through the bronchi, or of an encysted empyema discharging through the
third or fourth intercostal space in front; also, between abscess of
the superior portion of the liver and one in the base of the lung, or
between the latter and a pyo-pneumothorax. Very careful study of the
history in each case is of the first importance. Where this is not
attainable the difficulty is often much increased. In the case of the
empyema the discharge is more profuse at each time, the whole amount in
a given period is much greater, and the time of opening is much delayed
beyond that of the pneumonic abscess. Trousseau gives the case of a
child who brought up for more than six months 200 grammes of pus daily.
He makes children an exception to the rule as to the late opening of
the pleural abscesses. In the encysted empyema discharging either
internally or externally the difficulties are greater. A portion of the
lung-tissue may be so near behind the deposit of matter as to make the
physical signs confusing if the pus has opened externally. Some of
these and of the interlobular deposits it is almost impossible to
diagnose.
In hepatic abscess opening into the lung and bronchi the discharge is
copious, dirty brown, paroxysmal, and will generally, on careful
observation, show the bile color or its chemical reactions or some
microscopic débris of the liver. In Leyden's third class, or the
chronic abscess arising in the course of chronic pneumonia, the history
is so much like that of some forms of phthisis as scarcely to serve in
diagnosis. He thinks there are some macroscopic and microscopic
appearances which may serve for diagnosis. There are in the
expectoration dark and compact pieces of greenish-black color, not
unlike plugs of pus, and larger, black-pigmented fragments of
parenchyma, from a pin's head to a hempseed in size. Microscopically,
they consist of a close and strongly-pigmented parenchyma, which seldom
reveals alveolar structure. They show fatty degeneration and
cholesterin plates. This class of cases is mostly without fever. The
application of the bacilli-tuberculosis test would seem to offer some
assistance in diagnosis.
{300} PROGNOSIS.--A grave prognosis may be formulated if there be a
history of feeble constitution, and especially if it be further
impaired by habits of intemperance, if the patient belong to either
extreme of age, if there has been a recent debauch, or if there be wide
variation from the typical form of pneumonia. Variations will be shown
in such a complexus of symptoms as follows: fever of low grade, subject
to extremes in range; feeble and frequent pulse, but not so marked as
in gangrene of the lung; dyspnoea, objective and subjective; typhoid
depression; tongue dryish; delirium; copious and fetid or difficult
expectoration; physical signs of extensive lesion, such as a large
cavity with a large outlying pneumonic area. A favorable prognosis
would be conditioned on the appearance of a fewer number of these
symptoms or on their evolution in a milder form.
The capacity of the patient to endure a long-continued suppurative
discharge is principally determined by his natural vigor and his
ability to assimilate food, other elements, such as extent of injury to
the lung, being the same. A well-defined superficial cavity would be
more favorable, because within surgical relief.
In the pyæmic variety the force of the infectious element will
determine largely the result. Chills and sweats are important
prognostic elements in such a case.
In the secondary abscesses of either the empyematous or hepatic variety
prognosis is grave--more so in the latter than in the former, because
surgical procedure would be more promising in the former, and because
of the implication of an organ so liable to destructive inflammation as
the liver. A long and tedious course of suppuration is possible in
either. The dangers in an established abscess arise from liabilities to
septic infection and exhaustion consequent on want of reparative power
and persistent suppuration.
TREATMENT.--The treatment of abscess differs little if at all from that
of gangrene of the lung. The tendencies of the two diseases toward
exhaustion and infection are similar, but are less pronounced in the
former. The same remedies are necessary in both, such as stimulants,
tonics, antiseptics, anodynes, and expectorants internally, inhalations
and drainage externally; brandy and malt liquors as stimulants;
nourishing and concentrated food at frequent intervals; quinine as
tonic and antiseptic; carbolic acid and turpentine as most valuable
antiseptics (the latter being also an excellent stimulant); eucalyptus
in cases of profuse as well as fetid discharge; carbonate of ammonia,
senega, as expectorants; morphine and codeine or anodynes to control
cough; carbolic acid for inhalation; and in cases of definitely
localized cavities a free opening to be made with antiseptic
injections.
