GANGRENE OF THE LUNG.
BY WILLIAM CARSON, M.D.
DEFINITION.—Putrid necrosis of the lung-tissue.
SYNONYMS.—Lungenbrand, Gangrene du poumon, Gangræna pulmonum.
HISTORY.—By common consent, Laennec has the credit of first identifying, naming, and classifying gangrene of the lung as a distinct disease; yet Lieutaud1 in 1707 describes imperfectly a case of gangrene of the lung in a child: "the right lung, within and without, appeared entirely putrid." Bayle2 is considered, in his section on his fourth variety of phthisis (phthisis ulcereuse), to have described a rather chronic form of gangrene of the lung. Morgagni, Boerhaave, Stoll, J. Frank, and Cullen considered gangrene as one of the terminations of peripneumonia.3 Laennec's development of the subject has only in a few directions been enlarged. His classification is universally adopted. His description is adopted generally as the most complete. There have been, however, controversies on different points, such as the relation of pneumonia and of the obstruction of the vessels to gangrene of the lung.
1 Historia Anatomica Medica, 1787, Obs. 329, cited by Louisa Atkins, 1872.
2 Bayle, G. L., Recherches sur la Phthisis pulmonaire, 1809–10, p. 30.
3 I. Straus, Nouv. Dict. de Méd. et de Chir., p. 403, etc.
In the pathology and etiology of gangrene Virchow's investigations on embolism and thrombosis opened up important relations; in diagnosis, Traube and Leyden and Jaffee; in medical treatment, also Traube; and in surgical treatment, Haley and Lawson (1879),4 S. C. Smith (1880), E. Bull (1881), Fengar and Hollister (1881), Mosler and Voght (1882). The antecedent development of pulmonary surgery, through important work done by Mosler, Pepper, and others, had prepared the way for special applications of it to gangrene and abscess of the lung. Spencer Wells claims to have suggested similar proceedings nearly forty years ago.
4 Lungen Chirurgie, Mosler, xx. p. 67.
ETIOLOGY.—Predisposing Causes.—Constitutional weakness is a common predisposing influence: it may be a primary condition, but is more often secondary or dependent on some recently-acting debilitating cause, as typhoid fever, chronic lung disease, diabetes, etc. Chronic alcoholism is a cause which, besides its effect on the system at large, may add a special one on the lungs in producing hyperæmia or drunkard's pneumonia.
Of 46 cases we have collected mostly from the Vienna Hospital report, the youngest was nineteen years old and the oldest was forty-seven years. Lebert5 has collected altogether 60 cases, 32 of his own and 28 of others: 19 occurred between twenty and thirty years, and 1 between thirty and forty. Huntington6 gives 32 cases from the Massachusetts General Hospital Record between 1857 and 1875: 9 were between twenty and thirty years, and 12 between thirty and forty; the youngest was ten years old and the oldest sixty-four. It is noticeable that these figures coincide largely with those showing the incidence of phthisis. Louisa Atkins7 gives, as the youngest ages among all the varieties, one of three months and another of two months.
5 Klinik der Brustkrankheiten, vol. i. p. 827.
6 Boston Med. and Surg. Journal, vol. xcv. p. 486.
7 Gangræna Pulmonum bei Kindern, 1872.
Of the 46 Vienna Hospital cases, 43 were male and 3 female. Huntington's cases were males 24, females 8. Of Lebert's own 32 cases, 22 were males; of the 32 others summarized by him, in 4 sex was not mentioned, and of the remainder 17 were males and 11 females. These figures show the large predominance of males in the liability to attack.
Exciting Causes.—They may be classified as pulmonary and extra-pulmonary. The influence of the alcoholic habit has been referred to above among predisposing causes: debauches are a frequent antecedent, especially in hospital cases, by means of resulting pulmonary hyperæmia and drunkard's pneumonia. Its association with croupous pneumonia may be assumed as settled after some warm disputes. The pneumonia of Bright's disease and putrid bronchitis are occasionally causative; bronchiectasies result in it not unfrequently. Extension of diphtheritic inflammation from the tracheal and bronchial mucous membrane is another form. The catarrhal pneumonia secondary to measles may produce it in children.
