The Bradshaw lecture on the results of bronchial obstruction : delivered before the Royal College of Physicians of London on November 1st, 1910 / by G. Newton Pitt.

  • Pitt, G. Newton (George Newton), 1853-1929.
Date:
1910
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Credit: The Bradshaw lecture on the results of bronchial obstruction : delivered before the Royal College of Physicians of London on November 1st, 1910 / by G. Newton Pitt. Source: Wellcome Collection.

Provider: This material has been provided by The Royal College of Surgeons of England. The original may be consulted at The Royal College of Surgeons of England.

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    the presence o£ expectoration in amount shows that this is the more usual condition which results from the presence of a foreign body in a bronchus, and I have little doubt that in some cases the lung at first becomes over-distended, and is not always airless and collapsed. Schuller has shown that it is possible to introduce clean food into the bronchi of rabbits, and if it can disintegrate it will disappear with no change in the lung beyond that of catarrh; when it cannot, fibroid changes with bronchi- ectasis result. When dirt, however, was mixed with the food gangrene or septic pneumonia resulted. There have been the following cases: (1) Head of barley grass in left bronchus 129 days ; (2) pork in right bronchus possibly for six months; (3) woolen top of toy in left bronchus; (4) pea in left bronchus; (5) feather after tracheotomy in right bronchus, but not cause of death; (6) pipe stem in bronchus after fatal fall down ladder (not cause of death); (7) newspaper in trachea, introduced intentionally; and (8) sponges in trachea, introduced intentionally. The following case presents many very remarkable features. The boy swallowed a head of barley grass during a paroxysm of coughing, and this passed into his left bronchus, where it remained 129 days. He developed within two days after the entrance of the body an acute pneumonia which became gangrenous, and he had an extremely prolonged dangerous illness. Acid-fast bacilli were found on one occasion in the sputum, and were assumed to be tubercle bacilli, but he made an excellent recovery as soon as he expectorated the piece of grass. He never reacted specifically to tuber- culin. He has maintained perfect health for the five years since, and is now strong and well. It is very rare for any one to make such an excellent recovery after such extensive mischief in the lung, and it is suggested that the acid fast bacilli came from the grass, as these grasses are said to contain them. Case xvii.—Ear of Barley Grass in the Left Bronchus for 129 Days : Gangrene of the Lung : Complete Recovery. A boy aged 12 years, while recovering from an attack of whooping-cough, was playing with a head of grass in his mouth, when he was seized with an attack of coughing and the piece of grass disappeared. He tried in vain to make him- self sick. On the next day the temperature was 102.8°, and on July 25th—the following day—Dr. J. E. G. Calverley of Folke- stone, under whose care he was, found that the temperature was 105.2°, with a pulse of 100. There was pain in the epi- gastrium. The entry of air at the left apex in front was deficient. On the 28th there was diminished entry over the same area, with diminished movement but a hyper-resonant note. There was tracheal wheezing, conducted over the whole chest as rhonchi. The temperature, respiration, and pulse remained high, and on the 30th the boy had consolidation at the left apex down to the third rib, with bronchial breathing and pectoriloquy. The larynx was found to be normal. On August 1st there was profuse epistaxis, with a tympanitic note at the left apex in front, and down to the level of the fourth rib in the axilla. The entry of air remained deficient at the left apex. He became anaemic from recurrent epistaxis. He then passed under the care of Dr. R. B. Wrightson at Aldeburgh. The temperature gradually dropped to 99°, and the boy was able to get about. The sputum at first was frothy, but later became abundant and muco- purulent, and was said to contain tubercle bacilli. In the middle of September his temperature ran up to 104° and he developed signs of consolidation at the left base. In the upper lobe there was dullness at the apex with signs of a cavity in front in the second and third spaces. There was a marked oscillation of the temperature with very foul breath indicative of gan- grene. He was extremely ill for a long time with a very feeble pulse. He took creosote regularly and was well nursed in the open air, so that gradually he recovered his health. No tubercle bacilli could be again detected, and at tbe end of October he had gained a stone in weight. The sputum was reduced to \ oz. in amount daily, and was no longer foul. On November 30th, 129 days after swallowing the grass, he had a fit of coughing, and brought up a head of barley grass li in. long from the left bronchus. The long awns had broken off from decomposition, and so it was able to pass out again back- wards, which had been quite impossible so long as they were intact. There was a gradual retrocession of the signs, but there remained at the apex a deficient resonance, with indeter- minate breathing and increased voice sounds; a few moist sounds persisted at the lower part of the lung for some time. In December the opsonic index for tubercle was found to be 0.6 and 0.65 on two occasions. An attempt was made to see whether any acid-fast bacilli could be cultivated from the piece of grass, but none could be found, although many other organisms were present. Fig. 14 (Case xvm) shows a pea wedged in the lower bronchus on the right side. The upper part of the lung is healthy, but the rest of the lung is densely fibroid and riddled with intercommunicating cavities. The patient was a boy, aged 3 years, with cough and vomiting. He died with empyema and cerebral abscesses a month later. Case xix.