Pulmonary Gangrene. By Moreton Stille, M. D., of Phila-
delphia.
In the thirteenth volume of the Prague Quarterly Journal of
Practical Medicine, maybe found an article upon Pulmonary Gan-
grene, by Dr. Fischel, physician to the Insane Asylum of the city
of Prague. It is one of those valuable contributions to medical
literature, which, from being in a language not generally under-
stood, is not available to the mass of English readers. As, how-
ever, it relates to a subject rarely submitted to extended investiga-
tion, and contains many interesting observations, we propose to
make use of it as a basis for the remarks we have to offer on this
subject, and compare the opinions of the author with those of other
writers. The disease treated of, although a rare one, is at the
same time of much pathological interest, and on account of its in-
frequency is not as well understood as it ought to be. Reports of
the nature of that prepared by Dr. Fischel deserve to be made
generally known, for it is by such laborious investigations that
the bounds of our science are enlarged, and a wider field of profit-
able study reclaimed.
In the space of six years, viz., from 1840 to 1845 inclusive,
there were made, at the Prague institution for Morbid Anatomy
3437 autopsies. Of this number, 3102 came from the General
Hospital, the Lying-in and Foundling Hospitals, and 335 from the
Insane Asylum. The cases of pulmonary gangrene among the
former were 55, among the latter were 25, which is a proportion
among the sane of 1.6, and among the insane of 7.4 to every 100
autopsies. This excess of cases among the insane was constant
in each year, a fact which seems to preclude the idea that the great
mortality from gangrene of the lung was due to an epidemic in-
fluence. The form of insanity was melancholy in 12, epilepsy in
5, mania in 4, and in 4 idiocy.
Dr. Fischel considers that this predominance of the cases among
the insane, shows a greater liability to the disease upon their part;
an opinion which is in harmony with the views of Genest and
Guislain. He thinks also that its more frequent occurrence among
those suffering under the depressing forms of mental disease, con-
firms the idea of its being dependent upon an impairment of the
nervous energy, but does not venture to locate this supposed lesion,
as some have done, in the pneumogastric nerves. Its exciting
cause in the majority of his cases was insufficient and improper
food. Others enumerated were loss of blood, abuse of ardent
spirits, great physical exertion, and prolonged venereal excess.
This statement gives, of course, but a very imperfect view of the
etiology of gangrene of the lung. The persons who came under
Dr. Fischel’s observation were insane, and confined in a public
charitable institution, their energies were exhausted by poverty,
excess and actual disease, as well as by prolonged confinement,
and voluntary abstinence from food. It is not difficult, therefore,
to perceive how all these causes may have concurred to produce a
condition of the system favoring the development of gangrene. It
would not be correct, however, to regard them as the ordinary
causes of the disease as it occurs in persons not under the same
unfavorable hygienic circumstances. If its incidental development
in the course of diseases of a typhous character be excepted, it will
be found that it usually occurs under the influence of exposure to
cold and dampness, during periods of depression following great
excitement either of a mental or bodily nature. It cannot indeed
be denied that there is a certain kind of constitution in which it
seems to be more readily developed than in others, but it is very
difficult to describe it. Schbnlein says that it attacks principally
young people of delicate skin and florid complexion, who have
given themselves up to an intemperate course of living. Canstatt
collected twenty-two fatal cases, in sixteen of which the constitu-
tional strength of the patient was noted, and twelve of them are
described as being remarkably healthy persons. (Med. Clini/c,
Bd. 3.) Dr. Gerhard says that “ gangrene occurs in exhausted
subjects, either affected with diseases calculated to weaken the
powers of the system or enfeebled by a life of intemperance, but
there are exceptions to this rule. (Am. Journ. Vol. xviii, p. 301.)
It is probable that these statements which appear to be somewhat
at variance with each other, (and more of the same kind might
easily be cited,) result from the frequent want of correspondence
between the apparent muscular strength and the constitutional power
of resistance to disease. While the first remains but little im-
paired, the foundations of the latter may have been long secretly
undermined ; cases exemplifying this truth are of daily observation,
especially in our large hospitals, both in the medical and surgical
practice; it being no uncommon event, that men of large stature
and powerful frame, but of intemperate habits, succumb rapidly
under injuries or diseases, apparently of a trifling character.
Gangrene occurs in such persons most readily, being at one time
the consequence and at another the cause of phlebitis, or the index
of a general or of a local deficient vitality.
