practice. It has had warm advocates among modern physicians. Graves
places vivisection first and ipecacuanha next in his plan of treatment.
Trousseau strongly recommended it. Peter and the French practitioners
also strongly endorse its use in the severe forms. We have no doubt of
its efficacy. It is important to exclude if possible the existence of a
pulmonary aneurism or any such source of blooding, as there are no
special means by which this can be done. It is a good rule to use the
ipecacuanha in the cases of early or first-stage hæmoptyses. We would
give it as it is given in dysentery. Precede its administration half an
hour with thirty drops of laudanum, then give ten grains in water. If
vomiting comes on, repeat it in an hour, and again, if hemorrhage
continue, in two hours. The usual experience is that tolerance is
established after two or three doses. It has also an application in
small doses of one-quarter to one-half a grain in the milder forms,
with irritative cough and slight fever.
Graves calls attention especially to the excellent effect of opium in
all kinds of passive hemorrhage, hæmoptysis as well, but insists that
it should be given only after vivisection has been performed or when
the hæmoptysis has become rather passive, or in scorbutic and similar
cases. His direction on one occasion to a physician, in a case of
protracted bleeding of the gums, was, "Go home and give two grains of
opium immediately, and then half a grain every hour until the bleeding
stops." A combination applicable to the persistent bleeding recurring
day by day is the sulphate of magnesia made soluble in rose-water by
the free use of dilute sulphuric acid--one teaspoonful of the former,
fifteen drops of the acid, one-half to one ounce of the rose or plain
water. Many other remedies might be mentioned, and among them atropia.
After the bleeding has ceased it is necessary to be assured as to the
condition in which the lung has been left, and to counteract, if
needed, any persistence of irritation. Fever is the most valuable
evidence as to this point. If it exist, the use of quinia and ergot had
better be continued freely. A three-grain ergotin pill about three
times daily, and five grains of quinia morning and evening, can be
tolerated two or three weeks. Local irritation should be applied if
physical signs or pain warrants it.
{293}
PULMONARY APOPLEXY.
BY WILLIAM CARSON, M.D.
DEFINITION.--Escape of blood into the pulmonary parenchyma, with
laceration of its substance.
SYNONYMS.--Hemorrhage (pulmonaire) foyer (Jaccoud); Diffuse pulmonary
apoplexy or Diffuse pneumorrhagia (Fleich); Diffuse pulmonary apoplexy
(Loomis); Pneumo-hemorrhagie (Gendrin), etc.
HISTORY.--Latour[1] is quoted as being the first to use the words,
"apoplexie du poumon."[2] Yet Duguet[3] also quotes from Frank that
Dolocus had a long time before employed it. It is known that cases had
been described long before this, as by Corvisart in 1808, Allan Burnes
in 1809, among those of this century, and by Prosper Martiano, Bonet,
Morgagni, Haller, etc., among the more ancient authors.[4] Again,
Laennec gives the weight of his authority, and establishes Latour's use
of the name, until, as the synonyms show, modern usage has almost
abandoned it. Among the multitude of those who have treated of
pulmonary apoplexy, we will have filled the requirements of this brief
historical statement by mentioning Virchow and his pathological
investigations into embolism, and also Cohnheim,[5] and later
Litten's[6] studies on infarction, which have some indirect connection
with pulmonary apoplexy.
[Footnote 1: _Histoire philosophique et médicale des Hémorrhagies_,
1815, passage misquoted in _L'apoplexie pulmonaire_ by Duguet.]
[Footnote 2: _Op. cit._, pp. 220, 222, and 224.]
[Footnote 3: _Op. cit._, p. 11.]
[Footnote 4: Duguet, p. 10, etc.]
[Footnote 5: _Untersuchungen über die Embolischen processe_, 1872.]
[Footnote 6: _Zeitschrift für klinisch Medicin_, Erster Band, 131.]
ETIOLOGY.--Predisposing Causes.--The male sex affords predominance of
cases, because of greater liability to accidents, to the various forms
of ulcerative destruction of lung-tissue, and to aneurisms of the aorta
and pulmonary artery.
