262 THE INDIAN MEDICAL GAZETTE [May, 1942

LUNG ABSCESS

By WAMAN DATTATRAYA SULAKHE, m.b.,

b.s. (Bom.), m.r.c.p. (Lond.), f.r.f.p.s. (Glas.), t.d.d. (Wales)

Honorary Assistant Physician to Sir J. J. Hospital and Tutor in Medicine to Grant Medical College,

Bombay

Abscess of the lung is aptly defined by Max- well (1934) as 'non-tuberculous suppuration with cavitation occurring in the lung tissue \

Nowadays, it is generally agreed that abscess and gangrene of the lung clinically are different stages of the same pathological process which is likely to appear under certain conditions. The

stage of the suppurative process will depend upon the virulence of the infection and resist- ance offered by the patient. Thus, when the infection is highly virulent and the patient is

debilitated, he is likely to develop gangrene; while if the infection is mild and the resistance of the patient good, he will probably have the comparatively localized intra-pulmonary suppu- ration called the abscess of the lung. The purpose of this paper is to report the

findings of the study of 53 consecutive case-

records of lung abscess that were admitted in Sir J. J. Hospital, Bombay, during the last six years, from 1936 onwards. The condition is known from ancient times,

but it seems that with increased facilities at

our disposal for its diagnosis and careful clinical observation has led us to suppose that it is

occurring more commonly these days than before. The increase is not real but only apparent. The diagnosis is helped very much by the radiological examination of the chest which has now come to be a routine in chest

cases wherever it is available. Thus, the yearly incidence in the present series was as given in the table below :?

1936 1937

6

1938

10

1939

14

1940 1941

(up to Oct.)

13

One can only say that we are more correctly diagnosing lung abscesses nowadays than before. This series includes all cases of non-tuberculous

intra-pulmonary suppuration, and so the abscesses secondary to new growth and bron- chiectasis are not excluded from these.

AEtiology Age Abscess of the lung can occur at any

age from infancy to old age. The present series includes patients only above 13 years of age and the incidence was as follows :?

10-20 20-30

10

30-40 | 40-50

17 17

50-60 60-70

The youngest patient in this series was

14 years of age and the oldest was 66 years. The maximum incidence (64 per cent) was found from 30 to 50 years. Sex incidence.?The abscess of the lung is

more common in males than in females. There were 50 males and only 3 females in the present series.

The lung abscess commonly occurs either as

a post-operative complication or as a result of inflammation of the lung. Rarely, it may oc- cur secondarily to chest injury, actinomycosis, amcebiasis, pneumonokoniosis or new growth. Regarding the pathogenesis of post-operative abscess there are two schools of thought. One thinks that the aspiration of the septic material during operations on the upper respiratory passages plays the chief role in the causation of lung abscess, whilst the other thinks the embolic phenomena to be the chief mechanism. The operation chiefly blamed is tonsillectomy. Maxwell (loc. cit.) has reported that lung abscesses occur frequently after abdominal operations also. In a recent paper, Shah (1939) found only 4 cases out of 50 as due to aspiration and embolism. Taylor et al. (1940) while reporting 7 cases of lung abscess support the contention that post-operative lung abscesses are seen to be much less in this country. Fisher and Finney (1940) found that only 15 per cent of 88 cases of lung abscess could be attributed to post-operative complications, whilst pneumonia, broncho-pneumonia and upper respiratory infections were responsible for 49 per cent of

the cases in the above-mentioned series. Shah also found that the incidence of abscesses

secondary to pneumonia, broncho-pneumonia and respiratory infections was 42 per cent in his series of 50 cases.

In the present series the incidence was as

given below :?

Cases

Pneumonia, broncho-pneumonia, 20 (37 per cent)

bronchitis, influenza.

Unknown (preceding conditions 31 (58 per cent) not known, symptoms of lung abscess presenting first).

Trauma .. .. .. 1 ( 2 per cent)

Embolism (after septic abortion) 1(2 per cent)

The findings in this series support the observations of Shah (loc. cit.) and Taylor et al. (loc. cit.). The maximum incidence was found to be of so-called primary lung abscess. In this series there was not a single case

wherein previous history of surgical operations was elicited.

Location of abscess.?It is a general belief that abscess is more common on the right side than on the left, and that it is commoner in the lower lobe than in the upper lobe. This is

well supported by reports in the literature. In

May, 1942] LUNG ABSCESS : SULAKHE 263

the present series the distribution was as given below :?

