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Article I.— Case of Cirrhosis of the Lung. By Thomas B. Peacock, M.D., Assistant-Physician to St Thomas's Hospital, and Physician of the City of London Hospital for Diseases of the Chest.
Francis Macqueen, set. 17, first came under my notice in Nov. 1849, when he was an in-patient at St Thomas's Hospital, under the care of Dr Bennett. He then stated that he had been ailing for three years; his illness commenced with cough, followed by expectoration. His general health then became impaired, and he had continued ill ever since.
When seen on the 3d of December he complained of a severe cough, and expectorated a peculiar, brownish-coloured purulent fluid, of a very fetid odour. This expectoration was extremely profuse, and was brought up in large quantities when he reposed upon the back, and especially on the left side. He ordinarily occupied the right side. He complained of headache but was frefffrom pain in the chest. The tongue was clean, the pulse 100 and feeble, the bowels regular, the appetite and digestion moderate. His face was somewhat livid; he was much emaciated, and his fingers were bulbous and the nails incurvated.
On examination the right side of the chest was in front flatter than the left, and especially between the outer end of the clavicle and the nipple, but in the right dorsal regions it was fuller than in the left. The cardiac pulsation was visible on the right side below the nipple. On percussion the resonance was impaired in the sub-clavicular region, and entirely dull below the nipple. On auscultation vesicular respiration was audible only immediately bel ow the sternal half of the clavicle, while below the outer extremity of that bone there was loud gurgling respiration and cavernous sounds with the voice and cough, and occasionally with a metallic resonance. Elsewhere respiration was attended with loud mucous rhonchus. The left side of the chest sounded throughout clear on percussion, and the respiration was there loud and puerile. He was then taking three teaspoonfuls of the cod liver oil three times daily, and at night five grains of the compound ipecacuan powder, and was allowed a generous diet.
On the 2l8t of August 1850, the following notes were taken:—There is now considerable improvement in his general appearance, and he has gained both flesh and strength. He has not much appetite, the tongue is somewhat furred, the pulse accelerated, the bowels regular. The falling in below the acromial end of the right clavicle is very obvious, and in this situation there is an obscure tympanitic resonance, and the pot fele sound is occasionally heard on percussion, and there are loud cavernous respiratory, vocal and cough sounds,
NEW SEHIES.—NO. IV. ArRII. 1855. 2 N
but little evidence of fluid. On the left side of the chest there is clear resonance on percussion, and loud compensating respiration is heard.
Dec. 4.—He has continued to improve since the last notes were taken. With the exception of the flattening beneath the acromial end of the right clavicle, the inequality between the two sides of the chest is not very marked. The right side is still somewhat dull on percussion, the left quite clear; in the flattened space there is an imperfect tympanitic resonance on percussion, anJ occasionally the cracked pot sound is elicited, with cavernous respiration but without rhonchus, except on forced inspiration. The same signs are heard »t the supra-scapular region. He still expectorates the fetid brownish coloured fluid but in lesser quantity, it is brought up in gulps, and, except at that time, he has little cough. His appetite is tolerably good and he is gaining strength.
At the commencement of the year 1851 he was discharged from the hospital, and became an out-patient of my own, and continued to attend till April, when, after exposure to cold, he was seized with great difficulty of breathing, increased cough, and expectorated much blood. He was readmitted into the hospital on the 6th, and died asphyxiated on the 11th, or about four years and a half from the commencement of his illness.
The following notes of the examination of the body were made by Dr Bristowe.
Body short and small, and altogether resembling that of a much younger person than he is known to be. It is spare but not very much emaciated; the fingers are remarkably clubbed.