The adult age is most exposed for similar reasons. Ogston's
statistics[7] support in a general way, but not with strictly technical
force, their quotation by Herz.[8] Omitting the last 4 of his 20 cases
(2 of which were from poisoning, 1 from fracture of skull by a fall
down stairs, and 1 from drowning), the average for males (12) was 56.4,
and 55.3 for females (4).
[Footnote 7: _Brit. and For. Med.-Chir. Rev._, vol. xxxvii., 1866, p.
459.]
[Footnote 8: _Ziemssen's Handbook_, vol. v. p. 298. Ogston says (p.
465) it did not appear, however, that any distinct rent of their
substance had taken place--to any extent, at least. "When we consider
that the area of the extravasation was sufficient to involve often one
or two entire lobes, and that death was in most of them very sudden,
the cases may be adopted as showing the action of causes similar in
kind, if not in degree, to those operative in undoubted pulmonary
apoplexy."]
As more efficient predisposing causes than either age or sex, may be
mentioned aneurisms of the aorta and pulmonary artery, amyloid
degeneration of bronchial and pulmonary vessels, the influence of
Bright's disease in producing disease of blood-vessels, and
atheromatous diseases of the pulmonary artery.
Exciting Causes.--Penetrating and contused wounds of the chest by their
{294} direct mechanical effect, and diseases and injuries of the brain
through the medium of the nervous system, may produce pulmonary
apoplexy, the result in the latter case being usually an infiltration
or small infarction.
SYMPTOMATOLOGY.--Pulmonary apoplexy is the least common of the two
forms of distinctive pulmonary hemorrhage, the other being pulmonary
infarction, already treated of under HÆMOPTYSIS. A proportion of cases
is associated with mitral disease in its most advanced stages. At that
time we may expect pneumorrhagia, but whether from infarction or
apoplectic laceration even the event can only occasionally determine.
In the latter, if hemorrhage makes its appearance it will be copious
and generally overwhelming; at other times the hemorrhage may not
appear, and the patient dies suddenly with possibly other indications
of the internal flow. The physical signs cannot be relied on, for often
the pulmonary tissue is already changed by the long-continued
obstruction of circulation. Rupture of aneurism, particularly of aorta,
in the great majority of cases takes place into a bronchus, and not
into the parenchyma. In case of wounds of the contused variety a
laceration of parenchyma occurs at times sufficient to produce marked
hæmoptysis. If the blood be not ejected, there are no certain
indications of what has happened. If the case be seen immediately after
the accident, such physical signs as moist bubbling râles on the margin
of an area of feeble or suppressed vesicular murmur, possibly attended
with a dull, high-pitched percussion note over that area, would afford
a strong presumption in favor of ruptured lung and consequent
hemorrhage.
The same signs later might be due to a limited traumatic pneumonia. If
the internal hemorrhage, whether traumatic or spontaneous, has made its
way through the pleura, then, if the patient live long enough for
examination, besides such symptoms as great oppression and exhaustion,
the physical signs peculiar to pleural effusion may appear to a limited
degree. This opportunity seldom occurs, as such a rupture produces
almost invariably a fulminant and rapidly fatal result.
COURSE, DURATION, AND TERMINATION.--The course of the lighter cases is
much like that of pulmonary infarction, and that of the severe forms
too brief for observation. As to termination, it is quite possible
there are cases of laceration so limited as to allow complete recovery,
but clinical experience shows that pulmonary apoplexy is usually fatal.
PATHOLOGY AND MORBID ANATOMY.--With branches of the pulmonary vessels
weakened by long-continued heart disease, or with such vessels as are
found with chronic nephritis, a sudden increase of tension in them from
unusual effort or excitement will precipitate a fatal rupture.
Sometimes the progress of the degeneration is so insidious and complete
that a rupture may occur without obvious exciting cause. This is also
the natural history of aortic aneurism. An examination soon after the
laceration will show a mass of blood, usually coagulated, sometimes
partly fluid, lying in an irregular cavity with walls of the lacerated
lung-tissue. After a longer time the lung-tissue beyond the walls of
the hemorrhagic focus becomes oedematous to a certain extent. A
contraction of the cavity, with change of contents, may proceed to the
extent that an encapsuled mass of very small size will remain as the
final result (Rokitansky).
