Diseases of the bronchi, lungs, and pleura

Front matter

Google to make the world's books discoverable online.

It has survived long enough for the copyright to expire and the book to enter the public domain. A public domain book is one that was never subject

to copyright or whose legal copyright term has expired. Whether a book is in the public domain may vary country to country. Public domain books

Preface

It is hoped that the following pages will fill the present need of a practical treatise on the diseases of the respiratory organs. The aim has been to present current knowledge, founded on the literature and the experience gained in the wards and pathologic laboratory of the Massachusetts General Hospital, in such form as to be of value to students and practitioners and also to provide a basis for further research. References are given to the most important original articles in order that the literature may be readily available to those who wish to go more fully into particular problems. Pulmonary tuberculosis is not considered under a separate heading, but special attention is given to conditions which simulate pulmonary tul)erculosis and their differential diagnosis.

I am greatly indebted to Sir William Osier and Dr. Thomas McCrae and to the publishers, Messrs. Lea & Febiger, for the privilege of revising and including in this work the sections on the diseases of the pleura written for Osier and McCrae*s Modern Medicine. It is a pleasure to acknowledge my share in the obligation of all students of respiratory diseases to the publications of Dr. Albert Fraenkel. My thanks are due to Dr. James Homer Wright for the use of pathologic material, to Dr. Walter J. Dodd for the x-ray plates, and to Mr. Lewis S. Brown

for the photographs.

F. T. L.

Boston, Mass., 1915.

Section II. Diseases Of The Lungs

CHAPTER VIII.

CHAPTER IX.

Emphysema

2. Acute Vesicular Emphysema .

3. Compensatory Emphysema

4. Senile Emphysema

5. Interstitial Emphysema

CHAPTER X.

Lobar Pneumonia. Ordinary Lobar Pneumonia

CHAPTER XI.

Friedlander's Bacillus Pneumonia

140 140 152 152 153 153

CHAPTER XII.

Psittacosis 241

CHAPTER XIII.

CHAPTER XIV.

CHAPTER XV.

Pneumonoconiosis

CHAPTER XVI.

CHAPTER XVII.

Circulatory Disturbances Pulmonary Congestion .

Active Congestion Passive Congestion Pulmonary Edenm Chronio Form . \cuto P'orm r

5fc.

t ^^K

K

•

CONTENTS ix

CHAFfER Xyill.

Pulmonary Thrombosis, Embolism, and Infarction 328

CHAPTER XIX.

Hemoptysis 352

CHAPTER XX.

Pulmonary Syphilis 364

CHAPTER XXI.

Pulmonary Actinomycosis 371

CHAPTER XXII.

Pulmonary Streptothricosis 389

CHAPTER XXIII.

Pulmonary Blastomycosis 302

CHAPTER XXIV.

Pulmonary Aspergillosis 399

CHAPTER XXV.

Animal Parasites 404

2. Pulmonary Distomatosis (Lung-fluke Disease) 420

3. Other Parasites 426

CHAFIER XXVI.

1. Benign 427

2. Mahgnant 428

(o) Primary Cancer of the Lung 428

(6) Primary Sarcoma of the Lung 432

(c) Secondary Mahgnant Disease of the Lung 446

CHAPTER XXVII.

Lung Hernia 448

CHAPTER XXVIH.

Pulmonary Arteriosclerosis 451

X CONTENTS

Section III. Diseases Of The Pleura

CHAPTER XXIX.

Pleuritib 453

CHAPTER XXX.

Special Fobms of Pleuritis 531

1. Diaphragmatic Pleurisy 531

2. Encysted Empyema 531

3. Actinomycosis and Streptothricosis 533

4. Peripleuritis 534

5. Syphilis of the Pleura 535

6. Chronic Pleuritis 535

CHAPTER XXXI.

Hydrothorax 537

CHAPTER XXXII.

