importance of guarding against the development of this disease in all
cases of bronchitis occurring in children or in delicate adults. This
care is essential not only in idiopathic bronchitis, but in those
general diseases, such as measles and whooping cough, in which
bronchitis is constantly present. As children of bad constitution and
those exposed to depressing hygienic conditions, such as over-crowding,
bad air, and the like, are most liable to become attacked with this
form of pneumonia during the course of a bronchitis, it is especially
in such cases that our precautions must be most stringent. They should
include a strict attention to the condition of the sick-room, which
should be well ventilated, but free from drafts, the temperature not
being allowed to rise above 68° or 70°, and the air being kept moist by
the generation of steam. The diet must be carefully regulated, so that
the child's strength shall be as far as possible maintained, and
stimulants must be used if indicated by weakness of the pulse or by a
tendency to failure of respiratory power. Stimulating applications
should be made to the chest, both to serve as counter-irritants and
because they stimulate respiration. It would be manifestly unsuitable
to enter here into the details of the treatment of such cases of
bronchitis, and the above remarks have been made chiefly for the
purpose of calling attention in an emphatic manner to the great
importance and value of strict and thorough treatment of all severe
cases of bronchitis, especially in children, not only with a view to
the prompt cure of the primary disease, but because thus also will the
development of the more serious conditions of pulmonary collapse and of
pneumonia most surely be prevented.
So soon, however, as the coexistence of catarrhal pneumonia is
established the gravity of the disease should be promptly recognized,
and the closest attention should be paid to every detail of treatment.
The condition of the sick-room as to temperature, ventilation, the
absence of drafts, and the suitable moisture of the air must be even
more carefully watched. The clothing of the child and the bed-covers
must be adapted to the season, the weather, and the patient's habit and
strength. It is certainly true that aggravations of the disease are
often induced by apparently slight indiscretions in the above respects.
It is rarely desirable to employ poultices. Unless skilfully made and
dexterously applied, they fatigue by their weight; dangerous exposure
is incurred in the frequent changing necessary; and, especially in the
case of children, they do not keep their position well. A layer of
cotton batting stitched inside of a merino shirt of suitable weight,
upon the outside of which oiled silk may be stitched, forms an equally
efficient and vastly more comfortable and convenient protection. This
should be directed when the bronchitis assumes a severe type, or
certainly as soon as pneumonia is suspected. It will not be necessary
to change this for a week or ten days, unless copious sweating calls
for its more frequent renewal. Among the advantages of this application
must be reckoned the fact that it allows us to employ at any part of
the chest, and as often as desired, local stimulants or
counter-irritants, such as turpentine liniment, mustard plasters, or,
what is one of the most valuable, the repeated application of tincture
of iodine of suitable strength so as not to cause too severe
irritation.
The next most important part of the treatment relates to the
restoration and maintenance of the digestive function, which is so
commonly disturbed in this disease. No one factor contributes more
powerfully to produce vital {370} debility, which in turn rapidly
increases the gravity of the lung disease by the failure of respiration
and the development of collapse, than does gastro-intestinal disorder.
Not only the diet, but the entire medication, must therefore be
rendered subordinate to the conditions of the digestive tract. It has
been seen that, at the onset of the attack, vomiting and diarrhoea are
not rare symptoms, and that throughout the course of the disease the
condition of the tongue, of the appetite, and of digestion often shows
that a catarrhal process exists in the gastro-intestinal as well as in
the bronchial mucous membrane. It is therefore frequently advisable for
a day or two to avoid all remedies directed to the condition of the
lung, and to address the treatment, dietetic and medicinal, solely to
the state of the alimentary canal. Thus it will often be of service to
employ minute doses of calomel and bicarbonate of soda or of Dover's
powder, as in the following formulas, adapted for children of five
years of age:
Rx. Hydrargyri chloridi mitis, gr. j;
Sodii bicarb. gr. xxiv;
M. et div. in Chart No. xij or No. xvj.
S. One every two or three hours until the bowels are moved once or
twice.
