INFLAMMATION AND ABSCESSES OF THE LUNG 
CAUSED BY 
CLOSURE OF THE PRIMARY BRONCHUS. 
BY CALVIN ELLIS, M. D. 
Communicated to the Boston Society for Medical Improvement, Sept. 8th, 1856. 
On February 29th, 1856, an intemperate woman was brought to 
the Massachusetts General Hospital, with a fracture of the left tibia 
and fibula, and a great effusion of blood into the thigh. With the 
exception of a tendency to delirium tremens, nothing remarkable 
occurred, until March 17th, when she was reported to have cough- 
ed much in the night. On the following day, duhiess and bron- 
chial respiration were detected in front, over the left side of the 
chest. The tongue was brown, dry and cracked. Pulse 80. On 
the 19th, the physical signs remained the same, and the patient de- 
clared that the expectoration had been of a reddish color, but no- 
thing of the kind was seen by the nurse or house-surgeon. Its 
appearance was not at this time, nor afterwards, in any way re- 
markable. On March 27th, the upper part of the left side of the 
chest, as she lay in bed, was more resonant, but on sitting up the 
dulness became universal. The prostration at first was such that 
the back could not be examined, but bronchophony was now' heard 
in the upper part, where there was an absence of fremitus. On June 
24th, the resonance was reported as much more marked in the left 
side of the chest. Here the record of the physical signs ceased. 
The cough in the mean time had been occasionally troublesome, but 
was not generally so. During two or three days, in the early part 26 
of April, there was considerable heat of the skin, and the patient 
was, a number of times afterwards, troubled with profuse perspira- 
tion. The pulse generally varied from 82 to 96. Pain was several 
times complained of in the lower part of the left chest, but, judging 
from the record, this was neither a prominent nor frequent symptom. 
From the first the debility was marked, but, as the fractured 
bones united, she was able to move about on crutches. On June 
29th, however, the pulse became quick, the perspiration profuse, 
and she was confined to her bed. On the 30th of August she was 
able to sit up, but on Sept. 5lh there was a marked loss of strength 
and appetite. On the 7th, she had a violent paroxysm of cough, 
raised herself in bed, expectorated two ounces of blood, and then 
expired, her mouth being filled with a dark, dirty fluid. 
Autopsy, 11 hours after death. The dura mater was flaccid. At- 
tached to, but easily separable from, the under surface of that por- 
tion covering the convexity of the brain, was a pretty firm, yellow- 
ish-white, semi-gelatinous layer, about a line in thickness. There 
was more serum than usual beneath the arachnoid. The substance 
of the brain was rather soft. 
The upper and posterior part of the left lung was firmly adhe- 
rent to the parietes, the uniting membrane being very old and 
strong. The remaining cavity was lined with an old, thick, irregu- 
lar false membrane, within which were found three pints of pus. 
Floating in this were a number of long cylindrical coagula, evi- 
dently recent, and moulded in some narrow passage. Several of 
these were also found hanging from openings in the false membrane, 
through one of which a probe passed into a cavity in the lung, to be 
described hereafter. The arch of the. aorta was considerably dilated. 
In the descending portion was an abrupt aneurismal dilatation, per- 
haps two inches in diameter, with a smooth, well-defined mouth of 
about half that size. At the bottom of the sac was an opening through 
which a probe passed into the left primary bronchus, at a point be- 
tween two and three inches from the bifurcation of the trachea. 
Above the opening was an old pale-red coagulum, which had appa- 
rently closed the passage, but the blood from the ruptured aneurism 
had forced its way into the trachea. The bronchi contained many 
coagula, and much dirty brownish fluid. The lung- was but five 
inches in length. Scattered throughout its substance were cavities 
from three lines to an inch in diameter, communicating freely with 
the bronchi, with the mucous membrane of which their rough, 27 
ragged walls were continuous. They also contained much dirty- 
brownish fluid and coagula. The intervening substance was quite 
firm, and of a dark-gray color, looking very much like pumice- 
stone. There was no tuberculous disease ; no pneumonia ; no 
gangrenous odor. It was evident that the coagula found in the 
pleural cavity had the same source as those in the air passages. 
Two ounces of serum existed in the right pleural cavity. The 
right lung was very large and fully distended with air. In its sub- 
stance were many bloody spots, evidently owing to the entrance of 
blood into the bronchi. The pericardium contained about two 
ounces of whitish serum. The heart was flaccid. Blood thin. 
There was one pint of serum in the peritoneal cavity. The arch 
of the colon was adherent to the parietes. 