Hemorrhagic Pleural Fluids 539

1. Hemoserothorax 539

2. Traumatic Hemothorax 541

CHAI>TER XXXIII.

Chylothorax 546

CHAPTER XXXIV.

Tumors of the Pleura 550

1. Benign 550

2. Primary Malignant Tumors .551

(a) Carcinoma 551

{b) Sarcoma 555

3. Secondary Malignant Tumors 556

CHAPl^ER XXXV.

EcniNococcus Disease of the Pleura 557

1 . Pleural Echinococcus 557

2. Parapleural Echinococcus 558

CHAPTER XXXVI.

Chapter I. Bronchostenosis

Etiology. — The causes may be briefly summarized and for convenience divided into those aflFecting the large and medium-sized and the small bronchi.

A. Stenosis of the Large and Medium-sized Bronchi. — Partial or complete occlusion may be due to the following:

1. Extrabronchial Cavses, — Compression from without may arise from aortic aneurysm, malignant disease of the lung, mediastinum, or esophagus, enlarged tracheobronchial lymph glands, pericardial effusion, dilatation of the left auricle, mediastinal abscess, or echinococcus disease. Bronchostenosis from dilatation of the left auricle is probably more common than is generally supposed. A slight degree of stenosis undetectable by ordinary methods may be recognized by bronchoscopic examination. Kahler^ has reported 13 cases, in 11 of which the clinical diagnosis was mitral stenosis, 1 mitral insufficiency, and 1 aortic insufficiency. In one case Schrotter^ noted narrowing of the bronchi from dislocation of the mediastinum in consequence of pneumohydrothorax. A discussion of these causes falls without the scope of this work.

2. Diseases of the Bronchial Wall, — In this group, benign and malignant tumors, syphilis, tuberculosis and scleroma may be mentioned and are described elsewhere. The lesions of leprosy, glanders, and variola may, in rare instances, give rise to bronchial occlusion. BrindeP reported the case of a man, aged sixty-four years, who was severely wounded in the neck thirty-four years before by a fragment of a shell. Thirteen years later a hard tumor appeared over the cicatrix and gradually increased to the size of the fist, with adhesion to the deeper parts and the trachea. Consequent disturbance of respiration led

» Monatsschr. f. Ohrcnhcilk., 1912, xlvi, 573. * Klinik der Bronchoskopie, 1906. p. 265.

' Atr^e de la trached ct des grosses broDches par n6ofomiation scl^rematcuse d'origine traumatique, Gaz. bebd. dcs sci. m^d., 26 F6v., 1905.

to tracheotomy. Bronchoscopy showed diminution in the caliber of the trachea and bronchi. Histologic examination of the tumor showed cicatricial fibrous tissue.

3. Ijitrabronchial Causes. — In this class may be placed foreign bodies which gain entrance to the air passages by aspiration, or arise from within. They are considered under a separate heading. Devi^ reports sudden bronchial obstruction from the accumulation of thick mucus during an attack of acute bronchial catarrh. Killian^ found and removed, by lower tracheoscopy, tenacious secretion partly occluding the lower trachea and primary bronchi in a patient with laryngeal tuberculosis.

B. Stenosis of the Smaller Bronchi — Owing to the narrow lumen of the smaller passages, their proximity to the lung and the small area of pulmonary tissue supplied by individual branches, occlusion by compression from without, disease of the bronchial wall or foreign bodies fails to give rise to striking clinical features referable to the bronchi unless a large number of the smaller passages are simultaneously involved. In such conditions as widespread capillary bronchitis, bronchial asthma with spasm of the bronchioles, bronchitis fibrosa, and bronchitis and bronchiolitis obliterans, the obstruction to free entrance and exit of air may cause serious symptoms. These causes are considered elsewhere.

