In some cases gangrene of the gums or cheek has been observed ; and if the signs from the lungs are not marked, the fetor of breath may be attributed to the presence of these lesions.
The duration of the illness in cases which terminate in death is never very prolonged. Dr. L. Atkins, who has collected thirty-one cases of the affection, states that it varies between two days and twenty. The child usually dies from asthenia. The complexion grows more and more livid, the pulse weaker and more rapid, and death may be preceded by a gush of blood from the mouth or by rupture of the lung and the formation of pneumo-thorax.
In the rare cases in which recovery has been recorded, the fetor of the breath disappeared at the end of a fortnight or three weeks ; but con valescence was very slow.
The physical signs in cases of pulmonary gangrene are not distinctive of the lesion. At first the signs are usually those of bronchitis. Percus sion of the chest discovers no dulness, and with the stethoscope we find merely large bubbling rhonchus pervading the lung on both sides. After a few days a limited area of duhiess is detected at some part of the chest— usually the posterior base ; the breath-sound becomes bronchial, and the riles are drier and more crepitating in character. The dulness usually extends its area and may pass to the front of the chest. If eventually a cavity form, it may give no evidence of its presence unless its situation be near the periphery. In that case the breathing may become bronchial, blowing, or cavernous, and the rhonchus larger and more distinctly gurg ling. In the case of a large cavity amphoric respiration with metallic tinkle may be discovered at some point in the dull area.
In a case which was under the care of my colleague Dr. Donkin, in the East London Children's Hospital—a microcephalic idiot, between two and three years old, who was admitted for rigidity and paralysis of joints, with partial loss of consciousness—the breath a few days before death was noticed to have an insupportably offensive odour. The child began to cough slight ly, and the pulse and respiration were greatly hurried. On examination of the chest dulness was discovered at the left base, passing round from the back to the front, being most intense beneath the left axilla. Much large bubbling rhonchus was heard all over both sides, especially the left. The child grew rapidly worse, the face became much pinched, and peteclii appeared upon the abdomen. The temperature, which had
been always high, rose to 108° shortly before death. An autopsy revealed two small embolic infarctions in the left lung. The lower lobe was com pletely solidified, and contained a cavity the size of a hen's egg. This excavation was partially liked with a membrane, and held much stinking fluid and detritus. The right lung was merely congested with patches of collapse.
In this case the high temperature noted before death was probably due more to the condition of the brain than to that of the lung. The cavity seems to have been the consequence of breaking down of an inflam matory consolidation set up by a metastatic infarction, the gangrenous nature of the process being determined by the low nervous power of the patient.
Diagnosis.—On account of the uncertain character of the symptoms and physical signs which present no definite features by which the disease can be recognised, we are forced to rely solely upon a gangrenous odour from the breath and expectoration for evidence of the nature of the lesion. Without this symptom there is really nothing in the condition of the child to suggest that the inflammatory process has gone on to mortification of tissue ; for a cachectic appearance, great feebleness, a hag gard look, constant restlessness, and varying intensity of symptoms are common to many forms of illness. If the characteristic fetor of breath be present alone, it may be the consequence of other conditions. In gangrenous stomatitis and gangrene of the pharynx the same phenom enon may be observed ; and in many cases of cirrhosis of the lung, when secretion is retained and becomes decomposed in the dilated tubes, the odour of the breath may be exceedingly offensive. In the latter dis ease, although the breath and expectoration may be very offensive without obvious gangrene being present, shreds of sphacelated tissue are, no doubt, present in the matters discharged from the lung. If gangrene of the lung coincide with the same condition of the mouth the unpleasant odour is usually attributed to the lesion which is within reach of the eye, and the pulmonary gangrene may not improbably pass unrecognised. The ap pearance of offensive expectoration, however, at once directs attention to the lung, and if linioptysis occur, the blood giving out the same unbear able odour, doubt is no longer possible.