Successful cases of surgical interference are reported, and such
treatment is now recognized as proper when the system is giving way
under septic poison, evinced in chills, sweats, and great prostration,
where the purulent discharge is fitful and imperfect, and where the
physical signs are clear enough to show the locality of the abscess.
{301}
GANGRENE OF THE LUNG.
BY WILLIAM CARSON, M.D.
DEFINITION.--Putrid necrosis of the lung-tissue.
SYNONYMS.--Lungenbrand, Gangrene du poumon, Gangræna pulmonum.
HISTORY.--By common consent, Laennec has the credit of first
identifying, naming, and classifying gangrene of the lung as a distinct
disease; yet Lieutaud[1] in 1707 describes imperfectly a case of
gangrene of the lung in a child: "the right lung, within and without,
appeared entirely putrid." Bayle[2] is considered, in his section on
his fourth variety of phthisis (phthisis ulcereuse), to have described
a rather chronic form of gangrene of the lung. Morgagni, Boerhaave,
Stoll, J. Frank, and Cullen considered gangrene as one of the
terminations of peripneumonia.[3] Laennec's development of the subject
has only in a few directions been enlarged. His classification is
universally adopted. His description is adopted generally as the most
complete. There have been, however, controversies on different points,
such as the relation of pneumonia and of the obstruction of the vessels
to gangrene of the lung.
[Footnote 1: _Historia Anatomica Medica_, 1787, Obs. 329, cited by
Louisa Atkins, 1872.]
[Footnote 2: Bayle, G. L., _Recherches sur la Phthisis pulmonaire_,
1809-10, p. 30.]
[Footnote 3: I. Straus, _Nouv. Dict. de Méd. et de Chir._, p. 403,
etc.]
In the pathology and etiology of gangrene Virchow's investigations on
embolism and thrombosis opened up important relations; in diagnosis,
Traube and Leyden and Jaffee; in medical treatment, also Traube; and in
surgical treatment, Haley and Lawson (1879),[4] S. C. Smith (1880), E.
Bull (1881), Fengar and Hollister (1881), Mosler and Voght (1882). The
antecedent development of pulmonary surgery, through important work
done by Mosler, Pepper, and others, had prepared the way for special
applications of it to gangrene and abscess of the lung. Spencer Wells
claims to have suggested similar proceedings nearly forty years ago.
[Footnote 4: _Lungen Chirurgie_, Mosler, xx. p. 67.]
ETIOLOGY.--Predisposing Causes.--Constitutional weakness is a common
predisposing influence: it may be a primary condition, but is more
often secondary or dependent on some recently-acting debilitating
cause, as typhoid fever, chronic lung disease, diabetes, etc. Chronic
alcoholism is a cause which, besides its effect on the system at large,
may add a special one on the lungs in producing hyperæmia or drunkard's
pneumonia.
Of 46 cases we have collected mostly from the Vienna Hospital report,
the youngest was nineteen years old and the oldest was forty-seven
years. Lebert[5] has collected altogether 60 cases, 32 of his own and
28 of others: 19 occurred between twenty and thirty years, and 1
between thirty and forty. Huntington[6] gives 32 cases from the
Massachusetts General Hospital Record between 1857 and 1875: 9 were
between twenty and thirty years, and 12 between thirty and forty; the
youngest was ten years old and the oldest sixty-four. It is noticeable
that these figures coincide largely with those {302} showing the
incidence of phthisis. Louisa Atkins[7] gives, as the youngest ages
among all the varieties, one of three months and another of two months.
[Footnote 5: _Klinik der Brustkrankheiten_, vol. i. p. 827.]
[Footnote 6: _Boston Med. and Surg. Journal_, vol. xcv. p. 486.]
[Footnote 7: _Gangræna Pulmonum bei Kindern_, 1872.]
Of the 46 Vienna Hospital cases, 43 were male and 3 female.
Huntington's cases were males 24, females 8. Of Lebert's own 32 cases,
22 were males; of the 32 others summarized by him, in 4 sex was not
mentioned, and of the remainder 17 were males and 11 females. These
figures show the large predominance of males in the liability to
attack.