Pathology. — Sudden total occlusion, as by a foreign body, is followed by atelectasis and reduction in size of the part of the lung supplied by the occluded passage from absorption of air. Partial occlusion is more common, however, and is followed by diminished air content of the affected pulmonary territory. In early cases other lesions may be lacking, but if the occlusion persists for more than a few days, important changes occur, and for the most part as a result of stasis of secretion and infection by organisms always present and ready to set up inflammatory processes in the damaged region beyond the obstruction. Retained mucus is transformed into mucopurulent and purulent material. The infection extends to the pulmonary tissue, giving rise to bronchopneumonia, abscess, or gangrene. Bacterial invasion of the bronchial wall, the pressure of retained secretion, and disintegration of the supporting pulmonary tissue lead to the development of bronchiectasis. Chronic interstitial pneumonia and contraction of the pulmonary tissue follow^ the more acute inflammatory processes. Osler^ speaks of the bronchiectasis and pulmonary suppuration following compression of a bronchus as aneurysmal phthisis. Extension to the pleura may cause fibrinous, serofibrinous, or purulent pleurisy. Pulmonary tuberculosis may develop. Its occurrence has been specially noted in connection with compression of the trachea

' Poster ni4d. Chir. Presse, 1884, xx, 115. ' Quoted from Schrotter, loc. cit., p. 265. 3 Practice of Medicine, 1905, p. 856.

BRONCHOSTENOSIS 19

or bronchi from aortic aneurysm. Of 45 cases of aneurysm of the thoracic aorta reported by Frankel/ in 4 there was chronic pulmonary inflammation and induration and in 3 other cases (about 7 per cent.) extensive tuberculosis with predominant infection of the left lung. In two of the three, considerable narrowing of the left primary bronchus was noted.

Sjrmptoms and Signs. — The frequent coincident involvement of the trachea and primar^'^ bronchi in the conditions leading to bronchial stenosis makes it difficult or impossible in many instances to draw any sharp distinction between clinical features referable to one or the other, and the manifestations common to the various causes of tracheobronchial stenosis are first considered.

Gerhardt,^ in his study of syphilitic tracheal stenosis, in which the important changes are often just above or at the bifurcation, noted three periods in the clinical picture, and these are also applicable with some modification to tracheobronchial stenosis from other causes. During the initial period of a gradually increasing obstruction there may be such irritative symptoms as cough with or without expectoration, a substernal tickling or uncomfortable sensation, weakening of the voice, and slight dyspnea on exertion. As the lumen of the involved passage diminishes, the first passes insensibly into the second stage, in which there is persistent dyspnea with the patient at rest, and this in turn into the third and final stage of suffocation and death. The different periods are often not clearly recognizable, and transient suffocative attacks, with cyanosis, severe dyspnea, and even unconsciousness for a time may appear early and recur at intervals throughout the disturbance. They may be due to catarrhal swelling of the mucous membrane about the site of a partial obstruction, to occlusion by secretion, or to acute cardiac dilatation. The strain upon the heart as a consequence of tracheobronchial obstruction is probably largely due to increase of pressure in the pulmpnary circuit during forced expiration.

Hoarseness may be due to coincident disease of the larynx or recurrent laryngeal paralysis, but weakness of the voice may be observed quite independent of a disturbance of the larynx and may be ascribed to diminished volume of the air current in consequence of the trouble below.

The dyspnea of tracheobronchial obstruction is both inspiratory and expiratory. Predominant expiratory dyspnea is occasionally observed, and may be ascribed to the narrowing of the caliber of the trachea and bronchi and greater obstruction to the passage of air through an already partially occluded lumen during this phase of respiration. The head may be held forward with the chin approaching the chest, for the purpose of relaxing and widening the trachea. Immo-

^ Spez. path. u. Ther. d. Lungenkrankheiten, 1904, p. 65. « Deut. Arch. f. klin. Med., 1866-67, ii, 538.

bility of the larynx during respiration may be noted. These features may be contrasted with the predominant inspiratory dyspnea, tendency to hold the head backward, and greater amplitude of laryngeal excursion with laryngeal stenosis. The use of the accessory muscles of respiration, the inspiratory depression of the tissues at the root of the neck, the intercostal spaces, the epigastrium, and the lower parts of the chest in the region of the diaphragmatic attachment may also be noted. Inspiratory and expiratory or predominantly expiratory stridor may be heard. It is spoken of as "cornage" by the French, and is due to the passage of air through an obstructed tube.

