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 end of 1906 there was an impairment of resonance developing at the left base; there were still an absence of air- entry, diminished tactile vocal fremitus and voice sounds. He now developed pain with sweating at night, cough, and expec- toration, and at the apex behind there were distant breath sounds. A somewhat tympanitic note was noticed near the cardiac area. No tubercle bacilli could be found. Daring the next month or two he had a large amount of muco purulent expectoration which was not foul. In February he began to develop slight clubbing of the fingers, and a rub was audible over the left chest. On February 27th he had a rigor with a temperature of 105° and a leucocytosis of 33,700. He had a sharp attack of pleurisy lasting for ten days. In March the impulse of the heart had returned to the left sile of the sternum. There were consonating rales at the back of the left lung and not much difference between the note on the two sides. It was at first difficult to explain the attacks of severe pleurisy which followed both attempts at exploration. It was clear afterwards that infective fluid from the distended bronchi had inoculated the pleura, as, doubtless owing to the great pressure under which it was retained, some leaked into the pleura from the puncture Had the lung not been under tension it would probably not have set up any infection. The obstruction to the bronchus was not complete, as there was expectoration, although the movement was so feeble that we could not hear air being sucked up to the surface of the lung. It is noticeable that so long as the lung remained quiet, and before it became fibroid, so that the contents did not pass into the lymphatics but re- mained in the lung, or were expectorated, the patient re- mained free from fever, yet the faintest trace in the pleura set up a violent reaction. His symptoms gradually quieted down, and he con- tinued fairly well. I did not see him from April, 1906, to the end of February, 1907, when he was seized with general pains, pyrexia, and troublesome cough. Soon the expectoration became abun- dant and extremely foul, so that he vomited frequently. On readmission he was very ill and feeble. The left chest was contracted; the move- ment was deficient, there was an impaired note at the apex and below, and it was also dull in the axilla. Over the upper spaces the entry was deficient and broncho-vesi- cular ; below it was lost. Numerous rales were audible, with compensatory breathing on the right side. The pulse was irregular, 108; the im- pulse was dragged 1 in. out- side the nipple by contraction of the lung. A diagnosis of gangrene of the lung was made. The condition proved fatal on the 26th, three days after admission. Post mortem a saccular aneurysm opening just at the commencement of the descending aorta had com- pressed the left bronchus and produced a condition of fibrosis of the whole of the left lung with recent septic bronchopneumonia (Fig. 4). There was bronchiectasis of the tubes beyond the compression, with cavitation due to recent putrefactive infection, which was most marked in the posterior part of the lower lobe (Fig. 5). Until I saw this case I was quite unaware that a partial compression of a bronchus was capable of producing an over-distended lung, which might be confused with pneumothorax. Case ii.—The over-distension of a lung when there is pressure on the trachea, together with urgent dyspnoea, is well shown in Fig. 6. The patient was a man who was admitted with bronchitis and intense dyspnoea which soon proved fatal. The trachea was found to be compressed by an aneurysm of the transverse aorta. The lung was enormously over-distended and had rup- tured, producing interlobular emphysema, as shown by the lines of the interlobular septa, which, when fresh, were distended with air, but now are collapsed and empty. I am indebted to Dr. E. W. Martin for the two following skiagrams, which excellently illustrate my contention. Fig. 7 represents a chest taken from the back. The left side is uniformly transparent; the intercostal spaces are wider than on the right. The diaphragm is flattened and displaced downwards and the heart to the right. The aneurysmal dilatation of the arch, with the marked excur- sion of pulsation, is well shown. There were well-marked signs of an aneurysm compressing the left bronchus. The condition was diagnosed on account of the skiagram as pneumothorax with aneurysm, but the appearance is really due to an over-distended lung. This will be at once apparent if we contrast it with an equally good skiagram of a pneumothorax (Fig. 8), also taken so long ago as 1902 by him. Here the air space is more trans- parent than was the over-distended lung, but the lung, shrunk up near its root, is obvious; this was wanting in the other picture. The heart and diaphragm are more