gangrene. Nevertheless, Lancereaux has shown that cancerous nodules may
be produced by metastasis. This belief in the possibility of a simple
embolus taking on a cancerous change, and carrying this disease to
far-removed parts, has been strongly combated by Cohn. Neither
experimental nor human pathology has thus far decided the subject in an
absolute manner. Certain it is, {387} however, that the power of emboli
from cancerous foci to carry similar disease elsewhere depends partly
upon the vitality of the cancerous particles, partly upon the power of
receptivity as shown by certain constitutions for developing special
diseases, and which relates, after all, to the general question of
dyscrasia. Langenbeck has shown that certain animals will die within a
few hours after the injection of cancerous juice. On the other hand, it
is known that the infective power of the juice only lasts a very brief
period. Weber, Luzzato, and others have reported numerous examples of
secondary tumors of similar nature developed in the lungs when
epithelioma, enchondroma, sarcoma, or carcinoma existed somewhere in
the body. Finally, it would appear that emboli containing hydatids in
embryo have been the means of transporting these parasites into the
pulmonary structure.
DIAGNOSIS.--The sudden commencement of the accidents, especially when a
peripheral thrombus has existed previously in one of the large veins of
the extremities, renders the diagnosis almost certain. If the patient
has been suffering from the effects of a traumatism (contusion,
fractures, operation on the veins of the limbs or rectum, etc.), and is
almost instantaneously attacked with intense dyspnoea and a feeling of
anguish which he refers to the thoracic region, we shall be able
usually to eliminate other intercurrent affections and to diagnosticate
the existence of pulmonary embolism.
This accident is often confounded with cardiac thrombosis. It may
usually be separated from it by the following differential symptoms:
Cardiac obstruction from a clot usually comes on insidiously, by
degrees; the heart-beats are irregular, tumultuous, muffled, and
distant; there may be a murmur from one or other of the cardiac
orifices; there is no initial chill; peripheral thrombosis is not
present as a rule; there is no sensation of localized obstruction in
the chest.
In pulmonary embolism the début may be instantaneous and death follow
in a few seconds; or, again, the beginning may be rapid, ushered in by
stifling in the chest, a chill, cyanosed face, followed soon by
excessive pallor, a distinct sensation of obstacle to breathing in a
particular region. Percussion and auscultation may remain negative. The
patient may have a succession of similar accidents, and yet finally
recover. According to Ball, pulmonary embolism and pulmonary thrombosis
cannot be distinguished during life. In one case which he reports where
pulmonary embolism should have been present without question the
autopsy showed the presence of a thrombus in the pulmonary artery. A
succession of chills, general malaise, febrile excitement, the
localized phenomena of pneumonia or gangrene of the lung, point
indubitably to the existence of septic emboli.
The differential diagnosis between pulmonary embolism and other
affections, such as angina pectoris, a foreign body in the
air-passages, pneumothorax, etc., may usually be reached without much
difficulty. Sometimes the paroxysmal dyspnoea with sensations of great
oppression which accompanies mitral stenosis may be mistaken for
pulmonary embolism. In these instances the absence of a discoverable
cause of the attack in pre-existing emboli, and the presystolic murmur
with marked general anæmia, may surely lead to an accurate diagnosis.
It must, however, always be remembered that in mitral stenosis it is
not infrequent to have cardiac coagula formed in the right auricle,
which may become detached and give rise to pulmonary emboli. Under
these circumstances a severe localized pain in the side of the chest
has considerable diagnostic importance as pointing to the presence of a
pulmonary embolus (Cohn).
When there is pre-existing cardiac disease of organic nature a syncopal
attack may sometimes occasion doubt with respect of a correct
diagnosis. The sudden loss of consciousness, excessive pallor, and
absence of pulse will ordinarily, however, confirm the diagnosis of
syncope. Rupture of the heart {388} is accompanied with symptoms of
syncope rather than those of suffocation (Balzer). Emboli of the
bronchial arteries are not accompanied by any characteristic symptoms
which will enable us to make a differential diagnosis. There is the
same sudden dyspnoea, the initial chill and hæmoptysis, as in pulmonary
embolism (Penzold).