On examination of the lungs, little or nothing of significance may be found earlv in the course of tracheobronchial obstruction, and before secondary inflammatory processes have arisen below the point of obstruction. The stridor may be of maximum intensity to one or the other side of the median line, as an indication of its point of origin; but it may be conducted along the trachea to the neck and heard best in this region when the site of obstruction is below. A considerable degree of obstruction may lead to inflation of the lung, hyperresonance, relative immobility, and abnormally low position of the pulmonary margin and other signs of emphysema.

With unilateral bronchostenosis the symptoms are the same, but less severe than with tracheobronchial obstruction. Complete sudden closure of a primary bronchus is followed by severe dyspnea and suffocative symptoms, which usually subside after a short time, and seldom terminate fatally unless complicated by other disturbances in the respiratory or circulatory system. Following the initial disturbance of sudden occlusion, or in the course of a gradually increasing partial obstruction, troublesome dyspnea may be present only on exertion. On examination, diminished respiratory excursion, resonance on percussion, and weakened breath sounds, voice, whisper, and tactile fremitus are found over the parts of the lung supplied by the occluded bronchus. Measurement may show some narrowing of the affected side. Stridor may be heard over the site of the obstruction. Signs of compensatory emphysema can be demonstrated over the unaffected lung.

Clinical manifestations arising in consequence of obstruction of individual bronchi become less striking and less typical, the more gradual the obstruction and the smaller the occluded passage. It not infrequently happens that bronchostenosis arising from disease of the bronchial wall or foreign bodies is masked by manifestations referable to secondary infection of the lung, or that bronchial obstruction due to compression from without is an inconspicuous and unheeded incident in the course of serious intrathoracic disease, the clinical features of which dominate the picture.

Diagnosis. — The differentiation between bronchostenosis arising from compression and that due to endobronchial causes is at times difficult or impossible. The extrabronchial causes comprise, for the

BRONCHOSTENOSIS 21

most part, disease which develops in or about the mediastinum or invades this region, as in the case of malignant disease by metastasis. They may give indication of their presence by dulness in the supracardiac region or over the vertebrae between the third and the ninth dorsal spines, and such signs of pressure upon other organs as dysphagia, inequality of the pupils or the pulses, variation in the blood-pressure in the two arms, "tracheal tug," recurrent laryngeal paralysis, engorgement of the vessels of the head and neck or one arm, and dilated superficial thoracic veins. A history of syphilis, attacks of pain like angina pectoris, pulsation of the dull area, systolic thrill and murmur, diastolic shock, and aortic regurgitation speak for aneurysm. Cachexia and enlarged cervical or axillary glands suggest malignant disease. Mediastinal involvement in a child with tuberculosis is likely to be due to enlarged and tuberculous glands. Examination with the ar-rays is important, and may lead to the detection of extrabronchial disease, of which there is no indication on physical examination.

In the absence of indications, on physical and radioscopic examination, of an extrabronchial cause, foreign body or disease of the bronchial wall may be suspected. If there is a definite history of aspiration of a foreign body, followed by pulmonary symptoms and signs of unilateral bronchostenosis, the diagnosis is easily made, but it is important to remember, as is noted in the section on aspirated foreign bodies, that there may be nothing in the history or physical examination to indicate such a cause. Here also radioscopic examination may be helpful, but negative a;-rays do not exclude a foreign body.

Bronchostenosis from syphilis may be suspected in a syphilitic subject after the exclusion of other causes. Scleroma and tuberculosis are uncommon, and there are usually other indications pointing to the diagnosis. Primary malignant disease of the bronchi is the most difficult of diagnosis.

