over-action of the heart or a sudden recession of blood may cause death
in a short time, or may disappear, either spontaneously or under
appropriate treatment, almost as suddenly as it has come on. The
abatement of the symptoms is generally attended with profuse serous
expectoration, and sometimes with hemorrhage, by which the congested
vessels are relieved, so that they return to their natural state.
When acute oedema of the lungs is due to Bright's disease in the acute
or one of the chronic forms, it is often quickly fatal, though if
properly treated it may disappear. When a consequence of chronic renal
disease it is apt sooner or later to return. Chronic passive hyperæmia
and chronic oedema of the lungs admit of only temporary relief, because
they are occasioned by such diseases of the heart or kidneys as are
themselves generally incurable; and they are very sure to recur, even
though they may be relieved for a time. It is not uncommon in cases of
this sort to see the symptoms of chronic oedema suddenly aggravated by
the occurrence of an acute attack, which is the immediate cause of
death.
PATHOLOGY AND MORBID ANATOMY.--The pathological appearance of a
congested lung varies according to the form of the congestion and the
manner in which it has been occasioned. Acute congestion may occur very
suddenly from some of the causes that have been mentioned, and may
disappear with equal rapidity, leaving no traces behind. But sometimes,
from the extent of the congestion, respiration is interrupted to such a
degree that life is quickly destroyed. In such cases the affected
portion of the lung is of a dark color from being engorged with blood,
which flows from it if an incision is made. The part is heavier and
crepitates less than normal lung-tissue. The bronchial mucous membrane
is apt to be hyperæmic, as might be expected from the communication
that exists between the pulmonary and bronchial vessels, and the tubes
themselves are filled with mucus and sometimes with frothy and bloody
serum.
Where the tonicity of the pulmonary vessels has been impaired by
sickness, age, or other debilitating influences, passive congestion of
the lungs is very likely to ensue if the heart become weakened; and as
the effect of gravity will aid in determining the stasis of the blood,
the resulting congestion is in life most marked in the lower and
posterior regions of the lungs, where the changes are chiefly found
after death. As gravity may thus determine the congestion to one part
of the lungs, so a change in the patient's position may cause it to
disappear from where it was first manifest and to appear in another
part which has become most dependent. The condition thus brought about
is known as hypostatic congestion. One of the consequences of passive
{262} hyperæmia thus induced is a transudation of the serum of the
blood into the air-cells and connective tissue of the lungs; and this
is one way in which pulmonary oedema may be occasioned. When hypostatic
congestion has lasted for some time, it may no longer be affected by
changing the patient's position; and when this is the case it may be
accompanied by exudation of fibrin into the air-cells and by
proliferation of epithelium, thus producing the condition termed
hypostatic pneumonia.
All three of these states may be present in one lung at the same time,
one portion being passively congested, another oedematous, while the
most dependent part may be the seat of hypostatic pneumonia.
The congested parts of the lungs are very dark in color, in some cases
almost black; blood flows freely from a section through them, and serum
exudes from the alveoli and interstitial tissue when oedema exists. If
the altered condition of the lung has lasted for some time, the texture
of the affected part may be so firm as to resemble that of the spleen;
whence this change is sometimes termed splenization. In this condition
dark-red points consisting of extravasated blood may be seen scattered
about. If the state already described as hypostatic pneumonia exists,
the affected part is still more firm and dense in texture, and presents
a granular appearance on section from the exudation of fibrin which has
probably taken place, so that it resembles a portion of a lung that has
been the seat of an inflammatory process from the first.
DIAGNOSIS.--The diagnosis of pulmonary congestion in its different
forms, and of pulmonary oedema, is in general not difficult if the
symptoms of the causative diseases are carefully observed. Acute
pulmonary congestion coming on suddenly, and not preceded by any other
affection, needs to be distinguished from the early congestive stage of
pneumonia, which it somewhat resembles from the slightly impaired
resonance on percussion and the dyspnoea that may occur in both
diseases. The chief points of distinction between the two affections
are the absence in congestion of initial chill, of pain in the side,
and of rise of temperature; all of which are in general present in
pneumonia. As the case advances the divergence between the two
affections will be wider.
