ACTINOMYCOSIS OF THE LUNG.
Actinomycosis of the lung may be recognized by the sputum and also by the pus discharged from any breaking-down cavity within the affected area. (See section on the [Pleura].) If a localized focus could be diagnosticated or recognized after exposure the portion of the lung thus involved might be removed.
ABSCESS OF THE LUNG.
Abscess of the lung is always the result of some local or distant infectious process. The mechanism of production of the multiple metastatic abscesses which characterize pyemia has been described in the earlier portion of this work. For such conditions surgery affords no aid. Circumscribed abscess may be the result of the presence of a foreign body—i. e., a bullet or a parasite—or it may result from embolism with infarct, in consequence of such affections as ulcerative endocarditis, puerperal septicemia, sloughing fibroid, an otitis media, or a septic pneumonia produced from any cause. It may be the result of extension from an osteomyelitis of some portion of the bony wall of the thorax, which itself may result either from injury or from local infection. Abscess of the lung is seen not infrequently in connection with empyema, and often results from suppurating tuberculous bronchial nodes. It may be produced, also, by extension of trouble from below the diaphragm, as hepatic abscess, subphrenic abscess, and the like. It is always a secondary rather than a primary affection.
Such abscesses are to be recognized by the character and offensiveness of the sputum, the pus discharged being colored green or brown, containing shreds of tissue, with masses of bacteria and crystals of fat. Some believe the presence of elastic fibers to be pathognomonic. When pulmonary abscess is diagnosticated it is necessary, in addition, to determine whether multiple lesions or a circumscribed collection are to be dealt with. In the former instance it is of little avail to intervene. In the latter the physical signs will usually furnish evidence of adhesions between the lung and the chest wall, by whose presence the operative procedure is simplified.
The term pneumotomy is applied to the exposure and evacuation of pus in the lung, whether it be found in connection with an ordinary abscess or a suppurating hydatid cyst. It is essentially a thoracotomy, plus the added measure of whatever may be done to the lung itself, and will be described in connection with other operations upon the chest.
If a tuberculous abscess could be located it also might be treated upon the same general principles. Thus Lane and others have suggested early operations for relief of tuberculous lesions. For obvious reasons, however, the method has not found general acceptance.
GANGRENE OF THE LUNG.
Gangrene of the lung is the terminal stage of a local infection, and unless relieved may prove fatal to the patient. It is due to the causes above mentioned as producing abscess in the lung, while to them may perhaps be added a few others, especially expressions of embolism or thrombus of the pulmonary circulation by which, the blood supply being cut off, death of tissue occurs before there is time for phlegmonous development. Thus it is met with occasionally after the acute exanthems and the infectious fevers and after violent pertussis. When diffuse it is of the miliary type. When circumscribed it may be due to more localized causes. In any event it is more frequent in the lower portions of the lung.
Pulmonary gangrene may be recognized by the extreme condition of the patient, offensive odor of the breath, and expectoration of sputum which may at first be frothy and bloody, but becomes rapidly purulent and finally necrotic in type. Meantime, the function of the lung being materially interfered with, respiration is rapid and there will be more or less cough, pain, and finally collapse. When the sputum is allowed to stand in a test tube there will form an upper layer, opaque and frothy; a middle, more frothy layer; while the lower and denser portion will be of a dirty green color and contain shreds of dead tissue with bacteria, crystals of triple phosphates, fat debris, and pus. According to the nature of the case the cavity or the area of dead lung may be outlined by physical signs. There is a form of fetid bronchitis which has been mistaken for pulmonary gangrene, but the character of the sputum and the progress of the case will be quite different.