Important advances in methods of investigation have made it possible in many instances to resolve the difficulty of establishing the cause of bronchostenosis in doubtful cases. Laryngoscopy, tracheoscopy, and bronchoscopy, with suitable instruments in skilful hands, now permit earlier and more accurate diagnosis, and more especially in the case of foreign bodies and syphilis the institution of earlier and more successful treatment. A discussion of bronchoscopy will be found in the section on Foreign Bodies.

ProinAOsis and Treatment. — ^The prognosis depends on the cause of the occlusion. The outlook is grave in any case in which the obstruction cannot be removed. It is most unfavorable with malignant disease, only little better in aneurysm, and adds to the seriousness of tuberculous glands, pericardial effusion, dilated left auricle, and mediastinal abscess or echinococcus disease, the dangers of mechanical hindrance to respiration, cardiac strain, and pulmonary infection beyond the obstruction. If discovered early, syphilis offers considerable hope of relief. The prospect with foreign bodies grows increasingly bright with advances in bronehoscopic removal, and even the chronic cases should not be regarded as hopeless. P'urther discussion of prognosis and treatment will be found in the separate sections.

1. TUMORS OF THE BRONCHI.

Benign Tumors. — These occur only in very rare instances. In Rokitansky's^ case a submucous lipoma almost filled the lumen of the left primary bronchus. Seigert^ at autopsy found a papUloina at the bifurcation of the trachea apparently filling the trachea and projecting into the right bronchus. Spiess' found a polyp, 4 cm. long and 1.5 cm. thick, taking its origin from the right bronchus just below the bifurcation. The right bronchus was completely and the left partially occluded. There were cough, severe dyspnea, and attacks of suffocation. The tumor was successfully removed by low^r bronchoscopy. Enchondrovia^ have been observed. Tumors containing cartilage may occur as flat, rounded, or nodular circumscribed growths, taking their origin from the larger or smaller bronchi. It is difficult to differentiate simple hyperplasia or enchondrosis and true enchondroma. A beanshaped cartilaginous tumor occluding the lumen of a bronchus to the right middle lobe and leading to bronchial dilatation is described by Siegert.* Eicken^ removed from the left primary bronchus by means of bronchoscopy a polypous mass containing islands of cartilage. In Blecher's® case there was found at autopsy a hard, spherical tumor, (ossified enchondrosis of a bronchial cartilage) the size of a hazelnut, in the left primary bronchus, beyond which the bronchi were dilated. Chiari^ reported an intrabronchial tumor of a complicated structure (lipoma, chondroma, and adenoma).

Malignant Tumors. — The malignant tumors of the bronchi may spring from the primary bronchi or their larger or smaller divisions, and are usually cylindrical-celled carcinoma, less commonly flat-celled carcinoma. Extension by way of the lymph channels or direct continuity soon leads to malignant disease of the neighboring or more remote parts of the lung and peribronchial or other lymph glands. When the growth develops from the wall of the primar\' bronchus or one of its larger branches it soon leads to occlusion of the bronchial lumen, with bronchitis, bronchiectasis, abscess formation, and bronchopneumonia and interstitial pneumonia in the affected region. Although

^ Lehrb. d. path. Anat., 1861, Band iii. ' Virchow's Arch., Band cxxix, p. 413.

* Mtinch. med. Woch., 4 Okt., 1910.

* Virchow's Arch., 1892, Band cxxix.

* Ueber die klinische Bedeutung d. Bronchialokchondrosen, Mitt. a. d. Gronzgeb. d. Med. u. Chir., 1910, xxi, 837.

* Prager m^d. W'och , 1883, viii.

SYPHILIS OF THE TRACHEA AND BRONCHI 23

the question cannot yet be regarded as settled, it is probable that carcinoma of the lung almost invariably arises from the bronchi. The clinical features are predominantly pulmonary, and malignant tumors of the bronchi are therefore discussed under Tumors of the Lung.