The diagnosis of acute oedema and of chronic congestion and oedema is
based upon the physical signs belonging to them, taken in connection
with the symptoms of cardiac and renal disease with which they are
associated.
Capillary bronchitis bears some resemblance to pulmonary oedema, since
in both affections there are moist subcrepitant râles; but in capillary
bronchitis there is no such loss of percussion resonance as occurs in
pulmonary oedema, and, moreover, fever is not present in oedema, as it
is in the inflammatory affection. The character of the expectoration is
also different in the two diseases, being thicker and more tenacious in
bronchitis and serous or watery in oedema. From hydrothorax, oedema is
distinguishable by the shifting line of dulness and by the absence of
râles in hydrothorax.
PROGNOSIS.--Acute congestion of the lungs is always a serious
affection, and, as already stated, terminates fatally in some cases in
a short time. In the majority of instances, however, it disappears
spontaneously or under suitable treatment, and the lungs are in general
restored to their integrity. It may result in pulmonary hemorrhage,
from which recovery may take place, or which may give rise to
hemorrhagic infarction, the blood being drawn into the alveoli.
Passive congestion being a secondary affection, its prognosis depends
upon the diseases which occasion it.
In pulmonary oedema the prognosis is always very grave. When occurring
suddenly as a consequence of acute congestive nephritis, it may wholly
{263} disappear under proper treatment, and if the kidney affection is
likewise cured there will be no further return of the pulmonary
complication. When it comes on in the course of chronic renal disease,
it may disappear and recur from time to time, but it is apparently not
often the direct cause of death by itself. Sometimes, however, it is
associated with cerebral oedema and other conditions which together
occasion a fatal termination. When due to pneumonia, oedema adds very
much to the gravity of the affection, and may be the immediate cause of
death.
TREATMENT.--The treatment of acute pulmonary congestion consists in the
use of means to check the undue flow of blood into the engorged lungs.
Of these the best, if the patient be seen promptly and the strength of
the pulse admit of it, is general bloodletting, by which the mass of
the blood is lessened and the action of the heart and pressure within
the blood-vessels are lowered, so that both the amount of blood in the
hyperæmic vessels and the force with which it reaches them will be
diminished.
This measure may be also useful in the way of preventing or checking
acute pulmonary oedema by lessening the blood-pressure. Should
venesection be thought inadmissible, cups may be applied to the chest
in front or behind, and at the same time the volume of the blood may be
temporarily lessened by placing ligatures around the thighs, so as to
check the flow of blood in the veins near the surface. Revulsion from
the congested vessels of the lungs may also be effected by mustard
foot-baths or the application of mustard poultices to the chest.
Aconite may be serviceable by controlling over-action of the heart, and
may be given in the dose of 1 or 2 drops of the tincture of the root at
intervals of half an hour until some effect on the circulation is
produced.
It is of importance to remove any blood or serum that may be present in
the air-cells and smaller bronchi; and for this purpose one of the
quickly-acting and non-depressing emetics may be given, such as
apomorphia hypodermically or the sulphate of zinc or turpeth mineral by
the mouth. Respect must be had to the condition of the patient's
strength in ordering an emetic, since if there be much prostration, or
if the interference with respiration has seriously depressed the heart,
more harm than good might result from its use. Expectorants may
somewhat later supplement the action of emetics, or serve to keep up
the good effects gotten from them by helping to remove the residual
fluids from the air-passages. Among the best of these are the syrup of
senega and the carbonate or hydrochlorate of ammonium.
Passive congestion of the lungs, being dependent upon a weakened
condition of the circulation, requires the use of means to sustain and
reinforce the heart's action. The alcoholic and ammoniacal stimulants
are here of great importance, and digitalis may be of sovereign
efficacy, especially in cases where the congestion is associated with
dilatation and attenuation of the heart. The power possessed by this
drug of increasing arterial pressure, and thus producing diuretic
action, may render it further serviceable when the congestion is
accompanied with oedema, as in this way the serous infiltration may be
absorbed and removed. From 10 to 20 drops of the tincture or from 2 to
4 drachms of the infusion of digitalis may be given every two hours
until some effect on the pulse or the kidneys is noticed. If the
stomach should not bear digitalis well in either of these forms, as is
the case with some patients, the alkaloid digitalin in the dose of 1/60
grain may be given. The convallaria recently introduced as synergistic
with digitalis may be substituted for it, and in the dose of from 20
minims to 1 drachm of the fluid extract it will be found not uncommonly
to be an efficient heart-tonic. Like digitalis, too, it possesses
diuretic power from the increased arterial pressure that it occasions.