Embolism is the most frequent cause in the class of extra-pulmonary causes. It may be mechanical or infecting. A bronchial artery may be plugged so as to produce a gangrenous slough from mechanical cutting off of nutrition. Embolism of the pulmonary artery branches is more frequent, and by bringing about infarction and apoplexy may produce gangrene. Of the infecting variety may be mentioned emboli from the peripheral veins, as in surgical or uterine phlebitis, or from cerebral sinuses secondarily involved from otitis. Other causes acting from without on the lungs are foreign bodies, as particles of food passing beyond the trachea into the lungs, as in case of the insane or drunkards, and blows on the walls of the chest. These latter are capable of producing not only the ordinary phenomena of contusion-pneumonia8 but gangrene, and without evidence of external injury or fracture of the ribs.
8 M. Litten, p. 26, vol. v., Zeitschrift für klinische Medicin.
SYMPTOMATOLOGY.—Gangrene of the lung is the termination of a process the beginning and progress of which are not declared or cannot be followed through characteristic symptoms. Even its final occurrence may remain unknown if a communication be not established with a bronchus, which event is followed by the true symptoms, the expectoration and its odor. Whatever symptoms occur previous to that event may occur independent of it. Adopting Lebert's dictum,9 gangrene of the lung is not a pathological unit. As its pathogenesis varies, so does its symptomatology. A feature common to its several varieties is marked constitutional depression and variations from the typical form of the disease in which it occurs. If pneumonia, croupous or catarrhal, be the precedent or associated disease, it will be marked by soft and feeble and frequent pulse, restlessness, dulness or distress of countenance, more or less cyanosis, cool and relaxed skin, possibly delirium, dry tongue, unusual dyspnoea and pleuritic pain, copious prune-juice expectoration, irregular or non-typical temperatures. Along with these functional variations occur some in physical signs, as a lesser amount of dulness or of bronchial breathing, indicative of less structural density and corresponding exudation. A case with such an evolution may afford a presumption of an outcome in gangrene, but appearance of the characteristic expectoration and fetor is necessary to exclude it from irregular forms of pneumonia, which have no such termination. The same general remark applies to the cases of gangrene in bronchiectasic cavities. Perhaps some aggravation of the general condition may excite apprehension, but the characteristic phenomena of expectoration, odor, etc. must decide. If the cause be of embolic origin, we may expect some suddenness and perhaps shock in the beginning, and later the evidences of a more limited inflammation of the lung-tissue, such as circumscribed dulness and modified respiratory sound, which finally end in those indicating destruction of lung-tissue.
9 Op. cit., p. 803.
The macroscopic characters of the expectoration are those of a putrid or fetid liquid of varying shades of color, ashy gray, dirty green, or greenish-yellow, prune-juice, or more or less hemorrhagic. The odor, which is at first so fetid and penetrating, often disappears after the expectoration has been standing a while. It is separable, as first described by Traube,10 into three principal layers. The uppermost, covered with a layer of foam, consists of, first, dirty green, crumbling, confluent lumps; second, of larger, homogeneous, green muco-purulent masses; and, third, of whitish-gray, transparent, mucous masses. The second layer is formed of a colorless fluid. At the bottom is a fine yellowish-white sediment. Microscopically are found fat-acid crystals, many large fat-drops, and finely granular débris, masses of free, black pigment. It is said elastic tissue is nowhere to be found, but to this statement there are no doubt exceptions. Other bodies have been found by Leyden and Jaffee,11 which they named Leptothrix pulmonalis. Kannenberg,12 besides the above forms, found constantly infusoria of the family of monads in the sputa of 11 out of 14 cases of pulmonary gangrene. He considers them peculiar to the processes of decomposition in the lungs.
10 Gesammte Beiträge zur Pathologie und Physiologie, Zweiter Band, p. 452, etc.
11 Deutsches Archiv für klin. Med., Band ii. pp. 488, etc., "Ueber putride Sputa."
12 Virchow's Archiv, Band lxxv.; Zeitschrift für klinische Med., Band i. p. 228.
PROGNOSIS in general is unfavorable. Individually, the gravity of the case is determined by the evidence bearing on previous habits and constitution; by the violence of the onset, as shown in prostration, severe pain in the chest, dyspnoea, persistent and violent cough, delirium, feebleness and softness of the pulse; by the variations from the typical standards of croupous, or especially catarrhal, pneumonia, such as greater amount of septic or infectious or typhoidal element, non-typical and low temperatures in the early stages and also in the stage of disintegration; by the amount of the latter as shown in the physical signs of extensive lesion and in the amount of gangrenous sputum; and by the irritant effect of this in producing bronchial catarrh, and consequent catarrhal secretion, which may of itself become an element of danger in a system already much prostrated. Favorable prognosis is allowable when these conditions are being gradually reversed.
