A Pathological Condition of the Lungs Hitherto Undescribed in this Country, but which is not Infrequent. F. PEYRE PORCHER, A.8., M.D., BY ONE OF THE PHYSICIANS TO THE CITY HOSPITAL, CHARLES- TON, S. C. Recfd in the Section of ClhsfeJaict anti. Diseases of IV-omen, at the Forty-second Annual Meeting of the American Medical Associa- tion, held at Washington, D. C., May, i&gi. Reprinted from the “Journal of the American Medical Association,” June 6, 1891. PUBLISHED AT THE OFFICE OF THE ASSOCIATION. CHICAGO; iBgi. A PATHOLOGICAL CONDITION OF THE LUNGS, HITHERTO UNDESCRIBED IN THIS COUNTRY, BUT WHICH IS NOT INFREQUENT. F. PEYRE PORCHER, A.8., M.D., ONE OF THE PHYSICIANS TO HOSPITAL, CHARLESTON, S. C. During the course of a very prolonged service in hospitals, I have repeatedly observed a condi- tion of the lungs which is markedly distinct and characteristic, which I have not seen described. A full account of this appeared in the New York Medical Record, October 19, 1889. I will give here a succinct review of the main features and symptoms, in order that we may decide whether it is only a pathological .state, or wheth- er it should rank as a distinct disease. Patients presented the following symptoms: Dulness or sub-dulness, generally at the middle, lateral or posterior portions of the chest; there was always imperfect respiration; scarcely any rale present, or if so sparsely disseminated, and generally the subcrepitant; or perhaps there was only rough breathing. The condition was con- sequent on antecedent morbid states, and was 2 discoverable weeks before death, if a fatal result ensued. There was not necessarily fever or ele- vation of temperature; there did not exist evi- dence of any acute inflammation, or any of the well-known diseases of the chest—no phthisis, pneumonia, bronchitis, pleurisy, emphysema, by* drothorax, etc. The positive physical signs of these diseases were all absent—there were no crepitant, or sibilant, or crackling rales; neither were there pain or rubbing sounds. So all the diseases which these signs indicated had to be excluded. To continue the citation of positive and nega- tive symptoms: The respiratory murmur, though not normal, was not absent, for the lung was still pervious to air; the vocal resonance, or what I prefer to call the reverberation of voice, was slightly affected; some complementary respira- tion might be present, but this was not very de- cided, because there was no absolute consolida- tion. Scarcely any dyspnoea may exist, and the cough be moderate or absent. Hepatization, solidification and asthma had also to be excluded, for there was no absolute dulness, complementary or puerile respiration characterizing the two first, or crepitant rales to indicate the last. The crep- itant rale, the fever or the rusty-colored sputa essential to pneumonia were not present. There were no frothy, watery, blood-stained expectora- tion, blueness of lips, lividity, or cold extremities, as in extreme cases of oedemas; no pure hyperae- mia—for in our cases we have blood and serum 3 mixed; no pulmonary congestion, for there is “no copious, watery, blood-stained expectora- tion ” which accompanies this, which is, besides, an acute disease. Whenever an autopsy was afforded in such cases, the physical evidences of the diseases above cited were absent, and there was invariably preseyit a large amount of bloody serum exudingfrom the cut surfaces, and it would flow mostfreely when the lung was squeezed. Here was plainly, there- fore, a gross morbid fact which was the chief feature, which had to be noted and accounted for, and which, if a name was required, must neces- sarily be embraced under such appellation. The conditions with which our cases would be most likely to be confounded would be the hypo- static congestion, or the hypostatic pneumonia of recent authors, or infiltration of the lungs. But there are none of the physical signs of pneumo- nia present; and the term infiltration is too vague and undefined—-for infiltration may either follow pneumonia or be tubercular, and our cases were neither of these. We must also decidedly exclude the term hy- postatic congestion in the old sense of the term, which implied a condition of stasis just preceding death, dependent upon recumbency, position, etc. A name was needed for the symptoms which had been isolated, and I long since began to des- ignate the disease referred to as “ Engorgement of the lungs’’—serum being always mixed with blood. I was compelled to the use of these terms 4 because they only were true, applicable, and essen- tial in describing and interpreting the condition. My cases of engorgement of the lungs exist for days and weeks, and do not depend, as was stated, upon the accidences of position, recumbency, sta- sis of the blood, age of patient, or want of vital- ity—for the powers of life are not specially en- feebled. I published a note in the Ainerican Journal of the Medical Sciences, as far back as October, 1869, under