Or, Rx. Hydrargyri chloridi mitis, gr. j;
Pulv. ipecac. composit. gr. x;
M. et div. in Chart No. xij or No. xvj.
S. One every three or four hours.
During this early stage of cases attended with marked gastro-intestinal
irritation it may be desirable to use remedies to allay high fever, for
which purpose fractional doses of tincture of aconite by the mouth and
quinia by enema or suppository are efficient, while avoiding all risk
of injuring the stomach. The diet at first should be carefully
restricted: it is not at this time that prostration is to be feared,
while by a thorough allaying of gastric irritation and by the
establishment of fair digestion an ally of immense value for the later
and more dangerous stages is secured. But at all periods of this
disease the occurrence of vomiting or of diarrhoea should be the signal
for instant revision of the diet and for the omission of any remedy, no
matter how strongly indicated on other grounds, which could be regarded
as the cause of the disturbance.
Milk, skimmed or whole; gruel, light broths, or beef-tea; junket,
arrowroot, or similar light yet nourishing articles, are most suitable.
Stimulants are frequently indicated on account of the tendency to
failure of the respiration and heart, and owing to the typhoid nervous
symptoms. They are required at all ages, especially by young children
and by the aged. Children in particular bear relatively large amounts,
and respond to their use well and promptly. The form and strength of
the stimulant must be adapted to the state of the stomach. Wine-whey
and weak milk-punch are often serviceable. Many children will take
brandy or whiskey in water, but will refuse the former preparations.
Dry champagne has proved highly valuable in many serious cases,
especially in older persons, for young children will rarely take it.
Other important indications are to favor expectoration and to stimulate
the respiratory forces. These are closely associated, and are of prime
importance, since in catarrhal pneumonia the principal danger to life
undoubtedly comes from the progressive diminution of the pulmonary area
open to respiration, and from the increasing failure of the respiratory
muscles to overcome the obstruction to full inflation. It is through
this agency that pulmonary collapse extends, that heart failure
subsequently occurs, and that carbonic acid poisoning, with its
attendant nervous symptoms, is finally developed.
The preparations of ammonia seem to be the most valuable remedies to
meet these indications. In adults, where the disease is attended with
high fever, the following may be ordered: {371}
Rx. Ammonii chloridi, gr. lxxx;
Syr. scillæ vel syr. senegæ, fluidrachm iij;
Liq. ammoniæ acetatis, q. s. ad fluidounce iv.
Ft. sol. S. A dessertspoonful in water every three hours. To this may
be added one or two drops of tincture of aconite in each dose, watching
carefully for the appearance of its effects; or small doses of morphia
or of deodorized tincture of opium may be added, according to the
severity of cough or of nervous restlessness. But to children in nearly
all cases, and frequently to adults, it is best to give carbonate of
ammonia at once, as follows:
Rx. Ammoniæ carbonatis, gr. xlviij;
Pulv. acaciæ et sacchari, _aa_ q. s.
Sp. lavandulæ comp. fluidrachm ij;
Aquæ, q. s. ad fluidounce iv.
Ft. mist. S. One teaspoonful in water every two or three hours for a
child five years old.
It may occasionally be necessary, owing to the abundance and the
viscidity of the bronchial secretions, to administer an emetic, but
this should be avoided if possible. If required, choice should be made
of one which will act promptly and decisively without subsequent nausea
or relaxation. Such is a combination of alum and ipecacuanha, or of
sulphate of zinc and ipecacuanha, which have proved very satisfactory
in my hands. Jürgensen recommends apomorphine, administered
hypodermically, as the agent which he has found most efficient. The
dose of this substance is about gr. 1/12 for an adult, whilst for a
child of five years it should not be more than gr. 1/30 or gr. 1/25.
The dose may be repeated in 15 or 30 minutes if no emetic action is
secured.