Dr. Fischel makes the usual division of pulmonary gangrene
into two kinds, viz., the circumscribed and the diffused. Although
Cruveilhier (Path. Anat. t. i. liv. ii.) thinks that both varieties are
equally common, we believe he is the only'writer of any authority
who expresses such an opinion. Lawrence out of sixty-eight cases
met with diffused gangrene only six times, and Laennec only twice
in twenty-four years. In the Report for the year 1848 of the
Vienna Institute of Morbid Anatomy, by Dr. Lauthner, we find
that 1069 post mortem examinations were made in the year, and
of this large number there were only five cases of gangrene of the
lung, one only of which was of the diffused kind. In Dr. Fischel’s
eighty cases there were but four diffused. Dr. Fischel’s results
confirm also the general impression that the disease occurs prefer-
ably in the lower portion of the lung, and chiefly in that of the
right side ; except, indeed, where it is consecutive to tubercular
disease, when it may occur, of course, in any part of the organ so
affected.
We have not met with any description of the forming stage of
pulmonary gangrene, drawn from actual inspection of the lung,
with the exception of a case reported by Dr. Gerhard (loc. cit.
Case VIII.) In this case, which was one of diffused gangrene,
the death of the patient took place at a very early period in the
disease ; the texture of the lung was not broken down, although
infiltrated with serum, diminished in consistence, and of a gangre-
nous odor. The later stages of the gangrenous process are well
known and may be easily recognised, but, in the absence of any
very positive knowledge of its mode of commencement, it is usual
and convenient to ascribe it to inflammation. It is very certain,
however, that not being an ordinary result of inflammation, it must
depend upon something extrinsic to this process, but not essential
to it. If inflammation does not really include (as it is sometimes
made to do) every possible morbid process, it is far more simple to
confine it within the limits of stasis and exudation, and to regard the
phenomena of resorption or of organization of the effused fibrin, as
processes of reparation, complementary to, but not parts of the
inflammation. And, in like manner, gangrene cannot be esteemed
a result of inflammation, unless, indeed, we are to receive the
etymological meaning of the word as the proper one, and consider
that the death of the tissue is due to a sort of combustion. Such
would seem to be the opinion of those, who speak of gangrene as
the result of excessive inflammation. There really exists no such
thing as too violent inflammation in this sense ; it is by its diffusion
that it becomes excessive or dangerous, since it cannot, in the
ascending scale, go beyond the limit of an effusion of a more or less
plastic material. When the blood vessels have been relieved, by its
discharge, the phenomena which follow, are those of repair, and this
process is more or less complete, according to the tissue affected,
and the constitutional strength of the individual. The sentiment
cannot be too often repeated, paradoxical as it may seem, that
inflammation is, essentially, a conservative process, and that when,
by interference with the functions of organs essential to life,
it becomes lethal, it is so, either by its extent or by the feeble
recuperative power of the patient. If grangrene supervene upon
inflammation, it is therefore to be attributed, not to the violence
of this, but to causes, which although difficult to appreciate, are
known to act by impairing or destroying the constitutional power
of resistance. The engorgement and hepatization which are found
around the gangrened portion of the lung cannot be regarded as
manifesting a prior stage of the process of mortification, but are
rather an indication of an effort made by nature, to throw up a
barrier against the extension of the disease, by which the dead
tissue is circumscribed and the source of the contamination isolated
from the rest of the organ. It is the same process, essentially,
which is seen in gangrene of the extremities, the progress of which
it is designed to limit; when it does not occur, it is plain that no
reliance can be placed upon the recuperative powers of the system.
We may seem to be begging the question if we assert that gan-
grene is never a result of pneumonia, but as the direct anatomical
proof of the fact cannot be procured, it is fair to refer to this as a
matter of general experience, that so common a disease as is
pulmonary inflammation, equally rare is gangrene of the lung, and
that if it be a consequence of violent pneumonia the fact is a
very remarkable one that it should occur so seldom. Indeed, all
authors who have given particular attention to this point, agree
that it does never succeed to a frank pneumonia; which is certainly
equivalent to an admission that if it depends at all upon inflam-
mation it is assuredly not due to an excess of it. Dr. Hodgkin
[Lectures—Mucous Membrane} says, that it “ generally if not
always, seems to require some peculiarity in the constitution of
the individual, rather than merely to depend on intense inflamma-
tion;” also, “ it sometimes affects small spots scattered through the
substance of the lungs; which quickly lose their vitality, without
the precurrence of the ordinary symptoms of inflammation of the
lungs.” Genest and Grisolle do not think that inflammation alone
can produce it. The latter has never seen it follow a well charac-
terized pneumonia. [Trait prat de la Pneumonie, p. 345.) Dr.