DIAGNOSIS from bronchial hemorrhage by the probable existence of
phthisical conditions and history. The quantity of blood ejected may be
profuse in either case, and therefore be no criterion. From pulmonary
infarction, as the other form of pulmonary hemorrhage, by the larger
amount of hæmoptysis. If there be no hæmoptysis, a presumption would
exist in favor of apoplexy in case of extreme dyspnoea or a fatal
result. The associated diseases or causes being similar, no inference
from the medical history would be reliable except in case of injuries.
{295} PROGNOSIS.--As we meet with it in recognizable form, the result
is almost invariably fatal. A qualification is allowed because of the
experience of such a pathologist as Rokitansky, who describes a process
of cure in a few cases. The prognosis in such would be determined
partly by the severity of the antecedent or accompanying disease, as in
heart lesions, and partly by the increased respiratory distress, pain,
exhaustion, and hemorrhage.
TREATMENT.--As has been before intimated, a case of pulmonary apoplexy
distinctive enough to be diagnosed is usually one that is beyond the
reach of treatment. Remedies that may relieve dyspnoea, exhaustion, and
hemorrhage are those to be relied on. External irritants, as
turpentine-stupe stimulants, ergot, turpentine internally, and such
other remedies as are of known effect in the treatment of the
associated heart troubles and of the incidental pulmonary infarctions.
{296}
ABSCESS OF THE LUNG.
BY WILLIAM CARSON, M.D.
DEFINITION.--A circumscribed suppuration of the lung, resulting in a
cavity.
SYNONYMS.--Abcés du poumon; Lungenabscess.
HISTORY.--The ancients described abscess of the lung, and placed it
among the terminations of the inflammation of that organ. They believed
that if the inflammation did not resolve itself by the fourteenth or
twenty-first day its termination was to be by suppuration. Hippocrates,
Van Swieten, and others are mentioned among those who maintained these
views and consequent frequency of such cases which prevailed until
physical methods and pathological investigation proved their
incorrectness. J. P. Frank, Bayle, and Cayol[1] are given credit for a
partial reversal of this opinion. Avenbrugger,[2] a pupil of Van
Swieten, in describing vomicæ, divides them into two kinds--the
ichorous and the purulent. By the purulent vomica he means an encysted
abscess of the chest resulting from the conversion of an inflamed spot
into a white, thick, glutinous, fatty matter. When these communicate
with the bronchi and discharge any of their contents by expectoration,
they are called open; otherwise, close or shut. He gives symptoms and
signs belonging to the respective varieties. Corvisart, in his comments
on these propositions, says: "In fact, the purulent vomica is always
the result of an inflammation, more or less acute, of the lung." He
makes distinctions between the various kinds of purulent vomica and the
ichorous vomica. Laennec, as in many other subjects of which he
treated, has the credit of placing this one on its modern basis, at
least so far as the frequent termination of pneumonia in abscess is
concerned. Among English writers Stokes deserves especial mention.
Abscess was the fifth and the last of the stages of pneumonia,
according to his classification. He treated largely of the perforating
abscess. Traube, Trousseau, and Leyden are among those who have
contributed largely to the elucidation of the subject. The latter has
especially claimed for this subject a more prominent place in the
literature of practical medicine, and has strongly enforced his views.
[Footnote 1: _Nouv. Dict. de Méd. et de Chirurgie_, tome xxix. p. 394;
and Leyden, "Ueber Lungenabscess," _Sammlung klinische Vorträge_, von
Richard Volkmann, Nos. 114, 115.]
[Footnote 2: _On Percussion of the Chest_, a translation of
Avenbrugger's original treatise by John Forbes, with comment by
Corvisart, 1761-1808, pp. 38, 43, etc.]
ETIOLOGY.--Predisposing Causes.--Everything tending to debilitate the
constitution may become a factor in the production of abscess of the
lung. Senile constitutions, Bright's disease, chronic alcoholism,
diabetes mellitus, and insanity are some of the predisposing causes.
Exciting Causes.--These may be divided, as in the case of gangrene,
into the pulmonary, or those originating in the lung or pleura, and the
intra-pulmonary, or those originating outside of the lung or pleura.