The spleen was of large size ; weight, 101 ounces. 
The kidneys were large. 
The condition of the lung was considered very interesting in 
connection with the closure of the primary bronchus. It. may, 
however, be maintained that, as the rupture took place below the. 
coagulum and was followed by haemoptysis, there could not have 
been complete closure ; but it is evident that the blood forced 
its way beyond the obstruction, at the lime of the accident, 
as it was only after this that the mouth was filled with the dirty 
fluid, found in such abundance throughout the lung. Nor is the 
existence of bronchial respiration incompatible with complete clo- 
sure, for it is well known that sounds formed in one side of the 
chest may be heard in the other, and the dense tissue of the left 
lung might readily transmit a sound formed in the lower part of the 
trachea or right primary bronchus. 
The appearances, in this case, recalled a similar one, seen a num- 
ber of years since. The examination was made by Dr. J. B. S. 
Jackson, to whom I am indebted for the following facts. 
The patient was perfectly healthy before his last illness, and was 
engaged in active business, in which he had exerted himself more 
than usual. While in California, in the latter part of May, 1848, he 
went to bed as well as usual, and awoke in the morning with dysp- 
noea and a sense of oppression about the upper part of the sternum 
symptoms which never afterwards disappeared. On Dec. 10th, he 
returned to Boston, having borne the journey across the Isthmus pret- 
ty well, though much reduced in general health. Examined three 
days afterwards, the pulsations of the heart were felt more towards 28 
ihe right side than usual. The pulse was the same in bolh wrists. 
A pulsating tumor or fulness was found about the cartilage of the 
second left rib, where there was dulnesson percussion. The respi- 
ration was feeble over the whole of the left side of the chest, and a 
click was heard in forced inspiration. 
During the last three months of his life he was confined to his 
bed, lying most easily on his back, the dyspnoea not being urgent, 
though increased if he sat up in bed. Through the winter, there 
was a slight cough, attended by a little frothy expectoration. 
Five weeks before his death he suddenly raised half a pint of 
pus, and from that time expectorated the same copiously. He 
would sometimes speak of oppression in his chest, turn upon the 
right side, expectorate a large quantity of pus, obtain relief, turn 
back and go to sleep. The tumor about the second rib disappeared 
after the pus was first raised, and never returned. 
Two weeks before death an abscess pointed, not far from the 
outside of the left nipple. On the following day it was punctured, 
and about a quart, of offensive pus discharged. The expectoration 
then ceased. Finally, on the 6th of April, 1849, after being raised 
in bed by an assistant, he expectorated a little blood, a gurgling 
was felt in his chest, and he expired ; two or three ounces of fresh, 
frothy blood flowing from the external opening. 
At the examination, the body was found much emaciated. 
Rising from the arch of the aorta, and involving the whole cir- 
cumference with the exception of a strip, perhaps three fourths of 
an inch wide, from which the pervious brachio-cephalic trunks arose, 
was a rounded aneurismal tumor, of the size of an orange. Its 
cavity was filled with fibrine, whitish, in layers and rather soft. 
'The parietes of the sac were, in some parts, continuous with those 
of the aorta, and contained many patches, presenting the same ap- 
pearance as the wall of the vessel itself. In some places the parie- 
tes were entirely destroyed, and, where the sac approached the left 
primary bronchus, it had sloughed, or was about sloughing, to the 
extent, perhaps, of three fourths of an inch. 
The right branch of the pulmonary artery was much compressed. 
The left lung was the seat of an abscess extending from the apex 
to the base, containing a thick and rather bloody fluid. What lit- 
tle remained of the lung consisted of a solid, crumbling, gray sub- 
stance, projecting most irregularly into the cavity of the abscess. 
There was no gangrene, nor any offensive odor. The pleural cavi- 
ty was entirely obliterated. 29 
rphe left, primary bronchus must have been pushed back, as it was 
cut into during the removal of the oesophagus. The parietes were 
soft and discolored, and the cartilaginous rings to a considerable 
extent detached, standing up like the ribs of a boiled fish. The 
lower portion of the trachea was of a deep-red color, and the seat 
of what appeared to be minute ulcers. 
In the right pleural cavity were about three pints of fluid. The 
lung contained a few gray granulations in the upper half, but was 
in other respects healthy. 
The other organs were not remarkable. 
In remarks appended to this case, the peculiar condition of the 
lung and its connection with closure of the bronchus, are particu- 
larly alluded to by Dr. Jackson, who refers to a similar case which 
occurred in the Hospital many years before, an account of which 
we here subjoin. 
