In the diffused variety the gangrenous change involves more or less of the whole lobe. Thus, in a case recorded by Dr. Hayes, after the death of the patient—a boy of seven years of age—the lower half of the inferior lobe of the right lung was in a state of grey hepatisation. Its tissue was very friable, and drops of pus exuded from it on pressure. The remainder of the lung was of a dark purplish colour. Its tissue broke down on the slightest pressure and gave forth an unbearable stench. The centre of the middle lobe was occupied by an irregular cavity, about the size of a large walnut, filled with putrid matter.
In the circumscribed form the seat of the lesion is usually the lower lobe or the periphery of the organ. In the latter case the pleura may be inflamed or may participate in the sphacelating process. In my own case, related elsewhere, not only was the whole of the left lung in a. state of gangrene, but adhesions had formed between the adjacent layers of the pleura at the posterior surface. Moreover, the chest-wall had been perforated in the eighth intercostal space, and a communication had formed between the disintegrated lung and an extensive abscess which lay outside the wall of the chest.
If adhesion of the pleura does not occur, pneumothorax may arise from: rupture of the lung into the pleural cavity.
In many cases the bronchial glands are enlarged and cheesy. In two of Millet and Barthez' cases they were gangrenous.
Symptoms.—The symptoms of the disease are often very indefinite. They may consist only of general drooping, disinclination to exertion, pallor and wasting, with slight cough and obscure pains about the chest.
The physical signs may be also indefinite, consisting merely of slight dul ness at a certain part of the chest, with feebleness of breath-sound. After. a time the child dies without any more characteristic symptoms having been developed, and the autopsy discovers a patch of gangrene in the lung. In almost all the cases observed by Rilliet and Barthez, these experienced physicians failed to detect the nature of the illness during the life of the patient.
In more pronounced cases the disease may begin gradually or sud denly. In the first case the child is noticed to be failing. His appetite is poor, he looks pale, and his flesh feels flabby. Soon he complains of pains in the chest, coughs occasionally, and sits by the fire if the weather is chilly, refusing to play, and objecting to any exertion. He is thirsty and sleeps restlessly at night, being often disturbed in his sleep by cough.
The sudden onset may be announced by headache and sickness, a feeling of chilliness, or even a rigor. The child is feverish, with a dry skin ; is very restless and anxious, and the pulse is quickened. Perhaps there may be pain in the side and a dry cough.
When the symptoms are fully developed the patient is pale and weakly looking, with a haggard expression of countenance, and dull, sunken eyes. The tongue is foul, and appetite is almost completely lost. The bowels are seldom relaxed ; sometimes there is marked constipation. There is often great restlessness, so that the child is in constant uneasy movement in his bed. The pulse is feeble and frequent, 130-150 ; the respirations 30-40. The temperature is high, and may reach 103° or 104° in the even ing, usually falling in the mornino. to 100° or 101°. The cough is frequent and loose. It is often excited by movement and may be accompanied by pains in the back or side. Usually there is expectoration even in young children, for the sputum is too offensive to be swallowed. It exhales a sickening odour, and is frothy and reddish-brown in colour. On standing it deposits a reddish-brown, shreddy sediment, containing greyish putrid granules, in which Leyden and Jaffe have discovered bacteria and a special fungus—the leptothrix pulmonaris. In quantity the expectoration varies from time to time, being sometimes copious, sometimes scanty and more tenacious. Occasionally the fetid odour ceases to be noticed, but it usually quickly returns. A similar odour is perceived in the breath of the patient, especially during cough. As in the case of the expectoration, its offensive ness occasionally ceases for a time. The cough may be so harassing and frequent as almost entirely to prevent sleep ; and the consequent exhaus tion, combined with the unwillingness of the child to take adequate nourishment, adds greatly to his weakness.
In most published cases great variation has been noticed in the in tensity of the symptoms. Sometimes the pulse is excessively frequent and feeble, the eyes sunken and lustreless, the restlessness extreme, the cough distressing, and the face earthy or lead-coloured. The breathing also may be laboured and difficult. Thus, in a case recorded by Dr. Sturges there were attacks of violent dyspncea in which the face looked pinched and blue, the expression was terrified, the body was covered with a clammy sweat, and no pulse could be felt at the wrist. At other times the symptoms are less distressing, the face looks brighter, the cough is quieter, the pulse fuller, and the manner more composed. The patient, however, from day to day grows evidently weaker, and in the large majority of cases sinks after a further period of suffering. Sometimes death is. preceded by one or more attacks of hamoptysis. In a case reported by Dr. Hayes, the child, on the afternoon before his death, after a fit of coughing, spat up half a pint of red, frothy blood ; and the haamoptysis was repeated in the evening shortly before he died.