. Diagnostic médical pour l'étudiant et praticien. mptoms dulnessand ou percussion seulement quelle que soit la compression. Rarement des difficultés insurmontables.-En dépit de ce fait, dans les practicethe auteur n'a pas trouvé le diagnostic d'abcès pulmonaire sodifficult même fermé une question qu'on pourrait le supposer. * Il a semblé à l'auteur qui, autrement, le silence de blocs de la zone pulmonaire mayaccount meilleur pour beaucoup de l'extrême abrupt, mais des périodes transitoires de la dyspnée urgent andprecordial l'oppression si souvent observés dans les cas cardio-vasculaires décompensée. Diagnosiseasy orimpossible,. Le typicalcase. M

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. Medical diagnosis for the student and practitioner. mptoms whatever or only percussion dulnessand compression. Difficulties Seldom Insurmountable.—Despite this fact, in actual practicethe author has not found the diagnosis of even closed pulmonary abscess sodifficult a matter as one might assume. * It has seemed to the author that otherwise silent blocks in the pulmonary area mayaccount best for many of the extreme abrupt, but transitory periods of urgent dyspnea andprecordial oppression so often observed in decompensated cardio-vascular cases. Diagnosiseasy, orimpossible. The typicalcase. Multiplelesions. Sudden pain. Dyspnea andhemoptysis. Silent infarcts. Often obscure. Perforation. Foulsputum. Silent cases. 420 MEDICAL DIAGNOSIS The septic temperature is rarely absent and if localized dulness (often showinga central maximum and shading into a circumferential hyperresonance) can bedetermined, the free use of a clean aspirating needle introduced if possible at thecenter of maximum dulness point usually makes the diagnosis positive.. Fig. 155.—Closed abscess in left lung. The roentgen-ray is often of the utmost value in these cases. In localized and walled-off (encysted) empyemas the symptoms may beprecisely the same as closed pulmonary abscess, though the area of percussiondulness or flatness is usually more sharply delimited than is that of abscess. Prognosis.—Embolic abscess is almost invariably fatal and the prognosisis bad in all, though their course may oftentimes be prolonged or recoveryachieved through surgical interference. PULMONARY GANGRENE.—The etiologic factors are chiefly those ofseptic pneumonia and pulmonary abscess. It is a rare complication of diabetes DISEASES OF THE LUNGS AND PLEURA 421 and pneumonia, exceptionally rare in tuberculosis, and varies greatly in extent, being either circumscribed or diffuse and usually but not always affecting thelower lobe. The involved areas are surrounded by consolidated, congested or edematousareas. An

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