l\ *>v \ ^v> f^ Z- ^^m THE DISEASES OF THE LUNGS BY JAMES KINGSTON FOWLEE, M.A., M.D., F.R.C.P. PHYSICIAJf TO THE MIDDLESEX HOSPCTAL AND TO THE HOSPITAL FOR CONSUMPTION AND DISEASES OE THE CHEST, BROMPTON LATE EXAMINER IN MEDICINE AT THE UNIVERSITY OP CAMBRIDGE AND ON THE CONJOINT EXAMINING BOARD IN ENGLAND AND EICKMAN JOHN GODLEE, M.S., F.E.C.S. FELLOW AND PROFESSOR OF CLINICAL SURGERY, UNIVERSITY COLLEGE, LONDON SURGEON TO UNH'ERSITY COLLEGE HOSPITAL AND TO THE HOSPITAL FOR CONSUJIPTION AND DISEASES OF THE CHEST, BROMPTON SURGEON IX ORDINARY TO HER MAJESTY'S HOUSEHOLD WITH ONE HUNDRED AND SIXTY ILLUSTRATIONS LONGMANS, GKEEN, AND CO 39 PATERNOSTER ROW, LONDON NEW YORK AND BOMBAY 1898 All rights reserved Digitized by tine Internet Archive in 2010 with funding from Open Knowledge Commons http://www.archive.org/details/diseasesoflungsOOfowl PEBFAGB In this work an endeavour has been made, by the associa- tion in authorship of a physician and a surgeon, to present a continuous picture of the medical and surgical aspects of pulmonary disease. The book does not aspu-e to the position of a treatise on the diseases of the lungs, the object kept in view throughout having been to produce a work likely to prove useful to those engaged in the practice of medicine. The authors have read and discussed each other's work, but it has been thought advisable in order to obviate any doubt which might arise as to the identity of the writer who expresses an opinion or recommends any particular method of treatment, that each chapter should be initialled by the author who is responsible for it. An anatomical chapter has been introduced, which, while not intended to include all that can be said about the anatomy of the lungs and the surrounding parts, will, it is believed, be found to contain, in an accessible form, a number of useful facts such as the reader would only be able to discover with much labour in the textbooks of anatomy. In the revision of this chapter they have had the invaluable help of Professor G. D. Thane, of University College. It is hoped that due acknowledgment has been made in the text of the indebtedness of the authors to the works of previous writers, and particularly, as regards the medical aspect of the subject, to the masterly treatise of Dr. Wilson Fox on ' Diseases of the Lungs and Pleura.' vi PREFACE The valuable material contained in the clinical and patho- logical records of the Hospital for Consumption and Diseases of the Chest, Brompton, has supplied the authors with many illustrative cases, and they desire to thank their colleagues there for permission to make use of the notes. The thanks of the medical author are especially due to his friends Dr. Percy Kidd and Dr. A. F. Voelcker, for the loan of microscopical specimens and for other assistance, and of both authors to Dr. J. J. Perkins, for his kindness in under- taking to read the proofs and prepare the Index. J. K. FOWLER. E. J. GODLEE. March 1898. CONTENTS ■CHAPTKR PARK I. Anatomical 1 II. Physical Diagnosis 50 III. Diseases of the Trachea 71 IV. Acute Bronchitis 87 V. Chronic Bronchitis ........ 103 VI. Secondary Bronchitis 115 VII. Plastic Bronchitis . . . . . . • .119 VIII. Bronchiectasis 123 IX. Bronchiectasis in Children 143 X. Bronchial Stenosis and Obstruction 150 XI. Diseases of the Bronchial Gl.ands 153 XII. Emphysema of the Lungs . . .• . • • • 158 XIII. Interlobular or Interstitial Emphysema .... 181 XIV. Asthma 183 XV. Pneumonia • 195 XVI. Pneumonia (continued) 215 XVII. Pneumonia (continued) 22G XVIII. Pneumonia terminating in Fibrosis (Sub-acute Indurative Pneumonia) 236 XIX. Abscess op the Lung . . - 241 XX. Gangrene of the Lungs 244 XXI. Broncho-pneumonia (Catarrhal Pneumonia, Lobular Pneu- monia) 252 viii CONTENTS CHAPTER rA(lE XXII. Pulmonary Fibrosis (Chronic Pnkumonia, Cirrhosis of the Lunct, Interstitial Pneumonia) 260 XXIII. Diseases due to the Inhalation of Dust (Pneumoconiosis, Anthracosis, Suberosis) 2(59 XXIV. Congestion, O-^dema and Hypostatic Pneumonia . . . 276 XXV. Brown Induration of the Lung (Chronic Congestion) . 283 XXVI. Collapse of the Lungs 285 XXVII. Pulmonary Tuberculosis 205 XXVIII. Pulmonary Tuberculosis [continued). The Varieties of Pulmonary Tuberculosis ....... 318 XXIX. Pulmonary Tuberculosis [contimied). Pyrexia in Pul- monary Tuberculosis ....... 323 XXX. Pulmonary Tuberculosis [continued). Miliary Tubercu- losis OF the Lungs 331 XXXI. Pulmonary Tuberculosis [continued). Caseous Tubercu- losis OF THE Lungs ........ 336 XXXII. Pulmonary Tuberculosis [continued). Fibroid Tubercu- losis OF THE Lungs 342 XXXIII. Pulmonary Tuberculosis [contimied). Chronic or Fibro- CAREous Tuberculosis of the Lungs .... 346 XXXIV. Chronic Pulmonary Tuberculosis [contimied). Symptoma- tology, Physical Signs, Diagnosis, Prognosis . . . 364 XXXV. CirRoNic Pulmonary Tuberculosis [continued). Tre.\tment 38.5 XXXVI. Surgical Treatment of Pulmonary Cavities . . . . 416 XXXVII. Pulmonary Syphilis 429 XXXVIII. Actinomycosis .......... 453 XXXIX. Pi'lmonary Mycosis (Pneumomycosis) 459 XL. Hydatid Disease of the Lungs 472 XLI. Hydatid Disease of the Pleura 480 XLII. Tumours of the Lungs 485 XLIII. Injuries of the Lungs ........ 493 XJjIV. Diseases of the Pulmonary Vessels, Embolism of the Pulmonary Artery ... .... 500 XLV. Thrombosis of the Pulmonary Artery .... 508 CONTENTS ^ IX CHAPTER '■^"'' XLVI. Ankdrysm of the Pulmonary Artery 514 XLVII. Haemoptysis (H.kmorrhage from the Lungs) . . • 519 XLVIII. Pulmonary Complications of some Acute Specific Diseases 529 XLIX. Injuries of the Pleura 536 L. AcxTE Inflammation of the Pleura (Acute Pleurisy) . . 543 LI. Chronic Pleurisy ....••••• "'" LII. Tubercular Pleurisy 580 Appendix to Chapter LII. A Brief Account of the Various Forms of Pleurisy from a Bacteriological Point of View 590 LIII. Surgical Treatment of Diseases of the Pleura . . . 593 LIV. Surgical Treatment of Diseases of the Pleura {continued) 610 LV. Peripleuritis, Caries and Necrosis of Eibs, Mediastinitis 621 626 645 648 650 LVI. Pneubiothorax ....•••• LVII. Hydrothorax LVIII. H.EHOTHORAX . LIX. Chy-lothorax (Chylous Pleurisy) LX. Tumours of the Pleura 656 LXI. Diseases of the Diaphragm 665 LXII. Pain in Diseases of the Lungs and Pleura . . • 672 LXIII. Tumours of the Mediastinum 675 LXIV. Dermoid Cysts 695 LXV. Changes in Joints and Bones associated with Intrathoracic Diseases (Pulmonary Osteo-arthropathy) . . . ■ 700 LXVI. Clubbing of the Fingers 706 Index . . 709 LIST OF ILLUSTKATIONS PLATES TO FACE PAGE I. (Fig. 1) Actinomycosis of the Liver, bursting through the Eibs, and (Fig. 2) of the Lung and Pleura (coloured) [vide also Figs. 114 and 119) 456 II. Part of the Liver shown in Plate I. Fig. 1 {vide also Fig. 119) . . 456 III. Cells found in clear Inflammatory Pleuritic Effusions . . . . 552 IV. Photograph of hand showing Clubbing of the Fingers from a case of Bronchiectasis 706 V. Skiagram of the same hand, showing absence of enlargement of the Bones 707 ILLUSTBATIONS IN THE TEXT FIG. PAGE 1. Frontal Section through the Trunk 2 2. Sagittal Section through the Trunk (Right) 3 3. Sagittal Section through the Trunk (Left) 3 4. Sagittal Section through the Trunk (Median) 4 5. Diagram of the Fifth Thoracic Vertebra and Costal Arch . . 5 6. Diagram of the First and Seventh Ribs 5 7. Interchondral Articulations ........ 7 8. Diaphragm of Medium Height in the Relaxed and in the Contracted Position 9 9, 10. Highly Arched Diaphragm from the Front and the Side in the Relaxed and in the Contracted Conditions ..... 10 11. The Diaphragm seen from Above . . . . . . . 11 12. The Diaphragm seen from Behind 11 13. Normal Male Chest 12 14. Normal Female Chest 13 15. Infant Chest 14 16. Emphysematous Chest 15 LIST OF ILLUSTRATIONS FIG. PAGE 17. Phthinoid Chest 15 18. Phthinoid Chest 15 19. Section through Third Dorsal Vertebra 19 20. Section through Fourth Dorsal Vertebra 20 21. Section through Sixth Dorsal Vertebra 20 22. Section through Eighth Dorsal Vertebra 21 23. Section through Ninth Dorsal Vertebra 22 24. Back View of Chest of an old man with Spine and Eibs removed . 24 25. Back View of the Sternum, showing the Relations of the Pleurae to the Front of the Chest 25 26. Appearances seen in the case from which the Sternum shown in Fig. 25 was removed 26 27. Back View of the Sternum, showing the less usual arrangement of the Anterior Border of the Left Pleura 27 28. Front of Chest, showing relations of Lungs and Pleura . . .28 29. Back View of Chest, showing relations of Lungs and Pleura . . 29 30. View of Bight Side of Chest 30 31. View of Left Side of Chest 31 32. Inner Aspect of Right Lung (from His's Model) .... 32 33. Inner Aspect of Left Lung (from His's Model) 33 34. Outer Aspect of Right Lung (from His's Model) .... 34 35. Outer Aspect of Left Lung (from His's Model) 35 36. Outer Aspect of Chest 36 37. Root of the Lung and the Mediastinum 37 38. View of the Arrangement of the Structures and Organs on the Left Side 38 39. The same as Fig. 38, after Removal of the Lung showing the root of the Lung 39 40. Cast of the Interior of the Trachea and Bronchi (Aeby) ... 43 41. Cast of the Interior of the Trachea and Bronchi (Aeby) . . . 44 42. The Lower End of the Trachea, its Divisions into the two Bronchial Trunks and the Course and Chief Divisions of these within the Lungs from Before (after Aeb^') 45 43. Dissection of the Bronchi and Pulmonary Vessels from the Side . 47 44. Diphtheria of the Larynx, Trachea and Bronchi .... 73 45. Tubercular Ulceration of the Trachea 75 46. Syphilitic Stenosis of the Trachea and Main Bronchi ... 78 47. Syphilitic Stenosis of the Trachea 79 48. Stenosis of the Trachea from Enlargement of the Thyroid Gland . 80 49. A Growth containing Thyroid Gland Structure compressing the Trachea 81 50. Section of the same Growth, and of the contained Tumour and Trachea, showing the degree of Stenosis 81 51. Perforation of the Trachea by an Enlarged Gland, and Discharge of the Gland into the Trachea 84 52. Perforation of the Trachea by an Aneurysm of the Innominate Artery 85 53. Microscopical Appearances in Acute Bronchitis 88 54. Microscopical Appearances in Chronic Bronchitis .... 104 55. Casts of the Tubes from a case of Plastic Bronchitis . . . . 120 LIST OF ILLUSTRATIONS xiii PIG. PAGE 56. Cylindrical Bronchiectasis 124 57. Saccular Bronchiectasis 126 58. Section of a ' Honeycomb ' Lung 145 59. Section through a Minute Cavity in a case of Honeycomb Lung . 146 60. Emphysema of the Lung 164 61. Curschmann's Spirals 185 62. Pneumococci in the Sputum from a case of Pneumonia . . . 199 63. Pneumonia, Eed Hepatisation, Low Power 20.8 64. Pneumonia, Red Hepatisation, High Power 203 65. Pneumonia, Grey Hepatisation 204 66. Temperature Chart from a Case of Pneumonia, Crisis on Seventh Day 212 67. Temperature Chart from a Case of Pneumonia, Crisis on Seventh Day 213 68. Temperature Chart from a Case of Pneumonia, showing Fall by Lysis 216 69. Temperature Chart from a Case of Pneumonia, showing Fall by Lysis and subsequent Recurrence of Pyrexia . . . . . 217 70. Temperature Chart from a Case of Pneumonia of Prolonged Dura- tion 218 71. Temperature Chart from a Case of Pneumonia, Sudden Fall of Temperature following the Application of an Ice-bag. Subse- quent Recurrence of Fever 219 72. Temperature Chart from a Case of Pneumonia, Fatal on the Twelfth Day 220 73. Temperature Chart from a Case of Pneumonia, Fatal on the Seventh Day, showing moderate degree of Pyrexia . . . . . 221 74. Curve of Mortality from Pneumonia at Different Age Periods . . 229 75. Sub-acute Indurative Pneumonia 239 76. Microscopical Appearances in Broncho-pneumonia .... 254 77. Pulmonary Fibrosis 262 78. Acute Pleurisy with Thickening of the Connective Tissue of the Lung 263 79. Reticular Fibrosis of the Lung with Emphysema . . . . 267 80. Congestion of the Lung 278 81. GEdema of the Lung 279 82. Hypostatic Pneumonia 280 83. Tubercle Bacilli in Sputum (coloured) 297 84. Tubercle 300 85. Tubercle undergoing Caseation 303 86. Tubercle undergoing Fibrosis 304 87. Continuous Type of Pyrexia in Miliary Tuberculosis . . . . 325 88. Inverse Type of Pyrexia in Miliary Tuberculosis .... 326 89. Inverse Type of Pyrexia in Miliary Tuberculosis 326 90. Pyrexia in Caseous Tuberculosis 327 91. Chart from a Case of Caseous Tuberculosis 327 92. Pyrexia in Caseous Tuberculosis, with Failure of Vital Power . 328 93. Chart from a Case of Fibroid Tuberculosis 328 94. Chart from a Case of Chronic Tuberculosis, Quiescent . . . 329 5. Chart from a Case of Chronic Tuberculosis, Infiltration with commencing Softening 329 xiv LIST OF ILLUSTRATIONS KIG. PAGE 96. Diagram of a Vertical Median Section of the Lung, showing one of the Sites of Primary Infiltration in Tuberculosis, &c. . . . 351 97. Diagram of Lateral Aspect of the Lung, showing a Less Usual Site of Primary Disease of the Apex 351 98. Diagram showing the Eelations of the Lobes of the Lungs to the Chest Wall Posteriorly 352 99. Diagram illustrating the Extension of a Lesion of the Lower Lobe along the Interlobar Septum 353 100. Showing the Position of the Arm in which the Vertebral Border of the Scapula indicates (roughly) the Usual Line of Extension of Lesions along the Interlobar Septum 353 101. Showing the Usual Mode of Extension of Tubercular Disease towards the Base of the Lung 354 102. Typical Arrangement of Lesions in a Case of Apical Tuberculosis, with Non-tuberculous Disease of the Lower Lobe . . . 354 103. Lateral View of Lung, showing an Occasional Site of Lesion in a Lung not primarily affected ........ 355 104 & 105. Illustrating a ' Crossed Lesion ' 355 106. Site of Lesions in Secondary Tubercular Infection of the Lung . . 356 107'. Illustrating an Unusual Arrangement of Lesions in the Lower Lobe ............ 356 108. Elastic Tissue of the Lung, from the Sputum of a Case of Tuber- culosis 367 109. Pyrexia during the ' Reaction ' produced by the Injection of Tuber- culin 399 110. Chart showing the Effect upon the Temperature of the Administra- tion of Phenacetin and of the omission of the Drug . . . 405 111. Forceps for the Extraction of a Foreign Body from a Bronchus . 426 112. Bent Wire for the Extraction of a Foreign Body from a Bronchus . 427 113. Changes in the Lung Secondary to Syphilitic Stenosis of the Trachea and Main Bronchi 442 114. Front View of a Boy suffering from Actinomycosis of the Eight Lung and Pleura 454 115. Back View of the same Patient 455 116. Actinomycosis ; Clubs as usually found in Cattle . . . . 456 117. Actinomycosis ; Method of Spreading. Low Power . . . 456 118. Actinomycosis ; Threads as usually found in Man (Highly Mag- nified) 456 119. Front View of Patient suffering from Actinomycosis of the Liver, affecting secondarily the Right Lung and Pleura . . 457 120. Aspergillus Fumigatus 461 121. A Tubercular-looking Nodule in the Lung in a Case of Aspergillo- myco.sis 462 122. Mycelium in the Sputum in a Case of Aspergillo-mycosis . . . 463 123. Section of Lung from a Case of Protozoic Infection, secondary to Disease of the Skin (Coloured) 471 124. Hydatid Cyst in the Lung 478 125. Aneurysms of the Pulmonary Artery in Cavities in the Lung . . 516 126. Ruptured Aneurysm of the Pulmonary Artery in a Cavity in the Lung 516 LIST OF ILLUSTRATIONS xv [.■If J. rAGF. 127. Chart showing Initial Lowering of Temperature and subsequent Pyrexia accompanying an Attack of Hfpmoptysis . . . 522 128. Microscopical Appearances in Acute Pleurisy 552 120. Diagram illustrating the Exudation of Fluid within a Sac lined by Coagulated Fibrin 560 130. Diagram showing the Physical Signs in a Case of Long-standing Large Effusion in the Left Pleura (Front Aspect) . . . . 5G1 131. Diagram showing the Physical Signs in a Case of Long-standing Large Effusion in the Left Pleura (Posterior Aspect) . . . 5G2 132. Thickening of the Pleura secondary to Chronic Tuberculosis of the Lung . . . ... 579 133. Eib six weeks after a part was removed 597 134. Eegenerated Eib after a part had been removed 597 135. Eegenerated Eib after a part had been removed .... 598 136. Bony Eing formed by Bars on each Side of a Drainage Tube . . 598 137. Volkmann's Periosteum Elevator 599 138. Blunt Periosteum Elevator 599 139. Blunt Forceps for cutting Eibs 599 140. Operation lor Empyema. The Patient Lying on the Back . . 601 141. Operation for Empyema. The Patient Lying on the Side . . 602 142. Drainage Tube 603 143. Lateral Curvature following Empyema 608 144. Eesult of Estlander's Operation 612 145. Chart showing the Eapid Fall of Temperature on the Occurrence of Pneumothorax .......... 634 146. Chart from a Case in which Pneumothorax occurred without Marked Symptoms 635 147 & 148. Groups of Cells from a Case of Tumour of the Pleura . . 663 149. Mediastinal Lympho-sarcoma 681 150. Fleshy Processes covered with Thick Skin from which Hairs are Growing. From a Dermoid Cyst of the Lung .... 696 151. A Similar Fleshy Process 697 152. Hands of a Patient suffering from a Pulmonary Cavity showing Bony Enlargement • ■ 703 158. Skiagram of Hands and Forearm of a Patient, showing Bony Enlargement 704 154. Hands of a Patient in whom there was no evidence of Bony Enlargement • 705 THE DISEASES OF THE LUNGS CHAPTER I ANATOMICAL PAGE Introductory 1 Thoracic spine 2 The ribs 3 Anomalies of ribs ......... 7 Intercostal spaces .......... 8 The sternum . 8 Anomalies of the sternum ....... 9 The diaphragm 10 Shape of the chest altered by position ..... 13 Other circumstances modifying the shape of the chest . . 13 The intercostal vessels . . . ' . . . . .16 The intercostal nerves ........ 18 Lymphatics of the thoracic wall . . . . . . .18 The mediastinum . . . . . . . . .19 The pleura 21 The lungs 28 Movements of the lung 40 The trachea .......... 40 The bronchi and pulmonary arteries ...... 42 Pulmonary veins .......... 46 Bronchial arteries and veins ....... 48 Lymphatics of the lungs ........ 48 Lymphatics of the pleura ........ 49 Introductory. — The modern study of anatomy by means of frozen sections has emphasised the fact that a small part only of the chest is occupied by the lungs. The marked projection forward of the spine and the height to which the diaphragm reaches account for this in great part, and one result is that neither the anatomy nor the pathology of the lungs and pleura can be dealt with without discussing those of the surrounding parts, to say nothing of those of the structures occupying the mediastinum. This is well illus- trated by the appearances seen in a coronal section of the chest (fig-l). . ^ The bony framework of the chest is made up of the thoracic spine, the ribs, and the sternum. B 2 THE DISEASES OF 'J^HE LUNGS Thoracic spine. — The thoracic spine, composed of the twelve thoracic vertebrae, presents normally two curves : one with the convexity backwards is always present ; the other, a lateral one, usually with the convexity to the right but occasionally to the left, is often so slight as to be scarcely perceptible. The thoracic Fig. 1. — Frontal Section jhuovoh the Tkunk From a platiter cast: 1 to 10, ribs; l' L, V L, upper lobes of lungs; ^f X, middle lobe of riplit lung ; L L^ L L, lower lobes of lungs ; /J, diaiiliragm. The jtleura is marked by a red line. is the least flexible region of the movable part of the vertebral column, the antero-posterior movements being Hmited by the small amount of intervertebral substance and the imbrication of the spines and lamin.'o, the lateral movements by the approximation of the ribs ; a slight degree of rotation about a vertical axis is, how- ever, permitted. It is probably due to tlie slight ol)hquity of the articular processes that whenever exaggeration of the normal lateral curve of the spine occurs, as in scoliosis or after empyema, a certain amount of rotation or torsion is invariably present. As a ANATOMICAL result of this torsion the spines always point towards the concavity of the curve, while the bodies of the vertebrae are twisted outwards, and consequently the angles of the ribs become more prominent on the convex side of the curve, and the rib cartilages on the concave side. These distortions of the chest modify very much the relations of the thoracic viscera to the surface of the body. Fig. 2. — Sagittax, Section (right). (After Riidinger) 1 to 12, ribs ; CI, clavicle ; Sc, scapula ; D, diaphragm ; U L, upper lobe of luug ; M L, middle lobe of lung ; L L, lower lobe of lung. The pleura is marked by a red line. Fig. -Sagitt.u. Section (left). (After Eiiclinger) 1 to 10, ribs ; CI, clavicle ; Sc, scapula : D, diapliragm ; U L, upper lobe of lung ; L L, lower lobe of lung. The pleura is markeil by a red line. The manner in which the spine projects into the thoracic cavity, and forms as it were part of a septum dividing it into two parts, is dealt with in the next section. The ribs. — The ribs, the shape of which approximates above to that of segments of circles, but which become sickle-shaped in the middle of the series and much straighter below, are attached to the spine with varying degrees of obliquity ; but they all slope 4 THE DISEASES OF THE LUNGS downwards, outwards, and forwards. They thus, together with their cartilages, the sternum, and the spine, form a hollow cone, open both above and below, flattened from before backwards, and extend- ing further, both upwards and downwards, behind than in front. The enclosed space is very much encroached upon by the spine, so that there is a suggestion of a division into two laterally applied hollow cones, each of which is more or less circular, or rather oval, in horizontal section. The average distance between 7^ CM I2'-'D.V! Fig. 4. — Sagittal Section (median). (After Riidinger) 7tli (! J', seventli cervical vertebra; 12th D V, twelfth dorsal verti'bra ; J/.S', manulirium sterni ; (/, gladiolus; X A, xiphoid appendix ; (Es, (jcsupliagus ; Tr. trachea : L I I', left iiinoniiiiatc vein ; ^, heart ; /^ pericardium; />, diaplir!it.'m ; /'/«, iieritoneum : /,, liver: A. desoeiidintr aorta. There was some lateral dorsal curve of the spine to the riRht. the sternum and the spine is not much more than about two-thirds of that between the angles of the ribs and front of the chest (figs. 2, 8, 4). The ribs are attached by synovial joints to the bodies and the transverse processes of the vertebrsi", and in front they are directly continuous with their cartilages (except in the case of the first, where a synovial cavity is occasionally found), between the car- tilages of the true ribs and the sternum there are synovial joints, except in the case of the first and often of the sixth and seventh. ANATOMICAL 5 The joint of the second is commonly divided into two by a short inter- articular ligament. The movement of the ribs is principally one of rotation upwards and downwards, round an axis, which is directed obliquely outwards and backwards, as well as somewhat downwards, passing through the costo- central articulation and the neck of the rib and a little in front of the costo-transverse joint (fig. 5). A.S the ribs are directed obliquely downwards and forwards from the spine, the rotation upwards is necessarily accompanied by an in- crease of the sagittal (antero-posterior) diameter of the thorax (fig. 6), and as the axis of rotation is directed backwards and downwards Fig. 5. — Diagram of the Fifth Thoeacic Veetebea and Costal Aech Projected into a horizontal plane, to show the axis of movement of the rib, and the manner in which the sagittal and coronal diameters of the thorax are increased. The continuous lines indicate the position in expiration, the broken lines in inspiration. (Professor G-. D. Thane, from ' Quain's Anatomy.') the movement is also accompanied by an increase of the transverse diameter (fig. 5). The necks of the ribs are more oblique, and the axis of rotation is directed more backwards in the lower than in the upper part of the chest, and consequently the lateral expansion is greater below than above. The last two or three ribs move chiefly backwards in inspiration and forwards in expiration. Elevation of the first rib takes place to a considerable extent, but lateral expansion of this region is very limited. These movements could not, of course, take place were it not for the flexibility of the rib cartilages and the joints between them and the sternum ; and the slight movement which is possible between the manubrium and the gladiolus no doubt aids them. Those rib cartilages are longer and 6 THE DISEASES OF THE EUNGS therefore more flexible, which correspond to the ribs whose excur- sions are greatest (seventh and eighth). When they become ossified from old age,' the expansion of the chest is limited as com- pletely as when the rotation of the spinal end is prevented by caries of the spine or spondylitis deformans. The line of the costo-chondral junctions on each side is, on the whole, directed downwards and outwards ; that of the first rib is in an adult about 1^ inch from the sternum,- that of the second rib somewhat nearer the middle line ; the others lie behind an oblique line drawn downwards and outwards from the latter point to the tip of the tenth rib. Fig. C. — DiAGitAM of the Firsj' and Sev?:nth Kids lu connection with tlie spine and the steniuni, sliowing liow tlie latter is carried upwards and foi-wards in inspiration. The expiratory position is indicated by con- tinuous lines, tlie inspiratory by broken lines. (Professor G. D. Tliaiie, from ' Quain's Anatomy.') The narrowest parts of the ribs are about a hand's breadth from the sternum, and the broadest parts a little outside the angles. The periosteum covering the ribs is strong ; it is easily detachable from the outer surface, but is firmly fixed to the internal surface owing to the attachment of the intercostal muscles. ' This i^rocess consists in a deposit of bone; round tlie costal cartilages, not- a calcification or ossification of the whole of the cartilage. It is usually jDrescnt to a greater or less extent round the cartilage of the first rib in adult males, sometimes forming a complete sheath round the cartilage. In advanced life the other cartilages become usually affected in the same way ; but the degree to which it advances and the time at which it begins are liable to great varia- tion. It is much less marked in women than in men, and in some quite old people the cartilages sire remarkably free from bony deposit. - See 15. 8 with regard to the breadth of the sternum. ANAl'OiMICAL Anomalies of ribs. — Anomalies in the number and shape of the ribs are occasionally met with. A cervical rib sometimes forms a tumour in the supraclavicular region of the neck, but has no influence on the anatomy of the thorax. The twelfth rib varies in length from less than an inch to eight inches, and in many cases does not project beyond the edge of the erector spinae. This may lead to confusion in counting the ribs if this be begun from below. A similar mistake may arise in the rare event of the presence of a lumbar rib of considerable length. Bifurcation of the anterior extremity of a rib and the corresponding cartilage is occasionally met with ; or there may be an additional cartilage projecting from the side of the sternum. These anomalies are mostly unilateral, Fig. 7. — Inteechondkal Articulations From a dissection by Profesi-or G. D. Tliane. Tlie interclioudral articulations are seen in the sixtli, seventh and eiahth interspaces. The third rib prefcuts the common irregu- larity described on p. 6. and the additional cartilage is almost always in the third inter- space (fig. 7). Extremely prominent ribs or rib cartilages are not unfrequently met with, and, as far as I have seen, mostly in the same situation ; these may give rise to the suspicion of tumour, and therefore claim a brief notice in this work. I have notes of at least three cases, of young women, to whom considerable mental anxiety, and apparently a good deal of pain, were caused by this anatomical peculiarity. It is to be observed that the second cartilage is normally more prominent than the others, and prolongs horizontally outwards, 8 THE DISEASES OF THE LUNGS the ridge formed by the sternal angle (see p. 8). The eighth rib is often a true rib — that is, it articulates directly with the sternum. Intercostal spaces. — The intercostal spaces, filled by the inter- costal muscles and aponeuroses, and containing the intercostal vessels and nerves, vary in width at different parts of the chest, and at different periods of the respiratory act. Modifications of the shape of the chest also cause great alterations in the distance between the ribs. The second, third, tenth, and eleventh interspaces are, in a well- formed chest, the widest. The widest part of any individual space is near the anterior part of the rib (not between the cartilages). The anterior ends of the intercostal spaces tend to become pointed. This is only slightly marked in the first, third, and fourth inter- spaces, and not at all in the second. It is very obvious in the sixth, seventh, eighth, and ninth interspaces, some or all of which are completely interrupted by the interchondral articulations (fig. 7). The assertion that the intercostal spaces become wider during inspiration is not, as regards them all, strictly true ; though the fact that the ribs become more nearly horizontal than during expiration would, at first sight, seem to imply that this is the case. It is too complicated a subject for discussion in this work. Extension of the spine widens the intercostal spaces, flexion of it contracts them, lateral bending of the spine widens those on one side and contracts those upon the other. The intercostal spaces can be everywhere traced with the finger except where they are covered by the clavicle and the scapula and by the thick spinal muscles. It is important to recognise their normal condition in order to compare it with that of the undue prominence caused by intra-pleural effusions. The sternum.— The sternum varies much in size, shape, and direction. It is usually longer in men than in women, and the gladiolus is, as a rule, relatively shorter in women than in men. The length of the sternum is not by any means always proportionate to the size of the individiial ; it varies not only in length, but also in breadth and thickness. The general direction of the bone is commonly at an angle of twenty degrees to twenty-five degrees with the perpendicular, but the direction of the manubrium is not the same as that of the gladiolus. This gives I'ise to the sternal angle {angulus Ludovici) named after Louis of Paris. Much discussion has taken place as to the importance of this angle in the movements of the chest, and as to the causes of its exaggeration in some cases. The reader is referred to an exhaustive article l)y the late Wilhelm Braune in the ' Archiv fiir Anatomie und EntAvicklungsgeschichte,' 1H8H (p. H04). I^raune Itegins by stating that this angle has been used as the diagnostic sign of commencing phthisis, it being supposed that the contraction of the apices of the lungs causes a falling backwards of the manubrium. He says, however, that experience shows that exaggeration of the angle by no means always accompanies phthisis, but, on the other ANATOMICAL hand, is often met with when the lungs are normal, and very fre- quently in cases of emphysema. This angle is rendered more marked by exaggerated movements of inspiration, and if the manu- brium be separated from the gladiolus, forcible inflation of the lungs makes it more prominent than before. He does not deny that, in very marked contraction of the apices, the manubrium may fall backwards. By means of a simple mechanical contrivance it is easy to satisfy oneself of the actual size of this angle, and of the extent to which it is altered by the movements of respiration, it will be found to vary from about 170 degrees to 160 degrees, but it may be much more acute, and the difference in size caused by a deep inspiration, which may be as great as ten degrees or even more in healthy young women, is much less in adult men, and does not exist when the two parts of the bone are synostosed as in the rigid chests of the aged, or after that not very uncommon disease, strumous caries of the joint between the manubrium and the gladiolus. Anomalies of the sternum. — The sternum is liable to congenital defects, most of which are not of importance to the practical surgeon or physician. Passing over cases of ectopia cordis, mention mast be made of deficiency of one half or the whole of the bone, with consequent un- covering of some part of the heart and the probable forma- tion of a pulmonary hernia. Clefts in the sternum, which may involve complete non-union of the two halves, or may consist of triangular, oval, or elongated fissures, are occasionally met with. They are filled by strong membrane, and are not usually recognis- able during life ; but the existence of a cleft increases the danger of punctured wounds of the front of the chest. A small aperture (sternal foramen) in the lower part of the gladiolus is not uncommon. A deep hollow in the lower part of the sternal region is also occasionally met with congenitally, similar to that which is supposed to be produced by following such trades as that of a cobbler. Occasionally the manubrium is synostosed with the second segment of the bone, while the latter forms an articulation with the re- mainder of the gladiolus. The jugular or suprasternal notch varies very much in breadth and depth, owing to the direction of the surfaces on the manubrium Fig. 8. — Diaphragm of Medium Height IN THE Relaxed and in the Conteacted Position (Pansch) lo THE DISEASES OF THE LUNCIS for articulation with the clavicles and the distance between the two heads of the sterno-niastoid muscles. The xiphoid appendix varies much in shape (it is often bifid), in length, and in its direction. Sometimes when it is directed very much backwards it appears to give rise to pain, and in that case may require removal. Often the seventh, and sometimes even the eighth, cartilages meet in front of it, under which circumstances it is scarcely to be felt through the abdominal walls. Diaphragm. — The encroachment of the abdominal viscera on the space contained within the bony thorax is shown by such diagrams as figs. 8, 9 and 10. Fig. 8 is supposed to represent a diaphragm of medium height ; figs. 9 and 10 a highly arched Fifi.s. y AND 10. — Highly Akchkh Diapheagm kkom the Front ani> THE Side ix the Relaxed and in the Contracted Condition diaphragm such as may be met with in the young and powerful, and still more markedly in the newly born. Statements about the heiglit of the diaphragm are open to the criticism that they result from post-mortem observations, in which the state of extreme expiration only is met with, and that conse- quently they may not apply to the condition existing during life. We are probably justified in stating that the part corresponding to the heart remains almost stationary during respiration, and that the vault or dome on the right side reaches in the state of rest to the level of the lower part of the fourth interspace in front, which corresponds in the scapular line to the eighth rib, and in the axillary line to the sixth rib. The left dome does not reach so high by one finger's breadth. ANATOMICAL SSSW'^ Fig. 11.— The Diaphragm seen fhom Above, showing the peculiar SHAPE OF the Tendon and the bianner in which it adapts itself TO THE SHAPE OF THE SpINE A, aorta ; Oe oesophagus ; li A, right auricle : P, pericardium. R.A Fig. 12.— The Diaphragm seen from Behind 1, right side of teudon ; 2, left side of tendon ; 3, right crus ; 4, left crus ; 5, origin fr-om ribs ; A, aorta ; Oe, oesophagus ; /', peiicarUium ; R A, right auricle. THE DISEASES OF THE LUNGS Probably in cases of extreme arching it does not reach higher on the right side than the level of a line drawn through the third rib cartilages, while in cases of low arching the level will be that of the junction of the sixth rib cartilages with the sternum. The shape of the diaphragm in a state of expiration may be gathered from the accompanying figures (figs. 11 and 12), drawn from a preparation of the muscle in situ, on a cast made by pouring plaster of Paris into the abdomen after the removal of the viscera. The great narrowing of the central part by the projection forward of the vertebral column, the inequality in the arching on the two sides, the irregular shape of the tendon and its very faint resemblance to that of a trefoil leaf, and the predominantly vertical direction of the muscular part are well shown. It is impossible to define accurately the precise shape assumed by the diaphragm during extreme inspiration or when the pleura is Fig. 13. — Normal Male Chest A, a;t. 28, from Liischka's 'Brustorgane iles Jleusclieii,' 1857 ; B, itt. about 50, from a preparation by tlie autlior. distended. If the abdominal viscera be removed, and the lungs be inflated by blowing into a tube fitted into the trachea, the dia- phragm can be made to project downwards below the level of the stationary part corresponding to the heart, and the descent of the liver under somewhat similar circumstances during life shows that a corresponding descent of the diaphragm has occurred. The removal of the abdominal viscera, however, so completely alters the physical conditions that too much stress must not be laid upon the details of such observations. The origin of the diaphragm and the central part of it being comparatively speaking fixed, it follows that the result of a con- traction of its fibres will be a diminution in the height of the arch. ]>ut it must be remeni])ered that the lower part of the thorax is by no means rigid, and in young people it is very flexible. If it be impossible to draw air into the lungs, as in cases of obstruction of ANATOMICAL 13 the trachea, retraction of the lower part of the chest wall will naturally follow from the forcible contraction of the diaphragm. Hence arises the practice of observing the lower part of the chest in estimating the amount of obstruction to the upper air passages in cases of dyspnoea possibly requiring tracheotomy. Under some circumstances, as, for example, when the chest has become very rigid, or when the intercostal muscles are paralysed, the diaphragm becomes the chief, or, indeed, the only muscle of respiration — respiration being then more or less completely ab- dominal. Under all circumstances it is a very important muscle, and any interference with its movements, as by the accumulation of food or gas in the stomach or fluid in the peritoneum, soon shows itself by causing dyspnoea. The sternal portion of the diaphragm is not infrequently want- FiG. 14. — Female Chest A, normal healthy subject, fet. 18, from Lucse's ' Zur Anatomiedes weiblichen Torso ; ' B, deformed by tight lacing, from JVIerkeFs 'Handbuch der topographischeu Anatomie." ing, and in cases of diaphragmatic hernia much larger portions of the muscle may be absent. Shape of the chest altered by position.— The general shape of the chest is altered, like that of the abdomen, by changes of posture ; for example, in the recumbent posture, the spine is straightened out and the upper ribs are somewhat raised, rendering further inspiratory movement difficult ; and at the same time the abdominal viscera fall up against the diaphragm, tending to elevate it and opposing its descent. Hence arises the difficulty of breathing in the recumbent posture when dyspnoea is present. Other circumstances modifying shape of the chest. — Something must be said about what may be called normal varieties of the shape of the chest, and other changes due to disease. In the infant, and especially in the new-born child, the ribs are less inclined than in the adult, the thorax is short and conical owina' 14 THE DISEASES OF THE LUNGS to the straight spine, the small size of the lungs, and the large size of the liver (fig. 15). In old age the forward curve of the spine becomes increased, and the lungs are probably atrophied, the ribs become more oblique, and the chest is altogether smaller, its movements also are much restricted if the cartilages are ossified. The adult male chest is moi'e or less conical, and the subcostal angle is broad (fig. 18). The form of -the adult female chest (fig. li) differs from that of the male, not only in the relatively short sternum and delicacy of the ribs, but also in being more barrel-shaped — that is, less expanded below. Consequently the subcostal angle is smaller. The female chest is, in civilised countries, often much modified in shape by tight lacing. This, by constricting the lower ribs still further diminishes the subcostal angle ; to such an extent indeed, some- FiG. 15.— Infant Chest A, at Ijirtli, from Hi'iike's ' Anatomic do.s Kindesiilters ;' B, ajt. 3 years, from a preparation by the author. times, as to make some of the cartilages below the seventh touch or even overlap one another. This, of course, drives the liver down- wards, and restricts the possible thoracic respiration to the upper part of the chest. Prolonged decumbency may produce alteration in the curves of the spine, which depend upon the position habitually assumed by the patient. Those who are constantly propped up by pillows develop an exaggeration of the dorsal curve, while those who lie more flat lose some of the lumbar curve ; indeed, this part of the spine may even become slightly convex backwards. Chronic bron- chitis may also lead to an exaggeration of the dorsal curve. In the emphysematous chest (fig. 1(5), the ribs approximate to the horizontal direction, the interspaces are widened and the sub- costal angle is large, the thorax is said to be barrel-shaped, but it is really more nearly conical than in the normal condition. It may be said to correspond to a full inspiratory type. O .S, fourth dorsaj spine; 5th/) )', fifth dorsal arti- cular processes ; (S/, sternum ; //w, humerus ; ,Sf, scapula ; 2, 3, 4, 5, ribs ; ^o, aorta; V C S, vena cava superior ; P, perioardium ; Tr, tracl'ieg,,; (Es, oesophagus ; Up. L, upper lobes of lungs ; Lo. L, lower lobe of left lung. The pleura is indicated by a red line. Lo.L. Lo. L. 5'!^D.S.6i^D.V Fig. 21. — Through Sixth Dorsal Vertebra Cth /> I', sixtli dorsal vertebra; 5th /> iS', fifth dorsal spine; .S'c, scii]mla ; ////.humerus; »SY, sterniini ; 3, 4, 5, 6, ribs ; /-", pericardium ; Ao, ar)rta ; /' -1, i)\diii(inarv artery ; V C S, vena cava superior; K .4 j)/, vena nzygos major ; / ^o, descending thoracic aorta; V A M, vena azygos major; ffi^s-, cesophagns ; P, pericardium ; Up. L, upper lobes of lungs ; Lo. L, lower lobes of lungs ; Mid. L, middle lobe of right lung. The pleura is indicated by a red line. The pleura. — The shape of , the cavity of the pleura corre- sponds to that of the contained lung, except on the left side in front of a portion of the pericardium, and on both sides below, where, for a variable distance, the diaphragm comes into contact with the chest wall. This unoccupied portion of the pleural cavity {pleural sinus), varying in extent with each act of respiration, is seen in figs. 28 to 31. It is only possible, by very careful auscultation and percussion, to estimate its extent. An exaggerated idea of it is obtained by post-mortem examinations, and it is indeed probable that the lung may reach to the bottom of it in extreme inspiration if the two surfaces have not, as is often the case, been more or less united by pleural adhesions. The visceral layer of the pleura invests the lung completely^ dipping to the bottom of the sulci between the lobes. The parietal layer lines the ribs and the intercostal muscles, to THE DISEASES OF THE LUNGS which it is connected by a layer of areolar tissue, the so-called endo-thoracic fascia, which is the structure affected in the inflam- matory condition known as peripleuritis. Near the spine the parietal pleura covers the intercostal vessels and nerves and the cord of the sympathetic, and is continued on to the sides of the bodies of the vertebrae, and the azygos veins to reach the sides of the mediastinum. On the right side the mediastinal pleura is in relation above the root of the lung with the trachea and vagus nerve, the innominate artery and vein, the phrenic nerve, the superior vena cava with the arch of the azygos vein and the beginning of the arch of the aorta. Behind the root of the lung it is in contact with the oeso- phagus, and in front of it and below it with the pericardium and phrenic nen-e (fig. 37). On the left side it touches at the upper part the oesophagus, the left subclavian and carotid arteries, the arch of the aorta, the left Mid.L. LO.L LO.L D.T.Ao. VAM smo.S. Fio. 23. — Through Ninth Dors.\l Vebtebba 9th D V, ninth dorsal vertebra : 9th A' A, ninth neural arch : 9th Tr. P, ninth transverse process ; 8th D .% eiphth dorsal spine : Si, sternum ; 5, 6, 7, 8, 9, ribs and cartilages ; /> T Ao, descending thoracic aorta; V C I, vena cava inferior; VA J/, vena azygos major ; (Et, oesopliagus ; Dia, diaphragm ; P, pericardium ; Cp. £, upper lobes of lungs ; Lo. L, lower lobes of lungs ; Mid. L, middle lotie of right lung. The pleura is indicated by a red line. phrenic and vagus nerves, and the beginning of the left innominate vein ; behind the root of the lung it is in contact with the descend- ing thoracic aorta, and near the diaphragm with the oesophagus, and anteriorly with the pericardium and phrenic nerve (fig. 39). The mediastinal and vi.sceral layers of the pleura become con- tinuous at the front and back of the roots of the lungs, and also by means of the lifjamentum latum pubnonis (figs. 37 and 39): a very short double layer of serous membrane, which occupies the interval between the root of the lung and tlie diaphragm, being attached externally to the inner surface of the lung, and on the inner side ANATOMICAL 23 joining the mediastinum at the back of the pericardium. It is, however, not attached to the diaphragm. The relation of the pleura to the oesophagus and the adjacent structures behind the roots of the lungs and the ligamenta lata pulmonum is worthy of attention. On the right side it dips in for a considerable distance between the back of the oesophagus and the front of the vertebrae and the vena azygos major, and sometimes extends for a short distance over the aorta below. On the left side there may be a smaller intrusion of the pleura between the oesophagus and the aorta. In this way the two pleura may come nearly into contact between the oesophagus and the aorta, about opposite the seventh, eighth, and ninth thoracic vertebrte.^ This fact serves in part to explain not only the lateral mobility of the mediastinum, but possibly also the occasional extension of morbid processes from one pleura to the other. Interiorly, the parietal pleura is reflected on to the upper surface of the diaphragm, and above it extends through the upper aperture of the thorax into the neck. This cervical part of the pleura is in contact on each side with the innominate vein, the scalenus anticus muscle, the subclavian artery, with its internal mammary and superior intercostal branches, and the lower trunk of the brachial plexus. The pleurae are not of precisely the same shape upon the two sides, the differences being principally accounted for by the projec- tion of the heart to the left side. Roughly speaking, each consists of a hollow cone flattened, and, indeed, hollowed on the mesial aspect, with a rounded apex and a concave base, and extending much further downwards at the back than in front. The highest point of all is the same upon the two sides and corresponds to the neck of the first rib, and it does not reach above the level of this, the highest part of the first rib ; but it will be remembered that the anterior end of the first rib is considerably below its head, and the pleura only projects very slightly above, or it might be said in front of the oblique plane in which the first rib lies. The apex of the pleura is situated above the inner end of the clavicle, and reaches as a rule about three-quarters of an inch above this bone. The greater the obliquity of the first rib, the greater is the distance of the apex of the pleura above the clavicle, from which it follows that during full inspiration this distance is less than during expiration. The pleura does not everywhere reach down as far as the attach- ment of the diaphragm, and therefore by no means corresponds to the lower margin of the bony thorax. The lower limit of the pleura is subject to considerable variation, but the following description may be taken to represent an average condition. On the right side, starting from the lower part of the sixth rib cartilage at its junction with the sternum or the sixth intercostal space, it passes obliquely ' Attention has been drawn to these recesses of the pleura by T. Jonnesco in Poirier's Traite cV Anatomic Humaine, tome iv. p. 185, 189-5. 24 THE DISEASES OF THE LUNGS to the junction of the seventli rib and its cartilage, then across the eighth, ninth, tenth, and eleventh ribs, at a gradually increasing distance from their distal ends, to reach the vertebral end of the twelfth rib (figs. 28 to 31). This line is, on the whole, convex I2^d.n. Fig. 24.— Back Vikw CUKST OF AN Ol1> MaN, WITH Sl'INE AND KlHS REJIOVEI) The body was inibeddeil after hardening in formalin. The diaphragm was cut away on tlie rifflit side. It will be observed that the twelfth rib was shorter on the right side than on the left. The pleura extended consideralily below the twelfth rib on the rifrht side. On the left side, thougli tlie twelfth rib was nuicli longer, tlie pleura cliil not reach below its lower border. 1 to 12, ribs; 7 (', seventh cervical vertebra : 1 I), first dorsal vertebra; 12 D, twelfth dorsal vertebra; 1 L, first lumbar vcrti'bra : .S .S, s<'ap\da' : (/.'«, (esophagus; 77(. />, tlioracic duct: A, aorta: I'.l, vena azygos : /V, ideura ; 12(/rt, twelfth dorsal artery; 12 j, insertions of diupliragin ; Ao, >, iiicisura cardiaca : »J« >Ji, pericardium in contact witli j)iilmonary artery i ►j*, iii^_muitL i.^ii>ii //.«, upper lobe of lung : fAii, middle lobe of right lung ; /J. lower lobe of lung Ao, aorta ; Ap, chest wall : may exist, and the right pleura may not even extend as far as the right border of the sternum. On the whole, it will be observed that the right pleura is shorter but broader than the left. The lungs. — The lower margins of the lungs do not reach so fai- down as tlie bottom of the pleural cavity, unless it be in forcible inspiration, and the left lung extends a finger's breadth lower than the right. Starting on the right side from the junction of the sixth ANATOMICAL cartilage with the sternum, this margin passes behind the junction of the sixth rib and its cartilage, and, pursuing a course at first oblique and then almost horizontal, reaches the vertebral end of the eleventh rib (fig. 29). The apex and anterior border of the right lung fit exactly into the corresponding parts of the pleura. The left lung, after completely filling the pleura as far as the level of the fourth cartilage, diverges from it in front of the heart to form what is Fig. 29. — Back View of Chest, showing eelations of Lungs AND Pleura (modified from Pansch) 1 to 12, ribs ; Tr^ trachea ; D, diaphragm ; PI pleura ; Lm, middle lobe of right luug ; Li, lower lobe of king. (The reference to the tipper lobes has been omitted by the engraver.) known as the V-shaped notch {incisura cardiaca, figs. 26 and 28). The anterior border must therefore be marked on the surface as leaving the middle line opposite the fourth cartilage, and passing obliquely downwards, almost to the apex of the heart ; from this point it returns towards the sternum, and joins the lower border at a variable distance from the sternum, either behind the sixth cartilage or the sixth intercostal space. Posteriorly, the lungs are separated by a space corresponding to the width of the vertebral bodies. 30 THE DISEASES OF THE LUNGS The great fissure which separates the lower lobe from the rest of the lung follows a line which runs from the second dorsal spine (fig. 29), at first horizontally outwards and then obliquely downwards to join the lower border of the lung opposite the middle of the sixth cartilage or fifth intercostal space just above this point, and usually passes just below the nipple (fig. 28). The smaller fissure which separates the upper and the middle lobes of the right lung leaves this line about the middle and joins the anterior border opposite the fourth /' I. Fig. 30. — liiiiHT Sidk of Chest (after I'ansch) I. siiinous process of first tlioracie vertebra: /'I2, spiiious process of twelftli tl vcrtfljrii ; 1 to 12, ribs ; .1/, iiii)i)le ; /,.<, upper lobe of lung ; Lm, middle lol)e of />/, liiwiT lolie ot luutr ; I'l, I'leuru. loracic luug; cartilage (figs. 29, 80 and 28). For the greater part of its extent it follows approximately the line of the fourth rib and cartilage (fig. 8G). Very little idea of the ahape of the hcalthij lung is obtained from its appearance in the post-mortem room. A better notion is given by one that is solidified by disease, and a still better one from casts obtained by hardening the whole body and pouring plaster of Paris into the cavities which are left by removing one organ after another. But whatever method of study is followed, it is impossible ANATOMICAL 3' to obtain an actual view of the lung in anything except a state of expiration, unless it be artificially inflated, and as the degree of inflation which is permissible must be left to the judgment of the observer, no very definite results can be anticipated. It must be imagined, then, as filling the greater part of the pleural cavity and as taking its shape from the surrounding parts. ■ Thus the rounded costal surface receives impressions from the ribs, and in front of the apex there is a groove corresponding to the PiZ Fig. 81. — Left Side op Chest (after Pansch) P 1, spinous process of first thoracic vertebra ; P 12, spinous process of twelftli thoi-acic vertebra ; 1 to 12, ribs ; M, uipple ; 1), diapliragm ; PI, pleura ; Ls, upper lobe of lung ; Li, lower lobe of luug. The dotted line parallel with the spines represents the line of the front of the vertebral bodies in figs. 30 and 31. subclavian vessels. The inner surface is moulded on to all the irregularities of the bodies of the vertebrae and the structures con- tained in the mediastinum, and the lower surface fits on to the smooth surface of the diaphragm, as will be explained in detail on pages 33 to 35. Little is gained by ascribing an exact geometrical figure to the 32 THE DISEASES OF THE LUNGS shape of the hing. It is enough to recognise for descriptive purposes an apex and a base, an inner and an outer surface, and an anterior and a posterior border. By the latter is meant the rounded part that fits into the hollow formed by the angles of the ribs and which serves in a very indefinite manner to separate the inner from the outer surfaces. The anterior border is, on the other hand, very thin, except at the upper part. Beginning at the apex it is rounded and not very definite and is interrupted by the groove for the sub- VCI Fig. 32. — Inner Aspect of Kioht Lung (from His's Model), showing the parts in contact with the lung 6'^ 7y, Upper lobe of lung; i i, lower lobe of lung: ML, miildle lobe of lung; .S ^', sub- clavian vessels; J' C' .S', vena cava superior ; f^s, (I'sopluigus ; ^ -1, left auricle ; Ji A, right auricle; V li, vertebral bodies; A, aorta; JI, main bronchus; A' B, oparterial bronchus ; /' A, pulmonary artery ; /-* V, pulmonary veins : D, diaphragm ; )' C /, vena cava inferior. clavian vessels. It takes a curved course round the structures passing from the thorax into the neck with the concavity inwards, and then it becomes very thin opposite the sterno-clavicular articu- lation, and runs down in the line described on p. 29 to join the sharp margin which separates the base from the outer surface of the lung. This lower border is thin for the most part, it sweeps round the lower surface of the lung with an even curve until it reaches the bodies of the vertebras, after which it becomes irregular ANATOMICAL 33 in shape as it is moulded round tiie vertebral bodies, the aorta and oesophagus, and on the right side round the right auricle, as the vena cava inferior enters it ; and on the left side round the left ventricle and the apex of the heart. On looking Sit the mesial aspect of the hing (figs. 32 and 33), it is seen that there is a considerable difference between the inner surfaces of the two organs. Each is roughly triangular in shape, and is divided into two unequal parts by a curved line almost parallel| with the Fig. 33. — Ixnek Aspect of Left Lung (feom His's Model), showing MARKS of STEUCTUKES IN CONTACT WITH LuNG V L, uppei' lobe of lung: L L, lower lobe of lung; -S' I', subclavian vessels; A A, arch of aorta ; A', couus arteriosus and left auricular appendix : D A, descending aorta ; CEs, cesopliagits : A diaphragm : L V. left ventricle : B, bronchus -.PA, pulmonarj- artery ; P V, pulmonary vein ; V B, bodies of vertebras. posterior border. The part behind this line is much larger than that in front of it, and is marked by impressions corresponding to the bodies of the vertebrae and the ribs. The smaller anterior portion is deeply hollowed, and much more deeply on the left side than on the right owing to the presence of the heart. At the upper and posterior part of this depression is the irregularly triangular or oval-shaped hilum at which the bronchus and vessels pass into and from the lung. Running upwards from the upper and anterior part of the cardiac impression on the right side is a deep groove which D 34 THE DISEASES OF THE LUNdS corresponds to the vena cava, and the right innominate vessels, and behind the cardiac impression is a shallow groove for the neso- phagus. On the left side is seen a well-marked curved impression above and behind that for the heart, which is caused by the arch of the aorta and the descending thoracic aorta, and from the middle of the groove corresponding to the arch ascends a perpendicular groove for the left subclavian artery. Just in front of the lower end of the groove for the descending aorta is a shallow impression of small extent corresponding to the cardiac end of the oesophagus. The line of separation between the upper and lower lobes crosses the Fig. ii-k. — OuTEK Aspect m- Iih.ijt ijiNci (from His's Model) f' /y, upper lobe : .1/ /., inidillc lobo of luiiK : /, /„ lower lobe of hiiif,'. upper and posterior part of the inner surface of each lung, to reach the upper part of the hilum. It then leaves the lower part of the hiluni, and passes obliquely downwards and forwards across the cardiac surface to the base. Only a very small portion of the cardiac surface on the right side belongs to the lower lobe, but a considerable portion does so on the left side. The line of separation between the upper and middle lobes on the right side passes almost horizontally forwai-ds from the middle of the front of the hilum, so that on this side almost half of the cai'diac surface corresponds to the upper, and half to the middle lobe. ANATOMICAL 35 The otUer surface of each lung (figs. 34, 35) is marked by the deep impressions of the ribs. The lines corresponding to the upper borders of the lower lobes cross this surface from about the middle of the posterior border obliquely downwards and forwards. On the right side the line reaches the lower border about the junction of the anterior and middle thirds ; on the left side it passes into the base just behind the junction of the anterior and lower borders. The interval between the middle and upper lobes of the right lung crosses the outer surface about the middle, and runs almost hori- zontally forwards. Fig. 35. — Outer Aspect of Leet Lung (feom His's Model) U L, upper lobe of lung ; L L, lower lobe of lung. The base of the lung is deeply hollowed by the diaphragm, especially on the right side. On the right side rather less than a third belongs to the middle lobe, and the remainder to the lower lobe. On the left side all except a very minute portion close to the junction of the lower and anterior borders of the lung which is formed by the upper lobe is constituted by the lower lobe. It is important to recognise how large a part of the outer surface of the organ is occupied by the lower lobe. There is a tendency to forget the fact that the upper part of the lower lobe reaches the level of the third dorsal spine. But the importance of the observation is D 2 36 THE DISEASES OF THE LUxNGS obvious in connection with the appreciation of the progress of pneu- monia, phthisis, and other diseases, and the diagnosis of solid affections of the lower lobe from accumulations of fluid in the pleura. Fig. 3(). — Outku Aspkct of Cmkht Tlie Iwdy was iiijecteil witli formalin and the ribs removed. 1 to 9, ribs ; (1, cliiviule : /', uellet of fat : /J, diapliragm : f^ A, upper lobe of lung: J/ A, mi /-, lowci- lobe of lung ; A. fissure between upper and middle lobes ; /i, tlssure between middle and lower lobes. A transverse section of the root of the linuj is of an irregular oval shape becoming narrower below (figs. fi7 and H9, 32 and 88). The various structures entering and leaving tbe lung are firmly bound together by dense areolar tissue, containing rather large ANATOMICAL 37 lymphatic glands, which are wedged in amongst the bronchi and vessels, and assume very irregular shapes in consequence. On the left side, the bronchus enters about the middle of the posterior part of the hilum, and one vein is in front of it. The other vein is directly Fig. 37. -Fbom the s.uie Subject as Fig. 36, showing the Koot OF THE Lung and the MEDIASTrNUM 1 to 9, ribs ; CI, clavicle ; D, diaphragm ; S V C, superior veua cava ; F .1 Jj, vena azygos major ; k B, eparterial bronchus ; L G, lymphatic glands ; P A, pulmonary artery ; B, main bronchus ; P V, pulmonary veins ; L L P, ligamentum latum pulmonis ; P, peri- cardium : F, lappet of fat. ft 38 THE DISEASES OF THE LUNGS below it. The artery is the highest structure in the hilum. On the right side the arrangement is modified by the presence of the epar- terial bronchus (page 43, figs. 40 to 42), which, with its accompany- Fifi. 'iiH. — Fkoji thk samk Suhjkct as Fig. 3(5, showixo ihe AURANUKMENT ON THE LeFT SiHE 1 to 9, ribs : CI, clavicle ; /•', lappet of fat : />, diaiiliragm : /I, fissm-u between lobes r /., upper lobe of lung- ; /, /,, lower lobe of lung. ing artery, enters the hmg above the main branch of the puhuonary artery. Immediately after entering tlu; lung, the bronchus and the vessels subdivide. A little dissection then shows the followhig arrangement. The branches of vein occupy an oblique line running downwards and backwards at the lower part, the bronchi a parallel ANATOMICAL 39 line above them, and the branches of artery are above the bronchi ; but the eparterial bronchus still maintains the highest position. Fig. 39. — The same as Fig 38, aftee kemoval of the Lung, SHOWING THE EoOT OF LuNG 1 to 9 ribs ; CI, clavicle : D, diaiiliragm : F, laiipet of fat ; P, pericardium ; L S A, left sub- clavian artery : A A, arch of aorta : D A, descending aorta ; S I V, superior intercostal vein : PV, pericardial vein ; 1' N, phrenic nerve : P A, pulmonary artery ; P V, pulmonar\- veins: 5, bronchus dividing; /, 6', lymphatic glands; X X /*, ligamentum latum pul- monis. The roots of the lungs are opposite the fifth, sixth, seventh, and sometimes the eighth thoracic vertebrae. In front of the right is the superior vena cava and part of the 40 THE DISEASES OF THE LUNGS right auricle and the phrenic nerve. The vena azygos major arches above it. Behind it is the cesophagus and the vagus nerve. In front of the root of the left lung is part of the left auricle and the phrenic nerve. Above it is the arch of the aorta, and behind it is the descending thoracic aorta and the vagus nerve. The close relation of the arch of the aorta to the left bronchus will be remembered in connection with the not infrequent occurrence of partial or complete obstruction of this bronchus by aortic aneurysms, and the consequent development of acute bronchiectasis. The relation to it of the oesophagus is of equal pathological im- portance. Movements of the lung. — The movements of the lung during respiration are of two sorts, a general expansion as the walls of the chest expand, and a downward movement as the diaphragm contracts. During the process of the expansion of the chest walls the ribs are raised. From both of these causes, therefore, it follows that the surface of the lung glides downwards over the inner surface of the chest walls during inspiration, an obvious fact which appa- rently has only comparatively recently been noticed by physiologists, although the presence of friction fremitus in the course of pleurisy gives a constant object lesson of its truth. The movements of different parts of the lungs are subject to great variations. Thus the expansion of the upper part is more marked in women than in men, and in the former is probably increased by the habit of restraining the movements of the lower ribs by tight corsets. It is in tight-laced women that the heaving of the upper part of the chest during inspiration is most obvious. In men, on the other hand, quiet respiration is mostly abdominal. A rigid chest restrains the movements of the upper parts of the lungs, and it is probable that the very shape of the phthinoid chest may have something to do with the predilection shown by tubercle to affect the apex of the lung. The root of the lung is clearly by far the most fixed part of the organ. The trachea. -Starting in the middle line opposite the lower border of the sixth cervical vertebra, the trachea passes downwards with a very slight inclination to the right at the lower part, and ends at the level of the disc between the fourth and the fifth thoracic vertebrae. It also follows the direction of the thoracic spine from which it is separated by the flattened oesophagus, and thus reaches further and further from the anterior surface of the body as it descends. Thus, whereas at the commencement it is almost sub- cutaneous, it is separated from the skin by a distance of one and three-quarter inch or more at the level of the top of the sternum in a well-grown man (fig. 4), and it is usually from two and a half to three inches from the surface at its bifurcation. The bifurcation of the trachea is just above the level of the junction between the manu- brium sterni and the gladiolus, and corresponds behind with that of tlie spines of the scapula? (fig. 29). When tlieface looks directly forward the cricoid cartilage is from two to three inches above the top of tlie sternum ; if the head be ANATOMICAL 41 thrown back the distance between the two is increased by an inch, and when the chin is lowered the cricoid cartilage may be made to approximate or even pass behind the top of the sternum. Thus in cases of ankylosed and flexed cervical spine, as for example after caries or some rhemiiatic affections, there may be absolutely no trachea in the neck available for tracheotomy. In the infant the cervical part of the trachea is relatively longer than in adult life, and the bifurcation of the trachea is one vertebra higher at birth than during adult life (Symington). The length of the trachea does not bear any constant relation to the height of the body. It is difficult to measure it accurately unless the measurement be taken to the angle between the divergent bronchi, which seems to give rather more to the trachea than actually belongs to it. It is said to be on an average about four inches to four and a half inches (10 to 11 cm.) long; but the variations are so great that these numbers are not of any great value, and, moreover, the length varies to some extent with the position of the neck — Braune says as much as an inch. It does not become obviously curved, even when the neck is greatly flexed or extended.' Its shape hi section is roughly that of a circle with the posterior part cut off, the shape being maintained by the sixteen or twenty cartilaginous rings embedded in its wall. Metal casts of the tube are nearly round because the weight of the metal bulges the posterior wall backwards, but in frozen sections the posterior wall bulges slightly into the trachea, though presumably during life it is nearly flat. Its outside measurement is said to be from three-quarters of an inch to one inch.- It has been stated (Aeby) that the trachea gradually increases in calibre from above downwards, and by others (Braune and Stahl) that it is smallest at its commencement, but gradually increases in size to within about three centimetres of the bifurcation, where it again enlarges. At the lower end it becomes flattened from before back. In the last edition of Quain's ' Anatomy ' it is stated by J. Symington that in an infant six months old the trachea will admit a tube 4 mm. in diameter, at two years one of 5 mm., and at six years of age one of 6 or 7 mm. In the female the diameter of the trachea is smaller than in the male, though there is not much, if any, difterence in the average length. The cartilages do not as a rule begin to ossify before the age of sixty, while in man they often show this change at forty years of age. The trachea rests on the oesophagus and the vertebral column. ' Topograph. Anat. Atlas, s. 21 ; Leipsic, 1875. - Lejars, Rcvuc de Cliinirgie, 10 avril, 1891, onzieme ann^e, No. iv. p. 336 : sag. diam. 11 mm.; tr. diameter 12-5 mm. Marc See, Gazette Hehdcnn.dcMi'd. ct de Chiriirg. 2, mai, 1884, tome xxi, No. 18, p. 29-4 : average diameter, men, 18 mm. ; women, 14-5 mm. Aeby : sag. diam. 17-6 mm. ; tr. diameter, l»rO mm. These measurements apply to the himen of the tube, and are not outside measurements. 42 THE DISEASES OF THE LUNCIS At the beginning the (I'sophagi^s is directly behind it, but at the lower part of the neck the oesophagus inclines so much to the left that the back of the trachea is usually applied directly to the front of the vertebral column. In the neck it has tlie sternohyoid and sternothyroid muscles, the thyroid gland and the inferior thyroid veins, and possibly the thyroidea ima artery in front of it, while to each side are the carotid arteries and the recurrent laryngeal nerves, the latter being placed laterally between the trachea and the oesophagus. In the thorax it lies behind the manubrium sterni, and is crossed by the arch of the aorta and by the left innominate vein. The innominate artery and the left carotid are at first in front and then somewhat to the sides of the trachea. The pleura and the vagus touch it on the right side. On the left side it is in contact with the left subclavian artery, the arch of the aorta, and some of the cardiac nerves. The deep cardiac plexus of nerves is situated between the arch of the aorta and the bifurcation of the trachea. The bronchi and pulmonary arteries. There is a wide difference between the modern way of describing the course and method of subdivision of the bronchial tubes from that which was adopted some time ago. This is principally due to the observa- tions of Aeby, in great part confirmed by later anatomists. It partly also depends on the fact that there is really a considerable variety in the length and relative position of the main bronchi, as may be seen by studying a number of metal casts. It used to be said that the right bronchus came off more abruptly from the trachea than the left, a mistake which arose from the fact that its first branch comes oft' earlier than the first branch on the other side, and thus apparently alters the direction of the tube. It is now recognised that the right bronchus usually follows more nearly than the left the course of the trachea, which it will be remembered is directed slightly to the right at the lower eiul (figs. 29, 40 and 41). In many cases the trachea and the right bronchus are almost abso- lutely in the same line. The angle between the diverging bronchi is sometimes as wide as a right angle, but more frequently is decidedly acute (figs. 40 and 41). It also used to be said that the bronchi divided and subdivided dichotomously, and there was a considerable excuse for this descrip- tion, because the branches given oft" are often so nearly of the same size as the main stem that the appearance of dichotomous division is closely simulated. The study of comparative anatomy and of metallic casts has convinced almost everyone, with certain exceptions, such as that of Dr. Ewart, that, as in other animals, there is really one main stem starting from the bifurcation of tlie trachea and running down the lung to end in the thin posterior part between the diaphragm and the ribs, about three inches from the middle line of the body. This main stem is thus directed downwards and backwards, on the left side it is also curved considerably with the convexity outwards, on account of the presence of the heart. From those main stems are given oft' lateral branches, the ANAT0MICA1-. 43 arrangement of which is not precisely the same on the two sides. Before describing them it will be necessary to say a word about the relation of the pulmonary artery and its subdivisions to the bronchi. The main bronchial stem enters the hilum of the lung at the upper and posterior part. The main branch of the pulmonary artery enters at the upper part and in front, and, crossing the Fig. 40. — Cast of the Intekior of the Trachea and Bronchi, with THEIR chief ramifications WITHIN THE LUNG. (Aebj) This cast shows a type of division frequently met with, the right bronchus being almost in continuation of the line of the trachea, a, eparterial branch : 6, c, hj'parterial branches (ventral and dorsal). bronchus, reaches its posterior aspect. Throughout the lung the branches of the pulmonary artery accompany the bronchi, the smaller arteries lying behind the smaller bronchi. An account of the arrangement of the pulmonary veins in the lung is given after the completion of the description of that of the bronchi. The main bronchus on the right side gives oflt" a large branch to the upper lobe of the lung, before it is crossed by the pulmonary 44 THE DISEASES OF THE LUNGS artery, which is thus called the eparterial hronchus. On the left side there is no such arrangement. It follows from this that the right main undivided stem is shorter than the left, and on the left side all the branches are hyparterial. The lateral branches are more or less symmetrical on the two Fig. 41. — Cast of the Inxeiuok of the Thachea and Bkonchi, with THEIK CHIEF RAMIFICATIONS WITHIN THE LuNGS. (Aeby) This cast shows a tyfjc of division less fre<|ueiit tliaii the last, the right and left bmiiclii being at about a "right angle with one another, a. eparterial l)ranch ; 6, vi-ntral hyi)ar- terial branches ; 6', accessory (azygos) branch ; c, dorsal hyparterial branches. sides and are arranged in two sets, ventral and dorsal — four of each — of which the ventral or outer are much the larger, and, indeed, some of them are as large as the continuation of the main trunk. Besides the dorsal and ventral, there is a somewhat irregular aeries of branches called by Aeby accessory bronchi. They usually ANATOMICAL 45 arise from the front, being intermediate in position between the dorsal and ventral branches. One of these near the second left ventral branch on the right side was called the heart bronclius by Aeby, and it is interesting because in some animals it supplies a small separate lobe situated behind the pericardium which has received the name of the azygos lobe. Hasse points out that the lai'ger branches of the bronchi in the A.'ht Fig. 42. — Sketch showing the Lower End of the Teachea, its divi- sion INTO THE TWO BRONCHIAL TeUNKS, AND THE COURSE AND CHIEF branches of these WITHIN THE LuNGs FROM BEFORE (after Aeby) «, uppei', 6, middle, c, lower, lobe of the right lung ; h', upper, c', lower lobe of the left luug ; r^;, right pulmonary artery; 1 2', left artery; ?■ 6/-, right bronchial trunk; Ibr, left bronchial trunk ; e p,on the right side, eparterial branch supplying the upper lobe ; v /t', first ventral hyparterial bronchus supplying tlie middle lobe on the right side, the upper lobe on the left ; v h", v If, v h*, the remaining ventral hyparterial branches distributed in the lower lobe on each side ; d h\ d If, d If, d If, the four dorsal hyparterial branches distributed on both sides in the posterior and inner part of the lower lobe ; h, accessory bronchus arising close to the first dorsal hyparterial bronchus on the right side, and reijresenting the one which supplies the azygos lobe in some animals. The main branches of the pulmonary vessels are distributed like tlie bronchi. Within the lung the arterial trunks run behind the bronchial brandies, the venous trunks in front. upper and middle lobes of the right lung and the upper lobe of the left lung are directed outwards, upwards, and forwards, while those of the lower lobe of both lungs are directed downwards, inwards, and backwards, and says that these directions agree with the move- ments of the chest walls, which in the upper and anterior part expand in an upward, forward, and outward direction, while owing 46 THE DISEASES OF THE LUNGS to the descent of the diaphragm the lower part of the chest cavity is extended downwards and inwards.' The sectional area of the bronchial tubes, on the whole, increases as they subdivide. It has been stated above that the lateral branches are often quite as large as the main bronchus, so that the description here given, though most interesting and important from the point of view of comparative anatomy, is not of very great value from the practical aspect. It does not help the surgeon in his search for a foreign body of less than a certain size, and it has no great interest for the physician in helping him to the determination of the reasons for the selection of special spots for pulmonary cavities. Practically the surgeon knows that bronchi of very considerable size will be found throughout the lung, and that each of these bronchi will have a pulmonary artery closely attached to it on its posterior aspect, while pulmonary veins will not be far off on the anterior aspect, and he is often clearly reminded of this fact when, on puncturing the lung, the needle, after encountering some resistance, obviously enters a bronchus, and a somewhat copious hasmoptysis is the immediate result. The needle has passed through a large vessel before entering the bronchus, and laence the often somewhat alarming occurrence. Unfortunately, more often than not, he has to make the exploration either from the front or from the back, and cannot, therefore, avoid this accident, but, on the other hand, fortunately the bleeding is seldom serious unless the patient have been placed too deeply under the influence of the anaesthetic. Pulmonary veins. — Within the lung itself the pulmonary veins (with the exception of the smallest) generally run with the bronchial tubes and arteries, the bronchial tube having on the one side the arterial branch, and on the other the vein, which is not, however so closely applied to it as is the artery, and often takes a somewhat different direction. The absolute position of the veins in relation to the bronchial branches varies in different parts of the lung, as may be seen from tlie accompanying drawing (fig. 48). On approaching the hilum, and in the root, the larger veins have a different arrangement, and run independently of the air tubes and the arteries. Thus, on both sides, the veins from the lower lobe issue from the lung behind and below the bronchus, and unite into the lower trunk (figs. 82 and 88) ; while the veins from the upper lobe on the left side, and from the upper and middle lobes on the right side, emerge in front of the air tube, and joni together to form the upper trunk. Both trunks are very short, not exceeding three-quarters of an inch in length, and are directed nearly hori- zontally inwards and forwards on each side of the posterior part of the pericardium, which they pierce, and then immediately enter the left auricle. ' C. Hasse, ' Der Bau der Lunge des Menschen, bedingt durch die Bewegun- gcn der Brustwandung bei der Atniung,' Vcrhandl. des 10. Tnfernat. Medic. A'oJifyrcs.scs, Berlin, 1B90, Bd. ii. Abt. i. Anatomie ; ' Ueber den Bau der niensch- lichen Lungen,' Archiv fHr Anat. a. I'hyn. Anat. Abth. Jalirgang 1892. ANATOMICiVL 47 Fig. 43. — Dissection op Bkonchi and Puljionai;y Vessels fkoji the Side The subject was imbeilileil and the ribs were drawn before tliey were removed. The lobes of the lung: were drawn before the final dissection was made. 1 to 12, ribs : A B, A C, fissui-es between upper lobe and middle and lower lobes; />, lower border of lung; /J, lower limit of pleura ; Br, bronchi ; /-" A, pulmonary arteries : J' V, pulmonary veins : ^y, nipple; A' Y, front of vertebral bodies. 48 THE DISEASES OF THE LUNGS It is, however, to be remembered that the veins are less regular in their arrangement than the arteries, and that there is often a third intermediate trunk on the right side, and that the two veins on the left side may be united into a common stem before piercing the pericardium. Bronchial arteries and veins. — The bronchial artery comes on the right side from the first aortic intercostal, or by a common trunk with the left bronchial artery from the descending thoracic aorta. On the left side there are usually two bronchial arteries, both arising from the descending thoracic aorta. They run along the posterior surfaces of the bronchi, which they accompany. The bronchial veins receive small twigs from the trachea and mediastinum, and open, the right into the vena azygos major, and the left into the left upper azygos vein. Part of the blood con- veyed to the lungs by the bronchial arteries is returned by small vessels, which open into the pulmonary veins in the substance of the lung ; and there is a further communication between the systemic and pulmonary circulations by means of small anterior bronchial veins, which proceed from the larger bronchial tubes, the bronchial glands, and the mediastinal plexus to join the pulmonary veins at the root of the lung (Zuckerkandl). The distribution of the bronchial veins in the lung is of no practical importance, consisting as it does; of numerous small and freely communicating vessels. Lymphatics of the lungs. — The lymphatics of the lung are abundant and large. They are described as being arranged in two sets — the superficial or subpleural and the deep— but these communicate freely with one another. The superficial trunks arise from a network on the convex surface of the lung, turn round the margin to the inner surface, and dip into the interlobar fissures. Eventually they all reach the bronchial glands at the root of the lung. The deep lymphatics run with the bronchial tubes and the pulmonary vessels, and enter the bronchial glands with the super- ficial ^'essels. Some of the deep lymphatics from the lower part of the lung may, however, pass into the glands in the posterior mediastinum, and not infrequently join the lymphatic trunks coming from the hinder part of the diaphragm (Sappey). The bronchial lymphatic glands are numerous and large. They surround the bronchi as far as their first subdivisions, and extend some distance into the root of the lung. We have no precise observations on the exact distance to which they reach, but accord- ing to Sappey they do not penetrate to a greater depth than ;-J centi- meters ; some are placed between the air tubes and the lung substance ; but they do not appear to be found in the actual paren- chyma of the lung. It is, however, often difficult to distinguish the blackened tissue of the lymphatic glands from that of the lung itself. A considerable group of glands lies in the angle between the bronchi. Those in the liilum are wedged in amongst the bronchi and vessels, and are generally of juost irregular angular ANATOMICAL 49 shape. In the adult they are usually deeply pigmented, and often much enlarged and indurated, and have frequently undergone more or less calcareous degeneration. The efferent vessels ascend along the trachea, traversing other glands in this situation, and so make their way to the lymphatic trunks. liymphatics of the pleura. — -The existence of lymphatics in the pleura itself has been denied. But this is rather a refine- ment of anatomy, as an extensive network of large lymphatic vessels is found in the subpleural tissue, in the meshes of which is a net- work of smaller vessels. The lymphatics of the j^ulvwnary pleura are said by Miller to form at the hilum three, four, or five large trunks, which anas- tomose at this point with the lymphatics of the lung. He also states that at the border of the lung the large pleural lymphatics often dip into the lung for some distance, but only to come to the surface again without communicating with the lymphatics of the lung. The lymphatics of the parietal pleura. — Nothing further can be added on this subject to that which has been already stated on p. 18. The information, it must be owned, is meagre, but there does not appear to be much more to be said. R. J. G. so THE DISEASES OF THE LUNGS CHAPTEE II PHYSICAL DIAGNOSIS Regions of the chest . Examination of the chest Inspection . Palpation Fremitus — Vocal . Ehonchal Friction Tussive Position of the cardiac impul Percussion . Theory of percussion sounds Normal percussion sounds Morbid ,, ,, Increased resonance Tympanitic ,, Skodaic „ Diminished „ Absence of „ Dulness . Tubular percussion note Cracked-pot sound Auscultation Breath sounds Varieties of respiratory sounds Adventitious sounds Varieties Vocal resonance . Varieties Mensuration Cardio-pulmonary sounds PAGE 50 51 51 53 53 53 53 54 54 54 55 56 57 57 57 57 57 57 57 57 57 58 58 58 ()1 (il 65 65 . 66 , 67 The presence of disease is indicated by the occurrence of symptoms which are, strictly speaking, subjective sensations of the patient, and the presence of signs which are phenomena recognisable by an observer. Signs discovered by the aid of the various methods employed in diagnosis are termed ' physical signs.' REGIONS OF THE CHEST For convenience of description, the chest is divided into certain regions, but, as the terminology is somewhat variable, it is best in all cases to indicate the position of any physical sign by reference to certain vertical lines and a given rib or interspace. PHYSICAL DIAGNOSIS 51 The vertical lines are as follows : (1) The mid-sternal line ; (2) the nipple line ; (3) the anterior, mid, and posterior axillary lines ; (4) the posterior scapular line (vertebral border of the scapula) ; (5) the vertebral line. Other terms are used by some writers, but they are now rarely employed in practice — e.g. the ' parasternal line,' midway between the margin of the sternum and the nipple line. The normal position of the cardiac apex is gene- rally thus described : ' In the fifth left interspace one inch within the nipple line.' It is, however, preferable, in recording exact observa- tions on the position of the cardiac impulse, to measure the distance from the mid-sternal line. The following regions are commonly spoken of without their boundaries being accurately defined : — Anteriorly. — The supra-clavicular, the infra- or sub-clavicular, the mammary, and infra- or sub-mammary regions. The supra-sternal notch, the upper and lower sternal regions. Laterally. — The axillary and infra-axillary regions, or upper and lower axillary. Posteriorly. — The supra-spinous region or fossa, the infra- spinous region, the interscapular region, and the base. EXAMINATION OF THE CHEST The examination of the chest is conducted in the following order : (1) inspection, (2) palpation, (3) percussion, (4) ausculta- tion, (5) mensuration. It may be confidently observed that, no matter how experienced the examiner, it is rarely advisable to depart from this order, as so doing may entail the necessity of recommencing the examination when it is half finished. It is essential in every case to examine the whole of the chest, and not merely some part of it which is thought to be the most probable site of disease. INSPECTION This preliminary step, although much neglected by students, is certainly in importance equal to, if not greater than, any other part of the examination. So much is there to be learnt from inspection, that it is often possible by simply looking at the chest to make a near approach to an accurate diagnosis. We shall not attempt either to enumerate or describe all the morbid conditions which may be observed on inspection of the chest, as to do so would entail the repetition of much that may with greater advantage be considered elsewhere in this work. It will be sufficient to mention here the chief points to which attention should be directed in this part of the examination. The patient should be placed in a good light, and the observer E 2 52 THE DISEASES OF THE LUNGS should stand opposite to him. The condition of the integuments and of the superficial vessels should be first noticed. The chest wall may be cedematous, or the veins enlarged. The shajje of the chest is of importance. The normal chest is symmetrical and duly proportioned in its various diameters ; the sternal angle (angulus Ludovici) at the junction of the manubrium with the body of the sternum, at the level of the second costal cartilages, is fairly marked. In some persons the chest is long and nairow, the clavicles prominent and curved, the upper interspaces wide, and the antero- posterior and lateral diameters diminished, the shoulders sloping, and the scapulae winged (' alar ' thorax). In others in whom the chest is fairly broad, it is flattened in front. The sternum maybe prominent, as in the typical ' pigeon breast,' or it may be bordered on either side by the cartilages of the ribs, which are curved forwards to such an extent that the sternum lies in a hollow. In children the subjects of rickets there is often a depression running obliquely downwards and outwards to the costal margin, and the ribs are ' beaded.' The ' barrel-shaped ' chest typical of the large-lunged variety of emphysema may be noticed, with its prominent sternal angle and wide epigastric angle ; or the small chest of the atrophic form of that disease. The point of the shoulder may be lower and the supra-clavicular fossa deeper on one side than on the other, and there may be a depression beneath the clavicle — signs indicative of shrinkage of the upper part of the corresponding lung. Bulging of one side of the chest may indicate the presence of a pleural effusion, or a local bulging may be due to the presence of an aneurysm of the aorta. Eetraction of some part of the chest wall may have resulted from previous disease of the lung or pleura. The heart may be uncovered by the retraction of the left upper lobe, and the impulse of the heart may be displaced from a variety of causes. On the posterior aspect of the chest it is important to notice the distance of the border of the scapula from the spines of the vertebra", and to observe whether the angles of the scapula- are at corresponding levels on the two sides. The presence of a curvature of the spine should be looked for, and any undue obliquity of the ribs and narrowing of the intercostal spaces noted. The expansion of the normal chest is equal on the two sides, and causes an increase in all its diameters. In disease the ex- pansion may, from various causes, be unequal on the two sides, or enlargement may be effected by the descent of the diaphragm, the chest only moving upwards en. masse, or the chest may be rigid and motionless on inspiration. Collapse of a sufficiently extensive area of a lung is accompanied by absence of expansion of the correspond- ing part of the chest wall. Obstruction to the entrance of air into the lungs is indicated PHYSICAL DIAGNOSIS 53 by recession during inspiration of tlie supra-clavicular fossae, the suprasternal notch, the intercostal spaces, and the epigastrium. In children the thoracic walls are yielding, and obstruction to the entrance of air may be accompanied by marked recession of the lower lateral parts of the chest wall. PALPATION Palpation is the use of the hands in physical examination, in order to obtain information through the medium of the sense of touch. Fremitus. — Vocal fremitus is the vibratory sensation con- veyed to the hand when applied to the chest of a person during phonation. The nature of the sensation perceived will depend upon the character of the voice, there being wide differences in this respect. The deep vibrations of a man's voice are always much better con- ducted than the higher-pitched voice of a woman or child. The amount and kind of the tissues interposed between the hand and the lung will also influence the vocal fremitus, which is usually most marked in lean persons. Any condition which produces consolidation of the lung will increase the vocal fremitus, provided the bronchi are patent ; whilst the presence of fluid or air between the lung and the chest wall will diminish it, or altogether prevent its being felt. The vocal fremitus is normally more distinct beneath the right clavicle than on the opposite side. If, therefore, the vocal fremitus is equal on the two sides and well marked, it is probably increased at the left apex, and a presumption arises that the left upper lobe is the seat of disease. If the fremitus is more marked at the left apex than the right, the presumption that the left upper lobe is affected is still stronger. If, on the other hand, the vocal fremitus beneath the clavicles is equal, but less marked than normal, pro- bably the voice conduction is diminished at the right apex, and the condition of the right upper lobe must be carefully investigated in the further course of the examination. The significance of alterations of the vocal fremitus in the supraspinous foss^ is the same as corresponding changes beneath the clavicles. Similar indications may be obtained in children from the fremitus felt during the act of crying. Khonchal Fkemitus is felt when the vibrations produced by the passage of air through a bronchial tube, narrowed by the presence of mucus, are sufficiently intense to reach the hand applied to the chest. It is often present in bronchitis, and is especially frequent in the case of children suffering from that disease. When from any cause the breathing is accompanied by ' stridor ' the vibrations may be also conducted to the chest wall. Friction Fremitus. — The vibrations produced by the rubbing together of two inflamed surfaces of the pleura, and more rarely of 54 THE DISEASES OF THE LUNGS the pericardium or peritoneum, may sometimes be appreciated by the hand. The above term is used to indicate this sign. It is not uncommonly present in cases of dry pleurisy. Tussive Fremitus is felt when the hand is placed upon the chest whilst the patient coughs. It is sometimes of use in diagnosis in the case of children, and in adults when the condition of the voice prevents the production of vocal fremitus. Crepitus due to fracture of a rib, the tine crackling sensation felt in subcutaneous emphysema, and crackling due to the presence of blood beneath the skin may also be discovered on palpation. The position of the cardiac impulse, which may or may not have already been observed on inspection, will be more definitely ascertained by palpation. It may be here stated that the importance in all cases of jBxing this point accurately cannot be over-estimated, as the 'position of the cardiac impulse is the key to the diagnosis of many affections of the chest. The presence of pulsation in any abnormal bulging will be noted, and tenderness may be complained of on palpation. When due to hyperaesthesia of the surface the slightest touch may cause intense suffering, whereas if the patient's attention is distracted by conversation, deep pressure may be made without so much as attracting attention to the spot. PEECUSSION Percussion is a method of physical examination in which some part of the body is struck with a view either to elicit sound oi' to estimate density of substance. A slight difference in resonance brought out by an experienced examiner can be easily appreciated by others, but it requires long practice before the student is able to elicit the true note for himself, percussion being by far the most difficult of the arts of physical diagnosis. As an indication of the condition of the subjacent structures, the degree of ' resistance ' experienced on percussion is only second in importance to the alteration in sound. Method of percussing. — The chest may be struck directly with an instrumentorthe fingers (the_/;/r..s-.sor)=innnediate percussion, or the blow may be delivered upon some intervening substance (the ^j^ea;M?/,c/cr)=mediate percussion. The use of any instrument, either in the form of a hammer as a plessor or a flat or other shaped piece of ivory as a pleximeter, was, in this country at least, until lately almost a thing of the past. Recently various new forms of pleximeter have been invented, and some of them are used by physicians of experience. It is, however, essential that the student should begin by learning to use his fingers, whatever he may do at a later period. The use of the finger has additional advantages, in that it enables one to appreciate any increase of resistance, and to feel the vibra- tions of the chest wall. The middle finger of the left hand is generally used. It must PHYSICAL DIAGNOSIS 55 be applied firmly to the part, and should be struck with one, two, or three fingers of the right hand, the fingers being flexed, the blow delivered from the wrist and not from the elbow, and vertically to the pleximeter. Light percussion is best when it is desired to elicit sounds from the parts immediately subjacent, or to map the outline of the thoracic or abdominal viscera, also whenever there is tenderness of the chest wall, and, speaking generally, when examining the front of the chest. Over the supraspinous fossa3 and interscapular regions, it is often necessary to give a firm blow in order to bring out slight differences in resonance. This is sometimes termed ' deep ' percussion. The clavicles are percussed by tapping them directly Avith the finger. It is often possible to make out slight differences in resonance by percussion of the clavicles when no variation from the normal can be detected elsewhere ; also if the chest is percussed after a deep inspiration a slight difference in resonance, due to diminished entry of air into an affected part of the lung, may be discovered. These steps should therefore never be omitted in the examination of doubtful cases of tuberculosis of the apex of the lung. The sounds elicited from difi'erent chests and from different parts of the chest vary considerably ; it is therefore essential in all cases to compare the note obtained over any spot with that over the corresponding part on the opposite side ; interspace must be compared with interspace, and rib with rib, the finger being similarly applied and struck with equal force on each side. In percussing the back of the chest the patient must be directed to lean forwards, to fold the arms, and to 'let the shoulders drop,' so as to completely relax the scapular muscles. Auscultatory percussion is a term applied to the combined use of percussion and auscultation. The method is of service in defining the outlines of a large hollow cavity, such as a dilated stomach, a difference in the note being appreciated through the stethoscope when the pleximeter passes the boundary of the cavity. At the present time great importance is attached by some writers to the use of this method of diagnosis in determining the outlines of the heart. Theory of percussion sounds. — A^s already stated, per- cussion is an art only to be acquired by long practice, and its acquisition and application are but little assisted by a knowledge of the various conflicting theories which have been from time to time put forward to account for the normal and abnormal sounds so elicited. It is now accepted by most writers that the sound which is obtained when the healthy chest is percussed is ' mainly due to the vibration of the thoracic walls alone ' (Bristowe), and that any condition which interferes with the vibration of the chest walls alters the percussion note. According to another view, however, the middle-sized and largest bronchi (Gee) are the seat of the vibra- tions which produce the normal percussion tone. The nomenclattire of percussion sounds is almost as confusing as 56 THE DISEASES OF THE LUNCrS that of the breath sounds. The terms mentioned in the Provisional Report of the Committee of the International Medical Congress (1881) have been here adopted. Before proceeding to describe them it is necessary to refer to some of the synonyms in ordinary use, and also to describe the normal percussion signs. The term ' dulness ' is held to imply absence of ' tone ' (Gee), ' tone ' being the result of the regular succession of impulses which are present in a musical sound, but lacking in a mere noise. Of percussion sounds the highest in pitch is that produced by percussion over a bone (osteal) ; next in descending scale comes a note resembling that produced by percussion of the trachea when the glottis is open (tubular or tracheal) ; the lowest being that produced by percussion over a hollow cavity containing air, e.g. the stomach (tympanitic). The note over healthy lung (normal percus- sion tone) comes in point of pitch after the tracheal tone. Normal percussion sounds. — By long practice it is possible to form a rough standard of resonance for different regions of the chest, regard being had to the condition of the parietes and other considerations. This is of service when the percussion note of healthy lung cannot be obtained owing to the presence of disease in corre- sponding areas on both sides of the chest. Taking the front of the chest from above downwards, the normal condition of the percussion sounds is as follows : — Resonance commences about 1^ inch above the clavicle ; it is equal on the two sides until the sound is modified owing to the presence of the liver on the right side, and of the uncovered portion of the heart on the left. The whole of the sternum is resonant in the normal condition. The liver dulness commences at the upper border of the sixth rib in the nipple Une, and extends to the costal margin. A horizontal line drawn outwards on a level with the base of the ensiform cartilage crossing the eighth rib in the mid axillary line and the upper border of the eleventh rib posteriorly marks its upper border. In the median line the liver dulness extends about 1\ inch below the base of the ensiform cartilage. Precordial dulness. — The area of superficial precordial dulness, as obtained on light percussion, is bounded above by the fourth left costal cartilage, on the right by a line drawn along the left edge of the sternum, on the left by a vertical line drawn through the fifth left intercostal space an inch within the nipple line (normal site of the apex beat), and below by a horizontal line from the apex beat to the sternum. It is usually stated to merge below into the liver dulness, although it is said to be possible to differentiate the two. Behind. — The percussion note in the supraspinous fossfP, owing to the greater thickness of the muscles, is loss resonant. In the interscainilar region the resonance increases somewhat, and in the infrascapular region the note is almost equal to that beneath the clavicles. PHYSICAL DIAGNOSIS 57 On the right side resonance extends to the tenth rib, and on the left to the eleventh rib or thereabout. Morbid percussion sounds. - The following varieties may be recognised: — Increased Eesonance : Hyper-resonance. — This sound has the quality of the normal percussion note to an exaggerated degree. It is of more marked intensity than the normal note and of lower pitch. The percussion note over an emphysematous or over-dis- tended lung may be of this character. Tympanitic Resonance. — A somewhat musical sound of vary- ing pitch heard on percussion over a distended stomach or intestine, also over a pleural cavity containing air (pneumothorax), over a very large pulmonary cavity, and in complete excavation of the lung. Skodaic Resonance. — A clear sound of higher pitch than the last variety, but of the same quality, produced on percussion over the upper part of the chest, particularly the infraclavicular region, when the pleural cavity contains a certain amount of fluid, and also in some cases of pneumonia of the lower lobe. A similar note may occasionally be elicited by percussion over an area of deep-seated or incomplete consolidation of the lung. When present in cases of pleural effusion skodaic resonance beneath the clavicle is believed to be produced by relaxation of the upper part of the lung, which, however, still remains in contact with the chest wall. Dr. Bristowe attributes the raised pitch of this sound to the diminution in the vibrating area present under such conditions. Diminished Resonance [Dulness varying in degree). — A sound shorter, sharper, and higher in pitch, and lacking the tone of the normal note. It may be of a quality similar to that produced by percussion over a piece of wood (wooden) or a bone (osteal). The sound usually signifies either incomplete consolidation or dis- placement of the lung, or the presence of some morbid condition of the pleura or chest wall. With diminished resonance there is almost always increased resistance on percussion. Absence of Resonance (Z)MZ7icss). — A high-pitched note from which tone is more or less completely absent. The sound elicited by percussion over a pleural cavity containing fluid may be absolutely dull. Over consolidated lung the loss of tone is not usually complete. Tubular Percussion Note and Amphoric Besonance. — A sound similar to that obtained by percussing the trachea with the glottis open. It is usually produced over a large superficial cavity with free bronchial communication. This may be accompanied by the following Grached-pot Sound {Bruit-de-pot- fele). — A sound having an amphoric and slightly metallic quality produced on percussion over a superficial cavity, with slightly yielding walls and free bronchial communication, the mouth being at the time open. 58 THE DISEASES OF THE LUNGS AUSCULTATION Auscultation may be practised directh', by applying the ear to the chest wall, or mediately, by means of a stethoscope. The forms of stethoscope in common use are the rigid tube of wood, vulcanite, or metal, with broad ear-piece and narrow chest-piece, and the flexible, single or binaural, instrument. The first has the advantages of enabling the auscultator to appreciate any abnormal impulse of the heart or of an aneurysm, and also that it can be applied to the chest when covered with a layer of clothing, whereas the flexible instrument must be applied accurately to the skin itself. The binaural stethoscope, however, is more convenient for the examination of children and of patients in the recumlDent position. Breath sounds. — It is a misfortune to medicine, and a source of great difficulty to students, that the nomenclature of the aus- cultatory sounds should be in such a state of confusion. As uniformity in this respect can only be obtained by sinking individual preferences and submitting to the dictates of authority, it would have been a great advantage if the terminology recom- mended by the majority of contributors to the Provisional Report of the Committee of the International ]\Iedical Congress had been generally adopted. Unfortunately this has not been the case, and matters remain much as they were years ago. A knowledge of the normal breath sounds is obviously an essential preliminary to the auscultation of the chest in disease, and this can only be obtained by the examination of a large number of healthy subjects. Three varieties of respiratory sounds are to be recognised in every healthy chest — -(1) the sound produced at the glottis, and audible over the lower end of the trachea, which is termed ' tracheal ' or ' bronchial ' breathing ; (2) the sound which is believed by some writers to be produced in the alveoli and which is audible over the lungs, termed ' vesicular ' breathing; (3) the sound audible about the roots of the lungs, which combines the characters of the two preceding, and is termed ' broncho-vesicular ' breathing. As the normal respiratory sounds vary considerably in intensity in different individuals, there is no common standard of reference, and one side of the chest must always be compared with the other. Any change in the rpiallt;/ of the sounds, however, is to be regarded as abnormal. Varieties of respiratory sounds. — Vesicular Breath- ing. — This is a soft rustling sound audible during inspiration. It is generally followed, without any appreciable interval, by a sound, of lower pitch, shorter duration, and faintly blowing quality, heard during expiration, but this may be absent. The two sounds con- stitute the normal respiratory murmur audible over the healthy lun". PHYSICAL DIAGNOSIS 59 Prolonged Expiration. — The expiratory sound may be prolonged — a sign the significance of which varies with the pitch and quality of the sound. If high pitched and bronchial or tubular in quality, it usually indicates consolidation or compression of the lung ; if, on the other hand, the pitch is low and the quality faintly blowing, but not bronchial or tubular, emphysema is probably the cause. Exaggerated Breathing. — This is a sound possessing the characters of vesicular breathing in an exaggerated degree. It is the normal breath sound of children, but when met with in adults indicates that an increase of function in one part is compensating for deficient action elsewhere. Exaggerated breathing is perhaps best heard over the unaffected side in cases of pleural effusion. Diminished Breathing. — The characters of the normal breath sound are retained, but the intensity is much diminished. It is present under a variety of conditions involving lessened functional activity of the lung, and very commonly at the apex in an early but not the first stage of tubercular disease. Suppressed Breathing. — The breath sound is absent, a con- dition met with in some cases of pleurisy with effusion, also in certain cases of pneumonia, when the bronchi are filled with exuda- tion (massive pneumonia), in collapse of the lungs, and when from any cause a bronchus is completely occluded. Interrupted Breathing ; Wavy or Cogwheel Breathing. — The inspiratory sound is divided into two or three parts, owing to an irregular expansion of the lung, the result of disease of the bronchi or of the lung interrupting the entrance of air. It may also be due to irregular contraction of the muscles of respiration, and possibly also to the jpresence of pleural adhesions. It may be heard at the apex of the lung in the earliest stage of tuberculosis, but, taken alone, is an untrustworthy sign owing to its close simula- tion by the breath sound present in certain nervous conditions. It is also occasionally simulated by a succession of ' air-wave ' murmurs (cardio -pulmonary) produced by the impact of the heart upon the lung. Bronchial Breathing is the glottic sound, as heard in the normal chest over the seventh cervical spine. The sound there audible may be taken as the standard of comparison by which to gauge the quality of similar sounds heard elsewhere in the chest of the same patient, the term ' bronchial breathing ' being used to signify that the sound heard over an area of disease in the lung is of the same quality as that audible over the seventh cervical spine. It is of variable intensity, and differs from vesicular breathing in that the inspiratory sound is higher in pitch and tracheal in quality, whilst the expiratory sound is higher in pitch, separated from the former by a distinct interval, tracheal in quality, usually more intense, and of equal or longer duration. When heard in pneumonia or tuberculosis, it signifies the presence of consolidation in an area of lung. In large pleuritic 6o THE DISEASES OF THE LUNGS effusions it may be audible over the site occupied by the lung, and indicates that it is compressed or collapsed. It is occasionally audible over the whole of the affected side in cases of pleural effusion, especially in children ; when this occurs in adults, it is considered by some writers to indicate the existence of positive intrathoracic pressure ; as, however, it is occasionally present in cases of moderate effusion, that statement cannot be absolutely accepted. It probably indicates that the large bronchi of the collapsed lung are still patent. When a thoracic aneurysm or mediastinal growth is situated between the trachea or a large bronchus and the chest wall, bronchial breathing is often audible over the area occupied by the tumour. Broncho-vesicular Breathing, as the name implies, com- bines the characters of bronchial breathing with those of the normal respiratory sound, and indicates the presence of an amount of consolidation short of that necessary to produce bronchial breathing. It is heard normally over the manubrium in front, and the upper part of the interscapular region behind. In the in- spiratory sound the vesicular quality is diminished, but not absent ; the tracheal quality is more or less marked, according to the degree of consolidation ; the pitch is raised in proportion as the tracheal quality predominates over the vesicular ; the intensity is variable. The pitch, tracheal quality, and length of the expiratory sound correspond with the characters of the inspiratory sound. Tubular Breathing is the glottic sound conducted through an area of lung completely consolidated. Tubular breathing and bronchial breathing are often used as synonymous terms, but the former sound differs from the latter in possessing a ' whiffing ' character, and in its higher pitch. It is present typically in pneumonia, when the bronchi are patent. If present in tuberculosis, it indicates that a j)ortion of lung situated near the surface is completely consolidated, the bronchi being patent. Cavernous Breathing is a modification of the glottic sound, produced by the presence of a cavity within the lung or external to it, in communication with an open bronchus. The inspiratory sound is low-pitched, hollow, and blowing; the expiratory sound is still lower in pitch, has the hollow, blowing character more marked, and is usually more prolonged. It requires a partially empty cavity, in communication with an open bronchus, and at least equal in size to an unshelled walnut, to produce a breath sound of this character. The breath sound audible over the supposed cavity should always be compared with that over the lower end of tlie trachea, as errors in the diagnosis of cavities are of frequent occurrence, owing to the neglect of this precaution. Amphoric Breathing is a sound of variable intensity present- ing the hollow, blowing character of cavernous breathing i}i an exaggerated degree, and witli the addition of a distinctly ' metallic ' quality. PHYSICAL DIAGNOSIS 6r It indicates the presence of a laige cavity, either in the lung or in the pleura (pneumothorax), in communication with an open bronchus. The difference between vesicular, bronchial, tubular, cavernous, and amphoric breathing may be expressed in tabular form. Thus : 1 1 Pitch Quality luterval Duration Intensity- 1 Vesicular Breathing I. 1 E. Low Lower Vesicular Blowing - None E. shorter than I. ; or the sound may be absent during E. Variable 1 1 Bronchial Breathing i E. High Higher Tracheal \ (seventh cervical ',- Distinct spine) ' 1 Do. ) Tubular Breathing E. equal to or longer than I. Variable ! Greater I. 1 E. Higher than in bronchial breathing Higher Laryngeal or whiffing Do. 1- Distinct E. equal to or longer than I. Variable Greater Cavernous Breathing I. E. Low Lower Blowing and ■> hollow 1 Both - Distinct characters more marked i E. longer than I. Variable Greater Ainpho) •ic Breathing i Low Lower Hollow and metallic Both i characters I more marked - Distinct E. longer than I. Variable Greater I. = inspiration ; E. = expiration. Adventitious sounds. — A great variety of sounds to which, as a whole, the above term is applied, become audible in diseased conditions of the lungs, bronchi, and pleurae. Friction Sound is the name given to the rubbing, crepitant, or creaking sound heard on auscultation over the large serous sacs when their ordinarily smooth surfaces are roughened, usually by an inflammatory exudation. 