DISTRIBUTION OF PNEUMONIC LESIONS AND GRADES OF SEVERITY
═════════════════════════════════════ DEGREE OF INVOLVEMENT + ++ +++ Total Left upper lobe 10 6 7 23 Left lower lobe 4 10 17 31 Right upper lobe 12 8 9 29 Right middle lobe 10 9 4 23 Right lower lobe 5 9 18 3 ─────────────────────────────────────
All lobes were simultaneously involved in some grade of pneumonia in 18 cases—56 per cent.
at times quite remarkable. It may appear very early in disease. We have not met with a single case where the emphysema of the lung led to a rupture of the air sacs and an interstitial infiltration of air through lung, mediastinum, neck and subcutaneous tissues. Some very remarkable cases are reported by different authors where this emphysema was of astounding grade leading to a crepitating infiltration throughout the mediastinum, neck and the subcutaneous tissues over the thorax and abdomen as low as the pubis. The milder grade of emphysema consisted mainly of an abnormal expansion of the air sacs which were not infiltrated by exudate and which probably had some effect in preventing the diffusion of the inflammatory fluid from entering certain regions. These emphysematous areas could be readily recognized by the naked eye along the anterior borders of the lung as well as between the involved pneumonic patches within the lung.
These lungs, involved in this early serous and hemorrhagic exudate varied considerably in their appearance according to the regional and quantitative involvement. As is seen from Table viii, the lower lobes were more commonly occupied by massive exudate than the upper, and the involvement of multiple lobes was the usual. Still more remarkable is the fact that all lobes were simultaneously involved in some grade of reaction (pneumonia) in 56 per cent. of cases. In complicated influenza-pneumonia Goodpasture and Burnett found the inflammatory reaction in both lungs and involving to a greater or less degree the lobes on each side. Most commonly this involvement consisted of a lobar distribution in one or two lobes with a lobular or patchy disposition of exudate in one or more of the remaining lobes. Where the distribution was lobar the involved lobe was distended to its fullest and the pleura tightly stretched over the lung tissue which, heavy with fluid, was not solid but flabby. The lung could be moulded under the finger and could be compressed into various shapes. At first sight this flabby, heavy lung tissue suggested the appearance of the waterlogged lung which one encounters in renal disease or failing circulation. A closer analysis, and particularly when the lung was sliced, showed an entirely different character.