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LECTURE XIV.

COLLAPSE OF LUNG THAT HAS ONCE BEEN EXPANDED-described as lobular pneumonia by various writers-its characters-symptoms and differences from true pneumonia.— Observations of Bailly and Legendre.—Is not to be regarded as a post-mortem occurrence. Illustrative cases.-Instances of its occurrence in the adult.—Similar causes tend to produce it at all periods of life-hence very frequent in old age. INDURATION OF THE CELLULAR TISSUE-its characters-remarkable reduction of temperature that attends it-appearances after death-condition of deficient expansion, or of collapse of the lung, noticed by many observers, though misunderstood by most, is probable cause of the induration, or the oedema of the surface.

THE Condition of the lungs which we were occupied in examining at the last lecture is of importance, even if regarded merely as a congenital state, the result of nature having failed in the attempt to establish respiration, and to fit the child thoroughly for the new mode of existence to which it is destined after birth. But its claims on our attention are still greater when we bear in mind the possibility of its occurrence in consequence of a variety of causes operating after birth, so that lungs once permeable to air may cease to admit it, and death at length occur from apnoea without any serious structural change having taken place in the organs of respiration.

Appearances supposed to be the result of pneumonia had long attracted the notice of writers on diseases of children, by the wide differences which they presented from those which inflammation of the lungs give rise to in the adult. It had been observed that infants and children under five years of age often died after presenting some of the symptoms of inflammation of the lungs, such as cough and difficult breathing, together with more or less extensive dulness of the chest on percussion, and some or other of the auscultatory signs of solidification of the lung. In such cases these peculiar morbid appearances were especially well marked. But while they seemed to prove that these changes in the lung were the consequences of pneumonia, it happened not infrequently that the fever and the pneumonic symptoms underwent a great abatement before any sign of approaching death appeared, or that children who had seemed to die worn out from various causes, and during whose lifetime no indication of inflammation of the lungs had existed, presented the supposed anatomical evidences of pneumonia in a most remarkable degree. The frequency of occurrences of this kind led to the assumption that pneumonia was an extremely frequent concomitant of almost all the diseases of infancy and early childhood, that this pneumonia was very often latent (that is to say, that it did not manifest its existence by those symptoms which usually attend it), and lastly, that owing to causes which were differently stated by different observers, it gave rise to alterations in the lung very dissimilar from those which it occasioned in the adult.

One of the most remarkable peculiarities of this supposed infantile pneumonia led to its receiving the appellation of lobular pneumonia,

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as expressive of the fact that it did not attack a large tract of lung, or the whole of a lobe at one time, but that it affected isolated lobules, which might be seen of a dark colour, solid, often depressed below the surrounding parts, and sinking in water if detached from the healthy tissue in the midst of which they were situated. Sometimes the affection was strictly limited to a single lobule, the boundaries of which could be exactly traced; and though it often happened that a cluster of lobules was thus hard, and dark, and solid, still there was no gradual shading off from the darker to the lighter parts, so that it was evident that, in whatever way the disease extended, at any rate it did not advance by mere continuity of tissue. Sometimes almost the whole of one lobe was thus affected, a few lobules only still retaining a healthy aspect, and crepitating under the finger, and it often happened that the bronchi leading to it were full of mucus or pus, while at other times there was marked congestion of the lung, and in the midst of this congested tissue were two or three solid, hepatized patches. All these circumstances, as it may be conceived, variously modified the morbid appearances. In the last case the lobular pneumonia was thought to be becoming generalised, or, in other words the inflammation originally limited to certain lobules was supposed to have begun to extend to the adjacent tissues, constituting a kind of transition state between lobular and lobar pneumonia. The lower edge of the different lobes, the whole of the middle lobe of the right lung, and often a very considerable portion of the whole of one or other lower lobe, were also sometimes found in a state, to which, among other names, that of carnification was applied, on account of its close resemblance to a piece of muscular tissue. A portion of carnified lung showed the closest possible similarity to a lung that had been compressed by effusion into the pleura. It was dark, tough, solid, contained no air, presented a smooth surface when cut, yielded a small quantity of bloody serum, when pressed, and, indeed, seemed almost like a piece of flesh, in all which respects it resembled a portion of lung hepatized by lobular pneumonia, and differed from the lung of the adult when that has been rendered solid by inflammation.