PROGNOSIS.--As will be readily understood, the prognosis is sometimes
difficult to estimate and varies with many circumstances. Certain
emboli, even among those which have occasioned severe symptoms, have
never been recognized. Other pulmonary emboli always remain
comparatively latent. In this connection we should mention those which
take place in the lungs of tuberculous patients. Again, the size and
seat of the embolus will always have great importance in regard to the
prognosis. If the trunk or primary divisions of the pulmonary artery be
suddenly and completely obstructed by emboli, sudden death will surely
follow. If secondary divisions of the pulmonary artery are filled up,
more or less grave symptoms will usually follow. When emboli are
carried into the tertiary or still smaller branches of the artery, they
may not occasion any appreciable phenomena other than a moderate and
passing dyspnoea. If, however, there be a large number of small emboli
carried into both lungs at the same time, it is possible that rapid
death may follow their presence. It is true, however, according to
certain authors, that even a large embolus blocking up the main trunk
of the pulmonary artery may be followed by recovery. Such a case is
that of Jacquemier, reported by Ball. Even in this case, whilst the
presence of the embolus cannot perhaps be doubted, still the exact size
and location may be called in question. And here we may add that in all
cases of reported cure of this nature there will naturally and
inevitably exist an atmosphere of legitimate doubt about the correct
observations and diagnosis of the narrated facts.
What precedes relates exclusively to the existence of simple emboli. Of
course if the embolus be of septic origin, it will be followed by the
appearance in the lungs of foci of purulent pneumonia or of gangrenous
changes of tissue which will finally produce such structural
destruction as almost certainly to terminate in death.
TREATMENT.--The majority of those who have studied this subject have
recognized how vain are our efforts of treatment in many instances.
Pulmonary embolism is one of those accidents which we should always be
prepared to admit, however, when its characteristic symptoms show
themselves, and should endeavor rationally to combat by the therapeutic
means in our power. Even before we have any signs present which
indicate obstruction of the pulmonary circulation, we may have those
which point in a very certain manner to the existence of a peripheral
thrombus. This thrombus may block up completely one of the large veins
of the lower extremities, and may, owing to its possible detachment and
transport, be a constant menace to life. At times these peripheral
thrombi are accompanied by local inflammatory symptoms which belong to
phlebitis. This condition of things is not uncommon after fractures or
other traumatisms. Frequently there is no evidence of any inflammatory
state, and we recognize the thrombus solely by the signs which result
directly from obstructed venous circulation and by the existence of a
hard, indurated cord which fills the vein at a given level. Now, what
are the means we have at our command to prevent the transport of this
coagulum, or indeed to dissolve it, or absorb it in its place?
First, if inflammatory signs are present we should endeavor to subdue
these by local applications of an emollient character, for the reason
that excessive inflammation is apt to produce such changes as cause the
disaggregation of the clot, and hence its detachment. In either case,
whether there be or be not any local inflammatory condition, we should
insist upon absolute repose and quiet. We should not permit the limb to
be moved: we should be {389} extremely careful in all our manipulations
of it, and only employ those which are absolutely essential. The
patient should not be permitted to raise himself in bed, nor even eat
or drink without assistance. These counsels are very important, since
we know how frequently a very slight movement or exertion has been
followed immediately by the transport of the clot, pulmonary embolism,
and sudden death. In cases of fractures or severe wounds where such a
peripheral clot is discovered the surgeon should be particularly
careful in applying bandages and retentive apparatus. The risk of
displacement of the clot is greater after several days from the time of
the fracture or wound than it is at first, and it is at this period
that the most careful attention should be exercised. Instances are on
record in which so late as the fifty-seventh day after a fracture of
the lower extremity a peripheral thrombus was transported from its
original site and caused a fatal termination (Bouchard).