62 THE DISEASES OF THE I.UNGS In the case of the pleura, apart from the rubbing nature of the sound, its evidently superficial character, and the fact that it is usually audible both with inspiration and expiration, help the dia- gnosis. It is, however, often very difficult to decide whether a sound having a crepitant character is of pleural or pulmonary origin. In quiet breathing, if the sound is audible from the very beginning of inspiration, or if it only appears at the end of a deep inspiration, if it remains unchanged by cough, and if there is localised pain in- creased by inspiration, it is probably due to the presence of a patch of exudation on the underlying pleura, or of fine fibrous adhesions. The pleural origin of a crepitant sound is often indicated by the discovery of a ' rubbing ' friction sound in its im- mediate neighbourhood. A pleural friction sound in the precordial area may acquire a ' to and fro ' character and cardiac rhythm under the influence of the movements of the heart. Such a sound usually ceases when the lung is fixed by holding the breath after a deep inspiration. Rhonchi are dry, musical sounds produced in the bronchial tubes. When low-pitched, loud, and snoring in chai'acter, they are termed so)wro2is ; when high-pitched and whistling, they are called sibilant, the pitch of the sound being chiefly dependent upon the calibre of the tube in which it is produced. Sonorous rhonchi usually indicate that mucus is present in the large tubes ; sibilant rhonchi that the lining membrane of the smaller bronchi is swollen. The former often disappear when the patient coughs ; the latter are usually uninfluenced by cough. Rhonchi may be audible during either inspiration or expiration, or may accompany both parts of the respiratory act ; in bronchitis and asthma they are, as a rule, especially marked during expiration. Stkidor is a harsh vibrating sound resulting from obstruction of the larynx, trachea, or a main bronchus. This sound may be caused by a variety of local conditions, but is in thoracic disease most often due to direct pressure on or narrowing of the trachea by an aneurysm or an intrathoracic tumour, or to syphilitic stenosis of the trachea, or to bilateral paralysis of the abductors of the vocal cords, the result of pressure on one pneumogasti'ic nerve or on both recurrent laryngeal nerves. Rales are sounds produced by the passage of air through exuda- tion in the alveoli or bronchi, and by the separation of the surfaces of collapsed alveoli or of the swollen lining membrane of the finer bronchi. They vary much in character, being chiefly influenced by the condition of the lung, in the neighbourhood of which they are produced. The presence of consolidated lung gives a sharp, crackling, explosive (quality to the sound, whereas, when the surrounding lung is of normal texture, it is usually of a bubbling character. Sounds of the first variety are termed (1) small, (2) medium, or (8) large, crackling or crepitant rales. (1) Small crackling rales are sharply defined crackling sounds of small size, and often few in number, chiefly audible during inspiration, but also during expiration. PHYSICAL DIA(;N0SIS 63 They indicate the presence of a lesion in the ultimate divisions of the bronchi, or in the pulmonary alveoli, the surrounding lung being usually in process of consolidation. Sounds of this character are present when a tubercular deposit is forming, or a pneumonic exudation is undergoing softening. (2) Medium crackling relics are sounds presenting the same general characters as the above, but of larger size. They occur during the softening of tubercular deposits, also in broncho- pneumonia, and in the process of absorption of a pneumonic exudation. (3) Large crackling rales are sounds produced at the site of softening in the lung, when the process has extended to such a degree that small cavities, the size, perhaps, of a pea or hazel-nut, have formed, the surrounding lung being still consolidated. They are usually fewer in number than either of the former varieties. Eales of this character are of frequent occurrence in tuberculosis, and are also heard when a pneumonic area is breaking down. Adventitious sounds, presenting a sharp ringing or metallic character, are sometimes called ' consonating rales.' The term is, however, founded upon a misconception, and it would be an ad- vantage if it were no longer employed. Moist sounds produced in the neighbourhood of spongy lung are termed (1) small, (2) medium, and (3) large bubbling or mucous rales. (1) Small huhhling rales are sounds differing from the corre- sponding rale of the former variety in that they are less sharply defined, and suggest the bursting of a soft bubble rather than the explosion of a minute shell. They are produced by the passage of air through fluid in the bronchioles, the surrounding lung being of spongy texture. Sounds of this character are heard in cases of capillary bronchitis, especially in children. The term ' subcrepitant ' is sometimes applied to sounds of this character when the crackling quality is present, but to a diminished degree. (2) Medium huhhling rales. — These sounds are similar in quality to those above described, but are produced in larger tubes, and are therefore of larger size. (3) Large huhhling rales. — The character of these sounds is almost sufficiently indicated by the name. They are produced in the larger bronchi and trachea by the passage of air through frothy mucus, and are heard in cases of bronchitis and pulmonary engorge- ment when the vital powers are failing. Gurgling rales are large, liquid sounds of a reverberating cha- racter ; they are produced in a cavity in the lung, and are best elicited by making the patient cough. Clicking sounds. — The character of these sounds is best illus- trated by whispering the word ' click.' They differ from rales in being more ' sticky ' in quality,' are produced during inspiration only, and are most often heard at the apex of the lung in tuber- culosis. The presence of 'clicks,' as they are called by those who 64 THE DISEASES OF THE LUNGS make use of the term, is generally considered to indicate tlie commencement of softening in a tubercular deposit. These sounds are not distinguished by German writers from crackling rales, and it must be admitted that the difference is but shght, and with difficulty appreciated by students of auscultation. Crepitation is a sound almost exactly similar to that produced by rubbing the hair between the fingers close to the ear. It re- quires no qualif}ing adjective, such, for example, as ' fine,' and its use should be strictly limited to sounds of this character. Crepitation is caused by the passage of air into vesicles either containing a fibrinous exudation or in a condition of collapse. It is heard typically during the latter part of inspiration in the early stage of pneumonia, and also at the bases of the lungs when in a state of oedema, lobular collapse, and hypostatic pneumonia. Metallic tinkling and Amphoric echo. — When a sound is produced in or near a large dense walled cavity (pulmonary or pleural) con- taining air, or in a neighbouring bronchus in communication with it, the audible echo of the sound acquires a peculiar quality, which, when single, clear ringing and high pitched, is best described by the terms ' metallic ' and ' tinkhng.' When low pitched and of • buzzing ' rather than ' ringing ' quality it is termed amphoric echo. The ' metallic ' quality of the sound is also present in amphoric echo but is less marked. Sounds of this nature may be produced during the act of breathing, by coughing, by speaking, or by the movement of the heart. Snccussion splash.— A peculiar splashing sound, described by Hippocrates, is produced by the sudden movement of air and fluid in a cavity. It is present in cases of hydro- or pyopneumothorax, and is elicited by shaking the patient or making him cough. In cases of thoracic disease, it must not be confounded with a similar sound originating in the stomach. Bell sound. — In pneumothorax, and when a very large cavity is present in the lung, if a coin placed flat upon the chest is struck with another coin, a sound like the tinkling of a bell may be audible through the stethoscope applied over the aft'ected area. Post-tiissive suction is, as its name imphes, a sound of ' sucking ' character heard immediately after a cough. It is a very important and most trustworthy sign of a cavity in the lung. For its produc- tion it is necessary that the walls of the cavity should be yielding. 30 that during the act of coughing it may be compressed, when a slightly hissing sound becomes audible. By its re-expansion air is di-awn rapidly through the bronchial orifice, and thus the sucking sound is produced. It is sometimes called ' the india-rubber ball sound.' Veiled puff.— This sound, as described by Skoda, although the term was previously applied by Laennec to a sign the exact nature of which is doubtful, is a single, rather high-pitched sound of a ' puffing ' character which becomes suddenly audible towards the end of inspiration. It suggests the impression that a whiff or puff' of air has been blown into a small cavity situated inuncdiately PHYSICAL DIAGNOSIS 65 beneath the end of the stethoscope. It is, we believe, a valuable sign of the presence of sacculated bronchiectasia of small size. Vocal resonance. — The voice sound, as heard over the healthy lung, is diffused, distant, and low pitched. It varies in intensity in different individuals, being chiefly dependent upon the quality of the voice. The vocal resonance is normally more in- tense in the neighbourhood of the trachea and large bronchi than elsewhere, and in the right infraclavicular region than in the left. It is diviinislied in intensity by the intervention of any badly conducting medium between the lung and the chest wall, a con- dition present in pleurisy with effusion, in some cases of thickening of the pleura, and in pneumothorax. It is also diminished owing to the extremely spongy condition of the lung present in emphy- sema. Occlusion of the bronchi, owing to the presence of morbid growths in the lung or mediastinum, or of solid fibrinous exudations filling the tubes, such as occasionally occurs in croupous pneumonia (massive pneumonia), produces a similar effect. The voice sound is increased in loudness, but without alteration in pitch, when a degree of consolidation of the lung is present insufficient to pro- duce bronchophony, or when the voice is transmitted through a cavity not surrounded by consolidated lung (Flint). The conduction of the whispered voice is modified by the same conditions as affect the loud voice, and in a similar manner. Bronchophony is a sound of variable intensity characterised by concentration of the transmitted voice, elevation of pitch, and a degree of nearness to the ear falling short of the condition requisite for pectoriloquy — i.e. the sound, though seeming to originate near to the end of the stethoscope, passes away from the observer, and does not appear to have been spoken from the end of the instrument straight into his ear. Bronchophony is usually found with bronchial breathing, and has the same significance. It is normally present over the lower cervical spines, in the upper part of the inter- scapular region, and over the sternal portion of the infraclavicular regions. Pectoriloquy is by some writers considered to be merely an exaggerated degree of bronchophony. It differs from it, however, in the fact that, whilst in the latter the noise only is transmitted, in pectoriloquy articulate sj^eech, in addition to sound, becomes audible. Pectoriloquy has been divided into ' broncho- phonic pectoriloquy ' and 'cavernous pectoriloquy,' the one variety indicating the presence of consolidation of the lung, the other of a cavity. If pectoriloquy is accompanied by the characters of broncho- phony (nearness to the ear and elevation of pitch) the transmission is by solidified lung ; if, on the other hand, speech is transmitted, and the characters of bronchophony are wanting, the inference is that the pectoriloquy denotes a cavity (Flint). If words articulated in a whisper are conveyed to the ear of the auscultator, whispering pectoriloquy is said to be present. The sign has the same general significance as pectoriloquy of the loud voice. Bacelli has sought to prove that the character of a pleural effusion may be deter- P 06 THE DISEASES OF THE LUNGS mined by the conduction or nonconduction of the whispered voice {vide p. 562). CEgophony is a term apphed to a modification of the vocal resonance, in which the transmitted sound has a nasal or bleating character. It occurs in pleurisy when the amount of effusion is moderate, and is most often heard about the angle of the scapula. It was believed by Dr. Stone to depend upon the interception of the fundamental vowel tone by the exudation and the passage of the harmonic overtones. For Dr. F. Taylor's views on the subject the chapter on ' Pleurisy ' may be consulted {vide p. 561). MENSUKATION Mensuration, or the act of measuring, is a means of physical diagnosis especially applicable in diseases and deformities of the chest. The methodical examination of the chest concludes with men- suration, by which means the actual shape and dimensions of the chest as a whole, and the relative measurements of correspond- ing parts on the two sides, may be ascertained and recorded. The instrument in general use for this purpose is the cyrtometer. which consists of two lengths of soft metal united by a short piece of india-rubber tubing. The centre of the junction is applied to the vertebral spine at the desired level, and the metal pieces are accurately moulded to the chest wall, and are marked where they overlap in the mid- sternal line on a level with the point of application to the spine. The instrument is now removed and placed upon a large sheet of paper, and a tracing taken of its outline. The antero-posterior, transverse, and other measurements are then determined. In diseases of the lungs or pleura such records are chiefly of value in cases of suspected intrathoracic tumour or of pleurisy in the stage of effusion, or subsequently when collapse of the lung has occurred and treatment is being dii'ected to promote its re-expan- sion ; also in cases of tuberculosis in the stage of quiescence or arrest, when it is desired to ascertain the effect of climatic or other treatment upon the capacity of the chest. It is necessary to bear in mind that the outline is that of the chest wall only, and that its shape will be altered by the develop- ment of muscle or the deposition of fat as well as by expansion of the lung, a source of fallacy which, to some extent, militates against conclusions derived chiefly from this method of examination. By means of a tape the circumference of the chest can be determined, and diflerences on the two sides, either during expan- sion or in repose, can be determined by the use of single or double tape meastU'es. For the detection of subclavicular depression the trained eye is of moie service than any instrument. PHYSICAL DIAGNOSIS 67 CAEDIO-PULMONARY SOUNDS Sounds closely resembling those resulting from organic disease of the valves of the heart, but really produced outside the heart, are frequently present in disease within the thorax. They are termed false or cardio-pulmoJiary murmurs. The various conditions which may give rise to these sounds may be classified thus : — 1. Displacement of, or pressure upon, the heart, the result of disease of {a) the lung, {h) the pleura, (c) the thorax, or [d] the abdomen. 2. Effusion into the pleural cavity. 3, Chaiiges in the pleura of the precordial area. 4. Changes in the lung overlying the heart. 5. Changes in the pericardium. 1. [a) Displacement of the Heart, the Result of Disease of the Lung. — As a result of the contraction of a cavity, say in the apex of the left lung, the heart is frequently found dis- placed upwards, or upwards and outwards. Under these circum- stances a systolic murmur is often heard in the second or third left interspace, having its maximum intensity about two inches from the edge of the sternum. The presence of the cavity and of the indurated lung surrounding it intensifies the murmur, which may be so distinct as to be audible over the greater part of the left chest. This sound, though more commonly suggesting aortic disease or a hsemic murmur in the pulmonary artery, may be mistaken for the murmur of mitral regurgitation. When the presence of the cavity is detected, and the displacement of the heart recognised, the differential diagnosis should not be difficult, especially when the somewhat rare association of tuberculosis and valvular disease is home in mind. {h) Pbessuee upon or Displacement of the Heart, the Result of Disease of the Left Pleura. — Perhaps of all the false murmurs none are more common or present greater difficulties in diagnosis than those caused by pressure upon the heart result- ing from the contraction of the left side of the chest after an attack of pleurisy. The pleura is probably thickened, and the lower lobe of the left lung partially collapsed, and at each systole a sound is produced by the sudden impact of the heart displacing the air in the larger bronchi. This may be audible not only at the apex and in the axilla, but also at the angle of the left scapula, in the trachea, and in the mouth. In one case, seen by the writer, a systolic murmur produced in this manner was distinctly audible at a distance of two feet from the patient, and the presence of an aneurysm of the aorta com- pressing the trachea had been suspected. This murmur may be present even during attacks of functional palpitation. (c) Displacement of the Heart from Deformity op the Chest. — Murmurs originating from this cause are occasionally met with. In a case under the care of the writer the lower part of the sternum was depressed to such an extreme degree that by careful measurement it was clear that its posterior surface was only f2 68 THE DISEASES OF THE LUNGS sejparated from the spine by a distance of about two inches. The chest in section was shaped like a crescent with blunted horns, the left one holding the heart, and the organ could be, so to speak, grasped by the hand, and all its movements distinctly felt. In that case a loud systolic murmur was present. {d) The Upward Peessuee of a Large Effusion into THE Peritoneal Cavity is sometimes the cause of a false murmur, systolic in time, and audible at either the base or apex of the heart. When the fluid is withdrawn by paracentesis, the murmur disappears. A similar murmur has been heard in cases of hydatid of the liver. 2. Effusion into the Pleural Cavity. — Displacement Murmur. — In some cases of pleural effusion, more frequently when the left side of the chest is affected, a loud and prolonged systolic murmur may be heard, either near the apex or at the base of the displaced heart. Such a condition is likely to produce a murmur either in the pulmonary artery or in the aorta by pressure upon the vessel, or, what is more probable when the murmur is localised at the apex, within the ventricle itself. The murmur disappears on the removal of the fluid from the chest, in some cases immediately, in others not until some time after the operation. 3. Changes in the Pleura of the Prjecordial Area. — The sounds simulating cardiac murmurs resulting from this cause ^\dll be found described under 'Friction Sounds.' 4. Changes in the Lung overlying the Heart. — In the subjects of pulmonary tuberculosis it is very common to hear a systolic murmur about the apex of the heart, which closely resem- bles the murmur of mitral regurgitation. The sound is caused by the impact of the heart upon the lung tissue partially consolidated, producing an audible sound by displacement of the air in the bronchi in a similar way to that already described. It is almost always most distinct during expiration, is superficial, high pitched, and disappears when the breath is held after a deep inspiration, and often becomes inaudible when the patient lies down. This murmur may sometimes be heard in the axilla and at the angle of the left scapula. The most common site of a murmur thus produced is not, however, at the apex of the heart, but in the second left intercostal space, about two inches from the sternum. In doubtful cases of early tuberculosis of the left upper lobe, the presence of this morbid sound is strongly suggestive of consolidation of the lung. In many of these cases, however, it is probably due to some dis- placement of the pulmonary artery, the result of the disease of the neighbouring lung. Apart from disease of tin; lung, a false systolic murmur may often bo heard about the cardiac apex in neurotic subjects when the action of the heart is markedly excited. 5. Changes in the Pericardium. — False murmurs, when due to chronic changes in that membrane, are frequently heard at one particular spot viz., the sixth left interspace and over the seventh rib close to the base of the ensiform cartilage. Here the PHYSICAL DIAGNOSIS 69 right ventricle is in contact with the chest wall, and it is on its anterior surface that the ' white patch,' due to localised thicken- ing of the pericardium, is most commonly found. The sound produced by the movement upon each other of the pericardial surfaces at this spot is systolic in time, usually short, sharp, localised, and superficial ; it seldom acquires a blowing character. In fact, it often resembles more nearly a rough reduplication of the first sound than a murmur. It is, perhaps, doubtful whether the altered sound, which is so commonly heard at this spot, is in all cases due to the presence of a ' white patch ' on the pericardium. It is especially common in emphysema with downward displace- ment of the heart. The effect of change of position upon this sound is variable. It may disappear entirely when the patient is in the recumbent position, as often happens with friction sounds audible elsewhere over the heart, whilst at times it is hardly at all affected by such a change. When the heart is not displaced, a murmur presenting similar characters may often be heard in the fifth left interspace close to the sternum. Thickening of the pericardium of the left auricular appendix occasionally produces a rough systolic murmur in the second left interspace. The following precautions should be observed in the examination of all cases presenting murmurs. Assuming that the presence or absence of those consecutive changes in the heart which are almost invariably associated with disease of any given valve has been noted, if there is still room for doubt, the following points must be observed carefully ; — 1. The exact period in the cardiac cycle occupied by the murmur. False murmurs are often not exactly synchronous with the com- mencement of systole or diastole ; they may precede or follow the one or the other. 2. The site of maximum intensity and the line of conduction of the murmur. These do not usually coincide with what is found with similar murmurs of organic origin. 3. The condition of the lungs. With doubtful apex murmurs evidence of pulmonary engorgement is strongly in favour of organic valve disease, as that condition is almost invariably absent in the reflux of anaemia. 4. The effect of change of position upon the sound. It is essential to examiiie every case of sus])ectecl valve disease both in the standing and recmnhent position. It may be stated with con- fidence that an opinion given in a doubtful case without observing this precaution is of no value. Functional and false murmurs often disappear when the patient lies down, whilst an organic murmur, especially that of mitral stenosis, may be only audible in that position. A murmur which suddenly and completely dis- appears when the patient lies down, provided there is not at the same time any marked alteration in the pulse-rate, is almost certainly not due to organic disease of a valve. 6. It is important in all cases to auscultate the trachea. A murmur audible in the trachea may be due either (1) to the con- 70 THE DISEASES OF THE LUNGS duction of the murmur of aortic stenosis ; or (2) to the impulse of an aneurysm ; or (3) to the impulse of the heart causing an air wave in the hronchi and trachea, this latter heing by far the most common cause of tracheal murmurs. Mitral murmurs are not audible in the trachea. 6. False murmurs often disappear completely when the breath is held. 7. The state of the pulse may at once negative a suspicion of organic disease founded on the presence of a murmur. J. K. F. 71 CHAPTEE III DISEASES OF THE TEACHEA PAGE Acute inflammation. Acute tracheitis . . . . .71 Chronic tracheitis ......... 72 Diphtheria . . . . .73 Tuberculosis 74 SyphiUs 76 New growths .......... 76 Stenosis 77 Symptoms and diagnosis ....... 77 A. Stenosis from disease originating within the trachea . . 78 Stenosis from syphilis ....... 78 ,, „ tracheotomy tube . . . . .79 B. Stenosis from compression ....... 80 Enlargement of thyroid gland 80 Enlarged glands ........ 81 Aneurysm and tumour ....... 82 C. Stenosis from extension of neighbouring disease . . 83 Treatment of stenosis ........ 83 Perforation of the trachea ........ 83 Symptoms . . 85 Foreign bodies in the trachea 85 Symptoms 86 Treatment .......... 86 Acute inflammation. Acute tracheitis. — Catarrhal inflammation of the trachea usually accompanies a similar con- dition in the larynx or bronchi. An ordinary ' cold ' may first give evidence of its presence by producing a catarrh of the pharynx : this may extend to the larynx, and subsequently travel down the trachea to the bronchi. But in some cases the inflammation of the trachea is primary, and the change may be localised there and constitute a definite affection. Symptoms. — A sense of soreness — or, as it is often termed, ' a raw feeling ' — along the trachea, and particularly behind the sternum, is the most prominent symptom. This will be accompanied by a harsh dry cough, and possibly by pain on swallowing. If the affection is limited to the trachea, the voice will not be affected. Such general symptoms as ordinarily accompany a severe cold will also be present. On laryngoscopic examination it may be possible to observe the reddened and swollen condition of the mucous 72 THE DISEASES OF THE LUNGS membrane, and in some cases small ulcers have been present. Provided the change does not extend to the bronchi, a favourable termination may usually be looked for in the course of a few days, but occasionally a condition of chronic inflammation supervenes and may require more prolonged treatment. Treatment. — If the patient is anxious to be quickly rid of his ailment he will be well advised to remain indoors in a warm room (temp. 05° F.) with a bronchitis kettle on the fire. Many, however, regard the affection as too trivial to justify absence from work. A hot linseed-meal poultice applied over the trachea or a mustard-leaf at the root of the neck often gives relief. Steam inhalations with compound tincture of benzoin (Sj ad 0j of boiling water) have a soothing effect upon the inflamed mucous membrane ; they should be used for about ten minutes at intervals of an hour throughout the day. A hot mustard bath for the feet and a hot drink at bed- time are domestic remedies of approved value. A Turkish bath acts well in some cases, but we have known the dry heated air prove very irritating to the inflamed trachea. A saline diaphoretic mixture with a sedative (liq. ammon. acet. 5iv; spir. tietheris nitrosi )H.xx ; tinct. camph. co. in.xx ; aq. camph. ad 5J) may be taken every four hours, and a saline purgative should be administered. Chronic tracheitis. — This may be a sequel of an acute in- flammation which has probably been neglected, or it may accompany chronic bronchitis, particularly in the aged. It should be treated on the lines above laid down. There is also, however, a very rare form of chronic inflammation of the trachea attended by great thickening of the mucous membrane, which is a much more serious affection. In some of the few cases of this kind which have been recorded the disease has probably been due to syphilis. The following case is an example of chronic tracheitis, and its recital will best describe the symptoms and complications which characterise it, and the treatment which may be necessary. Edith B., fet. 25, admitted into the Brompton Hospital December 5, 1887, under the care of Dr. Percy Kidd. Five years ago the hair became thin, but she had no sore throat, rash, or other symptoms of sypliilis. Cough has been present for four years. Two years ago the patient first noticed inspiratory stridor. Dyspnoea has of late been increasing, and she now has orthopnoea at night. She has had several attacks of bronchitis during the period covered by the illness. Expectoration is very slight in amount. There has been no hemoptysis. Considerable emaciation has occurred, and she Las had occasional night sweats. There is no glandular enlargement, and no dysphagia. Examination of larynx. — The vocal cords were healthy and freely movable. Low down in the tracliea, apparently about half an inch above its bifurcation, a yellowish-white swelling was seeii on the posterior wall. This was believed to be a new growth, and the treatment adopted was undertaken with a view to its removal. DISEASES OF THE TRACHEA 73 On December 16 the patient was antiBsthetised, and Mr. Godlee performed tracheotomy below the isthmus of the thyroid gland. The third, fourth, fifth, and sixth rings of the trachea were divided, the incision extending to the episternal notch. A prominent fleshy-looking ridge was seen on the posterior wall of the trachea extending downwards almost to the bifurcation. There was no definite isolated tumour. A probe was passed without marked difiiculty into each main bronchus. Just above the bifurcation the swelling appeared to be more prominent than elsewhere. The upper part of the trachea was quite healthy. The surface of the promi- nence was cauterised with a galvano-caustic wire as far as its lower border. The patient was very seriously ill for five weeks following the operation, which was followed by bronchitis and broncho-pneumonia. Subsequently pericarditis su- pervened, but ultimately re- covery was complete and the stridor disappeared. On the day of the patient's discharge the bifurcation of the trachea was distinctly visible with the aid of the laryngoscope ; there was no bulging there, and the part presented a normal appear- ance. Microscopical examination of a small portion of the growth showed that it was covered with stratified epithe- lium in place of the normal columnar layer. Diphtheria. — In this disease an exudation com- mencing in the larynx very often extends to the trachea, and thence to the main bronchi and their branches, even the smaller tubes being affected. In the trachea the membrane may form a com- plete cylinder loosely attached to the tube, but in the smaller bronchi it is usually soft and puriform. In the accompanying draw- ing (fig. 44) the appearances above described are illustrated. Symptoms.— In a case of laryngeal diphtheria it is usually only an inference from the increasing severity of the dyspnoea, the onset Fig. 44. — Diphtheeia of the Larynx, Trachea and Bronchi a ami b, membrane in the trachea and broiiclii. 74 THE DISEASES OF THE LUNGS of cyanosis, and the more marked retraction of the lower ribs and interspaces, that the membrane has extended to the trachea and bronchi. Treatinent. — This condition indicates the necessity for tracheo- tomy. When the operation has been performed, membrane will be seen within the trachea, and as much of it as possible should be removed with a feather before the tube is hiserted. Casts of the lower part of the trachea and larger bronchi may subsequently be expectorated or removed in a similar manner. Such cases are not hopeless, but the prognosis is very grave. Tuberculosis. — Tubercular disease of the trachea is practi- cally unknown as a primary affection, but is by no means un- common as a complication of pulmonary tuberculosis. It is usually met with in cases in which the larynx is also involved, but may occur without any lesion in the latter site. Both membranous and cartilaginous portions are usually together affected, but the anterior wall may show the most advanced disease. Infiltration of the mucous and submucous coats of the membranous portion is followed by deep ulceration and thickening. Small rounded super- ficial erosions or ulcers, limited to the mucous membrane, are often seen over the cartilages. As the disease advances, these unite and lay bare the cartilages. This change, combined with much deeper and more extensive ulceration and swelling of the intervening tissue, often gives the anterior Avail the appearance of being formed by successive rings from above downwards, the smooth surface of the bare cartilage alternating with a ring presenting a coarsely granular aspect. In fig. 45 the appearances just described are illustrated, and the alternating smooth and roughened rings are well seen. The extent of the disease varies. In very advanced cases the whole length of the tube may be involved, and the lesion may extend into the main bronchi. Perforation may occur into the cellular tissue of the neck and be followed by subcutaneous emphysema. The cases of pulmonary tuberculosis in which lesions of the trachea are of most frequent occurrence are such as have run a rapid course and have been characterised by abundant expectora- tion of a thin purialent character. Similar secretion can be obtained post mortem, on pressure from the cavities and areaa of infiltration and softening within the lungs. The lesions are occasionally confined to the trachea, or are more advanced there than in the larynx. In 214 consecutive post-mortem examinations ' on cases of pulmonary tuberculosis the trachea was affected, and the larynx escaped in IH, wliilst in 28 of the cases both larynx and trachea were together involved. Symptoms. — Ah a rule the symptoms due to the accompanying pulmonary disease are so urgent as to mask those of the tracheal complication. ' P. M. lirgisfcr, JJiompton Hospital, 189H-i»4 DISEASES OF THE TRACHEA 75 When the larynx is also affected it is still less likely that it will be possible to recognise the tracheal lesion by any definite symptoms. Pain in the tracheal region may be complained of, and the cough in such cases is usually extremely severe. iipf,iii^i)i|ifi'iiil^ '11 mmm'^ FlG. 45. — TUBEECXJLAE UlCEEATION OF THE TeACHEA Treatment. — A cocaine spray (2 to 5 per cent.) may temporarily diininish the pain and distressing cough which usually accompany this affection. An insufflation of a powder consisting of morphine gr. ^ with sacch. lactis gr. ij is of great service in advanced 76 THE DISEASES OF THE LUNGS tubercular ulceration of the larynx, and may also be used for a similar condition of the trachea. Sedative inhalations of benzoin, hyoscyamus, hop,conium, or chloroform are also of service. The cough may also be relieved by the inhalation of ten minims of a 10 per cent, solution of menthol dropped on to the sponge of an oro-nasal inhaler, which may be worn for some hours at a time. In cases in which the condition of the larynx permits the use of intratracheal injections, it is possible that a solution of menthol (10 per cent.) in olive oil (5j) might give relief, but we have no actual experience of this mode of treatment in cases of tubercular ulceration of the trachea. Syphilis. — The trachea may share in the catarrhal symptoms which occasionally affect the bronchi in the secondary stage of syphilis. Nothing very definite is known as to the exact nature of the lesion in such cases ; it is possibly similar to that of the larynx, viz. a formation of mucous plaques. Cough and expectoration are almost invariably present. The trachea is often the site of tertiary syphilitic lesions, and as the majority of cases of stenosis from cicatricial contraction are of this nature, it will be more convenient to discuss the morbid anatomy of the condition under that heading. Treatment. — The presence of lesions in the trachea in the secondary stage of syphilis may be regarded as a proof either that mercurial treatment in the primary stage has been neglected or has not been sufficiently prolonged, or that the general health of the patient is impaired. In the former case a course of mercurial treatment of from one to two years' duration is essential ; in the latter the desirability of such treatment must be left to the judgment of the medical attendant. Iodide of potassimn in gradually increasing doses may be combined with the mercury. No effort should be spared to maintain the general health at as high a standard as possible, as under such a condition antisyphilitic treatment is much more likely to be successful. In the tertiary stage of syphilis it is of course hopeless to expect that well-marked stenosis due to the contraction of newly formed fibrous tissue will disappear under treatment by mercury or iodide of potassium, but their use may favourably influence the course of lesions which have not advanced to this stage, and is certainly worthy of prolonged trial. New growths. — New growths are not often met with in the trachea. Papilloma may occur and nuiy be successfully removed after tracheotomy.' A malignant growth may originate in the trachea, or, what is far more common, a primary cancer of the oesophagus may involve the trachea by extension. It will at first cause dyspncea and stridor, and, after softening and ulceration, cough with expectoration will follow. Such cases often terminate by the occurrence of dilfnse septic pneumonia. ' See St. /iart.'s Hosj). Hi'jiorts, vol. xviii.. hy Mr. lUitliii. Specimen ICi^Cta, St. Bart.'s Hosp. MuKeuin. DISEASES OF THE TRACHEA 77 Polypi are met with in the trachea, but are very rare. The symptoms will be those of tracheal obstruction, and their severity will depend upon the size of the growth. Osseous and cartilaginous growths have also been observed in the trachea, but such cases are exceedingly rare. It may be necessary, both for diagnosis and treatment, to perform tracheotomy. Stenosis. — Narrowing of the trachea may be due (a) to lesions origina.ting within, (b) to pressure from without, or (c) to the trachea becoming involved by the extension of morbid processes from neighbouring parts. Symptoms and diagnosis. — Dyspnoea is the most important symptom of narrowing, to whatever cause that may be due. It comes on gradually, and increases in proportion to the degree of stenosis. When this is considerable the dyspnoea may become paroxysmal in character and be so severe as to threaten life. Orthopnoea may be present, and short of this the breathing is often more embarrassed when the patient is lying down. Cough may be due to irritation or to the collection of mucus behind the obstruction. The latter condition gives rise to coarse tracheal rales, and when the quantity of mucus is considerable may be the immediate cause of the paroxysmal attacks of dyspnoea. The breathing is accompanied by stridor, chiefly on inspiration, and suggesting laryngeal obstruction ; but the larynx on examination may prove to be unaffected, and the stricture of the trachea may be seen. On auscultation over the trachea it may be possible to deter- mine the site of maximum intensity of the sound, and this may be a guide to the position of the stricture ; but in some cases the stridor is most marked over the larynx. Apart from the evidence obtained on laryngoscopic examination, the signs indicating tracheal as distinguished from laryngeal obstruction are that in the former condition the ' respiratory excursion ' of the larynx will not be increased and the voice, although weak, will not necessarily be otherwise affected. The position assumed by the patient in the two affections also differs. In laryngeal obstruction the patient as a rule sits up with the head thrown backwards, whereas in tracheal stenosis the head is held forwards with the face looking downwards. The breath sounds, though weak, will be equal on the two sides if the narrowing is confined to the trachea ; but it must be remembered that syphilitic lesions often affect one of the main bronchi to a greater degree than the other as well as the trachea. Aufrecht has recently described a ' mewing ' inspiratory murmur, most marked when the patient makes any bodily exertion, as characteristic of tracheal stenosis. The same author has observed that in some cases of tracheal stenosis the harsh bronchial sounds normally audible over the lower end of the trachea are replaced by soft low breath sounds of short duration or are not audible at all. 78 THE DISEASES OF THE LUNGS A. Stenosis from Disease originating within THE Trachea Syphilitic Stenosis. — Morbid anatomy. — The disease com- mences as a localised gummatous infiltration of the mucosa, causing, in the early stage, considerable swelling. The gumma may be absorbed and a cicatrix result, or it may break down and an ulcer form, and this may heal with the production of a scar. Portions of the cartilages may undergo necrosis after perichondritis and may be expectorated, or one or more cartilages may be absorbed. On laying open the trachea by section through the posterior wall berjeau Fifi. 16 Syphilitic Stenosis of thk Ti;aihi;a and main Uuonchi it may be found to present one or two or numerous cicatrices, and in severe cases the tube almost from end to end may be covered by white fibrous scars having a radiating appearance. The sub- mucous layer may be extremely thickened, measuring perhaps a quarter of an inch or more on section, and the lumen may be much diminished. The narrowing may be limited to or most marked at one spot, or may extend for some distance. The tube may be dilated above and below the seat of the stricture. The disease is DISEASES OF THE TRACHEA 79 most often situated at the lower end of the trachea. The accom- panying drawing (fig. 46) of a specimen in the museum of Brompton Hospital illustrates these changes. The patient was a woman aged 2o, whose case is reported in full in the chapter on Pulmonary Syphilis (see p. 447). The lesions in the trachea are thus described : ' 'A few small scars in the subglottic portion of the larynx. The lower half of the trachea was marked by numerous stellate puckered cicatrices, involving both membranous and cartilaginous portions, but especially the latter. The origin of the left bronchus was represented by a small opening, just admitting a probe. The surround- ing parts of the tracheal wall were extremely fibrous and puckered. There was scarring in the right bronchus, about the origin of the upper lobar branch.' The following is a description of the condition present in a case of syphilitic stenosis of the trachea of many years' duration, illustrated in fig. 47. ' On the anterior surface, about an inch from the larynx, is a patch of superficial ulceration. About two inches below this point the trachea is markedly constricted by a well-defined narrow ring of cica- tricial tissue with a sharp margin. Immediately above the bifurcation is another constriction, produced by extensive scarring and puckering of the wall ; between the two the lumen is narrower than normal. At the level of the lower stricture there is a mass of indurated and pigmented glands firmly uniting the trachea to the aorta. There is no ulceration of the lining mem- brane, or other evidence of recent change.' Stenosis following teacheotomy. — The irritation caused by the long-continued presence of a tracheotomy tube may lead to a growth of granulation tissue which may become organised into fibroid tissue and undergo contraction, the result being a narrowing of the trachea after the cicatrisation of the wound. The term ' post- Fitt. 47. -Syphilitic Stenosis of THE Tkachea Eepoited by Dr. Percy Kidd, Path. Soc. Trans, vol. xxxvii. p. 111. 8o THE DISEASES OK THE LUNGS tracheotomic vegetations, or polypi,' is applied to these growths. The condition is most frequently met with in male children, from a fortnight to a month after the wound has healed. B. Stenosis from Compression Enlargement of the thyroid gland, either as a whole or in part, may cause narrowmg, varying in kind and degree. Fig. 48 illustrates the alteration in the lumen of the tube which may result from enlargement of the isthmus and both lateral lobes Fig. 48. — Stknosis ok thk Tkachea khom icnlaugement of the TirYuoii) Glani> of the thyroid. The transverse diameter is seen to be diminished to such a degree that the walls are almost in contact. Below the site of narrowing the trachea is dilated. The middle lobe was spherical, as large as a tennis ball, and in an advanced stage of colloid degeneration. JJoth lateral lobes were considerably enlarged, and were compressed by the cervical fascia and muscles. The lower part of the trachea was coated with a false membrane, consisting of inspissated pus. The goitre had been present for DISEASES OF THE TRACHEA 8i eight years. Death was due to extensive tubercular disease of the lungs. The alteration in the axis and lumen of the trachea illustrated by figs. 49 and 50 ^ was produced by a growth containing within a fibrous capsule glandular structure similar to that of the thyroid (? parathyroid). The specimen was taken from a man aged 36, who was found dead in a street adjoining the Middlesex Hospital. No history of the case could be obtained. The tumour was possibly a parathyroid embedded in a thick fibrous capsule. The inner segment was firmly fixed to the trachea from the fourth to the ninth ring. The central part of the tumour exhibited under the microscope the characteristic structure of the thyroid gland. The capsule Fig. 49. — A Growth containing Thy- roid Gland structure compressing THE Trachea Fig. 50. — Section of the Growth and of the contained tumour AND Trachea, showing the degree OF Stenosis (natural size) consisted of dense laminae of fibrous tissue. The cyst on the thyro-hyoid membrane (fig. 49) was due to an enlargement of the bursa which is usually present between the body of the hyoid bone and the thyro-hyoid membrane. The e£fects produced by an enlargement of one lateral lobe of the thyroid are similar to those illustrated by figs. 49 and 50. The trachea may be compressed from the front by an enlarge- ment of the isthmus of the thyroid gland, and in cases in which the enlargement is extreme its lumen may be almost obliterated. Enlarged glands may compress the trachea and cause thinning, erosion or narrowing. In the neck the enlargement may be due to various causes. It is rare in adults for tubercular glands to cause • See Brit. Med. Jmir. March 2, 1895, p. 463, Clinical Lecture by Mr. J. Bland Sutton. G 82 THE DISEASES OF THE LUNGS serious compression, although in children this may occur. ^Ir. Making has reported a case ' (a child «t. 3 years) in which a sup- purating gland caused death by pressure on the trachea without the occurrence of perforation. In a case in an adult recently under the writer's care in the I>rompton Hospital, glands enlarged from tuberculosis caused such a degree of displacement of the larynx and trachea that the apex of the thyroid cartilage lay three-fifths of an inch to the opposite side of the median line. In syphilis the glands of the neck may enlarge and compress the trachea, and the enlargement may even be so considerable as to suggest a diagnosis of lymphadenoma. The lower part of the trachea within the thorax may be compressed by enlarged glands or by a mediastinal groivth, and in both cases the main bronchi may also be involved. An ANEURYSM of the carotid or innominate artery, or of the transverse part of the arch of the aorta, may compress the tube, and an abscess due to caries of the spine may have a similar effect. Symptoms and diagnosis of compression. — In the majority of cases the cause is obvious, but, if not, a careful examination of the upper part of the thorax must be made for signs of aneurysm or tumour. The presence of ' tracheal tugging,' with feeble or absent breath sounds over the left upper lobe, pomts very strongly indeed to aneurysm. The differential diagnosis of these two conditions is fully discussed in the chapter on Mediastinal Tumours (p. 691). It is, however, possible in cases of compression by an aneurysm or growth that narrowing of the trachea may be accompanied b} paralysis of the intrinsic muscles of the larynx from implication of the vagus or of one or both recurrent laryngeal nerves, or by fixation of one vocal cord from local disease of the larynx.'- In such cases the diagnosis may present some difHculty. The patient from whom the specimen illustrated in fig. 47 (p. 79) was obtained was long believed to be the subject of an- eurysm of the aorta, owing to the fact that in addition to the tracheal stridor there was fixation of the one vocal cord. On autopsy this was found to be due to local tuberculous disease, and not, as was expected, to pressure on the recurrent laryngeal nerve. It may also be difficult to distinguish between the symptoms arising from the presence of a malignant growth originating in or invading the trachea, and narrowing due to syphilis. The longer the tracheal symptoms liave lasted without producing definite signs of stenosis the more probable it is that they are due to syphilis. Marked stenosis, when the symptoms are of recent date, points to the presence of a groivth. ' I'dlli. Sue. Trans, xo], xxxv. -' Jbiil. vol. xxiv. ]). 4'2. DISEASES OF 1"HE TRACHEA 83 C. Stenosis fkom Extension to the Trachea of Disease IN Neighbouring Structures This occurs most frequently in malignant disease of the oeso- phagus, and owing to the fact that in some cases of that nature dysphagia is very slight or even absent, the origin of the disease in the oesophagus often remains unsuspected up to the time of the patient's death. Primary malignant disease of the bronchial or mediastinal glands may also invade the trachea and cause narrow- ing of its lumen. Treatment of stenosis. — It may become necessary to resort to tracheotomy in the event of the narrowing tending towards occlusion. It is scarcely necessary to point out that before the operation is decided on it is absolutely necessary to determine the site of the obstruction, and to make sure that the trachea can be opened below it. A careful examination of specimens of tracheal syphilis will show that in such cases the operation can rarely be of much service, owing to the fact that the disease is either not sufficiently localised or is situated too low down. It may, if unsuccessful, do harm, as it renders the cough less effective ; and as in such cases expectoration is often profuse, if it is allowed to accumulate, in- flammation and gangrene of the lungs is very hkely to follow. In cases of compression of the trachea associated with bilateral paralysis or spasm of the intrinsic muscles of the larynx from the pressure of an aneurysm or tumour upon one vagus, or from the implication of both recurrent laryngeal nerves, tracheotomy may give great relief for a time. Paroxysmal dyspnoea from compression of the trachea by an aneurysm may be reheved by inhalations of oxygen. In a case recently under the care of the writer this treatment alone gave relief. Subcutaneous injections of ether (nix) or strychnia (gr. ;fo— 5V) or inhalations of chloroform may also be tried, A mixture containing ether and ammonia may be given as a stimulant, and will also aid the patient in getting rid of accumulated mucus. In cases in which this latter symptom is not prominent, and where there is considerable nervous distress, morphia may be injected subcutaneously. If, as sometimes happens, the true cause of the paroxysms of dyspnoea has not been recognised, and a patient suffering from compression of the trachea by an aneurysm of the transverse arch of the aorta has been treated for ' bronchitis and emphysema,' rest in bed with gradually increasing doses of iodide of potassium will be quickly followed by great relief to the symptoms. PEKFOEATION OF THE TKACHEA The trachea may be perfdrated by a caseous lymphatic gland or by an aneurysm, or by a growth originating in the oesophagus. A collection of pus may also penetrate the trachea, but such an event is of rare occurrence. G 2 84 THE DISEASES OF THE LUNCiS If a gland, after perforating the tube, should undergo gradual disintegration, a diffuse broncho-pneumonia or tuberculosis may be set up, and may prove fatal. If, as occurred in a case observed by the writer, a communication is simultaneously established with the cesophagus, diffuse gangrene of the lung may follow. In rare cases the gi'eater part of the gland is discharged as a solid mass into the trachea, an event which may be immediately followed by death from asphyxia. Fig. 51 illustrates such a case. The patient was a boy aet. 7 years, admitted into the Brompton Hospital for a croupy cough and slightly stridulous breathing. He was apparently in fair health in the afternoon and was walking Fig. 51. — Pkkfoeation of the Trachea hy an enlaugkd Gland, and DISCHARGE OF THE GlaND INTO THE TrACHEA about. During the night he suddenly jumped up in bed, screamed, and gave a croupy cough. Death from asphyxia occurred in less than ten minutes.' A calcareous gland may rupture into the trachea and also into the aorta, and sudden death may occur from hiomorrhage into the lungs. The accompanying drawing (fig. 52) illustrates the effect pro- duced upon the trachea by perforation of an aneurysm of the in- nominate artery. The small nipple-like projections indicate points where rupture was impending from gradual erosion of the wall. ' The case is reported by Dr. I'urcy Kiild in the Pathological Society's 'I'lansactions, vol. xxxvi. p. 104. DISEASES OF THE TRACHEA 85 The specimen was taken from a man who was brought into the Middlesex Hospital dead. No history of the case could be obtained. Sy^nptoms. — The rupture of an aneurysm will be immediately followed by hfemoptysis, which is usually quickly fatal ; but in some cases only slight leakage occurs at first and life may be prolonged for a few days or more. The haemorrhage may cease and recur. The results of perforation by a gland have already been described. Perforation by an abscess will be followed by the expectoration of the pus, but probably a certain quantity will be inhaled, and if death does not immediately occur pneumonia may supervene. Fig. 52. -Peefokation of the Teachea by an aneurysm of the Innominate Aeteky Foreign Bodies. — A foreign body is more likely to lodge in one of the bronchi, especially the right, than in the trachea, as after passing the larynx it is not usually arrested above the bifurcation. A great variety of substances too numerous to mention have, however, been found in the trachea. A coin may become impacted in the trachea, and it may be possible, by the aid of the Rontgen rays, to determine its exact position. In a case under the care of the writer a portion of a tumour — a 86 THE DISEASES OF I'HE LUNGS sarcoma— Avhich had been moulded by extension into a large bronchus into the form of a solid cylinder, became detached, and was driven during an attack of coughing into the trachea, and becoming impacted below the vocal cords, caused sudden death from asphyxia. Si/iiqjtoin.s.— ^hisenma contain a large number of specimens showing portions of meat and other substance impacted in the larynx and extending through the glottis into the trachea. In such cases death from asphyxia is immediate. When the body is of smaller size and passes the larynx its presence in the' trachea causes dyspnor'a, varying in degree with the amount of obstruction to the breathing. Violent spasm is excited, particularly by bodies with roughened surfaces, and this by still further narrowing the tube increases the dyspnoea. In all the cases here described sudden asphyxia was produced by the body being forced by violent cough against the under surface of the glottis. A body such as a fish bone may become fixed in the wall of the trachea and may not cause obstruction, although it will give rise to pain, especially when the trachea is moved in the act of swallowing. Treatment. — If the foreign body can be seen on tracheoscopic examination, or if its position has been determined by the aid of the Rontgen rays, an effort may be made to remove it by the use of long tracheal forceps, an operation re(]uiring for success considerable skill and some good fortune. This failing, tracheotomy should be performed. J. K. F. 87 CHAPTER lY BEONCHITIS PAGE Classification 87 (a) Acute bronchitis of the larger tubes 87 Morbid anatomy ......... 87 Etiology 89 Symptoms and course 90 Physical examination ....... 92 Diagnosis 92 Prognosis 93 (b) Acute bronchitis of the smaller tubes. Capillary bronchitis 94 Morbid anatomy ' . 94 Etiology . . 94 Symptoms 94 Physical signs 95 Course 95 Prognosis 95 Diagnosis 96 Treatment of acute bronchitis of the larger tubes 97 „ of capillary bronchitis 99 A catarrhal inflammation of the bronchial tubes, of which the chief symptoms are cough, expectoration, and dyspnoea. Classification. — The varieties of bronchitis are so numerous that a single description will not suffice for all. The course of the disease is the basis for the first subdivision into the acute and chronic forms. The size of the tubes affected has such an important influence upon the severity of the attack that a separate account is necessary of Bronchitis of the Smaller Tubes. The disease occurs as a complication of so many and such diverse disorders as to require consideration under the head of Secondary Bronchitis ; and, lastly, a special and rare form of inflam- mation of a different character — Plastic Bronchitis — is so clearly marked off from any of the preceding varieties as to constitute practi- cally a separate disease. The disease will be described under the following headings : 1. Acute Bronchitis {a) of the Larger Tubes ; {b) of the Smaller Tubes. 2. Chronic Bronchitis. 3. Secondary Bronchitis. 4. Plastic Bronchitis. {a) ACUTE BEONCHITIS OF THE LARGER TUBES Morbid anatomy. —The first change observed in inflam- mation of the bronchi is hyperemia of the vessels of the inner 88 THE DISEASES OF THE LUNGS fibrous coat, which becomes swollen, relaxed, softened, and infil- trated with lymph cells. This is followed by oedema of the base- ment membrane, the surface of which now presents a wavy and folded appearance. These changes in the basement membrane loosen the attach- ment of the ciliated columnar epithelium, which separates in patches, and is shed into the lumen of the tube, whence it is either expectorated or inhaled into finer tubes. From the flat cells of the deeper layer of the epithelium thus exposed, new cells presenting various transitional forms, oval or pyriform, continue to be produced, cast off, and expectorated, along with the masses of Fig. 53. — Acute Bkonchitis Transversa section of nii'iliuni-sizeil bronclms, sliowing ((i) submucous iufiltnition with partial loss of eijitlit'liuiii : (6) detached epithelium in lumen of bronchus enilicilded in cellular exudation ; (c) epitlielium intact : (d) peribronchial infiltration. leucocytes which have left the congested vessels. As the change progresses, all the structures of the bronchial wall become in- volved, and leucocytes infiltrate the muscular and outer fibrous coats, and in the latter many larger flattened cells are seen : these probably arise from proliferation of the lymphatic endothelium (Hamilton). The hyperjemia of the mucous glands of the bronclii loads to an enormous increase in the secretion and discharge of mucus, the epithelial and secreting elements of the glands undergoing at the same time a process of desquamation. These changes naturally cause considerable narrowing of the tubes, some of the finer bronchi being completely occluded. Around BRONCHITIS 89 the latter, areas of collapse and broncho-pneumonia are frequently found, especially in children, the occluded tubes being not un- commonly dilated. The lymphatic glands along the main bronchi and at the root of the lung are enlarged from hyperemia, and the nerve ganglia are congested. On i)ost-morteyn examination the lungs are usually large and heavy, but nowhere completely consolidated. Areas of collapse, if present, are sharply defined and of a deep purple colour. The bronchial mucous membrane presents a velvety appearance and still shows the effect of hyperaemia, but this is probably in all cases less marked than during life. The larger tubes contain much mucopurulent secretion, and on section beads of pus may be squeezed from the finer bronchi. The posterior part of both the upper and lower lobes may be almost solid from oedema, collapse, and con- gestion, a more or less frothy watery fluid pouring out on pressure. Emphysema is commonly present upon the surface and along the margins, varying in extent according to the nature of the case, being often in part a relic of previous attacks of bronchitis. The right cavities of the heart are dilated and filled with blood, and the tricuspid valve may show marked incompetence. When the patient has succumbed to an acute attack which has supervened upon a chronic condition, an event of by no means uncommon occurrence, hypertrophy of the right ventricle will also be present. Dilatation of the large vessels carrying blood to the right side of the heart, and congestion of the organs, which they drain either directly or indirectly, are necessary consequences of the cardiac lesions. Etiology. — A chill from exposure to cold is the immediate exciting cause in many cases of bronchitis. Its mode of action in this as in other affections is obscure, and its importance as a factor in the causation of disease has possibly been over-estimated ; but as regards catarrh of the respiratory passages the belief in it remains unshaken. The effects of a chill are diverse. This may be explained by the fact that almost every individual has his ' weak point,' and in some at least this is an undue susceptibility of the mucous membranes to catarrhal inflammation. In cold and damp climates, and especially in the winter months and during the prevalence of cold winds, which in this country blow most commonly from the east and north-east, attacks of bronchitis are of most frequent occurrence. Imimrity of the air, from whatever cause arising — e.g. over- crowding, deficient ventilation in gas-lit workrooms, the presence of fog, or of irritating dust in suspension in the air — is another important factor in producing the disease, the condition acting either by its direct effect upon the mucous membrane, or by lowering the resisting power of the individual exposed to the injurious influence. That previous attacks increase the liability to the aftec- tion is undoubted, and that this is in great part due to the emphysema left behind is highly probable. The special liabihty of the subjects of spinal curvatiire to 90 THE DISEASES OF THE LUN(;s bronchitis arises from the distortion of the chest thereby entailed, and its effect upon the hin<>s. In cases of lateral curvature the posterior part of the lung on the convex aspect of the curve tends to become congested and collapsed from narrowing of the chest, and the opposite lung undergoes compensatory enlargement. Cough is excited by the congestion, emphysema follows, and the liability to bronchitis thus becomes established. Obstruction to the circulation joi the blood through the lungs, such as occurs in chronic valvular disease, by inducing pulmonary congestion, becomes an important etiological factor in bronchitis. Weakening and destruction of the elastic tissue of the lungs, and the change which follows thereupon — i.e. einplujsenia — by giving permanence to conditions favourable to the disease, also increase the tendency to its recurrence. Whatever views may be held as to heredity, it will hardly be denied that parents inay transmit to their offspring a constitution lacking in the resisting power to disease possessed by the healthy organism. It is at any rate probable that this lack of resisting power may specially affect certain organs or tissues, such as those of the respiratory system, or the mucous membranes. If this is so, it follows that a peculiar liability to catarrhal inflammation may be inherited, a conclusion fully justified by clinical experience. The presence in the body of some toxic materials, whether derived from without, as in the case of many of the acute specific diseases, especially measles and typhoid fever, or from within, as in gout and chronic Bright's disease, is also a frequent cause of bronchitis. Symptoms and course. An attack of acute bronchitis may vary in severity from that of a mild catarrhal inflammation of the trachea and larger bronchi from which recovery follows in a few days, to that of a severe or fatal illness ; but the cardinal symptoms — cough, expectoration, and dyspna'a — are never wholly absent. This statement may pass, although it is true that children below the age of five years do not expectorate, and that the dyspnwa caused by a slight catarrh of the larger tubes may be inappreciable. The mode of onset of the attack usually gives some indication of its probable severity. As a rule, when the disease is of a mild char- acter and limited to the trachea and larger tubes, it connnences as an ordinary catarrh, either nasal or laryngeal, accompanied by lioarseness and a tickling sensation in the throat, or with a sense of rawness behind the sternum from implication of the trachea. In an individual rendered susceptible by the presence of emphysema, the result of previous attacks, the onset is likely to be attended by a sense of tightness in the chest, an indication that the medium-sized bronchi are prinuirily att'ected. In similar cases the disease may present urgent symi)toms at a very early stage, begin- ning with a sense of oijprossion of the breathing, which quickly develops into marked dyspnoja. In children and old people an attack is often sudden in onset and severe in typo, and the liability to a fatal termination is far greater than in early adult and middle life. BRONCHITIS 91 The symptoms which usually accompany a chill, such as general malaise and pains, are present, but rigors are of rare occurrence. The degree of pyrexia is moderate, a temperature above 100'5° or 101° F. being unusual in an adult, but by no means so in a child. Cough is an early symptom. It is at first short, dry, and hacking, and often occurs in severe paroxysms. The cough retains this character until the hypenemia of the bronchial mucous mem- brane has given rise to secretion. The expectoration at this period consists of scanty, viscid, tenacious mucus, adhering to the surface of the vessel which receives it, and expelled with much difficulty. As it increases in quantity its characters alter, it is got rid of more easily, and the cough is said to have become ' loose.' It is now less viscid and tenacious, frothy from admixture of air, resembles the white of egg, and shows whitish streaks, and may contain streaks of blood. As the disease progresses, the denuded mucous membrane pours out increasing quantities of leucocytes, which give a purulent character to the expectoration. This is now opaque, yellow or yellowish green in colour, tends to form masses, and is expelled with less difficulty but in greater quantity, six to eight ounces or more in the twenty-four hours being by no means an unusual amount. Cough and expectoration are almost always worse after sleep, from the irritation due to accumulated secretion. The character of the sputa should be closely watched, as con- stituting the surest guide to the changes taking place within the chest. If, for example, the expectoration, previously free, copious, and mucopurulent, should diminish in quantity, again become viscid, mucoid, and difficult to expel, the patient will almost certainly complain of greater difficulty in breathing, and will probably say that he has ' caught a fresh chill.' On microscojncal examination the sputum is found in the early stage to consist of clear fluid, cylindrical and ciliated epithelium, and mucous corpuscles ; in the later stage, of large numbers of pus cells, various forms of epithelial cells and large hyaline cells, granular matter, and small oil globules. Pigment granules and blood corpuscles may also be present. The degree of dyspnoea present in a primary attack of acute bronchitis is a measure of the extent of the obstruction of the tubes ; but when emphysema, congestion, or oedema of the lungs, the result either of previous attacks or of cardiac failure, co-exist, a moderate degree of obstruction may produce marked difficulty in breathing. In children the respirations often number forty to sixty or more in the minute ; but in adults, when the large and medium-sized tubes only are afi'ected, there may not be much dyspnoea when the patient lies quietly in bed, with the shoulders well raised. After a paroxysm of cough, an attempt at exertion, or prolonged talking, the respirations are always quickened. The symptoms of an attack of acute bronchitis other than those already mentioned do not need a detailed description ; they are those of the febrile state — a quickened pulse, headache, thirst, a 92 'J'HE DISEASES OF THE LUNGS coated tongue, loss of appetite, usually constipation, scanty high- coloured urine with a deposit of lithates. The skin is at first dry, but quickly becomes moist, and before long there may be free per- spiration. This is not, however, necessarily accompanied by any marked relief to the symptoms, as it may be, according to its degree, an indication of failure of vital power. Physical examination. — On inspiration elevation is seen to be well marked, but simultaneous expansion of the lateral aspect of the thorax is often deficient, and in children recession of the ribs and interspaces in this region may occur from the combined effects of bronchial obstruction and weakness of the cartilages. This is especially common in the subjects of rickets, and is then associated with projection of the lower part of the sternum and recession of the supraclavicular regions. Emphysema of the ' large-lunged ' variety, the result of previous attacks, will, if present, be accompanied by its usual signs, of which the barrel- shaped outline of the chest, epigastric pulsation from downward displacement of the heart and over-distension of the right ventricle, are the most evident. On palpation rhonchal fremitus may be felt when adherent mucus is obstructing the larger tubes. The per- cussion note may be hyper-resonant from emphysema, whilst dulness at the bases of the lungs suggests the presence of con- gestion, collapse, and oedema. Auscidtation. — Harsh breath sounds, with prolonged expira- tion, constitute the typical condition. Absence of the breath sounds over a definite area points to complete bronchial obstruction or to collapse of the lung. Sibilant and sonorous rhonchi are the characteristic adventitious sounds of bronchitis. The former, due to narrowing of the smaller tubes, are uninfluenced by cough ; the latter, dependent upon the presence of mucus in the larger bronchi, often disappear or alter their site after cough. They may be present both on inspiration and expiration, but are usually most marked during the latter period. Bubbling rales, fine, medium, or large, which are more common at the bases than elsewhere, indicate the presence of nmcus in a more or less liquid condition in the medium-sized and smaller ti;bes. By daily examination a careful watch should be kept over the posterior aspect and the bases of the lungs in every case of bron- chitis, especially in children and the aged, as post-mortem ex- perience proves that there the chan.Lijes are usually most marked. This is the effect of the recumbent position, also of the gravitation of Huid, and of the frequent presence of emphysema not only at the margins but also on the posterior aspect of the lower lobes. It must not be at once assumed that medium-sized and fine rales audible at the bases are due to the attack then present, as they may, in the subjects of chronic bronchitis with an acute exacerba- tion, be rehcs of previous attacks. Fine crackling rales, either at the bases or elsewhere, usually indicate the presence of oedema, hypostatic pneumonia, or broncho-pneumonia. Diagnosis. — The diagnosis of acute bronchitis in an adult is BRONCHITIS 93 rarely attended with much difficulty. Twice, however, in the ex- perience of the writer the same patient has been admitted into hospital suffering from what was supposed to be bronchitis, when the real affection proved to be an acute congestion of the lungs from cardiac lailure secondary to mitral stenosis. As pointed out by Sir William Broadbent, the presystolic murmur under such circum- stances may disappear, and in any case its detection may be difficult owing to the adventitious sounds in the bronchi. The very rapid improvement which usually results from complete rest, the administration of digitalis, and from venesection, and the sub- sequent reappearance of the murmur lead, as a rule, to a correct diagnosis in a few days. In children the onset of acute diseases, such as whooping cough and measles, may be masked for a time by the bronchial inflammation. A convulsive cough leading to vomiting should in all cases excite suspicion of the former, and in the latter the appearance of the rash soon determines the nature of the case. Miliary tuberculosis of the lungs may usually be distinguished by the higher range of temperature, more persistent pyrexia, more marked prostration, and the tendency to delirium. Adventitious sounds may be entirely absent in tuberculosis, but if present they are not generally at first dry and at a later stage moist as in bron- chitis, but bubbling and fine crackling rales may predominate from the outset. Signs limited to one upper lobe, or to the apices of both lungs, even though catarrhal in character, should always suggest the presence of pulmonary tuberculosis rather than of bronchitis. In a child acute bronchitis is less likely than acute broncho-pneumonia to be mistaken for miliary tuberculosis of the lungs. Prognosis. — -As the physician's experience of acute bronchitis increases, he is less ready to assure a sufferer, even in apparently mild cases, that he will be ' all right in a few days.' The duration of the disease is apt to be very much longer than appears at first likely ; a mild case may last a fortnight, and, if at all severe, recovery rarely occurs in less than three weeks or a month. "When emphysema is present, recovery is almost always slow, the patient being confined to bed for weeks or months, and possibly to the house for the greater part of the winter. The only cases in which a fatal termination is to be feared are those occurring in young children and old people, or as a com- plication of chronic bronchitis and emphysema, associated or not with mitral or tricuspid disease. A primary attack of acute bronchitis limited to the larger and medium- sized tubes is hardly ever fatal in a previously healthy subject. The necessity for a careful examination of the sputum, and the indications to be obtained therefrom as to the course of the disease, have already been stated. The danger signals of acute bronchitis are evidence of over-distension of the right side of the heart — e.g. cyanosis, distension and pulsation of the veins of the neck- urgent dyspnoea or orthopuoea, and a tendency to sink down into 94 THE DISEASES OF THE LUNGS the bed, accompanied by cessation of expectoration. This latter symptom is of especially unfavourable import, but we have ob- served recovery take place after it has occurred. Great frequency with irregularity and intermission of the pulse are also very unfavourable signs. When the extremities become cold, and the skin is covered with profuse clammy perspiration, or the mind wanders, and coma threatens, it is obvious that recovery is almost hopeless. Even when improvement occurs it is well to remember that relapses are of common occurrence, and to be cautious in pro- gnosis. The patient should not be pronounced to be well until the cough and the adventitious sounds have disappeared. The treatment of the various forms of bronchitis is discussed on pages 97 102 and pages 108 and 117. {b) ACUTE BRONCHITIS OF THE SMALLER TUBES (syn. Capillary Bronchitis, Suffocative Catarrh) This is an affection of a very different degree of severity from that just described. It is never a slight disorder, or otherwise than a dangerous and possibly fatal malady. Morbid anatomy. — The changes which occur are similar to those described in the previous chapter, the urgency of the symptoms depending upon the great obstruction to respiration caused by inflammation of a large number of the smaller tubes. 'I'he lungs are either over-distended with air, or extensive emphy- sema may be present, and this may be, in great part, of recent origin. Areas of collapse of varying size may be seen, involving, in some cases, the greater part of a lobe. On section fine beads of pus may be expressed from the smaller tubes, some of which are often dilated. Others are found to be completely blocked by secretion, which may assume the form of a more or less organised exudation, and the lining membrane is invariably markedly injected. The presence of small, rounded, faintly yellow areas indicates that the alveoli have shared in the inflammatory process (broncho- pneumonia). The changes present in the medium-sized and larger tubes and in tlie heart and other viscera are similar to those described in the preceding section, but the latter are usually more marked owing to greater degree of venous obstruction. Etiology. — This variety of the disease does not differ as to causation from the milder type, and its occurrence probably de- pends upon the defective resisting power of the individual attacked. It is especially common in infants and young cliildren and in tlie aged. In mid-julult life it occurs, in our experience, most often in fat subjects who have had previous attacks of bronchitis, and especially in women. The very small capacity of the chest in fat women is often remarkabk,'. Those addicted to alcohoHc excesses are certainly more liable to this severe form of the disease ilian the temperate. Symptoms. —The affection of the smaller tubes may be primary, or the disease may extend downwards from the larger BRONCHITIS 95 bronchi ; the latter is usually stated to be the most common mode of onset, but in our experience the contrary has been the case. The onset is often sudden, a rigor may occur, or in a child a convulsion may take place. The cough is very frequent, and may be paroxysmal in character and accompanied by pain in the chest. It is at first dry and may remain so, expectoration being throughout absent, or it may be small in quantity and expelled with great difficulty. The alae nasi are widely dilated and the dyspnoea is severe, but on examination of the chest there may be few signs to account for it. Orthopnoea occurs early, the respiratory efforts and abdominal movements being markedly exaggerated. The face quickly becomes cyanotic, but the underlying pallor points to early cardiac failure, and there is marked prostration. Anxiety and restlessness are present almost from the outset, and often give place to delirium towards the close. The skin of the body may be bathed in sweat, whilst the lower extremities are cold. The pulse is rapid — 120 or more. The temperature is much higher than in the ordinary form of the disease, even 104° F. being by no means uncommonly observed in children. Physical signs. — The upper part of the chest is distended, whilst at the same time the recession of the lower intercostal spaces and of the epigastric, hypochondriac, and supraclavicular regions, shows how great is the obstruction to the entrance of air into the alveoli. The percussion note is either unaltered or hyper- resonant from emphysema, or there may be dulness at the bases from pulmonary collapse, a condition especially likely to occur in children. On auscultation the entrance of air may be observed to be fairly free into the upper and anterior parts of the lungs, but feeble at the bases. If, however, as is often the case in adults, the condition is complicated by coexistent emphysema, the breath sounds will be generally feeble. The adventitious sounds, which especially characterise this form of the disease, are fine bubbling rales, having in a minor degree the crepitant character ; they are sometimes described as ' hissing.' In severe cases they may be widely distributed over the chest, but as a rule they are most marked on the posterior aspect, and especially at the bases of the lungs. The ordinary adventitious sounds of bronchitis — sibilant and sonorous rhonchi — may also be present, chiefly over the upper and anterior aspects of the chest. Course. — A severe attack of the kind above described may be fatal in an infant in twenty-four hours ; in childhood the duration is usually more prolonged ; in an adult, the subject of emphysema and addicted to alcoholic excess, we have known death to occur in four days ; in the aged the disease may run a still shorter course. The indications of improvement are similar to those observed in the milder form of the disease. The duration of the attack in cases which recover is ahvays prolonged, and especially so in the subjects of emphysema. Prognosis. — The signs of special gravity are increasing dyspnoea with lividity, delirium, and coma. Eecovery in this 96 THE DISEASES OF THE LUNGS form of the disease rarely, if ever, occurs when expectoration has ceased and the patient has sunk down in the bed, lying perhaps on one side, -with the head low and bent forward. Diagnosis. — The recognition of this type of bronchitis is often attended with great difficulty. It may simulate imeuvionia, but its onset is not usually quite so sudden or attended with such a severe and prolonged rigor and such a marked rise of temperature as characterise that disease. Pain in the side is not so severe, whilst subjective dyspncea is more marked. Practically, however, the differential diagnosis rests upon the results of physical exami- nation of the chest ; the absence of signs of consolidation of the lungs and the presence of bronchitic rales being the determining factors. When pneumonia occurs in an individual the subject of chronic bronchitis, with its attendant emphysema, the problem becomes more difficult. The dulness on percussion over the con- solidated area may be masked, and the adventitious sounds may clearly point to an affection of the bronchi ; but tubular breathing, though faint and distant, will sooner or later appear, and is evidence that something more than bronchitis is present. Miliar 11 tuberculosis of the lungs in children may ultimately give rise to physical signs simulating this form of bronchitis, but if the case has been carefully watched from the commencement, there should not be much difficulty in distinguishing the two affections. The onset of tuberculosis is usually insidious ; there is pallor, wasting, some fever, loss of appetite, and alteration in disposition. The disease is rarely, if ever, limited to the lungs ; signs of implica- tion of the cerebral meninges or of the abdominal organs, such as enlargement of the liver and spleen, being as a rule present. If, however, the case is seen at a late stage, the resemblance to capillary bronchitis may be very close, especially when extensive broncho- pneumonia has supervened. But if expectoration is present, the results of the examination of the sputa for tubercle bacilli generally lead to a correct diagnosis. Acute caseoxis tuberculosis of the broncho-pneumonic type is characterised by a higher and more continued fever, by the absence of such marked dyspnoea as occurs in capillary bronchitis, and of signs of over-distension of the right side of the heart, and by the early occurrence of mucopurulent expectoration, in which as a rule tubercle bacilli are present. Physical examination of the chest nearly always indicates that the disease commenced at the apex of one lung, a condition practically unknown in acute bronchitis of the variety now under consideration. The family and personal history of the patient would in this, as indeed in all other cases, require due consideration. A first attack of astlima may be mistaken for bronchitis involv- ing the smaller tubes, but tlie absence of fever and of characteristic cough and expectoration, with the sudden onset of dyspna-a, as a rule suffice to prevent error. It must, however, be remembered that a spasmodic element may be present in the dyspnoea of acute bronchitis. HRONCHrrrs 97 TREATMENT OF ACUTE BRONCHITIS OF THE LARGER TUBES The patient should at once take to bed. The temperature of the room should be between G5° and 70° F., and it will be well to moisten the air by means of steam from a bronchitis kettle. The tendency certainly is to keep the air in the room too warm and too moist, and thus to produce a condition which is very apt to increase the difficulty the patient already experiences in breathing. In a hospital ward it may be necessary to surround the bed with a tent, but this is rarely so in a private house. The object of treatment in the early stage is to promote secretion from the inflamed bronchial mucous membrane, thereby diminishing the hyper?emia and swelling, and lessening the obstruction to the entrance of air. This is partly effected by the application of warmth to the chest. A hot linseed poultice lightly made, properly put on, and changed about every two hours, is probably the best local application ; it is certainly one for which the patient nearly always feels grateful. On the other hand, a badly made, lumpy, half-Avarm poultice, which is never in the right position and is allowed to remain on for hours after it has become cold, is almost certainly the worst. The addition of some mustard to the first poultices may be useful, but it is important not to produce so much irritation of the skin as may prevent their con- tinuous application. If a skilful nurse is not in attendance it is better to use stimulating liniments, containing turpentine and iodine (lin. tereb. 5vij ; tmct. iodi 5j), as local applications, the chest being covered with a layer of cotton-wool retained in position by a light many-tailed bandage. The drugs which are of most service in the early stage of the disease are vascular depressants, such as tartarated antimony and ipecacuanha, which give relief by increasing the secretion from the bronchial mucous membrane. Opium and morphia diminish the sensitiveness of the bronchial mucous membrane, and so lessen the cough. Pulv. ipecacuanha co. (gr. x-xv), which combines these two classes of remedies, is of much service in the treatment of the early stage of the disease. Liquor ammonige acetatis (3iv) and spirits of nitrous ether (ni.xxx-5j), by acting as diaphoretics, relieve the tension of the vascular system, and indirectly the condition of hypertemia of the bronchial mucous membrane. Formulae in which these time-honoured remedies are variously combined are to be found in every hospital pharmacopoeia. It will be sufficient, there- fore, to indicate the precautions which should be observed in their use. The dose of the depressant remedies should be small (vin. antimonialis ni,xv ; vin. ipecac. u\y], and that of morphia only sufficient to allay the irritability of the bronchial mucous mem- brane (liq. morphinfe acet. ui.x). These drugs may be given at first every three hours, in combination with the saline mixture. H 98 THE DISEASES OF THE LUNGS Tincture of aconite, in doses of iiy every half-hour, may be given to fairly robust patients for eight or ten doses, or until free perspiration is produced and the temperature is lowered. It will be well here to state clearly the limitations which govern the use of opium (or morphia) in all forms of acute bronchitis. It is (juite inadmissible in the case of young children, and almost so in old people. It should never be given to procure ' a good night's rest.' It is absolutely contraindicated in the capillary form of the disease, and in all severe cases where the bronchi are extensively obstructed. A cough which is effective in getting rid of secretion should never be suppressed by opium. The drug is only admissible in the early stage of acute bronchitis of a mild type, when the cough is harassing and ineffective, and is due not to the presence of secretion in the tubes, but to the increased sensibility of the inflamed membrane. Codeia (gr. ^), in combination with citric acid (gr. vj), vin. ipecac. (»»lij), and spirits of chloroform (niiij), is also useful as a sedative. A saline aperient should be given at the commencement of the treatment, and a regular daily action of the bowels should be subsequently secured. In the mild type of case now under consideration we may expect in from twenty-four to forty-eight hours to observe the change in the expectoration, which marks the transition from the stage of hyperftmia to that of free secretion. This will probably be accom- panied by a fall in the temperature. Remedies which promote expectoration, such as carbonate of ammonia and senega in com- bination with alkalies, should now ])e given. So long as fever is present, it is well to continue the use of poultices ; when it has disappeared a layer of cotton-wool should be substituted. When, at a later stage, but few catarrhal signs remain and the attack is obviously subsiding, (piinine and arsenic may be given as tonics to promote convalescence. The diet during the early febrile period should be chiefly liijuid. Warm drinks, such as hot milk, beef tea, clear soup, and chicken broth, in addition to their nutritive and stimulant properties, possess that of aiding the action of the skin and of relieving the cough, liarley water, well flavoured with lemon, is useful to allay thirst. The lemon is an imjjortant addition ; it appears, in the language of hospital patients, to ' cut the phlegm.' All kinds of white milk puddings may be allowed, and as soon as appetite retuins, chicken and white fish may be added to the diet. Many patients, particularly men accustomed to good living, dislike intensely a li(iuid diet with food at short intervals ; it is generally best in such cases to let them have light solid food, nearly at such times as they are accustomed to take their meals. Stimulants are rarely necessary as such, but brandy may be given with hot water, sugar, and lemon, oi' with hot milk, either to produce swi'atinjj; or to aid expeotoi'ation. BRONCHiriS 99 TREATMENT OF ACUTE BRONCHITIS OF THE SMALLER TUBES The suiToundings of the patient should be such as have been ah'eady described as regards warmth and a moist atmosphere, and jacket poultices should be continuously applied to the chest. At the onset of the disease in children a warm bath containing mustard is often of service. In adults it may be necessary to relieve the circulation by the application of leeches, six or eight in number, over the upper part of the sternum ; and in strong children two or three leeches may be applied without risk of harm being- done. In severe cases of rapid onset in robust adults, venesection to the amount of six or eight ounces may be required. The indica- tions for this measure are extreme dyspnoea, cyanosis, lividity, and evidence of over-distension of the right side of the heart. Vene- section is, however, rarely required in children, and should never be employed in the case of old people. If the case is seen early when the bronchial mucous membrane is still in a condition of hyperemia, antimony, either in the form of tartar emetic (gr. ^) or vinum antimoniale (ulxv to xx) may be given every three hours until about eight or ten doses have been taken. The action of all depi'essant remedies requires, however, to be carefully watched ; the indications for their omission being prostration, free perspiration, and a feeble pulse. If expectoration, previously absent, should appear and the breathing become less oppressed, benefit has been derived from their use. The dangers attendant on the administration of opium are tenfold greater in this than in the milder form of the disease. The patient's life practically depends upon the maintenance of the power to expectorate, and coughing is the agent by which this is effected. No treatment can therefore be worse than the adminis- tration of a drug, which deadens the sensibility of the bronchial mucous membrane, and so prevents the reflex act by Avhicli the secretion is got rid of. Patients often crave for a sleeping draught, and it may be difficult to resist their appeals ; but less harm is done by the absence of sleep than by the accumulation of mucus, which must occur during sleep. A sedative draught should not be given if the dyspnoea is urgent, and there are signs of engorgement of the right side of the heart and of the bases of the lungs. Bromide of potassium (gr. xv) combined with aromatic spirits of ammonia and possibly with a small dose of chloral (gr. v to x), or in place of this half a drachm of bromidia, are the best hypnotics, if it should be considered desirable to administer one ; but the period of sleep allowed must be short, say two hours, and special efforts should be made to promote expectoration when the patient is awakened. Free purgation, by the administration of calomel (gr. iij- v) at night and a saline draught on the following morning, tends to relieve the circulation by removing any congestion of the portal loo THE DISEASES OF THE LUNdS vessels that may be present. It should be resorted to as soon as the case is seen, and a free action of the bowels maintained so long as evidence of engorgement of the right side of the heart remains. Flatulent distension of the stomach and tympanites should be treated at once, the former by carminatives and purgatives, the latter by cnemata of turpentine or rue ; both conditions are serious, as they interfere greatly with respiration. Stimulants may be required at an early stage of the disease ; a tablespoonful or more of brandy, given with hot milk at intervals of four hours, is generally the best. All hot drinks tend to promote sweating, and long experience proves that a free action of the skin tends to relieve internal hypertemia and congestion. By the adoption of the foregoing measures more or less relief will be given, except in the most severe cases. Diminished viscidity of the expectoration, a lower temperature, less dyspnoea, a looser cough, and a more ' moist ' character of the niles constitute the best evidence of improvement. The more active depressant remedies, such as antimony, should now be discontinued ; small doses of vinum ipecacuanhte may, however, still be given, but in combination with stinuilant expectorants, such as carbonate of ammonia, tincture of S(juill, and infusion of senega. When this favourable change in the general symptoms is established it is very important that it should be maintained, a so-called ' relapse ' being usually due to some obvious cause. If, for example, the fire is not properly attended to during the night, the temperature of the room will fall during the early hom"s of the morning, and the patient will become chilled, especially if there is much moisture in the air. The same result will follow if the poultices are allowed to become cold. Inattention to the regular administration of food, stinuilants, and medicine during the night and in the early hours of the morning, when there is a naturtil depression of the vital powers, will check the secretion and discharge of mucus. If the patient is allowed to sleep too long, or if on waking he is not sufficiently roused to expectorate, mucus will accumulate in the tubes, the breathing will be more oppressed, the temperature may rise, and he will probably be said to have had a ' relapse.' It may be mentioned here that such cases should always he under the care of trained nurses day and night ; and if the wish of the friends, which is often expre?sed, to undertake the care of the patient during the day be acceded to, it will nearly always prove to his detriment. It may happen that notwithstanding the adoption of the mode of treatment here laid down, or from neglect of proper ti'eatment in the early stages of the disease, the symptoms continue to increase m gravity. This may also be due to the youth or advanced age of the patient, to feeble pliysi(|ue, to the presence of emphysema, or a feeble heart ; or the attack may from the onset have been of the severe type which often proves fatal in spite of every care. In such cases it may be well to substitute turpentine stujies to the chest for the poultices, but they nnist bo used with discretion, for the skin BRONCHITIS roi will probably by this time be tender. In children it is often desirable to stimnlate respiration by a sudden affusion of a small quantity of cold water on the chest whilst the patient is in a hot bath. In such cases also an emetic of ipecacuanha (gr. xx) may give great relief. During the act of vomiting, a large quantity of mucus is got rid of by the compression of the chest, and the breathing is for a time relieved. If its action is beneficial, the remedy may be repeated on the recurrence of the urgent symptoms. The adminis- tration of an emetic to an adult often requires some courage ; if it does no good it will almost certainly do harm, and if death should shortly follow, an occurrence by no means unknown, it may possibly be attributed to the treatment and not to the disease. In an adult, if venesection has not already been practised and there are indications of failure of the right side of the heart from over-distension, six to eight ounces of blood should be withdrawn, and the operation may be repeated if it is evident that the heart is again becoming dilated. We have seen great benefit, which is sometimes permanent , but more often temporary, follow the inhalation of oxygen in severe cases of bronchitis. The change in the patient's aspect may be most striking, cyanosis giving place to a healthy-looking flush after the gas has been inhaled for a few minutes, and the pulse showing marked improvement in tone. Sometimes, however, the oppression of the breathing is so extreme that the patient cannot bear the face- piece of the inhaler near the mouth ; in such a case it should be held, for half an hour or more at a time, as near as it can be borne ; otherwise the duration of the inhalation should be about ten minutes, with intervals of half an hour or less, according to the severity of the symptoms. Before taking the apparatus into the room, it is well to make sure that you have not been supplied by mistake Avith an empty cylinder, and also to fit the tube on to the nozzle and turn the tap so that the slightest further turn will let the gas into the bag ; otherwise the tube and bag are very likely to be blown off the nozzle, much to the alarm of the patient. A hypodermic injection of strychnine (liq. strychninjB hydrochl. ni,ij-iij) may be given to stimulate the respiratory centre, and repeated every three hours as an adjunct to other measures. In severe cases occurring in old people, it may be necessary to adopt from the outset a more stimulant plan of treatment, especially if the heart is feeble and expectoration difficult. As much as six or eight ounces of brandy may be required in the twenty-four hours, and a mixture containing digitalis, fether and ammonia may be given every four hours, or the digitalis (tr. digit. in_v-x) may be added to the hot brandy and milk. Dr. Wilson Fox was of opinion that dry rales with great dyspncea are not infrequently due to spasm of the tubes, and advocated the use of the tincture of lobelia (ni,xv-xx) in combination with ipecacuanha and ammonia, and small doses of opium or morphia I02 THE DISEASES OF THE LUNGS in such cases. If there is no doubt as to the existence of the spasmodic element this combination of remedies may be tried, but in doubtful cases it is well to omit the opium, as a mistake might be followed by dangerous and possibly fatal results. The point may sometimes be determined by watching the eftect of the inhalation of nitrite of amyl. If considerable relief to the breathing is experienced, we may be certain of the presence of a spasmodic element in the case. To observe an asthm^atic paroxysm disappear completely in a few minutes when a capsule of nitrite of amyl is broken beneath the nose, and, when the effect of the drug ceases, to see the dyspntca return as quickly as it went, is a remarkable clinical experience. The inhalation of ten to twenty minims of chloroform upon a piece of lint is also useful in similar cases, but its effect is often only temporary ; the administration should not be carried farther than is necessary to relieve the difficulty of breathing. When the severe symptoms have passed off, tonics, such as quinine, cinchona, and nux vomica, may be either added to the expectorant mixture or given separately. Iron and cod liver oil are useful at a later period. If expectoration sbould continue to be copious and purulent for a long period after all the acute symptoms have passed away, nourishing diet should be given and a tonic plan of treatment adopted. Tar water and remedies of the tur- pentine order, such as terebene, which tend to diminish secretion, are also serviceable at this period. A change of climate is often necessary to complete convalescence ; this should, speaking generally, be to one marked by a high and even temperature, in which the air is dry. All health resorts, both in this country and abroad, suitable for cases of bronchitis owe their reputation in great part to a position sheltered from cold and damp winds. This point is considered more fully in the discussion of the treatment of chronic bronchitis. J. K. F. T03 CHAPTEK V CHEONIC BEONCHITIS Etiology Morbid anatomy Symptoms . Pliysical signs Com-se Diagnosis Prognosis Treatment . Dry Catarrli. Catarrh Bronchorrhoea Foetid Bronchitis Sec I'AGK 103 104 105 106 106 107 107 108 113 113 114 The term ' chronic' as applied to this form of bronchitis does not necessarily imply that its course is continuous, as in its most typical variety, viz. chronic winter cough, the symptoms are at first limited to the period when the climatic conditions are most unfavourable. It is generally due to a recurrence of acute or subacute attacks of the disease. Chronic bronchitis occurs in the great majority of cases in associaiion with emphysema, of which condition it is the most common cause, and by the aid of which its permanence is secured. Examples of the disease differ so greatly both in type and in severity as to constitute varieties which require separate notice. Etiology.— As the most important factor in the etiology of chronic bronchitis is the occurrence of acute attacks, all the con- ditions which act as either predisposing or exciting causes of the acute disease may be concerned in the production of the chronic form. The presence of emphysema, of the degenerative changes incidental to advancing age, of alcoholism, chronic Bright's disease, and gout also predispose to the recurrence of attacks. Any lesion of the cardiac valves which affects the pulmonary circulation, particularly mitral disease, by producing congestion of the bronchial mucous membrane tends to excite catarrhal changes in the bronchi. The pressure of an aneurysm of the aorta or a mediastinal growth may act in a similar manner. I04 THE DISEASES OF THE LUN(;S Morbid Anatomy. Emphysema is almost invariably pre- sent in those parts of the lungs which are the common sites of that change. The bases "will probably be congested and a'dematous, and if, as is often the case, the patient has succumbed to an acute exacerbation of the disease the lesions of acute bronchitis will be superadded to those of the chronic form. The bronchi, especially those of medium size, contain much mucopurulent secretion, and the mucous membrane is congested and of a deep purple colour. It is often much thickened and longitudinal ridges of a greyish colour, formed by the elastic fibres of the inner fibrous coat, may be very obvious in the larger tubes. These changes cause narrowing of the lumen of the larger tubes. ^ ' ' ".