I attach great importance to the use of strychnia in catarrhal
pneumonia after symptoms of respiratory failure appear. Its value as a
stimulus to the muscles of respiration, and possibly directly to the
respiratory nervous centre, is established. It may be given alternating
with the ammonia mixture, thus:
Rx. Quiniæ sulph. gr. xxiv;
Strychniæ, gr. ¼;
Acid. muriatici diluti, gtt. xvj;
Glycerinæ, fluidrachm iij;
Liq. pepsinæ, q. s. ad fluidounce iv.
Ft. sol. S. Teaspoonful in water every three or four hours, for a child
of five years of age.
But when urgent symptoms arise it may be given in much larger doses and
hypodermically, so as to ensure its full absorption and effect. I have
thus given in many severe cases, and at times with unquestionably good
results, as much to an adult as gr. 1/24 every four hours, day and
night, for seventy-two or ninety-six hours.
The fever in catarrhal pneumonia does not demand special treatment
nearly so often as in the croupous form. Though the evening maxima may
be quite high, yet the occurrence of the morning remissions brings some
relief and obviates the necessity for vigorous antipyretic treatment.
The nervous system and the heart do not therefore suffer severely and
constantly from this cause in this disease. Still, there are not a few
cases when hyperpyrexia occurs and demands prompt treatment. If the
nervous symptoms are not threatening, and if the respirations are still
fairly well performed, it will be proper to try the effect of a few
full doses of quinia, or, if that fails, of antipyrine. But if, despite
these remedies, or in the event of the stomach rejecting them, or,
finally, if more urgent symptoms of nervous and respiratory failure are
impending, recourse should be had to cold effusion, particularly if the
highly laudatory statements of Bartels, Ziemssen, and Jürgensen be
confirmed by further observation. I have not found it necessary, or may
have failed to {372} appreciate the necessity, to resort to the
external use of cold in catarrhal pneumonia; but the remarks of
Jürgensen as to the remarkable influence of cold water dashed upon the
surface of the chest or directed against the cervical spine in
stimulating deep respirations accord with general observation, and
suggest this mode of treatment, especially in cases of sustained high
temperature with rapid, shallow, imperfect respirations and defective
aëration of the blood.
The nervous symptoms frequently are so severe as to require the
administration of sedatives. Remedies of this class must, however, be
used cautiously and sparingly. It were unwise to give those which
depress the heart and respiration, or, on the other hand, to administer
opium in such doses as would blunt perception and lessen cough to an
injurious degree. By the use of small doses of opium from the beginning
of the attack, however, combined with strict attention to the other
details of treatment, it is often possible to prevent the development
of severe nervous symptoms which would require powerful sedatives. In
cases of extreme restlessness and sleeplessness benefit may be found
from the use of such a suppository as the following:
Rx. Pulv. assafoetidæ, drachm j;
Quiniæ sulph. gr. xxx;
Ol. theobromæ, q. s.
To be made into twelve suppositories of small size, suitable for a
child of five years of age, one of which may be used and repeated in
three or four hours.
Enemas of chloral hydrate, from five grains for a child of five years
to twenty grains for an adult, may be used without fear of depressing
the heart or checking the secretions, and with great relief to the
nervous symptoms, especially if tending toward convulsions. In cases of
extremely active and restless delirium, where prompt sedative action is
demanded, and yet where the use of opiates is forbidden, the hypodermic
use of hyoscyamia in doses of gr. 1/80 to 1/100 for an adult may give
gratifying results.
In cases which pass into a subacute form a continuance is demanded of
every precaution as to the diet, the hygiene of the sick-room, and the
use of general tonic remedies. Advantage may then be found from the use
of oil of turpentine, which has seemed to me the most valuable
alterative and stimulating expectorant under such circumstances.
As the case progresses into the chronic form it becomes necessary to
gradually substitute for the more strict and special method of
treatment previously employed one in which the maintenance of the
general health shall be the prime object. The regulation of the diet,
care in dress, the cautious resumption of gentle exercise, and the use
of carefully-regulated pulmonary gymnastics so as to favor the full
inflation of the lungs and the invigoration of the respiratory muscles,
are to be closely attended to.