Exciting Causes.--They may be classified as pulmonary and
extra-pulmonary. The influence of the alcoholic habit has been referred
to above among predisposing causes: debauches are a frequent
antecedent, especially in hospital cases, by means of resulting
pulmonary hyperæmia and drunkard's pneumonia. Its association with
croupous pneumonia may be assumed as settled after some warm disputes.
The pneumonia of Bright's disease and putrid bronchitis are
occasionally causative; bronchiectasies result in it not unfrequently.
Extension of diphtheritic inflammation from the tracheal and bronchial
mucous membrane is another form. The catarrhal pneumonia secondary to
measles may produce it in children.
Embolism is the most frequent cause in the class of extra-pulmonary
causes. It may be mechanical or infecting. A bronchial artery may be
plugged so as to produce a gangrenous slough from mechanical cutting
off of nutrition. Embolism of the pulmonary artery branches is more
frequent, and by bringing about infarction and apoplexy may produce
gangrene. Of the infecting variety may be mentioned emboli from the
peripheral veins, as in surgical or uterine phlebitis, or from cerebral
sinuses secondarily involved from otitis. Other causes acting from
without on the lungs are foreign bodies, as particles of food passing
beyond the trachea into the lungs, as in case of the insane or
drunkards, and blows on the walls of the chest. These latter are
capable of producing not only the ordinary phenomena of
contusion-pneumonia[8] but gangrene, and without evidence of external
injury or fracture of the ribs.
[Footnote 8: M. Litten, p. 26, vol. v., _Zeitschrift für klinische
Medicin_.]
SYMPTOMATOLOGY.--Gangrene of the lung is the termination of a process
the beginning and progress of which are not declared or cannot be
followed through characteristic symptoms. Even its final occurrence may
remain unknown if a communication be not established with a bronchus,
which event is followed by the true symptoms, the expectoration and its
odor. Whatever symptoms occur previous to that event may occur
independent of it. Adopting Lebert's dictum,[9] gangrene of the lung is
not a pathological unit. As its pathogenesis varies, so does its
symptomatology. A feature common to its several varieties is marked
constitutional depression and variations from the typical form of the
disease in which it occurs. If pneumonia, croupous or catarrhal, be the
precedent or associated disease, it will be marked by soft and feeble
and frequent pulse, restlessness, dulness or distress of countenance,
more or less cyanosis, cool and relaxed skin, possibly delirium, dry
tongue, unusual dyspnoea and pleuritic pain, copious prune-juice
expectoration, irregular or non-typical temperatures. Along with these
functional variations occur some in physical signs, as a lesser amount
of dulness or of bronchial breathing, indicative of less structural
density and corresponding exudation. A case with such an evolution may
afford a presumption of an outcome in gangrene, but appearance of the
characteristic expectoration and fetor is necessary to exclude it from
irregular forms of pneumonia, which have no such termination. The same
general remark applies to the cases of gangrene in bronchiectasic
cavities. Perhaps some aggravation of the general condition may excite
apprehension, but the characteristic phenomena of expectoration, odor,
etc. must decide. If the cause be of embolic origin, we {303} may
expect some suddenness and perhaps shock in the beginning, and later
the evidences of a more limited inflammation of the lung-tissue, such
as circumscribed dulness and modified respiratory sound, which finally
end in those indicating destruction of lung-tissue.
[Footnote 9: _Op. cit._, p. 803.]
The macroscopic characters of the expectoration are those of a putrid
or fetid liquid of varying shades of color, ashy gray, dirty green, or
greenish-yellow, prune-juice, or more or less hemorrhagic. The odor,
which is at first so fetid and penetrating, often disappears after the
expectoration has been standing a while. It is separable, as first
described by Traube,[10] into three principal layers. The uppermost,
covered with a layer of foam, consists of, first, dirty green,
crumbling, confluent lumps; second, of larger, homogeneous, green
muco-purulent masses; and, third, of whitish-gray, transparent, mucous
masses. The second layer is formed of a colorless fluid. At the bottom
is a fine yellowish-white sediment. Microscopically are found fat-acid
crystals, many large fat-drops, and finely granular débris, masses of
free, black pigment. It is said elastic tissue is nowhere to be found,
but to this statement there are no doubt exceptions. Other bodies have
been found by Leyden and Jaffee,[11] which they named Leptothrix
pulmonalis. Kannenberg,[12] besides the above forms, found constantly
infusoria of the family of monads in the sputa of 11 out of 14 cases of
pulmonary gangrene. He considers them peculiar to the processes of
decomposition in the lungs.