Gerhard [loc. cit.} says, “ In every instance in which the patients
were seen in the early stages of the disease, I could distinguish
the humid rhonchi, indicating bronchitis, or at least the secretion
of liquid into the bronchial tubes. There was in no instance,
bronchial respiration, dull sound on percussion, or other unequivocal
evidence of pneumonia—and in one case only was there even
reason to suspect that pneumonia may have preceded gangrene.”
Laennec (Dis. of Chest, p. 207) says, that “ it can scarcely be
ranked among the terminations of pulmonary inflammation, and
still less can it be considered as the consequence of its intensity.”
The opinion of some eminent pathologists, particularly of Carswell,
Piorry, Cruveilhier, and Schroedervan der Kolk, that the oblitera-
tion or obturation of the arteries of the lung, is the proximate
cause of pulmonary gangrene, is hardly tenable, and that for
reasons analogous to those we have offered above. This obtura-
tion, it is reasonable to suppose, is the consequence and not the
cause of the death of the pulmonary structure, and depends possibly
upon an inflammation of the minute pulmonary vessels, in conse-
quence of the reception of the corrosive products of the gangrened
portion- of the lung, as well as upon the effusion of plastic lymph
in the structure around them, by which they are compressed and
their canals effaced. Dr. Fischel justly observes, that this inflamed
state of the pulmonary vessels, has never been found as a primary
affection. But however easy it may be to assign valid reasons
against these views, it is by no means equally so, to say what is
the proximate cause.
Dr. Fischel, indeed, in the spirit of the German “ Krasenleliref
—or doctrine of erases,—feels satisfied with referring it to a hypi-
nosis, or to a deficiency of fibrine in the blood ; but this is not a
sufficient explanation for one very plain reason, viz., that this
condition of the blood exists in several other pathological states of
the system, in which, nevertheless, no gangrene occurs, or is
dreaded. The view advocated by Genest, and Dr. Law, of Dublin,
that it is a consequence of pulmonary apoplexy, seems to have much
in its favor; for it is not difficult to conceive, that the effused
blood, if it remain in the lung, may become putrefied by the action of
the air, and become the source of the disease in that part with which
it is in immediate contact. We believe that gangrene may origi-
nate in this manner, but there are many cases which cannot be
explained by it. Heemorrhage from the lungs is not unfrequently
one of the first signs observed, yet it is more common in the pro-
gress of the diseasethan at its beginning,—a result of its progress,
not' the force which sets it in motion. The opinion of Dr.
Stokes, always of great value, and particularly so in relation to
this disease is, that the accidental putrefaction of blood effused in
the lungs, cannot be reckoned even as an ordinary cause of pul-
monary gangrene.” He has not seen any cases of the change
from one of these diseases to the other; and is of the opinion that
where a pulmonary clot does become putrid, “ the change is in
itself a proof of gangrenous disposition pre-existing.”—Diib. Jour.,
Feb., 1850.
While it is of practical importance that the idea of the depen-
dancy of gangrene of the lung upon inflammation should be
combated, and its relation to pulmonary apoplexy considered
as exceptional, it is not necessary for a correct knowledge of its
treatment that an acquaintance with the exact nature of the pro-
cess should first be possessed. For, knowing that all those causes
which depress the nervous energy and vitiate the blood, may take
part in its production, and that it appears, at times, to originate in
consequence of the deprivation of sufficient nutriment, a rational
treatment can be founded thereupon. In Dr. Fischel’s cases, this
last cause played an important part, and a large and interesting
portion of his paper is taken up with a narrative of the means by
which he sought to remedy it. We do not propose to enumerate
these, nor the remedies recommended by various writers, as we
would thereby trespass too much upon the space allotted to us.
We have desired to call attention merely in a general way, to the
anatomical characters of this formidable disease, and would take
the liberty of referring the reader, for a minute account of the same,
to a translation of Rokitansky’s description in Copland’s Medical
Dictionary. In order to understand the interesting process by
which, in favorable cases, a cure is accomplished, we might bring
together the results of the observations of Dr. Fischel, and the
accurate clinical reports of Dr. Gerhard, before referred to. By
such a comparison it will be seen how beneficial is the result of the
inflammation surrounding the gangrened portion of the lungs; the
extension of the disease being limited by an exudation of plastic
lymph around the dead tissue. This exuded fibrin forms a wall of
various thickness around the cavity left by the separation of the
slough, and after the latter has been removed by expectoration, the
wa 11s of the cavity, in course of time, gradually contract and
approach each other, and sometimes finally unite, forming a dense
cicatrix in the spot formerly occupied by the gangrenous eschar.