A man 30 years of age entered the Massachusetts General Hospi- 
tal on July 251h, 1835. Five months before, he was attacked, 
while in Liverpool, with severe pain in the abdomen, which lasted 
for three months. A fortnight after its disappearance, while on his 
way to this country, he was again seized with severe pain in the 
epigastrium, which continued until he entered the Hospital, and 
was then accompanied by tenderness on pressure. For a month, 
he had been troubled with a dry, harassing cough, by which the 
pain was increased. Much heat in the night, but no chills. No 
appetite. He was obliged to give up work on July 19th, and never 
resumed it. 
When first examined, there was a sibilant rale in both backs, and 
several days after, a strong mucous rale in the trachea; but the 
physical signs reported during a number of weeks were so variable 
and contradictory, that it was thought best to omit them. As early 
as August 10th, however, the respiratory murmur was much louder 
in the right side than in the left. On Sept. 2d, the lateral part of 
the left chest was more resonant than the corresponding portion of 
the right, but, behind, the lower part of the left back was less reso- 
nant than that of the right. On Sept. 10th, there was dulness on 
percussion over the whole of the left back, while the resonance over 
the right back was good. On forced inspiration, the murmur was 
distinct over the left side. On Oct. 3d, the left side of the chest was 
perfectly flat on percussion, with the exception of the axillary re- 30 
gion, where there was slight resonance. The two sides of the 
chest presenled the same appearance, with the exception of a little 
variation, incidental 1o a slight lateral curvature of the spine. On 
Oct. 23d, the respiratory murmur in the upper part of the left back, 
near the spine, was as strong as on the opposite side, and somewhat 
coarse, but was, elsewhere, inaudible. When lying on his back, 
the respiration was quite audible above the nipple, with bronchial 
respiration, particularly at the upper and inner parts; slightly audi- 
ble, also, at the lower part, but not at all decided. The left side of 
the chest was at this time the smallest, measuring, just below the 
mamma, one fourth of an inch less than the right ; while lower 
down, the difference was a little more marked. On Nov. 161h, 
however, the left side appeared to be enlarged, and the intercostal 
spaces, in some measure, tilled out. Still later, there was flatness 
on percussion, over the whole of the left side of the chest, which 
could be reached, with the exception of a region five or six inches 
in diameter, extending from the seventh rib to the cartilage of the 
twelfth, and from a vertical line through the nipple backward five 
or six inches. This part was tympanitic. No respiratory murmur 
was here heard, but occasionally gurgling, or a sound almost me- 
tallic. The voice was several times reported as modified on the 
diseased side. 
While these changes were taking place in the chest, the cough 
continued in frequent, severe paroxysms. At the time of his en- 
trance, it was spoken of as a little like that of laryngitis. The ex- 
pectoration was at first reported as serous, white and frothy, after- 
wards as mucous, then as opaque, and twice there was a gruel- 
like deposit. The quantity was seldom noticed, and when so, varied 
from two to four ounces. Blood was occasionally seen, and during 
the last month became almost constant, but the quantity was never 
large. For the first few days, he complained of great dyspnoea, 
but soon obtained relief, and though it remained afterwards a con- 
stant symptom, was only occasionally spoken of as urgent. There 
was much pain in the left side of the chest and in the epigastrium. 
The tongue, though at first slightly coated, soon became clean and 
continued so until the close. The appetite was generally good. 
Though frequently troubled with profuse perspiration, febrile heat 
of the skin was noticed but twice. The pulse generally ranged 
from 84 to 96, occasionally falling below or rising above these 
points. On Sept. 30th, he was reported to have lost flesh, but a 31 
tmonlh after he had apparently gained. During the greater part of 
the time he was able to move about, and on Oct. 29th walked in 
the yard twice. 
On the 26th of November, after a violent paroxysm of coughing, 
he was seized with copious haemoptysis. When first seen, he was 
sitting in a chair, having risen at the commencement of the attack. 
In five minutes he was unable to support his head, and gasped for 
breath, while the blood poured from his month and nose. In twelve 
or fifteen minutes the pulsations of the heart had ceased. 
At the examination, made by Dr. J. B. S. Jackson, there were 
found, on the left side, old and very strong pleural adhesions, uni- 
versal except at the apex, where there was a cavity containing a 
few ounces of liquid, which had depressed the lung at this part. 
The false membrane was from one to two or three lines in thick- 
ness, for the most part soft, reddish, striated, and so infiltrated with 
serum as to appear gelatinous. 
The lung- was much smaller than the other, and dense to the feel. 
