C O N S U L T A T I O N 3oi

CONSULTATION

CASE BY GEOFFREY MARSHALL,

M.D.~ F.R.C.P.

Physician to Guy's Hospital and to the Brompton Hospital for Consumptives and Diseases of the Chest.

Ml~s. T., aged sixty-two, had been subject to attacks of spasmodic asthma for many years. She was a vigorous and dictatorial old lady with three daughters and several grandchildren.

For the relief of the asthma she had consulted a number of practitioners, in this country and abroad, until in December, 1934, she met with one who prescribed hypodermic injections of heroin. She became an addict to this drug, and from that time continued to have at least two injections daily. In the early months of 1935 she was feeling well, and arranged to leave England in order to visit friends in Bermuda. She embarked on a ship on April 2, and on the first day at sea had a shivering fit, and her mouth temperature rose to lO2.8 ° F. On the following day it swung from IOI ° to lO5 °, and this hectic pyrexia with maximum reading of lO4 ° to lO5 ° continued until April 12. In the meantime she developed a spasmodic cough, with occasional vomiting. On April 12 she coughed up a cupful of bright red blood, and the pyrexia was reduced to a lower level, averaging 99 ° in the mornings and ioi ° in the evenings. She was now troubled by pain above the left breast, which was accentuated by cough or a deep breath, and she expectorated about 5 ounces of sputum daily. The sputum came up in thick yellow lumps, and it had an unpleasant taste and smell. There were profuse nightsweats, and during the last three days of the voyage she suffered from diarrhoea. On reaching Bermuda she was taken to hospital, where the diarrhoea ceased, but the other symptoms continued, and after a week she embarked on another boat and returned to England.

When seen in London on May 14, 1935 , her general condition was very fair, despite the swinging pyrexia and copious purulent expectoration.

There was no cyanosis or cedema, and the fingers were not clubbed.

3o~ T H E B R I T I S H J O U R N A L OF T U B E R C U L O S I S

The mouth and throat were clean, no enlarged lymph glands could be felt and nothing abnormal was detected in the abdomen or in the urine.

The chest was barrel-shaped, and movement was diminished on the left side. Resonance was impaired over the front of the left chest from the third to the sixth ribs. Air-entry was diminished in this part of the chest and mgophony was present. The sputum contained pus and gave a profuse growth of pneumococci. No tubercle bacilli and no elastic fibres could be detected. A blood-count recorded i2,ooo leucocytes per cubic millimetre, with a relative increase of polymorphonuclear cells.

Lung abscess was diagnosed, and skiagrams of the chest taken on the following day were confirmatory. These showed an opaque area above the outer half of the interlobar septum of the left lung, with a poorly defined cavity in the midst of the opacity. Bronchoscopy showed pus in the left upper lobe bronchi, but there was no evidence of growth or foreign body.

Under expectorants and postural drainage little improvement was achieved, so after ten days the chest wall was incised over the superficial aspect of the abscess, portions of two ribs being removed. Lung and chest wall were found to be firmly adherent, so the abscess was laid open and a large drainage tube inserted. There was a rapid improvement in the patient's condition, and she has been in fair health ever since. The wound in the chest wall was allowed to heal after three months, but there has always been an ounce or more of purulent but inoffensive sputum each day, doubtless indicating bronchiectasis in the neighbourhood of the original abscess.

Summary.

The symptoms at onset were characteristic of lung abscess; a rigor followed in due course by hzemoptysis and foul sputum. Its causation is worthy of consideration. I have seen several asthmatic patients with lung abscess, and in two instances this followed administration of atropine. I attributed the abscess in those two cases to bronchial obstruction brought about by a plug of sputum. Chevalier Jackson has shown us how remarkably viscid the sputum of asthmatics tends to be: and the administration of atropine would be likely to increase this viscidity. The question arises whether in the present case the heroin might have contributed to the disaster by de- pressing the cough reflex, thus preventing the dislodgement of a plug of sputum which was obstructing one of the smaller bronchi.