Passive pulmonary congestion may assume a chronic form in connection
with chronic cardiac and renal disease, and without presenting urgent
{264} symptoms may cause almost constant embarrassment of respiration
in greater or less degree. Under such circumstances the preparations of
iron are helpful by enriching the blood and increasing the tone of the
heart. One of the best preparations is the mixture of acetate of iron
and ammonium,[2] known as Basham's mixture, which combines diuretic
with chalybeate action. This may be given in the dose of from 1 to 4
drachms.
[Footnote 2: _U. S. Pharm._, 1882.]
It is of great importance in all cases of passive congestion and of
hypostatic pneumonia to change the patient's position from time to
time, so as to counteract the influence of gravity and relieve
dependent portions of the lungs.
Pulmonary oedema occurring in an acute form in the course of either
congestive nephritis or chronic renal disease may seriously imperil
life, and therefore it demands prompt and bold treatment. When it
results from acute nephritis, it is more immediately dangerous than
when dependent on chronic disease of the kidneys; yet in this acute
form it may admit of perfect cure if proper remedial measures be at
once instituted. Cups may be applied to the loins with the view of
relieving the engorged kidneys and enabling them to resume their work
of removing fluid from the body. In cases where the strength of the
pulse is sufficient, it may even be good practice to abstract blood by
the lancet to the amount of six to eight ounces. According to
Oppolzer,[3] this treatment may be proper even when somnolence
indicates oedema of the brain, provided there be no irregularity of
respiration or intermission in the pulse--signs which contraindicate
bloodletting.
[Footnote 3: _Ziemssen's Cyclop._, v. p. 285.]
Active diaphoretics are among the best medicinal agents to be employed,
their good effects being due to their derivative action and to the
large discharge of fluid from the skin which they occasion, thus
promoting the removal of what is effused in the lungs. The fluid
extract of jaborandi in the dose of from 20 minims to a drachm, or the
hypodermic injection of 1/8 to 1/6 grain of nitrate or muriate of
pilocarpine, frequently causes prompt and profuse perspiration. The
writer is confident that he has seen life saved by the use of this drug
when it has been in urgent peril from pulmonary oedema. In the absence
of this agent, or along with it, the hot-air bath, which can almost
always be extemporized in an efficient form, may serve to promote or
increase fluid discharge from the skin. If the patient's strength is
sufficient, one of the hydragogue cathartics may be given, and among
them the most prompt and active is elaterium in the dose of 1/12 to 1/8
grain every four hours. The action of this drug must be carefully
watched and its depressing tendency guarded against by the use of
alcoholic stimulants.
When pulmonary oedema results from weakness of the heart, as in
dilatation of that organ, or from chronic renal disease, all lowering
measures must be avoided. Bloodletting, whether general or local, would
still further depress the heart, and by increasing the hyperæmia of
chronic Bright's disease would favor the further effusion of serum into
the lungs. Dry cupping over the chest before and behind may be
serviceable as a revulsive measure. Stimulants and tonics are called
for, and digitalis or convallaria is directly indicated from the
special power possessed by these agents of improving the cardiac tone
and promoting the action of the kidneys by increasing blood-pressure.
Digitalis has been thought objectionable when there is much
irregularity of respiration, and perhaps it would be safest to postpone
its administration until this symptom is relieved by the use of
alcohol, ammonia, musk, or other prompt diffusible stimulants.
The writer has had repeated opportunities for observing the value of
quinia given hypodermically in checking effusion of serum into the
air-passages, and he would strongly recommend its use in the treatment
of pulmonary oedema in the form of the hypodermic injection of the
solution of hydrobromate of {265} quinia of the strength of 4 grains to
20 minims. Of this solution 10 to 20 minims may be injected at once. If
such a solution cannot be obtained, a full dose of 10 to 15 grains of
the sulphate of quinia may be given by the mouth.