PATHOLOGY.—The pathology of gangrene of the lung is scarcely more settled than it was forty years ago, when Stokes13 published his eighteen propositions, embodying his experience. Obstruction of vessels and inflammatory exudations are present as important pathological conditions, but of themselves are not pathogenetic of gangrene. Other, as yet unknown, elements of putrefactive agency are present. Leyden and Jaffee's observations and those of Kannenberg have been mentioned14 as efforts to throw light upon the pathogenesis of gangrene of lung, but how far the bodies described by them precede, coincide, or follow the familiar clinical phenomena are undetermined questions. Filehne,15 in his experiments to determine the reason of the almost universal absence of elastic fibres in the expectoration of patients with gangrene of lung, comes to the conclusion that there is a ferment which, acting under alkaline conditions, destroys the fibres. The agents of this ferment he does not try to determine. Stokes anticipates the tendency of modern experimental pathology by announcing as an alternative proposition that "a process of putrefactive secretion precedes in many cases the death of lung." The constitutional debility which is so early a symptom prepares the way for such an invasion. In reference to the relation between the septic material and thrombosis in gangrene, Kohler16 affirms that the septic material produces the fibrin-ferment, and thereby capillary thrombosis. Recklinghausen thinks that a special material capable of exciting coagulation has not yet been found in gangrenous substances, but that there may be several factors, such as anæmia, changes in the vessel-wall, imbibition with foreign substances, etc. Other experiments17 and views point toward the conclusion that there are substances formed in various diseased conditions which have the power of ferments and of producing coagulation of blood in the lesser circulation.
13 Dublin Quarterly Journal Med. Science, Feb. 1, 1850.
14 Op. cit.
15 "Sitzungsbericht der Phys. Med. Soc." in Erlangen Schmidt's Jahrbucher, 1877, No. 7.
16 Recklinghausen's Handbuch der Pathologie, p. 136.
17 Wooldridge, Du Bois-Reymond, Archiv Centralblatt für med. Wissenschaften, No. 41, vol. xi. 1874, p. 734.
MORBID ANATOMY.—The circumscribed variety, as it usually appears, is a cavity irregular in outline, with ragged walls, made so by the unequal invasion of the lung-tissue by the gangrenous process. Sometimes the cavity itself contains loose fragments of lung-tissue, or the contents may be of a dirty, greenish, or brownish color, with some of the odor of the expectorated matters. If the case has been a chronic one, the walls are smoother, with a more or less formed lining membrane and the contents of a less characteristic color or odor. The cavity is usually in the right lung, and in the middle or lower portion. There is much variety of statement on this point. The tissue immediately adjacent to the gangrenous walls shows more or less of the products of catarrhal pneumonia. The vessels terminating in the walls are obstructed by coagula. If the gangrenous part come to the pleural surface, belonging to what Fournet calls the superficial variety, it may produce adhesions there, or it may result in perforation, with the result that we have the products of pleuritic inflammation united with the contents of the gangrenous cavity. In multiple foci, some will show the less advanced stages of disease, such as incomplete softening and local inflammatory lesions. In the diffused variety the lesions are sometimes described as being the same except in extent. The demarcations, however, from surrounding tissue are not as well marked; the tissue is soft, breaking easily under pressure, sometimes oedematous, dark or dirty black on surface or on section of lung; at other times the surface is mottled with lighter-colored patches. A secondary result is the production of bronchitis by the contact of the irritant expectoration from the gangrenous cavity.
DIAGNOSIS.—Abscess of the lung is the disease most likely to be confounded with gangrene of the lung. In the former you do not have the same amount of profound constitutional depression; the symptoms have a more frank expression, as it were, because of better precedent conditions usually; the first eruption of matter from the abscess is more copious and sudden than the usual manner of expectoration of gangrenous sputum; the appearance of the contents of the abscess is that more nearly of healthy pus, though the latter has at times a dark dirty brown or hemorrhagic look; the separation into layers is not apt to occur; the odor is usually not so fetid; microscopically, elastic fibres are much more abundant in abscess than in gangrene of the lung. The cavernous physical signs are not reliable in either disease. There are cases in which it is impossible, and in which it is of no practical importance, to make a diagnosis between gangrenous abscess and pulmonary gangrene. Gangrene supervening in phthisical cavities is distinguished by the history of a chronic pulmonary disease in which a cavity has been previously marked. It is phthisis advanced to the destruction of tissue plus the unknown gangrenous element which has found a lodgment in a favorable place. Stagnation of cavity contents, depression of system, etc. are favoring conditions. The same remarks apply to bronchiectasic cavities and putrid bronchitis, physical signs in the latter being additional points of difference.