Al first view, it seemed to contain numerous small abscesses, but 
on close examination these were found to be mostly owing to dilat- 
ed bronchi, those of the smaller size being, perhaps, three or four 
times as large as natural, while the larger were little, if at all, dilat- 
ed. The inner surface of most of them was rough, and, in many 
others, was a little soft yellowish lymph. There were, however, a 
few small abscesses, lined with a yellow curdy substance, and open- 
ing rather abruptly into the bronchi. All of these cavities were 
filled with thick reddish pus, mixed with some dark coagulated 
blood, but the latter was much the most abundant in the right lung. 
The disease occupied, mostly, the centre and back part of the or- 
gan. The intervening portion contained no air. The tissue about 
the apex was grayish, dense, and semi-transparent ; towards the 
base more red, but, examined with a lens, was found to be mixed 
with much of the same grayish substance, found at the apex, where 
were several small, white, opaque bodies resembling tubercles, but 
which Dr. James Jackson thought were not so. Just outside of the 
lining membrane of the dilated bronchi there was, in many places, 
a layer of opaque, yellow, curdy substance, like that already no- 
ticed. A portion of the lung was also examined by Dr. John 
Ware, who found no trace of tubercle, and observed the same ap- 
pearances described above, with the exception of the abscesses, 
which the part examined by him did not happen to contain. Four 32 
aneurisms of 1 lie aorta were found : one, one third of an inch in 
diameter, al the arch ; another of large size, just beyond, and two 
at the entrance of the vessel into the abdomen. The largest com- 
menced at the point of origin of the left subclavian artery, and ex- 
tended two and one third inches along the course of the thoracic 
aorta. It was of the mixed kind, and would contain, perhaps, four 
ounces. Upon the right side of this were engrafted two false aneu- 
risms, the upper about two thirds of an inch in diameter, closely 
connected with the membranous portion of the trachea, just above 
the bifurcation. The second was situated just below, was some- 
what. larger and thicker than the first, and contained a thin layer of 
fibrine and coagulated blood. It lay upon, and was very intimately 
connected with, the left primary bronchus, just below the bifurca- 
tion of the trachea. This bronchus, which was not at all compress- 
ed or flattened, appeared to be filled by a firm coagulum, an inch 
and a half in length, consisting partly of fibrine, partly of recent 
blood, and evidently formed before death. The coagulum separat- 
ed, for the most part, easily from the inner surface of the bronchus, 
leaving it, however, rough. Near its upper termination, there was 
discovered at once an opening into the aneurism, through which a 
common director was readily passed. It was filled by a dark re- 
cent clot. 
Upon the right side there were universal old adhesions. The 
lung was scarcely at all collapsed, the anterior edge extending to 
the median line, and the upper lobe even beyond it. It was healthy 
in its structure, except for some stnall dark ecchymoses. No tuber- 
cles. The bronchi contained much coagulated blood, but were not 
dilated. 
'The cartilages of the larynx were ossified. The pericardium 
contained three ounces of clear yellow serum. The heart lay fur- 
ther to the left side than usual, but was normal, with the exception 
of some thickening of the parietes of the left ventricle. 
There were extensive old peritoneal adhesions. The spleen was 
large, and covered with a thick, dense, white, opaque coat. 
Struck with the similarity of these cases, it was thought that 
others like them must have been noticed, and, on examination of a 
large number of journals, two were found. Others undoubted- 
ly exist, for it is hardly possible that, exposed as the bronchi are 
to closure from various causes, it should not have oftener taken 
place. 33 
A brief summary only is given, as the details may be found in 
the journals referred to. The first is reported by Dr. Banks, in the 
Dublin Quarterly for August, 1851. 
The patient was a tailor, 40 years of age. On percussion, both 
lungs appeared equally resonant posteriorly, but the respiratory 
murmur in the left was extremely feeble. The whole of that side 
afterwards became dull, and no respiration was heard in any part of 
it. He died of an attack of diarrhoea. 
An aneurism, of nearly the size of a cocoa-nut, involved that part 
of the arch of the aorta from which the left carotid and subclavian 
arteries arose. It pressed backwards upon the oesophagus, and was 
mostly imbedded in the upper part of the left lung, " upon the root 
of which it impinged." The lung was universally adherent, except 
near the base behind, where were found eight ounces of pus. It 
was in a " cirrhosed " condition, tough, gristly, and riddled with 
small abscesses, varying in size from that of a walnut to that of a 
pea. The right lung was healthy. The large intestine was exten- 
sively ulcerated. 