Right upper lobe .. 13 Left upper lobe .. 5 Right middle lobe 4 Left middle lobe .. 1 Right lower lobe .. 15 Left lower lobe .. 11

32 17

Two patients had gangrene of the lung with multiple opacities, both sides without any cavitation, and two others died before the radiological examination could be done. Onset.?The mode of onset will depend upon

the aetiology of the abscess. In embolic

abspesses the onset is likely to be sudden. In aspiration cases the symptoms generally appear within 6 to 7 days after the operation on the upper respiratory passage. In post-pneumonic abscess the temperature does not come down to normal by crisis within the usual period and assumes an intermittent character. The onset ls generally insidious and the patient has a

cough with expectoration and fever. Later on, the patient complains of an unpleasant taste in the mouth and a foul smell of the breath. In some cases there is pain of the pleural type ^ the chest; this is often of localizing value. There may be haemoptysis?just tinging of the sputum. The sputum when collected in a

conical glass assumes the characteristic three

layers?upper frothy, the middle turbid, and the lower composed of thick purulent material. The foul smell is often the earliest symptom observed either by the patient himself or the relatives. The fever in acute cases comes with

rigor, and is high and intermittent. Later, when the abscess is partially open to the bronchus, ?t assumes an irregular character. The cough is often paroxysmal and is brought on by change of posture. In the present series, cough with expectoration was present in all cases. Fever as a presenting symptom was found in 37 cases

(69 per cent), pain in chest in 20 cases (37 per cent), foul smelling expectoration in 34 cases

(64 per cent), and haemoptysis in 9 cases

(17 per cent). ?

Physical signs.?Physical signs are often few and will depend upon the situation of the abscess and on the extent of the surrounding consolidation. If the abscess is superficial, there will be signs of consolidation first, e.g., impaired note on percussion and diminished or bronchial breath sounds with few foreign sounds, and later on, when it is in connection with the bronchus, there may be signs of cavita- tion if the cavity is empty, superficial and of fairly large size, e.g., impaired note on percus- sion, cavernous breath sounds, and metallic rales. Generally there is leucocytosis from 12,000 to 20,000 per c.mm. The sputum lamination shows streptococci, staphylococci, pneumococci and besides these there may be

fusiformis and Vincent's spirochaete. Elastic tissue is frequently found in the sputum. On

radiological examination during the early stages

of suppurative pneumonitis, there will be

opacity in the lung fields which may simulate lobar pneumonia. The opacity is not homo-

geneous but patchy and there may be thickening of the pleura over it. Later still, as the lung tissue breaks down and liquefies, a cavity with fluid level becomes apparent. Sometimes this is shown in lateral radiogram only and so it is necessary in suspected cases to have both the antero-posterior and lateral radiograms. Iodised oil if injected generally does not enter

* the cavity. _

It may prove useful in diagnosing the bronchiectatic abscess and the abscess formed distal to bronchial carcinoma.

In the present series physical signs were

vague as diminished air entry and few foreign sounds at one base in 29 cases, signs of con-

solidation were present in 22 cases and signs of cavity were found onty in 3 cases; clubbing of the fingers was present in 10 cases. Leucocytic count was done in 34 cases; it was above 15,000 per c.mm. in 10 cases, from 5,000 to 15,000 per c.mm. in 22 cases and less than 5,000 in 2 cases. Sputum examination was done in 47 cases

out of 53 and was negative to acid-fast

organisms in all with repeated observation by the antiformin method of concentration. In the majority of cases, a stained film showed

streptococci, staphylococci and pneumococci. In 2 cases only Vincent's organisms were

detected. The Wassermann reaction was posi- tive in 3 cases.

Diagnosis.?Diagnosis of lung abscess chiefly rests upon the considerations of all the factors collectively as symptoms, physical signs and the result of radiological investigations. New

growth of the bronchus will be difficult to ex- clude since abscess often co-exists distal to the

growth, but investigation with lipiodol and the bronchoscopic examination will help to prove

the real nature of the condition. It will often

be difficult to distinguish clinically between the abscess at an early stage from the pneumonic consolidation. Inter-lobar empyema will have to

be excluded. Duration.?The duration of the illness before

admission is held by many to be of great prog- nostic significance. Thus, Fisher and Finney (loc. cit.) mention King and Lord's obser- vations that short durations influence favourably towards spontaneous recovery and they also

support this by their figures in 88 cases. In the

present series, excluding one case where there was a history of illness for one year before admis- sion which is likely to be incorrect, the duration varied from 3 days to 120 days. It was less

than 10 days in 17 cases (6 deaths, 35 per cent) and more than 10 days in 36 cases (15 deaths, 41 per cent). The mean average duration of illness before admission in the present series was 30 days. From this it can be seen that

patients whose illness before admission exceeded 10 days had a slightly higher mortality than those whose history of illness was less than 10

days before admission. The stay in hospital

264 THE INDIAN MEDICAL GAZETTE [May, 1942

varied from 2 hours to 130 days, the average being 27 days. Results.?The average mortality for lung

abscess still ranges from 30 to 40 per cent for

cases treated with combined procedures?medi- cal and surgical. In the present series of 53

cases, 23 patients were discharged much

improved clinically and radiologically. There

were 21 deaths (39 per cent). Nine patients were discharged at request against medical advice.