displaced, and the latter has a much sharper outline. [Since the lecture Dr. Martin has been able to find me the following notes of this case, which was in Victoria Park Hospital in 1902 : There was pulsation over the upper part of the sternum with a dull note. The note over the left chest was resonant, no cardiac dullness, the apex beat was 1 in. to the left of the sternum in the fifth space, the heart sounds were very feeble, but best heard on the right of the sternum; extremely feeble breath sounds all over the left chest—it hardly moves at all—and the whole chest, both hack and front, is larger than the right. An exploring syringe was introduced in the seventh space posteriorly on the left side, and connected with a tube under water, when about thirty bubbles of air escaped. The condition at that time was considered to be one of pneumothorax with aneurysm. The escape of the bubbles of air naturally suggested this; the skia- gram, however, is definitely that of an over distended lung, and I am supported in this view by Dr. Hugh Walsham. The air must, therefore, have escaped from the interior of the lung itself, and the ex- planation is that it must have been retained under great pressure, which is also indicated by the con- dition of the lungs.] Case hi.—Aneurysm Com- pressing the Left Bronchus : Signs at one time suggesting Pneumothorax. The patient was a man, aged 39 years. In October, 1906, there was pain behind the sternum. The physical signs on admission left it doubtful whether he had pneumothorax or an obstruc- tion of the left bronchus. There were cough and stridor, there was deficient movement of the left side, but it looked enlarged. Some hyper-resonance was present. There were no tactile vocal fremitus, and no breath sounds, and voice sounds were diminished; on the right side there was compensatory breathing. The heart sounds were not well heard on the left side, but were better than normal on the right side. On December 15th a skia- gram showed slightly increased opacity in the region of the aorta. On January 7th there was no dullness; no breath sounds were audible over the left chest. In February breathing was audible behind in the upper part, but the cardiac impulse was not palpable. In March there was a better entry of air into the left lung, with a few rales. The impulse was in the sixth space one inch outside the nipple. On March 14th the left base was becoming dull ; when the patient went out in May the left chest had an im- paired note with deficient breath sounds. Fatal haemoptysis occurred a few weeks later. 'Case iv.—Saccular Aneurysm Compressing and Eroding the Left Bronchus: High-pitched Bote over the Left Chest: Signs suggestive of Pneumothorax: Fibrosis with Bronchi- ectasis. The patient, a man aged 38 years, had had cough and pain in the chest for six months. The left chest was less flattened than the right, there was defective movement, and a high- pitched note all over on the left side. There was no cardiac dullness and no dullness in the axilla. Voice sounds were deficient and breath sounds absent. Behind, the left chest DESCRIPTION OF SPECIAL PLATES. Fig. 1.—Trachea and bronchi opened from behind to show that an aneurysm of the transverse aorta presses on the anterior and outer side of the left bronchus. In this case the aneurysm is just beyond the transverse part, and has ruptured into the bronchus at A. Fig. 2.—A similar specimen with an aneurysm of the de- scending aorta laid open; this is seen to lie on the posterior surface of the left bronchus, which it compresses. Fig. 3.—Skiagram of a chest taken from the front, showing the greatly over-distended left lung, due to pressure on the bronchus from an aneurysm. The left lung is over-trans- parent. the diaphragm is pushed down, and the heart is pushed over to the right. Fig 4.—The bronchi of the same case laid open from behind. A small saccular aneurysm can be seen opening from the de- scending aorta, compressing, and almost occluding, the left bronchus, through which a glass rod (a) has been passed. Fig. 5.—A section of the corresponding lung, showing the re- sulting reduced size from fibrosis, with a general bronchi- ectasis. The fibrous trabeculae stand out, and there is, in addition, an acute destructive cavitation, chiefly in the posterior part of the lower lobe. Fig. 6.—A piece of lung showing interstitial emphysema. The lines of the interlobular septa were, when fresh, distended with air, due to rupture from over-distension of the lung, pro- duced by compression of the trachea by an aneurysm, and accompanied by intense dyspnoea. Fig. 7.—Skiagram taken from the back, showing an over- distended left lung, due to compression of the bronchus by an aneurysm The left chest is abnormally transparent, the aneurysm with its movement above is obvious, the heart is displaced to the right, and the diaphragm is 2 in. lower than the other side.