On removing the sternum and costal cartilages no part of the right lung was observable, the left lung extending much further to the right than is usual, and the heart being displaced to the right side. The layers of the left pleura were adherent by scattered firm cellular bauds, and the left lung was of large size, crepitant and healthy throughout, except at the apex, where there was some pucking and a small speck, not larger than a pin's head, of calcareous matter imbedded in its substance. The right lung was very much diminished in size, and its pleural surface was almost entirely adherent to the parieties byold and thick cellular attachments, the diminution in the size of the lung being compensated by the contraction of the right side of the thorax, by the ascent of the diaphragm and liver, and by the altered position of the heart. At the base of the lung the adhesions were somewhat softer than elsewhere, and had a vascular appearance, as if from some recent inflammation. On section the lung was found to be consolidated every where, except at the upper and anterior edge, where there was a portion of its substance partially permeable to air. The condensed portions were of a pale fawn colour, mottled with black pigmentary matter, and very firm. The primary branches of the right bronchus were increased in size, and the bronchi arising from them were more than proportionately dilated, being between a third and a quarter of an inch in diameter. The bronchi opened abruptly into cavities of various sizes, and these were separated from the surface of the organ by a layer of condensed tissue, from a quarter to half an inch in thickness. Some of the cavities, especially towards the apex of the lung, were of a regular oval figure and presented a smooth surface, which appeared to be continuous with the mucous membrane of the bronchi, so that they appeared to have been formed by the dilatation of the tubes, but in others the lining membrane had not the appearance of mucous membrane, so that the cavities seemed to have resulted from ulceration at a former period, and this was further rendered robable by the cavities, in some cases, communicating with two or more ronchial tubes. In the lower lobe of the lung there was a large cavity, which contained a considerable quautity of coagulum, and this cavity was unprovided by any lining membrane, and appeared to have resulted from recent ulceration or softening. The mucous membrane of the bronchial tube leading towards this cavity was very vascular and had a villous appearance, and in places there were ulcerated excavations, giving it the appearance of a network of coarse irregular meshes.
The tubes in the upper part of the lung were nearly free from secretion, but in the middle and lower parts they were filled with inuco-purulent matter, deeply tinged with blood. The cartilages of the tubes were much increased in size and thickness, and the longitudinal fibres were large, distinct, and separated into bundles having numerous depressions between them.
The pericardium and heart were healthy. The abdominal organs were also healthy, except that a large lumbricus was contained in the colon. The brain was not examined.
The case above related possesses much interest. The form of disease of which it affords an example, is one which is not of common occurrence. Though alluded to by Laennec as a variety of dilatation of the bronchial tubes, and subsequently by Dr Williams,1 the affection was first fully described by Dr Corrigan,8 and has consequently been generally known by the name of " cirrhosis of the lung," a term which, from a supposed analogy in its mode of formation to cirrhosis of the liver, he applied to it.
Laennec regarded dilatation of the bronchial tubes as always the sequence of chronic mucous catarrh, and as caused by the accumulation of secretion in the inflamed tubes, by which they became expanded, and by the pressure which they exercised on the adjacent pulmonary substance, caused the collapse of the cells, in the same way as collapse of the lungs is produced by the pressure of pleuritic effusions. Dr Williams supposed that the ordinary form of bronchial dilatation was caused by the efforts of inspiration and cough, acting upon tissues rendered more readily expansible from the effects of inflammation; but that the sacculated expansions with consolidation of the interjacent pulmonary substance, had an entirely different mode of formation. He regarded this form of disease as the result of attacks of pleurisy, in which, from long-continued compression, " the air tubes and cells become obliterated by the adhesion of their sides, so that when the liquid is removed from the pleura, they will not expand again with the enlargement of the chest, but the large and middle-sized bronchi are not obliterated; thy bear the whole force of the inspired air, and become completely dilated by it." Shortly after Dr Williams advanced these views, Dr Corrigan, in a valuable paper, gave a much fuller description of the disease than any previous writer, and suggested an entirely new view of its pathology. He supposes the contraction of the lung, the obliteration of the air cells, and the dilatation of the tubes, to be the result of a morbid condition of the cellular tissue, which is the matrix of the vessels and air tubes, and of the general flbro-cellular envelope of the lung, assisted by the elastic contraction of the longitudinal fibres of the air tubes. "In proportion
1 Lectures in Medical Gazette, 1838, and Rational Exposition of Diseases of the Chest.
» Dublin Journal, vol. xiii. 18.38. P. 272.
as the contraction of the fibres of the fibro-cellular tissue obliterates the small air vesicles, and as these contracting fibres, like so many elastic strings, extending from the root in all directions, tend to contract or draw in the tissue of the lung, obliterating its small air tubes and its blood-vessels, the larger bronchial tubes dilate to supply the place thus left, until, when the disease has reached its last stage, the tissue of the lung diminished to a very small size,
Iiresents no longer any permeable air vesicles, but a dense fibro-celluar or fibro-cartilaginous tissue, with its fibres radiating in every direction, through second and third sized bronchial tubes, dilated into cells, or ending in culs de sac, of every variety of size." "The dilatation of the bronchial tubes is partly owing to the contractile process going on in the tissue of the lung, partly to the expansive action of the parieties of the chest in the acts of inspiration." "If there were but one bronchial tube, with contracting fibro-cellular tissue placed around it, then the contracting tissue, would, as in the instance of stricture of the oesophagus or rectum, cause narrowing of the tube; but when there is, as in the lung, a number of bronchial tubes, and the contracting tissue not placed around the tubes, but occupying the intervals between the tubes, then the slow contraction of this tissue will tend to draw the parieties of one tube towards the parieties of another, and necessarily will dilate them."