Some eminent writers have thought by employing a suitable medication we
might hasten the solution of the peripheral thrombi and thus prevent
their migration. With this view Legroux has given the acetate of lead
internally and applied it in solution over the seat of the thrombus.
Richardson has vaunted the use of the carbonate of ammonium in large
and frequently-repeated doses as a solvent of the fibrin. By its means
he believes he prevents the fibrin from precipitating from the blood,
and further helps it to resorb when it has already become solid.
Prevost, Dumas, and Schutzenberger recommend specially the bicarbonate
of sodium, taken internally, with a view of rendering the blood more
fluid and also hastening the retrogressive changes in the clot by its
oxidizing power. According to Boyer, the very object which is thus
sought if it were accomplished would result injuriously to the patient,
since it would favor the detachment of the clot. Further, the continued
use of large and frequent doses of ammonia or soda is prone to lower
the general system very much, and in this manner to act to the
prejudice of the patient. According to Azam, it would appear that what
we most desire to effect is the organization and adhesion of the
thrombus to the walls of the vessel. This can best be accomplished by
fortifying the patient in every possible way and raising his nutrition
to the highest attainable point. Iron, cinchona, the most nutritious
food, should be freely given. Further, the greatest attention should be
paid to the hygienic surroundings. The air should be purified, and if
by chance the patient is suffering from a wound close attention should
be given to the renewal of the dressings and the employment of a
disinfectant locally applied. One of the reasons for this last counsel
is because if the thrombus were detached it is important that it should
be free of any septic taint and not lead to specific accidents
(purulent pneumonia, gangrenous abscess). In the above enumeration we
include the means usually to be employed as preventive measures against
the migration of clots.
Is there any other method which can be adopted with any chance of
success? Of the surgical attempts we should mention favorably in
certain cases, and especially in those where the affected vein is
superficial, the adoption of persistent compression between the clot
and the heart. This means has been alluded to by J. Hunter[65] as far
back as 1773. Ligature and section of the vein have also been supported
by some writers as suitable operations to bring into use with a like
intent. Unfortunately, we are obliged to make a second traumatism in
order to carry out this object, and, further, we make by the ligature
at least a second coagulation, which may be the origin of the very
accident we seek to avoid. Nevertheless, J. Teissier[66] of Lyons
reports a case {390} observed by himself in the service of Noël Guéneau
de Mussey, in which a ligature was instrumental in arresting the onward
progress of the clot, which otherwise would have given rise to the
accidents of pulmonary embolism.
[Footnote 65: _Observations of the Inflammation of the Internal Coats
of the Veins_, quoted in thesis of Levrat, p. 108.]
[Footnote 66: _Nouveaux Éléments de Pathologie et de Clinique
médicale_, t. ii. p. 931, quoted by Balzer.]
In the event of pulmonary embolism taking place in spite of all
preventive means employed, what shall we do in order to combat this
terrible accident? According to Ball,[67] there are three indications
to be observed: 1. To establish collateral circulation in the lungs; 2.
To diminish local congestions; 3. To favor the resorption of the
obstacle.
[Footnote 67: _Thèse_ quoted, Paris, 1862.]
The first indication cannot be effectually responded to, by reason of
the fact that there is no way in which a collateral circulation can be
promoted in the lung, owing to its anatomical structure.
The second indication is best observed by the application to the
chest-walls of dry cups in large number, mustard poultices, turpentine,
blisters. In this place we must consider the propriety of bleeding. As
a result of the embolism there is arterial anæmia and venous plethora.
This latter condition can be temporarily relieved by venesection. In
this method, indeed, we have an immediate help for the distended and
burdened heart, and we give time to the system to recuperate somewhat.
We should, however, remember that bloodletting establishes a greater
tendency in the system to the formation of emboli, and is therefore to
be avoided. Moreover, sometimes it is decidedly objectionable on
account of cardiac degeneration, anæmia, or great weakness.