~- ' ' ■"'■'v-'. "^ • ■^i'^if' ;*'•''.■!•' -K.""*».» **t^'*^*' I'lii. ■')\. CiniiiNK IJIIOXCIIITIS, .SH()\Vl.\(i <(IM1'I>KTE ])1SAP1'KARANCE OF THK Kl'ITIIEI.nTM IN l'I,A('ES, ANI> MAHKKli IIIK KKNIXG Oh THK WALLS OF THF, BnONCHUH whilst some of those of smaller calibre may be dilated. The bronchial glands are enlarged and of a coal-black tint. On micrn.scopical e.raniiu(itio)i, the ciliated columnar epithelium will be found to have, for the most, disappeared, its place being taken by cells of transitional form which are attached to the base- ment membrane. The inner fibrous coat is enormously thickened from cellular infiltration and dilatation of the blood-vessels, and its fibrous structure may be very indistinct. The muscular coat may be found in some bronchi to have undergone atrophy, in others it CHRONIC BRONCHITIS 105 is hypertrophied, the difference depending probably upon the stage of the disease, atrophy succeeding hypertrophy as the ceHular infiltration of the bronchial wall increases and dilatation of the tube occurs. The cellular infiltration extends to the outer fibrous coat, and evidence of peribronchial thickening is almost always present. The cartilages may be in process of absorption, or, more rarely and espe- cially in old people, they may be calcareous. The mucous glands may be found either filled with secretion or their secreting structure may be destroyed. The muscular coat of the small arteries is hyper- trophied and the capillary vessels are dilated. The changes in the heart and other internal organs are similar to those described under emphysema, and referred to also in the description of acute bronchitis. Symptoms. — The mildest and most common form of the disease is that already referred to as a chronic winter cough ; it is met with in middle-aged and elderly people, particularly in such as are somewhat obese and take a large quantity of food and alcohol. Such patients sufi^er from cough, perhaps preceded by some wheez- ing, chiefly on rising in the morning ; at the same time they bring up a moderate quantity of mucopurulent expectoration, and are then, as they commonly state, ' free for the day.' There is usually some degree of dyspnoea on exertion, this being in proportion to the amount of emphysema present. So long as they can follow their ordinary occupations, and the cough is confined to the winter months, they are rarely much troubled by the condition ; but, as time goes on, the summer intermission becomes shorter, and ihe symptoms in the winter more severe, until they are only free from cough and wheezing for a month or so throughout the year. Ultimately the cough, expectoration, and dyspnoea become con- tinuous all the year round, but the symptoms are always more severe during periods of cold and damp weather and when fog is present. The disease may be evolved in the manner just described, or it may occur as the result of one or more acute attacks without pre- senting such a prolonged coarse. Cases of chronic bronchitis of a more severe type are marked by an aggravation of all the ordinary symptoms ; the cough is more constant and severe, and may occur in paroxysms, during which there is marked cyanosis of the face, and after which the patient is for a time very breathless. The expectoration is less easily expelled, and when any slight exacerbation is present it may for a time be scanty and sticky in character. More often, however, it is profuse and mucopurulent, consisting of nummulated masses of a yellowish-green colour, which, according as air is or is not contained in it, sink or partially float in the liquid portion of the sputa or the sputa, if very viscid, may form a single mass in the spitting-cup. Dyspnoea is now present even when the patient is at rest, and the breathing is laboured and accompanied by rhonchi during expiration. Very often at this period the patient begins to suffer io6 THE DISEASKS OF THE LUNGS from attacks of dyspnoea of the asthmatic type (bronchial astlnna). These i;sually come on at night, and during their continuance his sufferings are much increased. There is also risk of the superven- tion of acute inflammation of the smaller tubes, a comphcation which, in such a condition of the lungs, is very likely to prove fatal. A more advanced stage of chronic bronchitis is characterised by emaciation, loss of strength, night sweating, increased difficulty in expectoration, and more severe and continuous dyspnoea. The patient now lies in bed propped up by many pillows, or is unable to breathe with any degree of comfort unless sitting in a chair. There is cyanosis, the veins of the neck are distended and the fingers and toes clubbed, and all the signs of over-distension of the right side of the heart are present. Towards the close of the case the legs become cedematous, the urine is scanty and contains albumen, tracheal rales become audible, and death occurs from dropsy due to gradual cardiac failure and ' clogging ' of the bronchi with secretion which the patient is too feeble to expectorate. Physical signs. IMuchof the description given of the physical signs of acute bronchitis applies also to those of the chronic form. On inspection the signs of emphysema, including the characteristic alterations in the shape of the chest, will very likely be found, Khonchal fremitus may be felt on palpation. The percussion note will be affected by coexistent emphysema, but otherwise will not differ from the normal. In advanced cases dulness may be present at the bases from ffidema, collapse, and hypo- static pneumonia. On auscultation, if but little emphysema be present, the breath sounds will be found to be harsh, expiration being prolonged ; if there be general emphysema the true respira- tory murmur will be feeble, but coarse rhonchi in the larger tubes may simulate a harsh breath sound. The adventitious sounds ai-e similar to those of the acute variety. Sibilant and sonorous rhonchi and bubbling rales predominate during an acute exacerbation or an intercurrent attack of bronchial asthnui. Fine bubbling and crack- ling rales may be audible over the bases, but it must not be at once concluded that their presence indicates extensive oedema or broncho- pneumonia, as they may be produced in the emphysematous area commonly found on the posterior aspect of both lower lobes. Rales of this character are often continuously present in the subjects of advanced emphysema. If bronchiectasis is present the hollow wavy character of the breath sounds characteristic of that condition may be audible, possibly only after the dilated tubes have been emptied by a paroxysm of cough attended with copious expectora- tion. Course. — -In a case of winter cough any shortening of the summer intermission marks an advance in the disease, and when the symptoms l)ec()me continuous throughout the year the ste]) is a very decided one. Thi' occurrence of the first serious attack of nocturnal dyspiKi'a is also significant. Each additional pillow wliich the patient finds he requires to enable him to breathe in comfort in CHRONIC BRONCHITIS 107 bed is evidence that dyspncta is tending towards orthopnea. An intercurrent acute attack may leave behind it a marked increase in the extent of the emphysema and so hasten the course of the disease. When a sufferer from chronic bronchitis begins to lose weight the change is generally of unfavourable omen, but this is nearly always observed to accompany an acute attack and may cease when it subsides. Progressive loss of strength and increasing breath- lessness on exertion are signs rarely unobserved or misinterpreted by the patient. CUear evidence of the occurrence and continuance of tricuspid regurgitation is an indication of cardiac dilatation and degeneration, and marks a decided advance in the morbid processes incidental to the disease. Diagnosis. — In all cases of chronic pulmonary disease the sputum should be examined for tubercle bacilli, not once only but frequently. If this precaution is not adopted, cases in which general or compensatory emphysema, the result of arrested or quiescent tuberculosis, is followed by chronic bronchitis, are liable to be misunderstood. But in the fibroid form of tuberculosis, which is usually present in such cases, tubercle bacilli are frequently absent from the sputa. Pulmonary tuberculosis may also be engrafted upon chronic bronchitis and emphysema, and its recog- nition may be difficult without the aid derived from an examina- tion of the sputum. Whenever the signs are more marked at the apices of the lungs, or at one apex, than elsewhere, tuberculosis should be suspected ; this holds good even though the signs are wholly catarrhal in character, and tubercle bacilli are not found in the sputa. In a case lately under observation, in which loud sonorous rhonchi Avere audible over both lungs, the diagnosis of chronic bron- chitis and emphysema was proved to be, at any rate, very incom- plete by the discovery of dulness over the manubrium, and other signs indicating compression of the trachea by an aneurysm of the transverse part of the arch of the aorta. In another case admitted into the Brompton Hospital, under the care of the writer and diagnosed by him as one of bronchitis and emphysema, a small growth origina- ting in the mediastinal glands and extending along the main bronchi was found on post-mortem examination. The absence of dulness on percussion may render the diagnosis of such a case very difficult. Stenosis of the trachea or main bronchi, the result of the con- traction of syphilitic gummata, is very likely to cause symptoms which may suggest a diagnosis of chronic bronchitis. Prognosis. — A sufferer from chronic winter cough who is able to spend the cold months of the year in a suitable climate may fairly hope to escape the annual recurrence of his malady, but whatever degree of emphysema may be present will necessarily remain. In such patients as continue in this country and attempt to follow their usual occupations the disease will almost certainly progress. io8 THE DISEASES OF 'I'HE LUNCiS Cases of chronic bronchitis and emphysema with attacks of bronchial astlima, occurring in young subjects, may undergo marked improvement as age advances, until indeed all urgent symptoms may ultimately disappear. In adults when the disease is well established, the great liability to a recurrence of acute attacks, and the permanence of the emphy- sema, render it impossible to hold out hopes of complete cure, especially when the condition is dependent upon or associated with cardiac or renal disease. The course of the disease is, however, as a rule very prolonged, and sufi'erers readily become accustomed to their ailment and tolerate it so long as the difficulty of breathing is moderate in degree. Treatment. — The treatment of chronic bronchitis and the various conditions so often associated with it is calculated to tax the resources of the physician to the utmost. The remedies which are suitable vary greatly in different cases, and much depends upon the constitution of the patient whether, for example, he is gouty or tubercular, or the subject of some renal or cardiac affection. In ordinary cases of winter cough the important indication is to shield the patient from inclement weather at whatever time of the year it may occur. He should, if possible, winter abroad, or at some dry and sheltered place in this country. If unable to do so (and to very many it is a counsel of perfection), he must by careful regulation of his life endeavour to maintain his health at the highest possible standard. He should wear warm woollen underclothing and be careful to avoid exposure to damp, fog, and cold. When obliged to be out in cold air, if he declines to use a respirator or wear a woollen muffler over his mouth, he should breathe only through the nose. Many patients derive great benefit from taking cod-liver oil as soon as the winter sets in and continuing to do so as long as it lasts ; it is, indeed, of almost as much service in chronic bi'onchitis as in tuberculosis. For the morning cough a mixture containing bicarbonate of sodium (gr. xv) and chloride of sodium (gr. v) with spirits of chloroform {u\y) in anise water, taken witla an equal quantity of warm water before rising, is a good remedy.' To this carl)onate of ammonia and iodide of potassium (afi gr. iij) may be added in cases where it is necessary to stimulate expectoration and reduce the viscidity of the secretion. We have known great benefit to follow this plan of treatment, which is based on that adopted at Ems. If an attack of coughing occurs on lying down at night, a dose of the medicine should be taken at that time also. It is not uncommon for patients with chronic bronchial catan*h and emphysema to wake during the night with slight attacks of wheezing of an asthmatic nature. In such cases it is well to advise them to have at their bedside the means of heating an ounce or two ' The ' Mistura sodii ct jr-tlier. chlor.' of tlu- liroiii/iton Ifosjiital Phar., addeil on the suggestion of Dr. I'.iirney Yeo. CHRONIC BRONCHI'l'IS 109 of water which may be added to a dose of the mixture above mentioned, A draught of hot milk to which about four ounces of Ems water have been added, taken before the attack of morning cough, is also a great aid to the expectoration of the mucus which has accumulated during sleep. In many cases of chronic bronchitis stimulating liniments, e.g. lin. terebinthinas (5vij), tinct. iodi (5j), applied to the chest at night give great relief. After a few days considerable irritation and a papular rash may appear on the chest and it may be necessary to use the liniment less frequently. The writer has even known a moderately severe attack of bronchial asthma subside very quickly solely under the use of the liniment recommended above ; possibly the vapour of the turpentine may have contributed to this result. A combination of the tincture of the perchloride of iron (nix) and spirits of chloroform (nix) is probably the best general tonic in cases of chronic bronchitis and emphysema ; it may be taken with advantage throughout the winter with the cod-liver oil. The use of the remedies so far recommended will, as a rule, suffice for an ordinary case of winter cough, but for the more advanced condition others are necessary. If the patient cannot leave this country, it is advisable that on the approach of winter he should take to the house and remain there so long as the weather is inclement. He should live in as large and airy rooms as possible and the air should be maintained at a uniform temperature of about 65° F. If fever is present the patient should be in bed. An intercurrent acute attack should be treated mainly on the lines already laid doAvn [vide p. 97) — except that the more decidedly depressant remedies such as tartar emetic and aconite are rarely required in chronic cases and should never be given to old or en- feebled patients. The condition of the expectoration will as before be the chief guide in the selection of remedies. If this is scanty, viscid, tenacious, and difficult to expel, liquor ammonia? acetatis, and vinum ipecacuanhie, with the addition perhaps of spirit of chloroform, may be given. As soon as the sputa become less viscid and the cough ' loose,' stimulant expectorants such as carbonate of ammonia and senega should be substituted. It may indeed be necessary to com- bine the two classes of remedies from the first, especially in feeble subjects. Linseed poultices with the addition of mustard are the most suitable local applications during acute periods, but in the intervals liniments are generally preferable. Turpentine stupes are of great value but must be used with caution, especially when the skin is naturally delicate or has been already made sensitive by local applications. The turpentine liniments of the Pharmacopoeia may also be employed. A distinguished member of the profession, who suffers from chronic bronchitis, deplores the fact that the Turkish bath is so little used in the treatment of intercurrent acute and subacute attacks of the disease, and has assured the writer that by the aid of a portable bath in his bedroom he can quickly cut short a threatened acute no THE DISEASES OK IHE LUNGS attack. The relief to the sense of tightness within the chest, as soon as free perspiration is in luced, is described as marvellous. The Turkish bath should be followed by a warm bath and retirement to a well-warmed bed, and a respirator with terebene (nixx-xxx) on the sponge should be worn during the night. This mode of treatment is certainly worthy of an extensive trial. When the acute stage is passing off, S(iuill may be administered in combination with carbonate of ammonia or the compound pill of ipecacuanha and s(|uill may be given at bedtime. Tonic remedies such as perchloride of iron, cinchona, strychnine, and cod-liver oil should be given during convalescence from an intercurrent acute aitack or in periods of comparative freedom from urgent symptoms. They are also of nuich service in checking profuse secretion. The attention of the sufferer from chronic bronchitis is, as a rule, chiefly centred upon the cough and he is urgent for its relief. Treatment should, however, be directed more towards the cause of the reflex act and less to the act itself, which is merely evidence of an irritable condition of the bronchial mucous membrane, due to the loss of its protective epithelial lining or of the presence of secretion within the tubes. As a general rule greater relief to the cough is obtained from the use of remedies which promote expectoration and of those which diminish secretion than from such as have a merely sedative action. A constant harassing and ineffective cough may be relieved by the use of sedative remedies, but a necessary and effective cough should not be checked, as the secretion must be got rid of and the cough is the only agent for this purpose. The cautions already given as to the use of sedatives and particularly opiates in the treatment of acute bronchitis are to be observed {v/'lc p. 99). The inhalation of the vapour arising from a pint of boiling water to which a teaspoonful of the compound tincture of benzoin has been added may afford relief to an irritable mucous membrane, or a small dose of tinct. camphora; comp. (ni.x-xv) may be added to the expectorant mixture. The inlialation of a few drops (tn.x xx) of chloroform is often of use in checkhig a very irritating cough. Codeia (gr. ^) in combination with citric acid (gr. vi), S})irits of chloroform, and mucilage may be given in cases where more decided sedatives are inadmissible. The warm alkaline draughts already recommended are also of great service in relieving cough. Darley water well flavoured with lemon is a pleasant drink and certainly has a similar effect. If tlie strife of l)i'eathing allows the patient to wear an oro-nasal respirator, ten drops of a 20 per cent, solution of menthol in alcohol may be poured on the sponge, and the instrument worn for some hours at a time. The condition of the bronchial mucous membrane may be favourably influenced by the use of remedies which are in part eliminated through the air passa,ges. .Most of the drugs of this class are given with a view to diminish excessive secretion ; such are turpentine, terebene (ti^v xx), terpene (gr. ij vj), creasote, tar, copaiba, benzoin, ainmoiiiacum, and tolu. Of those, turpentine CHRONIC BRONCHI'JIS iii and terebene are the most valuable. In common with nearly all the remedies just mentioned, they may be either administered internally, preferably in capsules (turpentine m,x, terebene mv), or used as an inhalation (e.g. ten drops of a mixture of equal parts of terebene, carbolic acid, and spirits of chloroform), or both methods of use may be combined. The perforated zinc respirator suggested by Dr. Burney Yeo is a very convenient means of employing many of these remedies by inhalation. Tar, in the form of tar water or pills, is a remedy long employed in checking the profuse secretion of chronic bronchitis. Creasote may be given either in capsules, or perles (each con- taining from two to three minims), or by inhalation. Chloride of ammonium, in the form of a spray, is also of great use, and may be combined with turpentine or its derivatives. The use of a spray of ipecacuanha wine has been strongly advocated by Drs-. Kinger and Murrell. When a case is first seen in the advanced stage of which urgent dyspnoea, cyanosis, and over-distension of the right side of the heart are the prominent signs, venesection to the extent of six or eight ounces may give great temporary relief. Inhalations of oxygen should also be used, and subcutaneous injections of strychnine (gr. -io-ttV)- A mixture containing eth^r, ammonia, and digitalis may also be given every four hours. Turpentine stupes should be applied to the back and front of the chest alternately, and their use continued so long as they can be borne without great discomfort. Emetics are probably less employed now than formerly in the treatment of severe cases of chronic bronchitis in adults, when secretion is profuse and is tend- ing to accumulate and block the tubes. Ifc requires a nice dis- crimination to determine whether the strength of the patient is sufficient to withstand the depressing effect of an emetic. If in doubt on this point it is better to avoid its use. If an emetic is given, great temporary relief may be afforded by the expulsion of a large quantity of mucus during the act of vomiting. Stimulants, of which good brandy is probably the best, are generally required in severe cases ; the dose must be determined with reference to the age and general condition of the patient and the state of the pulse and respiration. The diet should be ' plain ' and easily digestible, and all articles likely to give rise to flatulent distension of the stomach, and dried and salted foods which tend to increase the cough, should be avoided. In the treatment of an attack of dyspnoea of the asthmatic type occurring during the course of chronic bronchitis, the drugs of greatest value are iodide of potassium in large doses (gr. viij-xv), extract of stramonium (gr. \) and the ethereal tincture of lobelia (nixx) in combination Avith stimulant expectorants, such as carbonate of ammonia (gr. iij to v) or ether. Morphia, which is of such great service in the purely spasmodic type of asthma, should, if employed in these cases, be used with the greatest TI2 THE DISEASES OF THE EUNGS possible caution. A free action of the bowels, to be obtained by the use of saline purgatives, tends to relieve the congestion of the bron- chial vessels, and is an essential aid to other methods of treatment. The use of canipressed air hafhs in the treatment of emphysema and of chronic bronchitis maybe attended with very beneficial results. ^^'e have given the method an extensive trial at the lirompton Hospital, and our opinion agrees v,'ith that of Dr. Theodore Williams ('Aero-therapeutics,' p. 106), who speaks decidedly in its favour. Patients almost invariably state that whilst in tlie bath they breathe with less difficulty, and in some cases permanent benefit results. On the Continent, where this method of treatment is more extensively employed, it is held in higher esteem than in this country, where the number of baths available is limited. The subject is more fullv discussed in the chapter on Emphysema (p. 177). Climatic treatment. — The most desirable conditions are an e(|uable temperature, warmth, sunshine, and absence of cold winds and fog, a combination not easily obtainable in this country. All those who can aft'ord it and are able to do so should certainly pass the winter months abroad, where a large field of choice as to quar- ters lies open to them. ]\Iany sufferers habitually winter on the Riviera, the most sheltered place being Mentone. The disadvantages of the climate are the great differe)ice between the sun and shade temperature and the prevalence at certain periods of winds which come from almost every quarter of the compass, each having some particularly impleasant character of its own. These conditions obviously render it necessary for the patient to exercise the greatest prudence in avoiding exposure to cold. For some cases a still drier climate such as that of Egypt is found to be more suitable. Madeira is, from a purely climatic point of view, preferable as a winter resort for cases of chronic bronchitis. The moist air allays the irritability of the bronchial membrane, and so diminishes cough, whilst the equable temperature lessens the risk of fresh chill. Those who are unable to leave for a longer period may derive considerable benefit from a stay of a foiinight or three weeks at Madeira about Christmas time. ^lany patients, after a short stay, find the climate of Madeira too relaxing, and betake themselves to the Canaries, where the air is drier and more bracing. Algiers, Ajaccio, and Corfu are also nmch freijuented by catar- rhal subjects during the winter months. In this country the most sheltered places in which the sufferer from chronic bronchitis can spend the winter months are Torquay, Falmouth, Penzance, P>ournemouth, and the towns along the UndercHflf of the IsIh of Wight. Suft'erers from chronic l)roncliitis often derive much benefit from a course of muriated alkaline waters (Ems, Royat), or of sulphur waters (lOaux Bonnes), or of weak arsenical waters (La liourboule or Mont Dore), followed by a residence at some sheltered place in the lUack Forest or elsewhere. CHRONIC BRONCHITIS ji^ DRY CATARRH (CATARRH SEC OF LAENNEC) This affection is described by Laennec as of extremely common occurrence, and as affecting ' almost all the inhabitants of cold sea coasts and Immid valleys,' and ' one half at least of the most healthy adults in the driest parts of France.' It is said to be due to chronic congestion of the mucous membrane, particularly of the smaller bronchi, and to be characterised by the expectoration of semi-transparent airless globules of a pearly grey colour, ' of the consistence of pitch, and about the size of a hemp or millet seed.' The respiratory murmur over the part affected is said to be entireh' or almost completely absent. The affection is described as remain- ing moderate in degree and perfectly latent for a long series of years, the only sign being slight dyspnoea on attempting to run oi ascend a height. Later on, dyspnoea is felt even when at rest, and,, later still, ' the attacks of oppression are sufficiently severe to merit the name of asthma, and they usually last several days.' It is true that dry catarrhal sounds are not uncommonly present in the bronchi in the subjects of emphysema, and that attacks of asthma and bronchial asthma often terminate with the expectoration of pearly masses similar to those described by Laennec, but apart from these common conditions we know of no affection having the characters above described, nor do we think it probable that com- plete absence of the respiratory murmur over extensive areas of the lungs is ever due merely to engorgement of the bronchial mucous membrane. Bronchial catarrh accompanied by very little secretion is not uncommon in gouty subjects, and reference will be found to it in the description of secondary bronchitis of gouty origin (vide p. 116). BRONCHORRHCEA — S7jn. Beonchorehcea Seeosa (Bieemee)^ Cheonic Idiopathic Pituitous Cataeeh (Laennec), Broncho - BLENNOREHffiA, MUCOID AsTHMA Under the heading ' chronic idiopathic pituitous catarrh,' Laennec described an affection, characterised by paroxysms of cough and expectoration usually occurring night and morning, the quantity of sputa on each occasion being possibly as much as two or three pounds. It is predisposed to by ' frequent renewals of acute mucous catarrh ' (acute bronchitis) and attacks the ' aged or adults past the prime of life,' and gouty subjects. Laennec relates two cases, one that of a man upwards of seventy years of age who had expectorated daily for ten or twelve years about four pounds of a colourless ropy and frothy liquid ; the other that of a man over sixty years of age, of fair general health, able to take walking exercise, who had brought up every morning, ' by easy vomiting repeated at short intervals for some hours, from three to six pounds of a liquid 114 THE DISEASES OE THE LUNGS perfectly resembling the white of egg raiKed with one third part of water.' Andral describes two cases of a similar character which ran a more rapid course, and in which, on post-mortem examination, no other lesion or cause of death was discovered. Cases of chronic bronchitis and bronchiectasis with profuse expectoration are not uncommon, but those here described present unusual features, and that, in an idiopathic form, they are rare is admitted by Laennac He states, however, that ' this affection is syen in a high degree of development when a great number of miliary tubercles are simultaneously formed in the lungs and remain long in the same state.' F(ETID BRONCHITIS (PUTRID BRONCHITIS) This variety of the disease is very closely associated with bronchiectasis ; but foe tor of the expectoration, Avhich is the most characteristic feature of the affection, may accompany acute or chronic bronchitis without dilatation of the bronchi. Such cases, however, are of rare occurrence, and in any case it must be extremely difficult to exclude the possibility of bronchial dilatation. The features of putrid bronchitis, as regards the character of the sputa, the occurrence of pyrexia in association with broncho-pneumonia and gangrene, and the course of the disease, agree so nearly with the description of bronchiectasis given in this work, that we must refer our readers to the chapter on that subject. The only treatment of bronchitis attended by foetid expectoration, whether accompanied by bronchial dilatation or not, which is likely to be successful is the use of the creasote vapour bath {cide p. IBM). J. K. F. if5 CHAPTEK VI SBCONDAEY BRONCHITIS PAGE a. In acute febrile diseases . . . . . ' . . 115 b. In gout 116 c. In tuberculosis 117 cl. In syphilis .......... 117 Treatment of secondary bronchitis . . . . . .117 Bronchitis occurs as a complication of so many morbid conditions that it requires separate notice under the above heading. In most of these cases, however, the variations from the normal type as regards symptoms and physical signs are too slight to need detailed description, and it will be sufficient to indicate the relative importance of the several diseases as factors in the etiology of the affection, and the influence which they have upon its treatment. a. Acute febrile diseases. — In measles and enteric fever the bronchial complication assumes the greatest importance. It may, indeed, in both cases be the immediate cause of death. In the former, during the pyrexial period, the smaller tubes are very liable to be involved, and the inflammation may spread to the alveoli, producing broncho-pneumonia. In the latter there may be some rales at an early period of the disease, but it is not as a rule until the third week that the condition of the lungs gives cause for anxiety. The breathing then becomes quickened, the face dusky, and bubbling and crackling rales are found at the bases of the lungs ; but cough and expectoration may be absent, an im- portant point in the differential diagnosis of typhoid fever and bronchitis. It is probable that the pulmonary complications of typhoid fever are due to the presence in the vessels of the Jungs of the specific virus of the disease, and are not the result of an ordinary bronchitis extending to the alveoli. As a complication of typhus fever, bronchitis is almost always found in association with hypostatic congestion of the bases of the lungs, and the exudation into the tubes is probably, in part at least, due to congestion of the vessels, and not "to an acute inflammation of the lining membrane of the bronchi. Bronchitis, with collapse of portions of the lungs, may occur ii6 THE DISEASES OF THE LUNCIS as a sequel of whooping cough, and bronchial catarrh during con- valescence may cause a return of the characteristic symptoms of the original disease. Bronchitis may also be met with as a complication of smallpox, scarlatina, and some other acute diseases, but in such it rarely assumes importance. The bronchial and pulmonary complications of influenza are described elsewhere {vide p. 580). b. Gouty bronchitis. —It is in this variety of the disease that the influence of the etiological factor is most distinctly shown, and its recognition is essential for successful treatment. In individuals who have suffered from well-marked attacks of arthritis, there is as a rule but little difficulty in recognising the presence of the gouty element ; but prior to such an occurrence, and also in the subjects of hereditary and what is termed ' sup- pressed ' gout who have never had any typical manifestation of the disease, its influence in the production of a bronchial catarrh may not be so obvious. The affection in its milder form is usually found in association with emphysema, in men who have reached or passed middle age. It is marked by the presence of a ' dry catarrh ' (catarrh sec of Laennec), if such an expression is permissible. Cough is the most prominent symptom, and is in its violence quite out of proportion to the small amount of expectoration by which it is attended ; it is not infrequently accompanied by a degree of congestion of the face, almost amounting to cyanosis. The sputa are glutinous and of the so-called ' pearly ' character. Sibilant rhonchi are present, and the breathing may be accompanied by ' wheezing ' at night or in the early morning. The symptoms, owing to the co-existence of emphysema, may be more prominent during the winter months. Sufferers from gouty bronchitis are often subject to attacks which they have the support of the late Dr. Murchison in attributing to functional derangement of the liver. These are characterised by depression of spirits, pain in the right hypochondrium, anorexia, furred tongue, constipation, and the passage of dark-coloured, highly acid urine, in which on cooling there is an abundant deposit of pink lithates. During the continuance of such an attack the bronchial sym- ptoms are generally more pronounced. Another form of gouty bronchitis met with in middle-aged persons is characterised by a somewhat sudden onset and far more severe symptoms. The special feature which it presents, in addition to those of the milder form, is marked functional disturbance of the action of the heart, in which respect it resembles many other mani- festations of lithfcmia or so-called ' latent ' gout. Such attacks may be characterised by an almost sudden onset and signs of severe pulmonary congestion, such as dyspnoea, cough, and the presence of fine bubbling and crackling rales, particularly at the bases of the lungs ; but pyrexia may be very slight or even absent. These symptoms may be followed by an attack of acute arthritis, or they SECONDARY BRONCHITIS try may subside under treatment without the appearance of any joint affection. Some refuse to recognise them as ' gouty ' unless they are accompanied by the most complete manifestation of that disease, viz. acute arthritis ; but this is akin to denying the connection between a bud and a flower in full bloom. The subjects of gouty bronchitis may subsequently develop chronic interstitial nephritis ; and under such circumstances attacks similar to those just described may occur from temporary cardiac failure and pulmonary oedema. c. Catarrh of the bronchi, occurring in the subjects of tuberculosis of the lungs or in those inheriting a tendency to tubercular disease, does not present features which are so distinctive as to require separate description. In many cases of pulmonary tuberculosis there is no marked tendency to bronchial catarrh, but catarrhal symptoms are usually present when tuberculosis is associated with emphysema, a con- dition of more frequent occurrence than is generally believed. (1. Syphilitic bronchitis is considered in the chapter on Pulmonary Syphilis {vide p. 449). Treatment. — Bronchitis complicating the acute specific diseases requires, as a rule, a stimulant plan of treatment, as cases in which the affection is of sufficient importance to need direct attention are usually of a severe character and are often associated with some degree of cardiac failure. Carbonate of ammonia, or aromatic spirits of ammonia and spirits of tether may be combined with digitalis, the use of the latter being determined by the con- dition of the heart. Inhalations of oxygen and hypodermic injections of strychnine may also be required. Stimulating applications to the chest are generally necessary. The milder form of gouty bronchitis is best treated by careful attention to diet and the avoidance of chills. So long as the patient, by indulgence in alcohol and a highly nitrogenised diet, maintains a high tension within his vessels the cough will probably continue, whereas abstinence from alcohol and a ' white diet ' of fish, chicken &c., suitable to the gouty state will almost certainly by itself give relief. Warm alkaline drinks, as recommended in the treatment of acute bronchitis, are specially useful in these cases ; they may be given at bedtime and before rising in the morning. Free action of the bowels should be maintained by the use of saline aperients, such as Carlsbad salts. For more serious attacks of gouty bronchitis a more active treatment is necessary. Free jDurgation by means of salines and mercurials, and the administration of the iodides and bicarbonates of potassium or sodium fulfil the most important indications. Colchicum may be added with advantage unless there is marked failure of strength. The intermittence and functional disturbance of the action of the heart is to be met by the elimination of the waste nitrogenous products and the lowering of arterial tension rather than by the use of direct cardiac tonics, such as digitahs. ii8 THE DISEASES OF THE LUNCIS Stimulants may be required, but are to be avoided unless urgently called for. More robust patients may be recommended to take a course of waters at Carlsbad, Marienbad, Homburg, or Kissingen. The more weakly sufferers from tins form of bronchitis resort with advantage to Ems, La Bourboule, Eaux Bonnes, and elsewhere on the Continent for treatment by the inhalation of pulverised or atomised spray and drinking of alkaline waters. It is obvious that those prone from their parentage to tubercu- losis should avoid all conditions likely to diminish the functional integrity of the lungs, amongst which repeated catarrh of the bronchi must certainly be numbered. That there are such persons we continue to believe, in spite of recent confident assertions to the contrary. In bronchitis occurring in a tuberculous subject, cod-liver oil is of great use, and a general tonic plan of treatment is indicated. J. K. F. 119 CHAPTEK VII PLASTIC BRONCHITIS TAOK Pathology and moibid anatomy . . . . . . .119 Etiology 120 Symptoms 121 Physical signs and diagnosis 122 Prognosis ........... 122 Treatment 122 A DISEASE of rare occurrence, characterised by the exudation of a. plastic fibrinous material which forms either solid casts or hollow cylinders within the bronchi. Pathology and morbid anatomy. —Nothing definite is known as to the pathology of this affection. The appearance of the exudation naturally led to the suggestion that the disease is a form of diphtheria involving the bronchi, but in their clinical course the two diseases do not resemble one another, and there are prac- tically no other facts which lend support to this view. That plastic bronchitis is due to the presence of a micro-organism is possible,, and cultivation and staining experiments may eventually throw light upon its pathology. The exudation may be localised to a few- tubes only, or may be found in numerous areas scattered through both lungs. In some cases the casts expectorated from day to day resemble each other so closely as to prove clearly that they are formed again and again in the same bronchus. Nearly all pathological museums contain specimens of fibrinous casts expectorated by patients suffering from the disease, but preparations showing the casts in situ are very rare. This might have been expected, as a fatal termination is unusual, and when it occurs no casts may be present in the tubes after death, although they have been freely expectorated during life. The casts vary in size according to the diameter of the bronchus in which they are formed, but, like those found in ' massive pneumonia,' they do not completely fill the tubes. The smaller are usually solid, the larger may be hollow cylinders. They are often much branched, ending in fine rootlike processes {vide fig. 55), corresponding to the minute subdivisions of the bronchial I20 THE DISEASES OF THE LUNGS tree. Whether, as stated by Biermer, their bulbous ends correspond to the infundibula may be doubted ; if so, they should not be more than .-\, inch in diameter, and would probably be much less. They vary much in size, from one and a half to two inches being a common length, but they have been found to mea- sure from six to seven inches. They are white or pearly grey in colour, the larger of firm consist- ence, the smaller softer. Nodular swellings may be observed upon them, due to air or mucus contained within. On microscopical examination the exuda- tion of which the casts are composed is seen to consist of coagulated fibrin, arranged in con- centric laniintie, enclosing in its meshes leucocytes, mucus, and epithelial cells ; the latter may be ciliated, but this is rare. Charcot's crystals, pig- mented cells, and fat globules may also be in- cluded, and blood cor- puscles may be present in the outer layers. The trachea is appa- rently never affected in this disease. After death the epithelial lining of a bronchus containing a coagulum has in some cases been found intact and pale, but in others it has been congested or even absent. The bron- chial wall may show in- flammatory changes, and the surrounding lung may be in a condition of atelectasis or emphy- sema. Etiology. — Among of males is considerably Yn:. -Casts ok thk Tubes kkom a case OF Pl>A8TIC BnONCHITIS the recorded cases the preponderance over two to one. PLASTIC BRONCHITIS 121 The disease may occur at any period of life, but the majority of patients when first attacked have been between fifteen and forty- five. The various tables which have been compiled do not, however, prove that age is an etiological factor of much importance, but they show that the liability to the disease does not increase as age advances. The associated conditions recorded are various, and probably in most cases accidental. Pulmonary tuberculosis and valvular disease head the list, but it may be pointed out that they are very common affections. Pneumonia and typhoid fever have in a few cases preceded the onset of the disease, but by a considerable interval. Severe cutaneous diseases, such as pemphigus, have been found in association with plastic bronchitis, and it has also appeared in connection with pregnancy and the catamenia. As, however, in a considerable number of cases the patients have previously been healthy and even robust, and the onset of the attack has been sudden, it is apparent that but little importance can be attached to these facts. Symptoms. — The exudation of the fibrinous material into the bronchi is at first attended with signs of catarrh ; as it increases in amount and the cast is formed, dyspnoea is experienced in proportion to the extent of the area affected. In what is termed an ' acute ' case, paroxysmal cough and dyspnoea constitute the chief symptoms of the attack, and both may be of the most extreme severity. There is generally an abundant secretion of mucus, and this is expectorated before the cast, which may not appear until the attack has lasted for five or ten days or even longer. Great relief to all the symptoms almost invariably attends its expectoration, and for a time the patient may be almost free from cough and dyspnoea. If, however, as often happens, the exudation continues and the cast is re-formed, the symptoms return, and gradually increase in intensity until another is expelled. The intervals are very variable : they may be of one, two, or three days ; or not more than a few hours. In some of the recorded cases the daily quantity of sputum, of which a part has consisted of casts or fragments of them, has been a pint or more. The expectoration may be most abundant during the night. Pain may be due to the violence of the cough, and in rare cases localised pain may indicate the site of the lesion. Pyrexia commonly attends the severe paroxysms ; and rigors may occur, but they are rare, and possibly when present are due to an associated pneumonia. Hemoptysis, either in the form of blood streaks upon the casts, or in large quantity, is stated to occur in about one-third of the cases. It usually accompanies the expec- toration of the casts, but may precede or follow it. In one re- corded case which was fatal from this cause, tubercular disease of the lung was found post mortem, but there is no doubt that this is not present in all cases of plastic bronchitis attended by profuse haemoptysis. The source of such haemorrhage is doubtful. From 122 THE DISEASES OF THE LUNOS analogy it is probable that there is some definite pulmonary lesion to account for it, as blood in large quantity does not come from the vessels of the bronchial wall. A case marked by the recurrence at varying intervals of attacks, each consisting of a succession of paroxysms similar to those above described, is by some writers classed as ' chronic' The subdivision, however, of cases into ' acute ' and ' chronic,' based chiefly upon the fact of recurrence, which is a characteristic of the disease, is quite arbitrary and of little practical value. A single attack entails a liability to the disease which may last for life, but the intervals may be very prolonged, as is shown by a case in which the disease appeared at the following ages : :->G, 41, 4'2, and 60 years. Physical signs and diagnosis. — The disease does not appear to have been recognised in any case prior to the expectoration or dislodgment of the casts. When the diagnosis has been made it may be possible to determine the site of their formation by the presence of catarrhal signs limited to a certain area, followed possibly by evidence of complete bronchial obstruction and pul- monary collapse in the same region. The expectoration of the cast may be marked by the return of the breath sounds, and the percussion note, previously dull, may, as the lung re-expands> become resonant; but dulness,if due to pneumonia, would of course not suddenly disappear. In any case of paroxysmal dyspnoea without obvious cause, suddenl}- relieved by expectoration, a careful examination of the sputa should be made, as the cast may be rolled up into a rounded mass and so thickly covered with mucus as ta make its recognition difficult until it has been floated in water. Prognosis. — The marked liability to recurrence necessarily requires to be borne in mind, but a fatal termination is rare in cases uncomplicated by definite pulmonary disease, such as tuber- culosis. In a case recorded by Dr. Fagge the patient died suddenly . from asphyxia, owing to the lodgment of a displaced cast at the bifurcation of the trachea. Treatment. — The only drug which appears to have any effect upon the disease is iodide of potassium in large doses ; it is said to have been used with complete success in some cases, and is certainly worthy of trial. In a case recently under the observation of one of our colleagues, it was thought that intratracheal injec- tions of glycerine— a teaspoonful at a time — given several times daily, aided the separation of the casts. We should now be dis- posed to try the continuous inhalation of creasote vapour, if a suitable case presented itself. J. K. F. 123 CHAPTEE YIII BEONCHIEGTASIS (DILATATION OF THE BEONCHI) I'AGE Etiology 123 Morbid anatomy 125 Mode of production ......... 128 Intrinsic causes 128 Extrinsic causes 129 Clinical varieties .......... 131 Symptoms ........... 131 Course ............ 133 Physical examination . . . . . . . . .134 Diagnosis . . . . 135 Prognosis 137 Treatment 137 This affection was observed in 1808 by Professor Cajol, then a student in Paris. He brought his specimens under the notice of Laennec, to whom medicine is indebted for the first clinical and pathological description of the disease. Dilatation of the bronchi, viewed from the standpoint of morbid anatomy, is a condition of common occurrence, as it is frequently found in association with pulmonary tuberculosis. From a clinical point of view, however, the affection is comparatively rare. Etiology. — Dilatation of the bronchi is rarely, if ever, a primary disease ; it may be traced to some preceding affection of the bronchial wall or of the lung or pleura. The post-mortem records of the Brompton Hospital from 1887 to 1894 contain reports of thirty-five cases in which the condition was present in a marked degree ; an analysis of these cases shows them to have originated thus : No. of cases Acute bronchitis 1 Chronic bronchitis ........ 7 Syphilitic stenosis of the bronchi ..... 1 Pressure on bronchi by a mediastinal growth or an aneurysm ......... 1 Foreign bodies in the bronchi ...... 2 Bronchitis and asthma ....... 1 Broncho-pneumonia 5 Lobar pneumonia ........ 2 Chronic pneumonia and cirrhosis of lung .... 5 Pulmonary tuberculosis ....... 4 Pleurisy and empyema . . . . . . . 3 Hydatid cyst of the kidney ...... 1 Spinal curvature 2 35 124 THE DISEASES OF THE LUNGS This list illustrates the common causes of the affection. As to the relative frequency of their occurrence it is difficult to make any positive statement, but it is probable that this is fairly indicated by the number of cases here attributed to the various causes. We are acquainted with one case in which localised bronchiectasis Fig. 56. — Cylindrical Bkonchikctasis hkcondaky to the lodusiknt 01'' A TuOTIl IX A LAIiGE TxJBE followed upon the ubsorptioji of the blood in a hnemorrhagic in- farction. Sex. — Most statistics show a considerable preponderance of the male sex. In the above-mentioned cases twenty-nine occurred in males and six in females. Age. — The affection may be met with from childhood to old age, but it is most common in middle life. Excluding two cases BRONCHIECTASIS 125 which occurred in children aged six and nine, and one in a man of seventy-three years, the average age was thirty-four years. The above, however, refers to the age at death, and is a state- ment of comparatively little value, as the affection often runs a very chronic course, many cases originating in childhood and lasting twenty, thirty, or even forty years. The varied etiology of the condition shows of how little importance the age factor must necessarily be. Morbid anatomy. Varieties. — Two chief varieties of the affection are met with, the one cylindrical, simple, or uniform, the other saccular or globular. When the dilatations in the cylindrical form taper towards their extremities, the term fusiform is often applied. In another form which is occasionally observed beadlike dilatations are present at intervals upon a bronchus, the lumen of which is not elsewhere enlarged; this has been named vioniliform. In advanced cases the eylindiical and sacculated forms are often found in association. Cylindrical form. — This occurs chiefly in the larger tubes and those of medium calibre {vide fig. 56), but it may extend from the root to the surface of the lung. A dilated tube is rarely of uniform diameter for any considerable distance ; it usually presents constrictions here and there in its course, and tends to undergo a secondary enlargement at its distal end. The con- strictions are often due to a new growth of fibrous tissue which has replaced the muscular coats, and are sometimes so distinct as to form incomplete septa. Saccular form. — The appearances presented by the most typical examples of this form of the affection [vide fig. 57) are in marked contrast to those just described. On section of the lung all trace of pulmonary tissue may have disappeared over areas of considerable extent, and, in its place, large numbers of rounded, smooth-walled, shiny saccules are seen, each presenting a small opening in its floor. Their walls are usually thinner than normal, and neighbouring spaces may communicate. A whole lobe may be thus affected, or in some cases the whole lung, constituting the condition known as 'turtle lung,' from its similarity in appearance to the lung of that animal. At other parts of a specimen which shows the advanced condition earlier stages of the change may be seen, and the saccules there will be much smaller, and separated by areas of lung tissue in which the tubes are not dilated. In rare cases a single large saccale is found. The terminal bronchi are usually first affected, and the distal end of the dilated tube is generally closed at an early stage of the process. Size. — The size of the dilatation necessarily varies with that of the affected tube, but is said to. be proportionately greater in the case of the smaller tubes (Biermer). A cylindrical dilatation of a large tube which will admit the forefinger is by no means rare. Saccular dilatations in the early stage are so small as only to be discoverable by the aid of the microscope, whilst in the most advanced stage they may even be equal in size to a hen's egg. 126 THE DISEASES OF IHE LUNGS Extent. — In the great majority of cases a large number of tubes are found (post mortem) to be aft'ected, as is shown by the fact that, in the thirty-five cases above referred to, dilated bronchi wei'e found in all the lobes of one or both lungs in twenty-seven, whereas the lesion was limited to one lobe in only eight. In twenty-three cases (G5 per cent.) both lungs were affected. Fi(i. 57. — Saccular Uuonchikctasis or iiie Loweu Lohio ok a LrN(i At its commencement, however, the affection is much more limited. Frequent cough, the inhalation of secretion, and the inter- current attacks of bronchitis and septic broncho-pneumonia, which at one period or another are almost sure to occur, combine to favour its spread. Speaking generally, it may be stated that when the condition follows acute or chronic bronchitis or broncho-pneumonia, especially in childhood, many tubes are dilated ; whereas, when it is a se(]uel of collapse from jileural effusion, lobar pneumonia, the impaction of a foreign Ijody, or stenosis of a large lironchus, it may BRONCHIECTASIS 127 for a time be limited to the area of lung affected by the primary lesion. The lower lobe is more often primarily affected, but, when the lesion is secondary to tuberculosis, the apex is usually its earliest site. Changes in dilated bronchi. — In some cases the mucous membrane only shows the lesions of acute inflammation, but when the larger tubes are affected it is often swollen and reddened, and presents a velvety appearance. In the more chronic cases it may be greyish in tint and granular on the surface. The fibrous structures of the bronchial wall are usually in such cases thickened, and fibrous peri-bronchitis may be present, the thickened tubes on transverse section standing out from the cut surface of the lung ; but in other cases, particularly in those of the sacculated variety, the Avail of the tube may have undergone decided thinning. The tubes may be empty, or may contain large quantities of thick purulent fluid of remarkably foetid odour. This may be of a dirty grey or greyish- pink colour, stringy, curdy, or inspissated. In other cases the dilated tube throughout its length may be found filled with clear, sweet, gelatinous-looking niucus, somewhat resembling the contents of a culture tube of nutrient gelatine. On closer inspection in such a case it will be seen that the upper surface presents a yellowish tinge, and here a growth of micro-organisms may be found, rendering the likeness still more complete. In cases where all communication from the air has been shut off, cystlike cavities may be found filled with caseous-looking material. Changes in adjacent lung tissue. — The condition of the lung in the immediate neighbourhood of the dilatation varies greatly, and, as a rule, no single lesion is present alone. The lung may be healthy, emphysematous, collapsed, condensed, or fibroid. It is frequently oedematous. A lobe, or even the whole lung when the change is extensive, may be consolidated, tough, iron-grey in tint, and densely indurated. Extensive areas of broncho-pneumonia and of gangrene may also be found around dilated tubes. Associated pathological lesions. — In addition to the changes found in the affected tubes, more or less general bron- chitis is usually present, the mucous membrane being often intensely red or of a purplish tint. Acute pleurisy with effusion is rarely met with, but pleural adhesions are generally present post- mortem, though they have been absent in many cases submitted to operation. The adherent pleura is often much thickened, and the interlobar septa appear as dense fibrous bands extending from the surface towards the root of the lung. The interlobular connective tissue may also be increased. The process by which the thickening of the pleura and of its prolongations between the lobes is effected will be discussed later. Perforation of the pleura and pneumothorax may occur, or the cavity originating in a dilated bronchus may even penetrate the chest wall, and either rapture externally or form an abscess beneath the muscles. Perforation into the cellular tissue of the mediastinum 128 THE DISEASES OF THE LUNGS may give rise to interstitial or subcutaneous emphysema ; but all these events are of very rare occurrence, and when met with are usually complications of gangrene. In the cases accompanied by emphysema the morbid conditions incidental to that disease will be present. Of these, hypertrophy and dilatation of the right side of the heart and congestion of the systemic veins are the most important. Long- continued profuse purulent discharge may induce lardaceous disease. Cerebral abscess was the immediate cause of death in four of the series of cases previously referred to. The kidneys may present indurative changes from chronic venous congestion, or they may be lardaceous. Chronic parenchy- matous nephritis has also been observed. MODE OF PRODUCTION This is a point on which considerable di£terence of opinion exists ; all writers, however, agree that dilatation of the bronchi is not a primary disease, but a secondary result of some lesion, involving either the bronchial tubes, the lung, or the pleura. It will therefore be convenient to consider the mode of production under the headings intrinsic and extrinsic. INTRINSIC CAUSES (1) Acute and chronic bronchitis. — As dilatation of the bronchi may occur in the absence of any lesion of the surround- ing lung tissue, it is clear that the changes found in the bronchial walls are the only pathological conditions absolutely necessary for its production. No explanation, therefore, which does not take account of this fact can be accepted as satisfactory. Chronic bron- chitis is, as we have seen, in the great majority of cases associated with emphysema, and not with bronchiectasis. Violent expiratory efforts with the glottis closed, or partially closed, will give rise to emphysema, and for the uncomplicated cases of bronchiectasis, just referred to, a similar explanation is the only one which meets the facts. It is not easy to say why in the one case the alveoli dilate and in the other the bronchi, but it probably depends upon the fact that, when bronchiectasis occurs, inflammatory changes in the bron- chial wall have led to a loss of elasticity and muscular tone, and possibly to atrophy of the muscular tissue ; conditions most favourable to the occurrence of dilatation. Violent cough probably under all circumstances causes a slight temporary dilatation of the bronchi, but this is immediately followed by recoil so long as the integrity of the elastic and muscular tissues is maintained. If, however, these tissues be weakened and their loss of elasticity be out of proportion to that of the lung, the result will be bronchial dilatation instead of emphysema. Retained secretion, which is no longer permeable to air, must form a better i)oint (Vapimi for such a force than air contained in the tubes, and secretion may be retained before the lung tissue beyond has undergone collapse. . A deficient BRONCHIECTASIS 129 entry of air into any part of the lung, by producing incomplete expansion of the alveoli and so defective support of the bronchi, would necessarily favour dilatation of the tubes ; but such a con- dition, although commonly present in cases of bronchiectasis, cannot be regarded as essential. (2) Bronchial stenosis. — This is an important factor in the etiology of bronchiectasis. Narrowing may be caused by the con- traction of gummatous tissue in the bronchial wall, by the pressure of an aneurysm or a morbid growth, or the presence of a foreign body, and in other ways ; but, however produced, it leads to dilata- tion of the tubes beyond the site of constriction. Various causes contribute to this result. (a) Accumulation of secretion in the tubes leads to obstruction of the bronchioles and collapse of the tributary area. (b) Changes in the bronchi and peribronchial tissues diminish the power of resistance to pressure from within. (c) Fibrous thickening of the interlobular and interalveolar connective tissue, and of the lung as a result of inflarama- tion, lead to contraction of the surrounding tissue. The above conditions render effective the dilating force of violent expiratory efforts with a partially closed glottis, and this we regard as the indispensable factor in the pro- duction of dilatation. (3) Obstruction of a bronchus. — When a bronchus is suddenly obstructed, as, for instance, by a foreign body which fills its lumen, collapse of the area of lung to which it is distributed is the usual result, and this is followed either by emphysema of the surrounding tissue or by dilatation of a neighbouring bronchus. When, however, complete obstruction follows gradual narrowing, the tubes beyond have usually already undergone dilatation. EXTRINSIC CAUSES Changes in the lung. — (a) Collapse of the lung, from whatever cause arising, is liable to be followed by bronchi- ectasis, and is one of the most common causes of that condition in children. In such cases the collapse is gene- rally the result of capillary bronchitis. Stenosis and obstruction of a bronchus may, as we have already seen, lead to collapse of the corresponding area, and so favour the onset of bronchiectasis. Collapse of the lung secon- dary to pleurisy is considered under changes in the pleura {vide p. 131). (b) Pneumonia, either lobar or lobular, may be an antecedent of bronchial dilatation, and either form of pneumonia, but especially the latter, may supervene upon the lesion already established. In a remarkable case lately under observation at the Middlesex Hospital, signs, which were I30 THE DISEASES OF THE LUNGS clearly due to the dilatation of a bronchus at the apex, persisted after recovery from pneumonia of the left upper lobe, resolution having been incomplete. The patient had had seven attacks of pneumonia, for nearly all of which he had been an in-patient in the hospital, and, in all but the last, recovery of the lung had been complete. There was no sign of breaking down of the lung, and the absence of tubercle bacilli and elastic tissue from the sputa and the course of the attack negatived a diagnosis of tuberculosis. Without a knowledge of his history he would be now almost certainly regarded as a case of arrested tuberculosis of the apex. A pneumonia which has not undergone complete resolution may become in time a ' chronic pneumonia,' and with that condition bronchiectasis is very often associated. (c) Emphysema. — The same conditions which lead to emphy- sema may produce bronchiectasis, and a moderate degree of bronchial dilatation is not uncommonly observed in emphysema, but advanced emphysema and general bronchiectasis are rarely found in association. (fZ) Fibrosis of the lung arising from chronic pneumonia, tuber- culosis, or other causes is frequently complicated by bronchiectasis, and various views are held as to the pathogenesis of the latter condition under such circum- stances. Elaborate diagrams have failed to con\ance the writer of the correctness of the theory that traction by fibrous bands passing from the pleura to a bronchus or from one bronchus to another are the effective dilating force when bronchiectasis follows fibrosis of the lung. Moreover operations in cases of bronchiectasis have shown how commonly pleural adhesions, which are almost essential to the acceptance of this view, are absent when their presence has been regarded as practically certain. Areas of fibrosis, whether of tubercular origin or not, tend to shrink by a process of centripetal contraction, and if the whole lung is affected the small space it may ultimately occupy is very striking. Chronic cavities tend to contract and their lumen may be almost (very rarely quite) ob- literated ; the parietal and visceral layers of the pleura become separated as the lung retracts, and the intervening space is filled by a fluid exudation which ultimately becomes organised into densely firm fibrous tissue, or the neighbouring tissue, if still pervious to air, becomes emphy- sematous. Organs are displaced and other changes occur, all of which appear to be more likely to obliterate than to enlarge spaces within the affected area. That they are not completely obliterated is due partly to the dilating force of the chronic cough, wliich is commonly present, and partly to the fact that when, by the aid of such changes as approximation and overlapping of the ribs, BRONCHIECTASIS 131 curvature of the spine, displacement of organs and of the mediastinum, and enlargement of the opposite lung, every possible compensation has been made, equilibrium between the various forces is obtained before the cavities in the lung have been completely obliterated. Where a dilated bronchus is found opening into an irregu- larly shaped chronic tubercular cavity, neighbouring fibrous tracts may have had some share in producing the irregular outline, by preventing contraction rather than by acting as a dilating force ; but this is not, according to our view, an agent of any importance in the production of bronchi- ectasis. Changes in the pleura. — Pleurisy with effusion having led to collapse of the lung, either as a whole or in part, dila- tation of the bronchi and chronic thickening of the inter- lobular and interalveolar connective tissue may follow. It is probable, as suggested by Wilson Fox, that these changes proceed together, and that the dilatation of the bronchi is not due to the fibrosis of the lung, but to the distending force of the cough acting upon the weakened tissue of the bronchial wall. The question discussed above arises in connection with these cases also, but it is unnecessary to recapitulate the arguments there advanced. Such fibrous tracts or bands as are not due to the presence of chronic interstitial pneumonia are in most cases the thickened interlobar or interlobular septa. Inspiratory pressure. — The fact that the expansion of the affected part during inspiration is practically nii tells strongly against the effectiveness of that force as a factor in producing dilatation of the tubes. Clinical Yarieties of bronchiectasis.— Two varieties of the affection are observed, the acute and chronic. The former, which is more commonly met with in children, may be produced in a comparatively short time as a result of whooping cough, diphtheria, acute and capillary bronchitis, broncho-pneumonia, pul- monary collapse, or pleurisy. {Vide Bronchiectasis in Children, p. 143.) Cases of this type may occur in adults from similar causes and are not uncommon in typhoid fever. In a fatal case of that disease lately under the care of the writer cylindrical dilatation of the tubes was present in an area of consolidation produced by the coalescence of numerous foci of broncho-pneumonia ; one of the dilatations nearly approached the surface of the lung. This condition may lead to perforation of the pleura and pneumo- thorax. Symptoms. — In a disease owning such a varied etiology as bronchiectasis uniformity in symptoms is not to be expected, but in well-marked cases they are usually fairly typical. A paroxysmal cough, accompanied by the expectoration of a large quantity of purulent and often offensive secretion, is the com- ,32 THE DISEASES OF THE LUNGS bination of symptoms which most commonly suggests the presence of dilatation of the tubes. In the intervals between the paroxysms the patient may be fairly free from cough, except when there is much emphysema, the cough is then usually more frequent and may be painful. The dilated tubes lose their sensibility to a great extent and cough is not excited until, from the accumulation of secretion, healthy parts of the mucous membrane are irritated. Copious ex- pectoration then follows. The paroxysms tend to occur chiefly on lying down at night and rising in the morning, or when the patient assumes some particular position, generally the recumbent on the healthy side. The secre- tion then overflows into unaffected or less diseased bronchi and cough results. The site of the affection materially influences the severity of the cough. When the lesion is chiefly at the apices or in the area of the upper lobes from which there is free drainage, there is not the same tendency to accumulation as when the lower lobes are mainly affected. Expectoration may be easy, or effected with difficulty, owing to the presence of advanced emphysema or stenosis of a main bronchus or of marked induration of the tissue around the dilated tubes. Characters of the sputa. — It may be some years before the sputum presents an offensive odour ; then, for perhaps as long a period, a faint putrid smell is noticeable ; subsequently when bronchi- ectasis is fully developed, the sputa, owing to putrefactive changes, acquire the horribly fcetid character which is such a marked clinical feature of the disease. The odour is not quite the same as that of gangrene ; it has been compared to that of rotten cabbage ; but a more precise description is hardly necessary, as it will be readily appreciated, possibly at a distance from the patient. It may be more marked in tbe breath than in the sputa or vice versa. We have known it to be so horrible that, if the patient coughed, vomit- ing was innnediately induced in persons standing near him. The expectoration is usually diffluent, seldom nummulated. After standing for about twenty-four hours it settles into either two, or more often three, well-defined strata— an upper thin, brownish, frothy mucoid layer, a middle layer of greenish fluid, either clear or con- taining hanging threads, and a thick lower layer of purulent material, which forms a grey opaque mass. Where only two layers are present the upper is more or less stringy, or it may be clear, the solid matters sinking to the bottom. In the latter, on microscopical examination, pus cells, granular detritus, connective tissue, and many organisms are found, amongst which micrococci, bacteria, spirals and filaments of leptothrix are the most numerous. Traube's or DitDrich's plugs, which are soft, foetid, greyish-yellow bodies, formed in the bronchi and consisting of pus cells, granules, oil- globules and needle-shaped crystals, can usually be found in the lower layer by careful search. In some cases casts of the bronchi BRONCHIECTASIS 133 may also be found after floating a part of the deposit in water. Leucin and tyrosin may also be present. The quantity of the expectoration varies, but is usually profuse and may amount to 25 or 30 ounces or more during the twenty-four hours. In a case recently under the care of the writer it averaged 163 ounces a week for a period of six months. The reaction may be alkaline, or it may become acid from the presence of butyric, lactic, valerianic and acetic acids. Dysjynoia.— The breathing is not, as a rule, much quickened in the early stages, and then there may be no dyspnoea, but it is usually present to some degree on exertion, and it may be severe when cardiac complications exist. It is due rather to the co- existence of bronchitis, emphysema, or fibrosis than to dilatation of the tubes. During intercurrent attacks of bronchitis or pneumonia dyspnoea may be severe, as it almost invariably is towards the end of the case. Hcemoptysis is usually a late symptom, but its occurrence is by no means uncommon. It was present at some period in 14 out of the 35 cases analysed, and in several it was profuse in quantity and frequently repeated. Only three of these were cases of tuberculosis, and in one there was aortic stenosis. An ulcerative process start- ing in the bronchial wall may extend to a neighbouring branch of the pulmonary artery and so give rise to haemorrhage, or an aneurism on a branch of the pulmonary artery may project into a dilated tube, and the rupture of the sac may be followed by immediate death from haemoptysis. In three of the cases haemoptysis was the immediate cause of death, and in two of these a pulmonary aneurysm had ruptured into a dilated tube. Pyrexia. — There may be no pyrexia throughout the case. In the early stages it is often absent, but if secretion is retained the temperature will rise ; and towards the termination of a case, if septic broncho-pneumonia occurs, there is nearly always high fever of a remittent type. If death occurs from gradually increasing cyanosis, the temperature is generally sub -normal. Eemitting attacks of fever are apparently due to retention of secretion, or to localised pneumonia. Pain in the chest is usually due to pleurisy and is of importance, as possibly showing that the affection is approaching the surface of the lung. In cases originating in an attack of acute pleurisy there will almost certainly be a history of severe pain on the affected side. Diarrhaa may result from septic infection, or may be due to lardaceous disease of the intestine. Alhuminuria is common from amyloid disease of the kidneys. Clubbing of the fingers and toes, and also to a less degree of the nose, is such a marked feature of bronchiectasis as to be of decided value in diagnosis. Course. — In cases originating in chronic bronchitis certain fairly well-defined stages of the affection may usually be recog- nised. (34 THE DISEASES OF THE LUNGS 1. Expectoration is profuse and purulent, but not foetid. Pyrexia is absent, strength and nutrition are well main- tained. Exacerbations often occur in the winter months. 2. The expectoration acqiiires a faintly foetid odour and becomes more profuse in quantity. This change may be accom- panied by the signs marking the following stage, but it may precede their onset by a long period. There anay be slight pyrexia, but it is rarely continuous, being, as a rule, limited to periods when the sputa are diminished in amount or entirely absent. 3. The condition is now fully developed, the sputa are decidedly foetid, characteristic physical signs are present, and club- bing is well marked. 4. Pleural adhesions are formed as the result of an attack of acute pleurisy, or of one of a subacute type in which a ' dry ' friction sound is present over a large area for a considerable period. 5. Fibrosis of the lung is followed by retraction and thicken- ing of the pleura. Haemoptysis may occur, and may prove fatal. Emaciation, dyspnoea, and possibly pyrexia are present. 6. Absorption of the septic contents of the tubes induces pyrexia of a remittent type, or possibly a rigor and severe general symptoms. Death may be due to pericarditis, septictemia, pysemia, cerebral abscess, nephritis, diffuse bronchitis, or septic broncho-pneumonia, with necrosis of the consolidated areas. Cases originating in an attack of acute pleurisy or pneumonia may run a shorter course, e.fj. a male, aet. 88, previously healthy, had pleurisy (L) followed in three weeks by cough and expectoration, which became copious and offensive in three days. Three severe attacks of hajmoptysis followed, and in six months from the onset death occurred from the rupture of a pulmonary aneurysm into a dilated bronchus. In other cases the course of the affection is too variable to admit of analysis, but the three later stages described above may often be recognised. Physical examination.— To describe in detail all the physical signs which may be met with in cases of bronchiectasis would serve no useful purpose, as the condition may be a secon- dary result of such a variety of diseases, and many of the signs pertain to the primary affection rather than to the bronchial dila- tation. The physical signs will necessarily depend upon the nature of the primary affection, the extent of the lesions, the condition of the surrounding lung, the amount of secretion in the dilated tubes, and upon their distance from the surface of the chest. Inspection. — The chest may be markedly emphysematous in type, or with localised disease there may be retraction of the chest wall and displacement of the cardiac impulse. BRONCHIECTASIS 135 In some cases, expansion, though only slightly impaired over the upper lobes, is decidedly diminished at one or both bases. Palpation. — The vocal fremitus and resonance are increased in cases accompanied by fibrosis, and bronchophony or pectoriloquy may be present. Percussion. — The note obtained will depend upon the extent of the lesion and the condition of the lung surrounding the dilated tubes. If the lung is healthy or emphysematous, the note will be either normal or hyper-resonant, but when the condition is well marked and numerous dilatations are present in a given area, the note is usually raised in pitch and deficient in resonance, but the limits of impairment are not, as a rule, sharply defined. Where a whole lobe is converted into a mass of saccules, the note is tympanitic, or, if the saccules are very large, amphoric. The tympanitic quality may be more decided and the pitch higher when the mouth is open. Fibrosis around dilated tubes which are filled with secretion gives rise to an absolutely dull sound on percussion ; when they are emptied, the note is raised in pitch,andmay present various degrees of dulness up to a distinctly wooden note. Auscultation. — Cylindrical dilatations give rise to bronchial breath sounds of a blowing and rather hollow, but not cavernous quality. Both on inspiration and expiration the sound may be interrupted and wavy. With sacciilated dilatations the breathing may be truly cavernous, and gurgling rales may be present. The 'veiled puff' of Skoda may often be heard. It is a curious sound occurring at the end of inspiration and giving the impression that a puff of air has suddenly entered a small cavity situated just beneath the ear. When once recognised it is easily distinguished, and is in our experience more often present in bronchiectasis than any other condition. The character of the adventitious sounds depends to some degree upon the state of the surrounding lung. If this is spongy, they are ' bubbling ; ' if indurated from fibrosis, they become crackling in quality. The typical sound is a coarse rale of ringing or metallic quality. It may be almost constantly present over a certain area, or it may disappear and reappear according to the quantity of secretion in the tubes. A variety of other rales may be present, resulting from the co-existing bronchial and pulmonary lesions. Rales are not infrequently produced in bronchiectasis by the movements of the heart, and a loud systolic murmur is in some cases audible about the cardiac apex, also posteriorly and in the trachea and mouth. In one very marked example of this kind under the care of the writer a systolic murmur could be heard at a distance of two feet from the patient when the mouth was open, and its presence had led to the suspicion of aneurysm. Diagnosis. — The following sequence of events clearly and repeatedly observed is almost diagnostic of bronchiectasis, viz. the sudden expectoration of a large quantity of muco-purulent fluid, 136 THE DISEASES OF THE LUNGS foetid or not, followed by the discovery of cavernous breathing over a certain area, and the gradual disappearance of this sign as the secretion re-accumulates. The only other condition likely to be attended by similar signs is that which follows the rupture of an empyema into the lung. A case may be seen many times without this sign being observed, and it may, nevertheless, be present every day. The patient usually knows when the greatest amount of ex- pectoration will be brought up, or he may be able, by assuming a certain position, to induce a free flow. If the examination is made before and after this occurs, the alteration in the signs over a certain area may in some cases be readily recognised. The diagnosis from chronic bronchitis with emi)hyscma is often difiicult ; it depends chiefly upon the character of the expectoration and the peculiar mode of its evacuation. Persistent foetor points strongly to bronchiectasis, although in cases of 'putrid bronchitis' this condition of the sputa may be present, even though the tubes are not dilated. If the breath soimds are of the wavy bronchial quality, and are accompanied by coarse bubbling or ringing metallic rales, and particularly by the 'veiled puft",' it is very probable indeed that the tubes are dilated. When the signs are localised, and there is extreme foetor, with evidence of breaking down of the lung, in addition to consolidation, the diagnosis lies between pulmonary gangrene and bronchiectasis followed by ulcerative and destructive changes. The former condition is generally a sequel of acute pneumonia, broncho-pneumonia, or tuberculosis ; the latter is often the mode of termination in cases of simple bronchiectasis. The history and the results of examination of the sputum usually throw light upon the true nature of the case. The diagnosis from tuberculosis rests mainly upon the results of the examination of the sputum, but it must be remembered that tuberculosis may be engrafted upon bronchiectasis, although such an event is not of common occurrence. The fact that the disease has not followed what may be called the ordinary ' line of march ' of tuberculosis is a presumption against that diagnosis. Difficulty may, however, arise when a primary tubercular lesion in the upper lobe has undergone arrest, and in such a case the presence of the old lesion may be overlooked, and basic disease, although really secondary, may appear to be primary. Such cases are by no means infrequently met with. Fortunately, however, an exact pathological diagnosis is then of comparatively little importance. It is otherwise, however, when the diagnosis lies between a limited empyema with an opening into the lung and chronic pneumonia with bronchiectatic cavities in the lower lobe, as in the former case an operation is decidedly indicated, whereas in tlie latter it is rarely advisable. We are not now con- sidering those rare cases in which a single large bronchiectatic cavity is present in the lower lobe, as in such an operation is admissible and has been attended with success. An etnpycvia which has opened into the lung is a form of pneumothorax, and may be attended by the ordinary signs of that BRONCHIECTASIS 137 condition. In such a case the diagnosis is not as a rule difficult, but it is often almost impossible to distinguish between a loculated empyema situated between the lung and the diaphragm, or between the lobes of the lung with a perforation into the lung, and a cavity within its substance, and such a cavity may be bronchiec- tatic. In such a case puncture with an aspirator needle may aid the diagnosis ; but the proceeding is not without risk, as, if adhesions are absent, pus or air may enter the pleural cavity, or, as in a case reported by Dr. Carr, in which firm pleural adhesions were present, general subcutaneous emphysema may follow from the air being forced along the track of the needle during the act of coughing. A case of pulmonary disease, marked by long-continued copious foetid expectoration, from which tubercle iDacilli and elastic fibres are absent, by diffuse bronchial rather than limited cavernous or amphoric breathing, by coarse bubbling or metallic rather than gurgling rales, and by extreme clubbing of the fingers, toes, and nose, is probably one of bronchiectasis, in which many tubes have undergone dilatation. Prognosis. — When the affection is a sequel of measles or whooping cough in childhood, recovery, possibly complete, may follow a moderate degree of dilatation. Often, however, it becomes chronic ; but even then it may for many years take the form of a severe bronchitis aggravated by inclement weather. As a rule, the course of the disease is very chronic, and cases are on record in which it had been present for so long a period as forty or fifty years. When it originates from an unresolved pneumonia or follows upon collapse of the lung, the result of pleurisy with effusion, recovery is extremely rare, and the course is not usually so prolonged as in cases secondary to chronic inflammation of the bronchi. The chief dangers are from profuse broncho-pneumonia and gangrene, haemoptysis, and cerebral abscess. Cardiac and renal complications are common precursors of death. Treatment. — To prevent the decomposition and to diminish the quantity of the bronchial secretion are the main objects of treatment. For these purposes inhalations of creasote, carbolic acid, tar, and turpentine have long been in use, and these and similar remedies have been administered internally. Such treat- ment cannot, however, be said to have been attended with marked success. This is doubtless due in great part to the fact that the quantity of the remedial agent which reaches the affected tube by the ordinary use of sprays and inhalations is insufficient to effect any decided change in tbe local conditions. Eecently, however, other methods of treatment have been suggested, from which more decidedly beneficial results may be obtained. These are the con- tinuous inhalation of the vapour of coal-tar creasote, or cresoline, the use of intra- tracheal injections, and of hypodermic injections of sterilised oil of guaiacol or of creasote. 138 THE DISEASES OF THE LUNGS The use of creasote vapour baths was suggested by Dr. Arnold Chaphn.' The details of this method of treatment are as follows : A small room should be set apart for the purpose, and should be cleared of furniture, except such articles as wooden chairs and a table. In order to prevent the smell of the creasote vapour from pene- trating them, the patient should put on over his clothes a garment \\'ith sleeves shaped something like a smock frock. The eyes should be protected by well-fitting goggles, similar to those worn by Alpine climbers when on the snow, or a mask may be worn, made of surgical strapping with two watch-glasses between the adherent surfaces corresponding in position with the eyes, and tied with strings at the back of the head. Plugs of cotton-wool should be inserted in the nostrils. Women should cover the hair with a bag similar to that some- times used by them when bathing in the sea. Ordinary commercial creasote should be poured into a metal saucer on a ringed iron tripod, and the saucer heated with a spirit lamp placed beneath it. If the floor is of wood, the tripod should be placed upon a large flat stone slab, as the creasote may run over the edge of the saucer. As the creasote is heated, dense clouds of vapour arise and quickly fill the room. The effect upon the patient is to produce violent cough attended with profuse expectoration, nearly two-thirds of the daily quantity being usually ejected during the bath ; vomiting may follow the cough. The process is certainly not a pleasant one, but it is remarkable how readily some patients become accustomed to it. They usually state that the breathing is much freer after the bath, and that they enjoy a much longer interval of almost complete freedom from cough and expectoration. At first the bath may be given on alternate days for a quarter of an hour or twenty minutes ; but when the patient has become accustomed to the treatment the bath should be given daily, and the duration of it gradually increased up to an hour or an hour and a half. Some patients are able from the first to take a creasote bath daily, and to remain in it for a longer period than that stated above, and in severe cases it may with advantage be used twice daily. Under this treatment wo have known the fd'tor of the expectora- tion to disappear within a short time ; but this is by no means an invariable result. In some cases the quantity of the sputa diminishes at the same time, but in others it is but little affected. The treat- ment should be persevered with for long periods, a bath being taken daily for three or four months or more. At the Brompton Hospital two house physicians, who tried the baths, and several patients, ' lirit. }[<■(!. Jour. i. 1895, p. i;{71. BRONCHIECTASIS 139 have informed the writer that they noticed a remarkable increase of appetite to follow their use. The use of intra-tracheal injections has been advocated by Rosenberg and others {vide paper by Dr. Colin Campbell, 'Brit. Med. Jour.' ii. 1894, p. 1288). One of the formula^ recommended is as follows : Menthol 10 parts Guaiacol ..... 2 „ Olive oil 88 „ A drachm of this solution may be injected into the trachea without causing the patient any inconvenience, if care is taken that the end of the nozzle of the syringe has passed beyond the vocal cords, or at any rate that the fluid is not injected into the larynx. The dose of sterilised oil of guaiacol or creasote for sub- cutaneous injection is 30 minims of a solution of the strength of 1 in 4. We have given all these methods of treatment, singly and in combination, a prolonged trial, and have come to the conclusion that in cases of bronchiectasis the inhalation of creasote vapour is the most valuable. The results obtained, although far superior to those attending the use of any other measures with which we are acquainted, have not been so uniformly favourable as we were led to hope for from the experience of a remarkably successful case at the outset. This patient was at first too ill to be removed from bed, and was then given subcutaneous injections of sterilised oil of guaiacol. Subse- quently, when his condition had somewhat improved, he took creasote vapour baths, and to this he attributed his recovery. He was so confident of their good effect that, after leaving the hospital, he continued the treatment at home for a time. The following is a brief abstract of the notes of this case : James H., fet. 55, a shopkeeper, was admitted to the Brompton Hospital under the care of Dr. Fowler on May 20, 1896. He enjoyed good health up to April 1895. Since then he has had cough, accompanied lately by the expectoration of foetid sputum, which has frequently been blood-stained, but there has been no considerable haemoptysis. He has lost three stones in weight. Dyspnoea is only present when expectoration is difficult. On admission he was very weak, and in an almost prostrate condition. The expectoration was copious, purulent, and ex- tremely offensive. The temperature was normal. Over the left lung, front and back, there were coarse bubbling rales, but resonance was unimpaired. At the right base expansion was diminished, and resonance was much impaired. The percussion-note elsewhere was normal. The breath-sounds were bronchial about the angle of the scapula, and whispering pectoriloquy was present ; below this point they were feeble. Large bubbling rales were audible over the right upper lobe, front and back. The vocal fremitus was increased over the upper part of the I40 THE DISEASES OF THE LUNGS right chest, but somewhat dmiinished towards the base. No tubercle bacilH were found in the sputum. The diagnosis was ' bronchiectasis of the right lower lobe with incomplete consolida- tion ; dilated tubes in both upper lobes.' Ten days after admission, ihe temperature assumed a markedly hectic type — 99° in the morning and 103°-104° F. in the evening. For a month subsequently it was irregular, ranging between 99° and 101° M. and 102° and 103° E. The sputum during this period remained offensive, and averaged about 12 oz. daily. He was given 30 minims of sterilised oil of guaiacol by subcutaneous injections daily. From May 30 to June 24 the fever continued, and the ex- pectoration was exceedingly foetid. On June 25 and 29 htemo- ptysis occurred (2 oz. and 1 oz.). He continued to lose strength, and the r;iles at the right base became larger, and of metallic quality. Dulness appeared over right middle lobe. The sputum was still free from tubercle bacilli and elastic tissue. A very few streptococci were present, but no other organisms. Towards the end of July the expectoration diminished to about 5^ oz. daily, and the foetor was less. The temperature varied between"99°-101°. During the first week of August he was not so well, the appetite fell off", pyrexia was more marked, and the sputa increased in quantity and became much more offensive. From August 5 to 12 the patient had a creasote vapour bath for fifteen to twenty minutes on alternate days. The temperature had touched normal on August 4, but it remained so during the week. The sputum was slightly bloodstained, but not quite so offensive as previously. He gained 1 lb. in weight. The signs in the chest were unchanged. A fortnight later his condition was much improved. The sputum was only very slightly offensive, and the temperature was normal. During September the improvement continued. The quantity of expectoration was from 3 to 5 oz. daily. It was only slightly offensive, and often had no odour. There were very few rales audible, and the patient gained moi'e than a stone in weight during the month. The time spent in the bath was gradually increased, and during October was about an hour and a half daily. On his discharge the following note was made : ' The patient looks a healtby man. He has improved to a con- siderable degree, having come in and remained for some time in an apparently hopeless condition. The improvement has been especially marked since the commencement of the creasote vapour bath treatment.' Accurate notes of this case were taken by Dr. F. E. Leyton, house physician, to whose assiduous care the improvement in the condition of the patient was in great measure due. The writer cannot recal any case of chronic pulmonary disease in which BRONCHIECTASIS 141 recovery followed from a condition apparently so hopeless, and the result may be credited to the treatment adopted. It is unfortunate that such a favourable result cannot always be looked for. In a case recently under the treatment by creasote vapour baths for twenty-seven weeks, the weekly average of the sputa was almost exactly 100 oz., and during the last seven days the quantity ex- pectorated was larger (116^ oz.) and more fcetid than for any other period. This patient took creasote internally during the whole of this period, and had a creasote or cresoline vapour bath for half an hour nearly every day, and for a few days he also had intra-tracheal injections of guaiacol. In another case under treatment by baths and intra-tracheal injections (creasote ntiv ; sol. menthol (20 per cent.) tri^vi ; ol. olivae ad 5j) for ten weeks, in which the sputum had been foetid for five years, the odour disappeared in three weeks, but subsequently slight foetor was present for a short time, but again disappeared. After the baths had been discontinued the expectoration remained free from any offensive smell. There was, however, no diminution in the quantity of the sputa. The following is a brief account of the results obtained in a case of bronchiectasis of both lower lobes. During 28 weeks 108 creasote and 26 cresoline vapour baths were taken, and 69 intra-tracheal injections of guaiacol were given. The quantity of sputum in the week before the treatment was 109 oz. Subsequently, in six periods of four weeks each, the average per week was as follows : First month 160 oz. per week Second ,, ... 1751 Third „ ... 165" Fourth „ 170 Fifth „ ... 161 Sixth „ ... 149 This shows that a considerable increase in the quantity of the sputa followed the use of the baths (not necessarily an unfavour- able effect), but it subsequently continued profuse, although diminish- ing somewhat towards the latter part of the time. The foetor dis- appeared after the treatment had been continued for seven weeks and did not return. The gradual diminution, followed by complete absence of expec- toration which may attend the use of this mode of treatment, is illustrated by the following case : Edith T., pet. 14, admitted into the Brompton Hospital under the care of Dr. Fowler on May 14, 1897. Cough and copious expectoration had been present for eight years. Diagnosis — ' Chronic endocarditis (mitral stenosis) ; sacculated bronchiectasis with much retraction of the left upper and lower lobes ; com- mencing bronchiectasis in the right lower lobe.' The sputum was slightly offensive. ■ The patient took a creasote vapour bath for an hour and a half daily for six weeks. The total quantity of the 142 THE DISEASES OF THE LUNGS expectoration for six successive periods of one week each was as follows : First week ....... 45 oz. Second ,,....... 43^ „ Third „ 32 „ Fourth „ 25 „ Fifth „ 5 „ Sixth „ — This patient gained 7 lbs. in weight, the cough disappeared, and the moist sounds present in the lungs on admission were no longer audible. With our present experience of the creasote vapour bath treat- ment of bronchiectasis we have come to the following conclu- sions : (1) It presents no practical difficulties and is unattended by any unfavourable results. The benefit to be obtained from the use of creasote vapour baths in bronchiectasis is far greater than from any other form of treatment. (2) In exceptional cases a condition almost amounting to cure may follow their prolonged use. (8) As a rule the foetor of the sputa is modified, and not unfre- quently the odour disappears altogether, but in some cases it is unaffected. (4) The quantity of the sputa is not always or even as a rule diminished. It varies much from time to time and may be increased. (5) The general condition of the patients improves, and those symptoms which remain cause less distress. (6) The treatment requires to be continued for a long period, possibly as long as six months or more. In some cases its continuous use is advisable. Remedies such as copaiba, santal oil, myrtol, eucalyptus, the balsams and gum resins, also creasote, tar and terebene, which tend to diminish excessive bronchial secretion, may be administered internally at the same time that the above treatment is being carried out ; but we have not found this to be generally necessary. Cod-liver oil, iron and quinine may be also given for their effect upon the general health. A dry climate is indicated for cases in which profuse expectora- tion is present, and also one free from sudden changes of tempera- ture, which are likely to induce fresh catarrh of the air passages. The affection is not, we think, common amongst well-to-do patients ; but for such patients as can bear the expense the dry air of the desert would 1)6 most suital)le, and they might pass the winter in Egypt. In this country Bournemouth can be recommended. Whilst the expectoration continues fa'tid it is almost impossible for sufferers from this affection to mix with others in the ordinary life of an hotel, more particularly as they are often themselves unaware of the horrible odour which they exhale. J. K. F. 143 CHAPTER IX BEONOHIECTASIS IN CHILD EEN PAGK Etiology 143 Morbid anatomy 143 Symptoms ........... 147 Diagnosis ........... 148 Prognosis ........... 148 Treatment 149 Dilatation of the bronchi is not uncommonly met with in children, and in some cases the affection does not present any features which differ essentially from those observed in adults ; in others it runs a very acute course, and the finest ramifications of the tubes undergo dilatation, a condition to which the term ' bronchiolectasis ' has been applied. As pointed out by Dr. Walter Carr,^ to whose interesting paper the writer is much indebted, the subject has hitherto hardly received the attention which it deserves ; this fact and the exis- tence of the special features above mentioned render it desirable that a separate description should be given of the disease as it appears in young children. Eitiology. — The affection is most frequently observed in badly nourished syphilitic or rickety children who are attacked with bronchitis, which may be either primary or secondary to some acute specific disease, such as measles, whooping cough, or diphtheria. Such children are often the subjects of some deformity of the thorax, the result of previous disease. Morbid anatomy. — The lesions which specially characterise the most acute cases are : {a) acute peribronchitis ; (b) dilatation of the bronchioles throughout extensive areas of the lungs, or almost the whole of both organs ; (c) the presence of innumerable small cavities, which give the lungs a worm-eaten or honeycomb appearance ; and (d) the presence on the surface of the lungs of small vesicles containing air. ' ' Bronchiectasis in Young Cliildren,' Practitioner, Feb. 1891. 144 THE DISEASES OF THE LUNGS These changes may occur in association with miliary tuber- culosis of the lungs, but in the majority of cases hitherto recorded tubercle has been absent. In chronic cases the changes are such as have already been described. The following were the appearances in a case of acute bronchi- ectasis recorded by Dr. Sharkey.' ' The lungs were pale and curiously dotted with black pig- mented spots. These were hard to the touch, and the centre of each was occupied by a small bronchus. Microscopically an acute peri- bronchitis was found accompanied by extreme bronchiectasis, a certain amount of acute interstitial pneumonia, apparently spread- ing from the acute peribronchial inflammation and a little, but very little, emphysema. The walls of most of the finer bronchi were infiltrated with leucocytes, which invaded the peribronchial con- nective tissue in large numbers, forming a solid circular mass which was perforated by the dilated lumen of the bronchus. From these as centres the leucocytes invaded the walls of the surrounding alveoli, but those at a distance from the bronchi were but little altered ; catarrhal pneumonia was conspicuously absent. No tuber- cles were seen. The patient was a child aged two years. Death occurred twelve days after the onset of diphtheria. The child had previously enjoyed good health, with the exception that she had suffered from an attack of measles.' In another case of bronchiectasis of a rather less acute type, also reported by Dr. Sharkey,'*^ the following condition was found post- mortem : ' The lungs were very bulky ; their surfaces were thickly strewn with small, round, transparent, bladder-like elevations. On' section both lungs showed a precisely similar condition. A number of small cavities, the largest of about the size of a pea, were scattered through the organs and gave them a worm-eaten appearance. The cavities had perfectly smooth walls, and were either empty or full of frothy mucus. They were more, thickly distributed under the pleural surfaces. ' The larger bronchi were not perceptibly dilated and showed no sign of disease. In both lungs there were numerous patches of broncho-pneumonia, all of small size, and here and there was some collapse. There were no signs of tubercle. The bronchial glands were healthy. Microscopically it was seen that there was wide- spread but unequally distributed acute bronchitis with peribron- chitis, interstitial and alveolar broncho-pneumonia and pulmonary collapse. The bronchioles were extremely dilated and their walls thinned, and there was in addition considerable emphysema.' The patient was a child aged four years, who had previously en- joyed good health. He had sufi'ered from cough for two months, ac- companied by expectoration of thick phlegm and vomiting, the latter occurring three or four times a day. On admission the child was ' .S7. 77;o»u<.s'.s Hos])itnl Jlfporls, vol. xxii. - Loc. cit. BRONCHIECTASIS IN CHILDREN 145 poorly nourished, presented a dusky flushed face, and was breathing very rapidly (E. 44). Cyanosis developed, and crepitations became audible over the whole of both lungs. About a week before death, which occurred ten weeks after the onset of the illness, subcutaneous emphysema of the head, neck, arms, thorax and abdomen appeared, and post-mortem mediastinal and interstitial emphysema was found. In a similar case, occurring in a boy at. 18 months, reported by Dr. Howard Tooth, ^ under the heading 'Multiple Cavities in Broncho-pneumonia,' the lungs were thickly and uniformly studded Fig. 58. — Section of a Honeycomb Lung ( x 7 diameters) with minute smooth-walled cavities from ^^ to ^ of an inch in diameter. The cavities contained air only, and no direct communi- cation between them and the bronchi could be discovered. On microscopical examination there was evidence of broncho-pneumonia and acute peribronchitis. The walls of the cavities were for the most part formed by masses of inflammatory cells, but in some traces of an elastic lamina were observed. These cavities were believed to be dilated bronchioles, the dilatation being the result of the peribronchial inflammation. In a case recently observed at the Middlesex Hospital, similar lesions were present in association with tubercle of the lungs, thus confirming the opinion expressed by Dr. Voelcker in the discussion which followed the reading of Dr. Tooth's paper that there are two ' Path. Soc. Trans. 1897, p. 30. 146 THE DISEASES OF THE LUNGS varieties of this form of acute bronchiectasis, the one tubercular and the other non-tubercular. The naked eye appearances of the surface and of a section of the lung in this case were precisely similar to those described by Dr. Sharkey in the second of his cases, but the microscopical appear- ances were somewhat difierent, as numerous miliary tubercles were present throughout the lungs. Fig. 58 is from a section of a portion of the lung from this case, magnified seven diameters. It shows clearly that the bladder-like elevations on the surface are similar to the minute cavities within the substance of the lung. They have been mistaken for the beads of air seen on the surface of the lung in cases of interstitial and sub- Fin. 59. — Section ini n > >iixi 1 k Cavity in a Cask of HoNi;v(ithelial cells, (c) fibrin ; ( < s > o CO cu 1 < s > = * 1 t •^ o < y ^ i o o -* o> •: > o 00 oo «! -V > QO cu tv P."S on S* k^ ^ • o o u> •0 pa fUo 01 •i s, » oo CO o o lO < > > V • i •C > CVJ c2 cu in n •X •X ^0 < B U > 1 ■^ > CVi <2 o 12 CO o o O ooooooooo> aio> "5 a. a. ' 1 >; 1 ; U3 00 CVJ CO l< i j ^1 S oo CVJ I > ^ CO 00 CVJ 1 :>• CO cu CO •I •V *v ^ i o oo o cu o CO i{ CVi < > > 1 CO oo ■<1- cu 00 Ovj < ■"^ CVJ 00 cu CM «< > a CVJ to cu < s cu •£ y > cu 5 :•• 'J- oo CO cu • CO tn P i^ =0)) s' < ^ -^ 5 , o 00 cu c5 o 000000000>0> 1 _ PNEUMONIA 219 Cliart of N. W. (Fig. 71).— The patient was a girl aged 17, ad- mitted on the fourth day with incomplete consolidation of the left lower lobe. A sudden fall in the temperature to 96-6 with pheno- CO CM -- > 00 •I •< , 3* 05 00 CVJ r~ < 1 • 10 x:: ^ , — * ■ ' 10 CO to cc ^ >• oo 2 ■^ \ CO CO ■a- CM S2 1 ~ < a> CO CM - oo 00 CM 03 CM CM o> CO CVJ 00 00 rv < > <*• ■^ ^ < ■^ > « pan UJO ; ieqa D(. 1 >• CD CO eg ■* UOIS 9eq 8Q| euQ •<; ■a CO CM •fe. <2 C300 2 = 222 Q. 03 fH pR 2 20 THE DISEASES OF THE LUNGS mena of crisis followed the application of an ice-bag to the chest. The temperature remained normal for five days ; a relapse then occurred with fresh invasion of the anterior part of the left lower paj llUiO 90| «s 1 " Sui 93M 9^ :> CO OO o paSi odg < < -5X o to > pes JOJ eq 9 )l lagu odg. ^ — :::a4 pali odg — =: i::; i* C) F P f laSu Suo P odg Is* iSuo odg •< S 3« • • CO OJ 3a5u odg •£: • P i3uo Js* <: " CO. F 1 P 9§U sSu odg odg 3ds< < < < > t^ P 1 iSuo psl 1931/ dg « 'uod odg < S •« < 'V < > • >• CD > iT > q 83 1 u> )93l od^ •< < •< >. » o OJ ^ I33U .dg /^ ^ X . — • :=: )> <7> OO t u 01 SSI uipe < *'0 "N ^ "S In Q. V 3 a> o PNEUMONIA Z2I lobe. A period of pyrexia of a markedly intermittent character then ensued, and continued for eleven days. Resolution was not complete until twenty-seven days after the onset of the relapse. Chart of A. A. — Fig. 72 is from a severe and fatal case of double pneumonia in a youth aged 17. The patient was admitted on the fourth day of the disease with consolidation of the whole of the left lower lobe and incomplete consolidation of the right lower lobe. Death occurred on the twelfth day. Chart of B. F. — Fig. 73 is from a man aged 55, admitted on the second day. Complete consolidation of the right lower lobe developed, and death occurred on the seventh day. It will be observed that the temperature only once reached 104° and ranged between 101° and 103°. DayofDis 2 3 4 5 6 7 104° 103° 102° 101° 100° 39° 98° A, n \ A .-^ A 7 V lA. -vA J^ y Y s/ ^ Pulse 100 112 108 120 108 108 S3 39 136 Resp. 40 36 36 32 36 57 50 Pig. 73. — Tempeeatuee Chart feom a case of Pneumonia fatal on the SEVENTH day, SHOWING MODEEATE DEGREE OF PyEEXIA This is to be regarded as an illustration of the fact that pyrexia, within certain limits, is an evidence of vital activity and that a low temperature may be a sign of vital depression, such as occurs when pneumonia attacks old people or individuals weakened by starvation or chronic alcoholism. It is chiefly in such cases that death occurs although the temperature remains low. 5. Gas Pro -intestinal symptoms. — Vomiting is of frequent occur- rence at the onset in children. Diarrhoea more often appears about the time of crisis, and may be present in unfavourable cases in the absence of crisis. In a case recently under our care, a severe rigor was immediately followed by violent diarrhoea, the motions- for two days containing considerable quantities of blood. The temperature fell to normal on the seventh day and the patient recovered. 