This case was reported on account of the atrophy of the laryn- 
geal muscles on one side, but the peculiar condition of the lung 
excited no remark. 
The second case may be found in the Medical Times and Gazette 
for Sept. 11th, 1852. A man, 51 years of age, was admitted as an 
out-patient of St. Thomas's Hospital on Jan. 3d, 1852. Three 
weeks before, a swelling as large as a marble was noticed under 
the right clavicle. There was a severe cough and dyspnoea, the 
difficulty of breathing being increased by exertion. He could not 
lie down comfortably at night, sometimes not at all. On Feb. 9th, 
the respiratory murmur was attended by a loud ronchus. On 
March 8th, there was decisive evidence of a tumor pressing upon 
the left bronchus, for, while that side was resonant on percussion, 
the respiratory murmur was wholly abolished, a slight rale only 
being perceptible after forced inspiration. On May 27th, he was 
seized with pain in the throat and difficulty of swallowing, and 
vomited everything taken. On the 31st, he had a severe paroxysm 
of coughing, and vomited blood mixed with pus. Afterwards he 
was able to swallow small portions of food. The dyspnoea was 
so great, that he could scarcely lie down, and, at intervals, he 
coughed, and expectorated bloody matter. The respiration in the 
right side was very audible ; in the left it was attended by general 34 
crepitus, and the side was dull on percussion. He died on the 
2d of June. 
At the autopsy, on the following day, there was found a very 
large aneurism of the ascending aorta, which had pressed some- 
what upon the left primary bronchus; but the real cause of the 
closure of the latter was a collection of pus, contained within a 
cavity lying between the bronchus and oesophagus, into each of 
which it had opened. The mucous membrane of the bronchus was 
very dark colored, and, in places, deeply ulcerated. Apertures of 
considerable size established a communication with the abscess. 
The latter probably originated in one of the bronchial glands, as 
those adjacent were soft and apparently passing into suppuration. 
'The left lung was, throughout, adherent to the parietes, entirely so- 
lidified and passing into the stage of purulent infiltration. In some 
portions, more especially at the lower and posterior margin, it was 
studded with numerous small cavities, containing pus and gangre- 
nous pulmonary tissue. These cavities had probably originated in 
the smaller bronchial tubes, as the mucous membrane was every- 
where of a deep leaden hue, and, in places, ulcerated. The tubes, 
especially those of small size, contained much dark offensive secre- 
tion. The right lung was congested, but not otherwise diseased. 
Heart normal. 
These cases vary in some respects : in three there was more or 
less pleuritic diseasey in one the bronchi were dilated ; and in one, 
gangrenous tissue was spoken of, but certain features are common 
to them all. In every one the left primary bronchus was closed, 
and there is as great a similarity in the descriptions of the corres- 
ponding lung as could be reasonably expected from independent 
observers, who had no special point, to establish. Moreover, this 
closure was not caused in every instance by pressure, but, in two of 
the cases, by a coagulum which filled the bronchus. We may, 
therefore, safely assert that the disease was not the result of com- 
pression of the bronchial arteries, or of other parts, upon the in- 
tegrity of which the healthy condition of the lungs depends, but of 
the interruption to the entrance of the air. Taking this view, the 
following explanation does not seem unreasonable. 
The circulation in the capillaries of the lungs is, probably, mostly 
dependent upon the interchange of elements between the blood 
and the air. The bronchus being closed, there is, therefore, an ab- 
sence of the physiological conditions upon which this circulation 35 
depends, and stagnation is the result. Now, here, as in other parts 
of the body under similar circumstances, inflammation is excited 
and extends to the surrounding tissues. In other words, the pri- 
mary disease, is capillary phlebitis. It might seem that where such 
extensive obstruction of the smallest vessels exists, the large trunks 
should also be plugged ; but in the second case, where nearly the 
whole lung was destroyed, nothing of the kind is mentioned, which 
proves that the obstruction may be very general in the capillaries 
without extending to the primary branches of the pulmonary 
artery. 
However, this is only a theory, and the cases were not brought 
forward for the purpose of introducing it. They were intended 
to show that, in consequence of the closure of a primary bronchus, 
the lung may become inflamed, suppurate, and finally be destroyed. 
Of this fact no mention is made in any work on pathological 
anatomy, as far as has been ascertained. Dr. J. B. S. Jackson, 
in his private notes as above stated, speaks of the changes in the 
lung, and of its connection with closure of the primary bronchus; 
but in neither of the cases reported has it attracted attention as 
anything striking or peculiar.