Rokitansky1 adopts a view which was advanced by Dr Stokes, that the common form of dilatation of the bronchial tubes is due to the " atony and paralysis of the contractile and irritable elements of the tubes dependant on chronic inflammation and blennorrhoea, aggravated by the obstruction of the other tubes by secretion." The other description of disease he states to be the result of bronchitis in the ramifications of the bronchi, beyond those which become dilated; and he regards the dilatation as dependant on " their obstruction by the accumulation of secretion, on the tumid state of their mucous membrane, and finally on their actual obliteration." "It is produced by the hindrance which is presented to the free ingress of the inspired air, and is proportional to the difficulty of breathing, and the prolonged length of each individual inspiration; and is especially developed in and about the perfectly impermeable bronchial tubes. The parenchyma surrounding this portion of the bronchial system collapses, and this produces a space which becomes filled by the dilating bronchus. The dilatation thus lies entirely, or for the most part, in a collapsed, and apparently compressed, portion of the parenchyma; hence, the latter appears to be the primary anomaly, and the bronchial dilatation merely a resulting and consecutive morbid change." It will be seen from the above statements, which have been purposely quoted in the words of the writers, that Dr Williams, Dr Corrigan, and Rokitansky, agree in regarding the primary change which takes place in this disease as consisting in
1 Sydenham Society's Translation.
the collapse of the air cells, and the dilatation of the tubes as, in a greater or less degree, resulting from the expansion of the chest during the acts of respiration; but they differ as to the cause to which they assign the production of the collapse, Dr Williams regarding it as due to pressure exercised on the periphery of the lung, Ju>r Corrigan to a morbid change in the pulmonary substance itself, and liokitansky to obstruction to the entrance of air into the terminal portions of the tubes. Recently, Dr Gairdner,1 in his veiy able papers on the morbid anatomy of bronchitis, has discussed the mode of formation of the different forms of bronchial dilatation, and expresses opinions opposed, in some respects, to those of all the writers which have been mentioned. He remarks :—" The conclusion to which I have been led by this survey is, that almost all the so-called bronchial dilatations, and all those presenting the abrupt sacculated character here referred to, are in fact the result of ulcerative excavations of the lung communicating with the bronchi;" and, after explaining his reasons for adopting this opinion, he adds, that "the usual origin of bronchial dilatations is in cavities formed in atrophied lung, in consequence of bronchitis or tubercle, and afterwards expanded beyond their original dimensions by the inspiratory force."
The view advanced by Laennec as to the mode of production of this form of disease cannot be received. It is difficult to conceive that, apart from any other change in the lung, the accumulation of secretion in a tube, which maintains its communication with the main bronchus, could take place to such an extent as to give rise to the large cavities which are frequently seen; and still less is it probable that such dilated tube, by compressing the adjacent pulmonary substance, should cause the marked solidification which often occurs in these cases.
Dr Corrigan's views also, though very ingenious, do not afford a satisfactory explanation of the mode of production of the dilated tubes and consolidated pulmonary tissue. I have seen the most marked dilatation of the tubes without any great degree of adjacent consolidation; when, indeed, the whole of a portion of lung was converted into large dilatations communicating with the bronchi, and only separated from each other by thin septa. In other cases, where there are large tubular cavities and consolidated tissue in the same lung, the two conditions do not correspond in situation, so that the one could not be regarded as the cause of the other. A very remarkable example of the former description of disease was exhibited at the Pathological Society during this session by Dr Hare. In reference to the views of Dr Williams and Dr Gairdner, I believe both to be correct in some cases, and that by one or other of the modes mentioned by these writers all the various forms of so-called dilatation of the bronchial tubes which are observed may be explained. Of
'Lond. and Edin. Monthly Journal, vol. xiii. 1851. Pp. 248, 249.