6. Terminations. ^Snch. cases as do not run a favourable course may prove fatal during the acute period of the disease or after the 222 THE DISEASES OF THE LUNGS crisis. In the former case, the most common cause of death is cardiac faihire. This leads to congestion and cedema of the previously un- affected parts of the lungs, as evidenced by the presence of fine crackling rales. Expectoration ceases, mucus collects in the trachea and larger bronchi, giving rise to coarse rales. The respira- tions become increasingly frequent, the pulse extremely rapid and feeble, the face livid, a profuse sweat breaks out, and the extremities become cold, death being preceded by a condition of semi-coma, or consciousness may be retained almost to the end. In children a convulsion may then occur. Death may take place at the period of crisis from extreme prostration followed by collapse, but this is an event not often observed. In rare cases, most often met with in children, after an incom- plete crisis the fever may continue at a lower range for some weeks, death being ultimately due to extreme emaciation. The febrile period may terminate in a well-marked crisis, but the lung may remain solid and subsequently pyrexia may return, and the disease ultimately prove fatal. An example of this recently came under our notice in the case of a patient who was attacked by pneumonia in Ceylon. Contrary to advice he came home before the lung had undergone resolution, although fever had disappeared. On the voyage the temperature again rose, and on his ari'ival was found to range between 101° and 102°. This was steadily maintained for some weeks, but the lung showed no signs of breaking down. Death was preceded by severe diarrhoea of a dysenteric character. No post-mortem examination was made. On the occasion of the -writer's visit there were no signs suggesting the presence of an hepatic abscess, and none developed at a later period. The consolidated lung may breali down and an abscess may form, its contents being expectorated. This event is extremely rare in cases not of pyjemic origin. It is indicated by the occur- rence of profuse purulent expectoration, which may be foetid, and contain elastic tissue. The physical signs are those of softening and cavity formation. Pyrexia continues, the fever being of the hectic type ; there is marked emaciation, and death may be due to septic poisoning or rupture of the abscess into the pleura and pyo- pneumothorax. If the abscess can be localised, such cases may be successfully treated by making an external opening, and if no operation is possible, they may after many weeks' duration terminate favourably. GaiKjrene is also a very rare mode of termination, but somewhat less 80 than abscess formation. It is moi'e common in apex than basic pneumonia, and is more often of the circumscribed than of the diffuse variety. Its occurrence is marked by symptoms and signs very similar to those of abscess, a gangrenous odour of the breath and expectoration being the most distinctive. Abscess and gangrene are apt to cause infection of the opposite lung from the inhalation of ioul expectoration. The subject of pneumonia terminating in pulmonary fibrosis is PNEUMONIA 223 discussed in the chapter on Subacute Indurative Pneumonia {vide p. 236). 7. The influence of type. — Variation in type. — Variation in type is a characteristic of disease. To this rule pneumonia is not an exception, but of the many varieties of the affection which have been described a few only present features sufficiently well defined to be easily recognised. (a) Latent 'pneumonia. — A certain amount of vital activity of the organism is necessary in order to produce the symptoms of any acute disease. If the vital activity is depressed, morbid •changes may proceed and death may ensue without the mani- festations of the ordinary signs of the disease. The onset and course of pneumonia in old people and in individuals weakened by starvation or alcoholic excess, or the subjects of chronic renal disease, are often extremely insidious, and sometimes so slightly marked by symptoms that the true nature of the case is only discovered on post-mortem examination. {h) Migratory pneumonia. — This term is applied to cases of pneumonia characterised by ' successive invasion of different parts of the lung, while the physical signs disappear from the parts first attacked.' The term does not merely imply that the disease spreads from one part of the lung to another, or that a relapse occurs after apparent recovery, but that the extension into one part •coincides with resolution in another, and it is this which constitutes the distinguishing characteristic of the affection. Each successive invasion may be marked by a rigor with a repetition of many of the features of the onset of the disease, the course of which may thus be prolonged for several weeks. Such cases are rarely observed. The prognosis is not so unfavourable as would on a priori grounds appear to be likely. (c) Intermittent pmeumonia. — The co-existence of malaria and pneumonia may give to the pyrexia an intermittent type, but a similar course of the fever has been noted in cases where there was no reason to suspect the presence of malaria. The period of apyrexia is said to vary from twelve to thirty-six hours, during which no change is observed in the physical signs. We are unable to describe such cases from our own experience of the disease ; they are certainly not common in this country. {d) Cardiac pneumo7iia is a term applied to the disease when it occurs in the subjects of chronic affections of the mitral valve, especially stenosis. The peculiar features it presents are scarcely sufficient to justify a separate description. They are said to be the absence of pleurisy and the long continuance in the stage of red hepatisation. (e) The varieties of the disease, to which the names typhoid, bilious, puerperal, recurrent, pythogenic, and cerebral have been applied, are, in our opinion, either not sufficiently well defined or not so commonly met with in this country as to require detailed consideration. 8. The influence of complications. — Of the conditions 224 THE DISEASES OF THE LUNGS antecedent or subsequent to the onset of the attack which may modify its course, the more important are bronchitis, emphysema, pleuritic effusion and empyema, pericarditis, endocarditis and myocarditis, meningitis, chronic renal disease, and parotitis. Complications, although of rare occurrence in pneumonia, are of grave import, the mortality of cases in which they occur being nearly four times greater than in uncomplicated cases (Huss). (1) Bronchitis. — When widely diffused this is a serious com- plication, as it causes marked dyspnwa, and tends to increase the strain upon the right cavities of the heart. The cough is more frequent and less hacking, and expectoration is more abundant and mucoid. Paroxysmal attacks of dyspnoea of the true asthmatic type may be present in such cases. (2) Emphysema and bronchitis existing before the attack will increase the gravity of the prognosis, owing to the effect the}' produce upon the right ventricle, and to the tendency to cardiac failure and pulmonary engorgement thereby entailed. (3) Pleuritic effusion, followed as it often is, especially in children, by emjyyema, is a condition likely to be overlooked unless careful daily examination of the chest is made. The effusion may be primarily sero-fibrinous or htemorrhagic. The effect of this complication upon the course of the disease is to render the crisis incomplete, and to delay convalescence. When tubular breathing is followed by complete absence of respiratory sounds, vocal fremitus and resonance being diminished or absent, it must not hastily be concluded that an effusion has taken place into the pleura. In a case of apex pneumonia recently observed the occurrence of these signs led to puncture with a trocar. No' fluid was withdrawn, and post-mortem the lung was found to be solid, the bronchi throughout the area of consolidation being filled with solid fibrinous cyhnders— ' massive pneumonia.' Such cases are usually of a severe type, and often have a fatal termination. Similar physical signs have, however, been oljserved, when it was proved on post-mortem examination that the bronchi did not contain solid casts. The obstruction in such cases may have been only temporary, and due to the presence of mucus. The position of the cardiac apex is an important guide to the presence of fluid. In children tubular breathing often continues audible, notwithstanding the presence of a considerable eff"usion in the pleura. (4) Pericarditis is a grave complication of pneumonia, more than half the cases in which it occurs proving fatal (Huss). Like that last described, it is apt to be overlooked, but its presence may be suspected from the position assumed by the patient, who often prefers to be propped up by pillows instead of lying flat upon his back as in uncomplicated cases. A ' to- and-fro 'friction sound will be present, and remain until the effusion has become extreme. It must be remembered that an inflammation of the pleura overlying the heart may give rise to a friction sound having a ' to-and-fro ' chai'acter. PNEUMONIA 225 In cases complicated by pericarditis the crisis is often incomplete .•and the pyrexial period prolonged. The relative frequency of the association of pericarditis with right and left-sided pneumonia is •considered under Complications {vide p. 209). (5) Myocardial changes are present in all cases of severe peri- carditis, but they may occur independently. Their presence may be suspected when there is marked weakness of the heart's action, ivith evidence of engorgement and oedema of the lung. (6) Acute endocarditis is a somewhat rare but serious com- plication of pneumonia ; it may be either of the simple or ulcerative variety (see p. 209), and either primary or engrafted upon chronic ■endocardial changes. (7) Delirium tremens is one of the most grave complications of pneumonia, as it implies excessive indulgence in alcohol, with the ■defective resisting power and visceral changes which such a habit necessarily induces. (8) Meningitis is a rare but • almost invariably fatal com- plication. (9) Glivonic nephritis tends markedly to increase prostration, and to mask the more acute symptoms of pneumonia. Granular kidney, as already stated, is frequently found after death from pneumonia, when the presence during life of chronic renal disease has been unrecognised. (10) Parotitis deserves mention on account of its gravity, recovery in cases being exceptional when this complication is present. A painful and rapidly extending swelling appears behind the ramus of the jaw ; suppuration quickly occurs, and may be followed by gangrene. The affection may appear during the later part of the pyrexial period, or after the crisis. It is most commonly met with in patients over sixty years of age. It may be mentioned here that parotitis of this type differs from :a similar affection occurring as a complication of cases of abdominal disease, as in such cases suppuration is rare ; and if suppuration does not occur, the prognosis is favourable. Acute nephritis, jaundice, laryngitis, tonsillitis, and other complications are scarcely of sufficient importance to require de- scription. J. K. F. 226 THE DISEASES OE THE LUNGS CHAPTER XVII PNEUMONIA-ro//f.-;/./.Y7 DIAGNOSIS. PROGNOSIS. TREATMENT I'AGK Diagnosis 220 Pi'ognosis ........... 229 Treatment 230 DIAGNOSIS Ix typical cases the diagnosis of pneumonia rarely presents much difficulty, but if the patient is seen at a very early period it may be necessary to wait until the physical signs appear before expressing a positive opinion. A sudden and rapid rise of temperature, persisting after a severe rigor, should suggest pneumonia, if there is no affection of the throat to account for the symptoms. The appearance, decubitus, cough, sputa, altered pulse-respiration ratio, and severe pain in the side, together with the physical signs of consolidation of the lung, constitute a clinical picture which cannot well be mistaken. Pneumonia of the apex is much more likely to be overlooked than basic pneumonia. This arises partly from the fact that it is comparatively rare, and therefore, although the symptoms suggest the correct diagnosis, attention is directed to the base instead of the apex ; partly from the trivial fact that, when a patient sits up in bed and his night-gown is pulled up to his shoulders, the small area of the upper lobe (see fig. 98, p. ;-i52) which abuts posteriorly is covered and may escape examination. We have known apex pneumonia to be recognisable by physical signs in the supraspinous fossa for two days befoi'e any certain signs were present beneath the clavicle. The physical diagnosis of consolidated lung from fluid in the pleural cavity may be very simple, or present difficulties only to be solved by puncturing the chest ; but these difficulties do not often arise in the diagnosis of imeumonia from acute pleurisy xcith effusion. This is not a distinction without a difference, for PNEUMONIA 227 consolidation of the lung may be due to other causes than pneu- monia, and fluid in the pleura is not necessarily the result of acute pleurisy. Before discussing the question, we desire to emphasise two facts : first, that inspection is one of the most important stepis in physical diagnosis ; secondly, that^/ie position of the cardiac apex is the key to the diagnosis of nearly all the affections both of the lungs and of the heart. We shall compare* tAvo typical cases — one of pneumonia of the right lower lobe, and another of acute pleurisy with effusion on the right side. In pneumonia, on inspection, the movement of the affected side is limited, but less so than in pleurisy with eft'usion, whilst the increased movement of the opposite side in the latter condition is more marked than in pneumonia. There is no rounding of the side, or flattening or bulging of the intercostal spaces in pneumonia, and the apex beat of the heart is not displaced. Palpation. — Vocal fremitus is usually increased over consolidated lung, but diminished over the site of a pleural effusion. If, however, pleural adhesions over limited areas existed prior to the attack of pleurisy, the lung may be held in partial contact with the chest wall, and may act as a conductor of the laryngeal sounds to any point, or yield normal or modified breath sounds. The liver is not displaced downwards in pneumonia, it may be in pleurisy with effusion, but only if there is a positive pressure within the cavity of the pleura. Percussion. — The percussion note is dull in both affections, but the loss of resonance is more complete in pleurisy, and the sense of resistance is greater. In pneumonia the area of dulness corre- sponds to that of the lower lobe, whereas in pleurisy with effusion the upper limit of the dull area presents a curve with the highest point in the axilla. Sub -tympanitic resonance (skodaic note) may be elicited beneath the clavicle in both affections, but is more often present in pleurisy with effusion. It is, however, absent if the effusion is so large in amount as to completely fill the pleural cavity. Auscultation. — The breath sound is tubular in pneumonia or may possess a metallic quality ; whereas in pleuritic effusion the breath sound is absent as a rule, but tubular breathing may be audible through an effusion, a condition more often present in children than adults. Crepitation may be present in pneumonia but not in pleurisy, and is well marked. A pleural friction sound may be present in pneu- monia, accompanied, as it usually is, by pleurisy, but will not be audible over the site of a pleural effusion, although it may be present above the upper level of the fluid. Bronchophony is usually well marked in pneumonia ; in pleurisy, whispering pectoriloquy or oegophony may be present. Mensuration. — There is Uttle or no increase in the measurement of the affected as compared with the unaffected side in pneumonia, but there may be a marked increase in pleurisy with effusion. 228 THE DISEASES OF THE LUNGS The above is not intended as an exhaustive statement of the physical signs which may be met with in the two aifections, but only of such as are present in typical cases. Lobar caseous tuberculosis by which term {vide p. 336) we indicate a rare atfectiou in which a whole lobe of a lung becomes rapidly solid from tubercular disease — may simulate pneu- monia both in symptoms and signs, and it often happens that the nature of the case is not at first recognised. The absence of ' crisis ' and the continuance of pyrexia and consolidation suggest at a later period an examination of the sputum for tubercle bacilli, the dis- covery of which at once settles the diagnosis. In doubtful cases repeated examinations should be made, as until softening commences the bacilli will probably not be found. A large haemorrhagic infarction of the lungs, with acute pleurisy and eli'usion, occurring in a case of chronic valvular disease of the heart, is a condition which we have on several occa- sions seen mistaken for pneumonia. The first point which should attract notice in such a case is that the patient will almost certainly be sitting up in bed. It is a good rule never to come to a diagnosis of uncomplicated pneumonia when the patient is in that position. The ' erect posture,' of a well- known and most valuable textbook of medicine, as descriptive of the typical decubitus in pneumonia is surely an oversight. Dulness on percussion over the aftected side and marked tubular breathing over the consolidated area are usually present. The vocal fremitus may be absent towards the spine. Such cases are often too ill to bear the movement which is required to carry out a careful examination of the back of the chest. The cardiac apex may be displaced, but it should be possible to determine the presence of the valve lesion if that is not already known. Typhus fever is so seldom seen nowadays that it is rare for it to be mistaken for pneumonia. Typhoid fever. — The asthenic forms of pneumonia, which are due in many cases to septic infection and are accompanied by marked prostration, are liable to be mistaken for typhoid fever. The presence of herpes on the lips, and of signs of consolidation of the lung, are the most important distinguishing features of pneumonia as compared with typhoid fever. Pneumonia may, it is true, occur as a complication of typhoid, but it does so in the later stages of that disease, whilst the question of diagnosis almost always arises at an early period of the case. Meningitis. — The cerebral symptoms, such as headache and delirium, by which the onset of pneumoiiia, especially of the apex of the lung, is sometimes accompanied in children may for a time suggest a diagnosis of meningitis, either simple or tubercular. It is important to Ijear in mind that in most acute diseases headache as a rule subsides when delirium appears, Avhereas in meningitis headache and delirium are present together. The other symptoms which mark the stage of 'cerebral irritation ' in meningitis, such as the peculiar cry, the curled- up attitude, the retraction of the head PNEUMONIA 229 and of the abdomen, the vomiting without cause, and the intoler- ance of hght, are usually absent in pneumonia. From oedema of the lung pneumonia can usually be distinguished by the absence of fever and of the signs of complete consohdation. Although the resonance of the percussion note may be impaired at one or both bases, there is not the same degree of dulness as in pneumonia. The breath sounds in cedema are feeble. Crepitation indistinguishable from that of pneumonia may be present. From collapse of the lung, a condition which may in chil- dren affect a whole lobe, the diagnosis is often difficult. The tempe- rature is lower than in pneumonia. The affected side in cases of collapse is retracted, the breath sounds are absent ; or if, as is some- times the case, they are present and of bronchial or tubular quaJity, the soimd gives the impression of being conducted from a distance. The vocal fremitus and resonance are diminished and adventitious sounds are absent. PEOGNOSIS In forming a forecast of the probable issue of a case of pneumonia many factors have to be considered, and much depends upon the capacity to recognise the signs of danger, which can only be acquired by careful observation at the bedside. MOaTALITY PER CENT. YEARS. -10 -20 -oO -4-0 -50 j ASCVE. 50 i ^ / 40 1 i / 30 / ~J 20 / 10 ^^ \ ' Fig. 71. — Cukye of Moetajutt fboii PNE^lro^^li. xi DII^^EEz^^: Aue Pesiods (based on an'altsis of 2.03S cases) (From • Pneumonia,' by Sturges and Coupland. p. 141) ' It is probable that the smallest mortality from lobar pneumonia at any period of Kfe whatever occurs in early childhood.' ^ The fact that the disease is relatively more fatal in females than ' 'Pneumonia, Sturges and Coupland, "ind ed. p. loo. 230 THE DISEASES OF THE LUNGS in males depends upon the tendency which exists for pneumonia to occur during pregnancy. This is a dangerous condition, and often leads to abortion accompanied by severe haemorrhage. The extent of lung affected is perhaps the most important element in prognosis, double pneumonia and consolidation of a whole lung being more dangerous than the affection of a single lobe. In pneumonia of the right side, whether of the apex or of the base, the rate of mortality is higher than in that of the left, and in advanced life special danger attends apex pneumonia. Previous attacks do not appear to increase the danger, a fact illustrated by the case of a patient who had suffered on six previous occasions and made a fairly good recovery on the seventh. The danger attending the presence of any complication has been already referred to. The most dangerous amongst the common complications of pneumonia are alcoholism, chronic renal disease, and valvular disease of the heart. Apart from these considerations, the condition of the nervous system and the pulse give the most important indications for pro- gnosis. The gravity of violent delirium late in the disease, particu- larly if it occurs in an alcoholic subject, has already been dwelt upon. Convulsions in children are not of unfavourable import at the onset, but are serious if they occur at a later period. It has long been considered that cases accompanied by herpes of the lips as a rule run a favourable course, and statistics appear to support that view. TREATMENT Successive phases of medical opinion have left their mark on the history of the treatment of pneumonia, and the disease continues to be the favourite field for a trial of each new mode of combating the febrile state ; but as our object is to present an account of the views of the present day, we are obliged to leave the past to speak for itself. Although the view of the pathology of pneumonia which may be adopted will necessarily to some extent influence the treatment, certain measures must always remain suit- able for the grave condition inseparable from the disease. Of these complete rest in bed is the most essential, the room, as large and airy as can be obtained, being kept at an even temperature of about G5° F. The bed should be ' single,' and should stand away from the wall, as nothing interferes so much with the proper nursing of a case as a large double bed, in the centre of which the patient often lies in a hollow. Rest should be absolute from the first, and the patient should be prevented as much as possil)le from seeing and convers- ing with friends. At the outset three grains of calomel may be given, and should be followed by an aperient draught. The functions of the skin are to be maintained by the administration every three or four hours of a saline draught, containing citrate of potash and solution of acetate of ammonia, or quinine in doses of one to three PNEUMONIA 231 grains may be added to an etfervescent saline draught and given every four hours. The ett'ect of such remedies is to lower arterial tension and diminish venous engorgement by increasing the secretion from tlie ■skin and bowels. We regard the use of aconite and tartar emetic as depressant, and therefore harmful and to be avoided. The severe pain and restlessness accompanying the onset of the disease may be greatly relieved by a hypodermic injection of morphia (gr. ^-j), which may, if necessary, be repeated once after an interval of four hours, but except at this period the administration of morphia may be attended with danger. The diet should be liquid, and consist of not less than two pints of milk and a pint of beef tea in the twenty-four hours. Food should be given during the febrile stage at intervals of from two to three hours. The condition of the stomach should be carefully watched, and its outline determined by the aid of percussion. If, as not uncom- monly happens, the stomach is found to be increasing in size daily, and to contain at all times a large quantity of fluid and air, food should be given less frequently. It is apt to be overlooked that nutrition depends upon the absorption of food and not merely upon its inges- tion. It is useless and harmful to continue to pour liquid food into a stomach already greatly dilated and unable to absorb what it contains. Pneumonia is a febrile disease, and pyrexia is as essential to the natural development and course of the morbid process as are any other of its attendant phenomena. Moreover, statistics ^ appear to prove that the mortality is least when the temperature is 104° to 105° (7'4 per cent.), more frequent when under 103° (36'9 per cent.), rather more frequent when 106° to 107° (42'8 per cent.), and most frequent of all with extreme hyperpyrexia 107° to 109°, nearly all such cases proving fatal. We confess to a certain prejudice against conclusions drawn from statistics compiled by many separate observers, and Wilson Fox speaks of the above as * extraordinary ; ' but on one point our own experience is in accord, viz. that a low range of temperature is not necessarily a favourable sign, and we consider that so long as the fever keeps about or below 104° no very active treatment, such as the use of the cold bath or ice pack, is required, simply with a view of lowering the temperature. The antipyretic treatment of pneumonia, however, is advocated on wider grounds than that of causing a lowering of temperature. It is claimed for it, in addition, that it may arrest the development of the pulmonary lesion ; that the application of ice over the affected lung relieves pain ; that it dilates the superficial vessels ; that it produces a favourable change in the physical signs ; that it reduces "the frequency of the pulse ; that it acts as a sedative, and by ' Statistics of Thomas, Schrotter, and Bleuler, analysed by Wilson Fox, op. cit. p. .352. 232 THE DISEASES OF THE LUNGS inducing natural sleep renders the use of hypnotics unnecessary ;. that the improvement in the pulmonary condition obviates the necessity for venesection ; and, lastly, that it secures a more rapid convalescence. "We approached the trial of this method of treatment with a strong bias in its favour, the result of long experience of the extreme value of antipyretic measures in typhoid fever, the clinical aspect of that disease having, in our opinion, been almost revolutionised by their use. Notwithstanding this, however, we are now unable to give it more than a qualified support in pneumonia. Dr. Lees has strongly advocated the use of the icebag, and we have epitomised above the claims which he puts forward in its favour. That the application of an icebag lowers the temperature, and in some cases gives marked relief to pain, may be readily admitted, and we have frequently observed that sponging the surface of the body for from ten to fifteen minutes at a time with water at a tempera- ture of 80° F. is grateful to the patient, and that it lowers the temperature, relieves restlessness, and promotes sleep. It may, we think, be fairly claimed for the moderate and judicious use of antipyretic measures in pneumonia that the results obtained are as good as those from any other mode of treatment at present adopted ; but we are still unconvinced that the course of the disease is decidedly influenced by the systematic application of cold to the surface of the body. The more active antipyretic drugs, in doses sufficient to influence the temperature, are decidedly depressant in their efl:"ects, and should not in our opinion be employed. Possibly in an early stage of the disease they may sometimes give relief by inducing sweating, and in small doses in combination with quinine they may be useful as an adjunct to sponging. For the treatment of hyperpyrexia — by which is meant a temperature of 105-8° and over — the ice-cradle is preferable to the cold bath, as its use does not disturb the patient. If, however, the temperature cannot be controlled by this means, the ice-pack should be used, or a bath at 80° F. given for about ten to fifteen minutes. If the course of the fever is carefully watched, and sponging resorted to when the temperature rises above 104° F., the necessity for more severe anti-pyretic treatment may be obviated. The tendency to cardiac failure, which is evidenced by a feeble and irregular pulse and signs of increasing distension of the right ventricle with blueness of the lips, may be met by the early use of oxygen, as recommended by Sir E. Douglas Powell, who has pointed out ' that this most valuable agent is generally employed too late in the disease to be of any but temporary service. Carbonate of ammonia and digitalis should be given at the same time with a like object. In a very severe case of double pneumonia recently under our care in a boy aged 14, oxygen was used at an early period, and its beneficial eti'ect upon the pulse and respiration was most marked. ' Brit. Med. Jour. Nov. !), l«!lo, p. lir)l. PNEUMONIA 233 It is under such circumstances that stimulants are needed, and they may be required in large doses, e.g. six, eight, twelve, or even twenty ounces of brandy in the twenty-four hours. Whilst fully convinced of the necessity and value of stimulants in the treatment of pneumonia, increasing experience has convinced the writer that the practice, in which he was educated, of administering them in large doses and as a matter of routine in all cases of pneumonia, is both unnecessary and harmful, and that much injury may be done by the over-stimulation of a weak heart. By giving alcohol and digitalis together, the temporary stimulant effect upon the heart of the former and more permanent and tonic effect of the latter are best obtained. In addition to the measures already described, strychnine by hypodermic injection (gr. .-.V-y.V) and caffeine are valuable cardiac tonics which may be used at the same time as inhalations of oxygen in endeavouring to maintain a failing heart. Violent delirium at a late stage of the disease is, as already stated, a most dangerous condition, and is usually an indication for the administration of stimulants. Sir E. Douglas Powell has laid stress upon the value, under these circumstances, of a large dose or frequently repeated doses of alcohol given with food, followed by a hypodermic injection of morphine and atropine. In a severe case of apex pneumonia recently under our care, with marked but not violent delirium and almost incessant hiccough, a hypodermic in- jection of morphine was followed by sleep, the gradual disappearance of the hiccough, and by recovery. Its administration appeared to be the determining factor in the case. Pericarditis complicating pneumonia is always an indication that the attack is of a severe type, and calls for the administration of stimulants. Diarrhcea is rarely a prominent symptom ; if severe, it may be checked by the administration of Dover's powder. When at a late stage of the disease there is evidence of extend- ing implication of the lung with prostration, perchloride of iron in large doses has been found of service. Cyanosis and signs of over- distension of the right side of the heart, with epigastric pulsation and prominence of the jugular veins and a small and irregular pulse, are indications for venesection, and relief is generally given when six or eight ounces of blood have been withdrawn. The improvement is perhaps most obvious in cases accompanied by or following upon bronchiiis, but un- fortunately it is as a rule of only short duration. Dr. G. W. Balfour strongly advocates the use of chloral (gr. 10) combined with infusion of digitalis ( 5 ss) every four hours during the period of pyrexia, double the quantity of chloral being given for the first dose. It is claimed for this treatment that it gives the patient most relief from his sufferings, favours an early crisis, and has no drawbacks ; and that if, by its use, the mortality is not diminished, it is certainly not increased. By the combination with digitalis, the undoubtedly depressant effect of chloral upon the 234 THE 1)ISEASP:S OF IHK LUNGS heart and respiration is counteracted, but when not so combined its administration is not unattended "with dang'er. We are unable to speak from personal experience of the value of this mode of treatment. After the crisis, if, as is often the case, resolution makes slow progress, or if the lung continues solid, or a pleural effusion should remain, equal parts of the liniment and tincture of iodine should be painted over the side affected. This may be done every morning for several successive days until some irritation is produced, and subsequently repeated at longer intervals according to the condition of the skin, the susceptibility of which to the action of iodine varies gi'eatly in different individuals. If resolution is long delayed, the syrup of the iodide of iron with (]uinine may be given. A cotton-wool jacket should be worn until recovery is complete. With convalescence, appetite quickly returns, and should be satisfied by a liberal diet. Tonics such as iron and quinine should then be prescribed. After an attack of pneumonia, a stay for a time in a bracing air is generally advisable. The treatment of abscess of the lung and of pulmonary gangrene is considered elsewhere (ride pp. 243 and 250). Antito.ric treatment. — The increasing evidence in favour of its microbic origin has naturally led to the inclusion of pneumonia amongst the cliseases to which serum treatment is applicable, and every one must share in the hope that, at no distant date, this mode of dealing with the disease may come within the range of practical therapeutics. There are two possible sources of the serum. It may be obtained from the blood of a patient who has recently passed through the crisis of the disease or from an animal rendered immune to the disease by inoculation with a gradually increasing dose of the pneumococcus. It is naturally to the latter source that we must look for a supply of the material if the treatment Itecomes available for general use. At present the method can hardly be said to have passed beyond the experimental stage, J)r. Washbourn has succeeded in ' standardising ' the antitoxin, i.e. in obtaining a serum of uniform strength, so that the dose administered is accurately known. This is an important step in advance, and a certain inimber of severe cases have been thus treated, and recovery has followed. Whether this favourable result is to be attributed to the treatment adopted it is as yet impossible to say, but the results appear to be decidedly encouraging. No ill effects have followed its use. llecent experience has shown how extremely undesirable it is that a remedy of this nature should be generally employed until it has been most carefully tested by persons conapetent to form an opinion of its value. It is to be hoped that the mistake will not be repeated in the treatincnt of pneumonia. Local applications. — The severe pain which often accom- panies the onset of pneumonia is probably due to the stretching of the inflamed pleura by the engorged lung. It may be intense, when no friction sound is audible. As already stated, it may be relieved PNEUMONIA 235 by the application of an icebag, but we confess to a preference for the use of leeches followed by the application of a large linseed- meal poultice. Poultices are, it is true, somewhat out of fashion, but we have seen no reason to discard them, except in some cases in children, when their weight is an objection, as tending to impede the movements of the chest. Patients frequently express their appreciation of them, and we cannot remember to have heard a complaint against a well-made poultice. They should be large and light, properly secured in position, and changed every two or three hours during the day, and at rather longer intervals during the night. These details are important, and, if attention to them cannot be secured, it is far better to cover the affected side with a layer of cotton wool heated at the fire and sprinkled with a stimu- lating liniment. When for any reason the use of poultices is discontinued, a cotton- wool jacket should be worn. J. K. F. 236 THE DISEASES OF THE LUNGS CHAPTEK XVIII CHEONIC AND SUBACUTE PNEUMONIA (LOBAR TYPE) PAGH Differentiation from acute pneumonia 237 Morbid anatomy . . ■ 237 Etiology 239 Duration 239 Prognosis 239 Diagnosis 239 Treatment 240 It has long been, and in the opinion of some writers is still, an open question whether an attack of pneumonia is ever followed by permanent induration of the lung. That a point of this nature should remain undecided in connection with a disease of such frequent occurrence as pneumonia is in itself a proof that such a sequence of events must be infinitely rare. We entertain no doubt that it does occur, but it can hardly fall to the lot of any individual to observe more than a very few cases of the kind. Mention has already been made {cide p. 230) of a case which was observed by the writer in a youth who had had seven previous attacks of pneumonia, for most of which he had been an in-patient in the Middlesex Hospital, and who left convalescent after the last attack, but with signs of induration of the apex of the left lung. The breath sounds at this apex Avere almost cavernous in quality, although there had been no signs of softening. They were probably due to the dilatation of a bronchus. In the few undoubted cases of this kind recorded in medical literature, bronchiectasis has generally been found at the autopsy, death having in some been due to an acute septic broncho-pneumonia followed by gangrene. In others, l)ronchicctasis has been absent, or present to a very .slight degree only, and the condition has resembled that found in the cases about to be described, the clinical history of which differs somewhat from that of true pneumonia. CHRONIC ANIJ SUBACUTE PNEUMONIA 237 SUBACUTE INDURATIVE PNEUMONIA (Primary Parenchymatous Pneumonia) The former of the above terms, which appears to be preferable, was suggested by Dr. Percy Kidd,' the latter by Buhl, and is adopted by Heitler.^ These cases present certain features hitherto rarely recognised in addition to their mode of termination, by which they are differen- tiated from acute pneumonia. The chief points of difference may be thus summarised : — (1) The onset, although sudden, and accompanied by chills or rigors, is not marked by the single severe rigor of pneumonia. (2) The illness immediately following is not of the severe and acute character of pneumonia. The patient may, for example, be able, although feeling ill, to leave his bed on the second day. The prominent symptoms are fever, dyspnoea, a rapid pulse, and cough. Herpes may be present. (3) The accompanying pyrexia is not so marked as in pneu- monia, and there may be complete remission of the fever for short periods. (4) There is no critical fall of temperature. (5) The sputum may contain blood, but rarely presents the true rusty character. It is abundant in quantity, and has a decided tendency at a later stage to become foetid. (6) Diarrhoea is a more common symptom than in the acute disease. (7) The physical signs of consolidation of the lung do not appear to be so rapidly developed as is the case in pneumonia. (8) In pneumonia the constitutional symptoms tend gradually to diminish in severity when the exudation is absorbed, even though the lung has remained solid for a prolonged period ; but in subacute indurative pneumonia con- solidation persists, while the general condition of the patient becomes progressively more unfavourable, and putrid bronchitis and gangrene are very liable to precede a fatal termination. Morbid anatomy. — Pleural adhesions are present over the consolidated lung. They may be dense and fibrous, and the chest wall may be retracted over the corresponding area. Fibrosis and excavation are the chief lesions present. The fibroid change in the lung is lobar in distribution, but may be present in more than a single lobe and in various stages, and both lungs may be afi'ected. The consolidated part is airless, shrunken, and of firm consistence, ' Lancet, April 5, 1890. ■•^ Wiener Med. Wochcnschr. 1884, 1886. 238 THE DISEASES OF THE LUNGS granular on section, and either red, grey, slate-grey, or almost white in colour. These changes in colour represent stages of the morbid process. The consolidation may not be uniform throughout a lobe^ patches of air-containing lung intervening between areas of in- duration. "When cavities are present, the appearances they present vary with the duration of the lesion. If it is of somewhat recent date, softening may l)e in progress at various points, and the cavity walls are ragged and possibly gangrenous, a result of the necrosis of the indurated tissue. More chronic cavities present a smooth interior, and are limited by a fibrous capsule. Broncho-pneumonia and putrid bronchitis may result from the inhalation of the decomposed contents of cavities. These changes may occur in- dependently of bronchiectasis. On microscopical examination the changes observed are mainly of two kinds : the one showing that an alveolar exudation is in process of organisation, the other that the alveolar walls and the interstitial tissue of the lung are undergoing fibrous thickening. The early stage of the former process is best seen in the areas of red induration, and is thus described in Dr. Kidd's paper : ' The alveoli contained roundish masses of a coarsely granular opaque material, in which a few nuclei were visible. In places these plugs at their centre showed a delicate meshwork of fibrinous threads, and in rare instances consisted mainly of fibrinous matter. In every case the alveolar plugs were ensheathed in a more or less complete investment of young connective tissue, separating them from the alveolar walls.' Scanty capillary blood-vessels could be traced in the intra- alveolar connective-tissue capsules, and in some instances they w^ere clearly connected with the capillary network in the walls of the vesicles. The infundibula were filled with recent fibrinous exudation, containing a few leucocytes and red blood-corpuscles,, without any connective tissue investment. In the grey consolidation a more advanced stage of the same condition was found. The air sacs were stuffed with rounded masses of connective tissue, consisting of a central core of round and spindle cells with a meshwork of delicate fibres surrounded by a more distinctly fibrous outer zone. The interstitial tissue showed a slight dift'use thickening, more marked in the grey than the red area ; but this change was in- significant as compared with the intra- alveolar growth. The thickening of the alveolar walls was due to the presence of a moderate degree of small-celled infiltration. The interstitial changes are due to fibrous thickening of the alveolar walls, and of the interlobular septa and peribronchial and perivascular connective tissue. The appearances are illustrated in the following drawing of a sec- tion taken from the case described by Dr. Percy Kidd, and kindly lent by him. The associated lesions likely to be met with are hypertrophy CHRONIC AND SUBACUTE PNEUMONIA 239 and dilatation of the right side of the heart, chronic nephritis, fatty or nutmeg Hver, and amyloid changes in various viscera. Etiology. — No definite statements can be made as to the etiology of this affection. Alcoholism has been noted in some cases. The duration of the cases of this nature hitherto recognised has varied from five weeks to nine months, but it is possible that the condition may be still more chronic, and may then assume the characters described under Pulmonary Fibrosis {vide p. 2G0). Death has been due to cardiac failure, diffuse septic broncho- pneumonia and gangrene, or chronic renal disease. Fig. 75. — Subacute Indukative Pneumonia a, granular matter and capillary vessels in alveolus, with nucleated cells ; 6, connective tissue ensheathing exudation Prognosis. — This is necessarily very grave. When the sputa have become foetid a fatal termination may be looked for within a short period. Diagnosis. — Probably the first step in the recognition of such a case will be failure to find tubercle bacilli in the sputum. The diagnosis of bronchiectasis will probably next suggest itself, and will be excluded with greater difficulty, but careful attention to the history of the case should suffice for this. Keference may be made to the article on that subject, and par- ticularly to the stages through v;hich, in many cases, that affection passes {vide p. 134). There will be no history of such stages, but, on the contrary, there will be one of the more or less sudden onset of a disease of a somewhat severe character. The lobar distribution of the lesions may suggest that it is a case of pneumonia, but 240 THE DISEASES OF '1"HE LUNGS if diffuse septic broncho-pneumonia or gangrene is present, little help will be obtained from the observation of the area affected. Treatment. — The general treatment should be tonic and supporting, and the patient should be careful to avoid exposure to conditions likely to give rise to bronchial catarrh. If the sputa and breath are fcrtid, the use of the creasote vapour bath, as de- scribed in the chapter on Bronchiectasis, would be suitable. If the site of a large single basic cavity produced by necrosis, and possibly gangrene of lung, could be discovered, an attempt should be made to drain it as described in the chapter on the Surgical Treatment of Pulmonary Cavities. Any complications which arise sliould be treated upon general principles. J. K. F. 241 CHAPTER XIX ABSCESS OF THE LUNG Etiology .... Symptoms .... Physical signs and diagnosis Course ..... Prognosis .... Treatment .... PAGE 241 242 242 242 243 243 A MOBE or less circumscribed collection of pus within the lung may •occur as a secondary result of a great variety of affections. In the majority of conditions to which the term is applied, the similarity of the lesion to an ordinary ' abscess ' is, from a pathological point ■of view, not very close. Etiology. — An abscess may be met with in connection with — (1) Pneumonia followed by necrosis and softening of a con- siderable area of the consolidated lung. (2) Pulmonary tuberculosis, when a large caseous area under- goes rapid disintegration. (3) Chronic non-tubercular cavities. (4) Bronchiectasis, either with or without ulcerative changes in the bronchial walls and surrounding tissues. (5) Suppuration of an hydatid cyst. (6) Softening of a pyemic infarction. (7) Pulmonary embolism followed by softening. . (8) Perforation of the lung by a malignant growth in the oesophagus. (9) Suppuration of bronchial glands extending into the lung. (10) Empyema rupturing into the lung. (11) Perforation of the lung by a mediastinal abscess. (12) Perforation by an abscess extending through the dia- phragm. (13) Injuries of the lung. The precise nature of the lesion present in most of the above ■conditions is fully described elsewhere in this work ; it will there- fore only be necessary to consider here those to which the term ' abscess ' of the lung is commonly applied. Abscess of the lung may be either single or multiple. The 242 THE DISEASES OF THE LUNGS former variety is met with in pneumonia, and as a result of injuries,. such as fractures of the ribs, or wounds penetrating the lung, and in some other conditions. Multiple abscesses are generally pyjemic in origin, and are due to the softening of infarctions or to septic broncho-pneumonia. Abscesses of this nature are usually of small size, and, beyond the occasional presence of limited patches of pleural friction and possibly a small amount of foetid expectoration, give rise to no sym- ptoms which can be distinguished from those of the general condition, and in some cases even these symptoms are absent. Symptoms. — Pi/rexia.—Dnving the period of formation of an acute pulmonary abscess, as, for example, in pneumonia, there is continued fever, the temperature ranging at a high level ; subse- quently the pyrexia is of the hectic type commonly observed when matter is retained within the body, and during this period rigors may occur. The discharge of the pus is generally followed either by a fall of temperature or by the disappearance of the pyrexia. Expectoration. — The sudden expectoration of a large quan- tity of pus, in which, either with the naked eye or by the aid of the microscope, lung tissue is found, is the most characteristic sym- ptom. Micro-organisms varying in nature with the condition, but generally either pneumococci or streptococci, are invariably present. The expectoration is often, but not always, fcetid ; but, if free from odour when first discharged, it is apt to become foetid at a later period if the drainage of the cavity is not free. Physical signs and diagnosis. — The former are ex- tremely variable. \\'hen signs indicating the presence of a cavity are discovered shortly after the evacuation of a large quantity of pus, there cannot be miich doubt as to the nature of the case ; but, previously to this, dulness on percussion and absence of breath sounds may have suggested a diagnosis of pleural effusion. The absence of displacement of the cardiac apex and increased instead of diminished vocal fremitus should, however, prevent this error. Softening in several areas is accompanied by large crackling rales. When, instead of rupturing into a bronchus, the abscess perforates the pleura or the pericardium, it will be very difificult to determine the exact condition present. If situated near the surface of the lung, the pleura will certainly become involved, and the presence of a pleural friction sound may suggest the nature of the case when the import of other signs is doubtful. An abscess has been known to perforate the intercostal muscles, and to give rise to subcutaneous emphysema, and in rare cases to discharge itself externally. Very rapid softening of an area of caseous tuberculosis may simulate abscess of the lung, l)ut the true nature of the condition is revealed by the discovery of tubercle bacilli in the expectoration. The course of a case of pulmonary abscess will depend greatly upon the nature of the primary condition on which it depends.- ABSCESS OF THE LUNG 243 If it is a result of pneumonia the discharge of the contents may be followed by a gradual disappearance of symptoms and signs, and by the cicatrisation of the cavity, but such a favourable issue is extremely rare. More often death occurs from gradual exhaustion, or septic broncho-pneumonia caused by inhalation of the secretion from the abscess cavity. The prognosis is in all cases very grave, but, as already stated, the condition is not necessarily fatal. Treatment. — The indications are to increase by all possible means the resisting poAver of the patient and to bring about local conditions which may, when such a result is possible, lead to the contraction and ultimate obliteration of the cavity. The former is fulfilled by the administration of quinine in large doses and of perchloride of iron, with plenty of nourishing food, and by placing the patient under the most favourable hygienic conditions. The first step towards the latter is to secure free drainage from the cavity. When there is clear evidence of the presence of an abscess cavity within the lung, the question of surgical interference will arise, and will be decided by a careful consideration of the general condition of the patient, the nature of the primary disease, the site of the cavity, whether apical or basic, single or multiple, the possibility of securing free drainage, and the condition of the overlying pleura. . These points are fully considered in the chapter on the Surgicall/ Treatment of Pulmonary Cavities {vide p. 416 ff.). Abscesses due to pyemia are, however, practically beyond the reach of treatment. If, as is generally the case, the sputa are foetid, creasote may be given internally and by inhalation, either on an oro-nasal inhaler or, if the patient can bear it, by means of the creasote vapour bath. Cough which is effective in expelling secretion should not be checked by sedatives, as both seci'etion and cough will diminish with improvement in the local condition. J. K. F. e2 244 THE DISEASES OF THE LUNGS CHAPTEK XX GANGKENE OF THE LUNGS Varieties Circumscribed Diffuse . Micro-organisms . Etiology Primary lesions (a) Of the bronchi (b) „ lungs and mediastinum (c) „ vessels (d) By extension from neighbouring viscera ((') Wounds and injuries (/) General conditions . Symptoms . Physical signs Diagnosis Prognosis Treatment . PAGE 244 244 245 245 246 246 246 246 248 248 248 248 249 249 249 250 250 Gangrene of the lungs may occur as a secondary result of a great variety of conditions, but as a primary ati'ection it is practically un- known. It implies not only death but subsequent putrefaction of a portion of the lung. It is almost always the result of inflam- mation, and the organisms which bring about the putrefaction reach the part either from the bronchi or through the medium of the blood-vessels, or by direct extension from a lesion of some neigh- bouring organ. Pulmonary gangrene is rare, as is shown by the fact that 1,G21 consecutive autopsies made by the writer at the Middlesex Hospital furnished only seven examples of the disease. Laennec, to whom we are indebted for the recognition of the condition, described two varieties, viz. ' circumscribed,' and ' non- circumscribed ' or ' diffuse.' Although the presence of a limiting zone of inflammation, which forms the basis of this subdivision, can in many cases be neither demonstrated nor denied, the classification is useful and has been accepted by nearly all subsequent writers. Circumscribed gangrene. — In this form the lung tissue surrounding the gangrenous area is acutely inflamed and presents the appearances of a fairly well defined zone of hcpatisation. This GANGRENE OF THE LUNGS 245 is evidence of an attempt on the part of the organism to Hmit the process, resembling that which, in the case of gangrene of a hmb, leads to the formation of a ' line of demarcation.' "Within the limiting zone the lung tissue may persist as a black, grey, or greenish mass, or it may have broken down and have been in part expectorated. If a cavity has resulted the walls are ragged and shreddy in recent cases, but, if the duration of the process has been more prolonged, the necrosed tissue may have separated as a slough, and the walls may consist of a smooth layer of granulation tissue. In cases of a still more chronic nature there may be a well- defined zone of induration. The contents of the cavity are horribly foetid, grey, black, blackish-green or chocolate in colour, and either pulpy or diffluent in consistence. If recent haemorrhage has occurred the cavity may be filled with blood. The bronchi and large vessels of the affected area may have been destroyed in the process, or the vessels, filled with thrombi, may be found amongst shreds of necrosed tissue still adherent to the ragged walls. The neighbouring bronchi are acutely inflamed and usually contain foetid material similar to that found within the cavity. If the lesion is situated near the surface, the pleura over the affected part will be acutely inflamed and covered with lymph. The gangrenous area may be very small or it may, as in some cases following pneumonia, involve a considerable part of a lobe ; when of embolic origin, it is often wedge-shaped. Diffuse gangrene. — This, which is the rarer form of the lesion, is characterised by the absence of a limiting zone of inflam- mation, the gangrenous area merging with the surrounding lung tissue. The affected part is of a grey, greenish, or black colour ; gener- ally, but not invariably, of a foetid odour, and may be of any consis- tence from that of hepatised lung to that of a pulp, or it may present the appearance of blackish grumous fluid occupying a ragged cavity. The surrounding lung is oedematous, and generally emits a foetid odour. If the lesion is situated near the surface, the pleura will probably have undergone extensive necrosis and gangrene. Empyema and pyopneumothorax may be present. The bronchi and vessels of the affected area may still be recog- nisable, and the latter often contain thrombi. Micro-organisms of various kinds have been found in gangrenous areas in the lungs. The staphylococcus pyogenes aureus is be- lieved by Bonome ^ to be the primary cause of the necrosis of the pulmonary tissue, as injections of pure cultivations of the staphylococcus pyogenes aureus into susceptible animals are said by the same observer to be followed by gangrene of the lungs. Babes ^ has described a mobile rod-shaped organism from -8 to 1'5 fx in length, which was present in the sputa of a case of pul- ' Deut. Med. Woch. 1888, No. 52. - Cornil et Bab^s, Les Bacteries, 1890, tome i. 246 THP: diseases of the LUNCiS monary gangrene, and which, when injected into susceptible animals, gave rise to septicaemia. Cultivations of the organism were free from odour. Leptothrix, aspergilli, sarcina-, mucor mucedo, and other organisms have also been found. It is, however, improbable that pulmonary gangrene is due to the presence of any special organism ; it would rather appear to be dependent upon the com- bined action of several saprophytic organisms. Etiology. — The primary conditions leading to pulmonary gangrene may be classified under the following headings, viz. : (a) lesions of the bronchi ; (b) lesions of the lungs and media- stinum ; (c) lesions of the vessels ; (d) extension from lesion of neighbouring viscera ; (e) wounds of the lungs or thorax ; (/) general conditions. (a) Lesions of the Bronchi. — The retention of putrid secretions within the bronchi is not infrequently the cause of gangrene of the lungs. In the majority of cases originating in this way the bronchi are dilated ; but, as was stated in the description of j;?iinV/ bronchitis, dilatation is not an essential condition, although it is rarely absent when gangrene supervenes. In bronchiectasis the expectoration may be fcttid for years without the occurrence of gangrene ; but if, as not uncommonly happens towards the end of the case, a diffuse septic broncho-pneumonia should be set up, the lung is very likely to pass into gangrene. Any case of bronchiectasis may terminate in gangrene, which is not necessarily limited to the area in which the bronchi are dilated ; decomposing secretion driven by cough into the trachea may be inhaled into the opposite lung and induce gan- grene, usually of the lower lobe. In conditions of paralysis portions of food carrying with them septic organisms may pass unnoticed into the trachea. Diminished sensibility of the larynx, permitting the passage of food and secretions into the trachea, is probably one of the chief causes of the frequent occurrence of pulmonary gangrene in the insane. In melancholia, accompanied by refusal of food, a condition in which pulmonary gangrene has frequently been observed, it may possibly be an indirect result of defective nutrition ; but its occurrence has also been attributed to the passage of food into the trachea during forcible eeding. In fa'cal vomiting material regurgitated from the stomach may be drawn through the glottis and may induce pulmonary gan- grene, (iangrene of the lungs is not a very uncommon mode of termination of cases of epithelioma of the tongue, mouth and a'so- phagus, and it may occur as a secondary result of gangrene of the mouth and also of diphtheria. Gangrene may follow when a sup- purating bronchial gland has established a communication between the asophagus and the trachea or one of the main bronchi. (b) Lesions of the Lungs and Mediastinum. — Gangrene may be induced by any form of inflammation of the lungs if septic or- ganisms develop in the affected area, and, as already stated, broncho- pneumonia is usually present in the various conditions considered in the preceding section. Pneumonia may nndoul)tedly pass into gangrene, although (iANGRENE OF THE LUN(;S 247 many writers have doubted the possibihty of the occurrence. The following were the post-mortem appearances in a Avell-marked case of pneumonia of sudden onset admitted on the third day of the disease and fatal on the eighth day. ' Eight lung. — The lower and posterior half of the upper lobe was converted into a sloughy mass, lying in a ragged cavity which was filled with foul greenish opaque fluid. Shreds of gangrenous tissue were adherent to the walls of the cavity. A fairly defined boundary of hepatised lung, mottled, of a greyish red colour, separated the gangrenou.s area from the surrounding tissue. Some vessels in the walls of the cavity contained fibrinous coagula. The middle lobe was consolidated and in a condition of grey hepa- ■fcisation. The lower lobe was engorged. The pleura covering the upper lobe was intensely inflamed, studded with hfemorrhages, and <30vered with patches of lymph.' It will be observed that the middle lobe of the right lung pre- sented appearances similar to those of the hepatised but non-gan- grenous portion of the upper lobe. The hepatisation found in such cases has been stated to be the result and not the antecedent of the gangrene, but it is unlikely that the gangrenous process can induce a, true pneumonic consolidation of an adjacent lobe. The factor determining the occurrence of gangrene in cases of pneumonia can- not be exactly defined. A marked lack of resisting power such as that induced by starvation, alcoholism, diabetes, chronic nephritis, ■or advanced age, appears to be the determining cause in many cases. Assuming the microbic origin of pneumionia it may be held that in some cases there is a double infection and that septic organisms are present in addition to those now believed to be pathogenic of that disease. A similar association of septic and pathogenic organisms in diphtheria has been shown to exercise a marked effect upon the course of the disease. Broncho-pneumonia in children, especially when secondary to measles, may terminate in gangrene, but such an event is rare. The gangrene usually afiects many areas, which have a racemose arrangement. Chronic yneumonia — This condition, with which bronchiec- tasis is very often associated, is liable to be complicated by an acute septic inflammation of the neighbouring lung tissue, and under such circumstances gangrene may supervene. The mode of production of gangrene in cases of mediastinal tumour, aneurism, and growths originating within the lung must be considered doubtful. It has been variously attributed to septic pneumonia secondary to the retention of secretion in the bronchi, and to direct pressure either upon the lung or upon the bronchial vessels or upon the pulmonary plexus. In a case of lympho- sarcoma of the mediastinum recently under our observation obstruction of the main bronchus led to sacculated bronchiectasis throughout almost the whole of the aflected lung. This was followed by septic pneumonia and gangrene. This sequence of events is in our experience not uncommon. 248 THE DISEASES OF THE LUNCiS and we are disposed to consider the decomposition of retained! secretions of far more importance in the production of gangrene than any of the other causes mentioned ; it is indeed doubtful whether it may not be considered the only cause. Pulmonary tuberculosis — This disease very rarely ends^ in gangrene. Decomposition of secretions within cavities and changes in their walls may give to the breath a foetid odour, but the special characters observed in gangrene are absent. (c) Lesions of the Vessels. — When an embolus derived from a septic source lodges in a branch of the pulmonary artery an infarc- tion results and gangrene may follow ; but in the majority of cases a pysemic abscess forms, the occurrence of gangrene being rare. The area afitected usually has the wedge-shaped outline of the ordinary hsemorrhagic infarction. It must not, however, be thought that the presence post-mortem of coagula in the vessels in gangrene of the lungs necessarily indicates that the process was of embolic origin, as thrombi are often formed in such cases. On the other hand, in cases undoubtedly due to embolism the secondary thrombi may render it difficult to recognise the embolus. Common sources of septic emboli in cases of pulmonary gangrene are thrombi in the lateral sinus secondary to caries of the temporal bone, in the uterine veins in cases of puerperal fever, or in veins in the neighbour- hood of foci of septic suppuration, such as a sloughing bedsore. Pulmonary gangrene of embolic origin has also been observed, but only rarely, in erysipelas, carbuncle, typhoid fever, and various other morbid conditions. Fat embolism of the pulmonary capillaries has been shown to be capable of producing gangrene when the emboli are derived from a septic source. (fZ) Gangrene by extension from neighbouring Viscera. — A septic or gangrenous inflammation situated in the abdomen or thorax may involve the lungs by direct extension and gangrene may follow. Abscess of the liver and subdiaphragmatic abscess are the most common antecedent conditions originating in the abdomen. If in such cases the pleural surfaces are not adherent, empyema may precede the gangrene, which follows perforation of the visceral layer of the pleura. A f(ecal abscess may extend upwards to the thorax and be followed by similar results. Cancer and gangrene of the esophagus may also induce a similar change within the lung. {e) Wounds or Injuries of the Lung or Thorax. — Injuries to the chest wall accompanied by extravasation of blood into the lung tissue may be followed by gangrene. Gunshot wounds of the lung have in some campaigns frequently pi-esented this com- plication. In some cases of the above nature a true pneumonia appears also to have been present. (f) General Conditions. — Starvation, alcoholism, chronic ne- phritis, diabetes, and some of the specific fevers, more especially measles and typhoid fever, are the more important general con- ditions which have been followed by gangrene of the lungs. GANGRENE OF THE LUN(;S 249 Possibly some cases which have occurred after exposure to noxious emanations from sewers and other sources of foul air should be included under this heading. Symptoms. — Although gangrene of the lungs may occur without revealing itself by the characteristic odour of the breath and sputa, such a condition is, from a practical point of view, of but little importance, as in the absence of such signs its presence is rarely even so much as suspected. Such cases are chiefly met with in the insane, in diabetics, and in the subjects of gangrene from embolism. Putrefactive decomposition of retained secretions and gangrenous broncho-pneumonia may be present in bronchiectasis without causing foetor of the breath, if the upper air passages are cut off from communication with the dilated tubes. Havuig regard to the very varied conditions under which pul- monary gangrene may occur, uniformity in its clinical manifesta- tions and course is not to be expected. The onset is very often marked by a rigor, which may be repeated ; the general condition of the patient is usually one of marked prostration ; the involve- ment of the pleura in the process is evidenced by severe pain in the side. The progress of a destructive change in the lungs is attended by a liability to haemoptysis, which may be very profuse. Hfemo- ptysis has indeed in some cases been the first symptom observed. The changes in the general aspect of patients suffering from bronchiectasis or pneumonia when pulmonary gangrene sets in are dealt with on p. 134 and p. 222. The peculiar odour of the breath and sputa in cases of gan- grene is readily appreciated but difficult to describe. The expec- toration resembles that of bronchiectasis in the tendency to settle into three layers, after standing for about twelve hours, but differs from it in the variety of colours which may be present. These are probably owing to the intermixture of blood pig- ment and the chemical changes which it undergoes. The sputa may be milky white, green, brown, chocolate coloured, yellow, or obviously blood-stained. In the thick lower layer, pus cor- puscles, elastic tissue, Dettrich's plugs, crystals of fatty acids, spirals, sarcin^, and leptothrix, flagellated monads, staphylo- coccus pyogenes aureus, and the micro-organisms usually associated with putrefactive changes may be present. The physical signs in cases of gangrene present no distin- guishing features. They depend upon the condition of the affected area, whether it be consolidated, or softening, or already excavated, and upon the previous condition of the lung, if it has been affected by some definite lesion such as bronchiectasis. In children the signs are often those of broncho-pneumonia only. The difficulties which attend the localisation of the exact site of the lesion, especially if a cavity has formed, are referred to later in the chapter on the Surgical Treatment of Pulmonary Cavities. Diagnosis. — The presence of the condition is, as a rule, readily recognised by the characteristic odour of the breath and 2SO THE DISEASES OF THE LUNGS sputa, and the presence in the expectoration of broken-down iung tisue and elastic fibres. The accompanying- constitutional sym- ptoms have been already described. It may, however, be here again pointed out that in conditions of extreme prostration, such as not infrequently accompany pulmonary gangrene, pyrexia may be absent. The affections which most nearly sinmlate it and in association with which it often occurs are bronchiectasis, putrid bronchitis, pulmonary abscess accompanied by factor, and the rupture of an empyema into the lung. Putrefactive changes in the walls or con- tents of a tubercular caxdty may also produce a condition only to be distinguished from gangrene by the presence of tubercle bacilli in the sputa. In all cases in which foetor is present the sputa should be stained in order to determine the nature of the organisms contained therein, and carefully examined microscopically for elastic tissue, as upon this in doubtful cases the diagnosis may rest. The diagnosis between gangrene and the perforation of the lung by an empyema is of great importance, as, in the latter condi- tion, recovery after surgical operation may fairly be hoped for. In a case of empyema there will be a history of pleurisy followed by the sudden expectoration of a quantity of purulent and possibly fcietid sputa ; but the gangrenous odour, and evidence of breaking down of the lung as shown by the presence of elastic fibres, will be wanting. Prognosis. — The course of the disease is, in the great majority of cases, unfavourable, death usually occurring within a fortnight of the onset of the symptoms. In rare cases a more chronic course is observed, and more rarely still the condition is followed by recovery, after the separation of a slough and the formation of a cavity, which then undergoes con- traction. Treatment. — The indications for the treatment of pulmonary gangrene are to maintain the general health, diminish the fcetor of the breath and expectoration, and to drain any cavity which may be present. It is obvious that of these the last is the more important, as upon it the others in great part depend. It will, however, be more convenient to discuss the measures suitable for adoption in the order above given. Rest in bed and the administration of stimulant and tonic remedies, such as brandy or port wine and quinine, and of nourishing food in such quantity as the patient can digest, fulfil the first indication, and by so doing render the arrest of the disease possible. This can only be brought about by the formation of a /.one of protective inflammation, for which the highest degree of resisting power of the individual is necessary. The horrible odour of the breath and sputa is often less distressing to the patient than to those about him, but attempts should always be made to diminish it, even if there is no prospect of his ultimate recovery. For this purpose the mode of treatment recommended in the chapter on Bronchiectasis (vide p. 18H), viz. GANGRENE OF THE LUN(;S 251 the use of a creasote bath accompanied or not by the subcutaneous injection of a solution of guaiacol, has proved in our experience more efficacious than any other. If the patient is too ill to bear this treatment, the continuous inhalation of creasote vapour may be secured by wearing an oro-nasal inhaler, the sponge of which has been saturated with a solution of creasote and menthol (20 per cent.), or of equal parts of creasote and chloroform. Weil strongly advises the subcutaneous injection of sterilised oil of guaiacol in doses of 15 grains or more per diem, and Lop ^ reports several cases in which the foetor entirely disappeared, while there was a fall in the temperature and a marked diminution in the quantity of expectoration under this treatment. A temporary cessation of the treatment was followed by a return of the fcetor, an increase in the quantity of sputa, and a rise of temperature. The case of bronchiectasis recorded on p. 139, in which recovery from a condition which at first appeared almost hopeless followed the use of subcutaneous injections of oil of guaiacol and creasote baths, may be referred to. Inhalations of the vapour of carbolic acid in solution (2-4 per cent.), and the internal administration of the same drug in large doses — 4-15 grains per diem — have also given good results in many cases. We have no experience of the direct injection by the aid of Pravaz's syringe with a long needle of antiseptic substances such as guaiacol, iodoform, and creasote into the parenchyma of the lung at the supposed site of the lesion. Traube recommended the internal use of acetate of lead, and Wilson Fox adopted this treatment in the only case under his care in which recovery took place. Keference may be made to the chapter on Bronchiectasis, where the use of a variety of antiseptic substances in the treatment of fcetid expectoration is considered {vide p. 137). J. K. F. ' Gaz. des Hup. 1893, No. 27, p. 249. 252 THE DISEASES OF THE LUNGS CHAPTEK XXI BEONCHO-PNEUMONIA (CATARRHAL PNEUMONIA. LOBULAR PNEUMONIA) I'AOK Etiology 252 Morbid anatomy 253 Associated lesions ......... 255 Symptoms and course 255 Physical signs 256 Diagnosis 256 Prognosis 257 Treatment 257 This form of pneumonia, wliich until lately was considered to be generally due to the direct extension of a simple catarrhal inflamma- tion from the bronchi to the lungs, is now by many writers ascribed to the presence of septic organisms, which multiply in the oro-nasal passages where they are commonly present, and owing to changes in the tracheal and bronchial mucous membrane are enabled to make their way thence towards the lungs, into the alveoli of which they either spread or are drawn by inhalation. Various organisms are found in broncho-pneumonia, and as a rule infection is mixed. The micrococcus lanceolatus, the strepto- coccus pyogenes aureus and s. p. albus, staphylococci, and Fried- liinder's pneumococcus have all been identified. Etiology. — In its typical form the affection is essentially one of infancy and childhood, and occurs with especial frequency as a secondary complication of bronchitis, whooping cough, and measles. It is also often present in cases of diphtheria when the disease has extended to the bronchi, and it has been observed in association with extensive burns of the skin (Wilks). The pulmonary affection common in influenza resembles broncho-pneumonia in its distribu- tion, although differing from it somewhat in its nature {vide p. 580). A diffuse broncho-pneumonia may occur as a complication of ERONCHO-PNEUMONIA, 253 bronchiectasis, and of chronic pneumonia. It may also be caused by the entrance of septic material into the bronchi. Malnutrition, rickets, the breathing of impure air, and any conditions leading to a defect of resisting power, act as powerful predisposing causes of the affection. It may occur as a secondary complication of collapse of the lungs, but more often is the direct cause of that condition. The affection has the highest mortality in early childhood, a very large proportion of fatal cases occurring before the age of four years. It is also a very serious disease when it occurs as a compli- cation of bronchitis in old people. Morbid anatomy. — Both lungs are affected as a rule, but the lesions are generally more extensive in one than the other. The surface of the lung is usually studded with depressed areas of collapse presenting the purple colour and sharply defined angular outline typical of that condition. Elsewhere small areas of con- solidation project from the surface, and the pleura covering them may show evidence of inflammation, although this as a rule is slight, and rarely approaches in extent to that observed in pneumonia. The lobules surrounding the solid areas are often over-distended with air. On section, the lung is seen to be congested, and scattered through it there are rounded areas of consolidation about the size of peas, with a slightly granular surface and ill-defined outline. The inflamed lobules are in the early stage of a deep reddish-brown tint ; at a later period they may become grey, and still later they are of a yellow or greyish-yellow colour. They may be discrete or aggregated in racemose groups, the confluence of which may pro- duce large areas of consolidation involving in some cases the greater part of a lobe. Even then, however, there is little difficulty in deciding on the nature of the process, as the consolidated part lacks the uniform appearance of pneumonia, and here and there small areas of unaffected or collapsed or merely oedematous lung will be seen. An entire lobe is, moreover, rarely if ever completely consolidated. Collapse may be present in scattered areas, or occur in patches of considerable extent. The latter are especially common towards the base of the lung. Inflamed lobules are often present in the collapsed patches, and may be recognised by their granular surface. On compression of the lung, beads of puriform mucus will be seen to issue from the smaller bronchi, which are acutely inflamed, whilst the lining membrane of the larger tubes is also inflamed and of a deep purple colour. On microscopical examination {vide fig. 76) the alveoli are seen to be filled with small round cells, and large round or oval cells of an epithelial type containing one or more nuclei. The latter are the result of a proliferation of the alveolar epithelium, as is shown by their attachment in places to the wall of the air vesicle, and by their greater abundance at the periphery of the exudation. Fibrin may also be present, but to a much less extent than in pneu- 254 THE DISEASES OF THE LUNGS monia. The cells of both varieties are often seen to be undergoing a process of fatty degeneration. The bronchioles of the inflamed areas are also filled with an exudation chiefly consisting of small round cells. At the margin of the inflamed area, where the process is less advanced, the epithelial cells lining the alveoli are enlarged and undergoing proliferative changes ; the walls are thickened and the vessels are distended with red blood corpuscles. The inter- lobular septa are also swollen, chiefly from congestion of the vessels with coloured corpuscles. The walls of the finer bronchi show infiltration with small round cells, and the epithelial lining is seen to be undergoing active proliferative changes, and may in places be Ji* ^, Fig. 70. — Brokcho-pnecjionia, showing an Alveolus filled with large Cataurhal Cells ani> thickening of the Alveolar Wall detached. Peril)ronchinl infiltration is connuonly present. The smaller tubes are often dilated, this change being especially common when the disease has followed whooping cough. In cases due to the inhalation of septic material, micrococci in large numbers may be found in the inflamed alveoli and around the bronchi and vessels. The consolidated areas may undergo a process of softening, small abscesses being formed and extensive destruction of the lung taking place. In such cases gangrene may follow. The diffuse broncho-pneumonia which often occurs at the termination of a case of broncliiectasis is an example of this process. In some of the cases which recover, the inflammatory process BRONCHO-PNEUMONIA. 255 undergoes arrest, and absorption of the effused products is followed by a return of the part to its normal condition. In other cases the lung remains in a condition of chronic pneumonia, and bronchiec- tasis subsequently occurs. As stated in the chapter on Phnphysema, a condition of acute over-distension of the pulmonary alveoli, the result of violent cough, is often found post mortem in cases of broncho-pneumonia following whooping cough in children, but the atrophic changes essential to true emphysema are absent. Emphysema, however,, may have preceded the acute attack, or it may subsequently super- vene in cases where resolution is incomplete and fibrosis of the lung follows. Associated lesions. — The bronchial glands are almost in- variably enlarged, but they are not caseous. The right auricle and ventricle are dilated as a result of the obstruction of the pulmonary circulation, and all the organs emptying their blood into the systemic veins show signs of congestion. The intestines often show evidence of the presence of acute catarrh, and sometimes even of ulceration. Thrombosis of the pulmonary artery and pericarditis may be- mentioned as rare complications. Symptoms and course. — The onset of the disease is marked by a sudden rise of temperature. A temperature ranging between 103° and 105°, or even higher, is by no means uncommon. The fever is of an irregular type, and considerable remissions and exacerbations occur, often without obvious cause. The difference between the morning and evening temperature may be tv,fo or three degrees or more, the higher temperature being occasionally recorded in the morning. Rigors rarely occur, and vomiting is uncommon. Cerebral symptoms, such as delirium and convulsions, suggestive of tbe presence of meningitis, may occur in children at the onset, but they are not very common, and are usually of sbort duration. The breathing is markedly quickened, from 50 to 80 or even more short and shallow respirations per minute being often ob- served. There is an urgent sense of dyspnoea, the alfe nasi are widely dilated, and the patient prefers to lie with the head high and the back well supported by pillows. When the disease occurs as a complication of bronchitis, its onset is often first recognised by a change in the cough, which, if it has previously been loose and painless, now becomes short, dry, more frequent, and accompanied by pain. Free secretion from the bronchial mucous membrane ceases, and the sputum is viscid and difficult to expel ; it may be streaked with blood, but never presents the rusty character typical of pneumonia. Expectoration is usually absent in young children. The face is at first pale, then, as the breathing becomes in- creasingly laboured, livid or cyanotic in tint. The lips and the finger-nails also show cyanosis. The expression is anxious, and restlessness is often marked. The pulse is small, feeble, and very quick — 150 or more — and sometimes uncountable. Heat and dry- 256 THE DISEASES OF THE LUNGS ness of the skin may alternate with perspiration. The tongue soon becomes dry ; diarrhoea is a somewhat common symptom ; and in acute cases emaciation rapidly occurs. The disease, if not quickly fatal, as it may be in infants and young children, usually runs a somewhat protracted course, from fourteen days to three weeks being a common duration, and the period may be much more prolonged. The temperature falls by lysis, a critical defervescence being very rarely observed. The dyspnwa slowly passes oft", the pulse gradually diminishes in frequency, and the physical signs clear up. Physical signs. — On inspection of the chest the inspiration is seen to be short and the expiration prolonged. There is some elevation but little true expansion of the chest, the lower intercostal spaces, the submammary regions, and the epigastrium receding with inspiration, whilst the sternum is raised and arched forward. The percussion note may be normal, if the consolidated areas are few in number, and widely scattered through the lungs. If a suffi- ciently extensive area has been consolidated by coalescence of foci of inflammation, and if, as is often the case, there is collapse of neighbouring lobules, resonance may be impaired, or there may be patches of dulness. At a more advanced stage a hyper-resonant note may be obtained owing to the over-distension of vesicles sur- rounding small foci of inflammation. The breath sounds are usually harsh over the upper lobes, absent, feeble, or bronchial at the bases, their exact character being dependent upon the relative predominance and extent of consolidation and collapse. Collapse is indicated by retraction of the side and diminution or absence of breath sounds, and of vocal fremitus and vocal resonance ; consolidation, of some extent, by an increased conduction of the voice sounds, and by the presence of bronchial breathing and bronchophony. The typical adventitious sounds of broncho- pneumonia are fine crackling rales, not hmited to the period of inspiration ; rhonchus and sibilus, if present, are due to co-existing bronchitis. The percussion note in collapse is less dull than in consolidation, and may have a tympanitic quality. Diagnosis. — The diagnosis of broncho-pneumonia from ac^itc dissciiii netted tuberculosis of the caseous type may be very difficult, particularly if the case is seen at a late stage when marked emaciation has taken place, and, owing to the previous dilatation of the finer bronchi, the rfiles have acquired a coarse and almost metallic quality, highly suggestive of softening tubercle. It should be remembered that this form of tuberculosis is very rai*e, the acute miliary variety, which is unaccompanied by softening and marked by i-elatively few adventitious sounds, being far more common in children, in whom the difficulty of diagnosis is most likely to arise. The physical signs in tuberculosis will almost certainly be more marked in the upper lobes, whilst in broncho-pneumonia with l)ronchiectasis the lower lobes are, as a rule, more afifected. If expectoration is present, and the sputum contains tubercle >5R0NCH0- PNEUMONIA 257 bacilli, the difficulty at once disappears. Careful attention to the previous history of the patient and to the course of the illness will often settle the point ; but, if doubt remains, it is well not to commit oneself to an opinion that tubercle is present. In uncomplicated collapse of the htmjs there is no rise of temperature. The physical signs of collapsed lung, and the way in which they differ from those of broncho-pneumonia, have been already stated. From bronchitis the disease is differentiated by the higher range of temperature and the character of the adventitious sounds. When the greater part of a lobe has become consolidated by the •confluence of separate foci of broncho-pneumonia, it may be ex- tremely difficult to diagnose the affection from pnciunonia by the physical signs alone ; but the history will be different in the two <3ases, and the temperature will, as a rule, show less marked remissions in pneumonia than in broncho-pneumonia. If the illness has lasted over a week and no crisis has occurred, the case is probably one of broncho-pneumonia. Typhoid fever, especially in children, may be accompanied by ■extensive broncho-pneumonia at an early stage of the disease. In such cases the absence of any obvious cause of the pulmonary affection, such as previous bronchitis, and the presence of enlarge- ment of the spleen point to a diagnosis of typhoid fever. The cerebral symptoms that often accompany the onset of broncho-pneumonia in children may at first suggest meningitis, but the fact that many acute diseases are ushered in by similar •symptoms should prevent a rash diagnosis of meningitis, and the presence of a considerable degree of dyspnoea and of the physical signs of pulmonary disease are strongly in favour of that of broncho-pneumonia. Prognosis. — This is grave in all severe cases, as the disease has a high rate of mortality. In infants and in young rickety children the probability of a fatal termination is always great, especially when the affection complicates whooping cough. The association of extensive collapse and broncliitis affecting the finer tubes with cyanosis or lividity, constitutes a very unfavourable condition. A very high temperature is always an unfavourable sign. The character of the pulse is often a safer guide than the rate of the breathing, a very feeble, rapid, and ' running ' pulse being of more serious import than rapid respiration. Convulsions occurring at the onset of the disease are not necessarily unfavourable, but at a later period they are very likely to be followed by death. Broncho-pneumonia may lead to enlargement of the bronchial glands, which may be a source of trouble at a later period, and to bronchiectasis. Children weakened by broncho-pneumonia are very liable to infection from tuberculosis. Treatment.— The general treatment of broncho-pneumonia, whether in the young or old, should be stimulant, and such as is likely to support the patient's strength. 258 THE DISEASES OF THE LUNGS The room should be maintained at an even temperature of 65'' F., and the air should be moistened by the use of a bronchitis kettle. It is usual to surround the bed of the patient, if a young child, with a tent ; but opinions differ as to the value of this measure, and it is very easy to produce within the tent an atmo- sphere so saturated with watery vapour that respiration is impeded rather than assisted. If it is used, great care is necessary to maintain the temperature of the room in the early hours of the morning, or the patient may be chilled by bis cold and damp surroundings. Stimulant expectorants, such as carbonate of ammonia and senega, may be required from the outset. i)r. Burney Yeo speaks highly of the use of benzoate of soda internally, and of a warm alkaline spray containing bicarbonate of soda and glycerine of carbolic acid. The ett'ect of alkaline remedies in diminishing the viscidity of the bronchial secretion has been referred to in discussing the treatment of bronchitis. This mode of treatment has also a beneficial effect upon the cough by re- heving the dryness of the bronchial mucous membrane. If the cough is very troublesome in children, small doses of Dover's powder (gr. h-1) may be given twice daily, but, speaking generally, the administration of opiates is to be avoided in this disease as much as in bronchitis. As a rule, all lowering remedies should be avoided, except in the early stage in children, when very small doses of tincture of aconite (m.| to ni.1 every hour) may be given for a few hours. Its use sometimes induces diaphoresis, and so lowers the temperature and relieves restlessness. Also at a later period, when the bronchi tend to become obstructed and there is much cyanosis, an emetic of ipecacuanha may be useful by effecting the expulsion of the secretion during the act of vomiting. The early use of oxygen inhalations is often of great service by improving tbe action of the heart. The oxygen should be warmed by passing it through a spiral metal coil placedin a vessel containing hot water ; if this is done the inhalation may be continuous. Sub- cutaneous injections of strychnine (gr. ,,\„-.-A.) at intervals may be employed as aids to other methods of treatment ; the drug acts by stimulating the respiratory centre. Stimulants are often neces- sary from an early stage of the illness, and brandy may be given in doses of from 10 to 15 minims, or more, every two hours to an infant, and the quantity may be gradually increased if the symptoms become more severe. In some cases, large quantities, such as giss in the twenty-four hours, may be given to an infant. The frequency of the pulse and respirations constitutes the best guide to the necessity for the use of stimulants, and also for an increase of the dose. Dr. Wilson Fox writes with approval of the use of cold baths and cold applications to the chest in broncho-pneumonia in children. The cold bath, at a temperature of 05° to 70° F., is used for a few minutes (one to three). Jurgensen preferred a longer immersion (twenty minutes) in a BRONCHO-PNEUMONIA 259 bath at a temperature of from 77° to 80° F. Cold sponging of the chest may also be employed for the reduction of temperature, and is preferable to the use of cold cloths. It may be repeated as often as the threatening symptoms return, or the temperature rises to 103° F. A diminished frequency both of the pulse and respiration is the best evidence that the application of cold is doing good, whatever method may be employed. A valuable method of treatment when the temperature ia high and death is threatening from engorgement of the venous syotem, as evidenced by cyanosis and urgent dyspnoea, is to place the child in a hot bath (temp. 104° to 110° F.), and at the same time to pour cold water (temp. 60° to 65° F.) over the chest and back. The effect is to produce a sudden deep inspiration, in which col- lapsed lobules are doubtless opened up and air passes beyond retained mucus, which it subsequently helps to expel. The breath- ing for a time continues deeper, and cyanosis may be markedly diminished. As local applications to the chest poultices, at one time almost invariably used, are now somewhat out of fashion. To surround the chest of a rickety child with a heavy poultice must impede the expansion and favour collapse of the lungs ; but this objection is to some extent removed by applying the poultice only to the back of the chest, whilst the front is covered with cotton wool, on which turpentine or dry mustard may be sprinkled. Mustard leaves are also of great use as a local application. The choice of the local application will depend very much on the efficiency of the nursing ; in the absence of trained attendants the use of poultices should, as a rule, be avoided. The food should consist of milk, jelly, beef-tea, chicken broth, essences and juices of meat, and eggs in milk. It should be given at intervals of from two to three hours in severe cases. When the symptoms are subsiding especial care is necessary to prevent the occurrence of a relapse, and, during convalescence, far greater watchfulness is required than after recovery from pneumonia. Cod-liver oil and tonics are then of great service. J. K. F. 26o THE DISEASES OF THE LUNGS CHAPTER XXII PULMONAEY FIBROSIS CHEONIC PNEUMONIA, CIRRHOSIS OF THE LUNG, INTERSTITIAL PNEUMONIA I'AGE Etiology 260 Morbid anatomy 261 Symptoms ........... 264 Physical signs .......... 264 Course ........... 265 Diagnosis . . . . . . 265 Prognosis ........... 266 Treatment 266 Keticular fibrosis . 266 The essential feature of the condition to which the above terms -are applied is the presence of an excess of fibrous tissue within the lung. This may arise from a development of new tissue in the walls of the pulmonary alveoli or from fibrous thickening of the sub-pleural, interalveolar, interlobular, peribronchial, or peri- vascular connective tissue. In the majority of cases the above lesions are found in association, but one or other may predominate. Etiology. — Fibrous induration of the lung may occur as a result of a great variety of conditions. It may be secondary to — 1. Pulmoiiarn fuberciclosis. — This is by far the most common cause, the change being especially marked in the chronic and fibroid forms of the afiection. It will be more convenient to consider here only those forms of the lesion which occur independently of the presence of tubercle. 2. Pncianoiiiaandfinhnrntc indurative ^'nciuiioiiid. (lobar type). — The occurrence of induration as a sequel of pneumonia and in the special form of disease to which the latter of the above titles is given is dealt with in the preceding chapter. H>. Bronclio-pncnvionui iiu'lh collapse. In children this affection not infrequently passes into a chronic condition accompanied by PULMONARY FIBROSIS 261 induration of the lung, which commences as a fibrous thickening of the alveolar walls. 4. Bronchiectasis. — As a rule, when dilatation of the bronchi is found in association with induration of the lung, the pulmonary lesion is primary; bronchiectasis, from whatever cause arising, may however be followed by induration of the lung. Usually the change in such cases is limited to the neighbourhood of the dilated tubes. 5. The inhalation of irritant substances. — In the large majority of cases of so-called ' knife-grinders' phthisis ' or ' stonemasons' phthisis,' &c., the condition is the combined result of tuberculosis and fibrosis of the lung, the latter being only in part due to the irritant effect of solid particles inhaled in the course of the patient's occupation. In a certain number, however, tubercle is absent, and in such the induration is to be ascribed to the inhalation of irritant substances (vide ' Diseases due to Inhalation of Dust,' p. 269). 6. Pleurisy. — Lesions of the pleura may be the starting point of indurative changes in the lung, a condition to which the term ' pleurogenic cirrhosis ' is applied. We are of opinion that such a sequence of events is not of such common occurrence as it appears to be considered by some writers ; it is indeed in many cases remarkable to what a short distance the lesions of subjacent parts of the lungs extend in cases of pleurisy, whether acute or chronic, and we doubt whether pleurisy unaccompanied by any pulmonary lesion is capable of producing extensive fibrosis of the lung. 7. Syphilis. — On reference to the chapter on Pulmonary Syphilis (p. 431) it will be seen that the lungs of infants suffering from congenital syphilis often present in a very typical manner the lesions characteristic of interstitial pneumonia. In adults, areas of fibrous induration occasionally mark the site of previously existing gummata. 8. Foreign bodies in the bronchi. — Induration of the lung in association with bronchiectasis and other lesions is not infrequently the result of the long continued presence of foreign bodies in the air passages. 9. The pressure of an aneurysm may induce localised fibrosis of the lung. 10. Malignant growths of the lung, pleura, or oesophagus may also set up indurative changes in the lung. Morbid Anatomy. — Three varieties of the lesion are met with: a. The massive or lobar form ; 6. The insular or broncho- pneumonic form, in which fibrosis occurs in patches ; c. Beticular fibrosis; this variety is separately considered at the end of this chapter. a. The lobar form, as a rule, affects one lobe of a lung. It is unilateral in distribution, and involves the lower lobe. The lung is of a greyish colour, with irregular marbled areas, solid and indurated on section ; in some cases it presents a finely granular appearance. It subsequently shrinks, owing to the contraction of the newly- formed fibrous tissue. Dilatation of the bronchi, generally of tlie 262 THE DISEASES OF THE LUNGS cylindrical variety, but sometimes of the saccular, may occur at a later period, and the changes incidental to that affection, viz. diffuse septic broncho-pneumonia, necrosis, and gangrene are common in fatal cases. Bronchiectasis is, however, more connnon in the succeeding variety. Pulmonary aneurysms may form in cavities. Emphysema is usually present in the neighbourhood of the contracting lesions, and pleural adhesions are commonly found. h. The broncho-pneumonic form, which is the most common, is often secondary to measles, whooping cough, and scarlet fever. Fig. 77. — Pulmonaky Fiukosis ( x 7 diameters) Showing, «, tliickeiied intcrlohnlar septa ; h, tliiokcned ])leura : c, empliysematous lung in neiglibourliood of lesion ; .•.■•-./,v.».-5?' -vH*/ l<':v: '^■■■■■''T-sf ^ Vlli. 84. — TUHEKCLE Showing Icncoeytes cliiefly at the marf^iii ; cpitlielioiil cells and giant colls. According to Ziegler and Koch the cellular elements of a tubercle arc chiefiy derived from the white corpuscles which have left the vessels, the share taken by the fixed cells of the tissues lieing of secondary importance. Arnold, Baumgarten, Weigert, and others have, however, shown that the latter play a much more important, and indeed a preponderating role in its formation. This view is now accepted by most i)athologists. When tubercle bacilli obtain a lodgment in the tissues of the lung or elsewhere, they multiply and produce in the nuclei of the fixed cells of the part the changes characteristic of karyokinesis. Proliferation of the nuclei and division of the cell protoplasm lead to tlie formation of new cells, which gradually assume the epithelioid character. These are rounded, polygonal, or cubical in form, and PULMONARY TUBERCULOSIS 301 present a clear oval vesicular nucleus. These changes are not Ihnited to the connective-tissue cells, but occur also in the epithelial elements of the part and the endothelial cells of the capillaries. Some of the cells undergoing proliferation contain one or more bacilli, but the majority are free from organisms. Subsequently leucocytes leave the neighbouring vessels and surround the epithelioid cells in gradually increasing numbers. The migratory cells of the body are of various kinds, and recent researches following those of Metschnikoff upon phagocytosis have thrown much light on their properties and functions, particularly with regard to their action upon micro-organisms and foreign bodies. The following varieties are recognised : ' Lymphocytes, or immature leucocytes, which resemble the elements of lymphoid tissue, and are non-phagocytic. Hyaline cells (macrophagocytes), containing a round or uniform nucleus and abundant non-granular protoplasm. These are actively amcebic and phagocytic, but are rare in blood (2 per cent.), though abundant in the body fluid. Coarsely granular oxyphile cells, with horseshoe-shaped nuclei, staining deeply with acid aniline dyes. These, like the last variety, are few in number in the blood, but are abundant in the body fluid, in serous cavities and areolar tissue spaces. They possess amceboid properties, but are non-phagocytic. Finely granular cells (microphagocytes), smaller than the last variety, poly- nuclear, staining with acid dyes. These are abundant in the blood, and are actively amceboid and phagocytic. This is the most common form of leucocyte and pus cell. Coarsely and finely granular cells, staining with basic dyes. The former are non-phagocytic and absent from human blood ; the latter are present in small numbers (1 to 5 per cent.). The hyaline cell is the only form of leucocyte which is believed to undergo the proliferative nuclear changes characteristic of karyokinesis. The mode of formation of the giant cells of tubercles is still a matter of controversy. According to Baumgarten and Weigert they result from the nuclear proliferation of a single epithelioid cell under the influence of an irritation which is insufficient to affect the cell protoplasm. By others the giant cells of tubercle are regarded as Plasmodia formed by the fusion of many smaller cells. Metschnikoff considers that both tlae epithelioid and giant cells are types of phagocytes, that is, of cells which engage in a struggle for mastery with the bacilli, and, when successful, destroy them by a process of intracellular digestion. In giant cells, as already stated, the nuclei are found at the periphery of the cell, either occupying its whole circumference, or grouped at one of the poles, leaving a considerable area of the cell free. The bacilli are generally seen either between the nuclei and the free area, or in the intervals between the nuclei ; they are only rarely present in the part of the cell which is void of nuclei. In tubercles which are undergoing caseous degeneration a similar arrangement of bacilli and nuclei is generally found ; ' Vide art. 'Inflammation,' by J. G. Adami, AUbutt's System of Medicine^ vol. i. p. 79. 302 THE DISEASES OF THE LUNGS both are absent from the caseous area, while at the periphery of the nodules, bacilli and nuclei are present in considerable numbers. The inference is that the bacilli which primarily occupied the central area have disappeared under the influence of a necrotic process which proved uiifavourable to their multiplication, and that at the periphery of a tubercle and of a giant cell where both nuclei and bacilli are present, the tissue is still in a living condition. According to this view, which is the one more generally accepted, a giant cell is to be regarded as a structure undergoing retrograde changes which are most advanced in the area void of bacilli and nuclei. The fact that this part of the cell no longer stains with carmine and the l)asic aniline dyes favours the correct- ness of this view of its nature. The view i\i?ii phacjocytoain constitutes the sole mode of defence of the body against the action of micro-organisms, which is not now held in its most al)Solute form even l)y its author, is l)eing gradually displaced by a theory which, while admitting the importance and correctness of Metschnikoff's observations, attributes the phenomena following upon microliic infection to the joint action of the leuco- cytes and the fluids of the body. The bactericidal and antitoxic action of the serum and blood plasma, which is far greater after the blood has been withdrawn from the body than while it is circulating within the vessels, is believed to be derived from the leucocytes, either by a process of excretion, or as a result of their destruction, and to constitute by itself an important aid to phagocytosis in protecting the Ijody from the injurious effects of micro-organisms. Subsequent changes in tubercles in the lungs.— 1. A tubercle may undergo caseation either before or after it has coalesced with neighbouring nodules. 2. It may undergo fibroid transformation, a process which is followed as a rule by the deposit of pigment. Fibrosis may affect only a few granulations, or by its extent may form a marked feature of a tubercular lesion. Which of these events happens depends to a great extent upon the resisting power of the tissues of the individual. If the resisting power is low, caseation occurs ; if on the other hand it is con- siderable, the tendency is towards fibrosis. If the infection of the lungs has occurred during a period of ill-health of a temporary nature, it is possible that when the normal resisting power of the body has returned, the tubercles, or groups of tubercles which have coalesced, may, if completely caseous, become encapsuled ; and if only caseous in part, or still of the miliary character, they may undergo fibroid transformation. The process of caseation. After a certain time the cells occupying the centre of a tubercle become swollen and iri-egular. They lose their outline, their nuclei disappear, the cells fuse together and form a structureless mass. This process is a form of necrosis — the coagulative necrosis of Cohnheim — and constitutes a step towards caseation. The cell elements, after the process of coagulation has occurred, PULMONARY TUBERCULOSIS 303 become condensed and undergo fatty degeneration. All traces of the structure of the tissue are lost, and the area becomes opaque and homogeneous and of a yellow colour and firm consistence, charac- ters which suggested its similarity to cheese. When a number of separate tubercular foci have undergone this change, a caseous area of variable extent is the result. Such a mass may then soften and be discharged through the bronchi, a cavity resulting, or it Fig. 85. — Tubeecle undergoing Caseation a, caseous central area ; 6, cellular peripheral area ; c, c, giant cells ; d, smaU-celled infiltration of surrounding alveolar walls and spaces ; e, pigment. may excite inflammatory changes around, which end in the forma- tion of a fibrous capsule. In such a condition it may remain for the life of the individual, or the capsule may rupture owing to changes in its neighbourhood, and the discharge of the still virulent caseous material may set up a widespread tuberculosis of the lungs. The writer has recorded a case in which the breaking down of an encapsuled caseous mass, which had probably existed for forty years, caused acute tuber- culosis of the lungs. A caseous mass corresponds to the crude or yellow tubercle of old writers. Caseous masses frequently become hardened by the deposit of 304 THE DISEASES OF THE LUNC.S lime salts, and in such a condition they may be expectorated or found in the lungs after death. Fibrosis. — The process of coagulative necrosis may proceed to a limited extent, but instead of the tubercle becoming caseous it may become transformed into a small, firm, fibroid nodule, still re- taining its normal outline. This change is produced by an over- growth of the connective tissue elements and the formation of fibroid tissue both within the tubercle and in the neighbouring structures. It is of far less common occurrence than caseation, and it implies a greater degree of resisting power on the part of the tissues. Tubercle bacilli may be present in small numbers in fibroid nodules ; but when the lesion is very chronic they can rarely be found. Fig. 80, — TiiBEi!C'r,E UN])EH(it>iN(i Finuosis Showing, a, periplicry, comiilctcl.v tibnms ; 6, centra,! urea, sliowiiifr ub-st'iice of coiniilete fibrosis ; r, r, remains of {riant cells ; J. K. F. 323 CHAPTEE XXIX PULMONAEY TUBEEGULOSIS {continued) PAfJE Pyrexia in miliary tuberculosis ....... 