As in the case of passive congestion of the lungs, so in oedema,
advantage may be gained by changing the patient's position from time to
time, so as to prevent the constant gravitation of fluid to the same
portion of the affected organs.
{266}
HÆMOPTYSIS.
BY WILLIAM CARSON, M.D.
The word means, literally, spitting of blood, from two words, [Greek:
haima], blood, and [Greek: ptyô], I spit.
SYNONYMS.--If we go back far in the history of medicine, we find many
synonyms, such as Hæmoptoe, Emptoe, Emptoica passio, Pneumorrhagia,
Hæmorrhagia pulmonis, Crachement de sang, etc., etc.
DEFINITION.--Bronchial hæmoptysis is the spitting or expectoration of
blood which has been effused into the bronchi or bronchioles from the
bronchial vessels. Pulmonary hæmoptysis is the spitting or
expectoration of blood which has been effused into the air-cells, the
inter-alveolar and interlobular tissues. This distinction is not always
practicable in diagnosis or practice. It may, however, serve for a
grouping of some well-known clinical forms of hæmoptysis.
It is not possible to give indications by which the origin of blood in
the lungs may be positively determined except by a reference to other
symptoms than the hæmoptysis. In general, bronchial hemorrhage is
characterized by a bright-red, fresh color, is aërated, unmixed, and
uncoagulated. In pulmonary or parenchymatous hæmoptysis the blood is
dark, non-aërated, and coagulated to some degree, and often alternates
with a mixed blood and mucus sputum. These distinctions are not
reliable, and must be supplemented by all of our clinical resources in
the case before us. The author maintains that in the hæmoptysis of
phthisis the hemorrhage in the large majority of cases is both
bronchial and pulmonary. The typical parenchymatous hemorrhage is found
in hemorrhagic infarction and pulmonary apoplexy, which, compared with
phthisis, are rare occasions for hæmoptysis. This general statement
will form the basis of what follows in this exposition.
HISTORY.--Historically, there are not many phases in the doctrine of
hæmoptysis. Controversy has been chiefly confined to its relations to
phthisis as cause or effect.
The simplicity and directness of observation of the ancients give a
special interest to their views of hæmoptysis. They believed that it
was oftener cause than effect. They found a warranty of that opinion in
what they thought was a direct conversion of blood into pus, and in the
irritating qualities of the latter. Hippocrates'[1] fundamental
statements are, "Ex sanguinis sputo, puris sputum malum;" "Ex sanguinis
vomitione tabes et puris purgatio per superiora purgatio;" "Ex
sanguinis sputo puris sputum et fluor, ubi autem sputum retinetur
moriuntur." Another statement of his is given in translation by
Peter:[2] "When some of the veins of the lung are ruptured the
hemorrhage is in proportion to the size of the vessel; a part, on the
contrary, unless the vein be very small, diffuses itself in the lung,
putrefies {267} there, and after having putrefied forms pus. As a
result, it is at one time true pus, at another pus mixed with blood,
and another time it is pure blood, which is rejected; and if the vein
was very full it is from it that the mass of the blood comes, and thick
pus, mixed with putrefied pituitous secretion, is expectorated."
[Footnote 1: Edition 1696, book 7, p. 1141, Aphorisms 15 and 16, 80 and
81.]
[Footnote 2: _Clinique médicale_, tome 112, p. 243. The precise
locality of this quotation is not given by Peter, but it is from
Hippocrates' _Opera_, ed. Kuhn, Leipsic, 1825, vol. ii. p. 178.]
Thomas Young[3] gives the following sentences from Hippocrates'
_Predictions and Aphorisms_: "The most dangerous consumptives are cured
by a rupture of the great vessel which corrodes the lungs;" "Purulent
expectoration after hæmoptysis is dangerous;" "In some cases
consumption originates from an effusion of blood into the lungs without
hæmoptysis, especially after a strain or accidental injury; a
collection of phlegmatic humors form around it by causing pain and
cough, with purulent and bloody expectoration." All of these quotations
show the Hippocratic doctrine distinctly, that the hæmoptysis where it
appeared in a case was mostly the cause of the subsequent phthisis, and
that phthisis ab hæmoptoe was not only one of the most common, but one
of the most dangerous forms.
[Footnote 3: _A Practical Historical Treatise on Consumption Diseases_,
London, 1815, p. 111.]