2. STPHIUS OF THE TRACHEA AND BRONCHI.

The initial sore of syphilis has not been observed in the trachea or bronchi. Such secondary lesions as catarrhal inflammation, hyperemic spots, and mucous patches have been noted in rare instances, but are of little clinical importance. Tertiary manifestations are found with diminishing frequency from above downward, occurring commonly in the uppermost parts of the tract, less often between pharynx and trachea, and only rarely in the trachea and bronchi.

Munk's^ case seems to have been the first in which disease of the trachea and bronchi was ascribed to syphilis. In 1867, Gerhardt* reported 5 cases and summarized the clinical features. In 1878 Vierling^ collected 46 cases, to which, in 1903, Conner^ added 82. Conner's article is the most complete and careful study in the literature. Recently the number of reported cases has rapidly increased, owing to the greater frequency of diagnosis by means of bronchoscopy. Schrotter^ was able to report in 1896 that 13 cases of tracheobronchial syphilis had come under his observation, from which the conclusion may be drawn that careful bronchoscopic investigation discloses more cases than would otherwise be found. Tracheal ulceration ascribed to syphilis was found in only 2 cases (Nos. 29 and 1196) among 3000 autopsies at the Massachusetts General Hospital.

Tracheobronchial manifestations may follow acquired or inherited syphilis, a variable interval elapsing between infection and the onset of symptoms. Of 31 cases of acquired syphilis in Conner's® series in which the interval was noted it averaged ten years, the extremes being nine months and forty-two years. In 10 cases of inherited syphilis the average age was ten years, the two oldest cases being nineteen and twenty years.

The upper or lower third of the trachea is most frequently involved, the region just above the bifurcation being a point of election. Combined lesions of the lower end of the trachea and the bronchi are common. In some cases one or both bronchi alone are involved. Bronchial branches of the third or fourth order are rarely if ever invaded. The frequency of syphilitic manifestations in the region of the tracheal bifurcation and the main bronchi may be ascribed to local irritation

1 London Medical Gazette, 1841, p. 20.

« Deut. Arch. f. klin. Med., 1867, ii, 535. » Ibid., vol. xxi, p. 325.

* Amer. Jour. Med. Sci., 1903, N. S., exxvi.

• Klinik der Bronchoskopie, 1906, p. 342. « Loc. cit.

of the tissue by dust particles in consequence of the division of the air current.

Pathology. — Three principal pathologic lesions, representing the evolution of the syphilitic process, may be recognized singly or combined in the same or different cases. (1) Gvmmaia occur as circumscribed or diffuse, single or multiple, large or small reddish masses, projecting into and encroaching on the lumen of the trachea or bronchi. They may be rounded or irregular and hard or soft. In some instances, fibrinous or purulent exudate or ulceration is seen on the surface. (2) Ulcers may be single or multiple, discrete or confluent, large or small and superficial or deep, irregular or circular in outline, and with a thick or thin and at times undermined margin. The loss of substance may be confined to the mucosa or submucosa, or include the fibrocartilaginous layer, with erosion and destruction of cartilage, fragments of which may be expectorated. Cicatrization may or may not accompany the destructive changes. Perforation of the trachea or bronchi and extension to neighboring tissues may occur. Mediastinal abscess and perforation of the esophagus have been observed. The opening of a bloodvessel may be followed by fatal hemorrhage. Circumscribed or diffuse (3) scars develop as a result of the syphilitic process. Endotracheal or endobronchial increase of connective tissue leads to the production of cicatrices of variable shape and extent, always tending to narrow and at times even obliterating the lumen of the affected passage. Band-like, annular or membranous strictures may be found. Gerhardt^ likened the resulting appearance of the trachea to that of a rope-ladder. Fibrous peritracheitis or peribronchitis may involve adjacent structures, especially the recurrent laryngeal nerves. Associated enlargement of the tracheobronchial glands may cause compression stenosis. Tracheal or bronchial dilatation may be found above and below an obstruction.