325 „ „ caseous „ ....... 327 Temperature in fibroid „ ....... 328 Pyrexia in chronic or fibro-caseous tuberculosis .... 329 PYEEXIA IN PULMONAEY TUBERCULOSIS Some years ago the writer ^ called attention to the fact that hy observation of the temperature in a case of pulmonary tuberculosis it is possible to determine the nature of the changes in progress in the lungs, and subsequent experience has confirmed the correctness of the views he then expressed. The miliary, caseous, and fibroid varieties of the disease are characterised in each case by a definite and distinct range of temperature, and this is present both in typical examples of those forms of the disease and also when, as frequently happens, they appear as temporary complications during the course of a case of chronic pulmonary tuberculosis. In order to render as clear as possible at the outset the features by which each variety of the disease may be recognised, we shall now consider the characters of the accompanying pyrexia. Before doing so, however, something may be said as to the daily range of temperature often met with in tubercular disease. Pyrexia com- mences or increases in the afternoon, often about 2 p.m. ; the temperature gradually rises, and attains its maximum between 6 and 10 p.m., the exact time varying in different cases. A. con- tinuous decline then occurs until 4 or 5 a.m., when in some cases the thermometer may register a temperature of one, two, or even three degrees below the normal. A temperature so low as 91 "6° F, has even been recorded. This fall is followed by a recovery of body heat, and at 10 or 11 a.m. the temperature may in such cases be normal. ' Practitioner, vol. li. No. 4. t2 324 THE DISEASES OF THE LUNGS This type of pyrexia is not, however, peculiar to tubercular disease, although it certainly occurs therein with especial frequency ; it is an exaggeration of the normal daily range of the body temperature. When the daily range of temperature in a case of pulmonary tuberculosis accompanied by rapid disintegration of the lung is marked by an extreme difference between the highest a.nd lowest points ('hectic type'), the fever is generally ascribed to septic infection. Koch has recently stated ' that a temperature over 100'4° in a case of pulmonary tuberculosis implies the presence of septic organisms, and contra-indicates the use of his new tuberculin product. Other writers also profess to be able in such cases to distinguish between the pyrexia due to specific and septic infection respectively, and base their classification of cases suitable for certain kinds of climatic treatment on the presence or absence of septic fever. It is clear therefore that this question of the cause of the fever in tuberculosis is one of great importance. The views which the writer has long held on this point are somewhat at variance with those just stated. When fever arises from ' septic infection ' the condition present is septicaemia, a disease accompanied by certain lesions — and particularly by enlargement of the spleen — which have not, so far as we are aware, been shown to occur in cases of pulmonary tubercu- losis characterised by pyrexia of this type. Pyrexia of this character may be observed in its most typical form in cases of tubercular pleurisy or peritonitis, where there is no evidence of septic infection. In a case of double pleurisy, almost certainly of tuberculous origin, under the care of the writer in the Middlesex Hospital, a ' hectic ' temperature persisted for nearly eleven weeks, suggesting at first the presence of an empy- ema, a suspicion which was twice negatived by the withdrawal of a clear serous fluid from the chest. The conclusions to which we have been led by a comparison of the temperature charts in fatal cases of the disease with the lesions found post mortem are, speaking generally, as follows : (1 ) The degree of fever present in cases of pulmonary tuberculosis is a measure of the activity of the morbid process. (2) Marked pyrexia is always associated with an increase in the tubercular lesions. (3) The action of the septic organisms present in the lung has little or no share in its production. (4) The occurrence of miliary, fibi-oid, and caseous lesions is indi- cated by distinct types of pyrexia. It is perhaps scarcely necessary to add that the subjects of tuberculosis are, like other individuals, liable to fever from various causes, and that the foregoing statements do not imply a belief that pyrexia in such cases is always due to an extension of the disease present in the lungs. ' Deutsch. mod. Wochaischr., April 1, 1807. PULMONARY TUBERCULOSIS 325 The pyrexia is most marked when the disease is making rapid progress in an organism still capable of reaction. This latter con- dition is essential, as in cases characterised by considerable failure of vital power, continuous extension of the disease, leading up to a fatal termination, is not uncommonly observed in association with an absence of pyrexia. PYEEXIA IN MILIARY TUBERCULOSIS Miliary tuberculosis of the lungs may, as already stated, occur as part of a general infection, or as a terminal event in a case of the chronic form of the disease. It is characterised by two distinct varieties of pyrexia, (a) the continuous and (h) the inverse. (a) The continuous type is represented in the accompanying chart from a case of chronic tuberculosis terminating with an acute January I Dsv oFMonth 6 7 8 9 10 M 12 13 14 15 16 17 18 19 so 104° 103° 102° 101° 100° 99° 98° / A A A A A /• K.A / \ A T v^ / \r ■J v ^' \l A A A h 4 \J V / A \A I V 9 Fig. 87. — Continuous Type of Pyrexia in Miliary Tuberculosis infiltration of miliary tubercles throughout the remaining unaffected portions of the lungs. When in a case of this kind an infiltration of miliary tubercle is in progress, the temperature usually, rises gradually for a few days and then continues high, with very slight morning remissions. In this case it ranged between 101° and 103°, but it may fluctuate at a still higher level. (b) The ' inverse ' type of temperature is characterised by the fact that the pyrexia attains its maximum in the morning instead of the evening. This may be met with in cases of pulmonary tuberculosis previously of the chronic variety, and also in cases of general acute tuberculosis, and may then be the only trustworthy sign of the nature of the disease. Eeference may be made to a case of the latter nature recorded by Dr. D. W. Finlay in vol. xxii. of the 'Transactions of the Clinical Society of London.' The accompanying chart (fig. 88) is taken from a case of chronic tuberculosis under the care of the writer in the Brompton Hospital, 326 THE DISEASES OF THE LUNGS in which the lungs, except in such parts as were not the site of old lesions, were found after death to be infiltrated with miliary tubercles, chiefly of recent formation. The temperature curve in this type of May 1 Dart IS 14 li 16 17 i« 19 20 21 22 23 24 25 26 27 28 23 30 Hour M E M £ M t Mf M t M t M E M E M E M E M E ME M E ME M E M E M t- M £ 104° W3° 10 e° 101° 10.0° s?° S8° \ I h i' \ ' ^ / \/ kJ \ 'K I SI K ^ ^ V y y V V \ J \ V 'n 1^ \ / V to V \ ; v I ki < \J / <: \ ^ u 1 I t Puhe 120 106 120 120 114 loe 108 100 IOC 108 106 /08 I0£ Re&p. 28 30 26 J9 2ft 29 26 28 36 28 30 Fig. 88.— Invebse Tyi'e of Pykexia in Miliary Tubekculosis pyrexia differs from that just described, not only in the reversal of the period of the day in which the maximum of fever occurs, but also in the occurrence of more marked remissions or of short inter- missions. Death may in such cases be preceded for some days by a fall of temperature, but the inverse type may still be maintained. Fio. 89. — Inveuse Type of Pyrexia in MilIjVRy Tuberculosis The accompanying chart (fig. 89) shows that this type of fever maybe produced by the evening rise of tenipei'ature being continued into the early hours of the morning (2 to a.m.). PULMONARY TUBERCULOSIS 327 The importance of the inverse type of temperature as a guide to prognosis is considered on page 38L PYEEXIA IN CASEOUS TUBERCULOSIS This variety of the disease is marked by a high remittent type of pyrexia, and in the most acute cases ahnost throughout their course. December \ Oa^oF Month / 2 3 4 5 6 7 8 8 fO II 12 13 14- (05° f04° (03° 102° 101° 100° 99° 9S° A X R f A V \h / \K h ^/^ i .A A K A / V V V Y J Y v Y r ir \/ Y • y X y 9 • Fig. 90. — Pyrexia in Caseous Tuberculosis The temperature ranges between 101° and 104° {vide fig. 90), the remissions being as a rule much more marked than in .cases of miliary tuberculosis. The following chart (fig. 91) is from a case which commenced with extremely acute symptoms ; and illustrates the type of pyrexia 104° 103° 102° 101° 100° 99° 98° A A ^. "S^ A 0^ J ^ V V \ / M> Ti \ r / V V ^ 7 / V ^ u Fig. 91. — Chart for the first fortnight from a case of Caseous Tuber- culosis, IN WHICH THE DISEASE SUBSEQUENTLY UNDERWENT ARREST at the onset of an attack of tuberculosis which afterwards assumed the caseous form. The disease, after a duration of about eighteen months, finally underwent arrest. 328 THE DISEASES OI'' THE LUNGS At a later stage, when cavities have formed in both upper lobes and active softening is in progress in the lower lobes, and vital power is diminishing, the fever tends to assume the intermittent July Fig. 92. — Pykexia in Caseous Tubkkculosis with failure of Vital Poweu type illustrated in fig. 92, a very marked rise in the evening to 102° or 103° F., or even higher, being followed by a fall in the early morning to 97° or 96° F. TEMPERATURE IN FIBROID TUBERCULOSIS This variety of the disease is characterised by a more or less complete absence of fever (vide fig. 98). Often for periods of June Day of Month 17 18 19 20 21 22 23 24 25 26 27 28 T. o 100 99" 98 97° M E M E M E M E M E M E M E M E M E M E M E M E 1 A A 'A '^ A A A A , -1 / V V A A / V y^ V N V r V vl v V y 1 i 1 1 Fifi. '.)'.i. CltAItT FltO.M A CASF OF FlimoiD TuiiERCULOSIS j)rolonged duration the temperature may not be above normal, and for several days in succession it may be subnormal. PULMONARY TUBERCULOSIS 329' In some cases a moderate evening rise, perhaps to 99'^ F., may be observed to occur occasionally. PYREXIA IN CHRONIC OR FIBKO-CASEOUS TUBERCULOSIS- The temperature present during the prolonged course of a case- of chronic tuberculosis is marked by great variety of range, and for long periods, during which the disease is quiescent or completely j|,rrested, fever may be absent. March Day of Month 8 9 10 11 12 13 14 15 16 17 18 19 T. 100° 99 08 97° M E M E M E M E M E M E M E M E M E M E M E M E i A \^ « A ^ 1 A y \/ V - A / \ / lA A A / ^ /■ y V V '^ Y \l \J V V / \ V / ^ V / \ v V ! 1 • Fig. 94. — Chart from a case of Chronic Tuberculosis, quiescent; Periods of activity are accompanied by pyrexia in which the fever assumes the characters already described as peculiar to the- various lesions. The changes in the lung Avhich immediately follow infection by the virus of tubercle and attend the formation of the initial October Fiu. 95. -Chart from a case of Chronic Tuberculosis, Infiltration AND Commencing Softening lesion are probably accompanied by pyrexia, but it is not possible to make any definite statement upon this point. It is very common indeed to meet with cases in an early stage of the disease presenting signs of infiltration limited to one .330 THE DISEASES OF THE LUNGS apex, or possibly also involving the lower lobe of the same lung, in which fever is absent. It is possible, however, that the disease is then in a condition of arrest. A sudden increase in the area of lung affected, or an accession of activity of the morbid process with- out the presence of definite signs of extension, is almost invariably marked by the occurrence of fever. As infiltration progresses and foci of softening make their appear- ance, about the apex or elsewhere, the temperature curve is apt to assume the form shown in fig. 95. The tuberculous type is main- tained, but the evening rise is still moderate (100"5° or 101° ¥.), and the morning fall is distinctly marked. It is often observed that with the formation of a well-defined cavity the pyrexia either subsides or disappears altogether. Such an event almost invariably marks the onset of a period of quiescence or complete arrest of the morbid process. Speaking generally, the temperature in chronic tuberculosis of the lungs is characterised by great regularity ; it may rise in the evening and fall in the morning almost to the same points for days or even weeks in succession, provided no marked change occurs m the activity of the morbid process. The remarkable regularity of the evening rise and morning fall is liable to be disturbed by a number of mischances, some one of which is almost sure to happen sooner or later in any given case. For example, when a sudden increase in the evening fever is associated with a less markedmorningremission, when on successive days the lowest point touched gradually recedes from the normal, and regularity is replaced by marked variability, we are rarely wrong in concluding that an extension of the morbid process has occurred. This may take the form of a rather rapid consolidation in the neighbourhood of the area of active change, but is more often due to a formation of miliary tubercle in parts of the lung hitherto unaffected. In attempting to determine from the character of the pyrexia the nature of the changes in progress in the lung, the ob- server is very likely to fall into error unless he is careful not to form an opinion without a knowledge of the morning and evening tem- peratures for at least a week. [In acute cases the temperature should be taken every four hours.] Even this period may be too short when the surroundings of the patient have been I'ecently changed ; for example, the temperature during the four or five days following the admission of a patient into a hospital may give indications which are quite unreliable. The temperature chart and the record of the patient's weight should always be considered together. If a low temperature or a diminution of fever is accompanied by a gain of weight, it is almost certain that the morbid process is at any rate inactive, and it may be in arrest. The significance of a low temperature which is accompanied by a loss of weight may be quite different. J. K. F. 331 CHAPTEE XXX PULMONARY TUBERCULOSIS {coritinued) MILIARY TUBERCULOSIS OF THE LUNGS Etiology Morbid anatomy Symptoms . Physical signs Diagnosis Prognosis Treatment . PAGE 331 332 333 334 334 335 335 Etiology. — It was first pointed out by Buhl that in the majority of cases of acute generahsed tuberculosis, if careful search be made, a softening caseous mass will be discovered in some organ or tissue of the body. This was found in twenty-one out of twenty- three cases of the kind recorded by him. When the lungs are specially affected, it is generally a tubercular lesion which has broken down and discharged its virulent contents into a blood- vessel which, as pointed out by Weigert, is often a branch of the pulmonary vein ; sometimes a caseous tracheal or bronchial gland is the source of infection. Keference has already been made to the fact that many cases of chronic pulmonary tuberculosis terminate with an acute formation of miliary tubercle in the parts of the lungs hitherto free from disease. The statistics of the writer,' and of Heitler,- giving the cause of death in cases presenting obsolete tubercular lesions of the lungs, show that in these cases also death often occurs from acute tuber- culosis, and that these obsolete lesions are the source of infection. The risk of such an occurrence is very great when a caseous mass is present ; it is decidedly less when tubercle has undergone fibroid transformation. ' Arrested Pulmonary Tiiberculosis, p. 10. 2 Wie7ier Klinik, 1879, p. 209. 332 THE DISEASES OF THE LUNGS 111 a case recorded by the writer,' a caseous mass at the apex of the left lung, which had probably been encapsuled for forty years, broke down and caused death from acute pulmonary tuberculosis in twenty-eight days. There was an exactly similar mass firmly encapsuled at the apex of the right lung. In some cases, however, no obvious source of infection is dis- covered post mortem. In a considerable proportion of these the disease has followed upon some acute fever, such as measles or whooping cough, and more rarely typhoid fever. It is possible that in such cases either a general lack of resisting power may have been induced by the pre%'ious disease, or the lungs may have been ren- dered specially susceptible by the associated catarrh or broncho- pneumonia. Miliary tuberculosis of the lungs is common in young children, and the lesions are then widely disseminated. It may, however, occur at any age, but is comparatively rare after 50. Of twenty-five cases observed at the Middlesex Hospital from 1884 to 1890 nineteen occurred in males and six in females ; this preponderance of the male sex is in accord with general experience. In the above series an old caseous mass in the lungs was the source of infection in nine cases, a chronic cavity was present in five, an 'unresolved pneumonia infected by tubercle ' in one, and in one case ' old i)ig- mented scars ' at the apex were the only obsolete tubercular lesions found. In one case in a child aged 5 years a caseous bronchial gland appeared to have been the primary focus ; two were probably secondary to tubercular pleurisy, and in three infection spread from the lungs, but no old lesions were found there ; in three no source oE infection was discovered. In nineteen cases therefore out of the twenty-five the lungs were the original seat of the disease. Morbid anatomy.— Mihary tubercles are usually found in great numbers throughout the lungs, and the appearance of the granulations is always suggestive of a recent formation. In children they are commonly of the grey, semitransparent character, varying in size from a pin's head to a pin's point, and may show no sign of caseation. When the disease is secondary to chronic tuberculosis of the lungs in adults, some granulations may be of this nature, whilst others are rather less sharply defined and tend to run into groups, and although obviously of quite recent formation they are already beginning to caseate. In such cases they are always present in greatest number in the neighbourhood of the primary lesion, and gradually diminish in number towards the bases of the lungs. In children they are as a rule discrete, uniformly and thickly scattered throughout the organs, and the same appearances are observed in adults with miliary tuberculosis when many organs are affected. The lungs are often large and intensely hypericmic ; the bronchi are inflamed and the bronchial glands enlarged, and generally in process of caseation. In many cases the pleura is extensively infil- ' Proceedings of (lie Mvd.-Chir. Soc, series iii. vol. viii. p. 48. PULMONARY TUBERCULOSIS 333 trated with discrete miliary granulations. If the cerebral meninges are involved the infiltration may be widespread and present the ordinary appearances of tubercular meningitis, or death may occur when only a few very fine granulations have formed around the circle of Willis and at the inner extremity of the Sylvian fissure. In cases of generalised miliary tuberculosis the infiltration of the peritoneum may be extensive, but it is often limited to the under surface of the diaphragm, where a number of fine granulations may be found. They usually caseate very rapidly in this situation. Symptoms. — The onset may be either gradual or somewhat sudden, the former being the more common. The symptoms are those which usually attend an acute febrile illness, such as malaise, loss of appetite, headache and depression, but an initial rigor is rarely observed. The skin is generally moist and there may be free perspiration. An attack of haemoptysis may mark the onset of the acute illness when an old tubercular lesion is present in the lungs. In a child aged 3 years who died suddenly from profuse hfemoptysis, the writer found post mortem, in addition to a discrete miliary tuberculosis of the hmgs, a recent caseous patch the size of a hazel nut at the anterior margin of the right lower lobe.. This had softened in the centre, and the small cavity thus formed contained an aneurysm, the rupture of which was the cause of the haemo- ptysis. The pulmonary symptoms vary with the nature of the case. If the infiltration of the lungs is part of a general acute tuberculosis they may be but slightly marked and only suggestive of a moderately severe bronchial catarrh. Cough is usually present ; it may be hack- ing and dry or accompanied by clear mucoid expectoration. When the lungs are primarily or chiefly affected, cough is more severe and of the same character. Expectoration may be completely absent throughout the illness ; if present, it may be mucoid or muco- purulent or streaked with blood ; it is said occasionally to have the ' rusty ' character of pneumonia, but this must be rare. Dyspnoea is observed almost from the first, and as the case progresses the respirations become extraordinarily rapid, perhaps fifty or sixty per minute in an adult, and as many as eighty or even more in a child. Cyanosis is a very important symptom of the disease ; it appears as soon as the extent of lung affected is considerable, and gradually increases with the progress of the infiltration. It is most marked in the lips and the tips of the fingers, whilst the cheeks are flushed or of a slightly cyanotic tint. Pyrexia is always present in the pulmonary type of the aflection , although it may be absent or but slightly marked in general tuber- culosis if the patient is extremely debilitated. The characters of the pyrexia have already been described {vide p. 325). The pulse is feeble and extremely rapid. The spleen is gene- rally enlarged, and if infiltrated it may be tender. Albuminuria may be present. 334 THE DISEASES OF THE LUNGS When, towards the end, the disease becomes widespread, the patient may fall into the so-called 'typhoid' condition, with dry brown tongue, low muttering delirium, and subsultus. Physical signs. — If there is an old and well-marked pul- monary lesion it will be recognised by the ordinary signs ; but in cases of arrested tuberculosis with a limited area of disease, close attention should be paid to signs observed on inspection and palpation of the upper part of the chest. A very slight defect in the expansion at one apex and a slight increase in the vocal fremitus beneath the clavicle may be the only signs indicating the presence of an old lesion. Owing to the small size of the granulations and the way in which they are scattered through the lungs, the resonance of the percussion note may be normal or it may be only slightly impaired, or the note may be hyper-resonant from the over-distended state of the lungs. Alterations in the note observed from day to day have been attri- buted to local collapse, followed by re-expansion (Eustace Smith). On auscultation the respiratory sounds may be harsh and expiration prolonged, and fine rales may be heard, possibly only after cough. These are at first usually bubbling or faintly crackling in character, and may be accompanied by sibilant rhonchi. As the case progresses the rales may acquire a more decidedly crackling or crepitant character. When miliary infiltration occurs as the terminal event in a case of chronic tuberculosis, there may be few signs, if any, in the previously unaffected portions of the lungs to indicate that a- rapid formation of tubercle is in progress there. The marked discrepancy between the physical signs and the general condition of the patient, and the presence of cyanosis and of the characteristic temperature, are then the most important guides to a correct diagnosis of the disease. Diagnosis. — The ordinary proof of the existence of a tuber- cular lesion of the lungs — viz. the discovery in the sputa of tubercle bacilli -often fails in these cases. There may indeed be no ex- pectoration to examine, and, if there is, it often does not contain bacilli, owing to the fact that the tubercular nodules are in process of formation, and not of softening and discharge. The examination should, however, always be made and be frequently repeated. Miliar'y tul)orculosis limited to the lungs does not, like acute general tuberculosis, simulate ti/phoid fever, as extreme rapidity of breathing and cyanosis and marked emaciation are not present at an early stage of typhoid fever, when the difficulty of diagnosis is greatest. A (Ustinguishing feature between acute tuberculosis and typhoid fever is that in the former disease the course of tlie temperature is less regular than in the latter, and it may be of the inverse type ; also in acute tuberculosis the temperature may fall to the normal or below it in the morning. This applies to cases of general acute tuberculosis, but is not observed when miliary tuberculosis PULMONARY TUBERCULOSIS 335., of the lungs supervenes upon chronic puhiionary tuberculosis. The blood serum test may be, if conducted by a competent observer, a reliable method of distinguishing between typhoid fever and tuberculosis. A positive reaction is pathognomonic of typhoid, but a negative reaction, especially in the first few days of the disease, does not exclude that diagnosis. The urine should also be examined to see whether Ehrlich's reaction can be obtained. The previous existence of pulmonary symptoms or of tubercular disease of glands, bone, or joints, or of the epididymis or testes, often suggests the true nature of the case, and the family history of the patient may also aid the diagnosis. If the cerebral meninges or the choroid become involved in the spread of the disease, any doubt which may still remain as to the diagnosis usually disappears. In acute hronchitis of the smaller tubes the general aspect of the case is not unlike that of miliary tuberculosis, and if catarrhal pneumonia and acute dilatation of the bronchi are also present, the physical signs may suggest that softening of a tubercular deposit is in progress throughout the lungs. But in the form of disease under consideration the miliary tubercles do not as a rule break down, and this fact alone should prevent error. There may, however, be a limited degree of softening at one apex. Prognosis. — It has been suggested that miliary tuberculosis of the lungs may undergo arrest, but if this ever happens after extensive infiltration has occurred, it must be an event of extremely rare occurrence. In the course of a considerable pathological experience the writer has never observed appearances indicating such a condition, and the recorded cases are far from conclusive. The disease generally ends fatally in from ten days to about three weeks, but life may be prolonged for three months, or even for a longer period. Treatment. — The indications are to maintain the strength of the patient by rest and the administration of an abundant or of what may even apppear to be an excessive quantity of food, which should chiefly consist of milk and eggs, and to relieve those sym- ptoms which cause the most suffering. We may be allowed to hope that, as a result of bacteriological research, a remedy will be found which will arrest the disease at the outset ; unfortunately^ at present we know of none. J. K. F. 336 THE DISEASES OF THE LUNGS CHAPTEK XXXI PULMONARY TUBERCULOSIS {(■() tit i lined) CASEOUS TUBERCULOSTS OF THE LUNGS PAGE P^tiology 33fi Morbid anatomy .......... 337 Symptoms .......•.•- 339 Physical signs 339 Course 340 Diagnosis ........... 340 Prognosis ........... 341 Treatment 341 In this variety of the disease the lesions may be widely scattered throughout the lung, the disseminated or hroncho-imeumonic type ; or involve only a single lobe, the lobar type. Etiology. — The disseminated form is more common than the lobar, but the two together constitute only a very small percentage of the total cases of tubercular disease of the lungs. The proportion has been variously estimated at from 2-0 to 19 per cent. Of the cases analysed by the writer, which, however, did not include any children, the percentage was 2-4. Cases of the lobar variety are extremely rare. The disseminated form is most common in children and young adults, especially females, with a marked hereditary predisposition to tuberculosis ; but it may occur in persons who had previously enjoyed good health, but had recently suffered from overwork or anxiety. Children are often infected during convalescence from an acute disease, such as measles or whooping cough. The lobar form is more often met with in adults than children. The disease usually occurs as a primary pulmonary affection, but it may be secondary to a chronic tuberculosis of the lungs. We have never observed it as a sequel of the complete arrest of tuberculosis, but its occurrence under such circumstances is de- scribed. It is, however, certainly not nearly so commonly met with then as }niliary infiltration. PULMONAR\' l^UBERCULOSIS 337 Morbid anatomy. — In the disseminated variety the process, 'which is from the outset not only tubercular but also acutely in- flammatory in character, commences in the bronchioles; thence it quickly spreads to the alveoli, thus presenting a distinctly broncho- pneumonic type. It was possible, previous to the discovery of the tubercle bacillus, to hold with Niemeyer that the inflammatory lesions present in the lungs in ' phthisis ' are primary and of the first importance, and that they may lead to destruction of the organs without the aid of any specific virus ; but this view is no longer tenable. A cellular exudation, consisting in part of • epithelial cells and in part of more distinctly tubercular products, fills both bronchi and alveoli, and undergoes a rapid caseous aiecrosis. In the early stage it appears to the naked eye as greyish- red foci ; these enlarge, and coalesce with neighbouring areas to ■form masses of varying size. The obliteration of the vessels as the ■ exudation increases gives a dull white colour to the consolidated , areas, and when caseation is complete they present the typical yellow cheesy appearance. The lobular outline is for some time preserved, and even when the lesion is diffused over a large surface, , air-containing tissue, usually much injected, occupies the spaces between neighbouring masses, or the intervening lung may be in a ■ condition resembling red hepatisation. The caseous masses present a finely granular surface, and are • either dry and friable or of a moderately firm consistence. Lesions • of this nature may be irregularly scattered throughout one or both lungs almost from apex to base. Smaller nodules in the form of numerous soft white opaque, grey or caseous tubercles are also present. Softening may be in progress at numerous points, or ■ extensive cavities may have formed ; both changes are usually most advanced at the apices, but single small cavities may be found both there and in the lower lobes, and may present a fairly well-defined • outline after the complete softening or the discharge of their caseous • contents. In some less acute cases the consolidated areas present in part a grey or reddish-grey or gelatinous appearance. When excavation has occurred, the bronchi may be dilated and ■ open directly into the cavities. Recent pleural adhesions may be 1 present, or there may be evidence of acute inflammation of the pleura, or the membrane may be studded with miliary tubercles. The microscopical cq^pearances present in such cases are various. The alveoli are seen in places to be filled with epithelial cells and with small-celled growth from the walls. The latter and the septa : are thickened from a similar infiltration, which causes a narrowing of the lumen of the alveolus. The capillaries are obliterated at an • early stage of the process. Where the process is more advanced : all traces of cell structure have disappeared, and only an amorphous or finely fibrillated granular caseous debris is present. A small- > celled growth is abundant around the bronchioles and in their walls, and also around the vessels. Elsewhere a similar in- ; filtration is found, either in agglomerated masses or difl'used ..throughout a considerable tract of tissue. The smaller bronchi 338 THE DISEASES OF THE LUNGS may be filled with dried secretion. Giant cells may be found, and tubercle bacilli are usually present in considerable numbers. The effect of a widespread infiltration of tubercle accompanied by inflammatory chan<;es in the intervening parts of the lung,. when the process is somewhat less acute than that just described,. is to produce an area of consolidation of a more or less uniform grey colour. It is at first soft and presents a slightly granular surface and breaks down easily on pressure, but at a later period it becomes firmer in texture, and has a glistening or gelatinous appearance on section. The stage of grey infiltration is probably preceded by one to which the term ' red infiltration ' has been applied, in which the lung still contains blood and is more granular and opaque on section and of softer texture, as in some cases tissue presenting this appearance may be seen to merge into an area of grey in- filtration. The stage of grey infiltration may be followed by caseation, which usually commences at numerous well-defined foci in an area of infiltration, the size of the caseous nodules varying from that of a pin's head or a pea to that of a walnut. Softening of the in- filtrated areas very rarely occurs without the previous appearance of caseation. In the lobar variety of the disease the appearances presented post mortem are far from uniform, but they vai'y less widely than in any other type of the disease. The lesion may be limited to a single lobe, or more rarely almost the whole of one lung may be involved. The consolidation is seen to be as complete as in a case of pneumonia. On section the aft'ected area is caseous throughout, yellow or yellowish white or greyish white in colour, dry and airless. The surface is smooth and cheese-like or finely granular. No tubercular foci are visible as a rule, the change being uniform over the affected part. In other cases softening may be in progress at the apex, for the upper lobes are most often affected, and a cavity may have formed. The margin is ragged, and there are no signs of limitation of the destructive process, such as are afforded by the presence of a distinct wall ; the contents of the cavity consist of puriform debris. In other cases the section presents a greyish-white appearance, is less firm in consistence, and more granular on section. The evidence of the tubercular nature of the change is then more obvious, aggre- gated masses of granulations in part constituting the consolidated areas. The appearances as a whole are then less uniform, caseous areas being in places l)ordered by consolidated tissue which is hypera^mic. If the change occurs in an emphysematous lung, the surface of the section may present a worm-eaten appearance. The pleura over the affected areas is generally inflamed, and may be covered with pah; adherent exudation. Necrosis of the pleura followed by perforation and pneumothorax is especially likely to occur in this variety of the disease. The bronchial glands are enlarged, and often caseous. PULMONARY TUBERCULOSIS 339 Secondary tubercular lesions may be present in the larynx, trachea, and intestines. In some cases the true nature of the changes found in the lungs is not obvious until the whole of the organs have been examined, when typical tubercular lesions are discovered elsewhere. Symptoms. — The onset may be sudden or more or less insidious. In the former event there may be repeated rigors, in the latter languor, anorexia, pains in the limbs, cough, slight pyrexia, and progressive loss of strength may precede its complete development. In some cases haemoptysis is the first symptom noticed. In nearly all cases after a short time the general symptoms become well marked, there is high fever, rapid emaciation, a hectic flush on the cheeks, burning heat of the skin, night sweats, chills, and evidence that disease is rapidly extending throughout the lungs. The expectoration is at first mucoid and may be blood-stained, but soon becomes mucopurulent or puriform, and has been observed in some cases to present a greenish tint. In a very acute case recently under the observation of the writer, it w^as of a bright lemon-yellow colour. Tubercle bacilli are almost invariably present, and in con- siderable numbers. The pulse is extremely rapid, and respiration is as a rule markedly quickened, the ratio being very often three or even four to one. The character of the pyrexia has already been described {vide p. 327). In the lobar form of the disease the onset of the acute illness may have been preceded by a period of impaired health, and the clinical history of the patient may indicate a tendency to pulmonary disease ; but in many cases the previous health has been good, and there may be no evidence of tubercular disease in the family. The patient, possibly after exposure to a chill, is suddenly seized with a severe rigor followed by pain in the side, the attack in this, as in other respects, resembling one of pneumonia ; there is high fever, cough, urgent dyspnoea, and rusty expectoration, and for a week or ten days the true nature of the disease is likely to remain un- suspected. Physical signs.- — These usually appear first at the apices, loss of resonance on percussion being accompanied by crepitation. In the case just referred to, in which the sputa were of a lemon tint, the signs of consolidation were first observed just external to the left nipple, and from there the disease spread rapidly over the lower lobe and to the opposite lung. Very often the first signs are difluse rales over both lungs, at first bubbling in character, but rapidly becoming of a crackling or metallic quahty. The breath sounds may be bronchial, but typical tubular breathing is not often heard. This is due, no doubt, to the bronchi of the consolidated areas being tilled with exudation. Broncho- phony is commonly present. The formation of cavities is attended by the usual signs. A pleural friction sound is often present, and may be followed by signs indicatmg that effusion has occurred. In the lobar variety the physical signs are those of pneumonia — viz. dulness on percussion, with crepitation and tubular breathing. 340 THE DISEASES OF THE EUNC^S Nothing, indeed, may be wanting to justify a diagnosis of pneumonia, and cases are almost invariably for a time regarded as of that nature, no doubt arising until the period has elapsed during which a crisis generally occurs. The absence of the crisis, a more rapid pulse, sweating, and an unusual degree of emaciation then suggest an examination of the sputa for tubercle bacilli, and their discovery reveals the real nature of the disease. J3acilli may, however, be absent for a time, and may only be found after repeated examination, and when the sputa have assumed a mucopurulent character. Course. — The disease is characterised by a rapid course, a fatal termination ha\'ing been observed in so short a time as a fortnight. This is, however, quite exceptional, the ordinary duration of an acute case of the broncho-pneumonic type being from two to three months. A remission of the acute symptoms may, how- ever, occur after a variable period, and the case may assume a subacute or chronic character. This is occasionally observed to occur in children after an acute illness lasting from a fortnight to three weeks. Death may be due to rapidly increasing prostration and emacia- tion, or, as is frequently the case, to the occurrence of pneumo- thorax, the pleura over the central portion of a caseous j)atch iilcerating before adhesions have had time to form. An attack of hfemoptysis may also be the immediate cause of death, but hemorrhage is not common in this variety of the disease. Gangrene of the lungs is met with occasionally, and quickly proves fatal. The course of the disease in cases of the lobar type is often still more rapid. A fatal termination may occur in so short a time as a fortnight, while the longest duration is rarely more than three or four months. The lung may be found still solid post mortem, or softening may have occurred, usually at the apex, where cavities are in course of formation. Diagnosis. — In all cases of pulmonary disease, no matter how innocent their seeming character, the sputa should be examined for tubercle bacilli. If this rule be observed, a correct diagnosis will generally be made in cases of caseous tuberculosis. The discovery of elastic tissue in the sputa is a sign that the lung is breaking down. In children, however, these tests may not be applicable, because the expectoration is usually swallowed, and in such patients a diagnosis of broncho-pneumonia is not uncommonly only disproved by a ))ost-mortem examination. The fact, however, that diffuse ])roncho-pneumonia attended by acute dilatation of the bi-onchi may give rise to physical signs for a time indistinguishable from those of disseminated caseous tuberculosis suggests caution in giving an unfavourable opinion. When there are unmistakable signs that the lung is breaking down, and tubercle bacilli are present in the sputum, the real nature of the case becomes clear, and in doubtful cases it is well to wait for their appearance before committing oneself. PULMONARN' TUBERCULOSIS 341 It will be apparent from the description of the lobar form of the afiection, that pneumonia is the disease for which it is most likely to be mistaken, and in the early stages the error is not only pardonable, it may even be said to be necessary, and, provided the true character of the disease is recognised as soon as the evidence is clear, no harm is done. These cases are of very rare occurrence, and any one who feared that every case of ordinary pneumonia he observed might prove to be of this nature would by his unusual alertness probably do more harm than good. • , Prognosis. — It follows from the description of the disease that this is in all cases unfavourable. It is, however, not quite so grave in the broncho-pneumonic as in the lobar form. In the less acute cases it may fairly be hoped that the disease may pass into a subacute or chronic stage. Treatment. — It is of the first importance to maintain the strength of the patient, as the only hope of an abatement in the severity of the symptoms lies in the recovery of a resisting power which may have been lost through temporary causes. There may be some chance of this if appetite is retained, as it sometimes is, but very little otherwise. Complete rest in bed is essential, the air of the room being kept as fresh as possible. Not only abundance l)ut what might be considered an excess of nourishing food should l)e given, chiefly in a liquid form, the only limit to the quantity being the ability of the organs of digestion to deal with it satis- factorily. No drugs should be administered which are at all likely to produce nausea or impair digestion. All lowering remedies are to be avoided, particularly those of this character so often given to diminish the pyrexia, then- effects being in the writer's experience distinctly harmful. The temperature certainly falls, but no effect is produced upon the course of the disease, and when they are omitted there is an immediate return of the fever. Sponging the body with water at a temperature of 85° F. is often decidedly refreshing to the patient ; it lowers the temperature and exercises a general tonic effect. It should be done in the afternoon or evening, when the fever is at its highest point. Toilet vinegar or eau-de-Cologne may be added to the water with advantage. A saline effervescing mixture containing two grains of quinine may with advantage be given every three or four hours. Food should be given at intervals of about two hours, and should consist of milk, jelly, beef tea, meat essence, and chicken broth. Stimulants, of which old brandy is probal^ly the best, may be needed in con- siderable quantity. The detailed consideration of much of this part of the subject may conveniently be deferred to the chapter on Chronic Pulmonary Tuberculosis {ride p. 404, Treatment of Pyrexia). ■J. K. F. 342 THE I)ISEASP:S OF THE LUNGS CHAPTER XXXII PULMONAEY TUBEECULOSIS {coutinuerl) FIBEOID TUBERCULOSIS OF THE LUNGS I'AUE Etiology 342 Morbid anatomy 342 Symptoms and course ......... 344 I Physical signs .......... 344 Diagnosis ........... 345 I'rognosis ........... 345 Treatment 345 Etiology. — The subjects of this form of the disease are often of good muscular development, and possess a resisting power which is greater than is met with in any other. This is shown by the tendency of the disease to undergo arrest, its slow course, the fibrous transformation of the tuberculous products, the few bacilli present in the lesions and in the sputa, and by the rare occurrence of infiltration generalised throughout the body. Men are more often affected than women, and the period of onset is later than in the chronic variety. There is often no family predisposition to tuberculosis, but in one of the most marked examples Icnown to the writer several brothers had suffered from tuberculous disease. The tendency to fibrosis is increased in those individuals whose lungs have been rendered vulnerable by inhaling irritating particles of dust ; the affection is therefore connnon amongst workers in various trades — c.fj. knife-grinders. Morbid anatomy. — The apex of the lung, as in other forms, is the site of the primary lesion. The typical fibroid lesions consist [a) of isolated granulations which are indurated and deeply pigmented, [h) of groups of such granulations having a racemose arrangement, and [c) of areas of induration either rounded or irregular in outlines, at the margins of which fibrous granulations are present. The central part of such areas is of a coal black colour, of a fibroid or cartilaginous density, and shows no trace of PULMONARY TUBERC:ULOSIS 345 the presence of granulations, the section being smooth and homo- geneous. The disease begins, as in the caseous form, in the finer bronchi, but its extension is more toward the peribronchial tissue than toward the alveoli. The primary lesion consists of tubercles which present the structure typical of such bodies, but instead of under- going caseation and softening they retain their rounded outline and become transformed into firm, fibrous, deeply pigmented bodies, which look and feel like shot embedded in the tissue of the lung. On microscopical examination the bronchus is seen to be filled with round and epithelial cells and the bronchial wall to be thickened from small-celled infiltration. Tubercles are present both in the wall of the bronchus and in the peribronchial tissue. The inflammatory changes in the alveoli are much less marked than in the caseous form. The larger areas of induration are in some cases formed by the ■ coalescence of granulations presenting a racemose arrangement, which extend by the formation of tubercle at their margins, and, as they increase in size, undergo transformation into pigmented fibrous tissue in the centre. To these racemose masses the name of " Carswell's grapes ' has been given. Fibrous thickening of the interlobular comiective tissue is. generally present, and may lead to the formation of bands which either unite the more densely indurated areas, or are so thickly set as to form tracts of fibroid tissue having a netlike structure. Racemose tubercles may also be present at the margins of these areas. In some cases areas of grey infiltration may be seen undergoing -a fibroid transformation. In lungs presenting these appearances small caseous or cal- ■careous masses may be found, but they are by no means constant. They are in some cases due to caseous change in tubercles, in vothers to the inspissation of the contents of the bronchi. A single -cavity or several of small size may be found at the apices or else- ^vhere ; they are usually smooth- walled and surrounded by in- >durated tissue. Their presence is by no means constant, and possibly indicates that the primary disease was of the ordinary ■chronic type, the fibroid change taking place wdth a return of resisting power in the individual. Except in cases of this kind the Ijronchi are rarely found dilated. The contraction of the fibrous areas is generally accompanied by ■emphysema of the surrounding tissue. If the. lesion is near the ^surface there may be adhesions, with scarring and puckering of the pleura, and large bullae may project from the surface of the lung. But the extreme thickening of the pleura which is so commonly found in cases of chronic tuberculosis is rarely if ever present in these cases. A few bacilh may be found in the more recent lesions, but they Lsare absent from the dense pigmented areas, and can rarely be -discovered in arrested fibrous lesions at the apices. 344 'J'HE DISEASES OF THE LUNGS Symptoms and course. — The onset is never acute, and in' some cases, after a moderate area of the apex of one Inng has- become involved, the process may undergo arrest, and there may be an entire absence of all symptoms from that date. If, indeed,, one may trust to the clinical history given by many patients found after death to have arrested lesions at one or both apices, the- symptoms could not at the time of the formation of the deposits- have been very marked, as there is rarely any reference to a previous pulmonary affection. Cough, with loss of weight and. strength, and probably a moderate degree of pyrexia, are the only symptoms likely to have been present. As the fibrous area increases in size and more of the sur- rounding lung becomes emphysematous, the patient suffers from dyspnoea, becomes more subject to catarrh and wheezing, and may have attacks of ' bronchial asthma.' In some cases, however,, there is not the slightest tendency to catarrhal affections. In delicate-looking individuals, the subjects of emphysema and liable - to attacks of bronchial asthma, the existence of an arrested or slowly extending fibroid tuberculosis of the lungs should always be suspected. Hiemoptysis in the early stages is very common ; it may be profuse and frequently recur, but recovery (quickly follows each attack, and there may be no physical signs indicating that the disease in the lungs has extended. The typical apyrexial course of the disease has been already described. It may be interrupted by short periods during which fever is present ; but the rise of temperature is, as a rule, only moderate, and there may indeed be complete absence of fever with an extension of the disease. The temperature is often subnormal in the morning. The cough is rarely very severe, except when associated with catarrh and emphysema, when it chiefly occurs in the morning. It has not the paroxysmal character and the tendency to produce vomiting, which are connnon in chronic tuberculosis with marked retraction of the chest, thickening of the pleura, and excavation of the lung (' fibroid phthisis '). The disease rarely extends to the larynx, and there is an absence of night sweats and diarrhoea. There may be little or no expectoration, and the sputa may be free from bacilli for long periods. In a case under the care of the writer bacilli were only found after repeated examinations extending over two months, and on subsc([uent re- admission to hospital after an interval of nearly a year, during Avhicli: the disease had apparently remained quiescent, none were found. In advanced cases the extensive area of the lungs involved iai often in striking contrast with the apparent well-being of the; patient, the appetite being good and emaciation but little marked. If there is a considerable degree of emphysema, epigastric pulsation and other signs of that condition will be present, and the i^eneral aspect of the patient and the alterations in the shape of the thorax will bo such as accompany that disease. Physical signs. — Some retraction of the supra and infra.- PULMONARY TUBERCULOSIS 345 clavicular regions of one side with impaired expansion may be observed, but if emphysema has developed around a contracted lesion retraction may not be noticeable. The condition of the vocal fremitus and resonance will depend upon the extent of the induration and its nearness to the surface of the lung, and also upon the presence or absence of emphysema of the intervening pulmonary tissue. There may be slightly defective resonance on percussion, or the note may indicate the presence of emphysema.- The breath sounds are usually weak and expiration is prolonged. Fine crackling rales, sometimes only audible with cough and accompanied by signs of catarrh, are the common adventitious sounds. The niles may be widely distributed, and, as in the chronic form of the disease, the lesions tend to spread from the apex of the upper to that of the lower lobe, and thence towards tlie base. The presence of a cavity, if it be of sufficient size, will be indicated by the ordinary signs ; such cavities are usually dry. Diagnosis. — The existence of the tubercular lesion may be- masked by the signs of emphysema and bronchitis, but a careful examination of the apices and particularly of the supra-spinous foss^- will generally lead to its recognition. The fact also that the signs are more marked over the upper lobes than at the bases should always excite suspicion. Repeated examination of the sputa should be made for tubercle bacilli ; if this is done, a few will generally be found at some period of the disease. It is often, however, impossible to be certain of the presence of an arrested fibroid lesion occupying only a small area and surrounded by emphysematous lung. Prognosis. — The recognition of this type of the disease is of great importance from the point of view of prognosis, owing to the fact that fibroid tuberculosis tends more than any other variety to undergo arrest, or failing that to run a very prolonged course. Complete and permanent arrest, however, rarely occurs when extensive areas of the lung have undergone induration ; the progress is slow and may be interrupted by periods of quiescence, but, as a rule, the patient dies of some pulmonary affection. The treatment of cases of this type does not differ from that suitable in the chi'onic form of the disease {vide p. 385 seq.). J. K. F, 346 THE DISEASES OF THE LUNGS CHAPTER XXXIII PULMONARY TUBEECULOSIS {continued) CHEONIC OE FIBEO-CASEOUS PULMONAEY TUBEECULOSIS Morbid anatomy ..... Classification of cavities Site and progress of the lesions . Upper lobe ..... Middle „ Lower ...... Crossed lesions .... Basic „ .... Lesions associated with pulmonary tuberculosis . PAGE 346 348 350 350 352 352 355 356 358 Morbid anatomy. — In this form of the disease the appear- ances present an almost infinite variety, but cavities are rarely absent. These, with the j)nmary lesions and the secondary changes which they subseqiiently undergo, together constitute its morbid anatomy, the presence of miliary granulations and areas of caseation indicating that the chronic course of the disease has been marked by periods during which the morbid process has been active. Such a period of activity often immediately precedes the death of the patient, and during its continuance miliary tubercles in great numbers may be formed in the parts of the lungs hitherto unaffected. The chronic nature of the process is revealed by induration of the granulations, in extensive tracts of consolidation, and in the walls of the cavities. Tlie more prolonged the duration of the case, the greater is the amount of fibroid change produced. The miliary, caseous, and fibroid lesions liave already been described in considering the varieties of the disease in which they severally predominate. Their mode of combination, and the secondary changes which they undergo, and also the lesions which are more or less special to this form of the disease, will now be described. PULMONARY TUBERCULOSIS 347 Granulations and nodules. Miliary granulations tend .-as a result of age to undergo fibrosis and pigmentation, and caseous nodules to become firm, dry, and granular. Caseous nodules which have coalesced are often seen to be surrounded by a zone of dense pigmented tissue, from which fibrous strife penetrate towards the centre. Sometimes the caseous areas are limited by tracts of semi- transparent indurated lung or a well-defined fibrous capsule. Caseous nodules may, from the deposit of lime salts, become calcareous, and in such a condition are often found encapsuled. The destruction of the capsule owing to recrudescence of the disease in the neighbourhood may lead to the escape of such masses into a bronchus, and their appearance in the expectoration. The pigmented racemose nodules found in the fibroid variety ■ of the disease are often present, and from their margins fibrous bands may be seen extending into the tissue around. Infiltrations and indurations. — When a large number of tubercles are present in a given area they may, as in cases of miliary tuberculosis, remain discrete, and be separated by lung tissue which is in a more or less normal condition, but in the majority of cases the tubercular foci are not thus distinctly cir- cumscribed, and changes are produced in the walls of neighbour- ing alveoli and bronchioles. These become thickened and infil- trated with small cells, and the alveoli filled with epithelial cells, leucocytes, and sero-fibrinous exudation. These changes as a whole result in the production of an area of consolidation of a grey colour, firm consistence, and, if of comparatively recent formation, granular appearance on section. Caseous foci are commonly present in such an area of infiltration : of these some may be under- going softening, whilst others are firm, dry, and granular. The tracts of grey infiltration become indurated with age, and may acquire an almost cartilaginous density. They are then smooth and glistening on section, but in the less chronic forms they may still present a slightly granular appearance. Pigmentation is a characteristic change in old lesions of whatever character. Areas of fibrosis, usually deeply pigmented, may occupy exten- sive tracts of the lung primarily affected ; they are formed by the coalescence of indurated granulations and nodules, or by the increase in thickness of fibrous bands extending from the mar- gins of conglomerate masses of tubercles which have undergone the fibrous change. The fibrous cicatricial tissue contracts and becomes puckered, and is often traversed by dilated bronchi of a fusiform shape which terminate in cavities. Pneumonia. — How far the ordinary processes of inflamma- tion, particularly those of the catarrhal form, take part in producing the morbid appearances found in the lungs in ' phthisis ' is a ques- tion which has given rise to prolonged controversy, but it is one which probably excites less interest at the present time than formerly. It is true that from the histological appearances it may be 348 THE DISEASES OF THE LUNGS almost impossible in the early stages to differentiate the lesions of catarrhal or broncho-pneumonia from those which in some cases accompany tubercular infiltration. It is the subsequent changes, the small celled infiltration of the alveolar walls, alveolar passages, bronchioles, and vessels, and the tendency to caseation and softening, which are characteristic of tuberculosis. The discovery that the specific virus of tubercle is almost constantly present in such lesions has practically set the (question at rest. The absorption of septic material from the disintegrating lesions is undoubtedly responsible for some of the inflammatory changes, but, viewed as a whole, it may be confidently stated that the ' broncho-pneumonia ' of pulmonary tviberculosis is mainly of specific origin. The gelatinous infiltration, or pneumonia, and the grey infiltration are primarily tubercular, and the subsequexit caseous change is a necrosis due to the action of the products of bacillary infection. True (croupous) pneumonia is a comparatively rare complication of progressive tubercular disease of the lungs, but it is by no means uncommon to find obsolete tubercular lesions in fatal cases of pneumonia. Cavities. — The common mode of formation of a cavity is by the softening of an area which has previously undergone caseation. When the caseous mass is firm and dry it may, however, be destroyed by a process of ' crumbling ; ' more often, however, softening is accompanied by liquefaction. The change may commence in groups of tubercular foci which have coalesced, or caseous areas of con- siderable extent may break down ' en masse,' the former process being far the more common. Softening usually occurs at about the same time at numerous points in a tract of consolidation ; a number of small cavities are thus formed, and by a gradual extension of the ulcerative process and the junction of neighbouring sites of soften- ing, an irregtilar anfractuous cavity results. When only a small area is involved the softening may be observed with the naked eye to have commenced at the centre of the caseous mass, and micro- scopically it is seen to begin about the termination of the bronchiole. The cavities have thus primarily a lobular arrangement, and this is retained in a more advanced stage so long as the intervening tracts of lung tissue remain undestroyed. The contents of the cavity are liquefied, and ultimately expec- torated after the opening up of a communication with a bronchus of sufficient size. In some cases solid masses of tissue may be separated and may subsequently undergo more or less complete disintegration within the cavity ; similar masses are often found post mortem still attached to the cavity wall. Classification of cavities.^A cavity of recent forma- tion is as a rule characterised by its irregular outline, ill-defined limits, ragged interior, and the absence of a distinct wall. If the cavity is of some size trabecular are generally present, but they may be absent when the necrotic process affects an extensive PULMONARY TUBERCULOSIS 349 :area. A recently formed cavity may, however, be well defined when a previously encapsuled caseous mass breaks down, or from the rapid softening of a limited area of caseation not surrounded by a capsule. The margin consists of tissue which is either consolidated or undergoing caseous necrosis, or in which a slight degree of fibrous change has occurred. The contents of a recently formed cavity are grumous and turbid from the presence of solid particles ; a foetid odour is rarely present. The cavity, especi- ally if of rapid formation, may be crossed by blood-vessels present- ing a smooth surface and a yellowish appearance, closely resem- bling in colour and consistency the fibro-elastic coat of a large artery, and showing the mode of branching special to the blood- vessels (Ewart). These appearances differentiate such bands from trabecule proper. Trabeculae are bridges of pulmonary tissue which originally separated distinct cavities. They consist of elastic elements derived from collapsed alveoli, contracted, thickened, and obliterated blood- vessels, fibrous structures derived from the peri-bronchial sheath, and a false membrane similar to the lining of the cavities (Ewart). ^ Bronchi very rarely enter into the composition of trabeculae. The non-cartilaginous tubes are destroyed early in the process by which the cavity is formed, and the larger tubes at a later period, the destruction of the larger bronchi being effected by a gradual ■enlargement of the apertures left by the removal of the smaller l)ranches.2 As the ulcerative process is more rapid about the aper- tures nearest to the root of the lung, the continuity of the tube is first destroyed on that side and an orifice is left. The distal por- tion of the bronchus is subsequently removed by gradual softening within the cavity. In a recently formed cavity such orifices are numerous, but as the cavity enlarges one bronchial set after another is destroyed, and finally it may be drained by the lobar bronchus alone. Contraction of the peri-bronchial sheath leads to a narrowing of the terminal orifices, the change being most marked in those which from their position are of little use for the purpose of drainage (Ewart). When the process of excavation is complete the cavity becomes limited by the formation of a definite wall, and assumes the -characters of the chronic cavity. It is now lined by a greyish false membrane, beneath this is a vascular layer, and externally a fibrous layer produced by the irritant effect of the process upon the neigh- Tjouring tissues. The lining membrane continues to secrete for a varying time ; ihe secretion, however, gradually becomes more liquid in cha- racter, and ultimately under favourable circumstances ceases to be formed. The cavity is then said to be ' dry.' The vascular layer of the cavity wall gradually diminishes in thickness, and no longer presents a bright red colour when the false membrane is removed by scraping, whilst the outer fibrous layer increases in thickness and density. ' Goulstonian Lectures, 1882. - Op. cit. THE DISEASES OF THE LUNGS THE SITE AND PROGRESS OF THE LESIONS The writer drew attention some years ago ' to the fact that * tubercular disease in its onward progress through the lungs in the- majority of cases follows a distinct route, from which it is only turned aside by the introduction of some disturbing factor,' and subsequent experience has confirmed the correctness of the views then expressed. This ' line of march ' of the disease is characteristic of cases of the chronic and fibroid varieties in which the progress of the disease is slow, but is less frequently observed in the caseous variety, which may be marked by rapid extension from lobe to lobe, and from one lung to another. Time is necessary for the temporary localisation of ' the disease which such a mode of progress requires, but there is rarely any inversion of the natural order ; the disease spreads in each lobe from above downwards, hardly ever from below upwards. The site and progress of the lesions. — The apex of the lung is the primary site of the disease in the large majority of cases.. Of Dhe many theories which have been put forward in explanation of this fact, that which attributes it to the lesser functional activity of the part appears on the whole to be most worthy of acceptance. In quiet automatic breathing the apices of the lungs are imper- fectly expanded. This is true even of the female, m whom the pec- toral regions, rather than the apex proper, are functionally most active. Impairment of function probably leads to a defective resist- ing power, and thus the tubercle bacillus is able to effect a lodg- ment at the apices, although in other areas of the hmgs the normal forces of the body are sufficient to insure its destruction. Lebert attributes the great proclivity of the apex to the disease to the effect of posture. He does not explain the influence of the erect position, but is probably correct in attributing to the supine posture an influence in promoting the extension of the lesions to the posterior aspect of the lungs. randflcisch explains the apical site of the primary lesion upon the hypothesis that the bronchial secretions there are thicker than in other parts, owing to the relative dryness of the apices from the subsidence of the blood, the effect of gravity. Tlie supposed larger size of the alveoli at the apex of the lung,, of which there is no proof, and the greater exposure of the upper parts of the lungs to the influence of cold air, are other explanations of the common site of the primary lesion which do not need detailed discussion. Sites of lesions in the upper lobes. The extreme apex of the lung is not often the site of the primary lesion ; this usually occupies the situation marked on the accompanying diagram (fig. *.)()). It is situated from an inch to an inch and a half ' Localisatiuti of the Lesions of Phthisis, p. 11 (1888). PULMONARY TUBERCULOSIS 351 below the summit of the lung, and rather nearer to its posterior and external borders. Lesions in this situation tend to spread in the first instance backwards, possibly from inhalation of the virus whilst the patient is lying down. This line of extension explains the fact that an examination of the supra-spinous fossa will often give certain evidence of the presence of disease when the physical signs observed beneath the clavicles are of doubtful import ; proving that the changes, as is generally the case, are more advanced behind than towards the anterior aspect. From this primary focus, which in front corresponds either to the supra-clavicular fossa or to a spot immediately below the centre of the clavicle, the lesions often spread downwards along the anterior aspect of the upper lobe, about three-fourths of an inch within its margin, frequently occurring in scattered nodules, separated perhaps Fig. 96. — Diagram of a Vertical Mkdian Section of the Lung, showing one of THE Sites of the Prijiary Infiltration in Tuberculosis ; also the Site of E.^LY Infiltration of the Lower Lobe Fig. 97. — Diagram of the Left- Lung, viewed from its outer Border, showing a less usual. Site of Primary Disease of THE Apex by an inch or more of healthy tissue. It is not unusual to find in these scattered nodules the only e\idence of . disease on the anterior aspect of the lung, when posteriorly excavation has advanced to such a degree that but little more than the pleura remains. A second and less usual site of the primary affection of the apex is seen in fig. 97. This corresponds on the chest wall with the first and second interspaces below the outer third of the cla\acle. The lines of extension are usually downwards, so that after a time an oval area of lung is involved, occupying the outer part of the upper lobe. It is possibly true that the spread of the disease is more rapid when the primary lesion occupies this site. The lesions in the advanced stages — indurations and cavities — are formed by the coalescence and extension of these primary foci. The scattered nodules of consolidation on the anterior surface of the lung often 35^ THE DISEASES OK THE LUNGS unite and break down, forming a long sinuous cavity which may extend ahnost to the lower margin of the upper lobe anteriorly ; pos- teriorly, where the signs of excavation are usually most distinct, the further progress of the disease is generally arrested at the pleural reflexion in the interlobar septum. This was found to be destroyed, and the cavities in the upper and lower lobes united, in only five out of one hundred and fifty-two consecutive cases of the disease examined post mortem by Dr. Ewart.' Site of lesions of the middle lobe. The middle lobe of the right lung (which is believed by Aeby, from the arrangement of the bronchi, to be the analogue of the \ipper lol»e of the left), is rarely the site of a pri- mary tuberculous lesion- It is almost invariably affected after the upper lobe of the same side and usually at a rather late period of the disease, whilst not uncommonly it escapes altogether. The lesions most commonly found there are coarsely granular nodules, often of large size, which are either undergoing casea- tion, or already present an area of softening in the centre. Extension to the lower lobe. — The lower lobe of the lung primarily diseased is usually affected at a very early period of the disease, often long before any extensive infiltration or destruction of the upper lobe has taken place, and as a rule before the apex of the opposite lung is attacked. The site of the secondary infiltration of the lower lobe is indicated in figs. 98 and 101. It is situated about an inch to an inch and a half below its highest point, although it may sometimes be nearer to and even at the apex of the lobe. This situation nearly corresponds on the chest wall to a spot opposite the fifth dorsal spine, midway between the border of the scapula and the spinous processes of the vertebra'. The infiltration of the lower lobe at this site in the early stage of pulmonary tuberculosis of the chronic and fibroid varieties is one of the most constant features in the pathological anatomy of Fig. 98. — Showing the Eklations of the Lohks TO THE Wall of the Chest posteriouly The X marks the usual site of early infiltration uf tlie lower lobes. ' Goulstonian Lectures, 1882. PULMONARY TUBERCULOSIS 353 the disease, and its recognition is a point of the greatest clinical importance, as the existence of a lesion in the lower lobe at this spot, coincident with physical signs at the apex, even though the latter are in themselves of doubtful import, is in the writer's experience almost positive proof of the presence of tubercular disease of the lung. It may be of great service in cases in which tubercle bacilli are absent from the sputa. It would therefore appear that the upper and posterior part of the lower lobe is a spot only second in point of vulnerability to the apex itself. It is very rare, except in cases of ' crossed lesions ' {vide p. 3-55), to meet with a case, either during life or on the post-mortem table, in which this area is affected whilst the apex of the lung is free from disease. I '^^ Fig. 99. — Showing the Line OF Extension of a Lesion OF THE Lower Lobe along THE InTEBLOBAE SePTUM Latei-al aspect of the lung. Fig. 100. — Showing the Position of the Arm when the Vertebral Boeder of the Scapula indicates (roughly) the usu.al Line of Extension of Lesions along the Interlobar Septum Cases in which active lesions are present at both apices, no other portion of either lung being affected, are rare, but both apices may be the seat of old disease when the process has been arrested before the lower lobe on either side has become affected. The early stage of the disease at which the lower lobe is implicated is well illustrated in lungs presenting old apex lesions which have undergone arrest. The area of disease may not be larger than a cherry or an olive, but if the process was tuberculous, a nodule wiU generally be found in the lower lobe. This lesion, once established, tends to spread backwards towards the posterior surface of the lung, and laterally along the line of the interlobar septum (fig. 99), forming a wedge-shaped area of infiltration. It follows from A A >54 THE DISEASES OF THE LUNGS this that even in the early stages of the disease, in order to ascertain the extent of lung affected, the lower lobe must be examined not only opposite the fifth dorsal spine, but also along the line of the interlobar septum. This line is roughly marked by the vertebral border of the scapula when, with the hand upon the spine of the opposite scapula, the elbow is raised above the level of the shoulder (tig. 100). The mode of extension towards the base of the lung is not usually by an advancing line of consolida- tion, but by scattered nodules of infiltration often arranged in a racemose manner (tig. 101). Even at the termination of a chronic case some healthy or at least unintiltrated tissue will generally be found at the base, even of the lung primarily affected. This freedom of the bases from tubercular lesions is another very marked feature in the pathological anatomy of the disease. Fig. 101. — Showing the usual Mode OF Extension of the Disease to- wards THE Base of the Lung Section from tlie iJO.sterior bonier towards the root ; opened out Fig. 102. — Typical aukangement of Lesions in a Case of Apical Tu- berculosis with Nontuderculous Disease of the Lower Lore In estimating the probability of any basic lesion being tuber- culous in origin, it is important to observe whether the physical signs of disease in the lower lobe are continuous from its apex to its base ; if so, the lesion is probably tuberculous. If the base is affected, but the apex of tlie lower lobe free from disease {ride tig. 10'2), the basic lesion is either non-tuberculous — e.g. due to (L'dema and collapse, followed by bronchiectasis, catarrhal pneu- monia, or pleurisy, &c. — or, if tuberculous, the resisting power of the base has bei'U diminished by some previous affection for example, an attacl< of i)leurisy followed by partial collapse ; but the presumption is strongly in favour of a non-tuberculous lesion. Mode of extension to the opposite upper lobe. —The upper lobe of the lung not primarily affected is often attacked at an early period, but not, as a rule, until after the lower lobe of the lung first affected. PULMONARY TUBERCULOSIS 355 The lesions may be found in either of the common situations indicated in figs. 96 and 97, and are therefore symmetrical in site but in different stages on the two sides. There is, however, a third site for the secondary infection of the opposite upper lobe, Avhich is figured in the accompanying diagram (fig. 103). Its site is close to the interlobar septum, about midway between its upper and lower extremities, and corre- sponds on the chest wall to the upper part of the axilla. There small areas of con- solidation form and coalesce, but rarely break down into a cavity of any considerable size. Once established, this lesion tends to spread in nearly all directions, and may occupy a considerable area of the lung whilst the apex is free from disease. Infiltration at this site, when present, is generally secondary to that of the lower lobe of the lung first affected. It follows from this fact that, in addition to the apex of the lung, the part corre- sponding to the axilla must be carefully examined before (say) the left lung can be pronounced to be free from disease, when the right is primarily affected. Extension to the loiver lobe. — The distribution of the lesions in the lower lobe of the lung secondarily diseased is usually similar to that on the opposite side, and presents no peculiarities. Fig. 103. — Lateral view OF Lung showing an OCCASIONAL Site of Le- sion IN THE Lung not primarily affected Figs. 104 and 105.— Illustrating a ' Crossed Lesion,' i.e. from Eight Apex to Left Lower Lobe Sections from the posterior border towards the root of the luug Crossed lesions of the lower lobe.— Occasionally the lower lobe of the lung primarily aflected escapes infiltration, and A A 2 356 THE DISEASES OF THE LUNGS the disease crosses over to the opposite lower lobe {vide figs.104, 105). In all cases, therefore, it is necessary to examine both lower lobes before deciding that the disease is limited to one apex. Exceptional arrangement of lesions. — When the usual sites of infiltration in the upper and lower lobes are already occupied by arrested lesions, and a second tubercular infection of the lung occurs at some later and perhaps distant date, the more recent lesion in the upper lobe usually occupies a position close to the interlobar septum, whilst that in the lower lobe is situated along the posterior border and extends almost to the base (fig. 106). This fact is of importance, as it helps in some cases to explain the occurrence of basic disease, and will be referred to again in the description of lesions of the lower lobes occupying exceptional situations. Fig. 106 — Site of Lesions in Secon- dary Infection a, a', arrested lesions ; b, b', recent lesions. Fig. 107. — Illustrating an unusual arrangement of Lesions in the Lower Lobe Loicer lobe. -The accompanying diagram (fig. 107) illustrates an unusual lesion, of which several examples have come under our notice. A second cavity, almost equal in size to that at the apex of the lower lobe, is present about midway between that spot and the base, and close to the posterior border of the lung, the intervening area being almost free from disease and the base quite unaffected. It IS, however, rare to meet with this lesion whilst tlie usual site of disease ni tlie lower lobe remains unaffected. Basic lesions. — Reference has already been made to the comparative freedom of the bases of the lungs from tuberculous disease ; whenever, therefore, a lesion is found in this situation, a most careful survey should be made, both of the history of the case and of the physical signs present, before cominor to the conclusion that the basic disease is tuberculous. PULMONARY TUBERCULOSIS 357 The most common varieties of chronic disease affecting the bases of the lungs may be classified thus : {a) NoN-TuBEKCULOus Basic Disease 1. Collapse of the lower lobe caused by pleural effusion, followed by absorption of the fluid and falling-in of the lower part of the chest on the afi"ected side. 2. Collapse from the same cause, followed by cirrhosis of the lung and bronchiectasis. 3. Empyema opening into the lung. 4. Hepatic abscess or hydatid cyst of the liver, communicating with the lung. 5. Collapse of the lower lobe from pressure on the main bronchi by growths or enlarged and infiltrated mediastinal glands, followed by bronchiectasis. 6. Diffuse gangrene of the lower lobe resulting from a com- munication through the bronchi with the oesophagus, either directly or through the medium of a softened bronchial gland. 7. Chronic pneumonia and bronchiectasis following on the im- paction of a foreign body in one of the bronchi of the lower lobe. 8. Unresolved and chronic pneumonia of the lower lobe. 9. Bronchiectasis secondary to catarrhal pneumonia and collapse. This lesion is rarely found except in children. [b) Non-Tuberculous Basic Disease complicated by SUBSEQUENT TUBERCULOSIS Cases presenting basic lesions are occasionally met with in which the disease, originally non-tubercular, has become so at some later period, the lower lobe being infected either directly or, as is perhaps more common, subsequently to the apex of the same lung. This complication is very likely to occur where bron- chiectasis forms a part of the original lesion, but may also be found in cases of chronic pneumonia and in some of the other forms of non-tuberculous basic disease enumerated above. (c) Basic Tuberculosis 1. Physical signs most marked at the base, but the oldest lesions at the apex. 2. Arrested lesions at the apex and at the posterior apex of the lower lobe, more recent lesions in the upper lobe and also at the base {vide fig. 106). 3. Primary basic tuberculosis. Cases illustrating several of the conditions here tabulated are described by Dr. Percy Kidd, in a paper on ' Basic Tuberculous Phthisis,' ' from which some of the headings here used are taken. It is unnecessary to discuss in detail the differential diagnosis of the various forms of basic disease here enumerated, as the physical ' Lancet, October 2, 1886. 358 THE DISEASES OF THE LUNGS signs by which they are attended are described in the appropriate chapters. It must suffice to repeat that the only positive proof of the tubercular nature of pulmonary disease is the discovery of bacilli in the sputa. LESIONS ASSOCIATED WITH PULMONARY TUBERCULOSIS In the following table, compiled from the Pathological Reports of the Brompton Hospital for the years 1892, 1893, and 1894, the more important lesions found in association with pulmonary tuber- culosis are stated. As the method of tabulation adopted in the Reports is not uniform throughout, it has not been possible to give complete figures under each heading. Per 1892 1893 1894 Total cases cent, of cases included Number of Cases 208 174 149 531 — i I. Eespiratory System : Laryngeal tuberculosis . 100 84 68 250 47 Tracheal ulceration 36 .82 28 96 18 ; Bronchial ,, ... (3 10 4 20 3-7 i Bronchiectasis .... 1 — 5 — — Pulmonary aneurysm . 1.5 16 8 39 7-3 Hfemoptysis (death from) 18 15 7 40 7-5 Pneumothorax .... IG 14 16 46 8-6 Pyo-pneumothorax 6 7 13 26 4-8 Pleural eti'usion .... — 12 12 — 7-4 Gangrene of lung .... — A 1 — 1-2 II. Digestive System : Alimentary canal — Tubercular ulceration of pharynx. 2 .S 2 7 1-3 : „ ,, tongue . 1 .s — — „ „ oesophagus - 1 1 — — ,, „ intestines 1(55 131 — 77-4 „ ,, stomach . __. — 2 — — Perforation of intestine 8 3 5 16 3 III. AliDOMINAL OnOANS : Peritonitis — (1) Non-tubercular 1.5 10 6 30 5-0 (2) Tubercular .... {\ 9 7 22 41 TAver — Amyloid ..... — 14 6 — — Cirrhotic 8 10 7 25 4-7 Miliary tubercle .... 1 4 4 9 1-6 Fatty — 54 68 — 37-7 Spleen — Amyloid — 22 16 — 111 Miliary tubercle .... — 3 2 — 1 2-7 Caseous ,, .... 1 \ 2 2 — PULMONARY TUBERCULOSIS 359 Per' 1892 1893 1894 Total cases cent, of cases iucluded III. Abdominal Organs {continued) : 1 Kidneys — Amyloid — 11 9 — 6-1 Parenchymatous nephritis . Il3 f 3 6 ' 8f; fi-7 Interstitial ,, 1 1 7 7 J Miliary tubercle .... 1.12 fll .5 1 35 6-5 Caseous ,, .... 1 I 2 5 J Tubercular pyelitis — 1 — — — Bladder — Tubercular ulceration . 1 2 1 4 •7 Suprarcnals — Tubercular •2 1 1 4 •7 Generative organs {male) — Tubercular epididymis . .3 4 2 9 1-6 „ prostate — 2 I 2 „ vesiculaa seminales — 4 I - ■ Generative organs (female) — Tubercular ovaries — 2 1 5 1 „ tubes — 2 IV. Circulatory Organs: Tubercular pericarditis . — — 4 — Acute endocarditis 2 — ■ — — — Chronic ,, ... 2 7 11 20 3-7 Congenital malformation 1 2 — — — V. Glandular System : Bronchial and mediastinal glands — Enlarged — 113 90 — 66 Caseous . . . . ' . — 25 6 — 9-5 Calcareous — 11 — — — Cervical glands — Caseous — 3 1 — , — Mesenteric glands — Caseous — 30 6 — 11 VI. Meninges and Brain : Tubercular meningitis . 2 8 8 18 3-3 tumours — 2 1 — — Cerebral abscess .... 1 — — — — Bronchi and trachea. — Acute inflammation of the bronclii may be present, and as a rule the lining membrane of the air passages is either intensely reddened or congested, and the tubes contain a quantity of muco-purulent secretion. When the trachea is the seat of tubercular ulceration the change often extends to the main bronchi, appearing either as piinctiform erosions or as irregular areas formed by the coalescence of separate foci. The lining membrane of bronchi which are in direct communi- •cation with cavities, or which pass through pneumonic areas, is often intensely injected and swollen, and may have undergone ■extensive tubercular ulceration. 36o THE DISEASES OF THE LUNGS IMiliary tubercles are often present in the mucous membrane of the bronchi, especially in the smaller tubes. If the tubercles break down a small erosion is left, which appears as a white or lighter coloured spot in the midst of the deeply injected membrane. Larger caseous nodules in the bronchi are occasionally observed to have perforated the tube. Tubercular infiltration of the peri- bronchial sheath leads to marked thickening of the tube and narrow- ing of its lumen. The subject of tubercular ulceration of the trachea is fully considered on page 74. Bronchicctdfiis is commonly present to a limited extent in cases of chronic tuberculosis accompanied by fibrous induration ; it occurs less frequently in the acute forms of the disease. It is generally of the cylindrical or fusiform variety, and is often associated with thickening of the wall of the tube, and marked injection of the mucous membrane, which may present a granular or velvety appearance. Saccular and fusiform dilatations are present occasionally along the sternal borders of the upper lobes when there is extensive disease at the apex, especially the left, and also along the anterior margins of the lower lobes. As a rule, however, saccular dilatations occur only when large tracts of tissue have undergone fibrous transformation (Wilson Fox). When the smaller tubes are affected the change is usually most marked at their peripheral divisions. There may, in such cases, be no induration of the surrounding tissue. Narrowing of a bronchus from the pressure of an enlarged, caseous, or calcareous gland, and from the contraction of fibroid tissue, may also lead to dilatation of the tube beyond the site of constriction. Ulceration of the walls of the dilated tubes is not uncommon, and caseous nodules may sometimes be seen at the bases of the ulcers. Lungs. — Empliysema is one of the most common affections to be associated with pulmonary tuberculosis. As a rule, it is found in the usual sites of emphysema, its occurrence elsewhere being determined by the presence of contracting tubercular lesions. Large bulhe are often formed around old lesions at the apices of the lungs, and when there is only one single contracted apical cavity the posterior apex of the corresponding lower lobe may undergo extreme emphysematous change. When the right apex is the site of an old contracted cavity the middle lobe may be found greatly enlarged ; the loAver and anterior parts of the left upper lobe are similarly aft'ected with con- tracting lesions at that apex. The enlargement of these areas and also of the upper lobe of the unaffected or less diseased lung in cases of very chronic disease of one apex may be in part due to emphysema, l)ut when accompanied by signs of increased functional activity, it must be regarded as a true compensatory change. A considerable degree of emphysema maybe produced in a com- paratively brief period in cases of miliary tuberculosis, and also in association with extensive but disseminated infiltration of the broncho-pneumonic type. PULMONARY TUBERCULOSIS 361 Collapse, the result of bronchial obstruction, may affect large areas, particularly of the lower lobes. In smaller patches it is commonly present in tissue around and between nodules and granulations. In cases of pneumothorax collapse may be complete if there are no pleural adhesions. The extent of collapse present in cases of pleural effusion accompanying tuberculosis is determined by the amount of the effusion and the site and nature of any adhesions which may be present. CEdema of the bases and of tissue intervening between areas of consolidation and elsewhere is rarely completely absent. Gangrene of the lungs is rarely found in association with tuberculosis. It may occur in areas of consolidation and in the walls of cavities in which ulcerative changes are in progress. The association of the following lesions with pulmonary tuber- culosis is elsewhere considered : Pulinonary Aneiiri/sm {vide^. 515), Pneumothorax and- Pyo-r)neumo thorax (vide p. 630), Gangrene of the Lungs {vide p. 244). Pleura. — Adhesions of the pleura are rarely, if ever, absent in chronic pulmonary tuberculosis. They vary in density from fine filamentous bands to cartilaginous coverings measuring half an inch or more in depth. In very chronic cases in which the upper lobes ar^e the site of contracting cavities surrounded by dense fibrous induration, the over-lying pleura may have become thickened to such a degree that' the lung is with difficulty removed from the thorax. "When death has been preceded by an acute attack of pleurisy, a thick layer of fibrinous exudation may cover the serous membrane and enclose a sero-fibrinous, hsemorrhagic, or purulent effusion. Miliary granulations and caseous nodules may be present on the free surface of the membrane or when the two layers have been united by adhesions. If the acute attack has been of earlier date the exudation may appear as a thick caseous mass, occupying, as a rule, the lower parts of the pleural cavity. In acute tuberculous pleurisy the process may extend from the pleura for a distance of half an inch or less into the underlying lung, often in the form of linear caseovis prolongations. The pleural lesions present in pulmonary tuberculosis are, however, by no means invariably of tubercular origin {vide Tubercular Pleurisy, p. 580). It is often extremely difficult to recognise tubercular lesions of the pleura. An examination of the interlobar septa, which are, so to speak, sealed up at an early period of the process, may imme- diately reveal the presence of miliary granulations, although else- where they may be hidden by inflammatory changes. Tubercular ulceration of the intestine. — The distri- bution of this lesion throughout the various parts of the intestine in 323 cases is illustrated in the following table : Jejunum. Ileum Cfpcuia . Vermiform appendix Colon . Rectum . 362 THE DISEASES OE THE EUNCuS Xo. of oases in which lesion was present Duodenum ........ 7 . 68 . 1'.I2 . v.m . IHo . 1H7 44 In 382 cases the small intestine was alone affected in 33 cases ; the large intestine alone in 63 cases ; both small and large intestine were affected in 200 cases. The large number of cases in which the vermiform appendix was the site of ulceration is jemarkable, but a ' perityphhtic abscess,' the result of perforation of the appendix, was only found in a single case. In IG cases in which perforation of a tubercular ulcer occurred, the site of perforation was as follows : Duodenum ........ 2 .Jejunum. ........ Ileum 7 Cifcum ......... o Vermiform ai)peii(lix ...... 1 Colon ......... 1 Rectum ......... k; Peritonitis. — Perforation of the intestine may be followed by acute suppurative peritonitis, or chronic peritonitis may be pre.sent and the area of inflammation may correspond to the peri- toneal aspect of ulcers which may or may not have perforated ; or the lesion may be general throughout the peritoneal cavity. In one of the cases analysed, purulent peritonitis occurred from tubercular ulceration of the intestine without perforation. Amyloid Disease. This form of degeneration is of connnon occurrence in the chronic variety of pulmonary tuberculosis. It was present in 323 cases as follows : Liver ....... Spleen ..... Kidneys ...... Stomach ...... Intestines ...... Liver. - Fatty infiltration of the liver occurs in rather more than one-third of the chronic cases ; it has been attributed to [a) the reabsorption of the fat i)ito the blood during the process of emaciation, and to diminished secretion of bile arising from im- perfect digestion, the fat al)sorbed being in part primarily expended in the formation of bile (Frericbs) ; {b) to an excessive production of easily oxidisaV)le fat by the liver ; (c) to an accumulation of fat owing to deficient oxidation througliout the body, in conse(iuence of the disease of the lungs. a?cs Per eent. 20 6-1 38 111 20 (M (') IS 17 .'5-3 PULMONARY TUBERCULOSIS 363 The exact cause of the accumulation of fat in the hver whilst it is heing removed from other parts of the body has not so far been ascertained. Tubercle of the liver is more common in children than in adults, and in the miliary than the chronic form of the disease. It is sometimes extremely difficult to recognise the presence of miliary tuberculosis of the liver with the naked eye, and when, as is not uncommonly the case, miliary tuberculosis and cirrhosis are associated, it may be impossible to do so without a microscopical examination. Spleen. — The spleen is the seat of tubercle in only a small proportion of cases (2'7 per cent.), miliary and caseous lesions occurring with nearly equal frequency. Kidney. — Tubercle of the kidney in association with the same disease in the lungs usually appears in the form of small granula- tions in the cortex and ]3yramidal portions. More extensive infil- tration may be present, and caseation may have occurred, but the large ' scrofulous ' kidney is a rare complication of chronic pulmonary tuberculosis, although pulmonary lesions are often present at a late stage of that affection. Amyloid degeneration is the most common renal lesion. It will be seen from the above table to have been present in 6'1 per cent, of the cases examined. No direct relation exists between the other forms of chronic Bright's disease and the pulmonary affection. Generative organs. — Tubercular disease of the generative organs in the male is rare as a complication of the pulmonary affection, but the epididymis and vesiculse seminales should always be carefully examined in cases of miliary tuberculosis in which the source of infection is doubtful. Chronic caseous disease of the ovaries and Fallopian tubes was met with in 2*7 per cent, of the cases analysed. Organs of circulation. — The subject of tuberculosis of the pericardium is considered in the chapter on general Serous Mem- brane Tuberculosis {vide p. 587). Chronic valvular lesions were met with in 3"7 per cent, of the Brompton Hospital cases, the mitral valve being most frequently affected (17 times in 20 cases). In 500 cases analysed by Dr. Percy Kidd, 27 examples of chronic endocarditis were found (5'4 per cent.). Cases of congenital stenosis of the pulmonary orifice not infrequently develops tubercular disease of the lungs. Glandular system. — Enlargement of the bronchial glands is commonly present (66 per cent.), and in a considerable number of cases these, and also the mesenteric glands, are either caseous or calcareous. Meninges and brain. — Tubercular lesions of these organs are more common in childhood and as a part of general miliary infection than as a complication of chronic pulmonary tuberculosis. It is indeed somewhat remarkable that tubercular meningitis should so rarely occur (3*3 per cent.). 364 THE DISEASES OF THE LUNGS CHAPTER XXXIV CHEONIC PULMONARY TUBEECULOSIS {contiinied) SYMPTOMATOLOGY— PHYSICAL SIGNS— DIAGNOSIS- PROGNOSIS PAGK Symptomatology 364 Modes of onset 364 Symptoms 366 Examination of expectoration ...... 366 Respiration 369' State of the blood 370 Pulse 371 Digestive system ......... 371 Physical signs 372 Of tubercular infiltration ....... 373 Of softening ' 375 Of excavation with contraction ...... 376 Diagnosis 377 Pseudo-tuberculosis 379 Prognosis 379 Modes of onset. — This varies much in different cases. The following)- cHnical types may he recognised : 1. Insidious. — This is the most common form in which the disease appears. The patient is either iniahle to fix definitely the time when his health became affected, or perhaps dates the attack from a cold of no unusual severity or from some illness in which the lungs were not apparently involved. Of late it has been ex- tremely common to find the following statement in the clinical history of cases of pulmonary tuberculosis : ' The patient suffered from an attack of influenza in , and states that he has never felt well since that tin^.e.' There is a history of gradual failure of strength, anamia, cough, expectoration, and emaciation. Sweating may have been present at night, and on exertion the breath has prol)ably been noticed to be short. Loss of appetite, dyspepsia. CHRONIC PULMONARY TUBERCULOSIS 365 •and vomiting after food often form a prominent feature in the history of such cases. The tongue may be furred, with prominent red papillae. If the temperature has been taken in the afternoon or evening, it will probably have been from one to two degrees above the normal. 2. Bronchial catarrh folloiccd bij emphysema. — The cases pre- senting this mode of onset are scarcely less numerous than the former. There is usually a history of repeated attacks of bronchial catarrh or of acute bronchitis ; cough may have been present in the winter for some years, and there may have been attacks of dyspnoea, with wheezing. Expectoration has probably been pro- fuse, and perhaps occasionally tinged with blood. The date of the tubercular infection may be ill-defined or marked by emaciation, loss of strength, an alteration in the character of the cough, and often by the occurrence of night sweats. In many cases presenting this mode of onset, the cough, which has previously disappeared in the summer, persists during that period of the year, and the more grave symptoms are first noticed in the following winter. 3. Pleuritic onset. — In these cases the appearance of the disease has been preceded by one or more attacks of pleurisy, either dry or with effusion ; if there has been effusion the fluid may have been completely absorbed. In some cases there is a history of pleurisy with effusion affecting first one side of the chest and after a varying interval the other, and after both attacks complete .a;bsorption of the fluid may have taken place. The immediate onset of the pulmonary lesion is generally marked by cough, emaciation, pyrexia, and night sweats. In such ■cases, as in those presenting the modes of onset previously de- scribed, there is often a history of tubercular disease in the parents or in other members of the family. 4. Hamoptoic onset. — In a certain proportion of cases the health is apparently but little affected prior to the occurrence of an attack of haemoptysis. This attack may be immediately followed by the ordinary symptoms and signs of the disease, or, as not uncommonly happens, the attack is quickly recovered from, and on examination of the chest shortly afterwards, few, if any, definite lesions may be detected. There may be a considerable interval before another attack of haemorrhage occurs, but after a time the ordinary symptoms of the affection appear. It is almost certain that in many cases of this kind there is an old tubercular lesion of the lung, and that the attack of haemoptysis apparently marking the onset of pulmonary tuberculosis has really been preceded by symptoms which have either escaped the notice or the memory of the patient. Cases presenting this mode of onset are not un- common in young men whose health has been impaired by over- work, and in men beyond middle age in whose family there is no history of tubercular disease. 5. Laryngeal onset. — Although in the vast majority of cases the larynx is involved secondarily to the lungs, the organs are sometimes attacked in the reverse order. On this point few who have had 366 THE DISEASES OF THE LUNGS extensive experience of the disease are in doubt, although the fact is admittedly difficult of proof in any given case, as the absence of pulmonary signs does not imply the absence of lesions, and such signs may be masked by the changes in the larynx. It is, however, quite certain that when tuberculosis is present in both situations, the laryngeal affection may be severe and advanced at an early period, long before it usually makes its appearance. The first symptoms complained of are irritable sensations in the larynx, mucoid expectoration, and cough ; subsequently the voice becomes hoarse and husky, and at a later period may be completely lost. When this condition is suspected to be present, the sputa, or some of the secretion removed from the larynx with a brush, should be examined for bacilli, as they may be present in the expectoration before the appearance of any signs of pulmonary disease. Symptoms. — The early symptoms are included in the fore- going description of the modes of onset of the disease. Of those which attend its course, coiigJi is the most prominent and the one which chiefly attracts the patient's attention. It also constitutes, and perhaps not unnaturally, his guide as to the efficacy of treat- ment. Cough is usually present at an early period of the illness, and throughout its course is rarely absent for any lengthened period, except in cases of complete arrest. At first short, dry, and ' hacking,' it is soon attended with expectoration, and assumes the character observed in bronchitis. It may be present at intervals throughout the day, but is commonly most troublesome after meals or unusual exertion, and on lying down at night and on rising in the morning. Paroxysms of cough, attended by difficulty in expectoration, frequently give rise at more advanced stages to vomiting and leave the patient very ' short of breath ' and much exhausted. Cough is often followed by vomiting, especially if severe and paroxysmal in character, as is often the case when cavities contain secretion which is expelled with difficulty owing either to rigidity of the cavity wall or to the contraction of the bronchial orifices. Pressure upon the lower part of the trachea or main bronchi by enlarged bronchial glands is a not uncommon cause of paroxysmal cough, especially in children. The most important points to notice with regard to the cough are, whether it is ' effective ' in producing the discharge of secre- tion, or only ' irritative ' in character, and, so to speak, useless ; on this difference the treatment of the symptom mainly depends. Expectoration, as a rule, occurs early in the disease ; it is rarely absent when symptoms liave been present for as long a period as two months. The exceptional cases include examples of miliary tuberculosis, caseous consolidation without softening, and fibroid tuberculosis. When tuberculosis follows chronic bronchitis, expec- toration may be profuse and catarrhal in character. It consists at first of clear viscid glairy mucus, but this may, by admixture with saliva, and in some cases independently of this, acquire a watery character ; subsequently small grey or greenish purulent masses CHRONIC PULMONARY TUBERCULOSIS 367 appear. Tubercle bacilli are most often found in these purulent masses, but they may be present in mucoid expectoration. With the advent of softening, the sputa become more profuse, mucopurulent, and yellow or greenish in colour. When the expectoration consists mainly of flattened purulent masses of a greenish-yellow colour which do not coalesce in the spitting-cup, it is said, from the similarity in appearance to a coin, to be ' nummu- lated.' Such sputum as a rule comes from cavities, but the secre- tion from chronically inflamed bronchi may present this appearance, although it is usually more fluid in character. Bayle drew attention to the presence m the expectoration of small opaque white or yellow masses, which he likened to boiled, rice. These are not all of the same nature (Wilson Fox). Such pellets in mucoid expectoration may be derived from the follicles of the throat, trachea, or bronchi, and possibly also from the alveoli. They consist of mucous and pus cells embedded in a matrix. Small opaque shreddy particles presenting a somewhat similar appearance may be shown, by floating them in water, to consist of elastic tissue fibres and fragments of lung tissue undergoing necrosis. In such masses tubercle bacilli are very likely to be found. The quantity expectorated daily depends chiefly upon the activity of the disease. When rapid destruction of the lung is in progress six to ten ounces or even more is by no means an uncommon quantity. Patients usually describe the sputa as either salt or sweet in taste ; the former is present in the early period , the latter when the expectoration has become purulent. The sputa, when puriform, have a faintly sweet odour. Bronchi- ectasis, gangrene, and putrid decomposition of secretion in cavities may render it offensive, but it is somewhat remarkable how rarely this occurs. The presence of blood, either as streaks, ' stains,' or clots, is- obvious from its colour ; when recent it is red, but when it has been retained for some time in the bronchi or in cavities, it is of a dark purple or blackish tint. Clots of this nature are almost invariably expectorated for some days after an attack of hjemoptysis. The characters of expectorated blood are more fully described in the chapter on Haemoptysis. The microscopical examination of the sputa is chiefly under- taken to determine the presence of elastic tissue or tubercle bacilli. Fk;. 