[Footnote 10: _Gesammte Beiträge zur Pathologie und Physiologie_,
Zweiter Band, p. 452, etc.]
[Footnote 11: _Deutsches Archiv für klin. Med._, Band ii. pp. 488,
etc., "Ueber putride Sputa."]
[Footnote 12: _Virchow's Archiv_, Band lxxv.; _Zeitschrift für
klinische Med._, Band i. p. 228.]
PROGNOSIS in general is unfavorable. Individually, the gravity of the
case is determined by the evidence bearing on previous habits and
constitution; by the violence of the onset, as shown in prostration,
severe pain in the chest, dyspnoea, persistent and violent cough,
delirium, feebleness and softness of the pulse; by the variations from
the typical standards of croupous, or especially catarrhal, pneumonia,
such as greater amount of septic or infectious or typhoidal element,
non-typical and low temperatures in the early stages and also in the
stage of disintegration; by the amount of the latter as shown in the
physical signs of extensive lesion and in the amount of gangrenous
sputum; and by the irritant effect of this in producing bronchial
catarrh, and consequent catarrhal secretion, which may of itself become
an element of danger in a system already much prostrated. Favorable
prognosis is allowable when these conditions are being gradually
reversed.
PATHOLOGY.--The pathology of gangrene of the lung is scarcely more
settled than it was forty years ago, when Stokes[13] published his
eighteen propositions, embodying his experience. Obstruction of vessels
and inflammatory exudations are present as important pathological
conditions, but of themselves are not pathogenetic of gangrene. Other,
as yet unknown, elements of putrefactive agency are present. Leyden and
Jaffee's observations and those of Kannenberg have been mentioned[14]
as efforts to throw light upon the pathogenesis of gangrene of lung,
but how far the bodies described by them precede, coincide, or follow
the familiar clinical phenomena are undetermined questions.
Filehne,[15] in his experiments to determine the reason of the almost
universal absence of elastic fibres in the expectoration of patients
with gangrene of lung, comes to the conclusion that there is a ferment
which, acting under alkaline conditions, destroys the fibres. The
agents of this ferment he does not try to determine. Stokes anticipates
the tendency of modern experimental pathology by announcing as an
alternative proposition that "a process of putrefactive secretion
precedes in many cases the death of lung." The constitutional debility
which is so early a symptom prepares the way for such {304} an
invasion. In reference to the relation between the septic material and
thrombosis in gangrene, Kohler[16] affirms that the septic material
produces the fibrin-ferment, and thereby capillary thrombosis.
Recklinghausen thinks that a special material capable of exciting
coagulation has not yet been found in gangrenous substances, but that
there may be several factors, such as anæmia, changes in the
vessel-wall, imbibition with foreign substances, etc. Other
experiments[17] and views point toward the conclusion that there are
substances formed in various diseased conditions which have the power
of ferments and of producing coagulation of blood in the lesser
circulation.
[Footnote 13: _Dublin Quarterly Journal Med. Science_, Feb. 1, 1850.]
[Footnote 14: _Op. cit._]
[Footnote 15: "Sitzungsbericht der Phys. Med. Soc." in _Erlangen
Schmidt's Jahrbucher_, 1877, No. 7.]
[Footnote 16: _Recklinghausen's Handbuch der Pathologie_, p. 136.]
[Footnote 17: Wooldridge, Du Bois-Reymond, _Archiv Centralblatt für
med. Wissenschaften_, No. 41, vol. xi. 1874, p. 734.]