Old or recent syphilis of the mouth, nose, pharynx, or larynx may be present. Bronchiectasis below the obstruction is not uncommon, and may be ascribed to the stenosis, weakening of the bronchial wall and the adjoining pulmonary tissue from syphilis or other disease. Lobar or bronchopneumonia may complicate the process. Coexistent pulmonary tuberculosis is occasionally observed. Emphysema is not infrequent.

Sjrmptoms and Signs. — An initial stage of irritation, followed in turn by permanent stenosis, and finally by suffocative attacks, as noted by Gerhardt,^ may be recognized in many cases. Cough is commonly the earliest symptom and is at first dry, but later accompanied by mucoid, mucopurulent or purulent, and occasionally blood-streaked sputum. Elastic tissue may be found in the sputum. Hemoptysis, when it occurs, is a prominent symptom in about half of the

' lior. cit. 2 L()c. cit.

SYPHILIS OF THE TRACHEA AND BRONCHI 25

cases. Of 16 cases in which it was noted it was of minor importance in 9 (1 to ») and fatal in 7 0^ to '^),

In 3 (", ^S ^') of the 7 fatal cases the bleeding was preceded by hemorrhage. An autopsy was performed on 6 and di^losed ulceration of the trachea and bronchi with perforation of the pulmonary artery in 3 (" to ^*) and the aorta ("), branches of the bronchial artery (**), and the superior vena cava Q^) in 1 each. Hemorrhage may be the first striking symptom, as in 1 of the Massachusetts General Hospital cases reported by Gannett." The patient, a man, aged thirty-seven years, had coughed without expectoration for three years. He had an abundant hemoptysis three days before entrance. Death occurred two days after admission from a recurrence of the bleeding and at autopsy (No. 1196) it was found that a large branch of the pulmonary artery had ruptured into the right primary bronchus through a cicatrix involving the wall of the bronchus and the artery. Other cicatrices were found in the trachea and the left primary bronchus. Interstitial orchitis with the findings in the trachea and bronchi suggested syphilis as a cause.

Symptoms of tracheobronchial stenosis are seldom absent. Persistent or paroxysmal dyspnea is the most constant and conspicuous manifestation, and may be ascribed to the obstruction to respiration and consequent cardiac insufficiency.

Suffocative attacks may follow exertion or occur at night. They are probably due to acute failure of an already overtaxed heart. During the paroxysm, orthopnea, cyanosis, inspiratory or both inspiratory and expiratory dyspnea and stridor; relative immobility of the larynx; inspiratory retraction of the tissues at the root of the neck, the lower intercostal spaces, and the epigastrium; diminished respiratory motion and feeble vesicular murmur, weak pulse, and even unconsciousness may be noted. On auscultation the stridor may be of maximum intensity over the site of the obstruction. In Prengrueber's^* case, a suffocative attack, after running up stairs, was the first symptom.

» Hanzel, Wein. kUn. Woch., 1898, xi, 955.

* Parrain, Th^se, Bordeaux, 1894, No. 89. Quoted from Conner. ' Chiari, Schrdtter's case, Monatschr. f. Ohrenh., 1881, xv, 196.

* Lancereux, Ann. des mal. d'Or., 1882, p. 117.

* Gairdner, Glasgow Med. Jour., 1890, xxxiii, 463.

* Silcock, Trans. Path. Soc, London, 1886, xxxvii, 115. ' Wright, New York Med. Jour., 1891, liii, 672.

» Wright, ibid.

* Norton, Trans. Path. Soc, London, 1872, xxiii, 44. " Sokolowsky, Beri. kiin. Woch., 1889. xxvi, 209.