108. — Elastic Tissue or the Lung. From the Sputum ( X DO) OF A Case of Tuberculosis Elastic tissue. — This appears as single or multiple, curled, branching, elastic fibres forming a network usually with traces of 368 THE DISEASES OF THE LUNGS the alveolar arrangement, and in cases of rapid softening, portions of pulmonary tissue may be found in which the alveolar structure can be clearly made out. If some of the thick purulent material is placed upon a glass plate about four inches square and compressed into a thin layer by a second glass plate about three inches square, the elastic tissue on a black background appears to the naked eye as greyish-yellow spots. The fragment may then ])e removed, placed upon a micro- scopic slide, and further examined (Andrew Clark). Another method in common use is Fenuick's. The sputum is boiied for a few minutes with an equal volume of a solution of caustic soda (20 grs. to the ounce), and the fluid is allowed to stand in a tall conical glass for twenty-four hours. The sediment is then examined microscopically. The ol)server must be careful to use a silk handkerchief to clean the slides and cover-glasses, and not to mistake threads of cotton or squamous epithelium seen edgewise, or other extraneous materials, for elastic tissue, which is characterised by the well-marked outlines and peculiar curve and the alveolar arrangement of the fibres, and their occurrence, for the most part, in groups. The alveolar arrangement of the fibres is the only trust- worthy appearance. Elastic fibres from bronchial ulcerations are said to be frag- mentary and to lack the curled appearance of those from the alveoli. The presence of elastic tissue in the sputa is absolute proof that a destructive disease of the lung is in progress, and in the great majority of cases in wliich elastic tissue is found the disease is tubercular. The test is, however, not perhaps so much used now as formerly, owing partly to the difficulty in finding the fibres when the expectora- tion is profuse, and to their frequent absence from the opaque masses ; but chiefly to the more complete information obtained from the discovery that the sputa contains tubercle bacilh. Tubercle bacilli are found in the sputa in the great majority of cases of the disease, and they should be sought for in every case in which there is any reason to suspect its presence. If a systematic examination of the sputa for bacilli be made in every case of chest disease of any imporoance, tlie observer will certainly meet with many cases in which they are absent, although everything pointed to the likelihood of their presence, and many also upon which their unexpected discovery throws quite a new hght. liepeated examinations should be made before the search is abandoned, as they may be discovered after many failures. They have been found by many ol)servers in the initial hiemoptysis. In purulent secretion from vomica), they are almost invariably pre- sent, and may be in large immbers. In cases of fibroid tuber culosis, on the contrary, they are often found with difficulty or not at all. It has been clearly established that there is no constant relation CHRONIC PULMONARY TUBERCULOSIS 369 between the number of bacilli in the sputa and the activity of the disease, but when rapid softening is in progress they are usually present in large numbers, and a tendency to quiescence of the morbid process is usually accompanied by a diminished discharge of bacilli, and with complete arrest they may be absent or there may be no expectoration. The continued presence of bacilli in the sputa does not appear necessarily to imply that the disease is in active progress. In a case under observation of the Avriter, bacilli have been present in the expec- toration on every occasion on which an examination has been made since 1882. The patient has during that period been actively at work, and has generally enjoyed good health ; he is certainly as well, if not better, now than he was fourteen years ago. Various crystals are found in tubercular sputa, also epithelial and pus cells, blood corpuscles, and many organisms, chiefly the various forms of micrococci ; but their presence is as yet of little clinical importance as compared with that of tubercle bacilli and elastic fibres. A diminution in the amount of the sputum and the absence of the purulent character are, speaking generally, signs of lessened activity of the disease, and when complete arrest has occurred there may be either none, or only so mu.ch on rising in the morning as is often expectorated by persons who consider themselves to be in good health. Pain in the chest is a common symptom. It is more often referred to the infra- or supra- clavicular regions than elsewhere, and in such cases usually indicates the presence of disease in the underlying pleura or lung. Complaint is often made of pain or tenderness about the apex of one lung or over the pectoral region when the morbid process is in a very early stage, even before any objective signs are present, and such a complaint should never be regarded lightly in cases where there is reason to suspect tuberculosis of the lungs from the general symptoms, although trustworthy physical signs are absent. Pain in the lower axillary or submammary regions is generally due to localised inflammation of the pleura, or to the stretching of adhesions during cough. The contraction of an apex cavity may be accompanied by pain from the changes in the pleura which almost invariably attend such a condition. Very severe pain in the supraspinous region, or at a lower level in the back, may be due to extension of the disease through both layers of the pleura, previously adherent, and the formation of a burrowing sinus in one or more intercostal spaces. Such a condition is not uncommonly present post mortem in acute cases. The importance of pain as a symptom of the occurrence of pneumothorax is emphasised in the chapter on that subject {vide p. 633), Bespiration. — The breathing is quickened in proportion to the area of lung involved and the rapidity with which the disease is extending, but in almost all cases the rate is above the normal. B B 37© THE DISEASES OF THE LUNGS As a rale it increases in frequency with the evening rise of tem- perature, but there is a less definite correspondence between the respiration and the degree of fever than between the former and the pulse rate. The variations between the rate of the pulse and the frequency of respiration are, however, so exti-eme that the observation of the pulse-respiration ratio is of comparatively little value. State of the Blood.— The state of the blood in pulmonary tuberculosis has been investigated by Stein and Erbmann.' Leuco- cytosis has been observed in tuberculosis under the following conditions : 1. Cavities in the lung. 2. Inflammatory processes at the end of a case of phthisis. 3. Chronic suppuration following on caries. 4. Tuberculous hyperplasia of glands Avithout much destructive change in the lung. The authors found that in the early stages and with limited lesions leucocytosis was absent. Leucocytosis increased with the occurrence of softening in tubercular foci. When fibroid lesions predominated leucocytosis was absent. Leucocytosis appears after haemoptysis (as after all forms of hiemorrhage), but subsequently disappears. They ascribe the occurrence of leucocytosis, not to the action of the specific organism of tuberculosis, but to a secondary infection by various virulent bacteria and micrococci which leads to the breaking down of the lung. They agree with Maragliano that the phenomena of the ' hectic ' stage of tuberculosis have nothing to do with tuber- culous infection, but are to be ascribed to the action of streptococci, staphylococci, and other organisms. The writer has expressed his dissent from this view elsewhere (vide p. 324). Cabot's ^ conclusions as to the state of the blood in tuberculosis are as follows : 1. The red corpuscles are usually normal. 2. The haemoglobin is diminished. 3. Both red corpuscles and haemoglobin are in some cases diminished. 4. The leucocytes undergo no changes in character. As to the occurrence of leucocytosis in pulmonary tubercu- losis, his statements agree in the main with those of Stein and Erbmann. 1. In the early stages the white corpuscles are normal. 2. After an attack of htemoptysis they are increased. 3. If cavities are present, there is no leucocytosis ; if increased, there is no cavity. 4. With extensive infiltration of the lungs (tubercular pneumonia) there may be marked leucocytosis, but this is not invariable. 6. In fibroid tuberculosis there is no increase of leucocytes. ' Deul. Archiv. filr Klin. Med. December 1895. ^ Yearbook of Treatment^ 1897, p. -i^, Dr. Schorstein. CHRONIC PULMONARY TUBERCULOSIS 371 6. If fever is absent there is no leucocytosis. If pyrexia is due "to the presence of pyogenic organisms, there is an increase in the white corpuscles ; if not, there is no leucocytosis. Djjsjvuea. — In cases of chronic tuberculosis the patient generally admits that he is * short of breath ' on exertion, but there is rarely a subjective sensation of dyspnoea until towards the end of the disease, unless emphysema has preceded tuberculosis. Urgent dyspnoea, apart from evidence of very extensive disease, should always suggest the presence of miliary tuberculosis of the previously unaffected parts of ihe lungs. Patients of the neurotic type often present this symptom in an unusual degree. Pulse. — An increase in the pulse rate is generally present when the disease is extending and there is considerable pyrexia, but the frequency of the pulse is influenced more by the strength of the patient than by the degree of fever (Wilson Fox). As a rule, how- ■ever, a slow pulse is associated with a moderate degree of pyrexia. The pulse rate falls after 9 p.m. and rises generally in the morn- ing after 5 a.m. (Edward Smith). Wilson Fox's observations show ■that the quickest pulses were usually observed in the morning. In the later stages of the chronic disease the pulse is usually very rapid and of low tension, and attacks of pseudo-angina and •of palpitation are common. The latter are especially observed in patients with marked retraction of the left lung (Powell). A rapid pulse with a low temperature is usually a sign of ex- haustion. Emaciation. — So long as the morbid process continues active the patient, generally speaking, loses weight, but it is not uncommon in hospital patients for a moderate increase of weight to accompany for a time an extension of the disease. This is a natural result of more abundant food and improved surroundings, and usually only continues for a short period. Should, however, no favourable change then occur, the weight previously gained is lost and emaciation progresses. Quiescence of the morbid process or its arrest is usually followed by an increase of weight. Loss of weight may take place, although pyrexia is absent, in ■chronic cases attended by a failure of vital power. Digestive system. — The onset of the disease is frequently accompanied by loss of appetite, thirst, and signs of gastric catarrh, and during its course disorders of digestion generally attend periods •of increased activity of the morbid process. As a general rule, if the appetite is good, digestion is unimpaired, and vice versa. The tongue is often covered with a thin fur and dotted with red papillae, or a thin white fur may be present over certain areas, whilst the remainder of the tongue is clean and the mucus mem- Tjrane looks red and irritable. When gastric symptoms are promi- nent the tongue may be thickly coated. An atonic condition of the ■digestive organs is usually accompanied by a large pale flabby iiongue with its edges marked by the teeth. B B 2 372 THE DISEASES OF THE LUNC.S In the later stages of the disease, when there is continuous; pyrexia of a remittent type, and when possibly ulceration of the intestine is present, the tongue is often red, raw, dry, and fissured. When the tongue is completely free from fur, red, and deeply marked by transverse fissures, it is important to ascertain that this is not, as it may be, its normal condition, as, owing to such a pos- sibility having been overlooked, we have known very erroneous inferences drawn. Vomiting is a common symptom in the later stages of the disease, but it may occur at quite an early period, even before the appearance of any well-marked physical signs in the lungs. When, as is frequently the case, it only occurs after a severe paroxysm of cough, it may be unconnected with any disorder of digestion ; but during periods of active change in the lungs vomiting is apt to occur shortly after meals, and may then possibly be due to an irritant lesion of the pneumogastric nerve. The early stages of the disease and periods marked by digestive disturbances may be attended by constipation, but this is not as a rule a marked symptom. Diarrhoea may appear early in the disease, and in some cases it occurs during its course from slight causes, such as errors in diet,, and passes otf imder appropriate treatment. When, however, as is more commonly the case, it first appears at a late stage of the disease, it is generally an indication of the presence of ulceration of the intestine. It is not necessarily proportionate in severity to the extent of the lesions, and may be absent in cases attended by widespread ulceration of both the small and large intestine. When there are signs of the presence of amyloid disease of other viscera, diarrhoea may be due to a similar condition of the intestine. Pain and tenderness on pressure may accompany ulceration of the bowel, but it is rarely severe, and may be slight or absent in cases attended by severe diarrhd'a. Hfemorrhage from the bowel is an event of rare occurrence. Fistula in ano occurs far more frequently in males than females,, being indeed exceedingly rare in the latter subjects. It may precede the development of obvious tuberculosis, but as a rule it forms after the disease has made considerable advance in the lungs. In such cases it is extremely probable that a tubercular ulcer has preceded the fistula. On reference to the table given on p. 802 it will be observed that tubercular ulceration of the rectum was found in 44 out of 828 cases examined post mortem, or in IS'O per cent. PHYSICAL SIGNS The signs present in the early period of chronic pulmonary tuberculosis must necessarily be iiitei-preted according to our know- ledge of its morbid anatomy, although little is certainly known of CHRONIC PULMONARY TUBERCULOSIS 373 the exact relation between the pathological conditions and the physical signs which mark this stage of the disease. Notwithstanding this fact, the anatomical basis is the most con- A^enient for purposes of description, and we shall consider the signs which attend (a) the stage of infiltration, ( b ) the softening of the tubercular lesion, (c) the formation of a cavity, and (d) the contrac- tion of a cavity, in the above order. Signs attending tubercular infiltration.— Inspec- tion. — The chief parts to which attention should be directed are the supra- and infra-clavicular regions. At a very early period nothing definite may be observed, but if the area of the lung affected is of some extent the expansion of the upper part of the chest on the ■corresponding side is diminished. This is often more noticeable if the observer stands behind the patient and looks over his shoulders, or if, when standing in front of the patient, he places his thumbs upon the second ribs below the clavicles, and fixes his eyes upon his thumbs while the patient breathes deeply. Palpation. — Changes in the vocal fremitus are of great importance in determining the presence of disease of the apex m an ■early stage. Beneath the right clavicle the vocal fremitus is nor- mally more distinct than on the left, and the trained hand acquires a standard by which variations from the normal are judged. If the vocal fremitus is equal on the two sides, and well marked, it is probably increased at the left apex, and a presumption _ arises that the left upper lobe is the seat of disease. If the fremitus is more marked at the left apex than the right, the presumption that the left upper lobe is affected is still stronger. If, on the other hand, the vocal fremitus beneath the clavicles is equal, but less marked than normal, probably the voice conduction is diminished at the right apex, and the condition of the right upper lobe must be carefully investigated in the further course of the examination. Percussion. — In the early stage a slight difference in the percussion note may sometimes be elicited by tapping the clavicles, -when elsewhere a difference is unappreciable. Resonance may not ■extend so high above the clavicle on one side as on the other, or a slight difference in the percussion note on the two sides may only be present when the breath is held after a deep inspiration, owing to the lesser amount of air which enters the affected lung. Firm percussion in the supra-spinous fosss will often elicit a dull note when the evidence obtained from the examination of the front of the chest is doubtful. Auscultation. — Normally, the respiratory murmur is slightly higher pitched on the right side, and expiration is rather more prolonged ; but the breath sounds may be bronchial beneath the right clavicle, when there is no disease at the apex of the right lung. This is a fruitful source of error in diagnosis, one of the most common mistakes of an inexperienced auscultator being the discovery of a cavity at this site when no lesion of any kind is really present. It is difficult to make an absolute statement as to the condi- 374 THE DISEASES OF THE LUNGS tion of the breath sounds at this stage. They are variously stated to be harsher than normal and weaker than normal. There is- probably considerable variation in this respect ; but, as a rule, the harsh wavy breath sound with prolonged expiration precedes the stage of feeble breathing. In the latter condition there is little difficulty in arriving at a correct diagnosis, as, when the breath sound is feeble, adventitious sounds can usually be elicited by making the patient cough, whereas with harsh, wavy, interrupted breathing rales are generally absent. It may often be noticed that when the breathing above the clavicle and immediately below it is feeble, the breath sounds in the second and possibly in the third niterspace present the harsh, wavy, interrupted character. In such cases it is certain that the area of most advanced disease underlies the site of feeble breathing. In neurotic subjects wavy, interrupted breath sounds do not necessarily indicate disease, and the condition is then bilateral.. Conduction of the voice and also of the heart sounds to the apex is facilitated by consolidation of the lung, and this increase of vocal resonance may be present when the area of disease is limited,. The presence of a systolic murmur in the subclavian artery is not a sign of much value in doubtful cases. As the area aft'ected becomes more densely infiltrated, the breath sounds become high pitched and acquire a bronchial or blowing character, which is present both on inspiration and expiration ; bronchophony may now be audible. The breath sounds over the posterior apex of the lower lobe may be harsh or bronchial, indicating that infiltration is in progress there. When the breathing is feeble at one apex it is often puerile over the opposite upper lobe from increased functional activity of the part — a favoiu'able condition, the presence of which should always be looked for. In such cases error as to the site of the disease is not uncommon, the feeble breath sound being overlooked and the significance of the harsh sound misinterpreted. Increase of functional activity is indicated by puerile breathing, increased expansion, and possibly also by enlargement of the part, whilst a harsh, wavy, interrupted breath sound, from which the vesicular quality is absent, and diminished expansion, are signs of the presence of disease. Adrcniitious sounds are, as a rule, absent at the earliest period, the first to appear being fine ' dry ' rales, often heard only with deep inspiration, and then limited to a single rale, or perhaps three or four such sounds may be heard, possibly only whilst the patient coughs. This rale is not so fine as ' crepitation ' (the ' fine crepitation ' of pneumonia), and when several such rales are present the individual crackles are not separated by equal intervals as in the crepitation of pneumonia. These rales may disappear if the disease becomes arrested at this stage, but as a rule they pass at a later period into sounds of a 'clicking' character, audible both on inspira- tion and expiration, but more distinct during the former act. CHRONIC PULMONARY TUBERCULOSIS 375 In doubtful cases one should never omit to note the effect of cough in the production of rales. A careful examination of the supra-spinous fossae is as necessary in all cases as of the supra- and infra-clavicular regions ; the signs in this situation often show that the disease is more advanced on the posterior aspect of the lung, and a positive diagnosis may often be made after an examination of this region when the investigation of the front of the chest has yielded doubtful results. The signs above described may never develop into those which mark the second stage of the pathological process. Post-mortem and clinical experience afford abundant proof of the frequency of arrest of the disease in the stage of infiltration. When arrest has occurred the breath sounds at the apex are usually weak, and rtxles are absent. The lesion contracts from the formation of fibroid tissue, emphysematous bullse are formed, the surface of the lung becomes puckered, and the percussion note more resonant. There is usually little if any retraction of the upper part of the chest with arrest in this stage. Softening of the tubercular lesion. — The altered character of the adventitious sounds affords the first evidence that the process of softening has commenced. The rales become more numerous, larger, and more ' liquid.' They are variously termed ' clicks,' medium sized and large crepitant rales, moist crepitation and humid crackle. Signs of softening may also possibly be detected at the apex of the lower lobe, and the area of infiltration along the interlobar septum will have extended. The breath sounds are now high pitched, blowing or bronchial, and the vesicular quality may be quite lost. The vocal resonance is increased, and bronchophony or even pectoriloquy may be present. The formation of a cavity. — The process of softening gradually merges in chronic cases into that of excavation. A case which has but recently advanced to this stage, and in which fibrous changes are only present to a moderate degree, may present some or all of the following signs : Insijection. — The point of the shoulder is depressed and the scapula and clavicle are prominent, the supra-clavicular and supra- spinous fossae are sunken, the pectoral region is flattened, and the first and second intercostal spaces are wide and deep ; there is a well-marked difference of expansion on the two sides. With disease at the left apex, the cardiac impulse may be slightly displaced upwards. Paljmtion. — Vocal fremitus is markedly increased both in front and in the supra-spinous fossae. Percussion. — The note is either high pitched and wooden or has a tubular or tympanitic quality. A tubular note gene- rally indicates that the cavity is surrounded by consolidated lung. A cavity of large size, with thin walls, near to the surface of the 376 THE DISEASES OF THE LUNGS lung, may give the cracked-pot sound on forcible percussion during inspiration, the patient's mouth being open at the time. The percussion note may indicate some degree of enlargement of the upper lobe of the opposite lung. Auscultation. — The typical breath sound is termed cavernous, the expiratory sound being lower pitched, more hollow, and more prolonged than the inspiratory. It may be metallic, and with a large ca^'ity may present the amphoric character. In some cases over a large cavity the breath sound is absent, or it may be absent in the first interspace but distinctly cavernous below. During or after cough, however, the nature of the condition usually becomes clear. The typical adventitious sounds are metallic or coarse gurgling rales ; they require for their production air and fluid in the cavity and a patent bronchus, conditions which are usually present in cases in the stage here described. Kales produced in the neighbourhood of a cavity may, howevei', acquire a metallic or ' echoing ' character. With a thin-walled cavity the post-tussive suction sound may be heard. Evidence of excavation may also be found at the apex of the lower lobe of the lung primarily affected, and of still more extensive infiltration with softening in that lobe. Pectoriloquy of both varieties is common, but it may be here remarked that whispering pectoriloquy is one of the most fallacious signs of the presence of a cavity. Signs of excavation with contraction. — The signs of a chronic contracted cavity at the apex of one lung, with induration around and marked thickening of the pleura, are as follows : Inspection. — The upper part of the chest is usually much con- tracted, and there may be some degree of curvature of the spine. Expansion may be absent ; the interspaces are depressed. In disease of the left upper lobe the heart may be markedly displaced lapwards and slightly outwards, and the impulse may be seen and felt in the third left interspace or even higher. If the lower lobe is also contracted, the apex beat may be in the left axilla. With contraction of a cavity in the right upper lobe the heart may be displaced to the right, and may lie Avholly to that side of tin- sternum. The displacement is less marked if, as sometimes occurs, there is great compensatory enlargement of the right middle lobe. With a contracted cavity at the left apex, pulsation may be observed over the cardiac area, owing to the heart having been either uncovered or displaced, and also close to the sternum in the second and third left interspaces from uncovering or displacement of the pulmonary artery, or uncovering of the auricular appendix. Percussion.- — There is high-pitched wooden dulness over the site of disease from thickening of the pleura and induration of the lung, and marked increase in the sense of resistance. The en- largement of the opposite upper lobe may be shown by the fact that there is resonance on percussion for two inches or more beyond the mid-sternal line towards the diseased side. CHRONIC PULMONARY TUBERCULOSIS 377 Auscultation. — There may be complete absence of breath sound in front, but if the arm is raised and the end of the stetho- scope placed at the apex of the axilla cavernous breathing will generally be detected. The cavity will probably be dry, and there may be no adventitious sounds. If there are any they ai-e of a metallic quality. The impulse of the displaced heart may cause a systolic ' air- wave ' murmur in the cavity (vide p. 67), and the murmur may be audible in the trachea or mouth, or even at a distance from the patient when his mouth is open. With a contracted cavity at the left apex, a loud systolic murmur, due either to displacement and compression of the pul- monary artery or to narrowing of the subclavian artery, may be heard in the first and second left interspaces. The writer has known such a case to be regarded for some time as one of valvular disease of the heart. There may now be evidence of contracted cavities surrounded by indurated tissue in the corresponding lower lobe. If the change in the opposite lung is chiefly emphysematous, the breath sound over the upper lobe will be Aveak ; if, on the other hand, as is commonly the case, it is in part at least hypertrophic and associated with increased functional activity, the breath sounds there will be harsh and expiration will be prolonged. DIAGNOSIS The recognition of the disease has been much facilitated by the discovery of the bacillus tuberculosis. In all cases of doubt the •diagnosis is greatly influenced by the results of the examination of the sputa. The presence of tubercle bacilli in the sputa is conclusive, and now that we are provided with an absolute positive test of the tubercular nature of a pulmonary lesion, the use of this method of •examination should be considered necessary in all cases, no matter how clear may be the indications derived from the clinical history and the physical examination of the chest. In some cases repeated examinations of the sputa are necessary, as bacilli may be absent at some period in all forms of the disease, except perhaps in cases accompanied by active softening. In a case of extensive disease of the larynx, considered for some •time by most competent observers to be certainly tubercular — a view the correctness of which was rendered extremely probable by the presence of obvious signs of a lesion at the apex of the right lung — repeated examination of the sputa for tubercle bacilli gave negative results. The use of this test had not at first been con- sidered necessary, as the import of the physical signs was thought to be unmistakable. Subsequently the syphilitic nature of the disease was rendered at any rate extremely probable by a very .marked improvement immediately following the administration of 378 THE DISEASES OF THE LUNGS iodide of potassium. The patient ultimately recovered completely,, physical signs of some induration alone remaining at the right apex ; but a moderate degree of laryngeal stenosis was produced, and will probably be permanent. In a case of fibroid tuberculosis of the left apex under the care of the writer no bacilli were found in the sputa on repeated examinations extending over a month during the first stay of the patient in hospital ; a few were then discovered. On subsequent admission after an interval of nearly a year tubercle bacilli were found at the first examination, whilst during a third stay in hospital of nearly three months' duration they were absent. If, on repeated examination of the expectoration, no tubercle bacilli are found, an exact diagnosis may not be possible, but, as just stated, the condition is not inconsistent with the presence of a fibroid lesion. If, however, there is evidence of extensive destructive disease of the lungs, accompanied by the formation of large cavities, and the sputa are free from bacilli, it is almost certain that the disease is not tubercular. The Museum of the Brompton Hospital contains many specimens illus- trating the occurrence of such lesions as a result of non-tubercular disease. This siibject is discussed in the chapter on Pulmonary Syphilis {vide p. 429). After a primary attack of h;emoptysis there may be no signs sufficiently definite to indicate the site of the lesion, and yet the disease may be proved to be tubercular by the discovery of bacilli in the expectorated blood. More often, however, the expectorated blood in such cases does not contain bacilli ; under these circum- stances, or when the blood has not been examined for tubercle bacilli, patients are often told that the blood has come from the back of the throat or elsewhere, and cannot have come from the lungs, as there are no signs of disease to be discovered in those oi'gans — a diagnosis the correctness of which is rarely borne out by the subsequent history of the case. The diagnosis may be attended with difficulty when the sym- ptoms suggest tubercular disease, but the physical signs are of doubtful import and there is no expectoration. The cases in which the above conditions are fulfilled are very often delicate-looking young women suffering from anaemia. In such cases, and in all others included in this category, it is a golden rule never to make a diagnosis of tuberculosis from doubtful physical signs, and particularly not from a single sign. The examination of the chest must be systematic ; the evidence obtained on inspection and palpation must be considered with and must agree with that derived from percussion and auscultation. When the signs, separately considered, are of doubtful import, but are yet in harmony and all point in one direction, a positive opinion may be given. But the observer must beware of relying upon auscultation with its many fallacies, and a definite opinion should rarely be given in doubtful cases unless a record of the morning and evening temperature for at least a week is available. The CHRONIC PULMONARY TUBERCULOSIS 379 absence of pyrexia is not conclusive, but it tells against a diagnosis of tubercular disease. When there is clear evidence of a pulmonary lesion, but expectoration is absent, or no tubercle bacilli can be found in it on repeated examination, the exact site of the lesions is, as we have already pointed out, a factor of great importance in estimating the probability of the disease being tubercular. As, however, primary basic tubercular disease, although ex- tremely rare, does occur, any particular case may happen to be of this nature. Pseudo-tuberculosis. — The use of this tenii, which appears to be gaining ground, is, we think, to be deprecated. It is applied to diseases which either present a superficial likeness to pulmonary tuberculosis or produce lesions similar to those of tubercle. A natural result of the systematic examination of the expectoration for tubercle bacilli, which we have long foreseen and which has mainly influenced the writer in insisting on the necessity of so doing, and. on the use of the term ' pulmonary tuberculosis ' as opposed to ' phthisis,' is the discovery that other agents besides the tubercle bacillus are capable of producing destructive disease of the lung, and also of lesions elsewhere which somewhat resemble those of tubercle. This is, however, in our opinion, no justification for the use of such a term as ' pseudo-tuberculosis.' It is an incentive to discover the nature of such diseases and to adopt a terminology based on etiological grounds. This point is further considered in the section dealing with diseases due to the presence of moulds and fungi {vide p. 459). PEOGNOSIS The prognosis in cases of the miliary, caseous, and fibroid varieties of the disease has already been described. In chronic pulmonary tuberculosis a prognosis is formed by a careful consideration of the following points : 1. The stage of the morbid process. 2. The rate of progress in relation to the duration of the symptoms. 3. The condition of the unaffected lung. 4. The character of the general symptoms. 5. The presence of complications. 6. The constitutional state and family history, including the age and sex of the patient. 1. The stage of the morbid process. — That arrest most commonly occurs in the stage of infiltration is abundantly proved both by clinical experience and by the nature of the obsolete lesions found on examination post-mortem of persons dying from non- tuberculous disease. In nearly 2,400 autopsies at the Middlesex Hospital obsolete tubercular lesions were found in the lungs in 219 or 9 per cent.' ' ' Arrested Pulmonary Tuberculosis,' J. K. Fowler. 38o THE DISEASES OF THE EUN(tS In 176 cases the lesion was either fibroid and pigmented, or caseous or calcareo-caseons. In 48 cases the word ' cavity ' occurs in the report. It does not, however, follow that in all these cases it was, or had ever been, a cavity recognisable by methods of clinical examination. In many cases so described the appearance of excavation is produced by the growth around a caseous mass of a fibrous capsule, which becomes smooth within — a condition which is often described in post-mortem reports as a cavity with hlackish-grey caseous contents. The complete cicatrisation and obliteration of a cavity, recognised as such during life, must be an event of very rare occurrence. The writer has never met with an example of such a condition. Arrest in the cavity stage may be complete and life may be in- definitely prolonged. The writer is acquainted with a lady who has at the left apex a well-marked -cavity which was almost certainly formed more than fifty years ago. As a rule, when arrest has occurred after the formation of a cavity, death, although possibly occurring after a very long interval, is due to tuberculous disease or to some lesion incidental to its presence. In cases marked in the early stage by an acute course the evacuation of the necrosed tissue is often followed either by decided improvement or a complete arrest of the disease. Arrest of the disease may occur after the lower lobe has become affected, and the writer has made an autopsy on a case in which complete arrest had taken place after a cavity had formed in that situation. As a rule, however, when a cavity has formed at one apex and there is extensive infiltration of the lower lobe on the same side, say for a distance of five inches along the line of the interlobar septum, the disease does not undergo complete and permanent arrest, although for long periods there may be little or no evidence of its extension. Such cases not uncommonly develop the characters of the very chronic type already described, the cavity becoming dry and surrounded by indurated lung and the pleura undergoing extreme thickening. The presence of a lesion at both apices is quite consistent with the occurrence of arrest ; it is, in fact, more common post-mortem to find lesions at both apices than at one only. The writer's results in 177 cases of obsolete tubercle were as follows : llight lung ....... 35 Left „ 36 Both lungs 106 177 Dr. Sidney Martin ' in 42 cases obtained similar results : Right lung 12 Left „ 9 Both lungs 21 42" ' Brit. Med. Journal, Oct. 31, 1891. CHRONIC PULMONARY TUBERCULOSIS 381 As it is contrary to clinical experience to find both apices simultaneously attacked and for the lesions to be equally distributed through the upper lobes, it follows that in such cases one lung is affected after the other and probaljly after arrest has taken place. The special danger which attends the condition of quiescence or arrest in the cavity stage is the formation and rupture of a pul- monary aneurism. 2. The rate of progress in relation to the duration of the symptoms is a very important factor in prognosis in the early stage of pulmonai'y tuberculosis. Signs that softening is in progress in the upper lobe and that the lower lobe is extensively infiltrated, the disease having been present for only a brief period, are necessarily of unfavourable import. But, again, it must be stated that many cases of an acute or subacute character at the outset subsequently undergo a favour- able change, and a period of quiescence if not of arrest follows. 3. The condition of the unaffected lung should be carefully noted in all cases. Enlargement accompanied by signs of increased functional activity of the upper lobe of the opposite lung are of decidedly favouraljle import, and their absence has a contrary significance. Early involvement of both lungs usually implies a rapid course ; but exceptions to this rule, as indeed to nearly all others with regard to prognosis in this disease, are not uncommonly observed. 4. The character of the general symptoms. — The state of the digestion and appetite, upon the maintenance of which nutrition necessarily depends, are factors of great importance in prognosis. When from almost every other aspect a case is un- favourable we may still be hopeful of a patient who has a good appetite and an unimpaired digestion, as in such cases a period of quiescence usually arrives sooner or later, and even should the course be progressive it will almost certainly be slow. It is rarely wise to express a positive opinion as to the immediate outlook without a knowledge of the course of the temperature, and the longer the period over which the observations have extended the better. The significance of the various types of fever as regards the character of the morbid process has been considered in the chapter on Pyrexia in Tuberculosis (p. 323). The most unfavourable condition in a chronic case is the sudden occurrence of continued pyrexia with very slight remissions, as it usually indicates the presence of acute miliary tuberculosis of parts of the lungs hitherto unaffected. The occurrence of pyrexia of the inverse type at an advanced stage of the disease — a point to which far too little attention has hitherto been given — is of hardly less unfavourable import. Of thirty cases of tuberculosis of the lungs, mostly of the chronic variety, under the care of the writer in the Brompton Hospital, in which this type of pyrexia was observed, fourteen died in hospital and one immediately after returning home ; eight left the hosjutal worse, some of them decidedly so (of these, all had lost weight) ;. 382 THE DISEASES OF THE LUNGS five were either ' relieved ' or about the same, but of these three had lost weight, and in the other two the gain of weight was trifling (i lb. and f| lb.). Of the thirty cases only tw^o improved, and in one of these the morning temperature was higher than the evening on two occasions only ; in the other the condition was of temporary duration, and was observed on eight occasions. A high evening temperature with morning remissions stands next in point of gravity. Moderate pyrexia with a normal or only slightly subnormal morning temperature is of favourable import. A complete absence of pyrexia associated with a gain of weight, diminished cough and expectoration, fewer bacilli in the sputa, and physical signs indicating quiescence of the disease together consti- tute the most hopeful condition. If the general state of the patient, the course of the tempera- ture, and the gain or loss of weight are considered as a whole, it is not difiicult to form a trustworthy prognosis for the immediate future. Error generally arises from undue attention having been given to a single aspect of the case. The significance, for example, of a low temperature depends entirely upon the general state. If this is one of exhaustion, the condition is very unfavourable. The physical signs, again, may on the first examination appear to indicate the presence of rapid softening with extension of the disease ; but this may be shown by subsequent observation of the temperature, and by a progressive gain of weight, to have been a mistaken inference. Perhaps no single element in prognosis is of greater importance than the condition of the appetite and digestion. 5. The presence of complications. — Laryngeal tubercu- losis.— In cases presenting this complication the prognosis is generally very unfavourable. As a rule it appears late in the course of the disease. The use of lactic acid has certainly rendered the outlook in such cases somewhat less unfavourable, and, if employed at an early stage, cicatrisation of an ulcer of limited extent may be hoped for from this mode of treatment. Spontaneous cicatrisation of a tubercular ulcer of the larynx may, however, occur, but such cases are very rarely met with. In the very rare cases in which the affection of the larynx is either primary or out of proportion to the extent of the pulmonary disease the prognosis is even more unfavourable. It is said, how- ever, that some cases in which the laryngeal affection, although not primary, appears early in the disease run a protracted course. Hcemoptysis. — The innnediate gravity of this symptom depends very much upon the stage of the morbid process at the time of its occurrence. In that of excavation a profuse hfcmoptysis is of very serious import, as it suggests the presence of a pulmonary aneurism. In 2H8 cases of profuse htemoptysis analysed by Dr. Theodore Williams, death was directly due to the hjemorrhage in 63, the per- centage of deaths in the progressive stages of infiltration, softening, and excavation being 13-1)5, 24-01, and 07-74 respectively. CHRONIC PULMONARY TUBERCULOSIS 383 The influence of haemoptysis upon the duration of Hfe in chronic tuberculosis depends in a similar manner upon the stage of the morbid process at tlie time of its occurrence. In the first stage the ■effect is but slight, whilst in the second and third it is very appreciable. Pneumonia, using the term in the sense in which we have em- ployed it elsewhere in this work — viz. to indicate the disease usually termed acute pneumonia or lobar pneumonia — is in our experience a very rare complication of the chronic form of the disease, but the occurrence is attended with considerable danger to life. Eecovery with resolution may occur ; but, if softening of the consolidated area follows, the downward progress is greatly accelerated. Bronchitis, especially if the smaller tubes are affected, is very liable to be followed by broncho-pneumonia, and in cases associated with extensive emphysema, or in which but little healthy "tissue remains, it may prove fatal. Pleural effusion. — It is difficult to state in anything like precise terms the effect of pleural effusion upon the course of •chronic pulmonary tuberculosis. Osier ^ is of opinion that the early implication of the pleura gives 'a stamp of chronicity to the case.' Possibly this may be due in part to the adhesion of the surfaces preventing the occurrence of pneumothorax. A sero-fibrinous effusion, even if tubercular, as it commonly is, may be completely absorbed, but the occurrence of a purulent or An hsemorrhagic effusion is certainly of very unfavourable import. It must be remembered, also, that in cases of sero-fibrinous effusion of tubercular origni, the infection of the pleura may be only a part •of general miliary tuberculosis. The relation of the various forms of pleural effusion to pulmonary tuberculosis is considered in the chapter on Pleurisy. Diarrhoea. — Severe diarrhoea often precedes the fatal termina- tion, and whether due to ulceration of the intestine — the most <5ommon cause- -or to lardaceous disease, the condition is almost equally unfavourable from the point of view of prognosis. Albuminuria. — The importance of the presence of albumen in the urine as a guide to prognosis depends entirely upon the cause of the condition. On reference to the table in which the lesions associated with pulmonary tuberculosis are given [vide p. 858), it will be seen that amyloid disease of the kidneys was found in 6*1 per cent., parenchymatous or interstitial nephritis in 6-7 per cent., and either miliary or caseous tubercles in 6-5 per cent, of the cases. If the albuminuria is due to the occurrence of any one of these lesions in an advanced stage, it is a sign of grave import. In order to determine its cause, the urine must be further examined microscopically for casts and for tubercle bacilli. It may be mentioned here that the discovery of tubercle bacilli in the urine is much facilitated by the use of the centri- i'ugator. The quantity of urine passed, the amount of albumen ' 'Tuberculous Pleurisy,' The Shattuck Lecture, p. 41. 384 THE DISEASES OF THE LUNGS present, the specific gravity of the urine, the nature of the casts (if any are found), the occurrence of degenerative changes in the vessels, and of hypertrophy of the heart, and of evidence of amyloid disease of other organs, are points which need careful consideration before an opinion can be given as to the cause of the albuminuria. That it is not necessarily of grave import is shown by the fact that in a case reported by Dr. Williams the patient was living eight years after albumen was found in the urine. Fncnmothorax. — This is of far more frequent occurrence as a compUcation of caseous tuberculosis than of the chronic form. The condition of the opposite lung is the chief guide in prognosis. If this is healthy or only slightly diseased, and the general condition of the patient is good, the air may be ultimately absorbed from the pleura, and the lung of the affected side may re-expand to some extent. When, however, there are extensive lesions in both lungs, a rapidly fatal termination is the rule. In thirty-nine cases collected by Sir K. Douglas-Powell ' in which death occurred after pneumo- thorax, the average duration of life was only twenty-seven days. One patient lived for twelve months, one for four and a half months, and one for four months. Death may occur in as short a period as ten minutes.. Dr. Williams ^ has recorded cases observed in private practice in which the results were much more favourable. In one case life was prolonged for twenty-one years, and in others recovery followed. Even should pyopneumothorax follow, the condition may become chronic. An out-patient in this condition attended under the care of the writer at the r>rompton Hospital for several years. His chief object in so doing was to demonstrate the ' succussion splash ' and receive the gi-atuities of the students. In rare cases the occurrence of pneumothorax leads to arrest of the disease, the condition of collapse of the lung which follows acting as a barrier to the further extension of the lesions, either through the air passages or lymphatics. Tlu' subject is more fully considered in the chapter {vide p. Q'^^'l) on Pneumothorax. Per lion it is. — The presence of any form of peritonitis as a com- plication of chronic tuberculosis of the lungs is a very unfavourable conditi(m. The peritonitis may be acute or chronic, simple or tubercu- lar, and either general or localised. Acute general peritonitis due to perforation of a tubercular ulcer of the intestine, or to tubercular ulceration without perforation is the most grave form of this compHcation. General tubercular peritonitis is frequently re- covered from when it occurs as a primary disease, but very rarely when it appears in a case in which the lungs are already extensively affected. A chronic tubercular peritonitis limited to the pelvis or elsewhere is a less serious complication. ' 0]>. lit. p. 1( -l. - Op. cit. p. 213. 38s CHAPTER XXXV CHEONIC PULMONAEY TUBEECULOSIS (confinued) TREATMENT "The subject of treatment is considered under the following headings : 1. Prophylactic (p. 385). 2. Prevention of infection (p. 386). 3. General : Food, alcohol, open-air, exercise (p. 389). 4. Specific and antiseptic remedies (p. 396). 5. Tonic remedies (p. 402). 6. Symptomatic, including the treatment of complications (p. 404). 7. Climatic (p. 408). Prophylactic. — A child of tubercular parentage requires unusual care. It should, if possible, be suckled by a healthy wet nurse, never by the mother, and during infancy and throughout the whole period of childhood special attention must be given to the ■diet, which should be both abundant and easily assimilated, and consist during the earlier years chiefly of milk, cream, eggs, and meat juice. The child should be weighed at regular intervals, and .a record kept of the results ; a progressive increase in weight being the best evidence that the food is suitable and that nutrition is well maintained. Under present conditions it is practically impossible for most people to be sure of the freedom from tubercular infection of the source of their milk supply, and, as already stated, milk is a most : active vehicle for the virus. Adults must in such a mattei' use their discretion ; but for children, particularly those of tubercular parentage, all the milk used should previously have been boiled. Such children should, if possible, be brought up in the country .and in a dry bracing air. Their rooms should be well ventilated both by day and night, and they should be much out of doors, and c c 386 THE DISEASES OE THE LUNGS exercises tending to promote the expansion of tlie chest may he commenced at an earlier age than usual. The clothing should be light but warm, and chiefly of woollen materials. The bath, during infancy and up to the age of about five years, will of course be warm, but after that age the tonic effect of a brief application of cold water may generally be included in the measures which are taken to promote bodily vigour. Sea air and salt water baths are of special value in these cases, especially when any glandular enlargement is present. Acute diseases, particularly measles and whooping-cough, which are apt to be complicated by bronchitis and broncho-pneumonia, should never in these subjects be regarded as ' childish ailments ' requiring little care. The condition of the throat and naso-pharynx requires careful attention. Enlargement of the tonsils may be followed by changes in neighbouring lymph glands, and through this path the specific virus of tubercle not unfrequently enters the body, whilst adenoid growths impede nasal respiration and diminish the expansion of tlie thorax. At a later period of life, a residence at a high altitude, by pro- moting deep breathing combined with the invigorating effect of pure mountain air, is of great service in developing the resisting power to tubercular infection. By the adoption of such measures the inherited defect of con- stitution may be overcome, and the child may grow up to manhood and escape the disease. These children are often highly intelligent, and therefore suffer no ultimate loss from their education in youth having been consi- dered as of secondary importance to the attainment of a high degree of bodily vigour. The view that tubercular parents may convey to their offspring a constitution which renders them more prone than others to deveh^p the disease is generally accepted by the laity, but the logical inference that individuals thus affected should not marry is very often set aside on the ground of exceptional circumstances. Although this liability specially affects children of tubercular parentage, it is certainly not limited to them. The offspring of the feeble-l)odied are likely to possess less resisting power than the children of the strong and healthy, and are therefore more prone to become the subjects of tul)erculosis. It is the duty of the medical attendant, if consulted, to point out the risk attendant upon the marriage and particularly the iiiter-marriiige of such persons. Prevention of infection. — The important question of the mode of origin of pulmonary tuberculosis is discussed elsewhere (vide p. 304 seq.). As already stated, if the view of its specific nature is accepted, there is no escape from the inference that in the great majority of cases the virus enters the body from without the exceptions being those cases in which tuberculosis is directly trans- mitted from parent to offspring, it follows that it is the duty of CHRONIC PULMONARY TUBERCULOSIS 387 everyone suffering from the disease to guard against becoming an agent in spreading infection. This he can do by refraining from expectorating in any public or private place, except into a disinfecting solution or a pocket handkerchief, and by not sending linen soiled by sputa to a laundry without previous disinfection. In hospitals for consumption there is little difticulty in framing and carrying out regulations by which the occurrence of infection can be effectually prevented, and it should not be thought that too much is asked of tubercular patients if both in public and private they are expected to adopt similar precautions. The following are the regulations adopted at the Brompton Hospital with a view to prevent the spread of infection : SjnUum. — {a) Each patient is provided with a spitting-cup, and similar cups are placed on the staircases, and in the pas- sages, out-patient department, and garden. Each spitting-cup contains one ounce of carbolic acid solution (1 in 20). (b) All knives, forks, spoons, and cups used in the wards are washed thoroughly with hot water to which washing soda has been added, and are then subjected to the action of boiling water for at least two minutes. (c) Handkerchiefs of a distinctive pattern are supplied to the in-patients, and are destroyed after use. No patient is allowed to use any other than a hospital pocket handkerchief. Each patient is provided with at least one clean pocket handkerchief daily. (d) All linen soiled with tuberculous matter is kept separate, and boiled in a vessel reserved for that purpose. (e) The sputum is disposed of as follows : the spitting cups are collected twice daily and removed in covered metal receptacles, s^Decially provided for that purpose, to the place where the sputum is destroyed. For the destruction of the sputum by heat, and also of the general refuse of the hospital, which may contain tuberculous matter, an automatic ' Destructor ' is used. This consists of a chamber the interior of which can be raised to a white heat. Each spitting-cup, after having been emptied into a vessel, is immediately placed in a vessel containing carbolic acid solution (] in 20). After all the spitting-cups have been emptied, they are placed for at least two minutes in water which is kept boiling, or are sub- jected to the action of super-heated steam. They are then cleaned and returned to the galleries. Printed directions describing the measures to be adopted to prevent infection are placed in the wards and out-patient rooms, and handbills giving information of a like character are given to out-patients at the discretion of the Assistant Physicians. c c 2 388 THE DISEASES OF THE T.UNGS Rules to be obseeved by Nurses The following are the rules to be observed by nurses in the wards : 1. Nurses are immediately to report to the Sister-in-charge any patient whom they observe spitting upon the floor, or in the fireplaces or washing basins, or elseAvhere than in the spitting- cups. 2. Nurses are to see that the spitting-cups and bed-pans are properly supplied with the disinfecting solution provided — carbolic acid solution (1 in 20) — and are on no account to allow the contents of them to become dry. 3. The contents of the bed-pans are to be mixed with more dis- infectant before being emptied, and the vessels are then to be thoroughly washed with boiling water. 4. In dusting the galleries special care is to be taken to wipe up the dust and not to raise it into the air. The duster should be damp and should not be shaken. All dusters after use are to be treated as soiled linen. 5. Nurses are to call the attention of the Sister-in-charge to any linen soiled by expectoration or otherwise, and such linen is to be kept separate and boiled before being sent to the laundry. 6. Nurses should be careful to wash their hands after contact with expectoration. Directions to Patients (These are suspended in the Galleries.) 1. Patients are required to use the spitting-cups provided in the hospital and grounds. Any patient infringing this rule by spitting upon the walls or floor, or in the fireplaces or washing basins, or elsewhere, is liable to be discharged. 2. Patients are required to use the pocket handkerchiefs provided by the hospital. Each patient will l)e provided with a clean hand- kerchief daily. 3. The expectoration should on no account be swallowed, as by so doing other organs of the body may become affected. Directions to Out-Patients {These are placed in the Waiting Boom.) Inasmuch as consumption is under certain circumstances a communicable disease, and as the chief source of danger is the expectoration or phlegm, especially wJicn it has become dry, the following precautions are desirable : 1. Never spit about the streets or on the floor or in the fire- place, or into any vessel unless it contains a disinfectant. 2. When indoors always use a cup or jar or hand spittoon containing a tablespoonful of strong solution of washing soda or CHRONIC PULMONARY TUBERCULOSIS 389 other disinfectant. Empty it daily down the water-closet ; never empty it upon the dust-heap. 3. When empty wash it thoroughly with boiling water and add a tablespoonful of the disinfectant (carbolic acid solution, 1 in 20). 1 4. Handkerchiefs used by consumptive patients should be fre- quently changed, at least once daily, and should be scalded before being washed. 5. Do not swallow the expectoration, as by so doing other organs of the body may become affected. 6. Keep your room well aired and clean. 7. A consumptive patient should, if possible, occupy a separate bedroom. 8. Any room which has been occupied by a consumptive patient should be thoroughly cleansed before again being used. 9. Milk may be a source of danger, and should be boiled before use. It has been shown that, if proper precautions are adopted, the dust from wards inhabited by tuberculous patients does not contain the virus of the disease ; but, in the dwellings of the poor, rooms so occupied are very likely, owing to neglect of proper safeguards, to become centres of infection. It will doubtless in time become the general practice to thoroughly disinfect such rooms, and in the interests of the community it should, as is now the case in some towns, be done at the public expense in the case of the poorer classes. Various portable spittoons have been devised, but it is difficult to induce patients, at any rate in this country, to carry them, and, provided the pocket handkerchief is frequently changed, and when soiled is plunged into boiling water, little risk of disseminating the virus is entailed by its use. The possibility of the transmission of the disease from husband to wife has been already discussed {vide p. 306). Localised tuber- cular infection has been clearly proved in a few cases to have been due to kissing on the lips. General. — The arrest of the disease is effected by the agency of forces which are inherent in all living organisms, and these are continually in operation even when the morbid process is most active. The main object of treatment is, therefore, to develop this resisting power of the individual, and so to enable the tissues either to destroy the specific organism, or to shut off from the body areas of disease in which it may be present. The maintenance of the nutrition is one of the most important objects to be kept in view in the treatment. At some future date the proper mode of administration of a specific remedy may occupy this place, but it is not so at present. Every patient ' This is given to the patients. 390 THE DISEASES OF THE LUNGS \vitli tuberculosis of the lungs should endeavour to increase in weight ; if he can grow fat he need have little fear that the disease is making progress. Hospital patients who have come from poor homes and have been ill fed may gain weight whilst the disease continues to advance, but this is rarely the case with those who have throughout their illness enjoyed every comfort which money can provide. Although in such cases the weight may be maintained whilst the appetite continues good, there is, as a rule, a close relation between the activity of the morbid process, as evidenced by the type and degree of the pyrexia, and the state of the nutrition. Tubercular patients with active disease require a much larger quan- tity of food than those in health, in order to compensate for the increased waste of tissue which it entails, and if the digestion is unimpaired they can usually assimilate well. In addition to the ordinary hours of meals, there are certain times in the day when food may with advantage be given to such patients ; these are early in the morning, about 11 a.m., just before bedtime, and in some cases during the night. A glass of hot milk given before the attack of coughing, which commonly occurs shortly after waking in the morning, assists expectoration and counteracts the feeling of exhaustion which often follows, and a tablespoonful of rum may be usefully added to the milk in cases with advanced mischief. At 11 a.m. a tumblerful of milk with some biscuits, or a cup of beef tea, is preferable to the glass of port wine which is com- monly recommended in such cases at this time. At bedtime a cup of some warm food prepared with milk, such as bread and milk sweetened, or arrowroot, helps to induce sleep, and by promoting expectoration relieves the attack of coughing, which in chi'onic cases often occurs on lying down. Some hot liquid food during the night generally relieves cough and promotes sleep more effectually than the administration of a sedative linctus or a draught. Attention to this point is a matter of the greatest importance in the treatment of all forms of tuber- culosis accompanied by active changes in the lungs. Various ' food- warmers ' are sold in which the heat from a night-light is utilised for the purpose of warming liquid food. The food taken at the ordinary mealtimes should be plain, well cooked, and as nourishing and varied as possible. Mutton and beef with fatty and starchy foods should enter largely into the dietary, but it is not, in our experience, either necessary or desirable to formulate a rigid diet table for such patients. They find it irk- some, and usually discard it after a short trial. Individual pro- clivities require to be considered, and they will be found to vary widely. During periods of acute illness, the diet should be abundant even to the point of excess, and such as is suitable for the febrile state. The use of various special articles of food has been from time to time advocated, but in this country, at any rate, they have not retained a permanent place in the dietary. CHRONIC PULMONARY TUBERCULOSIS 391 The ' Koumiss ' treatment, as carried out in Tartary, and particularly in the re,t;ion of Tsamara on the borders of the Caspian Hea, consists in drinking large quantities of the fermented milk of mares, unworked, and grazing on the Steppes. Koumiss is prepared from coAv's milk and sold in this country, hut its use at the Brornp- ton Hospital has not been attended by any very marked results. The Koumiss treatment, like many others, is attended with greater success in its native home than elsewhere, but its use has proved of undoubted value in cases accompanied by irritability of the stomach and frequent vomiting. Two pints or more may be given during the day, other kinds of food being almost withheld. The writer has no personal experience of the value of the ' raw-meat treatment.' It is highly spoken of on the Continent, but is hardly likely to come into favour here. Alcohol. — Stout, bitter ale, wine, or alcohol in some form taken with meals is often of great service by promoting appetite, and its use may enable a tubercular patient to take a much larger quantity of food than he otherwise would. The administration of large quantities of alcohol, apart from the urgent necessity which may arise from failure of vital power, has not, however, in the writer's experience been necessary, although some authorities, notably Flint, Brehmer of Gobersdorf, and Dettweiler of Falken- stein,' speak strongly in its favour. There is no evidence that the admittedly injurious effects of alcohol taken apart from food are not experienced in this disease, and we have frequently observed that patients who have previously been addicted to alcoholic excess suffer, when attacked by tuberculosis, far more severely, ■chiefly from loss of appetite, inability to digest food, and a very irritable cough, than those who have led temperate lives. During periods of acute illness and in the later stages of a chronic case, when strength is failing, brandy or champagne is the best stimulant. Open-air treatment. — There is a general agreement as to "the great value of the mode of treatment to which the above name is now applied, which was first systematised and successfully carried out by the late Dr. Brehmer at Gobersdorf, in Silesia. Many other Sanatoria have been founded in Germany upon his model ; of these, Falkenstein in the Taunus, until lately conducted by Dr. Dettweiler ; Rieboldsgruen in Saxony (Dr. Driver) ; St. Blasien in Baden (Dr. Haufe) ; Gobersdorf (Dr. Eoempler) ; Hohen- honnef on the Ehine, Altenbrak, and St. Andreasberg in the Harz ; Heidschloss (Holstein) ; Nordrach (Baden) ; Schomberg (Wurtem- burg) ; Kehburg (near Hanover) are the chief. Similar institutions are also to be found at Davos and Arosa in Switzerland. It will be seen that most of these Sanatoria are situated in mountainous places, although not at such high altitudes as the Swiss Alpine resorts. In these institutions the patients live under the close supervision ' Quoted, but not endorsed, by Dr. Burney Yeo, p. 98. 392 THE DISEASES OF THE LUNGS of the resident physicians, and every detail of their hfe is regulated in a manner rarely attempted in this country, and to which few Englishmen are willing to submit at the bidding of their own countrymen. The leading idea of the method is that as much of the day as possible should be spent in the open air. Either continuously or in the intervals of exercises the patients lie in covered balconies or in ' liegehalle,' or in hammocks stretched between pine trees and exposed to the sun and protected from the wind. Patients with active or advanced disease remain at rest in bed- rooms with open windows, either all the day or during the period when fever is present, whilst those who are less seriously ill spend some hours daily in walking or hill-climbing, and rest in the intervals. Most of the patients thus pass from seven to eleven hours daily in the open air in all kinds of weather. Dettweiler attaches most importance to rest in the open air, but Brehmer regards methodical hill-climbing as a factor of great importance in this method of treatment. Much importance is rightly attached in these Sanatoria to the maintenance of nutrition, food being taken frequently but in moderate quantity at each meal. The following is the dietary and distribution of mealtimes generally adopted : ' ' Breakfast between 7 and 8 a.m., consisting of coffee, cocoa, tea, white or brown bread and butter, and a glass of milk. At 10 o'clock, luncheon, consisting of from one to two glasses of milk and bread and butter, or perhaps broth, eggs, &c., and a glass of wine to finish with. At one o'clock, dinner of soup and three other courses, two of meat with vegetables and one of pudding, with one or two glasses of wine. About 4 p.m. afternoon tea (a repetition of the early breakfast) ; at 7 p.m. supper, of one or two courses, one cold and one hot with vegetables, and one glass of wine ; at 9 p.m. a glass of milk with two or three teaspoonfuls of cognac' The above applies to ordinary cases, not to such as from the presence of fever or other cause are upon a special diet. The following results are claimed by Dr. Brehmer of Gobersdorf to have followed this mode of treatment in 5,032 cases out of 5,440 during the eleven years from 1876-1886. No detailed reports are available of the remaining 408 cases. stage of disease Number Cured Nearly cured Total I. II. III. 1,390 (27-0%) 2,'2'25 (11-2%) 1,517 (28-17%) 5,032 387 (27-8%) 152 (6-8%) 12 (-8%) 551 (11%) 4.30 (31%) 325 (14-6%) 33 (2-3%) 788 (15-6%) 817 (58-8%) 477 (21-4%) 45 (3-14%) 1,539 (26-6%) ' Sanatoria for Consumptives, Von .laruntowsky. Dr. E. Clifford Beale. Englisli translation bi) CHRONIC PULMONARY TUBERCULOSIS 393 Inquiry made in 1890 into the subsequent history of cases described as ' cured ' or ' nearly cured ' showed that in five cases the cure had lasted from 20 to 29 years, in 52 cases from 12 to 21 years, in 38 cases from 7 to 12 years. Of forty patients discharged in 1876 as cured or nearly cured, and of whom particulars could be ascertained in 1890, twenty-five were therL living and in good health, one was suffering from ' fibroid phthisis,' one died in 1886 from ' phthisis,' and thirteen others had died from unknown causes. For the following account of the Sanatorium at Nordrach, which is under the direction of Dr. Otto Walther and can be thoroughly recommended, the writer is indebted to a former House Physician at the Brompton Hospital, himself a sufferer from tuber- culosis and for twelve months a patient under treatment at Nordrach. We take this opportunity of stating that we have never observed, coincident with the complete arrest of advanced disease, a more complete physical change in any individual. Before the onset of the disease he was thin and somewhat gaunt in appearance ; his height was 5 ft. 10 in., and his weight 11 st. After a severe illness, marked for fifteen weeks by continuous pyrexia and great emaciation, he went to Nordrach, whence he has lately returned so altered as to be scarcely recognisable, presenting an appearance of robust health, somewhat stout, and weighing 13 st. 10 lb. Physical examination of the chest indicates that complete arrest of the disease had taken place. ' Nordrach is a small village in the Baden Black Forest, nine miles from Biberach Zell, the nearest station on the Schwarzwald Bahn, and thirty miles distant from Strasburg. It is situated in a cul-de-sac at the remote end of a beautiful sub-alpine valley, 1,400 ft. above the sea. The valley is open to the south-west, and shut in by a horse-shoe-shaped range of hills rising another 1,400 ft. on the north and east. These hills are clothed with miles of pine forests, which prevent dust and afford walks sheltered from wind. The rainfall of the district is considerable at all seasons, so that the air is frequently washed free from impurities, and the floor of the valley is kept green by many springs and streams. On the other hand the geological formation is red sandstone, which rapidly absorbs the heaviest showers and leaves all paths in good condition for walking. The climate is almost as variable as that of England, but warmer in summer and colder in winter. The atmosphere is exceedingly pure, free from dust and charged with moisture, which has a marked influence in allaying cough. The Sanatorium consists of four houses, containing in all about forty-two bedrooms and a separate dining- hall, all carefully constructed to avoid the formation of dust, to cause patients while indoors to be practically in the open air, and to give the minimum exertion to those in bed. ' To these ends the Avails and ceiling of each room are of varnished wood, the floor covered with linoleum, which is swabbed with water every morning ; there is ample window space, and a hot-air heating apparatus. The large casement windows are practically open all 394 THE DISEASES OF THE LIJNGS the year round, so that thereis the least possible difference between the temperature of the air within and without ; as a consequence, colds are almost unknown. The walks on the surroundmg forest slopes are extremely varied and picturesque, the nearer specially laid out on easy gradients with benches at short intervals, and there are several small shelters for storms ; and the more distant paths are everywhere open to patients. Of anuisements, with the exception of occasional music, there are practically none, excitement and irregular exertion of all kinds being regarded as hindrances to the absolute mental and physical quietude which is considered a necessary part of the treatment The main features of the treat- ment by which it is sought to effect a really permanent cure are as follows : ' 1. An absolutely open-air life for every variety of case, whether acute or chronic, accompanied by fever or apyrexial, in all weathers and seasons, by night as by day. ' 2. A regular course from first to last of over-feeding — stuffing would be a more appropriate term — with a rich and varied diet, including much meat, milk, fatty and farinaceous food, given in large quantities at a time, with long intervals between the meals. ' 3. A judicious combination of exercise (hill-climbing), carefully regulated and carried out so as always to fall short of producing either dyspna-a or fatigue, in order not to iiiterfere with the pro- cesses of repair, with the maximum amount of mental and physical rest. ' 4. Every patient is under the constant personal supervision of the physician — a vital and distinctive factor in the treatment. ' During a year's residence at Nordrach the writer has never known a patient take a cold or chill. Every arrangement tends to force patients into the open air, and to overcome their natural timidity of draughts and damp clothes. It is found from experience, which has been very fully tested, that no amount of exposure to draughts or wet, or any variation of weather, causes the most delicate patient to take cold or any other harm, so long as an open- air life is led. Casement windows forming almost one side of the bedroom are almost always open, though closed at times in winter to warm the room when it is unoccupied. The windows of the dining-hall are actually taken out during a large part of the year. Patients have no sitting-rooms, and must be out all morn- ing for the daily walk, however short. This kind of life, at first uncomfortable, becomes in time quite natural, induces a hardening to cold and heat, and renders a return to town life at first quite distasteful. ' Three meals are given in the day ; breakfast, at 8 a.m., consists of coffee, bread and butter, and cold meat, such as ham, tongue, sausage, .Vc, and a half litre of milk. This after a time is reduced to a quarter litre, according to the patient's capacity and need for putting on flesh. Dinner at one o'clock consists of two hot courses of meat, or fish and meat, about four to six ounces being served to CHRONIC PULMONARY TUBERCULOSIS 395 each patient, with plenty of potatoes and green vegetables, and sauces in which butter is the main ingredient. The third course may be pastry, or farinaceous pudding, fruit and ice cream, with coffee and a half litre of milk. Supper at seven usually consists of one hot meat course as at dinner, and one cold, as at breakfast ; tea, and a half litre of milk. The two latter meals must be taken under the supervision of the Resident Physician, and servants may not take away the plates until everything has been eaten. Roughly speaking, the patient eats about double the amount of food he desires. Pyrexial cases in bed have the same diet, with if anything slightly larger portions ; and it is found that absolute rest in bed and over- feeding are the most potent means of reducing temperature. Patients rest on their couches from 12 to 1, and from 6 to 7, before meals. On this plan, patients invariably gain weight, averaging two, three, and even four pounds a week for the first few weeks, and afterwards by smaller increments. Not only fat but firm muscle is formed, and it is not uncommon for patients to gain one quarter to one third of their total weight in this way. ' Patients are not unfrequently sick during or shortly after a meal ; if this happens, they come back and finish the meal, finding as a rule no difficulty in retaining the remainder. 'The rest before meals and the long intervals between are valuable aids to complete assimilation, and dyspepsia is on the whole rare ; if present, it usually disappears as nutrition improves. ' Cases of active disease with high fever are treated by rest in bed, over-feeding, and usually by isolation, any exertion, such as talking, being spared as much as possible. When the temperature remains below 38° C. in the evening, and below 37° C. in the morning for a week or ten days, the patient is allowed a short walk in the morning, beginning with fifty yards or so, and gradually increasing the chstance tentatively. If the temperature tends to rise in the mornings to 37° C. or above, rest is resorted to again. ' Patients take their own temperatures in the rectum four times daily : on waking, at 12 m., immediately after the walk, at 5.30 p.m., and before going to bed. An average good morning temperature would be 36'3 C. '4, or '5, and after the walk a degree or a little more higher. This exertion temperature should in most cases not exceed 38° C. and must be taken at once, as it often falls rapidly in the first few minutes. 'Walking must be at a very slow uniform pace, and at first several rests should be taken, so as never to cause the least fatigue. Talking, except during rests, should be avoided, particularly when going uphill, and special cases are sometimes sent to walk by them- selves. The first part of the walk is usually an ascent, then a horizontal portion and a descent home. ' As energy revives, the distance is cautiously increased, regard being given to the temperature, until several miles can be done, involving a climb of five or six hundred feet during the morning ; but a slow, steady gait must always be observed. The afternoon is 396 THE DISEASES OF THE LUNGS usually spent in rest or a short walk, and patients go to bed about nine to half-past. The physician visits each patient three times daily, before each meal, except those who are convalescent ; to such patients one visit daily is considered sufficient. ' Every patient has one of Dettweiler's pocket flasks, and a cup in his bedroom to receive sputum, and spitting elsewhere is for- bidden. ' The chest is examined monthly, and at the same time the expectoration is very carefully examined for tubercle bacilli. The results of this treatment are in the majority of cases extra- ordinary. Dyspepsia disappears, antemia gives place to a healthy colour, weight is made to the extent of twenty to fifty pounds, cough and expectoration diminish, and physical signs correspondingly decrease, the whole constitution becoming totally reorganised. Finally, bacilli can no longer be found in the expectoration. As a final test, some expectoration is injected under the skin of a guinea- pig and an interval of three or four weeks is allowed to elapse. If no signs of tuberculosis develop in the animal, the patient is allowed to return home, often to do moderate work at once, which is regarded as the best mode of securing the favourable changes induced in the lungs.' ^Ye are glad to hear that the writer proposes to establish a sanatorium conducted on similar lines in this country, as such an institution is much needed, and England is now far behind con- tinental countries, particularly Germany and Switzerland, in the facilities it aftbrds for the ' open-air ' treatment of tubercular disease of the lungs. Exerci.se. — The more exercise the patient is able to take in the open air the better ; the exact form must depend upon a variety of considerations, but in all cases it should stop short of producing fatigue. Riding on horseback, or, for moderate distances, on a bicycle, although tiring to the beginner, are modes of taking exer- cise which entail comparatively little eft'ort upon the experienced.. Walking, particularly up gentle ascents, is especially valuable as promoting more complete expansion of the lungs. For patients with limited, or more or less completely arrested, disease, many of whom are found during the winter at St. Moritz, Davos, and other Alpine resorts, skating is, whilst they are there, a most suitable exercise. Curling and golf are also good forms of exercise for such patients. When no longer strong enough for these forms of exercise already mentioned, it is generally advisable for the patient, if his means allow of it, unless the disease is very advanced or there is high and continuous fever, to be out in a carriage or a bath chair, or reclining in the open air in some protected spot during part of the day. Specific treatment : tuberculin. — On August 4, 1890, eight years after his memorable discovery of the tubercle bacillus, Koch stated, at a general meeting of the International Medical Congress at Berlin, that he had, as a result of prolonged research, found 'a substance which, when inoculated into a guinea pig, CHRONIC PULMONARY TUBERCULOSIS 397 renders it incapable of reacting to the inoculation of the tubercular virus ; the same substance in guinea-pigs already attacked with advanced and generalised tuberculosis brings about a complete arrest of the development of the malady without the animal suffer- ing any harmful effects from the influence of the remedy.' On November IB, 1890, Koch published^ the results observed to follow the use of this remedy in tuberculous patients. The substance proved to be a glycerine extract of pure cultures ■of the tubercle bacillus. The great interest excited throughout the world by this •iinnouncement is still fresh in our memories ; the lamentable lack of judgment, of self-control, and of those critical faculties which should characterise the members of a scientific profession, displayed by many upon that occasion, may serve as a warning for the future. The history of medicine in still more recent times, however, appears to prove that the tendency to exploit for selfish purposes each new discovery in therapeutics, and to recommend it as a panacea for •almost every ailment of mankind, is ineradicable from the minds of the weaker brethren. The results of a prolonged and careful trial of tuberculin in cases of pulmonary tuberculosis under the care of eight physicians at the Brompton Hospital are thus summarised in a report signed by Drs. C. Theodore Williams and John Tatham : ' 1. That tuberculin, if introduced under the skin, speedily causes inflammatory changes in and around tubercular lesions. ' 2. That the action of tuberculin in lung tuberculosis is to cause iDreaking down of the tubercular masses and of the lung tissue in the neighbourhood, and thus to promote the formation of cavities. That this is the case is proved by (a) the appearance of lung tissue in the sputum, where it was previously absent, and (&) by the physical signs of cavity replacing those of consolidation. ' 3. That tuberculin increases the amount of expectoration, but that there is no proof that it diminishes the number of tubercle bacilli contained therein, for, in some of the patients, they apparently increased under its use. ' 4. That in many cases tuberculin injections are followed by a •distinct extension of disease, as evidenced by physical signs. ' 5. That the reactions due to tuberculin are exhausting to the patient, and cause loss of weight and strength. ' 6. That this treatment is specially contra-indicated in lung tuberculosis accompanied by pyrexia, as likely to convert intermittent into continuous pyrexia. ' 7. That lung excavation accompanying the use of tuberculin may be followed by contractile changes, due to increase of fibrosis. This was shown in two of the cases under observation, where diminution of cough and expectoration and gain of weight took place. * 8. That the tuberculin did not favourably influence the course of ' Deutsche Med. Wochenschr., No. 46a. 398 THE DISEASP:S OF THE LUNGS the disease in the majority of cases ; that in some the effects were detrimental ; and that even in the stationary and impvoved cases it was difficult to ascribe any distinct improvement to the injections, which might not have been equally attained under the treatment ordinarily employed in the hospital.' Professor Koch has recently ' stated that he still regards tuberculin as the best remedy against tuberculosis, but at the same time he brings forward three new preparations — viz., tuberculin A, O, and R, of which the last is recommended for clinical use. ' Tuberculin and R are prepared by vigorously pounding in a mortar dried cultures of the tubercle bacillus, and then adding distilled water. The whole is centrifugalised in a powerful machine. The clear but opalescent liquid collecting at the top contains no tubercle bacilli, and constitutes in the first centrifugalisation tiiberculin O. The remainder, containing the debris of the tubercle bacilli, forms tuberculin R. This remainder is dried and pounded, distilled water added, and the whole again centrifugalised. This process is repeated until hardly any residue remains. Twenty per cent, glycerine is then added to both preparations to ensure theii' preservation. The dose, by subcutaneous injection, is 1-500 mgr. to begin with. An injection is given every other day, and the dose is gradually increased up to 20 mgr.' If the temperature rise the injections should be stopped. It is claimed for the tuberculin R that it exerts both immunising and curative effects, and that cases of tuberculosis and lupus in an early stage are without exception greatly improved by its administra- tion, and that no unfavourable results attend its use. Guinea-pigs thus treated were so completely immunised that injections of virulent cultitres had no effect. Our experience of this remedy is not yet sufficient to justify any statement of opinion as to its value. Koch states that cases of tubercular disease in which the tem- perature rises above 100° -4 F. are not suitable for this mode of treatment, as such a degree of fever indicates the presence of mixed infection (streptococci and septic organisms). We have considered this question elsewhere {vide p. ;-i24). The discovery of tuberculin has undoubtedly proved of the greatest service to medical science, both by suggesting work on similar lines in connection with the toxines of other diseases, and by providing a test for the presence of tubercle in cattle. When its use foi' this purpose becomes general, and the slaughter of animals thus proved to be infected is made compulsory, milk will no longer be a source of infection, and the incidence of tubercular disease in childhood will probably be markedly diminished. Its value as a test for the presence of tubercle in human beings is not great, as reactions are obtained in several other diseases. A chaut of the temperature during the ' reaction ' produced by ' Iknl. Med. Wnch., April 1, ls'.)7, p. 20!). CHRONIC PULMONARY TUBERCULOSIS 399 the injection of tuberculin is subjoined in order to emphasise the fact that it is a remedy which produces fever. We are strongly of opinion that no remedy which has this effect is admissible in the treatment of tubercular disease of the lungs. The patient from whom this chart was obtained was under treatment with tuberculin for a period of thirty- six days, during which thirty-one injections of tuberculin were given. The dose was gradually increased from -001 cc. to -1 cc. During the course of the treatment four calcareous particles, one of which was surrounded by pigmented lung tissue and also another small portion of lung tissue, were expectorated, and signs of a small excavation appeared at the apex of one lung. These facts are sufficient to prove the great danger of lighting up active changes in quiescent lesions which attends the use of tuberculin in doses sufficient to produce fever. Fortunately the form of disease present in this case was markedly fibroid, and no subsequent ill-effects followed the treatment adopted. /Vol' mbrr Decembtr Day of Month 29 30 1 R M. A.M. P. M . A.M. g II 12 ZA5 3 S.30 7 3 12 1.15 Z 3 4- 7 8 9 12 h 9 I 1 105° 105° 104° 103° 102° 10 1° 100° 99° 98° 97^ ( 1 ! y r^ ^^ ^ V fs^ / /^ "^ ^ 1 i X >- N V ' J ^ Fic 109. — Pyeexi.\ during the ' Reaction ' produced by the Injection of Tuberculin Klein (Arthur) ^ has lately attempted to prove that the action of tubercuHn is not upon the specific virus of the disease, but upon the pyogenic organisms, streptococcus pyogenes, pneumococcus and the staphylococcus aureus, present in association with the tubercular lesions, and that the phenomena of the ' reaction ' are due to the multiphcation and increased virulence of these organisms. He was led to this conclusion primarily by the discovery of inflammatory lesions in which these organisms were present in great abundance around tubercular foci in patients dying whilst under treatment with tuberculin. This view, however, is disproved by the fact that the reaction is observed in perfectly healthy animals, and also by the clinical observation that with fibroid pulmonary lesions the ' UrsacJicn dcr TubcTcuUmvcrkung, 1893, Wien. 400 THE DISEASES OF THE LUNGS reaction is often more marked than when cavities are pi'esent con- taining multitudes of pyogenic organisms. We have ah-eady expressed the view that, speaking generally, the degree of pyrexia in a case of pulmonary tuberculosis is a measure of the activity of the disease, and that the fever is due to the action of the toxine produced by the bacillus, and is not the result of septic infection. It is possible that in the future an anti- toxin for tuberculosis may be discovered ; in that event we believe that its most obvious effect will be to lower the temperature. Serum treatment. — E. Maragliano of Genoa' claims to have produced a serum having a specific curative action on tuber- culosis. The serum is obtained from dogs, asses, and horses which have been injected with the highly toxic principles extracted from living bacilli. The exact nature of these ' principles ' is not stated. Maragliano claims - that in his own hands and those of his colleagues great success has attended the use of this serum. Indeed, he states that, in all afebrile cases with circumscribed lesions in which the treatment was thoroughly carried out a ' cure ' resulted. This is certainly the class of case in which favourable results may be expected from the use of a new remedy. In cases in which a cavity was present the percentage of cures was 7'7. Maragliano's conclusions are as follows : 1. The remedy has been proved to be quite innocuous. 2. It has caused subsidence of the fever. 3. It has had a modifying influence on local morbid processes. 4. It has caused the bacilli contained in the sputum to diminish in number or to disappear. The results obtained in Germany have not Ijeen of the favourable character claimed by Maragliano ; indeed, its use appears to have been attended with failure. We are unable from personal expe- rience to express an opinion as to the value of this mode of treat- ment. Nucleins. Nucleins are complex proteid bodies containing a large quantity of phosphorus. Nuclein, which consists of an organic phosphorus-containing acid termed ' nucleic acid 'in com- bination with proteid, is the chief chemical constituent of the living parts of cells. Nucleins may be obtained from yeast, yolk of egg, the spleen and other sources. The administration of these substances has been ol)served to be attended by an increase in the white corpuscles of the blood,'' and some nucleins are believed to possess bactericidal properties, the germicidal action of blood serum l)eing probably due to the presence of nuclein derived from the polynuclear white corpuscles. Nucleins have been given in a limited number of cases of pulmonary tuberculosis with the object of aiding phiigocytosis and increasing the resisting power of the organism, and in the incipient stage of the disease benefit is said to have resulted. ' Brit. Med. Journal, 1895, ii. 444. - Gaz. Med. Lombarda, April 20, 1896. * V. C. Vaughan, Journal of American Medical Assoc. 1H94, i. 824. ' CHRONIC PULMONARY TUBERCULOSIS 401 Antiseptic treatment. — This method of treatment was ■employed long before the specific nature of the disease was proved ; but, like many others, it fell into disuse. It has however, since then, been revived, and at the present time has the support of many physicians of experience. Antiseptic remedies may be administered with a vieAV to destroy the specific organism or to influence its vitality, or to influence the action of associated micro-organisms. Experiments undertaken with a view to determine the effect of various antiseptic agents upon tubercular sputa ' have shown that after an exposure for 20 hours to the action of a. 1 per cent, solution of creasote in water, of a 2 per cent, solution of carbolic acid in water, of a saturated solution of iodoform in water, or to volatilised iodoform or terebene, the organisms are still active, but a 3 per cent, aqueous solution of carbolic acid destroys the virulence of sputa in 20 hours. It has also been shown "-^ that the vapour of creasote and eucalyptus in contact with the surface of an agar culture of the bacillus has no effect upon the growth of the organism. Inocula- tion with a virulent culture of tubercle bacilli emulsified in a liquid holding in suspension 10 per cent, of iodoform is followed by generalised lesions, but the addition of the antiseptic agent modifies the activity of the morbid process. The evidence at present available tends to show that no antiseptic agent can be administered internally in sufficient doses to kill the tubercle bacilli in the lungs. It does not, however, follow that, as antiseptic remedies cannot be given in sufficient doses to destroy the tubercle bacillus in the lungs, they can exert no beneficial influence upon the course of the disease. They may possibly increase the resisting power of the pulmonary tissue to the action of the toxine of tubercle or they may modify the action of the septic organisms which are in some cases also present in the part affected. The latter no doubt assist in the local extension of the mischief, but, as already stated, periods of activity of the morbid process are accompanied by an increase in those lesions which are of a strictly tubercular nature. We have given a prolonged trial to drugs of this class — e.g. pure beech wood creasote, guaiacol carbonate, and benzosol — and, in default of better remedies, still continue to use them ; but with every desire to observe the highly beneficial effects which have been stated to follow their use, we are obliged to confess that we think those claims much exaggerated. It is now generally admitted that antiseptic remedies are of but little use during the acute phases of the disease, and it can hardly be denied that it is extremely difficult to be certain of the effects of remedies which are employed when the resisting forces inherent in the body have already proved sufficient either to overcome the virus •or at any rate to hold it in check. • Schill and Fischer, Mitt. a. d. kais. Gesund., BcT. 2, 1884, p. 133. '' P. Villemin, Thise de Paris, 1888. D D 402 THE DISEASES OF THE LUNGS For internal administration we prefer pure beechwood creasote, which is best given iii the form of 'pedes ' or palatinoids, each con- taining two or three minims of the drug. Of these perles two may be given three times daily with meals to begin with, and the dose may be gradually increased until the patient is taking from fifteen to twenty minims of the drug daily. Some writers, however, advocate the use of much larger doses. We are glad to observe that a protest has recently been raised against the use of this drug in the excessive doses sometimes recommended, a method of treatment to which the term ' creasotic orgie ' (!) has been applied. We have rarely found creasote interfere with digestion ; if this should happen, its use should be discontinued, as in the treatment of tuberculosis the assimilation of food is of far greater importance than the administration of any drug. Guaiacol carbonate may be given in cachets, in doses of eight to fifteen grains three times daily, and the dose may be gradually increased to twenty grains or even more. Benzosol may also be given, either in cachets or tabloids, in similar doses. Sterilised oil of guaiacol may be administered by subcutaneous injection, but no decided advantage counterbalances the obvious objections to this mode of treatment. Of the direct injection into the lungs of creasote or guaiacol we have no experience, and the use of these remedies in this disease by the method of intra-laryngeal injection has not been in our experience attended by any benefit. ^'arious other remedies of the antiseptic class have from time to time been employed, but as we have no experience of their use we refrain from mentioning them. For these, as for so many other remedies, the favourable results at first claimed have not been sub- stantiated by subsequent experience. So soon as any remedy is discovered which exercises a decided influence upon the virus, its eft'ects will probably be so easy to recognise that the matter will be speedily placed beyond the possi- bility of doubt. Antiseptic agents may also be employed in the volatile form as inhalations or sprays. Dr. Burney Yeo speaks highly of the favour- able effects of the continuous inhalation of equal parts of either creasote or carbolic acid and spirits of chloroform, in modifying the course of the disease and preventing infection of the larynx ; and Wilson Fox admitted the value of tliis method of treatment. One of the chief results observed to follow its use is a diminution in the amount of the expectoration. Eucalyptol, iodine, iodoform in ether, and oleum pini sylvestris are other agents of this class which may be used in the form of inhalations. Tonic remedies. Of these the most valuable are cod-liver oil, the hypophosphites, arsenic, quinine, nux vomica, mineral acids, and vegetable bitters such as gentian. As a general rule, their usefulness is most nuirked during periods of quiescence of the disease. CHRONIC PULMONARY TUBERCULOSIS 403 Cod-liver oil. — Owing to improved methods of preparation, cod-liver oil is now far less nauseous than formerly, and only the pure pale ' tasteless ' oil should be prescribed. The favourable effects of this remedy are specially observed during the apyrexial periods of the chronic variety of the disease,. a steady improvement in the nutrition of the body being the best evidence of its beneficial action. Continuous fever or even a high evening tem-perature, and the presence of gastric or intestinal catarrh, are conditions which con- tra-indicate its use, and it is rarely wise to force the remedy upon a patient who expresses a decided distaste for it, and never if it pro- duces nausea and impairs the appetite. As a rule, patients take the oil much more readily during cold than hot weather ; many Avho can assimilate it during the winter months being obliged to discontinue its use during the height of summer. Children usually take cod-liver oil withovit difficulty, and many acquire a decided taste for it. The best effects are obtained from moderate doses ; one to two teaspoonfuls may be taken twice or three times daily after meals for long periods. Some patients, who are unable to digest the oil after meals, are able to take it at bedtime without subsequent nausea. Cod-liver oil may be enclosed in capsules, or its taste may be disguised by some vehicle, such as orange or steel wine or lemon juice. At the Brompton Hospital, cold coffee with salt sprinkled on the surface of the oil has been found efficacious for this purpose. Some, who are unable to digest it when pure, can take it in the form of an emulsion, or in combination with creasote (creasote, jH,v— X, ol. morrh. 3ij, twice daily). Many remedies, such as pancreatic emulsion, cream, maltine, are used either as substitutes for cod-liver oil when from one cause or another the oil cannot be taken, or are given in combination with it. All those named are of service ; glycerine is another, but of more doubtful value. The administration of the hypophosphites of calcium, sodium, and potassium, but especially the former, is indicated in the early and less acute stages of chronic tuberculosis, and particularly in young subjects. These remedies may be given in the form of syrups, and in combination with iron and other tonics. The following is a useful formula : I^ calcis hypophosphitis, gr. v. ; syrupi ferri phosphatis, 5j; glycerini, 5j; inf. gent. co. ad 3 j ; ter in die. Arsenic. — In the early periods, and in chronic cases combined with asthma, much benefit has been observed to follow the ad- ministration of arsenic (Williams). Many physicians indeed regard it as a remedy of the greatest importance. Our own experience, however, is in accord with that of Dr. Burney Yeo, who states that he has not obtained any very brilliant results from its use. It is chiefly of service in cases associated with anemia. Iron, in the form of the syrup of the iodide or phosphate, is D D 2 404 THE DISEASES OF THE LUNGS indicated in cases accompanied by glandular enlargements, such as occur in young subjects. It may also be given with advantage, when marked anaemia is present, in the form of Blaud's pills, pro- vided that cough is not a prominent symptom. The disadvantages attending the administration of iron in pulmonary tuberculosis are that it increases the liability to haemorrhage, and if cough is present it may be made worse. Treatment of Special Symptoms Fever. — We have already dwelt upon the importance of this symptom as a guide to the degree of the activity of the morbid process. At the present time we are provided with many directly anti- pyretic remedies, but their usefulness in the treatment of tuberciilosis is somewhat limited. The temperature certainly falls after their administration, bixt, when the efi'ect of the dose has worn off, it rises again to its previous height. No improvement in the general condition of the patient, or in the physical signs, is observed to accompany the period of diminished pyrexia thus produced, and it is quite clear that these remedies exert no beneficial influence upon the activity of the morbid process, although during their admini- stration the patient may experience relief from certain unpleasant sensations which are the result of the high fever. In many cases, indeed, effects of a markedly depressing character attend their use. When the pyrexia is continuous, or the evening temperature very high, and the morning remission of short duration, it is essential that the patient should remain completely at rest. This is the first and most important measure to be adopted, and without it all others are likely to prove of little effect. A decided diminu- tion of the fever and an improvement in the general condition frequently occur, simply from keeping the patient in bed for a short period. Sponging the body with tepid water, to which some eau-de- Cologne or toilet vinegar may be added, generally has a very refreshing and tonic effect, and is a mode of lowering the tempera- ture much to be preferred to the administration of large doses of salicylic acid, antipyrin, antifebrin, or phenacetin. Quinine is free from the objections urged against the above remedies, and is of some value for its tonic properties, although its effect upon the temperature is not very marked. It may be given in an effer- vescing mixture, and may in some cases be usefully combined with digitalis. Quinine and arsenic are especially worthy of a trial in cases marked by daily recurring sensations of chilliness accom- panied by pyrexia. An effervescing mixture containing carbonate of ammonia given every four liours has in some cases the effect of diminishing the fever. Counter-irritation, in the form of a succession of blisters applied CHRONIC PULMONARY TUBERCULOSIS 405 about the site of tlie disease, is activity of the morbid pro- cess, and by so doing it diminishes the pyrexia. Cough. — It is difficult to lay too much stress upon the importance of deter- mining as nearly as pos- sible the cause of the cough in a case of pulmonary tuberculosis before pro- ceeding to treat it, or to condemn too strongly the indiscriminate administra- tion of sedatives to relieve this symptom. The chief points to which attention should be directed are, the time of occurrence of the cough, whether it is effec- tive in expelling secretion, and whether it prevents the patient from obtaining sleep. A cough which occurs in the morning, and is accompanied by expectora- tion, is useful, and should not be checked. A cup of hot milk, to which a tea- spoonful of rum or brandy may be added, given in the morning when the patient wakes, aids expectoration and so helps to clear the bronchi and lungs of secre- tion which has accumu- lated during sleep. A warm alkaline draught {e.g. 5o sodii bicarb, gr. x ; sodii chloridi, gr. v ; am- monii carb. gr. iij ; sp. chloroformi, tiiv ; aq. anisi ad §j, in an equal quan- tity of warm water), or a draught of ether and am- monia may also be given for this purpose. The for- mer is particularly useful when much catarrh of the bronchi is present. often of service in moderating the I Pi Sj ei/: '£•/< 7 - I ■0 , ? ! 6 — - z C: >. ^ I 2 -— >. ■o. I ■<: "* —- , ■t l^a iO 5C7 ■< > ■2 h" iO iO p ~ \.o iO iO / = ;.a aO iO \ ■> 2 > 6(7 iO < ^ - \.o iO iO ~^ :. -= iO iO < • - -wiJi Mj'^ uiy. oeu "/=/ y -. I I }!"■ 10 ' 'yd ' — . ■0 I J t 60 !.a iO < > .* iO so <^ ^ > ": iO iO <, ,." ; 60 iO «<7 iO 60 iO < ::: '' tO iO iO — =1 ^ Z \ to iO 6(7 ^ 1 , " "., - 4(7 iO iO ~~^ ~: ;.o iO 4(7 ■.^^ S 3 t s(7 • bO ~ i iO .0 60 :>H "-3 '■VJdl ZZTJ' uiy jeu Vd ' ~~, (%, J 4 "= —- "1 ~ 3 ■= —- , ■^ 2 "*^ -- • <. •" ^ - 5 ■ ' — >s -J "=^ ~ 3 ^ ^ ~ 3 w 1 i. ■^ocacsooo oocnm H p ° K K 2 ll != O H ,4o6 THE DISEASES OF THE LUNGS A similar metliod of treatment is often efficacious in relieving cough which occurs on lying down at night. If the cough continues during the night and prevents sleep, a dose of a linctus containing codeina or morphia should be given, and if necessary it may be repeated ; but the less often it is taken the better. Codeina (gr. ^), citric acid (gr. vj), spirits of chloroform (ni.iij to v), and a drachm of mucilage of acacia, or liquor morphinse ace- tatis (»n_viij), chloric wther (in.iij), lemon-juice (nixv), and a drachm of mucilage of acacia, are useful combinations. The use of sedative linctuses during the daytime should be avoided as much as possible. An irritating and ineffective cough, persisting during the day, is best treated by the use of inhalations or sprays. Ten drops of a twenty per cent, solution of menthol in alcohol may be sprinkled on the sponge of a perforated zinc inhaler, and this may be worn for an hour or more at a time. Antiseptic drugs, such as creasote, carbolic acid, eucalyptol, or the oleum pini sylvestris, in combination with a sedative volatile agent such as chloroform, may be used in a similar manner, or they may be employed in the form of sprays. • In addition to relieving cough, these remedies are of service by diminishing the quantity of the expectoration. Counter-irritation by the use of blisters or liniments containing tui'pentine and iodine {e.g. linimeutum terebinthinae, 5vj ; tinctura iodi, 5j), or a pigment composed of equal parts of the tincture and liniment of iodine, is often efficacious in relieving cough. Cough arising from laryngeal irritation may be relieved by the inhalation of medicated vapour. For this purpose a variety of remedies, such as conium, henbane, hop, or tincture of benzoin may be employed. The following is a useful formula : R chloro- formi, ni.x ; succi conii, 5j ; glycerini acidi carbolic! ad 5ij, to be added to half a pint of boiling water and the vapour inhaled. Pain referred to the axillary regions, and possibly due to a localised pleurisy, may generally be relieved by strapping the side. Pain over the front of the chest is best treated by the application of iodine, or by the use of a liniment of belladonna. The effect of iodine, however, requires to be carefully watched, as the sensitive- ness of the skin to its action varies greatly in different individuals, and in some persons intense irritation (which is apt to be mental as well as local) soon follows its use. Night sweating. — In the majority of cases this symptom is associated with pyrexia, the sweating occurring regularly in the early morning when the temperature begins to decline. Relief may often be obtained by sponging the body with cold or tepid water at bedtime in the manner reconnnended in the treatment of pyrexia. Quinine in conil)ination with digitalis often acts well in such cases. If these should fail, a trial may be given to oxide of zinc (gr. iij iv), either alone or in combination with extract of belladonna (gr. \-\), administered in the form of a pill at bed- time, or to atropine in doses of ii„ to ,/„ gr. in pill, or to sulphuric CHRONIC PULMONARY TUBERCULOSIS 407 acid. The disadvantage attending the use of the various prepara- tions of belladonna is their tendency to produce dryness of the throat. Arseniate of iron (gr. ^-^), nitrate of pilocarpine (gr. ./„-), picrotoxine (gr. ^^Lj^ agaricin (gr. -jL), have all been found of service in cases which have not yielded to the remedies mentioned above. When profuse sweating invariably attends sleep, it is generally a sign of exhaustion, and may be prevented by the administration of stimulants and hot liquid food at bedtime or in the early morning. When the patient Avakes in a profuse perspiration, the clothing and bed-linen should be changed at once, the skin thoroughly dried, and some hot milk and brandy given. If the sweating, as is not infrequently the case, follows a prolonged paroxysm of cough, the chief attention should be given to the treatment of the latter symptom. Diarrhoea. — In cases of acute ulceration of the intestine, rest in bed, the application of hot linseed-meal poultices to the abdomen, and the restriction of the diet to milk, meat essences, jelly beef-tea, and chicken broth, given at intervals of from two to three hours, constitute the most important measures of treatment. A small dose (5j-5ij) of castor oil should first be given to clear the bowel of any contents which may be a cause of irrita- tion, and subsequently subnitrate of bismuth in doses of gr. x-xv combined with opium (gr. ^), administered in powders every four hours. Diarrhoea due to chronic ulceration of the intestine occurring in the later stages of the chronic form of the disease is usually best treated by restriction of the diet to such articles as are easily absorbed and leave little residue, and by the administration of astringents combined with opium. Subnitrate of bismuth (gr. xx-xxx) with pulv. ipecac, co. (gr. x) forms a useful com- bination, which may be given, in milk every four hours. Mineral astringents such as acetate of lead (gr. ij-iij) and sulphate of copper (gr. x~2)' i^ combination with opium, are also of use when the remedies already mentioned fail. Kino, catechu, and hfematoxylum may also be tried in combina- tion with opium (tinct. catechu 5 ss ; tinct. opii ih_t-x ; mist, cretae §j ). The fluid extract of coto bark in doses of five minims, combined with compound tincture of cardamoms and mucilage is an effi- cacious remedy in advanced cases. An enema of starch and opium (tinct. opii 5ss ; mucilag. amyli §ij) is often of great service when the large intestine is the part of the bowel chiefly affected. Its use may be combined with the administration of a pill of acetate of lead and opium. If catarrh of the intestine is the cause of the diarrhoea, after the bowels have been cleared of any irritant by the use of a mild aperient, such as castor oil, the carbonate or subnitrate of bismuth may be given. Salol, salicylate of bismuth, and creasote may be used when diarrhoea is accompanied by marked foetor of the evacuations {e.g. salol, bismuthi salicylatis, sodii bicarb, aa gr. v in cachet). 