The condition of the skin demands careful attention also, and dry
friction, inunction, and suitable stimulating sponge-baths followed by
friction, according to the constitutional condition of each patient,
may be cautiously directed with great advantage.
The remedies suitable for the more acute stages may now be replaced by
cod-liver oil, arsenic, or iodide of iron. Occasionally alterative
expectorants, such as copaiba or yerba santa, with or without an
alkali, as muriate of ammonia, will still be found desirable.
Most signal benefit will also be obtained from suitable change of
climate, associated with a continuance of careful regimen and
treatment; and, indeed, we may be gratified by witnessing a complete
restoration to health, with the exception of unimportant residual lung
lesions, of cases in which the general symptoms and the physical signs
strongly indicated hopelessly incurable organic disease. Not only in
the acute, but in the most tedious chronic, cases of catarrhal
pneumonia must our efforts be continued to the very close.
{373}
PULMONARY EMBOLISM.
BY BEVERLEY ROBINSON, M.D.
DEFINITION.--Pulmonary embolism signifies the transport during life of
clots, or of other solid substances appearing within the right heart or
systemic veins, from these parts to the trunk or divisions of the
pulmonary artery.
SYNONYMS.--_Fr._ Embolie pulmonaire; _Ger._ Embolie der Lungenarterie;
_It._ Embolia pulmonare.
CLASSIFICATION.--A rigorous classification of the different kinds of
pulmonary emboli or a clear separation of them into distinct orders is
very difficult on account of the rôle in producing them, partly
mechanical, partly dyscrasic, of some of the affections in which they
are likely to occur. This is particularly true of the puerperal state,
uterine affections, and fractures.[1] Bertin, however, has made of them
four divisions, according as the cause is mechanical, dyscrasic, mixed,
or undetermined; but these are objected to by Luzzato on the ground of
their inadequacy, and he deems it preferable to regard them from the
point of view of their medical, surgical, or obstetrical origin. From
this latter point of view we also consider it best to consider them
until a more satisfactory separation shall be established.
HISTORY.--Latterly, the subject of pulmonary embolism, or the
obstruction of this artery by means of a clot which has had its origin
in the right heart or one of the systemic veins, has been very
carefully studied. Many cases of sudden death are properly and readily
explained in this manner, where formerly they would have been doubtful
or inexplicable. Sometimes the previous existence of a fibrinous
coagulum in the right heart or in the crural vein has been recognized
previous to the symptoms indicating plugging of the pulmonary artery;
occasionally these coagula have been wholly overlooked, and the sudden
cry with intense dyspnoea, pointing to obstruction of the blood-supply
to the lungs, is a matter of dread surprise to the beholder. According
to Trousseau,[2] our knowledge of embolism is due mainly to Legroux.