When this method is contraindicated we should not hesitate to recur to
the use of drastic purgatives (Jaccoud). Digitalis has been
recommended, so as to regulate the cardiac action and to increase its
power. Bertin has gone so far as to praise emetics and the use of the
faradic current over the thoracic parietes. It seems as if these were
dangerous methods to employ, since if a portion of the clot is still
undetached the efforts caused by these agents would be apt to separate
whatever portion remained in its original site. In order that a
quantity of oxygen should be inhaled in a given time sufficient to
supply the needs of the economy until a greater power of oxygenating
the blood is established, the inhalation of compressed air has been
vaunted. The objection to this means is merely the one which arises as
we reflect how improbable it is that this agent would be at hand in a
serviceable form when the sudden accidents of pulmonary embolism take
place.
The third indication, to favor the resorption of the obstacle, must be
virtually attended to by giving the alkalies in large doses internally.
The advantages and objections to this sort of treatment we have already
referred to.
After this exposition of the different means to be employed, both as
preventive and curative agents of pulmonary embolism, we are obliged to
recognize that very frequently they remain ineffectual. Usually the
accident takes place in a very sudden manner and when we are least
suspecting its advent. When the phenomena do occur which are caused by
its presence, they take place so suddenly, and terminate fatally in
such a brief period, that we scarcely have the time to employ the
remedial agents referred to. Finally, we must admit that in presence of
this complication, especially when there is complete obstruction of the
trunk or primary divisions of the pulmonary artery, all our therapeutic
means are without avail, and we are indeed almost powerless.
{391}
PULMONARY PHTHISIS (FIBROID PHTHISIS OR CHRONIC INTERSTITIAL
PNEUMONIA).
BY AUSTIN FLINT, M.D.
DEFINITION.--Pulmonary phthisis is a chronic disease, characterized in
its common form, anatomically, by a morbid product within the
air-cells, in a large majority of cases progressively increasing and
extending, having a tendency to cheesy degeneration and liquefaction
forming collections of puriform liquid which, evacuating by ulceration
into the bronchial tubes, are followed by cavities, these pathological
conditions accompanied by more or less induration from interstitial
morbid growth and by small granules called miliary tubercles. A
comparatively rare form of the disease is characterized by the great
predominance of interstitial growth, leading to notable diminution of
the volume of lung by atrophy and to dilatation of the bronchial tubes.
The latter form is now commonly distinguished as fibroid phthisis. This
will claim separate consideration after having considered the form
generally understood by the name pulmonary or pneumonic phthisis.
SYNONYMS.--Classification.--Much confusion, as regards nomenclature and
classification, followed the adoption by many of the theory of Virchow
that the sole characteristic of tuberculous disease is the presence of
the so-called miliary tubercles. According to this theory, the morbid
product which constitutes the most marked anatomical feature of the
common form of phthisis is simply an inflammatory exudation.
Heretofore, pulmonary phthisis and pulmonary tuberculosis were
considered as convertible terms, but, adopting Virchow's theory, in a
certain proportion of cases pulmonary phthisis is not a tuberculous
disease. Hence arose a variety of names denoting non-tuberculous
phthisis, such as chronic broncho-pneumonia, chronic lobular pneumonia,
catarrhal pneumonia, cheesy pneumonia, etc. These names have shared the
fate of the theory from which they originated, the latter, at the
present time, having but few supporters in any country. It is
convenient to distinguish the morbid product which is characteristic of
pulmonary phthisis as a tuberculous product, and it will be so
distinguished in this article.