The doctrine that blood effused into the lungs became pus, and produced
corroding and ulcerating effects, appears in many other prominent
authors between the Hippocratic writings and the nineteenth century.
Celsus[4] (30-40 A.C.) says: "Hæmoptysis is one of the causes of
purulent expectoration." Galen[5] (131-201 A.C.) says: "Phthisis is
lung ulceration;" and he thinks "that in the greatest number of cases
it originates in a mechanical way, through tearing of the tissue by
means of an outpouring of blood in consequence of a catarrh or strain."
This extract would imply that he thought the hæmoptysis in many cases
secondary, but that when it did occur it had the effect which
Hippocrates attributed to it, that of producing "purulence of the
lungs." Sylvius[6] (1614-1672) says: "Hæmoptysis is one of the causes
of purulent expectoration."
[Footnote 4: Young, _op. cit._, p. 128.]
[Footnote 5: Waldenburg, _Die Tuberculose_, p. 19.]
[Footnote 6: Waldenburg, _op. cit._, p. 28.]
Morton's[7] (1689) language partly is: "Decantatum istud medicorum
adagium, quod pus sequitur sanguinem;" and then, translated, he says:
"It (the adage) appears to have originated in the fact that 'purulence'
of the lungs, or phthisis pulmonalis, usually follows hæmoptysis more
quickly and oftener than any other disease." In the sentence
immediately following he suggests this result may be due to a
putrefaction of clots that the hæmoptysis has left behind in the lungs,
or to a copious effusion of humors from the whole body to the tender
lungs, or to an erosion of some vessel.
[Footnote 7: _Phthisiological Ed._, 1727, lib. 111, chap. v. p. 95.]
Another theory appears in Hoffmann's language,[8] and was probably
suggested, directly or indirectly, by Sylvius's description of
tubercles: "The blood is easily extravasated into the pulmonary
vesicles, stagnates there and putrefies, corrodes the neighboring
parts, and finally destroys the air-passages or they are converted into
nodes or tubercles." The blood becomes tubercularized, and the phthisis
ab hæmoptoe is established. This idea is found at different periods,
and we find a recent French author arguing against this hypothesis.
[Footnote 8: Peter, _loc. cit._, p. 244; Young, p. 211, _Opera_;
Hoffmann, _Physico-medica_, Geneva, 1740.]
The reversal of these ideas is generally acknowledged as the results of
Laennec's energy and genius, yet similar opinions to his had been
expressed by French and English physicians. Bayle does not place
phthisis ab hæmoptoe in his classification. Desault,[9] one of
Laennec's countrymen, near a hundred years before him, "insists that
tubercles constitute the essence of consumption, being generally
anterior to hæmoptysis." Mudge[10] says that hæmoptysis is often the
consequence of the obstruction produced by tubercles. A {268}
preparation for the positive opinions of Laennec is discernible in
these and other authors. His views on this particular topic were
opposed by Andral. The latter modified his earliest expressions to some
extent.
[Footnote 9: Young, p. 220, _Desault sur les Maladies venériennes, la
Rage et la Phthisic_, Bordeaux, 1733.]
[Footnote 10: Young, _loc. cit._, _Radical Cure for a Recent Catarrhic
Cough_, London, 1779, 2d ed.]
The next important historical epoch in the causative relations of
hæmoptysis and phthisis is in the energetic protests of Niemeyer. They
were in some respects a return to the Hippocratic doctrine, in that he
asserted the predominance of hæmoptysis as cause; but he gave the
doctrine a basis better adjusted to a better pathology, in that he made
the important element of inflammatory lesions the medium between the
effusion of blood and the final purulence or ulceration (ulcus
pulmonum) of the ancients. He energetically advocated the doctrine of
the positive effect of effusion of blood in the bronchi or pulmonary
substance in producing disorganization of the lungs, without reference
to any hereditary or predisposing element or existence of tubercles.
Jaccoud[11] calls attention to the fact that Graves had anticipated
Niemeyer in the partial revival of the Hippocratic doctrine and the
teachings of Morton and Hoffmann on phthisis ab hæmoptoe.
[Footnote 11: _Clinique médicale_, vol. ii. p. 302, Graves.]