Among the former are included pneumonia and empyema, perforating and
discharging into the {297} lung, or one variety of Stokes's perforating
abscess, pulmonary apoplexy, and suppurating bronchial glands, opening
up a passage through the lung and bronchial tube. Either croupous or
catarrhal pneumonia may be associated with or terminate in pneumonia.
Among the latter, or extra-pulmonary class are included cases of
embolism from the right heart, producing infarction, or from the
systemic veins. These emboli carry with them the productive capacity of
suppuration. Abscess external to thoracic walls, as in deep-seated
mastitis, will at times perforate the walls and enter the lung.
Abscesses of the liver not infrequently perforate the diaphragm, and
are discharged through the lung.
Foreign bodies in the bronchi may ulcerate through them and produce
suppuration of the lung, which may finally open a way externally
through the chest-walls.
SYMPTOMATOLOGY.--The symptoms of abscess of the lung, as may be
inferred from the enumeration of causes, are divisible into two
categories--one including those symptoms with which the abscess may be
associated, but which do not necessarily prognosticate it; and the
other including the symptoms which indicate the abscess as a fact
accomplished. In the simplest and most frequent clinical form, that
following pneumonia, the early symptoms would be those of a severe and
irregular form, as shown by very troublesome and uncontrollable cough
or unusual pain or respiratory embarrassment, high fever, but at that
time fairly typical pneumonic temperature, great prostration, etc.
These may all diminish in due time, and mostly do without suppuration
following. A return of pain, dyspnoea, fever, and general distress
should awaken suspicion, yet they may be the result of an extension of
pneumonia to other portions of the lungs. Rigors and sweats and
increased depression would point to a suppurative process and under
such circumstances to the lung as the locality. We cannot, then,
positively predict an abscess. It is suspected when a more or less
copious eruption of purulent discharge occurs suddenly, and sometimes
the discharge is so abundant and pus-like that any other alternative
than abscess is very remote; at other times the discharge is small in
quantity. The proof of physical cavernous signs is the final step. This
is often difficult. A slightly greater increase of lung-density,
probably at the middle or upper part, with imperfect bronchial
breathing, the appearance of a few moist râles or crepitus, the gradual
increase of these and merging into coarser crepitus, and revelation of
more or less of the cavity signs, is the physical history of many cases
of abscess of the lung. Others have a much more pronounced course, such
as the cases of so-called gangrenous abscess--a sort of connecting link
between gangrene and abscess of the lung. The breaking down of tissue
is ostensibly very sudden, and the cavernous signs are very soon
unmistakable. Other clinical forms are the pyæmia, to be distinguished
by the antecedent history, which will reveal a source for infectious
emboli. The abscesses are usually multiple and small, so that their
precise locality cannot be made out. The proof of infectious
transportation is sudden pneumonic symptoms, as pain, tinged and
finally purulent expectoration. Rupture into pleura may occur and
produce empyema. Rupture of hepatic abscess and discharge through the
lungs is also a clinical form shown by this antecedent event, pointing
to hepatic inflammation. The egress of the pus is sometimes through a
narrow track, and not by a reservoir within the pulmonary tissue; at
other times the lung is really excavated. The discharge of pus is
usually copious and paroxysmal. Leyden recognizes as his third class a
form of chronic abscess, or one coming on during a case of chronic
pneumonia and bearing great resemblance to a variety of phthisis. Its
general symptoms are much the same as in the acute variety,
differentiated by the element of time.
COURSE.--It may be said, in a general way, that the etiology has much
to {298} do with its course. If the cause be pneumonia, the course will
be such as the detail of symptoms already given shows. In some unknown
way the natural course of the disease is interrupted, and what promises
to be an average case is followed by the characteristic features of
abscess. If pyæmia be the precedent condition, a peculiar form of
pneumonia, embolic in origin, appears, and abscesses again follow.
Greater septicity and rapidity of destruction are probable sequences.
The perforating abscesses are subject to modifying influences of
mechanical effect, such as gravitation and the resistance of tissues,
and have their peculiar course, which is often marked by great
chronicity.
TERMINATION.--In the course of seventeen years the reports of the
Cincinnati Hospital show that there have been 6 cases of abscess of the
lung treated there. Of these 4 died and 2 were discharged as improved.