" Bamays, St. Louis Med. and Surg. Jour., 1880, xxxix, 250. " Watson, New York Jour, of Med., 1843, i, 57. *' Turner, Trans. Path. Soc, London, 1886, xxxvii, 117. " Gerhardt, Deut. Arch. f. klin. Med., 1867, u, 541. ** Kelly, Trans. Path. Soc, London, January 2, 1872, p. 45. " Gannett, Boston Med. and Surg. Jour., July 21, 1904. " Loc cit.

" Alg^rie M^dicale, 1870: also Rey. Syphilis trach6ale, Paris, 1874, quoted from Conner, loc cit.

26 OISBASES OF Till; fSROKClII

and wa3 followed by many similar attacks, during which the patient was for many hours unconscious, with barely perceptible pulse, while in the intervals she was quite well. In U of the cases collected by Conner' the patient died in a suffocative attack. In Wadsack's' 2 cases a sudden and fatal attack of suffocation terminated a period of comparative lienlth. Pain of a dull character and usually referred to the substernal region is at times observed. Dj'sphagia and aphonia may also be noted.

Unilateral bronchostenosis may be indicated by diminished respiratory motion, breathing, voice, whisper, and tactile fremitus on the affected side.

^rM

Diagnosis.— Tracheobronchial syphilis may be suspected when there is a history of the disease and such symptoms as cough, dyspnea, bloody sputum, or frank hemoptysis in the absence of otlier obvious cause. Manifestation of late syphilis elsewhere, especially in the upper parts of the respiratory tract, failure to react to tuberculin, a positive Wassermann test, and symptoms of tracheobronchial stenosis are important additional evidence. ■Foreign bodies in the air passages.

' Loc. cit.

■ Zwei pl&Uliche To(t<«{&11o i i IMS. mix. 211.

TUBERCULOSIS OF THE BRONCHI 27

tumors developing from the wall, and compression from without are most likely to oflFer difficulty of differentiation. Examination with the a:-ray will be of assistance in reaching a decision. Direct inspection by tracheoscopy or bronchoscopy may demonstrate ulceration and scarring of the trachea and bronchi. Such lesions are seldom due to other causes than syphilis, but neither the macroscopic nor the microscopic appearances can be regarded as establishing the diagnosis. Syphilis and tuberculosis cannot thus be distinguished, and only the demonstration of the spirochseta of syphilis is conclusive. In doubtful cases, therefore, the investigation of a small piece of excised tissue will be helpful.

Pro^n^osis. — Thus far the mortality has been high. In Vierling's* 46 cases death occurred in 39. In Conner's* 82 cases there were 58 deaths, giving a mortality of 76 per cent, in the two series. Pneumonia, a suffocative attack, hemorrhage from perforation of a large bloodvessel, exhaustion, or cardiac failure are the most common causes. The possibility of diagnosis by tracheoscopy and bronchoscopy during the early gummatous or ulcerative stage of the infection, and while treatment may still be effective, may be expected to favorably influence the chances of recovery. Tracheobronchial stenosis from firm, unyielding, and irremediable cicatrices is very unfavorable. The outlook is less hopeful the deeper down in the tract the syphilitic process occurs. The prognosis is worse w ith bronchial than with tracheal syphilis.

Treatment. — Chief reliance should be placed on salvarsan and mercury. The earlier the treatment is begun the better the chances of success. In 3 cases reported by Kehler,^ in which the diagnosis was made by bronchoscopy before the disease had advanced beyond the stage of gummata or superficial ulceration, cure was accomplished with little resulting stenosis. By bronchoscopic examination Halle^ saw gummata of the trachea disappear in fourteen days after the administration of 0.6 gram of salvarsan. Mechanical dilatation of a stricture has occasionally given relief, but is not unattended with danger. In the case reported by Seifert,^ cicatricial stenosis of the trachea and left main bronchus was almost completely relieved after ten weeks of almost daily dilatation of the obstruction.