, the effusion of recent lymph or serum into the pleural sacs, or marked evidences of inflammation of the bronchial mucous membrane.
In accordance, then, with this distinction, between an inflammatory and merely congested condition of the lungs, between an active and passive hyperemy
of their tissue, the sixty-two cases in the Table will be found to arrange themselves into four classes.
Ist.-Those in which there were evident signs of Pneumonia, as evinced either by the diseased condition being confined to one lung, by its having advanced to solidification, or by the co-existence of marks of inflammatory action in the pleuræ or bronchial mucous membrane. These cases are twenty-eight in number, or nearly one-half of the total amount of deaths.
2nd.-Doubtful cases-in which the lungs presented the characters that are common to the first stage of Pneumonia and to passive congestion, without there being any collateral circumstances by which the diagnosis could be more clearly established. These are eleven in number.
3rd.—Cases in which the lungs were found more or less diseased, but not inflamed or congested. These are nine in number.
4th.—Cases in which the lungs were found healthy. These are fourteen in number. *
Thus it will be seen that on examining the lungs of sixty-two individuals who had died from various surgical diseases, operations and injuries, there were found markedevidences of Pneumonia in twenty-eight, or forty-five and one-tenth per cent. of the whole. Of the remainder, it was doubtful in eleven whether the congestion that was met with was of an inflammatory
* It is probable that cadaveric congestion of the lungs may have existed in many of the cases in this class, but as no actual disease was found, they are entered as being healthy.
or passive character. In nine others, the lungs were more or less diseased, being tuberculous in three cases, bronchitic in four, cedematous in one, and gorged with fluid blood in another; and in fourteen cases only; or little less than a quarter of the total amount_22:5 per cent.—were these organs healthy.
Of the twenty-eight cases in which Pneumonia was found, that disease had advanced to its second stage, that of solidification, in seventeen. The lungs, in the eleven remaining instances, exhibiting the pathological characters of the first stage of Pneumonia, together with evidences of bronchitis, or of pleuritis, as shown by the inflamed condition of the bronchial mucous membrane, and by the effusion of recent lymph, or of serum, into the cavities of the pleuræ. There is one remarkable circumstance connected with the form of Pneumonia now under consideration; namely, the relative frequency of the occurrence of the disease in one or other lung, or in both, at the same time. Andral, Chomel, Forbes, and all pathologists, agree that in ordinary sthenic idiopathic Pneumonia, the right lung is most frequently affected, the left next, and, lastly, both organs conjointly. Now, on examining the twenty-eight cases already mentioned, it will be found that the right lung alone was affected but three times, the left lung alone also only three times, and both lungs together,-not, however, to the same degree,-in no less than twenty-two cases. The reason of this remarkable deviation from the
law, that appears to govern the occurrence of sthenic idiopathic Pneumonia, may be explained by the peculiar nature of the causes that predispose to and excite the congestive variety of the disease.
In two cases only were the upper lobes found inflamed. One of these was that of a child, who died of phthisis, with intercurrent Pneumonia; the other, that of an old woman, who had been operated on for strangulated hernia. In one case there was found lobular hepatization, the subject being a child twelve years of age, who died with phlegmonous erysipelas of the arm.
That form of inflammation of the lungs which occurs as a consequence of surgical operations and injuries is occasionally of a sthenic, but much more frequently of an asthenic or congestive character, corresponding to the variety of the disease that has received, from various authors, the names of putrid, malignant, congestive, erysipelatous, asthenic, typhoid, and hypostatic Pneumonia, and which is not an unusual sequela of continued fever, and of other affections, attended by much debility of the system generally, or by 'a vitiated condition of the fluids. I am unable to give the precise ratio of the comparative frequency of the occurrence of these two forms of the disease, the sthenic and the congestive; but I can state that the latter is by very much the most common, being found in by far the larger proportion of those who die of Pneumonia in the surgical wards of a hospital; the disease assuming but occasionally an active character, and that only