The name acute pulmonary tuberculosis denotes an affection which may be
sharply separated from the chronic forms of pulmonary phthisis. The
acute affection is characterized by the presence, exclusively or in
great abundance, of miliary tubercles. It runs a rapid course and the
symptoms are those of an acute disease. The name phthisis implies a
chronic affection. In a small proportion of the cases of pulmonary
phthisis miliary tubercles become developed in great abundance. In
these cases acute pulmonary tuberculosis supervenes upon chronic
phthisis. These cases, by those who regarded phthisis in its ordinary
form as a non-tuberculous affection, were designated cases of
tuberculous phthisis. The fact that in cases {392} of phthisis there is
a liability to the supervention of miliary tubercles as abundantly as
in cases of acute tuberculosis, is to be borne in mind, but it does not
seem necessary to make a distinct variety of the disease on the basis
of this fact. In some cases of pulmonary phthisis the tuberculous
product is notably large at the outset, and destructive changes in the
lungs go on continuously with unusual rapidity. To these cases the
names phthisis florida and galloping consumption have been applied.
In view of what has been stated, the classification in this article
will not extend beyond a division into the common form of pulmonary
phthisis and the form distinguished as fibroid phthisis. The latter
form has been designated chronic interstitial pneumonia, chronic
pneumonia, and cirrhosis of lung. It is to be understood that reference
is had to the common form of pulmonary phthisis, except in that portion
of this article which has for its heading Fibroid Phthisis.
HISTORY.--Pulmonary phthisis, in typical cases, is developed so
imperceptibly that it might with propriety be included among the
so-called insidious diseases. A slight dry cough is the first local
symptom. This increases, and after a variable period is accompanied by
the expectoration of a small quantity of mucus. The latter becomes
gradually more abundant, and has the characters of the sputa in cases
of bronchitis. So slow is the increase of those symptoms before they
are regarded as of sufficient importance to require attention that not
infrequently the patient is unable to state precisely how long they
have existed. They are generally attributed to a slight cold which will
take care of itself or call for only popular remedies, and the
existence of a grave disease may not have been suspected until a
physical examination of the chest discloses the fact that the
phthisical affection has already made considerable progress. Coincident
with or preceding the commencement of cough is often some obvious
impairment of the general health, as indicated by diminished muscular
strength and endurance, decrease in weight, pallor of the complexion,
and lessened appetite. The impairment, however, may not interfere with
customary occupations, and may be evident to others when the patient
takes no cognizance of it.
In not a few instances hæmoptysis is the event which first awakens
suspicion of an important disease. The hemorrhage generally takes place
without any apparent causation, and often in the night. It may be
either slight or profuse. It may occur but once, or there may be
recurrences after intervals of hours, days, or weeks. The cough in some
cases dates from the occurrence of hæmoptysis. In other cases the
hemorrhage or hemorrhages antedate the cough for a variable period.
From the time when the symptoms and physical signs render the diagnosis
of the disease positive the history in different cases presents notable
variations. Comparatively, the course of the disease is continuously
progressive and rapid in cases of so-called galloping consumption. The
characteristics of the disease in these cases are--an unusual degree of
cough with abundant expectoration, rapid breathing, frequency of the
pulse, persistent pyrexia, chills or chilly sensations followed by
exacerbations of fever, profuse perspirations, anorexia, rapid
emaciation with decreasing muscular strength, and a fatal termination
after a few months. The physical signs in these cases show a large and
progressively increasing amount of solidification from the morbid
product, followed quickly by destructive changes.
The disease pursues a rapid course, and ends fatally whenever acute
tuberculosis supervenes. This may occur in the early part of the
chronic phthisical affection or at any period during its course. The
supervention of the acute disease sometimes follows a profuse
hæmoptysis. The characteristics are high fever, frequency of the pulse,
cyanosis, prostration, and death within a few weeks or even a few days.
The physical signs which denote a large {393} extent of solidification
of lung and the consequent destructive changes are wanting in these
cases.
A small proportion only of cases of pulmonary phthisis fall in the
category either of galloping consumption or of the supervention of
acute tuberculosis. In by far the larger proportion the disease is
chronic from the beginning to the end, and a fatal termination takes
place after a period averaging from two to three years, the period
sometimes extending to many years.