the caption: “Frequency of Serous En- gorgement of the Eungs,” but have at last been able to get some confirmation of the probable correctness of my observations in Juergensen’s paper entitled “Diseases of the Respiratory Or- gans” (Ziemssen’s Cyclopaedia, Vol. v, p. 236). In this Piorry is quoted as having pointed out a distinct form of disease, corresponding in great measure with my own observations as stated above. It is best to quote what Juergensen says (Joe. cit, Sup.): “Hypostatic pneumonia, and hypo- static conditions of the lungs, were first recog- nized as a distinct form of pulmonary disease through the labors of the French writers. Pre- eminent among them is Piorry, who handles the subject with great clearness, and whose teachings are based upon a rich experience. He likewise gave the disease its name.” “ Piorry proved by experiments that a hypostatic condition diagnos- ticated during life, did not alter its location after death, under the laws of gravitation. As Piorry made his diagnosis long before death, it was evi- 5 dent that this condition did not result during the death struggle. By means of these experiments hypostasis ceased to be a condition of but little path- ological significance To quote still from Juergensen : “Does an inflammation of the lung actually exist ? Is the term ‘ hypostatic pneumonia’ correct? Here we must agree with Piorry, who answered this ques- tion in the negative in his nomenclature, and afterwards still further confirmed this opinion.’’ “ He calls this form of diseaszpneumoyiemie hypo- statique, and gives as a synonym engouement pul- monaire." vSo I am sustained by Piorry, not only as re- gards the existence of a special disease, and in the non-existence of an inflammation of the lung, but also in the use of the identical designation, engouement pulmonaire, which may be equivalent to “engorgement of the lungs.’’ Desiring to be brief, I will yet introduce the following from the paper cited above, and which may be compared with my own observations: “The local symptoms of hypostasis demonstrable by physical examination are the following; At first diminished resonance on percussion, begin- ning at the lower angle of the scapula, and on auscultation a lessening, sometimes a cessation, of the respiratory murmur, which is vesicular, or may be quite indefinite in character. At the point of attack the local fremitus is weak. If hypo- stasis is complicated with a local catarrh, new features foreign to the former disease will appear. u 6 Mucous rales, for example, are usually absent in simple hypostasis. The dulness on percussion and the auscultatory signs, as a rule, extend slowly from below upwards. There is a period at which absolutely no breathing is to be heard over the consolidated portion (Piorry). Then mucous rales gradually become audible, those in the larger tubes appearing first. In case of a fatal termination extensive oedema of the lungs super- venes, accompanied by auscultatory signs pecu- liar to that condition.” I have not been able to confirm this latter *observation, never finding the crepitant rale, which Taennec taught us is dis- tinctive of oedemas, as it is of pneumonia, and the congested area around a haemorrhagic spot. Piorry does not mention the causes of the con- dition he describes. In my paper in the Amer. Jour, of the Med. Sciences, I described them as “the result of neglected catarrhs, previously ex- isting bronchitis, or pneumonia in a chronic form, and sometimes the engorgement is partly hypo- static; but this terra should be reserved for post- mortem changes, or those occurring just before death.” Both of us, therefore, recognized and marked out a collection of symptoms which are often found associated, but which had not previously been designated as characterizing a special dis- eased condition. This collection, in my opinion, can have no other name than “ engorgement of the lungs; ” and all such terms as pneumonias, 7 hyperaemias, congestions, oedemas, etc., must be rejected, The merit of Piorry consists in his freeing hy- postatic processes from the imputation—ancient and deep grounded in all writings—of occurring just before death; and giving it its true place as a diseased condition of variable duration, to be recognized during life. If my cases of engorgement of the lungs are alleged to be only forms of hypostasis, which I do not believe to be true, I also recognized them as unconnected with position, the decubitus, or the death struggle, defined their ante- and post- mortem characteristics, as existing and to be studied and treated long before dissolution. Auscultation and percussion being a true sci- ence, founded on variable physical and morbid conditions, there is no obscurity or difficulty about the symptoms furnished by the disease we are dis- cussing. These symptoms, as in every other af- fection of the chest, arise out of and correspond necessarily with the internal morbid changes which exist, viz.: engorgement of the lungs.