The course of the disease in many of these cases during the life-time of the patient, and the results of medical treatment, tended to enhance the difficulties which the above-described anatomical peculiarities placed in the way of referring lobular pneumonia to the same category of affections with the pneumonia of the adult. Venesection, leeches, and mercurials, the ordinary antiphlogistic apparatus in the pneumonia of the adult, often appeared to hasten the child's death; blisters rarely effected any good, and the blistered surface often showed a remarkable indisposition to heal. On the other hand, emetics and rubefacients were frequently of service; a stimulant plan of treatment was almost always necessary at an early period, and sometimes seemed to be required almost from the outset of the affection. The rapidity of the changes that took place in the physical condition of the lung was another peculiarity which rendered the nature of the affection still more obscure, for where air was heard entering freely on one day, none would be perceptible on the morrow, but percussion of that part of the chest would yield a sound of

MISTAKEN FOR LOBULAR PNEUMONIA.

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complete dulness. On the other hand, it happened sometimes, though much less often, that dulness was succeeded just as quickly by resonance on percussion, and that breathing became distinctly audible where on the previous day no sound of air was to be heard.

Nothing can show more forcibly the influence of a name, than the fact that this condition of the lungs should have been described by all writers as lobular pneumonia, and that its symptoms should have been attributed to inflammation, while yet it was evident from the concurrent testimony of every one that neither in its progress nor in its results was it similar to inflammation of the lungs in the adult, much less identical with it. Having, however, once been called pneumonia, every person continued to call it so, though often with a full recognition of its peculiarities. Even the close resemblance which the lung presented to foetal lung, or to those undilated portions which are characteristic of atelektasis, was noticed and discussed by myself, and by many far better observers, apparently without a suspicion that both states were identical.

But while the peculiarities of lobular pneumonia were thus generally commented on, it seems strange that no one should have had recourse to the experiment of inflation in order to obtain a solution of some of the difficulties that existed with reference to its nature. This oversight seems the more extraordinary, when we call to mind that this very means had cleared up so many doubts concerning appearances in the lungs of new-born infants, which had once been supposed to be the result of pneumonia in the foetus, or of some arrest of developement. At length the experiment was tried by MM. Bailly and Legendre,' and though, as in the old tale of Columbus and the egg, the thing seems so obvious that there is some risk of our undertaking the merit of those who were the first to do it, it must not be forgotten, that, by that simple means they have thrown more light on the affections of the lungs in infancy and childhood, than all the writers of the previous ten years taken together.

MM. Bailly and Legendre state as the result of their observations that the appearances, to which the name of lobular pneumonia has commonly been given, are in reality produced by an occlusion of the pulmonary vesicles. This occlusion, say they, and the correctness of this opinion is now universally admitted, is due to the inspiratory power having been inadequate to overcome that elasticity of the lung concerning which I spoke to you at the last lecture; while it is in many instances favoured by the accumulation of secretions in the bronchi partly obstructing their canal and interposing a more than ordinary obstacle to the entrance of the air. Besides this cause they assign a second, in the direct compression of the air vesicles by an unusually congested state of their vessels; but in this opinion, in which I formerly coincided, they are now generally believed to have been mistaken, and the congestion is probably a secondary and accidental occurrence. Be this as it may, however, inflation of the lung will in either case

1 Nouvelles Recherches sur quelques Maladies du Poumon; in the Arch. Gén. de Méd., Jan., Févr., Mars, 1844.

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RESEARCHES OF BAILLY AND LEGENDRE.

remove the solidity of the lobules, and restore them almost or quite to their natural appearance.

It may, however, be objected that this is not in reality a morbid condition of the lung, but that it is only the effect of a somewhat greater degree than usual of that collapse of the organ which takes place when the breath leaves the body. It may be suggested that nothing more is needed to produce the complete emptying of some portions of the lung, and their consequent solidification, than the resiliency which they retain after death, coupled with the pressure of the parietes of the thorax upon them. The possibility of this condition supervening after death cannot be denied, but still it may safely be affirmed, that it is not usually, nor, indeed frequently a post-mortem occurrence. The frequency with which isolated lobules are found dark, unaerated, and solid, while all the surrounding tissue is perfectly healthy, can hardly be accounted for on the supposition that the state comes on after death. But conclusive evidence is afforded by the physical signs of solidification of the lung being observed in many cases in which this condition is found after death, and by the frequency with which sudden and fatal dyspnoea comes on in the course of various affections in early infancy, and leaves no trace of its cause other than a collapsed state of a considerable portion of the lungs.