These figures show the infrequency of such cases, and also represent a
greater mortality than probably occurs in the non-hospital class. We
know of no large statistics which show what is the percentage of
recoveries. Our own experience in private practice gives a majority of
recoveries. They were cases following typhoid fever, croupous and
catarrhal pneumonia, and hepatic abscess. A termination in a chronic
cavity now and then happens: perforation of the pleural cavity, with
subsequent pyo-pneumothorax, discharge externally through an
intercostal space, or even extension into the abdominal cavity, are
among the actual events of such abscesses.
DURATION.--The duration of an ordinary case is subject to wide
variations between one and six months. A few cases are recorded of
several years' duration. Previous constitutional condition has much to
do with this element. The degree of infectiousness in the pyæmic class
is important as to time. The abscesses become a subordinate condition
in the fate of the case. In this connection we may also refer to
Leyden's third variety, a so-called chronic abscess.
PATHOLOGY.--A close parallelism, etiologically and otherwise, is
observable up to certain points between gangrene and abscess of the
lung. Both are products of, or associated with, pneumonia. That which
finally determines whether the result shall be gangrene or abscess is
unknown to us. In the article on GANGRENE OF THE LUNG some
investigations are referred to which point to a probable solution in
the existence of specific forms having special pathogenetic force. The
tendency of experimental and clinical investigations is to connect the
suppurative process closely with the product of specific germs. Ogston
in 65 cases of acute abscess found micrococci present in all of them.
Obstruction of blood-vessels in the centre of the pneumonic area or on
the margin of the abscess walls is an important anatomical element in
the production of abscess, and it is claimed that it is often due to
colonies of micrococci within their calibre; so that it is probable
that there are both mechanical and biological or chemical influences at
work. If the view of the zymotic and infectious character of pneumonia
be tenable, the contingency of an abscess developing in its course
would seem not very remote. Yet the proportion of cases of abscess from
pneumonia is not more than 2 per cent. Leyden's high authority supports
the idea of the essential and specific differences in the chemical and
morphological peculiarities of gangrene and abscess of the lung, but
the subject is as yet on a hypothetical basis.
MORBID ANATOMY.--The fresh cavity, generally in the upper lobe, has
rough, ragged, and irregular walls, and may have bridles of the more
resistant structures, as bronchi and vessels, crossing it. Such a
cavity is quite likely to contain portions of undissolved parenchyma or
more or less malodorous pus. The older cavity becomes smoother walled,
and of more regular limits and cleaner contents. A gradation from
granular hepatization through congested to crepitant tissue is almost
uniform in the varieties of abscess, {299} whether simple or pyæmic. In
addition, some peculiarities are observable in the latter. These are
usually several, varying in size from a pea or less to a walnut, some
round and others wedge-shaped; others lying superficially and forming
slight elevations on the pleural surface. In proportion to the curative
progress the cavity will contract and disappear, occasionally leaving
behind a cicatricial mark. A lining pus-secreting membrane will
sometimes form, resulting in such a limitation of morbid action and
such a disappearance of reactionary symptoms as to make the disease
entirely local, but quite chronic.
DIAGNOSIS.--The more or less sudden and copious expectoration of pus,
without a specially offensive odor, in the course of a case having up
to that time the history of a pneumonia, would be considered as due to
the development of an abscess in the lung. Some degree of fetor in
breath and expectoration is observed, but it is far different from that
of gangrene. The detection of the débris of lung-structure in coarse
particles, and the microscopic discovery of elastic lung-tissue, are
important diagnostic points in contradistinction from the solution of
tissue that gangrene usually effects upon the parenchyma of the lung.
According to Leyden's[3] very complete investigations, the microscope
reveals fatty crystals, mostly in roundish fragments, of the size of
the epithelium of the lung and of a brilliant structure; pigment-débris
of a yellowish-brown or brownish-red color; hæmatoidin and bilirubin,
which Traube thought were due to hemorrhagic infarction, but which
Leyden has observed in all of his cases; and, lastly, micrococci, in
the well-known form of the round, granular micrococci colonies, which
differ from those in gangrenous fragments in that they show very little
movement and do not give the iodine reaction.
[Footnote 3: "Ueber Lungenabscess," _Volkmann's klin. Vorträge_, p.
994.]