—Piece of Pork in Right Bronchus: Bronchiectasis : Septic Pneumonia. In 1888 a man, aged 60 years, was admitted. For six months there had been wasting, and for two weeks foul breath. For two days there had been deficient movement of the lung on the right side, pleural rub in the axilla and base, deficient air entry, rales, with amphoric breathing over the middle lobe. At the inspection the right lung was fibroid with general bronchiectasis of the main bronchi. Low down was found a piece of pork J x | in. There were cavities in the lower lobe. There was acute pneumonia at the lower part of the upper lobe with oedema of the left lung. Had the pork been there for six months? Case xx.—Piece of Wood in Left Bronchus: Bronchiectasis oj Both Lungs. In 1905 a female child, aged 16 months, was seen. She was well until five weeks before admittance, when she had a cough and dyspnoea. The right lung was resonant on the anterior part in front, but impaired behind. There were crackling rales, bronchial breathing, and pectoriloquy behind. At the inspection there was advanced fibrosis with bronchiectasis of the right lower, the right middle, and the left lower portions, with a mass of dilated tubes in the midst of the parts of the lung which were fibroid. The two left upper lobes were distended; there was recent bronchopneumonia. In the left bronchus, just beyond the point of bifurcation, there was a smooth piece of wood broken off a toy. It was doubted at the necropsy whether the piece of wood had caused the bronchiectasis, because it was found in the left bronchus and the bronchiectasis was also ©n the right side, but probably at an earlier stage it was in the right bronchus, and had produced changes on that side and been displaced to the left later. Although many cases of foreign bodies in the bronchi have been recorded, in but very few has an accurate note been made of the physical signs in the lung in an early stage of the illness. The body generally passes into the right bronchus because it is more vertical and is also slightly larger. The changes are unilateral, serious, and progressive. The following are the most important evidences sugges- tive of a foreign body in a bronchus, and in any such case a bronchoscope should be passed in order that the con- dition of the tubes may be determined, and a positive opinion formed: (1) A most important factor in diagnosis, and one which until we had a: rays was absolutely essential, is the history of swallowing something immediately before the onset of an acute attack of severe dyspnoea and cough. (2) Not infrequently a whistling or wheezing sound which the patient can localize to one side, varying in quality if the object is not fixed in the bronchus. (3) Great distress, with not infrequently a constricting pain behind the sternum, made worse by movement. (4) Dyspnoea, with varying exacerbations, often intense and made worse by cough, but it may be elicited only by exertion. After a time there may be no distress. (5) Absent or, rarely, very noisy breath sounds, with some slight diminu- tion of voice and tactile vocal fremitus limited to one side of the chest. (6) At first resonance on the affected side, soon consolidation with dullness, and, after a time, the signs of cavities, and the simulation of phthisis; query occasionally hyper-resonance. The physical signs some- times vary from time to time. (7) With x rays, the defec- tive movement of the diaphragm and of the thorax, the alteration in the density of the lung, and not infrequently the outline of the foreign body itself, may be clearly made out. (8) Delay in the commencement of inspiration as compared with that on the other side. (9) Defective movement with consequent diminution in the size of the affected side. (10) Violent paroxysmal persistent cough, which is apparently most marked when the object is at the bifurcation, as the sensibility of the mucous membrane is greatest here, as can be noticed when passing a broncho- scope. (11) Early pyrexia, which later becomes hectic, associated with chills. (12) After a short time an expec- toration more or less 'profuse, purulent, often bloody, and later often fetid. (13) In some there are nausea and vomiting, which may be very troublesome. (14) Pneu- monia often develops in forty-eight hours; this may be septic and may be followed by gangrene. [I am indebted to Messrs. Bale, Sons and Danielsson for the loan of the block of the portrait of Dr. Bradshaw which appears on p. 1.]