4o8 THE DISEASES OF THE LUNGS Disorders of digestion. — We have already dwelt upon the fact that the resisthig power of the patient mainly depends upon the condition of his digestive organs. It is apt to be overlooked that the ingestion and assimilation of food are not the same thing, and that nutrition depends upon the latter only ; if, therefore, the disorder is due to the quantity of the food taken being in excess of the digestive power, it must be diminished. The best evidence of this condition is the presence of undigested food in the stools. Loss of appetite, a pale tongue, and a sense of weight after meals are indications for the administration, shortly after food, of mineral acids with strychnia or some other vegetable bitter. Pep- sine and hydrochloric acid often aid the digestion of food in such cases. Loss of appetite without digestive disorder is usually best treated by the administration of alkalies with vegetable bitters shortly before meals. We know of no combination so efficient as the mistura gentian* alkalina of the Brompton Pharmacopoeia, which contains bicarbonate of soda (gr. xv), dilute hydrocyanic acid (tn.iij I, and compound infusion of gentian (5J). Gastric catarrh, with a furred tongue and flatulent distension of the stomach after food, is often relieved by hot water taken in the early morning, and by the administration of carljonate of bismuth with hydrocyanic acid. Creasote is also useful under the same conditions. Attention to the diet and to the condition of the bowels is specially necessary in such cases. Pain in the region of the stomach and vomiting may be relieved by the administration of Ijismuth and lime-water, or of an effer- vescing mixture containing morphia. Climatic treatment. — The knowledge that is necessary in order to form a trustw^orthy opinion as to the place best adapted for a particular sufferer from this disease can rarely be obtained except by a personal visit to the place, and, if the medical adviser has not this experience, he will generally find it to the interest both of the patient and himself to leave the decision in other hands. Opinion is practically unanimous that in suitable cases the benefit resulting from change of climate — and in this statement we include the form of treatment described as the ' open-air ' method— far exceeds that to be obtained in any other way. But for the favoural)le changes thus induced to l)e of permanent or even of prolonged duration, it is essential that the patient should remain for a considerable time luider the influence of the conditions by the aid of which his health has been restored. It not infre(]uently happens that, after a winter spent at one of the resorts in the high altitudes, the complete return of strength and the al)sence of morbid signs in the lungs lead both the patient and his medical adviser to think that work may be resumed. The arrest of the disease appears to be complete, as indeed it may be, but the probability of it remaniing so is infinitely greater if a further period of twelve months is passed under conditions as nearly similar as it is possible to obtain. CHRONIC PULMONARY TUBERCULOSIS 409 A favourite aphorism of the late Sir George Humphry was ' nothing ever gets quite well.' It may not be absolutely true, but the sufferer from tuberculosis will do well to bear the saying in mind. When told that the disease has undergone complete arrest, or that he is ' cured ' and only a ' scar ' remains, he is very apt to think that no further danger is to be feared, and to govern himself accordingly. It is, however, impossible from a physical examination of the chest to state the exact pathological conditions present throughout an arrested lesion. In one case fibrosis may be complete, whilst in another life may depend upon the integrity of a fibrous capsule surrounding a caseous mass, a condition replete with possibilities of evil in the future. All who have had much experience in the treatment of this disease must be able to recall cases, apparently of the most favour- able character, in wliich the patient returned to work after too short an interval of rest, with the result that the mischief again became active. The chief points to be considered in advising a patient as to a change of climate are his means and social position, his general condition so far as strength and nutrition are concerned, and the ■ stage and degree of activity of the morbid process. Some might be disposed to reverse this order, but in practice the advice to be given more often depends upon the ability of the patient to bear the expense which is necessarily entailed by travel or absence from work for a very long period than upon any other consideration. Iij some cases, however, either the activity or the extent of the disease absolutely contra-indicates climatic treatment abroad. Patients with caseous tuberculosis of the broncho-pneumonic type, in which continuous pyrexia is associated with extensive caseation or rapid breaking down of the lung, should never be sent abroad. Cases of the chronic type, in which acute miliary in- filtration of the lung is in progress, also cases complicated with acute pleurisy or acute bronchitis, are equally unsuitable for this mode of treatment, as are also cases of laryngeal tuberculosis associated with advanced pulmonary lesions, and those in which extensive ulceration of the intestine is present. On the border line are cases of chronic tuberculosis, in which there is extensive disease of both lungs, and all hope of its arrest has been abandoned. In such cases the inclination of the patient, and to a less degree that of his friends, should have some weight. If he or his friends dread the idea that he may end his days away from the comfortable surroundings of home, and such an event appears not only possible but probable, it is very unwise to permit hnn to undertake a long journey, and positively cruel to advise such a step. If, on the other hand, the patient is anxious to go, is accustomed to travel, and is buoyed up with the hope that change of climate may lead to the restoration of his health, it may be better to fall in with his wishes, as the significance of a refusal to do so is fully appreciated. 4IO THE DISEASES OF THE LUNGS Patients with advanced disease should, however, only be allowed to travel to places at a moderate distance, within reach of their friends, and where good nursing and some at least of the comforts of a home are assured to them. A sea voyage in such cases is rarely, if ever, permissible. Treatment at high altitudes. — The evidence in favour of the beneficial effects of a prolonged stay in the high altitudes, and particularly at St. Moritz (G,100 feet), Davos (5,300 feet), and Arosa (G,209 feet) in the Swiss Alps, is so strong that it is un- necessary at the present time to regard the question as needing discussion. These effects are due to the purity of the air, and particularly to the al)sence of organic germs, to the stimulating effect of brilliant sunshine, to the dryness of the air, and to its rarefaction, which necessitates deeper inspiratory efforts, and thereby increases the functional activity of the lungs. Other factors of importance are the diathermancy of the atmosphere, Which implies a low air temperature, the comparative absence of winds, and the presence in the air of a large amount of ozone. Cases specially suitable for the Alpine treatment are those of the fibroid type and those of the chronic variety, in which the area of disease is limited and the patient was previously vigorous, but has been infected whilst run down in health. For example, after recovery from a primary attack of lijemoptysis, no signs of active mischief being present, a young and fairly vigorous patient may with confidence be recommended to betake himself to the Alps, and may, as the result of a residence there, fairly hope to obtain complete arrest of the disease. When the disease has extended from the apex primarily affected to the lower lobe on the same side, and the other lung is also involved, if the strength and nutrition are fairly good and fever is al)sent or moderate, the case may still be sent to the high altitudes, and pathological experience proves that, with a limited area of disease in these sites, complete arrest is still possible. When a cavity is present, the case is not necessarily unsuitable for the high altitudes ; but a careful consideration must be given to all its features — Cf/. the degree of activity of the morbid process, the bodily strength of the patient, and his ability to withstand cold. Dr. Hermann Weber ' is of opinion that even in cases in which the disease has advanced to this stage, ' greater benefit may be an- ticipated from a prolonged or indeed an indefinite sojourn in the Alps than from any other form of climatic treatment.' And witli this opinion we are completely in accord. Cases of tubercular pleurisy, with infiltration of the lung in an early stage, are usually greatly benefited by a residence at one of the high altitude stations. As a rule the patients who obtain most benefit from the change ' Art. ' Climate in the Treatment of Disease,' Allbutt's Si/stem, vol. i. p. 28(j. CHRONIC PULMONARY TUBERCULOSIS 411 are young subjects who are fond of outdoor exercises, such as skating, and are strong enough to take part in them, who whilst in the mountains spend tlie greater part of the day in the open air, and who are determined to do all in their power to regain their health. The conditions which contra-indicate a resort to a high altitude are : (1) The presence of certain complications such as albuminuria, advanced disease of the larynx, valvular disease of the heart, and extensive emphysema. (2) Extreme emaciation. (3) An irritable state of the nervous system with constantly quickened pulse, and a liability to feverish attacks. (4) A decided inability to bear cold. (5) To these must necessarily be added those conditions which, as already stated, render a case unsuitable for climatic treatment abroad. It is generally advisable for patients to arrive at the Alpine stations either at the end of September or the beginning of October, but many do not do so until a month later. If the disease does not declare itself until a later period of the year, it is rarely wise for a patient to start from this coxxntry after the end of January. The winter season ends at St. Moritz when the snow melts, in March or April ; patients can remain at Davos throughout the year. The chief winter resorts in Switzerland have already been men- tioned ; others are Les Avants (3,200 feet) above Montreux, Wiesen (4,771 feet), Thusis (2,448 feet) Grindelwald, Andermatt (4,738 feet), Meran (1,051 feet), Muhlen (4,793 feet), Seewis (2,985 feet), Leysin (4,757 feet), Ragatz (1,709 feet). Some of these are utihsed for continuous residence during the winter, others as stopping stations in the spring by patients who have spent the winter at a higher elevation and are making a gradual descent to a lower level, pre- paratory to returning home. Those who return to pass the summer in the Alps usually desire a change, and may then stay at Pontre- sina, Maloja, Wiesen, or elsewhere. Some patients find after a time that they are only able to live in comfort at a high altitude, and are perforce compelled to reside there continuously. Wherever the patient may spend the winter, he will do well to place himself under the care of a resident physician, and to consult him as to the time of leaving and where it is best to break the return journey. We do not, however, consider it essential that all patients should, on leaving the high altitudes, remain for a time at some place at a rather lower level, as we have known many who have returned direct to England without suffering any harm, and we have known cases in which some of the benefit obtained at a high elevation was lost during this gradual descent in the spring, when the weather at the lower levels may be very unfavourable. The shorter journey naturally renders the Swiss resorts more 412 THE DISEASES OF THE LUNGS attractive to patients from this country, but there are many more distant stations at even higher altitudes which are suitable for similar cases. In America among the chief health resorts at high elevations are Manitou (6,200 feet) and Colorado Springs (6,000 feet) in the Rocky Mountains, and Denver (5,200 feet), the capital of the State of Colorado. At some of the Colorado resorts, e.g. Denver, it is pos- sible for a patient who is strong enough to work to earn a livelihood, an advantage which is not presented by the Alpine stations. Dr. Osier states that he has seen better results in cases treated in the Adirondacks than elsewhere in America. For full information as to the various stations in Colorado, the reader is referred to Dr. Williams' work on Aerotherapeutics. The high table-lands of South Africa in the central and upper Karroo districts are suitable in the same class of cases as the Alpine stations ; but, owing to the absence of good hotels and to the rougher aspect of life, they are not visited by well-to-do English patients so much as the Swiss resorts. The most frequented places are Tarkastadt, Cradock, Beaufort West, Kimberley, Aliwal North, Bloemfontein, Lemoenfontein, and Grahamstown. South Africa is specially suitable for fairly vigorous young men in an early stage of the disease who know some trade, but it is essential that they should have sufficient means to enable them to live in comfort without the necessity of earning their livelihood until complete arrest of the disease has taken place, and for at least twelve months subsequently. The chief resorts in the Andes are Santa Fe de Bogota in New Granada, Quito in Ecuador, Arequipa in Tarma, Jauja and Huan- cayo in Peru, and La Paz in Bolivia. The great distance from this country of the Andean resorts requires that every case which it is proposed to send there should be made the subject of special consideration. The favourable changes observed to occur from a residence at a high altitude are that the cough and expectoration either diminish or disappear, the strength and appetite increase, and there is gener- ally some gain of weight. At the same time examination of the chest reveals changes in the physical signs, which indicate that the disease has either become quiescent or undergone complete arrest. The most satisfactory change is the disappearance of the adven- titious sounds. Dr. Theodore Williams has shown that an enlargement of the thorax follows a residence at a high altitude, and that the increased resonance of the percussion note observed is not limited to the site of the contracting lesions, where no doubt it is in part due to the production of emphysematous changes in the surrounding lung, but that it occurs in all regions of the tliorax. If the contraction of a cavity is followed by thickening of the overlying pleura, the percussion note does notimpi'ove in resonance, but becomes increasingly dull. CHRONIC PULMONARY TUBERCULOSIS 413 Dry ■warm climates. — Egypt.^Thtd climate of Egypt, ■especially where the inlluence of the desert is chiefly felt, is characterised by purity and dryness of the atmosphere, warmth, abundant sunshine, very little rain, and a great difference be- tween the night and day temperature. The disadvantages of the climate are the occurrence at certain periods of hot dust -laden winds from the desert, and at others of cold winds and the preva- lence of intestinal disorders. The reputation of Egypt as a resort for pulmonary invalids was gained chiefly by the good effects observed to follow a voyage up the Nile by daliabcyah, and that is probably still the best way in which an invalid can spend his time. The steamers, which now make the journey in a short time, present advantages to the tourist only. The chief health resorts are Mena House, a short distance from Cairo, Helouan, Assouan and Luxor. We have known advanced cases of the disease derive great benefit at Helouan, but patients must be prepared for a period of absolute dulness and must be content to spend the greater part of the day in the desert. Pulmonary invalids- should absolutely avoid Cairo. No case should be sent to Egypt unless there are clear indica- tions that it is unsuitable for treatment at a high altitude, and, owing to the distance and the expense of the journey, and the high cost of living, only patients with ample means are able to enjoy the luxury of wintering there. The invalid should, as a rule, arrive in Egypt about the middle of November and leave about the middle ■of April. The cases of tuberculosis most likely to derive benefit from a residence during the winter months in such a climate are those complicated by bronchitis and emphysema, but with a limited area of infiltration. The presence of albuminuria in an otherwise suit- able case is rather an indication than otherwise for this climate. The Biviera. — The climate of the French and Italian Eiviera is suitable for some cases in which the disease is more advanced, or when, from one or other of the various causes already stated, the high altitudes are contra-indicated. During the winter months the mean average temperature is higher by from 8° to 10° F. than that of this country, whilst the amount of sunshine and the number of days without rain is far greater. The disadvantages of the Eiviera climate are the great difference between the sun and the shade temperature, the marked fall of temperature immediately after sunset, and the prevalence, especially at certain times of the year, of winds which prove extremely trying to the invalid — conditions which necessitate the greatest care in order to avoid exposure to chill. The most sheltered place is the eastern bay of Mentone, but the almost complete protection from wind which is there obtained, combined with full exposure to the sun, produces a climate which is only suited to patients of rather feeble vitality, and which exercises .an enervating effect upon the more robust. 414 THE DISEASES OF THE LUNGS In the western bay, which is less sheltered, the air is cooler and decidedly more bracing. Costabelle, Hyeres, Cannes, Grasse, Cap Martin, Monte Carlo, Bordighera, San Remo, and Alassio are other well-known and much-frequented resorts upon the Riviera. Dr. Burney Yeo's conclusion is that ' the climate of the Riviera is by no means a perfect one. But if it has cold winds, and at times blinding dust, and if the air in places is exceedingly dry and irritating, it has also an immense proportion of fine days, clear skies, and bright sunshine, when from nine in the morning to three in the afternoon an invalid can live in the open air.' Malaga, Corfu, Algiers, Tangier, Southern California (Los Angeles and other places), Australia (the Riverina), Queensland (Darling Downs) also possess climates of this class, but present in each case some particular features for information as to which we are compelled to refer the reader to one or other of the many works in which the subject of climate in relation to disease is dealt with in a more complete manner than is here possible. Warm, moist climates. — Madeira is an example of a moist and warm climate, and as such is specially suitable for the relief of bronchial catarrh complicating tuberculosis ; but the clear proof of the advantage of a pure, dry, cold air over a warm, moist air in the treatment of the disease has of late years led to a marked dimi- nution in the number of patients resorting there. It has, however, happened to the writer to observe one case of rapidly advancing disease, complicated by renal tuberculosis, in which, during a winter spent at Madeira, a more remarkable improve- ment occurred than in almost any he can recall as a result of climatic treatment elsewhere. The climate of the Canary Islands is warmer and dryer than that of Madeira ; and Teneriffe and Orotava are places suited for cases in which a special liability to bronchial catarrh is a marked featiire. The rainfall is moderate, and the variation of temperature throughout the year is only 18° F. Home health resorts. — There are many health resorts in this country suitable for patients who are unable, from any cause, to avail themselves of the advantages of the altitudes, or of other places abroad more favoured as regards sunshine and shelter from cold winds. Those who are possessed of considerable vigour and prefer a bracing air, and are not subject to catarrh, may be recommended to winter at St. Leonards, Hastings, or Ramsgate. Bournemouth, Ventnor, and Sidmouth are suitable places for patients in the earlier stages of the disease, who require a sheltered but yet some- what bracing climate, whilst Torquay, Falmouth, and Penzance are better adapted for nervous irritable subjects who prefer a more relaxing air, and for patients who are enfeebled or liable to catarrh from sudden change of temperature or exposure to cold winds. Sea voyages. — A long sea voyage undoubtedly presents advantages in many cases of tuberculosis, but these are more obvious CHRONIC PULMONARY TUBERCULOSIS 415 when the disease has attacked the glands and bones than when the lungs are chiefly involved. There is, at the present time, a general agreement that no patient with advanced lesions should be sent for a long sea voyage, and also that in the early period of the disease the majority of cases derive far greater benefit from a residence in one of the ' open-air ' sanatoria or at a high altitude. Vigorous patients with limited or quiescent disease, who have a special liking for the sea, may make the voyage round the Cape to New Zealand or Austraha, or they may proceed by the Suez Canal to India, and thence to China and Japan. Notwithstanding statements to the contrary, we believe it is, as a rule, better for the patient to take a passage in a well-appointed steamer, in which every provision is made for his comfort, than in a sailing vessel. Mineral waters. — The warm sulphur springs of Eaux Bonnes and Cauterets are very useful in catarrhal conditions, and in some cases of quiescent tubercular disease of the lungs present- ing such complications, they may be resorted to with advantage. The sulphur springs have also a reputation for the relief of glandular tuberculosis. The arsenical waters of La Bourboule, and Mont Dore, and some of the common salt waters, particularly those of Ems, are of service in cases of fibroid or arrested tuberculosis associated with emphysema and bronchial catarrh. .J. K. F. .416 THE DISEASES OF THE LUNGS CHAPTER XXXYI SUEGICAL TREATMENT OP PULiVLONAEY CAVITIES INCLUDING THAT OF FOREIGN BODIES IN THE BRONCHI Classification I'AliB . 417 Acute abscess following pneumonia . 417 Steps of operation . 418 Anfpsthetic .... . 418 After-treatment .... . 420 Prognosis after operation . 4-21 Cases unsuited for surgical treatment . 421 Bronchiectatic cavities . 421 Operation . 422 Tubercular cavities .... . 423 Chronic non-tubercular cavities . . 425 Foreign bodies in the bronchi . 425 Treatment . 426 Conclusions ...... . 427 Historical.— In a work like the present, Avbicb is intended to be practical, it is probably unnecessary to enter into tbe history of tbe subject of surgical interference for tbe relief of cavities of tbe lung. I have discussed tbe subject fully in some lectures debvered at the Hospital for Consumption and Diseases of tbe Chest at l>rompton, wliicb are reported in tbe first volume of the ' Lancet,' 18B7, and those who desire still further to in- vestigate tbe matter will find a very extensive bibliography in Piiedinger, ' Verletzungen und chir. Krankbeiten des Thorax ' (Deutsche Chirurgie Lief. 42), 18H8. Here it may be briefly stated that Sir Edward Barry advocated the opening of phthisical cavities in 172(), and it is said that before bis time Bagbvi recom- mended the mcision of pulmonary cavities in 1714. Dr. John Hastings and ]\Ir. Starks treated some cases in 1830. A few years later (IBijG) Dr. Horace Green recommended tlie injec- tion of bronchiectatic and tubercular cavities by means of a tube passed through a bronchus. In 1873 I)r. F. Hosier of (Ireifswald described a process of injecting by means of a cannula and trocar passed through the SURGICAL TREATMENT OF PULMONARY CAVri'IES 417 chest wall, and an almost exactly similar method was advocated by Pepper of Pennsylvania and Beverley Piobinson of New York in lcS85, a method which was afterwards carried out by Dr. Shingleton Smith of Bristol. Still more heroic methods of treatment have been suggested in Italy by Dr. Dominico Biondi, who advised the removal of the affected part, a subject to which further reference will be made in dealing with the question of tumours of the lung. In 1830 Guerin and subsequently others have recommended that the puncture of the lungs should be performed by the actual cautery to avoid haemorrhage. Quincke,' for example, appears to prefer this method. He applies chloride of zinc paste as a preliminary pro- ceeding in order to ensure firm pleural adhesions, and thus occupies several days in the opening of a pulmonary abscess. This method, whatever may be urged in favour of it, has certain obvious disad- vantages, of which the principal one is the delay which this process involves. On the other hand, Qumcke claims that a more free incision into the lung is thus possible, and that thus not only may more than one part of a branched bronchiectatic cavity be drained, but that contraction of the surrounding lung is favoured. Classification. — From the point of view of surgical treat- ment, cavities of the lung may be divided into four classes : 1, acute abscesses following on pneumonia ; 2, bronchiectatic cavities ; 3, tubercular vomicae ; 4, chronic nontubercular cavities ; 5, cavities caused by the presence of foreign bodies. 1. Surgical treatment of acute abscess following on pneumonia. — If an abscess arising from acute gangrene, or as a result of the inflammatory process in pneumonia, be suspected to exist, an attempt to reach it from the outside should always be made, except only where the abscess has burst quite recently into a bronchus. When this has occurred, a short time should be allowed to elapse in order to see whether a cure is likely to result ; but, although this happens in a certain number of cases, in a far greater proportion the opening is insufficient, and the mischief not only spreads locally, but extends to other parts of the same lung, and also to the opposite lung, as the result of the inspiration of the septic material. The matter that is formed in these abscesses is always highly offensive, having a smell which, to those who have perceived it, is almost characteristic of the disease. It is generally of a brown colour, and mixed with shreds of broken-down lung tissue, and often with blood either in streaks or in larger quantities. The patient generally suffers from well-marked constitutional symptoms, and if he does not die from the affection of the lung, it is highly probable that he will fall into a state of septicaemia from which he will not be able to recover. Waiting for a short time means waiting for a day or two : and I think that if there be not a notable fall in the temperature and an obvious diminution in the amount of the expectoration by that ' 'Ueber Pneumotomie,' von H. Quincke {Grenzgcbietcn der Mcdi.-iit and Chinirgie, erster Band, 18'JG). E E 4i8 THE DISEASES OF THE LUNGS time the surgeon should proceed to make an external opening. It must not be supposed, however, that this is a perfectly simple operation ; the localisation of the cavity is often extremely difficult, principally because the physical signs of consolidation are apt to mask those which are caused by the cavity, but also because the abscess is often so deeply placed, that it practically gives rise to ho physical signs of a definite character. It has therefore not unfreciuently happened that, even after the discovery of an abscess and the introduction of a drainage tube, the post-mortem has revealed other cavities in the same or even in the opposite lung. Steps of the operation. — A.fter endeavouring by careful |)hysical examination to detcnnhic tlie wliercahouta of the abscess, the first point is to introduce the needle of an aspirator, and if the matter be not discovered at once, it should be introduced again and again, at any place at which the physical signs may render the exploration justifiable, even although they do not seem to indicate the presence of a cavity. Sometimes, for example, it may be found that there are marked signs of a cavity at the lower part of the lung whilst the abscess is situated near the apex of the lower lobe. It must not be forgotten that in puncturing a lung which is charged with highly septic material a risk is run of defiling a pleura in which no adhesions have taken place, but this danger is not so great as it is in the case of bronchiectasis. Supposing the exploration to have resulted in the discovery of pus the patient is ansiesthetised and the operation is proceeded with. The administration of an a.ncesthetic to patients who are expectorat- ing fcrtid material is fraught with the danger of encouraging the inspiration of this material into other parts of the lung, in addition to that of the chance of suffocation, which is a real danger, whatever the nature of the fluid may be. This is the reason for making the exploratory puncture before giving the anaesthetic, but obviously the advisability of doing so must depend on the particular case, it being impossible in dealing with nervous patients, especially if extremely ill, to carry out such a series of punctures as may be required before the surgeon feels justified in giving up the seai'ch as hopeless. As in the case of operating on empyemata, the best anaesthetic I think is chloroform, and the anitsthesia should not be carried to a very advanced degree. The objection to ether is that it occasions sometimes a copious bronchial secretion, which in itself interferes with respiration, and which, when added to the fluid expectorated, may become extremely dangerous to the patient. The anixjsthesia should not be very complete, because it is desirable that the patient should be able to cough up the accumulated fluid. Of course this cough is a' great inconvenience to the surgeon, but it is an inconvenience that he must put up with and learn to become accustomed to. From the same point of view it is advisable that the patient should not be turned too far on to the healthy side. In oi-der to render the operation possible, it may sometimes be neces- sary to draw tlie patient beyond the edge of the table, whilst the SURGICAL TREA TMENT OF PULMONARY CAVmES 419 surgeon sits upon a low stool (fig. 140, p. 601), and in very bad cases it may be wisest to place him altogetliei' on the diseased side, and standing upon the opposite side of the patient, to operate, as it were, from behind (fig. 141, p. 002.) These last remarks refer to the treatment of each of the three kinds of pulmonary abscesses. Having ascertained the ■presence of pus, it is not wise to with- draw the needle, but it should be kept in situ as a guide. This is easily said, but not so easily done. The assistant to whose care the needle is given over is liable to have his attention distracted, and if he looks aside for a moment he will very likely, by slightly moving his hand, either withdraw the needle, or insert it too deeply, or bend it to one side or the other ; and the same result may easily follow a chance touch from the hand of the operator, or from that of the assistant who is spongeing. An incision is then made as for the resecting of a rib, but seeing how often it is found that the excision of more than one rib is required, and also that after the opening is made it is the very lowest part of the cavity that has been opened, it will be usually wisest to make a vertical incision, rather than the oblique one which was recom- mended for cases of empyema. A piece of rib, probably above the intercostal space which has been perforated, is then removed, in doing which great care should be taken not to injure the pleura, because, although the presence of adhesions is very likely, it is not certain that they will be found. The cleverest physician cannot say whether adhesions will be met with or not, nor can he be quite sure how far the solidification of the lung will prevent that organ from falling away from the chest walls in case the pleura should be healthy. It therefore behoves the surgeon to proceed as if the lung was not adherent ; this has the incidental advantage that if it should actually be the case he will feel satisfied that he has not admitted septic material from the abscess into the healthy pleura. Having removed portions of one or two ribs, as the case may be — and he will most frequently find that one is not sufficient — a series of stitches should be placed with a full curved needle fixed to a Hagedorn's or any other suitable form of needle-holder. The stitches must pass through the pleura into the affected lung. A single row is quite sufficient, but a double row is of course safer. From six to eight stitches, including a circle of from one and a half to two inches diameter, are usually enough, and can be introduced in a very short time. Stitches may be made of silk or fishing gut or catgut, and they should enter about one half to three-quarters of an inch into the lung substance. The pleura is now to be incised, and it will be found, even if there be no adhesions, that if the stitches have been properly introduced a pneumothorax will not result ; should, however, air suck in at one part of the incision, further stitches must be used until the whole circumference has become air-tight. As to the method of incising the lung various opinions have. been held and many devices have been invented. The risk in connection with it depends upon the possibility of injuring one of the large E E 2 420 THE DISEASES OF THE LUNGS pulmonary vessels, our knowledge of the anatomy of which cannot be sufficiently accurate to enable us to avoid them with certainty. Some reference to their description on pp. 42 and 46 will give a general idea of where the main trunks are to be found, but the branches of the artery and the tributary veins are so large in all parts of the lung that this knowledge is not of much practical importance. In every part of the lung, indeed, vessels are to be found large enough to bleed to death from. Fortunately, however, the luemorrhage can usually be stopped by the pressure of a plug. It is from fear of hnemorrhage that many have advocated the use of the actual cautery ; it is not a procedure with which I am enamoured. The charring of the tissues is confusing to the finger which is introduced in order to explore the cavity, and, further, the destruction of the tissues encourages a subsequent foul condition of the wound. If the abscess be obviously near the surface, there can be no doubt that the best way is to open it by means of a pair of sharp-pointed forceps (siruis or dressing forceps) inti'oduced alongside the guiding caiuiula. After they have reached the cavity the blades are opened, and, the cannula being withdrawn, the finger is gently insinuated along the same track, which its passage enlarges sufficiently to permit the introduction of a drainage-tiibe of a suitable size. I have l)een in the hal)it of adopting the same plan for opening abscesses at a greater depth, and have not yet met with any insuperal)le difficulty in so doing, though I have sometimes been obliged to plug the wound. The finger explores the cavity as far as possible, and, if it is found easy of access, some iodoform or boracic acid or other suitable antiseptic powder may be introduced. The wound of the soft parts should be most thoroughly treated with chloride of zinc (40 grs. to the ounce), and plugged round the tube with some lint which has l)een soaked in the same solution and dusted with iodoform. The dressing is then applied, and, if the matter be very foul and frequent changing is likely to be required, some simple application, such as fomentations of boracic lint covered with wood wool or oakum, will be found most convenient for the purpose. After-treatment. — In the after-treatment of the case no effort should be s])arod to sweeten the cavity, but injections of fluid are inadmissible, as such would be sure to enter the trachea and cause troublesome coughing ; their place must be taken by powders, such as those referred to above. The tube must be frequently washed, but it is better to leave it for a day or two in .situ, so that the track ])y which it has entered the cavity may not be lost. The tul)e, it may be said, must reach to the end of the cavity, and may be provided with holes in the part that corresponds to the cavity. There is much more chance of the tube giving trouble than in the treatment of empyema, because, just as happens so frequently in cases of hepatic abscess, the process of cure is associated with more or less contraction of the organ, which changes the direction of the sinus and the position of tlie cavity. It thus is often advisable to prevent the slipping of the tube by placing a piece of trustworthy SUROICAT. TREATMENT OF PULMONARY CAVITIES 421 plaster across the deeper part of the dressing. The tul)e must be retained until the external discharge is reduced to a very small quantity after the complete stoppage of expectoration. Prognosis after operation. — It is obvious, from what has been said about the pathology of gangrene of the lung in pneumonia, that no very large percentage of recoveries can be expected to follow surgical interference, seeing that death may follow from extension of the pneumonia, from blood-poisoning, or from haemorrhage. While, therefore, too much must not be expected from the evacua- tion of the abscess, still, the chance of recovery being so slight without interference, I have no hesitation in recommending a course of procedure such as has been described. The least hopeful cases are those in which the abscess is most acute, in which there is reason to suspect affection of the opposite lung, and in which the expectoration has the dark brown colour with that particularly filthy smell which is so characteristic of the disease. The most promising cases are those of a less fulminating character, in which only one lung or, better still, only one lobe of one lung is affected, in which the physical signs are localised, and in which the expectoration, if any, is of a distinctly purulent character. Cases unsuitable for surgical treatment. — There is a class of case which must be considered here that is altogether beyond the reach of surgery. It comprises those in which collapse and gangrene follow upon the accumulation of septic material which has collected in the bronchi, either where one bronchus is pressed upon by a tumour, aneurysmal or otherwise, or where it has entered the trachea as the result, say, of cut-throat or tracheotomy. If this state of things has been clearly made out, no good can come of surgical interference. The mere exploration of such cases with the needle has been followed by the development of acute empyema, I once had to deal with such a case in which the history had not been explained to me at the time when I had to operate ; the pus of the empyema was highly offensive, but I did not discover till some time after at the post-mortem examination that a large aneurysm of the aorta was projecting into the pleura, which might conceivably have been injured at the time of the operation. I need hardly say that since this experience I always endeavour to obtain from the physician a strong opinion as to the possibility of the presence of this extremely dangerous complication to a surgical operation in cases where there seems to be the slightest likelihood of its presence. 2. Surgical treatment of bronchiectatic cavities. The next class of cases to be described is that of bronchiectasis, the pathology of which has been discussed on page 125 seq. It remains only to point out, from a surgical point of view, a fact which will be returned to later on — namely, that bronchiectasis is not unfrequently the result of a foreign body having been inspired, and also to indi- cate the mechanical difticulties that are presented to effectual drainage from the very nature of the complaint. From whatever cause the bronchiectasis may have arisen, the cavity is always of a 422 THE DISEASES OF THE LUNGS complicated nature, and, although communications may form between contiguous parts of a dilated bronchial tree, it must not be forgotten that as a rule the opening of each dilated bronchus into the main channel takes place at the upper part of the cavity. It follows from this that an incision into one part of such a branched cavity can do iiothing in the way of draining the others, and the advisability of resorting to any surgical interference depends very much upon whether or not the main part of the symptoms are caused by one cavity of considerable size. Soon after I became surgeon to the Brompton Hospital, I operated on a certain number of cases of bronchiectasis at the request of my colleagues. In not a few of them it was possible to open a considerable cavity, but in the greater number there were not only physical signs distributed over a very extensive area, but they were occasionally heard to a less extent upon the other side of the chest. The result, I am sorry to say, was not encouraging. It frequently happened that the symptoms were decidedly improved for a time, or rather it should be said that the most troublesome symptom — that of copioiis ex- pectoration — was to some extent alleviated ; but in almost every case, as the disease advanced, fresh cavities took the place of the one that had been drained, the amount of expectoration increased, and various maladies of an intercurrent nature, not directly attributable perhaps to the operation, made their appearance. The patients frequently suffered from hsBmoptysis, more than one developed cerebral abscess, and some died of acute septic nephritis. I cannot thei'efore encourage surgical interference in cases of bronchiectasis pure and simple, unless it can be shown that there is a high probability of the disease being confined to a very small part of the lung. In a few such cases recovery may take place. ])r. "Williams and myself reported one siich in the 'Transactions of the Royal Medical and Chirurgical Society ' for 1886 (vol. Ixix.), and I take this opportunity of saying that some years afterwards the patient died of heart disease, and I had the opportunity of verifying the correctness of Dr. Williams's diagnosis, and seeing that it was not, as some might have thought from the account of the case, an empyema. Operation. — Should, however, the operation be attempted, the steps of it do not differ from those described on page 418. It must be rememl)ered, notwithstanding all assertions that may be made to the contrary, and deductions from post-mortem examina- tions, that the surgeon seldom meets with adhesions in these cases ; and not only is this so, but if the pleura has been opened l)efore stitching up the lung, as was done in some of my early cases, the lung recedes far away from the opening, and feels to the fingers perfectly healthy, so that it is impossible to make out by the touch the position of the abscess. It is therefore essential to lix the lung before opening it, and if by cliance this precaution be omitted and air be allowed to enter the pleura, there is nothing for it but to close the wound and wait for the absorption of the pneumothorax before making another attempt. The feeling im- SURGICAL TREATMENT OE PULMONARY CAVriTES 423 parted to the finger by the interior of a bronchiectatic cavity is quite different from that of an abscess resulting from the breaking- down of the lung. In the latter case an irregular spongy mass is felt which is easily broken down ; in the former the lining is perfectly smooth and firm, and the cylindrical shape of the ■cavity is, moreover, usually easily determined. It is not im- probable that manipulation with the finger or the contact with the drainage tube will set up a fit of coughing. The after treat- ment of these cases does not call for any special comment. The discharge is usually copious, sometimes, but not always, offensive, and consists of sticky muco-pus. Should it be found that the patient has not derived much benefit from the operation, it may be thought wise to remove the tube, when the external opening will probably close, and the patient will be left no worse off than before. When an external incision has been made into a cavity com- municating with a bronchus by a large opening, a curious phenomenon is generally observed. Not only is the sound of the air entering and leaving the chest of a loud whiffing character, different from that which is heard in the case of cavities similarly opened that do not communicate with bronchi, but the com- munication is sometimes so free that the patient can breathe through it whilst keeping the mouth and the nose closed. I have seen cases where this could be done for quite a considerable time, and it could be determined by the stethoscope that air was entering freely into the opposite lung. Under such circumstances, when the dressing is removed, the patient is unable to talk above a whisper. Sometimes, indeed, he cannot do so even wlien the dressing is applied. Should this be the case, a small plug of wool placed in the orifice of the tube will be found a great comfort to him. 3. Surgical treatment of tubercular cavities. — The surgical treatment of tuhercular cavities does not appear up to the present to have called forth much enthusiasm, and yet it might have been thought (though here I am only expressing my own private opinion) that the same treatment would have been applicable to a tubercular deposit in the lung, as proves successful in almost every other part of the body, however inaccessible its position or however vital its functions. This excites the greater surprise when one thinks of the amount of inconvenience caused to the patient by the constant expectoration, and of the fact, so often insisted upon before, that profuse expectoration is frequently the means of disseminating mischief through previously healthy portions of the lung. It would therefore be rash to prophesy that there is not a future for this branch of therapeutics. Probably several reasons combine to dissuade physicians from calling in surgical aid. In the first place, it very commonly happens that, by the time a cavity of sufficient size to be diagnosed by physical signs has formed, the disease has already advanced so far as to be practically beyond the hope of relief, and almost certainly has reached such a stage as 424 THE DISEASES OF THE LUNOS to renclcv the possibility of removing the whole of the tubercular deposit impossible. Hecomlly, it is just those cases of single, stationary, or very slowly advancing cavities which promise the best field for surgery, that not unfrequently dry up and cicatrise. Thirdly, there is the fact that the expectoration from tubercular vomic.e, though, no doubt, often very troublesome, does not form so distressing a symptom as it does in some other cases of pul- nioniuy abscess. It must not be supposed that no plan of surgical treatment has been suggested or carried out. "Whole series of cases have been described by Dr. Shingleton Smith and others, in which antiseptic fluids (a favourite one being a solution of iodoform in ether) have been injected by means of a syringe introduced through an intercostal space. Of this plan of treatment I cannot speak from personal experience, and can only say that the use of these i)itirq)iilinnnarj/ and also of intralari/ngeal injections of various fluids is reported to have been attended by a varying degree of success. The most heroic method of treatment yet suggested comes from Italy,' and it has been followed up since then in Germany, the treatment being to remove the affected portion of the lung. Biondi made a number of experiments in rabbits, cats, and dogs, removing from tlieui the whole of one lung, and he showed that, although a large proportion of the animals died, a certain number survived, and some in whom tubercle had actually developed in the lung as tlis result of inoculation, not only lived but remained afterwards free from the disease. These observations are of great importance not only in connection with the study of pulmonary tuberculosis, but also in connection with the question of the removal of tumours of the hmgs (see page 4Hi)). As to this line of treatment also I have no personal experience. The most rational treatment of tubercular cavities appears to me to b(! the opening and draining of them in the same way as other cavities of the lung are treated. The first cases that were reported, about 184.5, did not give very satisfactory results, and at the Congress at Wiesbaden in 1883, the consensus of opinion was strongly against the opening of tubercular cavities, until, as it Avas said, a trustworthy specific tubercular bacillicide should be found. Writing in 1887, I said that though, on the whole, agreeing with that opinion, I could not help thinking that in a certain number of cases with single apex cavities and with trouble- some cough, not only might the symptoms be relieved, but the dang(!r of transfei-ring the mischief into the other lung might be to some extent lessened. I can see no reason for altering that opinion, l)iit I have never yet been asked to operate upon a large tubercular apex cavity, I have, however, treated several cases of tubercular cavity in other parts of the lung ; one of them at ' ' Estirpazione del ruliaone," per il Dr. IJiondi, Gior. hiicriiaz. d. Sc. Med, N.H. iv. 759. SURGICAL TREM'MENT OF PULMONARY CAVmES 425 least healed, though the patient died subsequently of pulmonary tuberculosis ; but in others the sinuses remained open, and the patients have appeared to be benefited by the escape of a certain amount of the disehai'ge externally. Not long ago my colleague Dr. Acland requested me to explore the chest of a man who was bringing up a large quantity, 20 to 80 ounces, of extremely fetid expectoration, which contained tubercle bacilli, and in whom physical signs suggested strongly a large cavity. This, however, the exploration failed to detect, and at the post-mortem examination it was found that the affected part of the lung was riddled with small gangrenous cavities. I have now in hospital a young woman who is the subject of syphilis ; she developed physical signs at the left base with pyrexia, and other symptoms which pointed either to an empyema or to a pulmonary cavity. Before long the abscess, which was in the lung, burst into a bronchus, but did not discharge sufficiently freely. I opened it by an incision in the side and inserted a long tube. She now keeps comparatively well as long as the sinus remains open, but if the tube is taken out the temperature rises. The pus is copious and muco-purulent, and contains tubercle bacilli. 4. Chronic non-tubercular cavities. — About this class of cavity nothing need be said except that they are occasion- ally met Avith, and that the treatment of them calls for no special notice. They are, however, the most promising of all for surgical interference. Some of them are caused by the rupture into the lung of abscesses which have originated elsewhere, for example in the liver. 5. Cavities caused by the presence of a foreign body in a bronchus. — It is practically useful to consider separately the results that are caused by very smooth and unirritating foreign bodies, and those that are caused by rough and irritating ones — for example, by such things as beads, or peas, or tracheotomy tubes and such objects as bits of straw, or nut-shells, or bones. The immediate effect of the lodgment of a smooth foreign body may be very slight. I have known the shield to come off a new vulcanite tracheotomy tube soon after its introduction ; and notwithstanding very careful physical examination, it was impossible for some days to be quite certain that the tube was in the chest, and that it had not been lost in the patient's bed. A piece of grass or a sharp bone, on the other hand, will give rise to immediate attacks of spasmodic cough, a result which has sometimes led to the error of supposing the disease to be whooping-cough, and the story of the inhalation of the foreign body to be apocryphal. I would most strongly insist upon the inadvisability of rejecting a patient's account of ' swtillowing ' a foreign body. It is an accident that forcibly impresses itself upon his mind. If the immediate effect has been slight, he may indeed have forgotten it ; but if he remembers the occurrence at ail, he is not very likely to be mistaken about it. Within a short time of the inspira- tion of the foreign body, whether it be rough or smooth, pneumonia will probably result ; but the i later effects vary very much in the two 426 THE DISEASES OF THE LUNGS cases! If a piece of grass or an ear of wheat have passed into the bronchus, it may possibly perforate the king and travel to a distant part and ultimately make its way through the skin ; l:)ut if this does not take place, it will set up acute changes consisting of dilatation of the bronchi, of breaking down of the lung, and most prol)al)ly of burrow- ing abscesses. If the body be a smooth one, the changes are much more chronic, and consist of dilatation of the bronchi with a certain amount of consolidation of the lung. Patients may go on for years with this condition of things, and if they have forgotten or do not mention the cause of their complaint, it is very likely that it will be taken for bronchiectasis arising from one of the more common causes. It is for this reason that I would impress upon the reader the importance of inquiring in every case of unilateral bronchiectasis as to the possibility of its having arisen from the inspiration of a foreign body. It is most important to remember that a very short residence of a foreign l)ody in a bronchus may give rise to an amount of Fig. Ill bronchiectasis from which recovery is impossible. I have notes of the case of a boy who, when seven years of age, had a small ivory knolj in his left bronchus for eight weeks in the year 1891. He has now diffuse bronchiectasis of the lower part of the left lung, which appears to be beyond surgical treatment, and shows no sign of any improvement. In another case the vertebra of a rabbit was impacted in a bronchus in December 1887. He developed well- marked bronchiectasis, upon which I operated in the hope of finding a foreign body ; but the bone was not coughed up till some time after the operation — namely, in April 1880. He is now, in 1890, very much improved, but there remains a cavity at the base of his lung which has never quite stopped secreting, and is liable to attacks of acute inflammation. There was, at University College Hospital, under my care, a boy who had the peg of a pegtop in his lung for years. After it had been expelled through an opening which I had made, but through which I had failed to reach it, he was left with a cavity wliich continues to discharge h considerable amount of pus, and lie still has severe attacks of ha-moptysis. Treatment. Seeing, therefore, the extreme improbability of SURGICAL TREATMENT OF PULMONARY CAVmES 427 a favourable result in chronic cases, I would urge most strongly that every case in which there is good reason to suppose the presence of a foreign body in the bronchus should be dealt with without delay. It is, I think, quite unjustifiable to wait for symptoms to declare themselves, as these symptoms may indicate the presence of mis- chief from which recovery is impossible. The right course of procedure is to perform tracheotomy, and to endeavour to extract the foreign body by means of forceps (the pair shown in the figure (fig. Ill), whicla are so arranged that when the points are slightly separated the combined width of the blades slightly diminishes, are very useful for the purpose), or by means of probangs, or by coin -catchers, or — that which will be found very useful — a piece of stout silver wire bent as indicated in fig. 112, which can easily be directed to the bronchus of either side. If this be unsuccessful, the patient may be inverted and shaken — a procedure which should not be attempted before tracheotomy has been performed. Subse- quently, if acute suppuration have occurred, there can be no doubt of the right course to pursue ; but the surgeon will be unusually fortunate if he meets with the foreign body, though a careful search for it should not be omitted. These cases are not un- likely to prove rapidly fatal. Fig. 112 In the chronic cases it is right to endeavour to de- termine the position of a large cavity, and to open this as described on page 418. It should then be explored as far as is possible with probes and forceps, and if these fail tracheotomy should be per- formed, and the same course pursued as in cases of recent impac- tion. Another method, Avhich was employed in the case of the boy who had swallowed the peg of the pegtop, is to make an incision into the pleura behind the place at which the abscess had been opened, and to feel over the back and under surface of the lung. It was not successful, but I can imagine that another time it might prove to be of value. This case also proved the advisability of retaining the tube for a long time, for it will be remembered that it was through my opening, and not through the trachea, that this large foreign body was at last expelled. Conclusions. — It may, I think, be safely stated : I. — that gan- grenous cavities should always be sought and if possible opened ; if the operation be successful and the opening free, the prognosis is not bad. II. — The same treatment should be applied to abscesses caused by the rupture of purulent collections from other parts into the lung, at least as regards the pulmonary complication. III. — Abscesses caused by the presence of foreign bodies should be opened, and if the body be not found, it must be remembered that, if of any considerable size, it probably lies not more than three inches from the middle line. If possible, these cases should be treated early by tracheotomy and inversion. IV. — Bronchiectatic cavities when single — a very rare condition — may be cured by operation ; when multiple — a very 428 THE DISEASES OF THE LUNGS common condition — they offer a very small chance of relief by our present methods ; still it may be wise in some cases to make an attempt to open the main cavity, if such is to be found, but only after it has been ascertained that the lung is adherent to the chest wall. V. — Basic tubercular cavities sometimes require the same treatment as is applied to other pulmonary cavities. VI. — It is not usual to open apex cavities, though this may be justified by an extremely harassing cough. Such operations cannot be expected to be curative. VII. — Tubercular cavities may be treated by in- jections, either through the larynx or through the chest wall, but intralaryngeal injections appear to be practically valueless, and little is to be hoped from intrapulmonary injections. R. J. G. 42 9 CHAPTER XXXYII PULMONARY SYPHILIS PAGE Hereditary syphilis ......... 430 Morbid anatomy ......... 430 Association of congenital syphilis and pulmonary tuberculosis 432 Acquired syphilis ......... 434 Pathology and morbid anatomy . . . . . . 434 Illustrative cases .......... 436 Symptoms ........... 449 Physical signs and diagnosis ....... 450 Prognosis ........... 451 Treatment 452 OuE knowledge of the anatomical characters and clinical history of syphilitic disease of the lungs is still very incomplete notwithstanding that much has been written on the subject. This is due in part to the rarity of the affection, but chiefly to the difficulty until lately experienced in distinguishing between the lesions of syphilis and those of tuberculosis. Up to the date of the discovery of the tubercle bacillus it was very often impossible to determine with certainty during life whether a given case of pulmonary disease was tubercular or not ; and, after death, appearances which some considered to be distinctive of tubercle were by others said not to possess that significance. Now, however, that we possess a testfor tubercular lesions it may reasonably be hoped that the whole subject of syphilitic disease of the lungs will be placed upon a secure foundation. That the disease is of rare occurrence is a fair inference from the fact that the museums of the London hospitals and of the Eoyal College of Surgeons, all of which the writer has recently visited, con- tain only twelve specimens which are believed to illustrate syphilitic lesions of the lungs ; and of these two may be excluded, as either not of that nature, or of a nature so doubtful, that in the present state of our knowledge they are inadmissible as evidence. None of these specimens is from a case of congenital syphilis. Morbid anatomy. — The following pulmonary lesions have been attributed to syphilis : (a) gumma ; (b) white hepatisation (Virchow, Weber), or 'epithelioma of the lung' (Lorain, Robin); 430 THE DISEASES OF 'J'HE LUNGS (c) grey infiltration (Welch, Pancritius) ; (d) lobular pneumonia or bronchopneumonia (Forster, Welch); (c) fibroid induration; (/') changes in the lymphatics (Hermann Weber) ; (g) a destructive disease, the so-called ' Syphilitic Phthisis.' It will be convenient to consider separately the lesions of the hereditary and the acquired disease. Hereditary syphilis. — The pulmonary changes in hereditary syphilis may be either circumscribed or diffuse ; to the former the term ' gumma ' is applied ; the latter are classified under the head of ' pneumonia.' It is, however, far more common to find the two changes associated than to meet with either separately. A. Gumma. — As this lesion is of comparatively rare occurrence in congenital syphilis, and when present does not differ either in appearance or in microscopical structure from that found in the acquired disease, a more distinct picture of the morbid anatomy of the two affections will be obtained by describing it under the latter heading. B. Pneumonia. — Two separate lesions are included under this heading, namely, ' white pneumonia ' and ' interstitial pneumonia ; ' but of these it must again be stated that they occur more often in combination than apart. (a) Wliite imeumonia (Virchow, Weber), Epithelioma of the lung (Lorain, Robin). — This lesion, which in its true form is rare, is- found only in the lungs of still-born children, or of such as have- survived their birth a very short time. Other unmistakable signs of congenital syphilis are usually present, and gestation has in such cases seldom proceeded to the full term. It is a diffuse change affecting a lobe either as a whole or in part ; or one or both lungs may be completely consolidated. In still-born children the affected part is bloodless and airless ; ■ and even if force be used it may be impossible to inflate it ; but in infants several days old the lung always contains some air. The lung is much increased in size and its surface may be marked by the ribs. It is solid, dry, white, yellowish, or greyish -white in colour; but sometimes presents a reddish marbled appearance. The section differs from that of Jin ordinary pneumonic lung in that the granular appearance characteristic of the latter is absent, the surface being smooth and somewhat shining. On microscopical examination in true cases the interstitial tissue is not increased. The alveolar walls are thickened, and the small bronchi and the alveoli are filled with masses of cells of which some are round and others have more or less the character of epithelial cells : the cells are for the most part undergoing fatty degeneration and are beginning to brealc down. The alveoli are markedly enlarged. The colour of the affected area is due partly to the above changes, but in part also to diiniiiished blood-supply the result of pressure upon the capillaries. The lung tissue surrounding the consolidated part may show some degree of emphysema. Ecchymoses may be present in the pleura, pericardium, and thymus gland ; but these appearances are probably incidental to the mode of death. PULMONARY SYPHILIS 431 The bronchial glands are as a rule enlarged and on section dense, from a new formation of fibrous tissue enclosing cells arranged in a concentric manner. White pneumonia is a lesion of purely pathological interest, as owing to the filling of the alveoli with cells, the subjects of it, if not still-born, are unable to maintain the respiratory function for any length of time and soon succumb. (&) Interstitial ^jneicmonia.- —This is the most common pul- monary manifestation of hereditary syphilis ; but it occurs more frequently in association with some of the changes described under ' white pneumonia ' than as a purely interstitial lesion. In its true form it is distinguished by a small-celled infiltration of the inter- alveolar connective tissue, the alveolar epithelium remaining un- afi'ected. This change may be present to a very varied extent. In some cases lungs so affected appear normal to the naked eye, the lesion being only discoverable on microscopic examination. In well-marked cases the lungs are large and hard and of a pale or dark greyish red tint. The change may be present throughout the organs, or a single lobe or portion of a lobe may be alone affected. To the naked eye the lung tissue presents a decidedly coarse appearance. On microscopical examination a marked increase is seen in the interalveolar and interlobular connective tissue, which forms broad meshes, including small spaces wherein the alveoli are either crowded together or completely obliterated. In some cases the interalveolar meshes appear to consist of a dense capillary network, the vessels being dilated and tortuous. Around the vessels and bronchi there is a marked increase of the connective tissue, and the tunica intima of the small arteries is thickened. The alveolar epithelium may show desquamative changes, and brown and yellow pigment granules may be present. Interstitial pneumonia is often found in association with con- genital syphilitic lesions in the skin, with interstitial hepatitis and changes in the epiphyses ; but it is also found in cases in which gummata are present in the lungs, liver, and other organs. The change begins during foetal life, and at birth may have affected the lungs extensively. In such cases life is of short duration and death occurs from asphyxia, as is shown post-mortem by the frequent presence of ecchymoses in the pleura, pericardium, and thymus gland. When the change is less advanced at birth such children may die at a later period by a slow process of carbonic acid poison- ing, the first sign of which may be that a child previously fretful and noisy becomes quiet. In cases in which the other organs are healthy, or nearly so, life may be prolonged for months or years ; such subjects are, however, specially liable to acute disease of the respiratory organs, such as pleurisy, acute bronchitis, and broncho-pneumonia. From, the above description it will be seen that the morbid processes concerned in the production of the gummatoasand diffuse changes found in the lungs of syphilitic children chiefly affect the connective tissue and small arteries. They are (i) a round-celled 432 THE DISEASES OF THE LUNGS infiltration and proliferation of the interlobular and interalveolar connective tissue, originating in the cellular tissue around the bronchi, and leading to marked thickening of the framework of the lung, (ii) An isolated perivascular cell proliferation, which begins around the small arteries, and is accompanied by changes in the tunica intima (Hochsinger). Both the periarterial and peribron- chial granulations may occur as sej)arate nodules or node-like foci ; or they may be diffused over large portions of the lungs. A well-marked desquamation of the alveolar and bronchial epithelium is almost always present, but it is quite a secondary process. In the account here given of the pulmonary changes found in hereditary syphilis the descriptions of Heller,' Spaundis,'^ and Hoch- singer have been followed, and to those authors the writer desires to acknowledge his indebtedness. Association of congenital syphilis and pulmo- nary tuberculosis. Syphilis, by lowering the resisting power of the individual, may predispose to tuberculosis ; and it has recently been shown by Hochsinger •' that the virus of syphilis and tuber- culosis may be jointly transmitted from parent to offspring. This observation is of much importance, and tlirows a new light upon the nature of the pulmonary lesions found in infants the subjects of congenital syphilis. It has often hitherto been assumed, on evidence wnich is now proved to be insufficient, that such lesions are of syphilitic origin, whereas it is clear that they may be due to an associated tubercular infection. In three infants suffering from congenital syphilis, and presenting symptoms of infiltration of the lungs, the pulmonary disease was found post-mortem to be due to tuberculosis and not to syphilis. Tubercle bacilli were found in the lungs in all the cases. The first case Avas observed in 1H91 in a child not quite three weeks old ; the second in 1891 in a child twenty-four days old ; the third in 1893 in a child eleven weeks old. Case I. — Anna B., set. nearly three weeks. The parents had been married nine years. The father acquired syphilis shortly before marriage. The mother died from pulmonary tuberculosis three months after the birth of the child. The first and second children of the marriage were stillborn ; the third and fourth died during the first week ; the fifth and sixth were living, ages four years and two years respectively. The case of the seventh child is here described. From the time of birth she was sickly and suft'ered from nasal obstruction, snuffles, and dyspnoea. Eales were present in the chest. At the end of the second week a bullous eruption ap- peared on the nates. The child presented all the ordinary external signs of congenital syphilis, and was shown at the \^ienna Dermato- logical Society as a case of gumniatous disease of the viscera. ' Heller, ' Die LunRenerkrankuiiKen bei angeborener Syphilis,' Dcuisch. Archivf. klin. Med. }k\. xlii. S. loK, IKKH. ■-' Spaundis, * Ueber congenitiile Lungensyphilis,' Inaugural Dissertation, Freiburg, 1891. » Hocli.siiiger, Wiener Med. lilatt. Nos. 20, 21, 1H94. PULMONARY SYPHILIS 433 On examination of the chest there was marked dulness on the left side from the angle of the scapula downwards, with bronchial breathing- over the dull area. The respiratory murmur was harsh over both lungs, with rhonchi and coarse rales. The spleen was enormously enlarged, extending as low as the anterior superior spine of the ilium ; the liver could be felt four fingers' breadth below the costal margin, it was hard and the edge was rounded. The diagnosis was pulmonai^y and visceral syphilis. Mercurial treatment was prescribed. The child died on the thirty-first day after birth. On post-mortem examination the internal organs were found extensively infiltrated with tubercle. Both lungs showed tubercles varying in size from a miliary granulation to a walnut. A nodule as large as a hen's egg occupied the right middle lobe. The left lobe of the liver was almost completely replaced by a caseous nodule ; numerous tubercles studded the right lobe. The spleen was enlarged to nearly four times its normal size and con- tained similar deposits. Tubercles were also present in the kidney, pericardium, and peritoneum. The mesenteric and bronchial glands were enormously enlarged, and in many places caseous. Tubercle bacilli were present in all the lesions. None of the lesions in the internal organs were of syphilitic origin. Case II. — Victoria S., twenty-four days old. The mother had previously brought three children suffering from congenital syphilis to the same clinic. She had previously stated that she had not had syphilis. Nothing was known of the father, and it is not certain that either parent was tuberculous. The child had snuffles and presented all the characteristic appearances of congenital syphilis. There was a confluent papular syphilitic eruption on the nates and elsewhere. The percussion note over the left lung was dull and the breathing bronchial, with consonating rales. The spleen was slightly, and the liver markedly, enlarged. The temperature was normal. Mercurial treatment was ordered. The patient was shown at the Vienna Dermatological Society as a case of syphilitic pemphigus and syphilitic pneumonia. The child died on the thirty-eighth day. On post-mortem examination the left lower lobe was solid from greyish-white infiltration. There was acute catarrh of the bronchi of the left upper lobe and throughout the right lung, also of the larynx and trachea. The mediastinal and bronchial glands were enlarged, but not obviously caseous. The liver was large, reddish brown, somewhat indurated and with rounded margin. On micro- scopical examination of the lungs confluent peribronchial and perivascular tuberculosis was found, with tubercle bacilli. In the liver recent interstitial inflammation was present, with fatty de- generation of the liver cells. No trace of tuberculous lesions were found in any other organ than the lungs. Case III. — Auguste G., eleven weeks old. The mother, £et. 28, was suffering from pulmonary tuberculosis. She had had five illegitimate children, and denied having had syphilis. Nothing was known of the father. The child presented the characteristic F F 434 THE DISEASES OF THE LUNGS appearances of congenital syphilis, and had snuffles and a syphilitic rash on the buttocks. The rash appeared during the third week. The child had suffered from cough since it was five weeks old. There was doubtful dulness over the right lower lobe, with bronchial breathing and abundant moist rtiles. The liver was very large and hard, with rounded edge. The spleen extended four fingers' breadth below the costal margin. The temperature was normal. Mercurial inunction was ordered. The child died aged sixteen weeks. Post-mortem. — The right lower lobe was solid from a homo- geneous, greyish-white infiltration. Greyish-red and yellow tubercles were disseminated throughout the upper lobe. The lower half of the left lower lobe was collapsed. The bronchial glands were enlarged and caseation was commencing. The liver was fatty and slightly granular. In the portal fissure there was a caseous lym- phatic gland the size of a hazel nut. The mesenteric glands were caseous. The spleen contained a large caseous nodule. Micro- scopic examination showed the characteristic signs of ' chronic tuberculous broncho-pneumonia, tuberculosis of the spleen and mesenteric glands, and syphilitic interstitial inflammation of the liver, with well-developed inflammation of the vessels.' It is clear from the perusal of these cases that it will be neces- sary in future, even when the evidence of syphilis in the fa^tus is undoubted, to examine carefully for tubercle bacilli before a pul- monary lesion is attributed to syphilis. Acquired syphilis. — To present a trustworthy account of the morbid anatomy of acquired syphilis of the lungs is a far more ditticult task than that just attempted. In considering a matter of such uncertainty we have preferred to rely upon evidence which is at hand and may be put to the test, rather than upon that to be found in the literature of a period when, owing to the absence of any certain test for tuberculosis, the difficulty of distinguishing between the pulmonary lesions of tubercle and syphilis was almost insuperable. A study of the specimens of pulmonary syphilis contained in the London, museums shows that the possibility of the changes being due to tubercle was in nearly all cases carefully considered. These specimens and the records connected with them probably constitute the most trustworthy evidence on which to base a description of the morbid anatomy of the acquired disease, and, as will be seen hereafter, they have been fully utilised. Pathology and morbid anatomy. Bronchial catarrh may occur as a manifestation of the secondary stage of syphihs, and possibly also of the period of incubation (Walshe). The fact that bronchitis, occiirring without obvious cause in syphilitic sub- jects, may be greatly alleviated or cured by the administration of mercury is strongly in favour of this view. In the late secondaiy and t(!rtiary stages gunnnatous infiltration of the subnmcous tissue of the trachea and bronchi is not infrequent, and may be followed by the formation of fibrous tissue which, subsequently undergoing PULMONARY SYPHILIS 435 cicatrisation, produces stenosis, one of the most characteristic syphilitic lesions in the main bronchi. No definite statement can be made as to the most conmion period of the occurrence of gumma in the lungs ; cases of which the real nature could not be doubted have been recorded as early as two years and as late as twenty years after infection. The pulmonary lesions of acqun-ed syphilis belong chiefly to the late tertiary stage of that disease. A. Gumma. — Gummata may occur either singly or in numbers, and may vary in size from that of a hempseed or a hazel nut to that of a hen's egg, but the latter size is of rare occurrence. A gumma may be found in any part of the lung, but more commonly within its substance than upon the surface ; and more often about the root, near the large vessels and bronchi, than elsewhere. The lower lobes are perhaps more often affected than the upper. A gumma is rarely seen in the very early stage, of which alone the name is in any sense descriptive ; but it is said then to present a gelatinous or glutinous appearance, thus resembling a similar growth in the liver. At a later stage it is of a grey colour, tinged with various shades of red, white, or yellow, and presents on section a smooth and semi-transparent appearance. At a still later period a gumma forms a well-defined nodule of a yellowish colour, firm and dry. Inflammatory changes in the surrounding lung may lead to the production of a well-marked fibrous capsule, but this may be absent. The gumma may break down, and its contents having been discharged, an irregular cavity may result ; but this is, both absolutely and also in comparison with the occurrence of a similar change in caseous tubercular masses, very rare. The chief difference between a gumma of the skin, for example, and one of the lung, is that whilst the former tends towards necrosis, the latter tends to be transformed into a mass of scar tissue, the contraction of Avhich causes puckeriiig of the surrounding lung and overlying pleura. By the deposition of lime salts a gumma may become calcareous. In histological structure a gumma of the lung does not differ essentially from a similar growth elsewhere. In the early stage it is seen to consist of a granulation tissue composed of small cells about TjsVo i^ich in diameter, arranged concentrically around the sheath of the small vessels, and in some cases around the small bronchi. At a later stage the nodule becomes opaque in the centre, and its cellular structure can no longer be recognised ; but fatty and albuminous granules are seen instead in the meshes of a dense fibrous stroma. Finally it becomes converted into a mass of dense cicatricial tissue. A gumma may form a centre from which a small-celled growth may infiltrate the surrounding tissue, spreading chietiy along the bronchioles. The walls of the neighbouring alveoli are also infiltrated with small cells ; and the alveolar spaces contain inflammatory products, due either to epithelial proliferation or to the presence of cells of a character similar to those constituting the nodular masses ahead v 436 THE DISEASES OF THE LUNGS described. Giant cells are occasionally present, but are not so characteristic a feature of gumma as of tubercle. According to Dr. Councilman ' the essential process in the pro- duction of a gumma in the lung is a pneumonia with fibrinous exudation, accompanied by fibrous change in the alveolar walls, the whole subsequently undergoing caseation. The first step in the process is stated to be a hyaline degeneration of the capillaries of the affected area ; this is followed by atrophy of the alveolar walls. The alveoli become distended with large pale epithelial cells and fibrin ; the cells also undergo the hyaline degeneration, forming smooth bodies staining with eosin, and varying in size from one-half the diameter of a red-blood corpuscle up to that of a large epithelial cell. The capillaries become con^•erted into rigid tubes, and their lumen is much narrowed. Similar changes occur in the small veins and arteries. Immediately around the bronchi and arteries there is a formation of connective tissue, and here the alveolar walls show much thickening and contain many small round cells. The whole of the structures thus altered tend to undergo necrosis, and when that change is complete a caseous-looking mass results. The following descriptions of specimens in the Museum of Guy's Hospital well illustrate the appearances presented by gum- mata in the lungs. It will be observed that all the specimens here described were removed from the lungs of adults. No. 254. — A portion of the upper lobe of a lung showing on the cut surface two masses, one of which was described in the recent state as ' consisting of a circumscribed nodule of a firm, yellowish, dry substance, corresponding in all particulars to that in the liver (a gumma), except in being somewhat less firm : the other is softening, breaking up, and in process of forming a cavity. His- tologically the nodules are seen to consist of fibroid tissue, with many areas of caseation and a few giant cells.' P'rom the report of this case by Dr. Wilks the following additional particulars have been derived : The patient was a sailor fet. 29. No history was obtained ; he was moribund from laryngeal obstruction whcsn admitted, and there was profuse ex- pectoration of mucus and blood. There was a scar in the groin, and phimosis from a contracting sore on the penis. The whole mucous membrane of the larynx and trachea was deeply ulcerated, and the walls thickened by an infiltration of fibrous tissue into the submucous structure, producing great induration. The thyroid cartilage was bare at one spot, the lymphatic glands in the neck were enlarged. The liver contained a do/en hard, round, fibrous tumours — the largest the size of a marble-yellowish white, tough, and of leathery consistence, dry, and emitting no juice on pressure. In two or tlu'ee the circumference of the tumour consisted of a translucent structure ; and this was evidently the more I'ecent formation, the ' Councilman, JoIuir Hopkins Jlnsjnldl liulkliii, vol. ii. No. 11, 1801. PULMONARY SVl'HTLIS 437 opaque and yellow parts being probably tissue undergoing a de- o;enerative change. At one spot a deep cicatricial appearance was produced by the contraction of a group of these small nodules. Microscopically the nodules consisted of nucleated fibres and fibrous tissue. No. 255. — The lower lobe of a left lung from a male patient ip.t. 27, who died from erysipelas of the larynx. The specimen shows at its hinder part a large yellowish mass partially separated from the surrounding tissue. Smaller nodules are seen in the adjacent lung. The pleura over the gumma is much thickened. Histologically the nodule consists of fibrous tissue which stains with difficulty. There were many gummata in the liver. With the exception of the above lesions and some bronchitis the lungs were healthy. There was a chancre on the penis, and suppurating buboes. No. 256. — A portion of lung showing scattered through it several small masses of irregular shape, yellowish in colour, and firm on section. These masses are easily separable from the surrounding lung, which is healthy. Histologically the nodules show a central area of caseous material surrounded by a narrow zone of fibrous tissue, in which are many small round cells. The liver contained a single gumma, and was in a condition of difluse syphilitic hepatitis. There were several gummata in the testes. From a male patient fet. 39, who had suffered from cough and dyspnoea for six months. He was admitted for hepatic ascites and slight jaundice. The following specimen from the same Museum illustrates the appearances presented by a gumma which has undergone fibrous transformation : No. 253. — A section of a right lung. From a man get. 36, admitted for fracture of the cervical spine. At the upper part of the lower lobe is a circumscribed patch of fibroid material, with radiating processes extending into the surrounding pulmonary tissue. The pleura over it is much thickened. The interlobar septum is thickened, and from its upper portion similar fine fibrous strands radiate into the upper lobe. Other portions are very emphysematous (also fibroid and pigmented). No tubercle was found anywhere. There was lardaceous disease of the liver, spleen, and kidneys. Both testes were good specimens of syphilitic orchitis. The following description of a specimen in the Museum of St. George's Hospital illustrates a combination of the caseous and fibrous stages of a gumma : ^ ' Section of a right lung near the root. In the posterior and upper part of the lower lobe, close to the spine, there is an area showing marked fibrosis ; situated within it is a caseous mass the size of a marble, somewhat loose. The overlying pleura is adherent and thickened ; bands of thick greyish fibrous tissue pass i]:i wards ' Eolleston, H. D., Path. Soc. Trans., xlii. 50. 438 THi: DISHASES OF THE LUNGS from the pleura, and joining with each other form a meshwork.' No tubercle in any organ ; surface of the liver scarred from peri- hepatitis. Large caseous gumma near the portal fissure, with smaller ones in its neighbourhood. Liver cirrhotic and lardaceous. Gummata in both testes. From a male patient who contracted syphilis in 1884, six years previoiis to his death. In 1886 he suffered from syphilitic disease of the testes and sores on the right elbow. Death was due to urjemia. B. Lobular or broncho-pneumonia. — A careful review of the evidence on which it is believed that inflammatory changes. of the lobular or broncho-pneumonic type occur as the direct result of syphilis impresses one with the conviction that many of the cases described in the past as presenting such lesions were really cases of tuberculosis. In the following case,' however, such a possibility may be excluded. It will be observed that the pulmonary lesions were secondary to and in continuity with the growth of large gum- mata in the liver and spleen. The specimen is in St. George's Hospital Museum. Left lung. — The lower lobe is deeply congested and partially consolidated ; the consolidation is in patches as in catarrhal pneu- monia. Some of these masses appeared purulent, others fatty or caseous. The size varied from 8 mm. to \ mm. ; each patch or nodule was surrounded by a deeply congested zone. Bight luiig.- The lower lobe i)resented changes similar to the above; it was adherent to the diaphragm, through which a large caseous gummft in the liver had extended into the lung. At the upper margin of the caseous mass there was much fibrous induration and exudative consolidation of the pulmonary tissue. For the microscoi^ical changes, which are given in great detail, the reader is referred to the original article. There was a gmnmatous mass chieliy iix the upper part of the right lobe of the liver measuring 5i in. by 4] in., and another occupying the upper third of the spleen. That organ was greatly enlarged, weighing 2 lbs. (5 oz. Both liver and spleen were firmly adherent to the diaphragm, and the muscular tissue of the latter was in part destroyed by the extension through it of the gumma in the liver. The specimen was taken from a man a^t. 43, who contracted syphilis in 1861, twenty-five years before his death. He had periostitis of the tibia in 1804, left hemiplegia in 1871, and again in ls7(!. C. Fibroid induration. The following are the more im- portant changes of this nature which have been attributed to sypliilis : (a) thickening extending from the hilus around the bronchi and vessels; (h) isolated masses of fibroid tissue in various parts of the lung ; (c) diffuse changes occupying the whole or the greater part of one lung. The marked tendency of gummatous lesions to spread along the vessels and bronchi has already been referred to. ' l)(li''[iiii(' and Sisley, I'ulli. Soc. Trans., xlii. 111. PULMONARY SYPHILIS 439 The following case ' is an example of sj'pliilitic fibrosis illus- trating the first variety of this lesion : Woman fet. 50. — Thrombosis of cerebral artery ; hemiplegia. Pigmented excavated scars on left leg, due to old syphilitic ulcera- tion. Emphysema. Lungs. — Eight lower lobe contained a deep depression and a much-puckered cicatrix due to pigmented fibroid bands running into the lung tissue. No caseous or calcareous nodules. No pleural adhesions. Microscopical examination. — The fibroid tissue is arranged chiefly around the vessels and bronchi with a more or less concentric disposition. The coats of the vessels are much thickened. There is a small- celled growth invading the alveolar walls, which are also much thickened. In places the cells and nuclei are aggregated in heaps. As an example of fibrosis in the form of scattered areas of induration, the following case may be cited from the same source : Woman ast. 25. — Fracture of cervical spine. Pigmented and puckered cicatrix and syphilitic ulcers on left leg. Calcified gumma in the liver. Bight lung. — Upper lobe healthy. Middle lobe presented in the centre large irregular patches formed by radiating bands of fibroid tissue ; also smaller scattered patches of the same nature ; the band whitish, not pigmented. One patch contains a calcified nodule. No pleural adhesions. Left lung. — Adhesions over lower lobe ; and whitish, puckered, depressed fibroid patches with irregular thickening of the pleura. On section extensive fibroid infiltration ; bands appear to run into the lungs from the pleura. Some small rounded caseous patches are also present. The following specimen from the Museum of Guy's Hospital '^ illustrates the appearances met with in ' diffuse syphilitic fibrosis of the lungs.' The patient was a man set. 54, who had suffered from winter cough for some years. No. 252. — A portion of a right lung in which there is a con- siderable excess of fibroid material appearing on the cut surface as a delicate network traversing the pulmonary tissue in all directions. The fibroid change is less marked at the apex than at the base, in which latter situation many of the air vesicles are dilated ; over this area the pleura is slightly thickened and is adherent. The dense fibroid tissue that pervades the lung shows, scattered through it, numerous collections of small round cells not undergoing caseation. No giant cells are present. The walls of the small arteries are thickened. One or two small cavities the size of peas, with soft caseous contents, were situated near the root of the right lung, probably softening gummata ; no tubercle bacilli could be found in them. The condition of the left lung resembled that of the right. The liver was scarred ; the testes were fibroid. Death was due to bronchitis. D. Changes in the bronchial glands and lym- phatics of the lung. — In a case of syphilitic disease of the ' Greenfield, Path. Soc. Trans., xxviii. 248. . ^ Perry, E. C, ibid. xlii. 53. 440 THE DISEASES OF THE LUNGS liver, lungs, dura mater, cranium, and sternum recorded by Dr. Hermann Weber,' tbe bronchial glands and lymphatics of the lung presented the following appearances : The bronchial glands were much enlarged — some being the size of a pigeon's egg, some only that of a hazel nut. From the greyish-white section of the larger glands, which were rather soft, a creamy fluid exuded, consisting of fat globules, granular corpuscles, and an abundance of large cells in a condition of fatty degeneration. The less enlarged glands were harder, their sections offered a marbled appearance, large white patches, almost like bacon, being inter- spersed with greyish-red, very vascular tissue. No juice exuded spontaneously or could be squeezed from the section. Large nuclei and nucleated cells were the principal microscopical elements, with a very small proportion of fibres thickly studded with nuclei. The lymphatics leading from the lungs to the enlarged glands were dilated and their ramifications on the surface and throughout the lungs were distended with creamy fluid. A similar appearance is described in the case of Drs. Delepine and Sisley already quoted. ' Immediately under the pleura there was a network composed of ramified tracks. The appearance suggested lymphatics distended with cells or some fatty products.' The lymphatics of the subserous layer of the pleura were con- siderably enlarged over areas corresponding to the yellow patches (■? of syphilitic broncho-pneumonia) within the lung. Dr. Weber rejects the view that the bronchial glands were first affected by the syphilitic virus, and that the engorgement of the pulmonary lymphatics resulted from obstruction to the passage of the lymph. E. A progressive destructive disease, the so-called ' syphilitic phthisis/ It appears to the writer that the question of the existence of a syphilitic lesion of the above nature can only be settled by a careful study of cases which fulfil the following conditions : (i) The cases must be complete — that is, the symptoms observed during life must be considered in connection with the lesions dis- covered on post-mortem examination. (ii) The evidence of syphilitic infection must be undoubted. (iii) Repeated examinations of the sputum must have been made, and tubercle bacilli have been invariably absent, and the absence of tubercle from the lungs (as the cause of the lesions) must be proved by post-mortem examination. (iv) Syphilitic lesions about the nature of which there can be no doubt must be found in other organs. It is from such t'vidence alone that we can hope to construct the clinical history and morbid anatomy of advanced syphilitic disease of the lungs. The following cases illustrate this variety of the disease : Case I. Charles N., Jct. 88, brickla3'er. In 1H9'2 he suffered ' Weber, Heriiuiini, I'ulh. Sue. Trans., xvii. 152. PULMONARY SYPHILIS 441 from cough, with expectoration and pain on the left side of the chest. In 1898 he had night sweats and dyspnoea. He has not lost weight, and, heyond an occasional streak of blood in the sputum, there has been no haemoptysis. From -January to May 1894 he was an in-patient of the Brompton Hospital, under the care of Dr. Mitchell Bruce ; the diagnosis then recorded was ' Syphilis (?), tracheal stenosis, chronic bronchial catarrh, indura- tion of the left upper lobe and of the left base with pleural adhesions over that area. Cicatrisation of the soft palate and adhesion of the right posterior pillar of the fauces to the back of the pharynx.' There were no bacilli in the sputum. He continued fairly well until October 1894, when he expectorated a large quantity of offensive purulent material for two consecutive days. Cough was very severe at this period. His health subsequently improved, and remained so until February 20, 1895 ; when in the course of a few days he brought up about a quart of blood-stained sputum. Haemorrhage then ceased and dyspnoea diminished. On March 5 cough and dyspnoea increased and he became seriously ill, with constant headache and slight delirium. Oedema of the feet sub- sequently supervened. On March 15, 1895, he was admitted to the Brompton Hospital under the care of Dr. Percy Kidd. On admission he was reported to be fairly well nourished ; stridor marked ; cough severe. Eight lung resonant everywhere ; breath sounds much exaggerated, expiration prolonged. Loud hoarse inspiratory and expiratory stridor all over the lung ; sibilant rhonchi general. Left lung. — Expansion much diminished ; reso- nance much impaired, front and back ; breath sounds weak ; expira- tion prolonged ; fine crackling rales over the whole of lung ; vocal fremitus and resonance diminished. Expectoration profuse and difficult to expel. No tubercle bacilli found. Temperature 99° F. It varied between that point and 96° F. during the time the patient was in hospital. The dyspnoea gradually increased and death occurred on April 10. Post-mortem. — Scars on tongue, glans penis, and scrotum ; and adhesion of skin to left testis. Marked thickening of the right tibia. Larynx normal. Trachea narrowed at the lower end. Eecent ulceration from cricoid downwards for two inches ; below this, down to point of bifiircation, there was extensive scarring of the cartilaginous portion ; and also at its line of junction with the posterior wall. The submucous tissue -was extremely thickened. Cartilages bare in several places. The main bronchi were much scarred and showed extreme narrowing. The bronchus to the left upper lobe was impermeable to a probe. Bight lung. — Old pleural adhesions over the upper lobe, recent pleurisy with effusion at the base. Emphysema, with reticular fibrosis especially around bronchioles. Deep in the upper lobe at the edge of one of the main bronchi there was a large black fibroid mass, with fibroid radiation into the surrounding tissue ; in other parts two small, hard, raised masses, one with fibrous strands running up to it. Base solid from broncho-pneumonia. No appearance of tubercle. 442 THE DISEASES OF THE LUNGS Left lung. — Upper lobe extremely contracted, containing no normal tissue. It consisted of deeply pigmented blackish-grey fibrous Fifj. 113.- Chancies in thr Lung skcondauy to Syphii-itic Stenosis Oi' THK TbACHEA AND MaIN BrONCHI a, eomiionsiitory fulnrgcmeut of lower lobe, wliicli forms tlic ;i]ic.\ of the \\\\\\i : b, the coii- tracteil left upper lobe : c, ciivity in the lower lobi-, with dilntcMl bronchi in its nciphbour- Iiooil. The cliaiiKeH in trnchea ami bronchi in this case arc slmu ii in ftp;. 4G, p. 7H. tissue surrounding the openings of ])ronchial tubes, and bronchi- ectasis. At the centre there was a smooth-walled cavity about the PULMONARY SYPHILIS 443 size of a small chestnut into which a bronchus opened. No appear- ance of tubercle. Lower lobe. — Emphysematous, with reticular fibrosis along the margin and at the base. ]3ronchi dilated, but not to a marked degree. About the centre point of the outer margin there was a small nodule, probably a gumma, white and tirm, and surrounded by a pigmented fibrous capsule. The extreme base consisted of indurated fibrous tissue extending from the pleura to a cavity, the size of a marble, into which a small bronchus opened. From this cavity fine fibrous bands radiated in all direc- tions, producing extensive fibrosis of the surrounding lung. Peri- hepatic and splenic adhesions. Liver scarred and nutmeg. Spleen contained several calcareous masses surrounded by a fibrous cap- sule. Testes fibrous. Case II. — E. D., a^t. 36 ; coachman. The family history is unimportant. At the age of 18 he had a sore on the penis, for which he was treated for several months with medicine and a lotion. In 1890 he became an out-patient under the care of Dr, Fowler at the Brompton Hospital ; he was suffering from cough and expectoration, which continued. There was an enlarged gland at the lower part of the neck on the right side, dulness at the right apex, with feeble breath sounds and bronchial breathing in the right supraspinous fossa. The liver was large, nodular, and very tender. He took iodide of potassium in gradually increasing doses and obtained some relief. He was subsequently an out- patient at the Middlesex Hospital. In March 1893 he caught a severe cold, but remained at work. In the following April he noticed oedema of the legs and scrotum. He was admitted into Middlesex Hospital, under Dr. Cayley, on May 13, 1893. He w^as pale and emaciated, the legs and scrotum were oedematous. He had troublesome cough, accompanied by the expectoration of large quantities of extremely foetid pus. The breath was fa-tid. Physical signs. — Expansion deficient on right side. Rela- tive dulness at right apex front and back, breath sounds feeble over dull area. Absolute dulness from level of fifth interspace in nipple line and in axilla to base ; behind from angle of scapula to base. Vocal fremitus and resonance diminished, and breath sounds scarcely audible over dull area. Left side normal. No. displace- ment of heart. Hepatic region prominent. Liver dulness extended three inches below the costal arch in right mammary fine and almost to umbilicus in middle line. Liver somewhat soft and elastic. Urine, sp. gr. 1-004, neutral, contained albumin and fatty casts. The expectoration consisted of frothy greenish pus, forming thick masses in a watery fluid. It contained no tubercle bacilli. May 17. — The chest was explored in the axillary and sub- mammary region. No pus was found. May 19. — Liver exposed by incision below costal arch, and a depressed cicatrix seen. The expectoration continued copious, green, and foetid. Absolute dulness appeared over whole of right side up to clavicle, with amphoric breathing and pectoriloquy below the clavicle. June 15. — Oft'ensive pus was evacuated through a cannula inserted in third 444 THE DISEASES OF THE LUNGS ri,i(ht interspace in mid-axillary line : a portion of the fourth rib resected, lung incised, more pus evacuated, drainage tube inserted. June 19 and 20. — Hjemorrhage from wound. June 21. — Death. Autopsy. Abstract of notes. — Old syphilitic scar in trachea, six rings above bifurcation, more recent scar at bifurcation, pro- ducing stenosis of the main bronchi to the right upper and lower lobes. One bronchial gland enlarged. Pleura over right lower lobe adherent and much thickened. Bronchi much dilated beyond the site of stenosis. At the base of the upper lobe were two large irregular cavities with sinuous outlines communicating with large brojiehi, lined by a distinct membrane and coiitaining sloughy portions of lung tissue. The anterior cavity had been opened by the incision. The section of the lung was smooth and presented a finely speckled yellow appearance. No pus exuded from the yellow spots on pressure. In the anterior part of the lower lobe there was a large irregular cavity, the walls of which showed no sign of any mucous membrane, they were covered with yellowish-grey sloughy material. No tubercle present and no caseation. The lung puckered in many places and fibrous almost throughout. Liver enlarged (76 oz.). Large puckered cicatrix on the upper surface of the left lobe, and many similar cicatrices elsewhere. A cretaceous and caseous gumma on the posterior aspect of the right lobe. Liver substance fatty and amyloid. Kidneys large, pale, amyloid, and fatty. Case III.— T. H., vei. o9 ; painter. Admitted into Middlesex Hospital under Dr. Fowler, February 4, 1898. Father died aged 70 ; mother aged 75. No history of tuberculosis in family. Accident to left knee set. 19, followed by formation of an ulcer. Chancre on penis in 1858 (ajt. 25), secondary rash and sore throat subsequently. In 180-1 ulcers on left leg, and twice subsequently. In 1880 ulcer on right leg, near external malleolus. Dry cough since 1887, worse in winter. Since December 1892 severe paroxysmal cough with offensive mucopurulent exjDectoration. Marked emacia- tion during this period. A pale, grey-haired, emaciated man. Breath very foetid. Exten- sive scars on left leg of old standing, more recent scars on right leg. Scar in right lumbar region where incision was made for ' abscess.' Jiifjht lung. — Hyper-resonant on percussion ; breath sounds at apex bronchial, front and back ; crackling rales in supraspinous fossa. 1 bronchophony and pectoriloquy well marked in same area. Dulness over lower lobe to angle of scapula, breath sounds bronchial, with coarse crackling rales over same area. Left lung. -Resonance impaired over clavicle and in supraclavicular fossa, elsewhere hyper-resonance. Bronchial breathing over upper lobe, front and back, with crackling rales. ]>reath sounds bronchial over upper part of lower lobe, with bubbling and coarse crackling rules, the latter extending to the base. Urine, sp. gr. 1-020; no albumin. Expectoration copious, purulent, and offensive. Frequent examina- tions made for tubercle bacilli, but none found. No elastic tissue found. Temp. 98"", pulse 84, respirations 44. February 21. — PULMONARY SYPHILIS 445 Dulness at both apices, and medium crackling rales. Temperature between 99° and 100° F. The respirations between 30 and 48. Cough severe, and the breath and expectoration offensive. Died February 23. Abstract of post-mortem notes, — Scar on corona of penis with some induration around. Calvarium thickened, dura mater adherent. Pleural adhesions over both lungs. Bight lung. — Emphysema along anterior margin and at base. Apex pigmented and consolidated from pneumonia and oedema. In lower part an oval cavity measuring 2^ inches by 2 inches, in communication with main bronchus, and containing greenish-yellow, offensive, shreddy material. Below this for an incli and a half the lung grey in colour and almost solid, a few small cavities with curdy contents. No tubercle found. The pleura covering the consolidated area much thickened. Left htng. — Upper lobe pigmented and 'nodular.' A cavity, from bronchial dilatation, occupies the posterior portion. The lower lobe emphysematous, and contained numerous encapsuled caseous masses about 2 mm. in diameter. Bronchial glands pigmented, but not caseated. No ulceration in air passages. No gummata in liver or spleen. Testes scarred and fibrous. Small white fibrous nodule in right kidney. The following cases are incomplete, and do not attain to the standard of evidence laid down, inasmuch as the patients are believed to be still living. Case IV. — Mary G., fet. 33, married. Three children alive, three dead — one stillborn, one died a few hours after birth. Has had four miscarriages. Admitted into the Brompton Hospital, June 13, 1894, under Dr. Fowler. No history of tubercular disease in the family. Ten years ago had some affection of the liver. Three years ago had an attack of influenza followed by pleurisy (Kj and congestion of the lungs. Eight pleurisy recurred in August 1893. Has had a slight cough for three years, worse since September 1893. Expectoration has been profuse, and for the last two months foetid and of a bitter taste. In October 1893 it was tinged with blood for three weeks. Dyspnoea worse since September 1893. Catamenia ceased since the birth of the last child on September 30, 1893, at which time she caught a chill. In February 1893 patient noticed a swelling in the left loin, which at first gradually increased in size and subsequently diminished. It is slightly movable and is not tender. It is about equal in size to a small Tangerine orange, is situated rather superficially, and over the erector spin* muscle, whether actually within the muscle could not be determined. Emaciation, cough, and weakness have been increasing lately, and night sweats have been continuous. Physical signs. — Bight lung. Marked flattening of the whole of the right side, particularly in front. Measurement at right nipple level : right 14^ inches, left 16 inches. Dulness over upper lobe, with distant cavernous breathing and bronchophony front and back. Impaired resonance over upper part of lov/er lobe posteriorly, where crackling rales are audible ; similar rales at the. 446 THE DISEASES OF THE LUNGS right base where percussion note is dull. Left lung. — Harsh breathing general ('? compensatory), no adventitious sounds. Liver much enlarged and nodular on the surface, margin irregular ; extends from the fourth space to below the umbilicus. Spleen not enlarged. Urine free from albumin. E^pectoration profuse and foetid. No tubercle bacilli. From June to September the expectoration was usually foetid. Bacilli repeatedly sought for, but never found. The cavity at the right apex extended. Septem- ber 5. — Retraction more marked at right apex. Cavity dry. Numerous crackling rales in axilla, and all over base. General • improvement. Ijiver appears more nodular. October. — Large crackling rales over base and in axilla. Cavity at apex dry. No bacilli to be found. Discharged October 18, Intratracheal injections of menthol appeai-edat first to have an etteet in diminish- ing and then removing the odour of the expectoration ; but subse- (juently the foetor returned and appeared to be uninfluenced by their continued use. The (j^uantity of expectoration was small during the period over which their administration extended ; but it had been steadily diminishing up to the time when this treat- ment was commenced. The pntient considered that she derived benefit from the injections. The nature of the tumour in the back was doubtful ; it was believed to be a gumma in the superficial part of the muscle. Inunction of mercurial ointment was made daily into the back from September li2 onwards. Case V. — Edward C, jet. -i? ; a waiter. Admitted into St. George's Hospital, April 18, 1H94, under Dr. Whipham.' His father and mother died of ' consumption.' Thirty years ago he had a hard chancre. He has had syphilitic psoriasis of the palms. He has not had lupm.optysis, night sweats, or emaciation. A fort- night before admission he was attacked with severe pain on the right side of the chest and dyspnoea. On admission he was anjemic, and complained of cough and profuse expectoration. The skin was of a brownish tint and presented numerous old rupial scars. Right lung. — Impaired resonance over upper lobe with feeble breathing. Just below the second rib there is a small area of increased dulness and cavernous breathing with whispering pectoriloquy. There are rlionchi all over the right lung and to a smaller extent over the left. The sputum is profuse and mucopurulent. No tubercle bacilli were found on any occasion, the examinations were made by several observers. Aj)ril 15. Ordered Potiodid. gr. v., Li], hydrarg. perchlor. 