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SALUTARY RESULTS OF SUPPURATION. 53
is nevertheless one salutary for the body ; being Nature's mode of removing a part so much injured by disease as to be incapable of living, and therefore liable to a much worse kind of decay, by putrefaction. In their active proliferation and power of assimilation, pus globules evince the vital attributes of germinal matter, which resist the common chemical tendencies to putrefactive decomposition. But if by its own solvent and penetrative action pus does not make its way to the surface, to be discharged outwardly, it after a time becomes inert: the cells collapse and form a curdy or cheesy purilage, closely resembling, in aspect and chemical composition, the softened cheesy matter of lymphatic glands and yellow tubercle. As in these instances, this change is accompanied by a considerable increase of fatty matter; and it has long been noticed that the matter of old abscesses abounds in fatty globules. So the latter end of chronic abscesses is a closer approximation to the end of tubercle and such aplastic matters, involving the parts affected in a destruction more gradual than that caused by suppuration and gangrene.
But there are many situations in which the formation of pus does not involve the destruction of tissue. Inflammation of mucous membranes causes an abundant formation and shedding of epithelium and mucus cells, which after a time present all the characters of pus globules; and the free discharge of these may terminate the inflammation. This is the common course of catarrhal inflammations. And further, where the inflammation is deeper, involving the submucous tissues, and even the connective tissue and parenchyma, so long as the sarcophytes, proceeding from the blood-vessels and proliferating in the tissues, retain their vital properties of motion and migration, they may likewise escape to the surface, and be thrown off; and thus the products of bronchitis and pneumonia may be cleared away by free mucous and purulent expectoration. But if the sarcophytes are deficient in these subtle properties of migration, and prematurely form granular cells (' formed matter,' Beale), which cannot escape, but choke up the tissues, theD is produced the red and grey hepatisation, which, if the inflammation continue, may pass on to the state of purulent infiltration, or may otherwise remain solid, as in caseous pneumonia, and other cacoplastic consolidations of the lungs, subject to the usual processes of fatty softening and decay. One or other of these evil results is to be feared, when, after the active stage of pulmonary inflammation, the pulse continues frequent, the heat keeps high, and the physical signs of obstruction and consolidation of the lung persist, with perhaps increasing liquidity and coarseness of the crepitation in parts.1 On the other hand, a favourable issue may
1 Such cases as the following are uncommon, but they teach us not to condemn all such as hopeless :—
Case 2.—A married lady, aged 44, of consumptive family, was attacked, in Dec. 1869, with double pleuro-pneumonia. I had attended her in a slighter attack on the right side two years previously. Two-thirds of the left lung, and the lower third of the right were now involved; and in spite of blistering and other treatment, the disease went on to hepatisation, with dulness and large tubular sounds on both sides, but on the left extending through nearly the whole lung. The strong vocal vibration showed that there was no liquid in the pleura. The orthopncea was distressing, and aggravated by a very sick stomach, which rendered the exhibition of food and medicine very difficult. In the third week from the beginning of the attack, there was no amendment. Pulse 120. Heat, above 100°. Sweats and purulent expectoration followed, with great loss of flosh; and the increased liquidity of the crepitus in parts of the left lung seemed to threaten softening and excavation. Just then a boil in the left axilla, which followed the blistering, began to assume large dimensions, and in a few days a largo abscess formed, and being opened by Mr. Squire, of Orchard Street, discharged a large quantity of healthy pus. From this time the stomach recovered its tone: food and stimulants, and cod-liver oil and tonics, were well borne; the pulse and temperature fell, and the chest symptoms subsided. But the most remarkable change was in the rapid restoration of the lung to a nearly healthy state, the chest sounding much clearer, the vesicular respiration returning, and the only sign of diseaso remaining was
be expected, for the present at least, when there is a reduction of the frequency of the pulse and heat of the
somo dulness and a little crepitus at the left base. The abscess continued to dischargo for six weeks, but the general health has since continued good, without cough, with increased flesh, and with only some remaining shortness of breath. This lady is now (June 1871) stout and well, except some shortness of breath. The sudden subsidence of the lung disease on the occurrence of the large abscess externally is strongly suggestive of a translation of the sarcophytes—by some way or other—perhaps by some migratory process more direct than through the blood-vessels.
Casr 3.—Mr. ,8»t.45. March 3, 1866 (seen with Dr. Humby).—
Strong and active, and in constant habit of locturing to large assemblies. A fortnight ago, after a chill, had a rigor, followed by pain in chest, cough, and rusty expectoration, with signs of consolidation of left lung (lower twothirds). To-day there is less dulness, but large liquid crepitus, impaired breath, and bronchial rhonchi in lower half of left lung. Cough violent; sputa mucopurulent. Profuse sweats. Is taking Dover's powder, and has been blistered. Nitric acid, calumbo, and glycerine three times daily. Morphia linctus at night.
10th.—Was better till two days ago; after talking on business, the cough has become more violent, with much purulent expectoration ; the pulse weaker and more frequent; and there is great failure of strength and appetite. Has wasted much. Clammy sweats.
