(2) LOCALIZATION AND NECROTIZATION OF THE PNEUMONIC PROCESS
In the preceding description, the gross and microscopic anatomical changes in the lung have been discussed minutely. The picture presented persists, even though it becomes less intense, and forms a background upon which later variations may be superimposed. There is no justification for the opinion that the changes described are necessarily the most acute, but it is presumably correct to suppose that an aplastic, inflammatory reaction will terminate fatally more quickly than a cellular reaction (160), and upon this basis the sequential description in this narrative is arranged.
In the group of fatal cases of influenza, now to be discussed, the lesions of the pulmonary parenchyma are characterized by more definite lung consolidation. Thirty-nine examples presenting an average illness of ten days are included in the following description.
The external examination of the body includes nothing not described in the previous group.
FIG. XIX. AUTOPSY NO. 123. A SMALL AIR BUBBLE IN THE INTERSTITIAL TISSUE. COMPARE FIGURE XVIII.
FIG. XX. AUTOPSY NO. 90. THE ACUTE SEROFIBRINOUS EXUDATE INVOLVES NOT ONLY ALVEOLI, BUT ALSO SUBPLEURAL AND INTERLOBULAR BANDS OF CONNECTIVE TISSUE. COMPARE FIGURES XXI, XXII, AND XXIII.
The fluid of the pleural cavities varies volumetrically as described in the preceding section. It is, however, usually not a clear fluid, but varies from a slightly turbid, blood-stained material to a typical purulent exudate. The cloudiness may be associated with minute flecks of suspended material, but in no instance has this fluid been of the thick inspissated type which formerly would have been designated as empyema.[8] (This is mentioned with the knowledge that the term empyema is being applied now to less viscid, purulent, pleural exudates). The turgidity of the mediastinal tissue also persists, but it is very rare indeed to find anything more than a small amount of clear fluid in the pericardial sac. Only once was there a typical, fibrinous pericarditis with effusion, and this occurred where a most extensive pleural exudate was also present.[9] Where such complications have been described in serous membranes, the bronchial lymph glands, particularly at the hilum of the lung, are more involved and show, not only an increase in size and a red color on cross section, but frequently also focal areas of necrosis at the periphery, which appear as yellow patches and subsequently undergo suppurative disintegration (2, 47).