5j. terdie. April 2H, — Expectoration andcougli less. Physical signs at right apex less mai'ked. Mai/ '2,. Discharged to convalescent home. The following case illustrates the fact, first pointed out by Dr. Pearson Irvine,'^ that stenosis of a main bronchus may give rise to destructive changes in the lung. It will be observed that the case was one in which a recent tuberculosis supervened on old syphilitic disease. ' The writer is indebted to Dr. Whipham for his kind permission to use the notes of this case. - J'ath. Sue. Trans., xxviii. HO. PULMONARY SYPHILIS 447 Case VI. — Margaret S., set. 25. Admitted into the Brompton Hospital .June 25, 1884, under Dr. Reginald Thompson. Family history good. Good health up to two years ago, when after marriage she had ' ulcerated legs.' No sore throat or skin eruption. Cough, expectoration, pain in left side, dyspncBa, night sweats, and emacia- tion have been present for eight months. On admission the fingers were clubbed ; there was a large circular ulcer on the back of the left thigh with some scarring, and coppery staining about the knee and leg on the same side. Cough, more or less paroxysmal ; expec- toration copious, nummular, and purulent. No tubercle bacilli. Right chest 16^ inches, left 15|. Dulness over left lung, absolute at base, where vocal fremitus is absent ; elsewhere it is diminished. Bronchial breathing, pectoriloquy, and crepitation over left upper lobe. Breath sounds absent at base, some rhonchus there. Slight crepitation at right base. The ulcer on the thigh yielded to antisyphilitic treatment. The physical signs remained much the same except that the breath sound at the left apex became cavernous. There was well-marked pyrexia throughout. The expectoration remained copious, at times it averaged a pint in the twenty-four hours. Death occurred on March 1, 1885, and was preceded by anasarca, ascites, and profuse diarrhoea. Autopsy. — A few small scars in the subglottic portion of the larynx. The lower half of the trachea marked by numerous stellate puckered cicatrices, involving both membranous and cartilaginous portions, but especially the latter. The origin of the left bronchus represented by a small opening just admitting a probe ; the sur- rounding parts of the tracheal wall extremely fibrous and puckered. Slight scarring in the right bronchus about the origin of the upper lobar branch. Left lung excavated from apex to base. Numerous trabeculated cavities in the upper lobe intersected by tough pig- mented bands ; walls thin and smooth. The ca\dties larger behind than in front, in the latter region they were more numerous ; and the intervening fibroid induration was more pronounced. Some bronchi appeared to expand uninterruptedly into the smaller cavities. Numerous small cavities in the lower lobe situated in indurated fibroid lung. The cavities contained extremely foetid reddish fluid secretion, and in some places some soft putty-like material. No tubercular nodules in this lung. The contents of the pulmonary cavities including the liquid and caseous parts were carefully examined for tubercle bacilli, but none could be found. Right lung crepitant, but studded with large tubercular groups, which were most plentiful in the middle lobe and lower part of the lower lobe. Amyloid disease of thyroid, mesenteric, and mediastinal glands, also of the kidneys, liver and spleen, and mucous membranes throughout the body. The recent tuberculosis of the right lung was obviously quite unconnected with the disease in the left, w'hich was secondary to the bronchial stenosis. This case proves very clearly that a progressive destructive 448 THE DISEASES OF THE LUNGS disease of the lung may result from syphilitic stenosis of a main bronchus ; but it does not prove that this disintegration of the lung is due to the continued action of the specific \'irus of the disease, as is the case in pulmonary tuberculosis. The fact that lesions similar to those here described may occur when the narrowing of the bronchus is due to pressure from without, as by an aneurysm, shows that the bronchial obstruction is the main factor in their production. Stenosis of the bronchus is followed by retention of secretion in the tubes, and this by bronchiectasis. Decomposition of the retained secretion induces inflammatory changes in the sur- rounding lung, and finally the part so affected breaks down and cavities are formed. The cases here described prove that in individuals undoubtedly the subjects of syphilis widely-spread destructive changes may be found in the lungs ; and that such lesions may occur independently of the presence of tubercle. Whether they are such as to entitle the condition to be termed ' syphilitic phthisis ' must be decided by those who continue to use the word ' phthisis,' a term which many teachers have ceased to employ. If the name ' phthisis ' is given to a group of symptoms and morbid changes, it can hardly be denied that a case (see Case I.) which is marked by such symptoms as severe cough, dyspnoea,, emaciation, fever, night sweats, profuse expectoration, and hfemor- rhage, and which, on examination after death, is found to present signs of consolidation, fibrosis, and excavation of the lungs, belongs to that category. The task before us, however, is to determine the real nature of the pathological lesions of pulmonary syphilis and of the symptoms which they produce ; whether they are such as to warrant the use of a vague nomenclature which it would be well to discard is a (juestion of but little importance. It may be of service, however, to draw attention to the chief points of difference between the pulmonary lesions of tuberculosis and syphilis. I. Tubercle usually affects the apex of the lung and subsequently the apex of the lower lobe, and tends to progress along a certain route. The prnnary lesion of syphilis is often about the root and central part of the lung ; the disease follows no definite line of march, and gummata may be found in any position. II. l>oth tubercles and gumma may undergo either necrosis and caseation, or fibrous transformation ; but with caseous tubercle the tendency towards softening and cavity formation is the rule, whereas a caseous gumma very rarely breaks down. III. The progressive destruction of the lung by a process of dis- integration leading to a gradual increase in the size of a cavity, a change so commonly observed in tubercular disease, is rarely if ever observed in syphilis, except as a secondary result of stenosis of one of the main bronchi. IV. In nearly all cases of advanced destruction of the lung occurring in the subjects of syphilis, stenosis either of the trachea or of one of the main bronchi is present, whereas this lesion is very rare indeed in tuberculosis. PULMONARY SYPHILIS 449 V. The cavities found in cases of pulmonary syphilis are usually bronchiectatie, but not invariably so ; whereas in tuberculosis they .-are commonly due to progressive destruction of the lung, but may l)e bronchiectatie. VI. The tendency to the formation of pulmonary aneurysms, which is so marked a feature in tuberculosis, is rarely observed in pulmonary syphilis. VII. Pulmonary lesions in tuberculosis are very common, whereas in syphilis they are extremely rare. The necessity for prolonged specific treatment is certainly more generally appreciated now than formerly ; and it is therefore probable that rare as these lesions have been in the past, they will be still rarer in the future. The conditions which favour their development are the neglect of mercurial treatment shortly after infection, and anything which, by lowering the general health, tends to dimmish the resisting power of the indi^^dual. When our knowledge of the virus of syphilis is as complete as that we even now possess of the bacillus tuberculosis, it may be possible to state definitely whether the destructive pulmonary lesions found in advanced cases of the acquired disease are directly due to the continued action of a specific micro-organism ; at present the question remains unanswered. Symptoms. — The only point worthy of mention in respect of •syphilitic lesions of the bronchi is that the catarrhal signs which accompany the secondary stage are, as a rule, general in their distribution ; whilst in the tertiary stage they are more often localised, owing to the tendency at that period to the formation of gummata in the main bronchi. Should stenosis occur there may at first be bronchial breathing limited in area, and often most marked about the root of the lung posteriorly. As the lumen of the tube diminishes, the breath sounds over the pulmonary area which it supplies become more and more feeble, and finally disappear when air ceases to pass the obstruction. If bronchiectasis is forming be- hind the site of stenosis there may be cough with profuse, purulent, and foetid expectoration, accompanied by general signs such as emaciation and moderate pyrexia. In the cases described in this chapter it will be observed that cough was as a rule the earliest and most prominent symptom. In the early stage it may be due to irritation, the result of laryngeal, tracheal, or bronchial lesions ; at a later period it is probably chiefly due to the changes within the lung itself. Dyspncea comes next in point of frequency. It varies in severity with the nature of the lesion : slight when this is limited, in cases of extensive fibrosis or stenosis of one of the main bronchi, it may be very severe. The dyspnoea tends to become paroxysmal and to assume the characters of bronchial asthma. Hamoptysis has not been of frequent occurrence in cases observed by the writer, but it may occur and may prove fatal. In one case of syphilis of the bronchial glands profuse and fatal haemorrhage occurred from softening of a gland and its rupture into a main branch of the pulmonary artery. G G 450 THE DISEASES OF THE EUNOS Expectoration may be profuse, purulent, and offensive. Factor ol the expectoration is common in cases of ad\anced pulmonary syphilis. The sputum will be free from tubercle bacilli. I'aiu may be present, but is not a very prominent feature of the disease. Emaciation is not as a rule nearly so extreme as in tuberculosis, but with advanced lesions in the lungs the difference is not so remarkable as to be of any value from a diagnostic point of view. Niglit sireats were present in several of the cases here described. When extensive lesions are present p^/r^.r/a may be considerable, and of the hectic type commonly observed in tubercular disease of the lungs, but in the early stages there may be a complete absence of fever. The general symptoms, as will be seen on reference to the cases desciibed, do not, in the presence of widely- spread lesions, differ markedly from those of advanced tubercular disease of the lung. Physical signs and diagnosis. — The lesions of syphilis are rarely of such a nature as to produce signs by which they can be distinguished from others of an entirely different origin. Consolidation and excavation will be recognised by their ordinary signs, probably before their syphilitic origin is suspected ; and it appears therefore unnecessary to describe them in detail, more particularly as in the cases here recorded the results of the physical examination are given in full. The features of pulmonary syphilis are certainly not as yet so clear that the disease can be recognised by any positive signs, but by a process of exclusion a diagnosis may generally be made. The case will prol)ably be regarded at first as one of pulmonary tuberculosis; but repeated examination of the sputum, and the failure to discover the presence of tubercle bacilli, will suggest another diagnosis. A careful inquiry, possibly previously omitted, will now be made as to syphilitic infection and as to the occurrence of any secondary or tertiary manifestations. Tlie absence of such a history in a hospital patient will not exclude syphilis ; but it is rare in private practice for a patient to have had syphilis with tertiary symptoms and to be ignorant of the fact. Evidence of tertiary lesions in the larynx, liver, spleen, or testes is of importance as showing that the viscera are affected. Careful search sbould also be nuidc for lesions of the calvarium, of the dura mater, and of the sternum and ribs. Speaking generally, the diagnosis of pulmonary syphilis from tuberculosis will de))end far more upon the examination of the sputum than on the results of physical examination. A careful examination of undoubted specimens of pulmonai-y syphilis does not bear out the statement that the lesions are generally limited to the middle part of the lung ; they are so often found elsewhere that little importance attaches to their exact site in deciding the question of diagnosis. It would be rash indeed to PULMONAR^■ SYPHILIS 451 diagnose pulmonary syphilis because of a lesion situated in and apparently limited to the middle of one lung, without having previously demonstrated, by frequent examinations, the absence of tubercle bacilli from the expectoration. Such points, however, are not without importance, as they may serve to arrest attention, as being unusual in a case possibly hitherto regarded as one of ' phthisis ' or ' consumption.' Evidence of excavation with fcetid expectoration, which does not contain tubercle bacilli, should always suggest the possibility of the case being one of pulmonary syphilis. When the physical signs indicate stenosis of the trachea or of one of the main bronchi, and the presence of a growth or an aneurysm can be excluded, it is very probable indeed that syphilis is the main factor^ in the case. Those who are content with a diagnosis of ' phthisis ' and neglect the systematic examination of the sputum, will almost certainly overlook a case of pulmonary syphilis if it should come in their way. A striking example of this has recently come under our notice. A mihtary officer who had contracted syphilis some years back began to suffer from symptoms of laryngitis, and on examination of the chest, well-marked signs of disease were found at the apex of the right lung. The laryngoscopic appearances did not suggest to several competent observers that the lesion was due to syphilis, and the case was regarded as one of ' consumption of the throat and lungs.' It occurred to a medical man who saw the patient at a later period to examine the sputa for tubercle bacilh, and, as none were found on repeated examination, doubt was cast upon the diagnosis of ' phthisis,' and mercury and large doses of iodide of potassium were prescribed and the patient rapidly improved, but the stenosis of the larynx remained. Prognosis.-— Extensive pulmonary lesions, particularly exca- vation, whether from bronchiectasis or disintegration, and foetid expectoration, are certainly very grave complications of syphilis. If there is also evidence of gummatous hepatitis, albuminuria, _ and amyloid disease, recovery is scarcely possible, and life is not likely to be much prolonged. It is probable, however, that with our present improved means of diagnosis of tuberculosis of the lungs syphilitic cases which would have formerly been considered tuberculous may be recog- nised at an earlier stage than formerly, and may recover under appropriate treatment. In an undoubted case of pulmonary syphilis which came under the writer's care at a late period of the disease, the affection had been kept in check for many years by repeated visits to Aix-la-Chapelle, and by the active employment of antisyphilitic treatment. In any case seen in an early stage great improvement, if not complete cure, may reasonably be looked lor from the use of similar measures. There are, however, limits to the action even of specific remedies ; and it is not to be expected that lesions, such as bronchial stenosis and dilatation, extensive fibrosis and excavation, or gummata in a state of fibrosis, will G G 2 452 THE DISEASES OF THE LUNGS disappear under the administration of mercury or iodide of potassium. Treatment. — If the disease in the bronchi or lungs is recog- nised when in an early stage, the patient should be advised to undergo a prolonged course of treatment with mercury. Iodide of potassium in gradually increasing doses is generally administered at the same time. If, however, the disease is advanced and the patient emaciated, it is better first to try the effect of iodide of potassium alone : giving at the same time cod liver oil and tonics. To maintain and improve the strength and general nutrition of the patient are matters of as much importance in the treatment of syphilitic as of tubercular disease of the lungs, and are to be secured by the same means. The warm sulphur baths of Aix-la-Chapelle in association with mercurial inunction enjoy a special reputation in the treatment of syphilis, and are to be recommended to sufferers from pulmonary syphilis who are able to go abroad for treatment. When tubercular disease of the lungs occurs in a syphilitic subject, the treatment will be mainly such as is suited to cases of tuberculosis. A mercurial course is rarely admissible, but iodine, in the form of the syrup of the iodide of iron, may be given with advantage. In cases accompanied by fcetid expectoration, creasote vapour baths and intratracheal injections of guaiacol should l)e tried. Cases of syphilitic disease of the lung accompanied by bronchiectasis have not, in the experience of the writer, been benefited by surgical measures undertaken with a view to drain the cavities. J. K. F. 453 CHAPTER XXXVIII ACTINOMYCOSIS I'AGK Symptoms and diagnosis 453 Course ............ 456 Treatment 457 The recognition of actinomycosis as a disease in the human being- dates only from tlie year 1878, though it had been described by Bollinger in the previous year as occurring in cattle, and had been figured as long ago as 1845 by Langenbeck in a case of abscess connected with vertebral caries, and also by Lebert in 1857 in a case of abscess in the chest wall. It is not proposed to enter fully into the history of this disease, for the details of which the reader is referred to what is now a very copious literature of the subject. Symptoms and diagnosis. — For the present purpose it is only necessary to point out the symptoms of the disease as it affects the chest, and especially to indicate the difficulties involved in its recognition. These are undoubtedly great, partly because the symptoms are frequently very like those of pulmonary tuberculosis, or of disease of bone, or of tumour, but the principal reason why actinomycosis is so frequently unrecognised is because so few have seen the disease that the possibility of its occurrence is not present to the mind. We believe, however, that it is much more common than is usually supposed, and that, when it is more accurately described in the text-books, there will be fewer instances of its being overlooked than is now undoubtedly the case, in support of which it may be said that the occurrence of five cases of actinomycosis in a little more than a year in the practice of one of us can hardly be looked upon as altogether accidental. It is known that the fungus makes its way into the body either by means of the mouth or through the alimentary or respiratory tracts. The affections of the mouth will not be considered here ; but, should the entrance be effected through either of the other channels, the obvious symptoms may be chiefly thoracic ; in such cases the disease affects either the lungs, the pleura, or the liver. The history of a patient with this affection will probably be as follows : the onset of the disease will be gradual, the patient for 454 THE DISEASES OF THE LUNGS some time complaining of nothing except weakness and gradual loss of strength ; there may be some cough setting in insidiously, with or without expectoration ; and this mayor may not be followed by pleurisy, with or without effusion. We have no records of the i^lujsical signs in the early stages of the disease, nor do we know how soon any alteration in tempera- ture manifests itself; but by the time a case comes under observa- tion it is not unlikely that some or all of the following symptoms may be apparent. The patient will l)e pale and anaemic, and will probably have lost flesh, and will complain of loss of appetite and of a troublesome cough. If there is expectora- tion it may be simple mucus or it may be purulent, and if so may possibly contain i/elloiv grami Ics which , if present and exhibit- ing the microscopical appearances described below, are character- istic of the disease. It is said that the sputa are sometimes rusty, as in pneumonia. It is also possible that the patient may say that he has expecto- rated at one time a large quantity of offen- sive yellow material. The temperature will be raised and may be of a hectic type. There may be localised dulness, or there may be the dulness characteristic of pleural effusion. Over the dull area it is likely that the breathing will be weak, and it is not improbable that there will be signs of a cavity. Up to this point it will be observed that there is a risk Fig. 114. — -Fkont View ok Buy sukkebing from Actinomycosis of the Eight Lung and Pleuisa in the early stage The bulging of the mass is seen below and external to the right nipple. ACTlNOxMYCOSIS 455 of mistaking the disease either for empyema or for puhnonary tuber- culosis, though the bases of the hmgs are more frequently aft'ected than the apices. It may be observed that, in order to make con- fusion more easy, it ap- pears to be quite com- mon for actinomycosis to occur in tubercular people, and sometimes mdeed to be actually associated with active tuberculosis of the lungs, and also that it is per- haps impossible at pre- sent to diagnose between the pulmonary and pleural cases. The next stage is reached when the mis- chief begins to involve the chest walls. An indefinite swelling now occurs, obliterating the intercostal spaces, and gradually involving the superficial and soft structures which become brawny and oedematous ; one or more spots in this swelling soften, the skin becomes red, and, if left alone, rupture takes place, with the discharge of a certain amount of pus, probably much less than the amount of the swelling would have led the surgeon to antici- pate. The movements of the chest at this period will be decidedly impaired, and the spine will probably be found slightly bent, with the concavity towards the aft'ected side (figs. 114 and 115). At this stage it is obvious that the disease is likely to be mistaken for an empyema or for caries of rib. It is, however, usually easy, after the abscess has burst, tojnake the diagnosis by the simple process of looking carefully at the pus, or the prominent granulations around the orifice of the sinus either with a magnifying Fig. 115. — Back View of Boy surFEnrxo Fi;rai Actinomycosis of the Eight Lung and Pleura in the early stage Figs. 114 and 115 illusti'ate the curving of the spine a'.vay from the aiieeted side. The later stage of the rliseai-e in tliis patient is shown in PUxte 1, fig. 2. 456 THE DISEASES OF THE LUNGS glass, or with the naked eye. Small, pale yellow, roundish granules are seen, sometimes in great abundance, but often not in large numbers. These, though they have been said to bear a resemblance to the crystals of iodoform, can really hardly be mistaken for them,, because the colour is paler, and they are obviously not flat, but globular. One of these picked out of the pus or off the granulations with a needle and placed in a little water on a glass slide, and slightly flattened out by pressure with the point of a needle on a cover glass, will generally exhil)it, if not in perfection, at all events quite clearly enough for practical purposes, the radiating arrange- ment of the mycelium, with the club-shaped bodies at the circum- ference which are'characteristic of the disease (figs. 116, 117 and 118). No complicated method of staining is necessary for this purpose, though of course more elegant preparations may be obtained by Gram's and other methods of staining ; which, however, do not appear up to the present time to have precisely decided to what class of cryptogamia this organism belongs. Fig. IIG.— Cluhs as usually fount* in Cattlk Fig. 117.— Mktho]. OF SPBEADING (LoW power) Fig. lis. — Threads as- USUALLY FOIINI) IN MaN (hIGHIA' MAGNIFIFIi) In some of the cases described as actinomycosis the mycelium only was found without any of the club-shaped bodies. After studying the next chapter, the reader cannot fail to ask whether it is not possible that some of these would not now have been con- sidered examples of aspergillosis. If the disease has originated in the liver and made its way through the ribs, the external appear- ances will be the same, but some hepatic enlargement will probably indicate the true origin of the disease (fig. 115>). Course. — The natural tendency of the disease is to advance ;, and thus, although when it occurs in the mouth a cure is generally if not always obtainable by free removal of the disease, all the early thoracic and abdominal cases ended fatally, because it did not seem possible to attack them surgically, and no treatment by drugs appeared to be of the slightest benefit. Should the disease advance unchecked the patient becomes extremely emaciated, large veins appear upon the; surfo.ce of the body, and openings are formed in many situations, whilst none of the old ones heal, the temperature renuuns of the hectic type, appetite is lost, the i)ulse becomes rapid and feeble, convulsions may occur, and the patient dies a lingering death from exhaustion, |)robal)ly associated with emljolic pviemia. DESCKIPTION OF PLATE I. Showing the appeakance of the Sorp^s and neigh- bouring PARTS IN the two CASES OF ACTINOMYCOSIS ILLUSTRATED IN FiGS. 114 AND 119. Fig. 1, actinomycosis of the liver bursting through the ribs (p. 457, fig. 119). Fig. 2, actinomycosis of the huig and pleura (p. 454, fig. 114). In both a indicates the open sore, h h the swellings beneath the skin which have not yet given way. Plate 1 B. \ Fig. I. '■*(r^?*' V- '^i Fig II 3a:'e (b" Danielsson, Chromo-Lith. PLA.TE II. l:^ PART OF THE LIVER OF THE PATIENT SHOWN IN FIG. 119 AND PLATE I., FIG. 1 Lr. Liver. A. Part affected with Actinomycosis. Lg. Luug. D. Diaphragm. R. R. E. Ribs : the lowest is divided through the cartilage. The probe passes t/ircif/h the opening in the xkin. helireen the ribs to the cavitii in the liver. ACTINOMYCOSIS 457 The appearance of the wounds and the surrounding tissues in the later stages of the patients shown in figs. 114 and 119 is given in Plate I. The first of these cases is carefully described in the ' Medico- Chirurgical Transactions' for 1889, vol. Ixxii, p. 175. Fig. 119. — Front View of Patient suffering from Actinomycosis of THE Liver, affecting secondarily the Eight Lung and Pleura A prominent mass is seen below and external to tlie right nipple, in the middle of which tliere is a sinus which was discharging. Treatment. — Within recent years the treatment by large doses of iodide of potassium appears to have been of real benefit in a certain number of instances, although in others the disease has continued to advance, if less slowly, towards a fatal termination in spite of the use of the drug. The iodide is well borne and may be 458 THE DISEASES OF THE LUNGS given in doses of grs. 30 to 40 three times a day. Still more recently the injection of iodide of potassium has been suggested. We do not think, however, that surgical treatment should be omitted, although the dangers attending it have to be pointed out, and the surgeon must be prepared to tind that the growth has extended into regions where it cannot be safely followed ; for example, it may run along one or more of the ribs and attack the vertebral colunm, or may involve large spaces of the pulmonary or hepatic tissue (cf. PI. I). If an incision be made into it the finger will pass into a soft brain-like material, breaking down with the utmost readiness, and suggesting at first a degenerate malignant growth ; but, although this material is yellow and looks as if it were extra- vascular, it often bleeds with great freedom, and, indeed, ha-morrhage is sometimes so severe as to imperil the life of the patient, who, it must be remembered, is probably, by the time the operation is undertaken, in an exceedingly feeble condition. If, therefore, any operation is commenced, the surgeon should be provided with a rather blunt but fairly large sharp-spoon, and he must have ready a numberof plugs, so that, after scraping as much as he deems judicious, he may without any delay arrest the ha-morrhage by pressure. It must be remembered that plugging is not a very satisfactory process when we are dealing with the interior of the lung, not much more satisfactory than it is in the equally common cases where actinomycosis occurs in and about the ca-cum; still, not- withstanding the risk of the operation, we are of opinion that, con- sidering the uncertainty of the treatment by iodide of potassium, and the inevitably fatal result if the disease be unchecked, a com- bination of surgery and medicine is the right course to pursue with this very formidable disease. What has been said about the luemorrhage suggests a point which may assist in the diagnosis. If, on opening an abscess which is supposed to be of considerable size, either connected with the rib, or pleural cavity, or spine, or kidney, or c;ecum, the amount of pus is found to be unexpectedly small and the haanorrhage is very free, suspicion should be aroused ; and if, after a few days of free drainage, it is found that insidious burrowing of matter is taking place beneath the skin, a careful search should be made for the granules of actinomyces. 11. J. G. 459 CHAPTEE XXXIX PULMONARY MYCOSIS (PNEUMOMYCOSIS) Primary aspergillomycosis . Aspergillus fumigatus . Pathology and morbid anatomy Case of Weichselbaum . Case of E. Boyce . Case of Wheaton . Etiology Symptoms . Physical signs Diagnosis Treatment . Secondary aspergillomycosis Etiology Pathogenesis. Morbid anatomy Symptoms, course, and diagnosis Treatment . Oidium Mucorinffi Pseudo-tuberculosis hominis streptotricha Appendix : Protozoic infection . PAGE 460 460 460 462 463 464 465 465 466 466 467 467 467 467 468 468 468 468 469 469 469 The first cases recorded in which the presence of fungi was recog- nised in the lungs are by Virchow (1854). Since then, from time to time, papers have appeared on the subject, and lately it has received much attention from French writers, particularly Eenon. The diseases of the lungs and bronchi produced by fungi, and particularly the aspergillus fumigatus, have, up to the present date, attracted but Uttle attention in this country, and only a few cases of the kind have been recorded. It is extremely probable that closer in- vestigation of those cases of destructive disease of the lungs which cannot be proved to be due to the action of the bacillus of tubercle will show that some of them are of this nature. Nodular lesions resembling tubercles are found in the lungs in cases of pneumomycosis, and this fact has led to the use of the term ' pseudo-tuberculosis ' as descriptive of such diseases. The term ' tuberculosis ' has now a special meaning ; it is no 46o THE DISEASES OF THE LUNCiS longer a disease in which lesions of a certain character are present, it is a disease due to the action of a specific micro-organism, the bacillus tuberculosis of Koch. Against this practice we have ventured to protest elsewhere in this work {vide p. 379), and have urged that the nomenclature of any newly discovered affections due to the presence of micro-organisms should be based upon their etiology, and not upon the appearances of the lesions produced by the action of the specific virus. We consider that the terms ' tubercle ' and ' tuberculosis ' should now be regarded as appropriated, and as therefore possessing, when used, a special significance. The literature of Pneumomycosis is already considerable, but from a practical point of view, w^hich is one we feel bound in this work to consider, the subject is not at present of sufficient impor- tance to justify us in devoting space to its detailed consideration. The reader who is interested in it may be referred to the work of Dr. Kenon,^ in which the affections produced in animals and man- kind by the aspergillus fumigatus are fully and most ably considered. Dr. Renon's work also contains a very complete bibliography of the subject. ASPEEGILLOMYCOSIS The aspergillus fumigatus, which is the fungus that has been most frequently met with in cases of this kind, is closely allied to aspergillus glaucus, the blue mould commonly met with on fruit, cheese, and other decaying matters. Aspergillus glaucus itself is not pathogenic, but some other members of the family appear to be so in dogs and rabbits, and perhaps in other animals. An aspergillus consists of a copious mycelium, like that possessed by most fungi, consisting of delicate, branched, transparent, jointed threads, which ramify in the substance and on the surface of the material on which the fungus is growing. From this mycelium arise other straight threads (carpophores or conidia threads) which bear the fruit. At the summit of these appear rayed divergent protuberances (sterigmata), and attached to each of these is a chain of spores (conidia). At a later period of its history a second kind of fructification is developed from the mycelium, namely a globose receptacle composed of cells, and containing in its interior minute oval bodies called asci, each of which holds eight sporidia. Aspergillus fumigatus Pathology and morbid anatomy. — Two views are held as to the nature of this organism : the one, which is supported by Virchow, Spring, and Robin, that it is invariably a saprophyte and that the lesions it produces are secondary to some original disease : the other, which is held by Rcnon and Dieulafoy, and which we think the former writer in his work above mentioned has clearly ' Etude sur Vasperqillose chcz les animaux ct chcz Vhomme. Paris : 1897. PULMONARY MYCOSIS 461 substantiated, is that it may be pathogenic, and the real cause of the lesions found in the lungs and other organs in cases in which it is present, although in other cases it is a secondary lesion. It is possible that in some of the cases which have been described Fig, 120 A, appearances in a scraping from the cnt siu'face of lung, showing rosette-like bodies ( X 450') ; B, from the patches growing in the right bronchus, showing mycelium and fructification ( x 450). Dr. Wheaton's case, ' Path. Soc. Trans.,' vol. xli. p. 34. the growth of the fungus may have been a post-mortem change. It must also be borne in mind that the aspergillus will grow in some preservative fluids in bottles, e.g. bichromate of potash and Miiller's fluid. 462 THE DISEASES OF THE LUNGS In fig. 120, which is taken from the paper by Dr. Wheaton referred to below, the appearances presented by the fungus are illustrated. The proof of its pathogenic nature rests upon the observa- tion of cases in animals and human beings, and upon evidence ob- tained by experimental research into the pathology of the disease. The first of the following illustrations (fig. 121), taken from Renon's work, shows the appearances presented by a tubercular-looking ■-»-.•'*■ Fig. 121. — A Tubercular-looking Nodule in the Lung in a case OF Aspkugillomycosis (R6non) nodule on the human lung in a case of aspergillomycosis ; the second (fig. 122) shows the mycelium in the sputum of a similar case. Eenon describes three varieties of lesions found in the lungs in primary aspergillomycosis. The appearances described in the inflammatory form are from a case recorded by Weichselbaum.' The description of the morl)id appearances in the second form are taken from a paper by Hubert Boyce in the ' Journal of Pathology and liacteriology' (1892). The paper is accompanied by numerous coloured drawings of the lesions present in the lung and of the fungus. {a) Inflammatory /'o?»/. — Separate nodules of rounded outline, measuring from two to four centimetres in diameter, which project ' Wiener Med. Wuch., 1.S7H, p. l-28'.>. PULMONARY MYCOSIS 463 from the surface of a section of the lung, and present to the naked eye an appearance of a honeycomb with alveoU. Around such nodules emphysema may be present. On microscopical examination the honeycomb appearance is seen to be due to distension of the alveoli, the walls of which are infiltrated with the mycelium, and the growth is found within the alveoli in the form of rosettes. In a case reported by Arkle and Hinds, ^ the lungs were markedly emphysematous and somewhat indurated, and the alveolar walls and small bronchi were thickened. Minute cavities filled with an abundant mycelium, but exhibiting no sign of spore formation, were present throughout a portion of the right lung. ■ V, , ,. ,T,fe Hr^:::;^''c^ Tig. 122. — Mycelium in the Sputum in a case of Aspergillomycosis (Renon) [V) Ahortive form. — In this variety the development of the parasite is slower, and the resisting power of the tissues tends to limit its spread. It takes the form seen in actinomycosis. In the case of a patient who died from valvular disease, reported by Boyce,- the apex of the lung presented some small intercommunicating passages which could be traced to irregular bronchial dilatations. In the passages there were some small white bodies about the size of pins' heads which at first sight appeared to be calcified tubercles. The passages were lined, and in some cases phigged Avith a brownish- black substance, replaced at certain spots by white dots which pro- jected from the walls ; similar whitish or whitish-yellow specks were found in the red hepatised lung tissue surrounding the small cavities. The blackish-brown material showed, on microscopical examination, a number of club-shaped conidiaphores. The spores ' Path. Soc. Trans., 1896, p. 8. • - Journal of Path, and Bact., 1892, p. 1()5. 464 THE DISEASES OF THE LUNCiS with one exception were detached from the basidia, from which they appeared to be formed by segmenttition. Crushed preparations of the harder white bodies projecting from the walls of the cavities showed that they were formed of hyplup (or threads) thicker than those before described. The walls of the irregular cavities were formed of lung tissue interwoven with hyphne, which on the inner aspect gave rise to pigmented conidia- phores, and on the outer sent out hypha^ which ramified for a considerable distance in the walls of the alveoli. (' Hyph.e ' are the filu.ments or threads of a fungus which, when matted together, form the mycelium. ' Conidia ' are asexual spores, and ' conidiaphores ' are the hyph;e which produce conidia. The • basidia ' are large cells borne on the spore-producing surface which give rise to spores at their free ends. ) In the hepatised tissue there were found tubercle -like points and some larger reniform ' pseudo-tubercles ' formed of alternating- zones of hyphfe of different density. The fibres of the mycelium loosely penetrated the reniform bodies, and spread out in the forjn of branches into a dense fan-like structure. The whole presented an appearance strikingly resembling that of actinomycosis. The smaller nodules in some cases started in the alveolar wall, presumably from a spore, as from one thickened central stock numerous irregular processes branched out dichotomously, and formed a mass presenting the appearance of a large mulberry. The alveoli of the hepatised tissue were filled with an exudation consisting of corpuscles and fibrin. Near the centre of the lesion the lung tissue and exudation were replaced by necrotic tissue, in which the chromatin granules of broken-down corpuscles were easily recognisable by the deep staining reaction. Leucocytes and macrophages were present, and the latter became more numerous near the aspergillary foci, and especially so near the hyphjo, some of which were completely surrounded by the macrophages. In all the sections a small thrombosed vessel was seen ; its wall was infiltrated with hyph;e which had also penetrated the thrombus. (c) The form com»licateil loitli tuberculosis.— The case recorded by Wheaton ' is regarded by Eenon as of this nature, although described by the author as a ' case primarily of tubercle in which a fungus (aspergillus) grew in the bronchi and lung, simulating actinomycosis.' The })atient was a girl, ;et. 2h, who had been ailing for two months with a slight cough and marked loss of flesh. There were signs of consolidation of the base of the right lung in front and of the right apex behind. Eight diiys after admission signs of breaking down appeared at the biise of the right lung posteriorly, and three days later a white patch ap])eared on the left side of the tongue. Severe continuous pyrexia, a|)peared (103"4°-105*4° F.), and later the temperature reached 106-4°. ' I'ath. Soc. Trans., vol. xli. p. HI. PULMONARY MYCOSIS ' 465 The white patch on the tongue, which had a gelatinous, semi- transhtcent look, and was very firmly adherent, gradually spread all over the tongue and hard and soft palates. The child died sixteen days after admission. Post-mortem. — The lower three quarters of the right lung were consolidated in patclies which were yellow, mottled with grey. The patches were riddled with small cavities containing pus, and in the surrounding lung were numbers of bright orange-coloured bodies about the size of a mustard seed, which could Ije picked out with the point of a knife. In the posterior part of the lower lobe there was a cavity the size of a tangerine orange, with irregular black walls covered with white granules. Exposed vessels ran across the cavity, which communicated freely with the main bronchus. In the latter were several white gelatinous patches similar to those on the tongue ; they peeled oft' with difficulty and left raw surfaces. The left lung contained scattered broncho-pneumonic patches and a few orange-coloured granules. Microscopical examination showed the absence of actinomyces and the appearances were typical of aspergillus. The mesenteric glands were enlarged, and contained yellow granules similar to those in the lung ; in a few places they were suppurating, and the pus contained mycelial filaments. The report states : ' Careful search was made for miliary tubercles, but none were found. . . . On careful search a few tubercles were found in the alveoli of the lung and in the mesenteric glands, but no bacilli.'' The evidence of the presence of tubercle at all in this case is therefore inconclusive. Eenon regards the case as certainly one of aspergillus fumigatus^ and not aspergillus niger ; but he misquotes the title of Dr. Wheaton's paper, as the word ' niger ' does not occur there. A case recorded by Dr. Bristowe ^ may also be consulted. Etiology. — The disease has been observed up to now chiefly in persons who in some way handle grain, flour, or meal infected with the spores of the aspergillus. Men engaged in the forcible feeding of pigeons in France not uncommonly suffer. Hair-combers who use flour in their work are also liable to be afiected. Millers and seedsmen may also possibly furnish examples of this affection. The hair-combers of Paris are stated by Renon to have noticed that they could not keep certain animals in their houses ; birds died from the disease in a fortnight or three weeks, after having suffered from cough and undergone emaciation ; dogs lived only three months, but cats proved insusceptible. Symptoms. — The disease in some cases sets m with haemo- ptysis, which may be either slight or profuse, and is generally repeated at intervals. A sense of fatigue and loss of strength are followed by dyspepsia and loss of appetite. Emaciation occurs and cough appears. This is at first dry and recurring in paroxysms ; subsequently it is attended by frothy expectoration, which quickly becomes greenish and purulent. The sputum is often blood- streaked^ ' Path. Soc. ■Trans., vol. v. H H 466 THE DISEASES OF THE LUNCJS Pyrexia is, as a rule, slight, the evening temperature rarely exceeding 38° or 38"5° C. Night sweating is occasionally observed. Dry pleurisy has been present in some cases. These symptoms generally suggest a diagnosis of pulmonary tuberculosis. Towards the close of the case weakness increases, severe haemo- ptysis may occur, and oedema of the legs appears. In other cases haemoptysis is slight or absent, the onset being marked by bronchitis, morning vomiting, feebleness and loss of appetite. Dyspnoea then becomes a marked feature and may assume an asthmatic type during the night, when cough is often incessant and accompanied by profuse frothy expectoration. At a later period the expectoration becomes greenish, purulent, and occasionally nummular. The physical signs in the earlier stages are those of bron- chitis, followed at a later period l)y evidence of consolidation, generally at the apex of one lung. The course of the disease is variable. Periods of improvement are generally observed, during Avhich the patient may gain weight and lose most of the symptoms. Arrest of the disease, accompanied by fibrosis of the lung, frequently occurs, and the aspergillus gradually disappears from the sputum. Cases have been observed which have lasted three, six, and eight years, or even longer. The danger most to be feared is the supervention of pulmonary tuberculosis, and the existence of such an affection, and its general similarity to pulmonary tuberculosis, is a proof of the necessity which exists of examining the sputa in all cases of pulmonary disease, a point which we have frequently urged in the course of this work. We have recently heard of a case which, owing to the neglect of this precaution, was overlooked for two months, being regarded as certainly one of tuberculosis. Diagnosis. — The disease can only be recognised by the discovery of the mycelium or of small rounded white or yellowish- white bodies in the expectoration, although before this its presence may be suspected when the patient is engaged in any of the occu- pations mentioned above. The sputa will probably be first examined for tubercle bacilli, under the impression that the case is one of tuberculosis. If none are found, the sputa should be examined for fragments of the mycelium, which may be stained with a watery solution of safranine, or better by staining with thionine (Renon). To make certain that the mycelium is that of the aspergillus, fresh sputa should l)e sown on tubes of sterilised ' liquide de Kaulin,' ' and kept at a temperature of 37° C. If spores or mycelium arc present, filaments, at first isolated, but which afterwards unite and form a clump, will be seen to arise on the second day, and slowly to reach the surface of the liquid. Some hours later they form a ' For the composition of liquido do Haulin see Renon , L'aspcrgiUose, p. oH PULMONARY MYCOSIS 467 whitish velvet-like carpet, which twenty hours later is covered with greenish spores which assume a black colour in a few days. The pathogenic nature of the fungus may be proved by injecting an emulsion of the spores into the axillary vein of a pigeon, or into the vein of the ear of a rabbit. The animal will die m from four to eight days, from generalised nodular lesions in all the viscera, but especially in the kidneys. A fragment of the kidney sown on a tube of ' liquide de Eaulin ' will reproduce, in from three to six days, a culture of the aspergillus fumigatus. Treatment. — The indications for treatment are to develop the resisting power of the patient by giving abundance of food, and by enforcing rest during periods of pyrexia. He should be removed to a place where the air is most free from organic impurities. They are, in fact, in all respects similar to those recommended in this work as suitable in the treatment of pulmonary tuberculosis. There is no specific remedy for the disease known at the present time. Eenon has found that animals attacked by the disease live longer if iodide of potassium and arsenic are administered to them, and on that ground recommends the use of these drugs in cases in human beings. The symptomatic treatment of the disease — i.e. of cough, haemo- ptysis, and asthmatic paroxysms — should be conducted on the lines elsewhere recommended. It is possible that the use of creasote vapour baths may prove of service. In the absence of pyrexia and urgent symptoms, cod-liver oil and tonic remedies should be given. SECONDAEY ASPERGILLOMYCOSIS OF THE LUNGS Etiology. — The diseases in which secondary infection by the fungus has hitherto been observed are chronic bronchitis, bronchi- ectasis, broncho-pneumonia, ha?morrhagic infarction of the lungs secondary to valvular disease, pulmonary tuberculosis, and malig- nant growths of the lung. In cases of dysentery, cancer of the pylorus, septicsemia, and •diabetes, the conditions present appear to favour the growth of the fungus. Pathogenesis. — Evidence of special exposure to infection by the fungus owing to the nature of the employment, has been lack- ing in cases in which the disease is secondary to some other affec- tion of the lungs. The cachexia induced by cancer probably acts as a predisposing cause by lowering the resisting power of the patient. In diabetes there may be some special condition present which favours the growth of the fungus. Infection is probably through the air in some cases, in others the organisms were most likely present in the nasal mucous membrane or in the saliva, and have acquired yirulent properties owing to some change in the condition of the 468 THE DISEASES OF THE LUNGS patient having proved favourable to their growth and multiplica- tion. The fungus has been found in the situations named and in the saliva when no affection of a mycotic nature was present in the individual. Morbid anatoDiy. — Renon describes three forms of lesion : [a] bronchial; {h] tubercular; (c) cavernous. [a) The growth in this form takes place upon and in the bron- chial walls and on the walls of bronchiectatic cavities. {h) In this variety nodules resembling tubercles are produced in the lung. They are firm, greyish -yellow, well-defined nodules composed of ramified mycelium. (c) In the cavernous form the growth takes place on the walls of pre-existing cavities in the lung. The fungus is, however, not present in all the cavities — a proof that it is not the cause of the lesions. The forms resembling actinomyces are never found when the disease is secondary. Symptoms, Course, andDiat/nosis. — The infection usually occurs as a terminal event in secondary cases and hastens the end. The symptoms do not, as in the primary form, undergo remission, as the course of the disease is progressive and a fatal termination appears to be invariable. There are practically no symptoms which can be directly attributed to the presence of the fungus, which is rarely suspected before the discovery of the mycelium in the sputa. This must be sought for and stained according to the methods already described. Treatment. — The treatment depends upon the nature of the pi-imary disease, and is practically uninfluenced l)y the presence of the complication. Oidium. — Gilchrist and Stokes ' report a case in which a fungus of this nature was present in the tissues of the skin in a disease resembling lupus, and termed ' pseudo-lupus vulgaris,' affecting the face. Stained sections of the skin showed hypertrophy of the epidermis, scattered through which were numerous variously sized well-defined miliary abscesses. In all these abscesses, and also among the granulation cells in the cortex, Avere numbers of double contoured refractive bodies of a round or ovoid shape. They varied from 10 to 20/x in diameter, many presented buds, and in some a vacuole was ol)served, but this appearance was not constant ; they were usually single, but some were in groups. The contents of the bodies consisted of granular protoplasm ; giant cells weie present, and the bodies were in some cases contained within these cells. The api)earances presented by these bodies closely i-esemble those desciibed below as found in a case of protozoic infection of the skin. No tubercle bacilli were found. Pure cultures of the organisms were injected into the external jugular vein of a dog, which was killed in two months. ' I'.iiUrt. Joliiis Hopkins Hospital, vol. vii. No (i4 : July iSDd. PULMONARY MYCOSIS 469 The appearances in the kings of the dog were as follows : Projecting from the pleural surface, and completely studding both pulmonary pleurte, were a large number of firm, light yellow nodules the size of a pea or larger. They extended from ^ to 2 cm. into the lung. The nodules were round and sharply defined. On section of the lungs both organs were found to be studded throughout Avith similar nodules. No cavities were present and there were no extensive areas of case- ation. Microscopical examination of the pulmonary nodules showed a central area undergoing eoagulative necrosis, in which giant cells were occasionally present. This was surrounded by a zone of large epithelioid and lymphoid cells, the whole forming a nodule to which the term pseudo-tubercle is applied in the report. The rounded bodies in the necrotic areas were stained of a light blue colour. No mycelium was found in the tissues. Cultivations of the bodies were injected into other animals and a similar disease developed. The fungus is believed by Mr. Gilchrist to be an o'idium, and allied to the yeast fungus. Some of the uiucoriiicB or moulds are believed to be pathogenic, but very few cases in which fungi of this class were observed have been at present described. Pseudo- tuberculosis hominis streptotricha. — Flex- ner ^ has reported under the above heading a very interesting case in which extensive consolidation, areas of softening, and numerous tubercle-like bodies were present in the lungs. Similar bodies were also scattered all over the peritoneum and in the omentum, which was rolled up and thickened. No tubercle bacilli were present. Cultures inoculated with material from the lungs showed in twenty-four hours a vigorous growth of a bacillus. The organism is believed to be a new species which Flexner names ' streptothrix pseiido-tuberculosa.' We mention it in this place owing to the fact that it produces nodules similar to those found in tuberculosis. J. K. F. APPENDIX TO CHAPTEE XXXIX PROTOZOIC INFECTION RiXFOED and Gilchrist have reported two very interesting cases, which are described as ' Protozoan or Coccidioidal Pseudo-tnberculosis.' For a full account of these cases we must refer the reader to the oi-iginal report." In the first case, which occurred in a man set. 40, a farm labourer, the disease began in 1885 as an elevated tender spot on the Johns Hojpkins Hospital Bullet. June 1897. Johns Hopkins Hosp. Rep. 1896, i. 209. 470 THE DISEASES OF THE LUN(;s back of the neck, and increased by the fomjation of new papillary eleva- tions. The parts chiefly affected were the back of the neck, the eyebrows, nose, cheeks, lips, ears, and hands. The progress of the disease was marked by alternating periods of qiiiescence and activity. In 1891 a sore, 2i by 5 inches, was present on the back of the neck, and there was probably also one on the forehead. The disease remained local until February 1S94, when the lymphatic glands of the neck enlai'ged and developed fluctuation. Scraping with a sharp spoon was employed in March 1894. In January 1895 the ]iatient became very somnolent, cough, fever, and emaciation developed, and the physical signs of disease found in the lungs led to the impression that the patient was dying of tuberculosis. The patient died on January 31, 1895. On post-mortem examination the hmgs were an*mic and light- coloured, and to the touch appeared to contain minute masses like grains of sand beneath a membrane. Uoth lungs were almost completely filled with greyish nodules of nearly uniform size, about one millimetre in diameter, and closely resembling miliary tubercles ; combined with these there were caseous nodules and small cavities. The upper parts of the lungs were more extensively affected than the lower. In the former there were found several small cavities, each containing more or less purulent fluid. Some portions of the lungs were completely consolidated. Many extensive contracting scars were also found in both lungs. The left apex was adherent to the chest wall, and portions of the pleura were studded with small, greyish, slightly- elevated nodules re- sembling miliar}^ tubercles. Nodules resembling tubercles were also found on the upper surface of the liver, the peritoneal surface of the diaphragm, the parietal peritoneum of the pelvis and iliac fossa, also in the spleen. The bronchial glands, the mesenteric glands, the vesicida' seminales, and the adrenals were enlarged, and, with the exception of the latter, contained pus. Pus from the testes, prostate, seminal vesicles, a sinus in the tibia, and an abscess in the hand contained numbers of protozoa similar to those which during life had been found in the lesions of the skin. The fluid in the pulmonary' cavities contained immense numbers of protozoa, and similar bodies were present in abiuidance in the hmg tissue, and also in the suprarenal capsules and the lymphatic glands. Microscopically, the tubercular-looking nodules were i'ound to present a histological structure precisely similar to that of tubercles, the re- semblance being so close as practically to amount to histological identity. The tubercle-like bodies not only 2)resented the same varieties of cells arranged in the same manner as are tound in true tubercles viz. epithelioid cells, giant cells, and lymphoid cells — but they were the seat of coagulative necrosis or caseation. By the kindness of Mr. CJilchrist we are able to give an illustration sliowing the appearances presented by these bodies. The organisms were present, often in considerable numbers, in tlie giant cells, and were scattered tluough the lung, Sporulating forms were fairly numerous. The appearances presented by the diseased lungs were practically similar to tliose found in tuberculosis, except that the tubercle bacilli were absent and their place was taken by the proto/.oa. The adult encapsulated organisms showed a distinct double-contoured capsule ; they were almost splierical. and varied from l-V '27/i in diameter. The capsule was thick and well defined, and stained deeply. Between PULMONARY MYCOSIS 471 the capsule and the contents there was a clear refractive layer, which either stamed with ditiiculty or more often did not stain at all. This clear zone appears to be homogeneous and structureless ; it varies in thickness from l/x-Sju., and is hardly discoverable when sporulation is in process. The protoplasm of the organism is surrounded by the clear layer, and stains readily ; it contains fine and some scattered coarse granules ; the latter are sometimes seen at the periphery, or they may form a network. Fig. 123. -Section of Lung fkom a case of Peotozoic Infection SECONDART TO DiSEASE OF THE SkIN The proof afforded by these observations that lesions, which to the naked eye and upon microscopical examination cannot be distinguished from those resulting from the presence of the bacillus tuberculosis of Koch, may be produced in the Imags by infection from fungi and protozoa is complete, and shows how absolutely necessary it is in all cases of suspected tuberculosis to search for the typical bacillus, and not to draw conclusions as to the nature of the disease merely from naked-eye or histological evidence. J. K. F. 472 THE DISEASES OF THE IXINC.S CHAPTEli XL HYDATID DISEASE OF THE LUNGS Etiology . IMorbid anatomy . Characters of hydatid fluid Subsequent changes . Symptoms and physical sigr Before rupture After rupture Diagnosis Prognosis Treatment . PAGR 473 473 474 474 475 475 47(5 477 478 479 Hydatid disease of the lungs, like that of other organs, is due to the introduction into the body of the ovum of the ttenia echinococcus. Out of 809 cases of single hydatid cyst occurring in the Austra- lasian hospitals collected by Thomas ' the thoracic organs were aftected in 141 cases as follows Lung . IMeura . Heart . ' Thorax 134 cases 2 1 case 141 Hydatids appear to be met with in the lungs in a larger propor- tion of cases in Australasia than in Europe, as is seen by a com- parison of the tables of Neisser and Thomas.^ Organ Projiovtioii \n'v cent, of total cases Liver Lung Neissi-r's tnlile Kui'ope 50-11 7-44 Tliomas's tables : Australasia ()5-7(; i(;-5(; Ratio of luiiK to liver cases In Europe, 1 to (J^ In Australasia, 1 to 4 lljjdiitid Disease. Sydney : 1k!)4. - Op. ciL, p. 122. HYDATID DISEASE OF THE LUNGS 473 Etiology." -The disease is most common in countries, such as Austraha and Iceland, in which infected dogs are numerous, and associate closely with human beings in their domestic life. Water containing the ova of the worm is probably the chief source of infection. Morbid anatomy. — A single hydatid cyst is generally present, but both lungs may be affected, and there may be more than one cyst in a single lung. Cysts in other organs are frequently met with. The right lung is more often affected than the left (right, 121 cases ; left, 74 cases : Thomas), and the lower lobes of the lungs than the upper. The multilocular variety of hydatid has been met with in the lungs, but it is of very rare occurrence. The ovum of the ta?nia echino- coccus having been taken into the stomach, its chitinous en- velope is dissolved by the aid of warmth and the action of the gastric juice, and the liberated ovum bores through the coats of the stomach or intestine, and probably in the majority of cases of hydatid disease enters a branch of the portal vein and is carried in the blood stream to the liver. In cases in which it becomes arrested in the lungs it is possible that it may have already passed through the capillaries of the portal and hepatic veins, or it may have entered a systemic vein after leaving the stomach. In either case it reaches the lungs through the pulmonary artery. Dr. Bird ' suggests that the greater prevalence of hydatid disease of the lungs in Australia than in Europe is due to the inhalation of dust containing the ova of the echinococcus. If this is the mode of infection the ova may possibly reach the lungs through the bronchial arteries ; but the share taken by the processes of vascular transportation and migration respectively in the distribution of the ova of the t;Bnia echinococcus must be considered doubtful. The changes which the ovum undergoes in the lungs are similar to those which occur in other organs. It loses its external hooks and is gradually converted into a cyst containing fluid. The cyst wall is composed of a thick transparent elastic laminated cuticle (ectocyst) and an internal granular or parenchymatous layer (endo- cyst). 124. —Hydatid THE LuxG Cyst in On Hydatids of the Lungs. Melbourne : 1877. 474 THE DISEASES OF THE LUNGS Characters of hiidatid fluid. — The fiuid is clear, transparent, colourless, and neutral ; the specific gravity varies between 1"005 and 1*015 ; chloride of sodium is present in considerable amount, and there may be traces of sugar ; l>ut, so long as the cyst is living, there is either no albumen or only an infinitesimally small quantity. In the lungs, as in other organs, brood capsules, scolices, and ultimately daughter cysts may be formed by a process of budding from the granular or parenchymatous layer of the cyst wall, or the cyst may be sterile. The presence of the cyst usually excites some inflammatory change in the surrounding tissue, and thus an adventitious capsule is formed ; but, except in cases of prolonged duration, this is rarely of the dense fibrous character commonly found in hydatids of the liver. There may indeed be no capsule at all, the lung tissue around being either normal, or only slightly condensed as a result of pressure. The frequent aljsence of a definite lining membrane to the cavity occupied by a hydatid cyst in the lungs is a fact of much importance. As the cyst enlarges it displaces the lung and erodes the tissue around, so that small or large Ijronchi may open directly on to the surface of the cyst ; but, so long as it is kept tense by the pressure of the fluid Avithin it, these apertures are closed. If, however, the cyst Ijecomes collapsed, either from rupture or puncture, as in the operation of paracentesis, the contents of the cyst are discharged into the bronchi and air enters the cavity. Subsequent changes. — Buphire into a bronchus is the most common event. It is followed l)y the discharge of the contents of the cyst, and possibly also of the cyst itself, in which case the cavity in which it was lying may be gradually obliterated and the disease thus undergo a cure. This favourable result is, however, of rare occurrence, and is never observed when the adventitious cyst wall is firm and fibroid, as under these circumstances the cavity remains and continues to discharge pus. liujyture into the pleura is usually attended with pneumothorax. The subsequent occurrence of inflammation of the pleura gives rise either to a serous or a purulent efi'usion, the appearances of which will be to some extent modified by the condition of the fluid contents of the sac previous to its rupture. liupture into the j)ericardiunt may be quickly followed by death. Pneumonia may occur in the tissue around, and may pass into gangrene; but such an event is rare so long as the cyst is living. The pneumonic process may become chronic and be folloAved by fibroid induration of the consolidated part of the lung. Su])puration. — Inflammatory changes in the adventitious capsule may lead to the death of the hydatid, and this may be followed by suppuration of the cyst and fa-tid decomposition of the sac and its contents. The condition is then one of pulmonary abscess, and rupture into a ])ronchus or into the pleura is very likely to occur. The cyst may, however, burrow through the diaphragm and form a sac between it and the liver. This may be followed by • HYDATID DISEASE OE THE LUNGS 475 the discharge of the contents of the cyst through an opening at the umbiHcus. After the death of the hydatid the fliud becomes turbid and albuminous. The mother cyst first presents a gkitinous appearance, then becomes opaque, and ultimately breaks up into fragments. Daughter cysts, if present, undergo similar changes, but at a rather later period than the parent cyst. Spontaneous retrogression of a hydatid cyst is not uncommonly observed in the liver, but is an event of rare occurrence in the lungs, especially after the cyst has attained a large size. In such cases the contents of the cyst undergo fatty degeneration, a putty- like mass is formed, and the cyst shrivels. Symptoms before rupture. — The cyst may give rise to few or no symptoms so long as it is small and centrally situated ; but, as it increases in size, cough is usually induced. This is generally diXj and hacking, but may be accompanied by some mucoid expectoration. The cough is occasionally paroxysmal in character, and may resemble that of whooping cough. HcBvioptjjsis takes place in the majority of cases ; it is usually small in quantity during this stage, the blood merely staining the expectoration ; but profuse luemoptysis may occur before rupture of the cyst. Owing to the slow growth of the cyst the lung accom- modates itself to its presence and dyspnoea is rarely severe ; it may still be slight in degree even when the cyst has attained a large size. Urgent dyspnoea is often the result of pressure upon a large vessel. Pain is rarely severe, and may be absent, or there may be a sense of weight in the chest. The onset of pain is sometimes an indication that the cyst has reached the surface of the lung and has involved the pleura. So long as no inflammatory changes are excited in the lung or pleura, there is no p)yrexia. The general health of the patient may be but slightly affected, although some degree of loss of flesh gene- rally occurs. The physical signs before rupture of the cyst depend upon its size and position in the lung, lithe cyst is small and deeply seated, nothing abnormal may be found. If it is of considerable size and near the surface of the lung, but separated from the pleura by compressed lung, the percussion note over it may be of a sub- tympanitic or skodaic character ; the expansion of the affected side is diminished, the breath sounds weak, and the cardiac impulse may be displaced. If the cyst is in contact with the pleura the chest wall at that spot may be rounded and the intercostal depressions obliterated. The vocal fremitus will be feeble or absent. The most characteristic physical sign is a rounded area of dulness on percus- sion, the note obtained being absolutely dull in the centre of the area and gradually increasing in resonance toward its margin, the breath sounds and vocal resonance over the same site being absent. The cyst, after coming into contact with the pleura, may in the course of its further enlargement project through an interspace 476 THE DISEASES OF THE EUNCJS and form a ,L>lobular tumour on iJte surface of the chest- a vei'y important and characteristic sign of the disease. Over such a tumour, or where no sweUing of the kind is present, a thrill may be felt on percussion — the so-called hydatid thrill^a sign which is, however, not limited to iluid-containing cavities of this nature. Some crepitant rales may be caused by congestion or oedema of lung tissue in the neighbourhood, and the cardiac impulse may be displaced. Displacement of the heart may, ni some cases, be almost the only abnormal sign for a long period, as occurred, for example, in a case lately undei* observation at the ]3rompton Hospital, in which the heart had been markedly displaced for six years previous to the onset of an attack of double pneumonia, during which the real nature of the disease was discovered. Signs of pressure upon the vessels, pneumogastric nerves, or oesophagus are very rarely met with. A cyrtometric tracing may show enlargement of the affected side when there is no definite tumour. It may prove to be possible, by the aid of the Rontgen rays, to determine the presence and exact position of a large hydatid cyst in the lungs. The ru2)ture of the cyst into a bronchus is accompanied by urgent symptoms which may have an immediately fatal termination. Rupture is usually attended by violent cough, severe pain in the chest, urgent dyspnoi'a, and the expectoration of a quantity of watery fluid containing booklets, and possibly by severe ha'moptysis. If daughter cysts and pieces of hydatid membrane arc found in the expectoration it shows that the bronchus in comnmnication with the hydatid cavity is a large one. If the opening into the bronchus is small the escape of the contents of the cyst may be more gradual and the symptoms immediately attending its rupture less severe. Copious haemorrhage from the vessels of the adventitious capsule may occur not only at the time of rupture, but on frequent occasions during the course of the sub- sequent illness. Symptoms after rupture. — If the patient recovers from these symptoms cough continues and is usually violent, a severe exacerbation attending each fresh esca))e of daughter cysts and frag- ments of membrane into the bronchi. The expectoration often Ijecomes fo'tid and purulent from suppuration within the cavity; in chronic cases it may l)e chocolate coloured and may resemble very closely the pus which is supposed to be characteristic of an hepatic abscesG. Severe pyrexia of a hectic type usually accompanies suppm'ation of the cyst, and under such circumstances there may be consideral)le emaciation, and clubbing of the fingers may occur. In some cases, however, the symptoms which follow rupture of the cyst into a l)ronchus are much less severe; and althougb (juan- titici} of cysts and meinl)raneare expectorated during many months, if fever is al)sent, the general health may not be seriously impaired. The expectoration of the cysts may, however, be attended by most urgent attacks of dyspncjea owing to their temporary impaction in HYDATID DISEASE OF THE LUNCIS 477 the glottis, and at siich times there may be danger of the occurrence of asphyxia. Physical signs. — After rupture. The signs of a cavity may usually l^e discovered, but in some cases it is impossible, owing to the contraction of the cavity which contained the cyst, to deter- mine its site by physical examination of the chest. The attempt is most likely to be successful if the chest is auscultated during or immediately after an attack of coughing, accompanied Ijy expec- toration. liupturc into the pleiira is attended by sudden severe pain, urgent dyspnwa, and possibly by collapse. Physical signs indicating the presence of fluid, and probably also of air, will immediately be present, and the heart will be markedly displaced to the oppo- site side. Rupture into the p)ericarcUtim is attended by severe pain in the chest and evidence of great embarrassment of the action of the heart, symptoms which may be quickly followed by death. The chief physical signs will be marked increase in the area of precor- dial dulness and absence of the cardiac impulse. Diagnosis.— Before rupture. The nature of the case may be suspected if the percussion signs already described as typical of the disease are present ; but until they appear or rupture takes place a diagnosis may be impossible. In a case under the care of the late Dr. Bristowe, a correct diagnosis Avas made from the fact that, although all the physical signs pointed to the presence of a pleural effusion, a friction sound loas audible all over the area of dulness. Displacement of the heart, for which no cause can be discovered, should suggest the possible presence of hydatids. In some cases the discovery of hydatids in other organs has suggested the true cause of obscure pulmonary symptoms. The diagnosis from tuber- cular disease of the lungs is to l)e made by close attention to the site of the lesions, the fact that they have not followed the ' line of march,' and the absence of tubercle bacilli from the sputa. The general health is, as a rule, far more seriously affected in pulmonary tuberculosis than when an unruptured hydatid cyst is present in the lung. After rupture. — The presence of hydatid disease will be suspected from the history of the symptoms attending the rupture of the cyst, and this suspicion may be confirmed by the discovery in the sputa of booklets or fragments of hydatid mem- brane. If an actively secreting cavity is present in the lung, but neither hooklets nor membrane are found in the sputa, the diagnosis may be difficult ; but it will be clear that the case is not one of pul- monary tuberculosis if repeated examination of the expectoration shows no tubercle bacilli. Tubercular infection of the lung may occur after the rupture of a hydatid cyst, but such cases are rarely met with. If the presence of a hydatid of the lung is suspected, no attempt 478 THE DISEASES OF THE LUN(tS should be made to convert suspicion into proof by the puncture of the chest with an aspirator needle, at any rate until the patient is on the operating table and under the influence of an anaesthetic, and every preparation has been made for an immediate incision should it prove to be necessary, as death has been known to follow from suffocation caused by the escape of the fluid into the bronchi. When a hydatid cyst is situated in the upper part of the right lobe of the liver and projects towards the thorax, there may be great difficulty in arriving at a diagnosis, as a cyst in the lower lobe of the right lung or an effusion at the base of the right pleura may give rise to very similar physical signs. If jaundice is present and the liver projects considerably below the costal margin, the cyst is probably situated in the liver ; but jaundice is often absent in hydatid disease of the liver, and the liver may be enlarged from some independent cause when a cyst is situated in the lung. If the upper line of the dulness is highest in the axilla and slopes downwards both towards the sternum and towards the spine, the probability is in favour of the presence of a pleural effusion, whereas if the upper level of the dulness at the right l)ase is rounded there may be a cyst in the liver projecting upwards, or the cyst may be situated in the lower lobe of the right lung ; but it may be possible by the aid of this sign to exclude the presence of a pleural effusion. If a hydatid cyst of the liver perforates the lung and the contents of the cyst are expectorated, a diagnosis of the primary seat of the hydatid may usually be made from the fact that the sputa are bile stained. Hydatid cysts of the kidney have also been known to perforate the lung. The diagnosis of such a condition may be made by close attention to the history of the case, and particularly by the fact that the tumour was primarily seated in the luml)ar region. The absence of pressiu'e upon the large vessels, trachea, main bronchi, pneumogastric nerves, and (I'sophagus are signs of most importance in the differential diagnosis of hydatid of the lung from other forms of intrathoracic tumour. If a pleural eft'usion can be excluded, and fluctuation is present, the case is almost certainly one of hydatid disease, as that sign is not found in any other affection which is limited to the lung and does not involve the pleura. Prognosis. — If a correct diagnosis is made before rupture of the sac occurs, the prospects of recovery after operation are good, as a very large proportion of cases treated by incision and drainage are cured. The chances of spontaneous cure taking place without rupture are so remote as to be excluded from consideration when tbere is good reason to suspect the presence of a hydatid in the lung. If death does not occur at the time of rupture of the cyst into a bronchus or elsewhere, the prospect of ultimate recovery is fairly good, as it follows in rather more than half the number of cases. The prognosis in such cases is chiefly determined by the character of the general symptoms, particularly the degree of fever, and the HYi:)ATll) DISEASE OF 'I'HE LUN(;S 479 extent of emaciation. Frequently repeated haemoptysis is an un- favoural)le condition. If the discharge of the contents of the cyst has been preceded by the death of the hydatid and a foetid abscess has resulted, the prognosis is much less favourable. It will depend chiefly upon the possibility of discovering the site of the cavity and of draining it effectually. Treatment. — Medical treatment is quite useless except to alleviate symptoms. Paracentesis, except as a preliminary step at the time of opera- tion, is al)solutely inadmissible. It has no doubt, in a certain number of cases, led to a cure without further operation, but the risk is too great to warrant such a procedure. For the sake of convenience the surgical treatment of hydatids is reserved for the chapter on Hydatids of the Pleura. J. K. F. rlUNTRI) B? SPornswooDK and co.. nrw-stiuck'I' si^itake LONDON A LIST OF WORKS ON MEDICINE, SURGERY, AND GENERAL SCIENCE, PUBLISHED BY LONGMANS, GREEN & CO., 39 PATERNOSTER ROW, LONDON, E.G. 91 AND 93 FIFTH AVENUE, NEW YORK, and 32 HORNBY ROAD, BOMBAY. gl^trkal aixb Swrgxcal Marks. ASHBY .— JVO/U^S by HENRY ASHBY, M.D. Lond., F.R.C.P., Physician to the General Hospital for Sick Children, Manchester ; formerly Demon- strator of Physiology, Liverpool School of Medicitie. NOTES ON PHYSIOLOGY FOR THE USE OF STUDENTS PREPARING FOR EXAMINATION, sixth Edition, thoroughly revised. With 141 Illustrations. i8mo, price 5^. HEALTH IN THE NURSERY. With 25 Illustrations. Crown 8 vo. y. 6d. ASHBY AND WRIGHT. THE DISEASES OF CHILDREN, MEDICAL AND SURGICAL. By HENRY ASHBY, M.D. Lond., F.R.C.P., Physician to the General Hospital for Sick Children, Man- chester ; Lecturer and Examiner in Diseases of Children in the Victoria University; and G. A. WRIGHT, B.A., M.B. Oxon., F.R.C.S. Eng., Assistant Surgeon to the Manchester Royal Infirmary and Surgeon to the Children's Hospital; formerly Examiner in Surgery in the University of Oxford. Enlarged and Improved Edition. With 192 Illustrations. 8vo, price 25^. BE\^HETT.— WORKS by WILLIAM H. BENNETT, F.R.C.S., Surgeon to St. George's Hospital; Member of the Board of Examiners, Royal College of Surgeons of E?igland. CLINICAL LECTURES ON VARICOSE VEINS OF THE LOWER EXTREMITIES. With 3 Plates. 8vo. 6.. ON VARICOCELE: A PRACTICAL TREATISE. With 4 Tables and a Diagram. 8vo. 5^-. CLINICAL LECTURES ON ABDOMINAL HERNIA : chiefly in relation to Treatment, including the Radical Cure. With 12 Diagrams in the Text. 8vo. 8j-. 6d. ON VARIX, ITS CAUSES AND TREATMENT, WITH ESPECIAL REFERENCE TO THROMBOSIS: an Address delivered at the Inaugural Meeting of the Nottingham Medico-Chirurgical Society, Session 1898 — 9. 8vo. y. 6d. BENTLEY. A TEXtTbOOK OF ORGANIC MATERIA MEDICA. Comprising a Description of the Vegetable and Animal Drugs of the British Pharmacopoeia, with some others in common use. Arranged Systematically, and Especially Designed for Students. By ROBERT BENTLEY, M.R.C.S. Eng., F.L.S. With 62 Illustrations on Wood. Crown 8vo, price 7^^. 6d. WORKS OA MEDICINE, SURGERY &-c. BRODIE. THE ESSENTIALS OF EXPERIMENTAL PHY- SIOLOGY. For the Use of Students. By T. G. BKODIE, M.D., Lecturer on Physiology, St. Thomas's Hospital Medical School. With 2 Plates and 177 Illustrations. 8vo. 6j. M. CABOT. WORKS by RICHARD C. CABOT, M.D., Physician to Oiit-Patients. Massachusetts General Hospital. A GUIDE TO THE CLINICAL EXAMIN.ATION OF THE BLOOD FOR DIAGNOSTIC PURPOSES. With 3 Coloured Plates and 28 Illustrations in the Text. Svo, i6j. THE SERU.M DIAGNOSIS OF DISEASE. with 31 Temperature Charts and 9 Illustrations. Royal Svo, 7^. dJ. CHEYNE AND BURGHARD. A MANUAL OF SURGICAL TREATMENT. By W. WATSONCHEYNE, M.B., F.R.CS., F.R.S., Professor of Surgery in King's College, London ; Surgeon 10 King's College Hospital, and the Children's Hospital, Paddington Green, &c. ; and F. F. BURGHARD, M.D. and M.S. (Lond.), F.R.C.S., Teacher of Practical Surgciy in King's College, London ; Surgeon to King's College Hospi'.al, and the Children's Hospital, PadcHngton Green, &g. (To be Published in Si.\ Parts.) PROPOSED DIVISION OF WORK. Part I. The Treatment of General Part HI. The treatment of the Surgical Surgical Diseases, including inflam- Affections of bones and joints, in- mation, suppuration, ulceration, gan- \ eluding fractures and dislocations, grene, wounds and their complica- ' excisions and amputations, tions, infective diseases and tumours ; [/n preparation. the administration of anesthetics. Part IV. The treatment of the Surgical With 66 Illustrations. Royal Svo^ Affections of the head, face, and \os. 6d. \_h'eady. neck ; throat, nose, and ear. J [/« preparation. Part II. The treatment of the Surgical Part V. The treatment of the Surgical Affections of the tissues, including ' Affections of the thorax, breast, the skin and subcutaneous tissue, the 1 spme, antl generative organs, fascia, bursac, muscles, tendons, and I \^In prepara'ion. tendon-sheaths, nerves, arteries, and ! Part VI. The treatment of the Surgical veins ; deformities. Affections of the alimentary and Yin preparation. urinary .systems. [In p?eparation. CLkRKE.— WORKS by J. JACKSON CLARKE, M.B. {Lond.), F.R.CS. , Assistant-Surgeon to the North-West London Hospital, Pathologist and Curator 0/ the Museum at St. Mary's Hospital. POST-MORTEM EXAMINATIONS IN MEDICO-LEGAL AND ORDINARY CASES. With Special Chapters on the Legal Aspects of Post-Mortems, and on Certificates of Death. Fcp. Svo, 2s. dd. SURGICAL PATHOLOGY AND PRINCIPLES, \vith 194 Illustrations. Crown Svo. lOJ. (td. COATS. A MANUAL OF PATHOLOGY. By JOSEPH COATS, M.D., Professor of Pathology in the University of Glasgow. Third Edition. Revised tlirougliout. With 507 Illustrations. Svo, 31^. 6d. PUBLISHED BY LONGMANS, GREEN <&- CO. OOOYJE.— WORKS by THOMAS COOKE, E.R.C.S. Etig., B.A., B.Sc, M.D. Paris, Senior Assistant Surgeon to the Westminster HospitaL 1 ABLt, 1 b Or ANAIUAIY. Being a Synopsis of Demonstrations given in the Westminster Hospital Medical School. Eleventh Edition in Three Parts, thoroughly brought up to date, and with over 700 Illustrations from all the best sources, British and Foreign. Post 410. Part I. The Bones, js. dd. net ; Part II. Limbs, Abdomen, Pelvis, IOJ-. dd. net ; Part III. Head and Neck, Thorax, Brain, loj. 6tf. net. Ai^HURlSMb IN APPLIED ANATOMY AND OPERATIVE SURGERY. Including lOO Typical vivd voce Questions on Surface Marking, &c. Crown 8vo, 35. (>d. DISSECTION GUIDES. Aiming at Extending and Facilitating such Practical Work in Anatomy as will be specially useful in connection with an ordinary Hospital Curriculum. 8vo, \os. 6d. DAKIN. A MANUAL OF MIDWIFERY. By WILLIAM RAD- FORD DAKIN, M.D., F.R.C.P., Obstetrical Physician and Lecturer on Midwifery at St. George's Hospital, Examiner in Midwifery and Diseases of Women on the Conjoint Board of the Royal Colleges of Physicians and Surgeons in England, &c. With 393 Illustrations. 8vo, 185. DICKINSON.— f^^O/s'A'^ by W. HOWSHIP DICKINSON, M.D. Cantab., F.R.C.P., Physician to, and Lect^irer on Medicine at, St. George's Hospital ; Consulting Physician to the Hospital /or Sick Children. ON RENAL AND URINARY AFFECTIONS. Complete in Three Parts, 8vo, with 12 Plates and 122 Woodcuts. Price £t, 45. 6d. THE TONGUE AS AN INDICATION OF DISEASE; being the Lumleian Lectures delivered at the Royal College of Physicians in March, 1888. 8vo, price 7^^. dd. THE HARVEIAN ORATION ON HARVEY IN ANCIENT AND MODERN MEDICINE. Crown 8vo, 2s. 6d OCCASIONAL PAPERS ON MEDICAL SUBJECTS, 1855-1896. 8vo, I2.f. DUCKWORTH.— f^O^/sf^ by Sir DYCE DUCKWORTH, M.D. LL.D., Fclloiu and Treasurer of the Royal College 0/ Physiciatis, &'c. THE SEQUELS OF DISEASE: being the Lumleian Lectures dehvered in the Royal College of Physicians, 1896. Together with Observations on Prognosis in Disease. 8vo, loj'. 6d. THE INFLUENCE OF CHARACTER AND RIGHT JUDG- MENT IN MEDICINE : the Harveian Oration, delivered before the Royal College of Physicians, October 11, 1898. Post 4to, 2s. 6d. ERICHSEN. THE SCIENCE AND ART OF SURGERY: A TREATISE ON SURGICAL INJURIES, DISEASES, AND OPERATIONS. By Sir JOHN ERIC ERICHSEN, Bart., F.R.S., LL.D. (Edin.), Hon. M. Ch. and F.R.C.S. (Ireland), late Surgeon Extra- ordinary to H.M. the Queen ; President of University College, London ; Fellow and Ex-President of the Royal College of Surgeons of England ; Emeritus Professor of Surgery in University College ; Consulting Surgeon to University College Hospital, and to many other Aledical Charities. Tenth Edition. Revised by the late MARCUS BECK, M.S. & M.B. (Lond.), F.R.C.S., Surgeon to University College Hospital, and Professor of Surgery in University College, London; and by RAYMOND JOHNSON, M.B. & B.S. (Lond.), F.R.C.S., Assistant Surgeon to University College Hospital, &c. Illustrated by nearly 1,000 Engravings on Wood. 2 Vols, royal 8vo, 485. WORKS ON MEDICINE, SURGERY &-c. FOWLER AND GODLEE. THE DISEASES OF THE LUNGS. By JAMES KINGSTON FOWLER, M.A., M.D., F.R.C.P., Physician to the Middlesex llospilal, and to the Hospital for Consumption and Diseases of the Chest, Brompton ; late Examiner in Medicine at the University of Cambridge, and on the Conjoint Examining Board in England ; and RICK- MAN JuHN GODLEE, M.S., F.R.C.S., Fellow and Professor of Clinical Surgery, University College, London ; Surgeon to University College Hospital and to the Hospital for Consumption and Diseases of the Chest, Brompton ; Surgeon in Ordinary to Her Majesty's Household. With i6o Illustrations. 8vo, 25.?. FRANKLAND. MICRO-ORGANISMS IN WATER, THEIR SIGNIFICANCE, IDENTIFICATION, AND REMOVAL. Together with an Account of the Bacteriological Methods Involved in their Investigation. Specially Designed for the Use of those connected with the Sanitary Aspects of Water Supply. By Professor PERCY FRANKLAND, Ph.D., B.Sc. (Lond.), F.R.S., Fellow of the Chemical Society; and Mrs. PERCY FRANKLAND, Joint Author of "Studies on Some New Micro- Organisms Obtained from Air." With 2 Plates and numerous Diagrams. 8vo. \6s. net. QP^RROD.— WORKS by Sir ALFRED BARING GARROD, M.D., F.R.S., ir'c. ; P/iys!Cian Extraordinary to II. M. the Queen; Consulting Physician to King's College Hospital; late Vice-President 0/ the Royal College 0/ Physicians. A TREATISE ON GOUT AND RHEUMATIC GOUT (RHEUMATOID ARTHRITIS). Third Edition, thoroughly revised and enlarged ; with 6 Plates, comprising 21 Figures (14 Coloured), and 27 Illustrations engraved on Wood. 8vo, price 2.\s. THE ESSENTIALS OF MATERIA MEDICA AND THERA- PEUTICS. The Fourteenth Edition, revised and edited, under the super- vision of the Author, by NE.STOR TIRARD, M.D. Lond., F.R.C.P., Professor of Materia Medica and Therapeutics in King's College, London, &c. Crown 8vo, price \2s. 6d. GRAY. ANATOMY, DESCRIPTIVE AND SURGICAL. By HENRY GRAY, F.R.S., late Lecturer on Anatomy at St. George's Hospital. The Fourteenth Edition, re-edited by T. PICKERING PICK, Surgeon to St. George's Hospital ; Inspector of Anatomy in England and Wales ; late Member of the Court of Examiners, Royal College of Surgeons of England. With 705 large Woodcut Illustrations, a large proportion of which are Coloured, the Arteries being coloured red, the Veins blue, and the Nerves yellow. The attachments of the muscles to the hones, in the section on Osteology, are also shown in coloured outline. Royal 8vo, price 361. HALUBURTON.— WORKS by W. D. HALLIBURTON, M.D., F.R..S., M. R.C.I'., Professor 0/ Physiology in King's College, London. A TEXT-BOOK OF CHEMICAL PHYSIOLOGY AND PATHOLOGY. With 104 Illustrations. 8vo, 28.f. THE ESSENTIALS OF CHEMICAL PHYSIOLOGY. For the Use of Students. Third Edition. With 77 Ilhislrations. 8vo, 5^. *,* This book treats of the subject in the same way as Prof. Schafer's "Essentials" treats of Histology. It contains a number of elementary and advanced practicil lessons, followed in each case by a brief descriptive account of the facts related to the exercises which are intended to be performed by each member of the class. \% PUBLISHED BY LONGMANS, GREEN &^ CO. LANG. THE METHODICAL EXAMINATION OF THE EYE. Being Part I. of a Guide to the Practice of Ophthalmology for Students and Practitioners. By WILLIAM LANG, F.R.C.S. Eng., Surgeon to the Royal London Ophthalmic Hospital, Moorfields, &c. With 15 Illustrations. Crovvu 8vu, 3^. 61?. LEUMANN. NOTES ON MICRO-ORGANISMS PATHO- GENIC TO MAN. By Surgeon-Captain B. H. S. LEUMANN, M.B., Indian Medical Service. 8vo, 35. LIVEING. HANDBOOK ON DISEASES OF THE SKIN. With especial reference to Diagnosis and Treatment. By ROBERT LIVEING, M.A. & M.D. Cantab., F.R.C.P. Lond., &c., Physician to the Department for Diseases of the Skin at the Middlesex Flospital, &c. Fifth Edition, revised and enlarged. Fcap. 8vo, price t^s. LUFF. TEXT -BOOK OF FORENSIC MEDICINE AND TOXICOLOGY. By ARTHUR P. LUFF, M.D., B.Sc. (Lend.), Physician in Charge of Out-Patients and Lecturer on Medical Jurisprudence and Toxicology in St. Mary's Hospital ; Examiner in Forensic Medicine in the University of London ; External Examiner in Forensic Medicine in the Victoria University ; Official Analyst to the Home Office. With numerous Illustrations. 2 vols., crown 8vo, 24J. MOORE. ELEMENTARY PHYSIOLOGY. By BENJAMIN MOORE, M.A , late Sharpey Research Scholar, and Assistant Professor of Physiology at University College, London. With 125 Illustrations. Crown 8vo, 2,5. 61L NE^NMAN, ON THE DISEASES OF THE KIDNEY AMENABLE TO SURGICAL TREATMENT. Lectures to Practitioners. By DAVID NEWMAN, M.D., Surgeon to the Western Infirmary Out-Door Department ; Pathologist and Lecturer on Pathology at the Glasgow Royal Infirmary ; Examiner in Pathology in the University of Glasgow ; Vice-President Glasgow Pathological and Clinical Society. 8vo, price 8s. NOTTER AND FIRTH. HYGIENE. By j. l. notter, m.a., M. D., Fellow and Member of Council of the Sanitary Institute of Great Britain, Kxaminer in Hygiene, Science and Art Department, etc.; and R. H. FIRTH, F.R.C.S., Assistant Examiner in Hygiene, Science and Art Department. With 93 Illustrations. Crown 8vo, 35. 6d, OWEN. A MANUAL OF ANATOMY FOR SENIOR STUDENTS. By EDMUND OWEN, M.B., F.R.S.C, Senior Surgeon to the Hospital for Sick Children, Great Ormond Street, Surgeon to St. Mary's Hospital, London, and co- Lecturer on Surgery, late Lecturer on Anatomy in its Medical School. With 210 Illustrations. Crown 8vo, price 12s. 6d. PICK. SURGERY : A TREATISE FOR STUDENTS AND PRACTITIONERS. By T. PICKERING PICK, Consulting Surgeon to St. George's Hospital ; Senior Surgeon to the Victoria Hospital for Children ; H.M. Inspector of Anatomy in England and Wales. With 441 Illustrations. Medium 8vo, 25^. WORKS ON MEDICINE, SURGERY &-c. POOLE. COOKERY FOR THE DIABETIC. By w. h. and Mrs. POOLE. With Preface by Ur. PAVY. Fcap. 8vo. 2s. 6d. POORE.— WORKS by GEORGE VIVIAN POORE, M.D., F.R.C.P. ESSAVS ON RURAL HYGIENE. Crown 8vo, 6^. 6./. THE DWELLING HOUSE. With 36 Illustrations. Crown Svo, 35. 6.?. QUAIN. A DICTIONARY OF MEDICINE; Including General Pathology, General Therapeutio, Hygiene, and the Diseases of Women and Children. By Various Writers. Edited by RICHARD QUAIN, Bart., M.D.Lond., LL.D.Edin. (Hon.), F.R.S, Physician Extraordinary to H.M. the Queen, President of the General Medical Council, Member of the Senate of the University of London, &c. Assisted by FREDERICK THO.M AS ROBERTS, M.D.Lond., B.Sc, Fellow of the Royal College of Physicians, Fellow of University College, Professor of Materia Medica and Therapeutics, University College, &c. ; and J. MITCHELL BRUCE, M.A.Abdn., M.D.Lond., Fellow of the Royal College of Physicians of London, Physician and Lecturer on the Principles and Practice of Medicine, Charing Cross Hospital, &c. New Edidon, Revised throughout and Enlarged. In 2 Vols, medium 8vo, cloth, red edges, price 405. net. QUAIN. QUAIN'S (JONES) ELEMENTS OF ANATOMY. New Edition. Edited by EDWARD ALBERT SCIIAFER, F.R.S.. Professor of Physiology in the University of Edinburgh ; and GEORGE DANCER THANE, Professor of Anatomy in University College, London. In 3 Vols. *,^* The several parts of this work form complete Ticxt-books ok thkir RESPECTJVE SUBJECTS. They can be obtained .separately as follows : — Vol. L, Part L EMBRYOLOGY. By E. A. SCHAFER, F.R.S. With 200 Illustrations. Royal 8vo, gj. VOL. I., Part II. GENERAL ANATOMY OR HISTOLOGY. By E. A. SCHAFER, F.R.S. With 291 Illustrations. Royal 8vo, \2s. U. Vol. IL, Part L OSTEOLOGY — ARTHROLOGY. By G. D. THANE. With 224 Illustrations. Royal 8vo, \\s. Vol. IL, Part II. MYOLOGY — ANGEIOLOGY. By G. D. THANE. With 199 Illustrations. Royal 8vo, ids. Vol. IIL, Part I. THE SPINAL CORD AND BRAIN. By E. a. SCHAFER, F.R.S. With 139 Illustrations. Royal 8vo, \2s. U. Vol. III., Part IL THE NERVES, liy G. D. THANE. With 102 Illustrations. Royal 8vo, 95. Vol. IIL, Part III. THE ORGANS OF THE SENSES. By E. a. SCHAFER, F.R.S. With 178 Illustrations. Royal 8vo, gs. Vol. IIL, Part IV. SPLANCHNOLOGY. By E. A. SCHAFER, F.R.S., and JOHNSON SY.MINGTON, M.D. With 337 Illustrations. Royal 8vo, i6.f. Appendix. SUPERFICIAL AND SURGICAL ANATOMY. By Professor G. D. THANE and Professor R. J. GODLEE, M.S. With 29 Illustrations. Royal S'vo. 6s. 6tl. PUBLISHED BY LONGMANS, GREEN 6- CO. 7 SCHAFER. THE ESSENTIALS OF HISTOLOGY: Descrip- tive and Practical. For the Use of Students. By E. A. Schafer, LL.D., F.R.S., Professor of Physiology in the University of Edinburgh; Editor of the Histological Portion of Quain's "Anatomy." Illustrated by nearly 400 Figures. Fifth Edition, Revised and Enlarged. Svo, %s. ; Interleaved, 105. 6af. SCHENK. MANUAL OF BACTERIOLOGY. For Practitioners and Students. With especial reference to Practical Methods. By Dr. S. L. SCHENK, Professor (Extraordinary) in the University of Vienna. Trans- lated from the German, with an Appendix, by W. R. DAWSON, B.A., M.D., Univ. Dub. ; late University Travelling Prizeman in Medicine. With 100 Illustrations, some of which are coloured. Svo. ic.f. net. SCHREiNER. THE ANGORA GOAT (published under the auspices of the South African Angora Goat Breeders' Association) ; and A PAPER ON THE OSTRICH (reprinted from the Zoologist for March, 1897). By S. C. CRONWRIGHT SCHREINER. With 26 Illustrations from Photo- graphs. Svo, \os. 6d. SMALE AND COLYER. DISEASES AND INJURIES OF THE TEETH, including Pathology and Treatment : a Manual of Practical Dentistry for Students and Practitioners. By MORTON SMALE, M.R.C.S., L.S.A., L.D.S., Dental Surgeon to St. Mary's Hospital, Dean of the School, Dental Hospital of London, &c. ; and J. F. COLYER, L.R.C.P., M.R.C.S., L. D.S. , Assistant Dental Surgeon to Charing Cross Hospital, and Assistant Dental Surgeon to the Dental Hospital of London. With 334 Illustrations. Large Crown Svo, 155. SMITH (H. F.). THE HANDBOOK FOR MIDWIVES. By HENRY FLY SMITH, B.A., M.B. Oxon., M.R.C.S. Second Edition. With 41 Woodcuts. Crown Svo, price 5^. STEEL.— WORKS by JOHN HENRY STEEL, F.R.C.V.S., F.Z.S., A.V.D., late Professor of Vetentiary Science attd Principal of Bombay Vetennary College. A TREATISE ON THE DISEASES OF THE DOG; being a Manual of Canine Pathology. Especially adapted for the use of Veterinary Practitioners and Students. 88 Illustrations. Svo, lOi'. 6d. A TREATISE ON THE DISEASES OF THE OX; being a Manual of Bovine Pathology. Especially adapted for the use of Veterinary Practitioners and Students. 2 Plates and 117 Woodcuts. Svo, \^s. A TREATISE ON THE DISEASES OF THE SHEEP; being a Manual of Ovine Pathology for the use of Veterinary Practitioners and Students. With Coloured Plate, and 99 Woodcuts. Svo, \2s. OUTLINES OF EQUINE ANATOMY: a Manual for the use of Veterinary Students in the Dissecting Room. Crown Svo, ^s. bd. WORKS ON MEDICINE, SURGERY &^c. STEVENSON. WOUNDS IN WAR: the Mechanism of their Production and their Treatment. By Surgeon-Colonel W. F. STEVENSON (Army Medical Staff), A.B., M.B., M.Ch. Dublin University; Professor of Military Surgery, Army Medical School, Netley. With 86 Illustrations. 8vo, price l2>s. "STONEHENGE." THE DOG IN HEALTH AND DISEASE. By "STONEHENGE." With 84 Wood Engravings. Square crown 8vo,7j. 6d. TAPPEINER. INTRODUCTION TO CHEMICAL METHODS OF CLINICAL DIAGNOSIS. By Dr. H. TAPPEINER, Pro- fessor of Pharmacology and Principal of the Pharmacological Institute of the University of Munich. Translated from the Sixth German Edition, with an Appendix on Micro-Biological Methods of Diagnosis, by EDMOND J. McWEENEV, M.A., M.D. (Royal Univ. of Ireland), L.R.C.P.I. &c. With 22 Illustrations. Crown Svo. xs. 6d. THORNTON. HUMAN PHYSIOLOGY. By JOHN Thornton, M.A., Author of "Elementary Physiography," "Advanced Physiography," &c. With 267 Illustrations, some of which are Coloured. Crown Svo, 6^. TIRARD. DIPHTHERIA AND ANTITOXIN. By NESTOR TIRARD, M.D. Lond., Fellow of the Royal College of Physicians ; Fellow of King's College, London ; Professor of Materia Medica and Therapeutics at King's College ; Physician to King's College Hospital ; and Senior Physician to the Evelina Hospital for Sick Children. Svo, Js. dd. WAKLEY. THE LIFE AND TIMES OF THOMAS WAKLEY, Founder and First Editor of the Lancet, Member of J'arliament for Finsbury, and Coroner for West Middlesex. By S. SQUIRE SPRIGGE, M B. Cantab. With 2 Portraits. Svo, 6.f. WALLER.— W'CA'A'.S- by AUGUSTUS D. WALLER, M.D., Lecturer on Physiology at St. Marys Hospital Medical School, London ; late External Examiner at the Victorian Uni'i'ersity. AN INTRODUCTION TO HUMAN PHYSIOLOGY. Third Edition, Revised. With 314 Illustrations. Svo, 185. EXERCISES IN PRACTICAL PHYSIOLOGY. Part I. — Elementary Physiological Chemistry. By AUGUS'iUS D. Waller and W. Leggf. Svmes. Svo, sewed, is. net. Part II. — In the Press. Part III. — Physiology of the Nervous System ; Electio-l'hysiology. Svo, 2^. bd. net. LECTURES ON PHYSIOLOGY. First Series. — On Animal Electricity. Svo, 5J. net. PUBLISHED BY LONGMANS, GREEN &- CO. WEICHSELBAUM. THE ELEMENTS OF PATHOLOGICAL HISTOLOGY, with Special Reference to Practical Methods. By Dr. ANTON WEICHSELBAUM, Professor of Pathology in the University of Vienna. Translated by W. R. DAWSON, M.D. (Dub.), Demonstrator of Pathology in the Royal College of Surgeons, Ireland, late Medical Travelling Prizeman of Dublin University, &c. With 221 Figures, partly in Colours, a Chromo-lithographic Plate, and 7 Photographic Plates. Royal 8vo, 215. net. « WILKS AND MOXON. LECTURES ON PATHOLOGICAL ANATOMY. By Sir SAMUEL WILKS, Bart., M.D., F.R.S., President of the Royal College of Physicians, and Physician Extraordinary to H. M. the Queen, and the late WALTER MOXON, M.D., F.R.C.P., Physician to, and some time Lecturer on Pathology at, Guy's Hospital. Third Edition, thoroughly Revised. By Sir SAMUEL WILKS, Bart., M.D., LL.D., F.R.S. bvo, i8.f. YOUATT.— JVORJirs ij will/am youatt. THE HORSE. Revised and Enlarged by W. WATSON, M.R.C.V.S. With 52 Woodcuts. 8vo, 7j. (id. THE DOG. Revised and Enlarged. With 33 Woodcuts. 8vo, bs. i^n^ral <^runlifu Morks. BEDDARD. THE STRUCTURE AND CLASSIFICATION OF BIRDS. By FRANK E. BEDDARD, M.A., F.R.S. , Prosector and Vice-Secretary of the Zoological Society of London. With 252 Illustrations. Svo, 2 1 J. net. BENNETT AND MURRAY. A HANDBOOK OF CRYP- TOGAMIC BOTANY. By A. W. BENNETT, M.A., B.Sc, F.L.S., and GEORGE R. MILNE MURRAY, F.L.S. With 378 Illustrations. Svo, i6j. CLERKE. THE SYSTEM OF THE STARS. By AGNES iM. CLERKE, Author of " A History of Astronomy during the Ninetetnth Century." With 6 Plates and Numerous Illustrations. 8vo, 21^. GENERAL SCIENTIFIC WORKS Q.V.QDD.— WORKS by EDWARD CLODD, Author of' The Childhood of the World," .S-v. THE STORY OF CREATION. a Hain Account of Evolution. With 77 Illustrations. Crown 8vo, 3J-. dd. A PRIMER OP^ EVOLUTION: being a Popular Abridged Edition of "The Story of Creation." With Illustrations. Fcp. 8vo, \s. 6d. CROOKES. SELECT METHODS IN CHEMICAL ANALYSIS (chiefly Inorganic). By Sir W. CROOKES, F.R.S., V.P.C.S., Editor of "The Chemical News." Third Edition, re-written and enlarged. Illus- trated with 67 Woodcuts. 8vo, 21s. iiei. CURTIS. A TEXT-BOOK OF GENERAL BOTANY. By CARLTON C. CURTIS, A.M. Ph.D. Tutor in Botany in Columbia University. With 87 Illustrations. Royal 8vo. 12s. net. DU BOIS. THE MAGNETIC CIRCUIT IN THEORY AND PRACTICE. By Dr. H. DU BOIS, Privat-docent in the University of Berlin. Translated from the German by Dr. E. ATKINSON. With 94 Illustrations. 8vo, \2s. net. EBERT. MAGNETIC FIELDS OF FORCE: An Exposition of the Phenomena of Magnetism, Electromagnetism, and Induction, based on the Conception of Lines of Force. By H. EBERT, Professor of I'hysics in the University of Kiel. Translated by C. V. BURTON, D.Sc. Part I. With 93 Illustrations. 8vu, \os. 6J. net. ^ GANOT. ELEMENTARY TREATISE ON PHYSICS; Experimental and Applied, for the use of Colleges and Schools. Translated and edited from Ganot's Elements de Physique (with the Author's sanction) by E. ATKINSON, Ph.D., F.C.S., formerly Professor of Experimental Science, Staff College, Sandhurst. Fifteenth Edition, revised and enlarged, with 9 Coloured Plates and 1,057 Woodcuts. Large crown 8vo, 15J. NATURAL PHILOSOPHY FOR GENERAL READERS AND YOUNG PERSONS ; Translated and Edited from Ganot's Coiirs EUuientaire de Physique (with the Author's sanction) by E. ATKIN- SON, Ph.D., F.C.S. Eighth Edition, carefully revised; with 7 Plates, 624 Woodcuts, and an Appendix of Questions. Crown 8vo, 7J. 6d. HALF-HOURS WITH THE STARS : a Plain and Easy Guide to the Knowledge of the Con- stellations. Showing in 12 Maps the position of the principal Star- Groups night after night through- out the Year. With Introduction and a separate Explanation of each Map. True for every Year. 4to, 35. 6d. THE STARS IN THEIR SEA- SONS. An Easy Guide to a Knowledge of the Star Groups, in 12 Large Maps. Imperial 8vo, ^s. OUR PLACE AMONG IN- FINITIES : a Series of Essays contrasting our Little Abode in Space and Time with the Infini- ties around Us. Crown 8vo, 3^-. 6d. ROUGH WAYS MADE SMOOTH. Familiar Essays on Scientific Sul)jects. Crown 8vo, 3 J. 6d. THE EXPANSE of HEAVEN. Essays on the Wonders of the Firmament. Crown 8vo, y. 6d. PLEASANT WAYS IN SCIENCE. Crown Svo, 3^. 6d. nature'^ STUDIES. By Grant Allen, A. Wilson, T. Foster, E. Clodd, and R.A. Proctor. Crown Svo, 3^. 6d. LEISURE READINGS. ByE. Clodd, A. Wilson, T. Foster, A. C. RuNYARD, and R. A. Proctor. Crown Svo, 35. 6d. STRENGTH: How to get Strong and keep Strong, with Chapters on Rowing and Swimming, Fat, Age, and the Waist. With 9 Il- lustrations. Crown Svo, 2s, PUBLISHED BY LONGMANS, GREEN &- CO. f5 REYNOLDS. EXPERIMENTAL CHEMISTRY for Junior Students. By J. EMERSON REYNOLDS, M.D., F.R.S., Professor of Chemistry, Univ. of Dublin. Fcp. 8vo, with numerous Woodcuts. Part I. — Introductory, \s. 6d. Part III. — Metals and Allied Bodies, ^s. bd. Part II. — Non-Metals, is. 6d. Part IV. — Chemistry of Ca7-bon Compounds, a^. ROMANES.— f^Ov^A'-S' by GEORGE JOHN ROMANES, M.A., LL.D., F.R.S. DARWIN, AND AFTER DARWIN : an Exposition on the Darwinian Theory, and a Discussion on Post-Darwinian Questions. Part I. The Dar- winian Theory. With Portrait of Darwin and 125 Illustrations. Crown 8vo, \os. 6d. Part II. Post-Darwinian Questions : Heredity and Utility. With Portrait of the Author and 5 Illustrations. Crown 8vo, 105. 6d. Part III. Post-Darwinian Questions : Isolation and Physiological Selection. Crown 8vo, 5^, AN EXAMINATION OE WEISMANNISM. Cr. 8vo, 6.. ESSAYS. Edited by C. LLOYD MORGAN, Principal of University Col- lege, Bristol. Crown 8vo, 6^-. Contexts : Primitive Natural History — The Darwinian Theory of Instinct — Man and Brute — Mind in Men and Animals — Origin of Human Faculty — • Mental Differences between Men and Women — W^hat is the Object of Life? — Recreation — Hypnotism — Plydrophobia and the Muzzling Order. SLINGO AND BROOKER. ELECTRICAL ENGINEERING FOR ELECTRIC-LIGHT ARTISANS AND STUDENTS. (Embracing those branches prescribed in the Syllabus issued by the City and Guilds Technical Institute.) By W. SLINGO and A. BROOKER. With 346 Illustrations. Crown 8vo, 12s. SORAUER. A POPULAR TREATISE ON THE PHYSIOLOGY OF PLANTS. For the Use of Gardeners, or for Students of Horticulture and of Agriculture. By Dr. PAUL SORAUER, Director of the Experimental Station at the Royal Pomological Institute in Proskau (Silesia). Translated by F. E. WEISS, B.Sc, F.L.S., Professor of Botany at the Owens College, Manchester. With 33 Illustrations. 8vo, gs. net. THORPE. A DICTIONARY OF APPLIED CHEMISTRY. ByT. E. THORPE, B.Sc. (Vict.), Ph.D., F.R.S., Treas. C.S., Professor of Chemistry in the Royal College of Science, London. Assisted by Eminent Contributors. To be published in 3 vols. 8vo. Vols. I. and II. £2 2s. each, Vol. III. ^3 3^- TILDEN. A SHORT HISTORY OF THE PROGRESS OF SCIENTIFIC CHEMISTRY IN OUR OWN TIMES. By WILLIAM A. TILDEN, D.Sc.Lond., D.Sc.Dub., -F.R.S., Fellow of the University of London, Professor of Chemistry in the Royal College of Science, London. Crown 8vo, ^s. net. i6 GENERAL SCIENTIEIC WORKS. TUBEUF. DISEASES OF PLANTS DUE TO CRYPTO- GAMIC PARASITES. Translated from the German of Dr. CARL FREIHERR VON TUBEUF, of the University of Munich, by WILLIAM G. SMITH, B.Sc, Ph.D., Lecturer on Plant Physiology to the University of Edinburgh. With 330 Illustrations. Royal 8vo, 18^. net. TYNDALL.— rf''6'/?A-5 by JOHN TYNDALL, E.R.S., &^c. FRAGMENTS OF SCIENCE. 2 Vols. Crown 8vo, i6j. NEW FRAGMENTS. Crown 8vo, los. bd. HEAT A MODE OF MOTION. Crown 8vo, I2J. SOUND. With 204 Woodcuts. Crown 8vo, \os. 6d. RESEARCHES ON DIAMAGNETISM AND MAGNE-CRYS- TALLIC ACTION, including the question of Diamagnetic Polarity. Crown 8vo, I2s. ESSAYS ON THE FLOATING-MATTER OF THE AIR in relation to Putrefaction and Infection. With. 24 Woodcuts. Crown 8vo, 7J. 6d. LECTURES ON LIGHT, delivered in America in 1872 and 1873. With 57 Diagrams. Crown 8vo, 55. LESSONS IN ELECTRICITY AT THE ROYAL INSTITU- TION, 1875-76. With 58 Woodcuts. Crown 8vo, 2s. 6d. NOTES OF A COURSE OF SEVEN LECTURES ON ELECTRICAL PHENOMENA AND THEORIES, delivered at the Royal Institution. Crown 8vo, is. 6d. NOTES OF A COURSE OF NINE LECTURES ON LIGHT, delivered at the Royal Institution. Crown 8vo, is. 6d. FARADAY AS A DISCOVERER. Crown 8vo, 35. 6d. THE GLACIERS OF THE ALPS : being a Narrative of E-vCursions and Ascents. An Account of the Origin and Phenomena of Glaciers, and an Exposition of the Physical Principles to which they are related. With 61 Illustrations. Cruwn 8vo, 6s. 6d. net. WEBB. CELESTIAL OBJECTS FOR COMMON TELESCOPES. By the Rev. T. W. WEBB, M.A.. F.R.A.S., Vicar of Hardwick, Hereford- shire. Fifth Edition, Revised and greatly Enlarged by the Rev T E ESPIN, M.A., F.K.A.S. (Two Volumes.) • • • Vol. I. With Portrait and a Reminiscence of the Author, 2 Plates, and numerous Illustrations. Crown 8vo, 6s. Vol. II. With Illustrations and Map of Star Spectra. Crown 8vo, 6s. 6d. WRIGHT. OPTICAL PROJECTION : A Treatise on the Use of the Lantern in Exhibition and Scientific Demonstration. By LEWIS WRIGHT Author of "Light: a Course of Experimental Optics." With 2-,2 Illustra- tions. Crown 8vo, 6s. BKADMUKV, AONKW, & CO. I.D., PRINTERS, LONDON AND TONBRIDGE.