Dulness, with large tubular sounds and gurgling at and below left scapula; coarse crepitation, and tubular sounds are heard now above right scapula also. To take cod-liver oil, with nitric acid, strychnia, and calumbo; back to be painted with iodine. Wine and nutriment increased.
March 22.—After a few more doubtful days, began to amend: taking more food, and cough and expectoration moderating, especially in the last week. Pulse reduced to 80. Perspirations have ceased. .
Less dulness, and more vesicular sound in left lung; loud bronchophony at and within left scapula; right lung clear.
April 5.—Convalescent; rapidly regaining flesh and strength; cough slight; expectoration mucous.
Dulness and tubular sounds much diminished, and a rough vesicular sound in left lung.
1871.—In two months resumed his lectures, and has been strong and active ever since.
For about a week both general symptoms and physical signs seemed to announce breaking up of the lung ; but this happily was averted.
Cash 4.—Mrs. , aet. 30. April 29, 1868 (under Mr. Theoph.
Taylor).—Without any previous ill-health except menstrual irregularity, after a chill, ten days ago, was attacked by vomiting and sharp pain of right side. At first the pain was supposed to be from gall-stones, as there was body; when the cough either subsides, or becomes looser and accompanied by easier and sometimes more copious expectoration of opaque matter, abounding in corpuscles, more or less of the pus-cell character, but presenting considerable variety in size and form. The occurrence of this expectoration is by no means constant, for in many cases, especially in the young, pneumonia subsides without cough or expectoration, the inflammatory products being dispersed by absorption. When it does occur, it gives us some insight into the changes of these products which accompany their dispersion; and in the bland inadhesive
absence of bile in the faeces, but cough followed, with catch in breath, rusty expectoration, scanty dark urine (slightly albuminous), and hot skin.
Dulness in whole right chest; mnst in lower half (which is tender on percussion), with crepitation in several parts; fine in axilla, near sternum, and above scapula; tubular sounds at and above scapula. The case (obviously pneumonia), was treated with effervescing saline with nitre, calomel and morphia at night, and repeated blisters. It went on to complete hepatisation of the lung, which at the end of the second week showed no signs of resolution, the dulness being still extensive, with large tubular sounds, and no crepitus or breath in the whole side. In a few days the expectoration became purulent, and coarse gurgling crepitus was heard in the large tubes. The pulse was still 120, and the weakness and perspirations increasing, although wine and liquid nutriment had been freely supplied. The patient had a strong prejudice against cod-liver oil, and it was only after much persuasion that she was induced to take it, which she did without difficulty in a mixture of nitric acid and orange infusion. The improvement in the general symptoms was striking, the pulse coming down in frequency, the sweats ceasing, the cough and expectoration moderating, and the appetite increased. The chief change in the physical signs was in the diminution of the liijuidity of the large crepitation; but the large snuffling bronchophony, simulating pectoriloquy, at and above the scapula, and the persisting intense dulness over a great part of the right lung, made it for a long time doubtful whether it would recover its normal state. The flesh, and in some degree the strength, were restored several months before the breath and the healthy sounds of the lung.
In the spring of 1869, a year after the attack, an examination was made, and there was only slight dulness and drficiency of motion of the right chest, and a genet al vesicular Inreathing less soft and uniform than on the left side. There has beon no recurrence of pulmonary symptoms since: (1871).
RESIDUAL EFFECTS—BRONCHIAL GLANDS. 57
quality of the sputa, with a diminution of the viscid and saline constituents, and an increase of the granules and fat, we can trace a resemblance to the process of fatty degeneration and disintegration of larger deposits; only in the latter case the lung tissue is involved in the decay, whereas in the case under consideration the matter expectorated contains the exudates only, and shows no fragment of the lung tissue under the microscope.
The resolution and dispersion of the inflammatory consolidation may be complete, leaving no trace behind; or it may be partial, sufficient to remove present danger of destructive suppuration, or of caseation, but leaving patches of consolidation; and these, if not gradually dispersed by the improved circulation and respiration of restored health, may prove sources of future irritation and obstruction, and become the nuclei of recurrent disease. The signs of these remnants of consolidation are commonly patches of dulness, with weaker or partially obstructed breath-sound, sometimes with roughness or slight remaining crepitus in the affected part. But a very common sign of remaining disease is a tubular sound, often loud, above one or both scapulae, most frequently the right; and this comes on sooner or later, even when the lower lobes of the lungs alone have been previously the seat of disease. I believe this sign to arise from enlargement of the bronchial glands, which, pressing on the lung, conduct the sound of the tracheal breath and voice through it. I have had few opportunities of verifying this by examination after death, as patients rarely die at this stage; but it is almost proved by the seat and nature of the bronchial sound, and the fact that it seldom supersedes the vesicular sound of the spot; and if it affects the stroke-sound, it is by adding somewhat of a tubular note, rather than deadening it. I notice these observations here because, if my inference is correct, it throws light on the pathology, in showing the