Our experience proves that the essential SYMPTOMATOLOGY of gangrene of lung, except the débris of lung-structure in the sputum, can occur where there was no gangrenous destruction, either circumscribed or diffuse, no bronchiectasic cavities or bronchial dilatations, and no phthisical cavity. In the case alluded to the gangrenous odor and general characters of the sputum and the separation into layers and the consolidation of tissue were present, but the post-mortem afforded no explanation of the fetid expectoration. It was a case of debauch and alcoholic excesses and exposure.
COURSE, DURATION, AND TERMINATION.—The course of this disease is essentially an acute one. Whatever the early condition be, the gangrenous element hastens its progress, as in cases beginning with the phenomena of acute pleuro-pneumonia. A pre-existing phthisical cavity will take on acute phases, also the septic element will be reinforced, and, as indicated in the enumeration of symptoms, clinical irregularities will be introduced. The early prostration is increased, and the patient dies from exhaustion after a period varying from three days to six weeks from the time the gangrene became manifest. Various complications, such as pleuritis and perforation of pleura and pneumothorax, hemorrhage, or extensive, diffused gangrene may cut short the patient's life within the average period. Occasionally the gangrenous cavity becomes chronic and the patient may live for months in imperfect health. The termination of the circumscribed variety is usually death. Diffuse gangrene is invariably fatal.
TREATMENT should be directed, first, to the known precedent states of constitutional weakness, bad habits, etc., which lay a foundation for unhealthy inflammatory processes, and for the pathogenetic elements that bring about the gangrenous and septic and exhausting conditions; second, to the special symptoms, such as severe pain in the side, harassing cough, dyspnoea, etc. Remedies of the first class are quinia, turpentine, early alcoholic stimulation, carbonate of ammonium, antiseptics, as carbolic acid, etc. An anticipation from the beginning of any irregular form of acute pulmonary disease of its termination in gangrene is impossible, and hence early treatment is necessarily general. It would be properly confined to the use of quinia, which would be useful, either before or after the gangrenous element had developed, in small doses frequently given, unless high temperature or the septic process indicate the use of large ones. Turpentine internally is desirable in proportion to the infectious or typhoidal character of the attack. Its use by inhalation is beneficial when gangrenous destruction has already taken place. Brandy or whiskey in moderate and frequent quantities, one-half to one tablespoonful every three hours, and carbonate of ammonium, meet the requirements which the tendencies to debility indicate. Milk, milk-punch, beef and chicken extracts should be given in the intervals between the administration of medicines. This general plan is applicable throughout the pre- and post-gangrenous stages. In the symptomatic treatment pain and a general respiratory distress often demand attention. Opium is then useful, both in relieving pain and moderating dyspnoea and cough. As these symptoms are often urgent in the later stages of gangrene of the lung, the treatment of the disease harmonizes both in its constitutional and symptomatic aspects. Prescriptions can also be readily prepared which contain remedies that have a decided effect in correcting the fetor of the breath and expectoration, and thus evincing an influence on the putrefactive process or ferment, which has become the prominent feature of the disease. The author recommends that carbolic acid, in the dose of one grain every four hours, be given for that purpose, and also its use by inhalation. Assistance can sometimes be given by putting the patient in such a position on the side as to promote the emptying of the cavity.
Tapping a gangrenous cavity and the introduction of drainage-tubes may be successfully resorted to. The cases suitable for such surgical treatment have been described by Fenger and Hollister18 as those where, "the presence of a gangrenous or ichorous cavity having been ascertained, it is found that notwithstanding an outlet through the bronchi for a portion of the contents of the cavity, it steadily fills up again; the partial evacuation does not relieve the patient; the infection of the healthy portions of the lung from the decomposed contents of the cavity has commenced or is evidently about to take place; the breath and expectoration continue fetid; absence of appetite; increasing weakness, with or without fever, etc." For the steps of the operative procedure reference may be made to the complete directions given by the same authors or to works on surgery. The double opening advised by the above authors would be the most efficient plan.
18 Amer. Journ. Med. Sci., Oct., 1881, p. 385.