MORBID ANATOMY.--The circumscribed variety, as it usually appears, is a
cavity irregular in outline, with ragged walls, made so by the unequal
invasion of the lung-tissue by the gangrenous process. Sometimes the
cavity itself contains loose fragments of lung-tissue, or the contents
may be of a dirty, greenish, or brownish color, with some of the odor
of the expectorated matters. If the case has been a chronic one, the
walls are smoother, with a more or less formed lining membrane and the
contents of a less characteristic color or odor. The cavity is usually
in the right lung, and in the middle or lower portion. There is much
variety of statement on this point. The tissue immediately adjacent to
the gangrenous walls shows more or less of the products of catarrhal
pneumonia. The vessels terminating in the walls are obstructed by
coagula. If the gangrenous part come to the pleural surface, belonging
to what Fournet calls the superficial variety, it may produce adhesions
there, or it may result in perforation, with the result that we have
the products of pleuritic inflammation united with the contents of the
gangrenous cavity. In multiple foci, some will show the less advanced
stages of disease, such as incomplete softening and local inflammatory
lesions. In the diffused variety the lesions are sometimes described as
being the same except in extent. The demarcations, however, from
surrounding tissue are not as well marked; the tissue is soft, breaking
easily under pressure, sometimes oedematous, dark or dirty black on
surface or on section of lung; at other times the surface is mottled
with lighter-colored patches. A secondary result is the production of
bronchitis by the contact of the irritant expectoration from the
gangrenous cavity.
DIAGNOSIS.--Abscess of the lung is the disease most likely to be
confounded with gangrene of the lung. In the former you do not have the
same amount of profound constitutional depression; the symptoms have a
more frank expression, as it were, because of better precedent
conditions usually; the first eruption of matter from the abscess is
more copious and sudden than the usual manner of expectoration of
gangrenous sputum; the appearance of the contents of the abscess is
that more nearly of healthy pus, though the latter has at times a dark
dirty brown or hemorrhagic look; the separation into layers is not apt
to occur; the odor is usually not so fetid; microscopically, elastic
fibres are much more abundant in abscess than in gangrene of the lung.
The cavernous physical signs are not reliable in either disease. There
are cases in which it is impossible, and in which it is of no practical
importance, to make a diagnosis between gangrenous abscess and
pulmonary gangrene. Gangrene supervening in phthisical cavities is
distinguished by the history of a chronic pulmonary disease in which a
cavity has been previously marked. It is phthisis advanced to the
destruction of tissue plus the unknown gangrenous element which has
found a lodgment in a favorable place. Stagnation of cavity contents,
depression of system, etc. are favoring conditions. The same remarks
apply to bronchiectasic cavities and putrid bronchitis, physical signs
in the latter being additional points of difference.
{305} Our experience proves that the essential SYMPTOMATOLOGY of
gangrene of lung, except the débris of lung-structure in the sputum,
can occur where there was no gangrenous destruction, either
circumscribed or diffuse, no bronchiectasic cavities or bronchial
dilatations, and no phthisical cavity. In the case alluded to the
gangrenous odor and general characters of the sputum and the separation
into layers and the consolidation of tissue were present, but the
post-mortem afforded no explanation of the fetid expectoration. It was
a case of debauch and alcoholic excesses and exposure.
COURSE, DURATION, AND TERMINATION.--The course of this disease is
essentially an acute one. Whatever the early condition be, the
gangrenous element hastens its progress, as in cases beginning with the
phenomena of acute pleuro-pneumonia. A pre-existing phthisical cavity
will take on acute phases, also the septic element will be reinforced,
and, as indicated in the enumeration of symptoms, clinical
irregularities will be introduced. The early prostration is increased,
and the patient dies from exhaustion after a period varying from three
days to six weeks from the time the gangrene became manifest. Various
complications, such as pleuritis and perforation of pleura and
pneumothorax, hemorrhage, or extensive, diffused gangrene may cut short
the patient's life within the average period. Occasionally the
gangrenous cavity becomes chronic and the patient may live for months
in imperfect health. The termination of the circumscribed variety is
usually death. Diffuse gangrene is invariably fatal.