Associated conditions.?Four patients had diabetes mellitus. Two suffered from acute

bacillary dysentery while under treatment for abscess lung. Two had chronic diarrhoea, with- out blood and mucus in the stools. Two

patients had empyema along with the abscess. One had severe anaemia and in one there was

suspicion of new-growth of the bronchus.

Treatment

Every case of lung abscess should be given expectant medical treatment from 4 to 6 weeks before any surgical procedure is contem-

plated, because there is a definite tendency to spontaneous recovery in a certain number of cases and the medical treatment in the form of

rest, postural drainage and drug treatment may help this natural tendency.

Complete rest in bed assists in building up the resistance of the patient. He should have plenty of fresh air without exposure to draught and should have good appetizing, nourishing, high- vitamin diet.

Postural drainage.?As soon as the diagnosis is confirmed, the location of the abscess should be decided by radiological examination, and, taking into consideration the situation of the

abscess, the patient should be encouraged to assume the special posture as required. There is a special bed devised for this purpose by Nelson. If this bed is not available, simple bending over the bed is often useful. An abscess in the upper zone can be drained with the patient sitting well propped up. In an abscess in lower

zone, the patient should be asked to bend over the bed, with the palms of the hand supporting him on the ground. Often the suitable position for drainage is found out by the patient himself by experimenting. The drainage should be done gradually, five minutes morning and evening, increasing the time slowly. Drug treatment.?French writers first advo-

cated this therapy consisting of intravenous injection of 5 c.cm. of 33 per cent alcohol daily, and they reported good results. But English physicians have not found this to be very useful and Edwards (1938) thinks that the claims made are not substantiated.

In the present series," this therapy was used in 43 cases, but unfortunately the value of it can- not be assessed as some other form of treatment was also used at the same time.

French writers have also reported good results with daily intravenous injection of sodium

benzoate, 20 c.cm. of 20 per cent solution. On the supposition that Vincent's spirochetes

are often present in the sputum in these cases, arsenic, either in the form of sulpharsenol or

neoarsphenamine, is given once a week in small doses parenterally.

Recently, Taylor et al. {loc. cit.) have found marked improvement by M.&B. 693 in 3 cases out of 7. Fisher and Finney {loc. cit.) found sulphanilamide beneficial in one case of lung abscess. Taking into consideration the fact that this group of drugs having proved ineffec- tual against anaerobic organisms, they think that these will not add much to the therapy of chronic lung abscess at least. In the present series 8 cases were given this group of drugs, either orally in the form of M.&B. 693 or in the form of injections of soluseptasine; out of these 5 patients ultimately died. In 3 cases the

patients improved comparatively early, but

taking into consideration the natural history of the disease and in absence of a control group, it seems rather over-optimism to attribute these successes to particular drug therapy only.

Surgical treatment.?Artificial pneumothorax treatment was used in abscesses in early days and it was found that this procedure as a routine treatment in lung abscess is dangerous, the chief risk being rupture of the abscess into the pleura giving rise to pyo-pneumothorax with ultimate high mortality. Thus, Roberts (1936) men-

tions 11 cases treated by artificial pneumothorax treatment. Nine cases developed acute pyo- pneumothorax and 5 died. He thinks the risk is too much. Maxwell {loc. cit.) suggests that it should be useful in abscess deeply situated and in connection with a bronchus.

Bronchoscopic aspiration is found useful where there is definite history of a foreign body. The most recognized procedure nowadays is

thoracotomy. The operation is done in two

stages; at first the pleura is made adherent by packing and then the abscess is drained through this adherent pleura. With these combined medical and surgical

procedures the mortality is becoming less and less recently.

Summary 1. Analysis of 53 case-records of lung

abscess is presented. They were studied chiefly from the clinical aspect of the disease and with a view to finding out the common etiological factors.

2. The series showed 39 per cent mortality. None of the cases followed surgical operation. In the majority there was no previous history of any respiratory infection. Respiratory in- fections accounted for 37 per cent of the cases

only. The abscess was on the right side in 60 per cent of the cases.

(Concluded on opposite page)

(.Continued, from previous -page) 3. Medical and surgical treatment is briefly

reviewed Acknowledgment.?I am thankful to Colonel

J; M. Shah, i.m.s.; Superintendent, Sir J. J. Hos- pital, Bombay, for allowing me to study the case-records and report the findings. I am also thankful to all the honorary medical staff under Whom these cases were admitted.

REFERENCES

Edwards, A. T. (1938). British Encyclopaedia oj Medical Practice, 8, 177. Butterworth and Co., Ltd.,

.p London. Wisher, A. M., and. Bull. Johns Hopkins Hosp., /inney, G. G. (1940). 66, 263. Maxwell, J. (1934) .. Quart. J. Med., 3, 467. Roberts, J. E. H. (1936). Brompton Hosjntal Report, Q London.

^hah, M. J. (1939) .. Indian Med. Gaz., 74, 668.

tuL0R> Yusuf, Lancet, ii, 320. M., and Chitkara, N- L- (1940).