A little girl was attacked, when a month old, by very severe diarrhoea which lasted for three weeks, and then left her greatly exhausted and much emaciated. No return of the purging occurred, and the child lived, though in a state of great weakness, till she was five months old. For the last five weeks of her life, she was under my care, and sometimes she seemed, for a day or two, as if she were gaining strength and might recover; but these signs of improvement were never of long duration. Three days before she died, her breath grew suddenly hurried; the dyspnoea was not attended with any cough, but, from the time of its coming on, the child's exhaustion increased, and her respiration grew more rapid until her death.

No organ showed any sign of disease, but all presented a most remarkable degree of anæmia. Two-thirds of the upper, and almost the whole of the lower lobe of the right lung, were dark, solid, and non-crepitant; and a few lobules of the left lung presented the same appearance.Inflation restored them to exactly the same state as the rest of the lung. The bronchi were preternaturally pale, and contained no secretions. It is not possible to say why the child's inspiratory power grew too feeble to fill the lungs at one moment rather than at another, but few will doubt that it had become so just at the time when the dyspnoea occurred. A portion of the lung having become collapsed, the elastic ribs tended to render abortive any faint effort to draw in more air, and thus the vital flame went out for want of air to feed it.

Sometimes the occurrence of this condition is long preceded by indications of the imperfect performance of the respiratory functions, but yet they go on sufficiently to keep the machinery of life in motion, till some trivial, perhaps some inappreciable cause, a draught of cold air, a little over-exertion, the horizontal posture too long continued, the customary food delayed an hour beyond the usual time,-sinks them so low that they soon cease forever.

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Some time ago I saw a little girl ten months old, who had lost her mother soon after her birth, and had been indebted to a stranger for what should have been a mother's cares. She never throve; her chest presented that peculiar malformation commonly called pigeon-breast, and the diaphragm drew her yielding ribs inwards, and thus produced a circular constriction around the base of the thorax.' But though she was a backward child, and though her respiration was always almost as abdominal as that of a new-born infant, there was no definite evidence of disease until she was nine months old. She then lost flesh rapidly, and began to cough without having had any previous catarrh. Her case seemed to be one of bronchial phthisis.

Four days before she died her breath suddenly became much oppressed, and her cough far more severe than it had been before. The dyspnoea rapidly increased, but her cough soon became less frequent. A few hours before her death her lips were quite livid; she was breathing from 80 to 86 times in the minute, the abdominal muscles acting most violently, but the chest being scarcely at all expanded. Auscultation detected nothing more than some rather large mucous râle in the lung.

After death no tubercle was found in any organ, but large portions of both lungs presented the undilated condition, which disappeared entirely on inflation. The bronchi were pale, and contained very little mucus, but the right side of the heart was greatly distended with coagulated blood, which its thin, pale, and flaccid substance had evidently been unequal to propel with the requisite vigour.

The imperfect respiration had here for some time manifested itself; the vital powers had long been feeble; nutrition had been ill performed, and the heart itself had shared in the general feebleness, till at length air ceased to permeate a large extent of the pulmonary substance, and the child died for want of air to produce the requisite changes in the blood.

In both of these cases the lung collapsed, because the inspiratory powers were too feeble to fill the minuter vessels with air. The result is the same if the obstacle be increased as if the power be diminished; and hence the supervention of this state of lung becomes one of the most perilous, while it is one of the most frequent, complications of infantile bronchitis. A little girl, previously quite healthy, was seized when ten months old with symptoms of acute bronchitis, a suffocative cough returning in paroxysms, and sometimes followed by the rejection of a muco-purulent fluid. The symptoms throughout did not seem to allow of depletion; but ammonia, with decoction of senega and tincture of squills, and other expectorants of a stimulating kind, were given with temporary amendment. The child did not, however, appear to have undergone any marked change, either for better or worse, except that she had certainly lost both flesh and strength, when coldness, faintness, and exceedingly laboured respiration, suddenly came on, under which symptoms she died in the course of twenty-four hours.

A few recent adhesions were found on each side of the chest, between

A very interesting explanation of the mechanism by which this deformity of the chest is produced is given by MM. Rilliet and Barthez, op. cit. vol. iii., p. 640.