This is not, however, the view of Ball[3] nor of Walshe, who attribute
the clearest insight into this process to the clinical and experimental
observations of Van Swieten, who, half a century before Legroux's time,
had injected different coagulating materials into the veins of animals
and produced the characteristic symptoms of pulmonary embolism. To
Virchow's[4] exhaustive researches, however, we are principally
indebted for a great deal of what is actually known upon this subject
to-day. True it is that contemporaneous writers have added many new
facts to those he so well elaborated, but the greater part of credit in
this line of study should be awarded to him. After Van Swieten's time
the doctrine of pulmonary embolism fell somewhat into disrepute, owing
to the lukewarmness of Hunter and {374} Morgagni. Cruveilhier (1842)
recognized their existence, but was so much impressed by his doctrine
of phlebitis that he believed the majority of pulmonary coagula were
autochthonous (formed on the spot), and not the consequence of
transport or migration in the venous current. This opinion was strongly
combated by Virchow, who held that pulmonary coagula formed some time
before death were not the result of an inflammation of this arterial
vein (Galien), but always had for origin a migratory clot which came
from some part of the venous system.[5] This doctrine of Virchow's is
certainly too exclusive, and although primary or secondary inflammation
of the pulmonary artery is certainly rare, it is certainly not unknown,
and when it exists will sufficiently explain the formation of a
fibrinous clot. Facts of this kind have been reported by Bumann,
Bouillaud, Andral, and more recently still by Lancereaux, who has shown
to the Anatomical Society of Paris[6] distinct new formations in the
pulmonary artery. Until further investigations are made on this point
it seems wise to abstain from having an opinion too categoric on one
side or the other. Virchow's first studies on pulmonary embolism were
published in 1846, and were based upon 11 cases of this disease. All
these cases were caused by migratory clots from the heart or one of the
systemic veins. In this first publication, and later on (1854-56),
Virchow gave the results of numerous experiments in which he had
injected bits of fibrin of diverse origin, particles of flesh, and
fragments of rubber into the jugular veins, and showed in an admirable
description the immediate effects of embolic plugs upon the blood, the
arterial coats, and the surrounding pulmonary tissues.[7]
[Footnote 1: _Étude critique de l'Embolie_, Paris, 1869.]
[Footnote 2: _Clinical Lectures_, Sydenham Society's ed., vol. iii. p.
414.]
[Footnote 3: _Des Embolies pulmonaire_, Thèse de Paris, 1862.]
[Footnote 4: _Froniep's Neue Notizen_, 1846, p. 910.]
[Footnote 5: Bucquoy, _Des Concrétions sanguines_, Paris, 1863, p.
138.]
[Footnote 6: _Bullétin_, 1861, p. 377.]
[Footnote 7: _Dict. de Médecine et de Chirurgie_, vol. xxix. p. 334.]
In 1852, Senhouse Kirkes[8] also studied very carefully different cases
of embolism, and showed how they were connected with organic disease.
Most of these cases, however, showed rather the effects on the brain
and the production of right or left hemiplegia than the asphyxic
sequelæ of obstruction of the trunk or divisions of the pulmonary
artery. In France the doctrine of embolism was at first received
doubtingly, and was the subject of animated discussions at the Medical
Society of the Hospitals in 1857. In this year Charcot and Ball
published the first case of pulmonary embolism which had been observed
in that country. Five years later (1862) pulmonary embolisms formed the
subject of a remarkable inaugural thesis by Ball, and articles of
considerable value were also written in regard to it by Velpeau,
Lancereaux, Lemarchand, Trousseau, etc. Spontaneous coagulation of the
blood in the right heart and pulmonary artery was considered by Meigs
in 1855 to be a frequent cause of death in the puerperal state.
Analogous cases, although none of them occurred after childbirth, had
five years previously been carefully studied by Paget.[9] The cases of
sudden death subsequent to confinement are now generally considered to
be due to pulmonary embolism.[10] Amongst the later sources of
information on the subject of pulmonary embolism or its consequences we
would direct special attention to the work of Luzzato[11] and the
theses of Duguet[12] and Levrat.[13] These and numerous other writers
have made researches as to the different varieties of pulmonary
embolism, such as the fatty (Flournoy), atmospheric, specific, those
following confinement, or traumatism.
[Footnote 8: _Med.-Chir. Trans._, vol. xxxv.]
[Footnote 9: _Ibid._, vol. xxvii. p. 162, and vol. xxviii. p. 352.]
[Footnote 10: Playfair, _A Treatise on the Science and Practice of
Midwifery_, Philada., 1882.]
[Footnote 11: "Embolia dell' Arteria pulmonale," _Annali Univers. di
Med. e Chir._, Milano, 1877-79.]
[Footnote 12: _De l'Apoplexie pulmonaire_, Paris, 1872.]
[Footnote 13: _Des Embolies veineuses d'Origine traumatique_, Paris,
1880.]