E. E., aged forty-two years, was confined for the first time on November 5, 1873, in the sixth month of utero-gestation. She had severe post-partum hemorrhage, depending on partially adherent placenta, which was removed artificially. She did perfectly well until the fourteenth day after delivery, when she was suddenly attacked with intense dyspnoea, aggravated in paroxysms. Pulse pretty full, 130, but distinctly intermittent. Air entered lungs freely, The heart's action was fluttering and irregular, and at the juncture of the fourth and fifth ribs with the sternum there was a loud blowing systolic murmur. This was certainly non-existent before, as the heart had been carefully auscultated before administering chloroform during labor. For two days the patient remained in the same state, her death being almost momentarily expected. On the 21stthat is, two days after the appearance of the chest symptoms-phlegmasia dolens of a severe kind developed itself in the right thigh and leg. She continued in the same state for many days, lying more or less tranquilly, but having paroxysms of the most intense apnoea, varying from two to six or eight in the twenty-four hours. No one who saw her in one of these could have expected her to live through it. Shortly after the first appearance of the paroxysms it was observed that the cellular tissue of the neck and part of the face became swollen and edematous, giving an appearance not unlike that of phlegmasia dolens, The attacks were always relieved by stimu lants. These she incessantly called for, declaring that she felt that they kept her alive. During all this time the mind was clear and collected. The pulse varied from 110 to 130; respirations about 60; temperature 101° to 102.5°. By slow degrees the patient seemed to be rallying. The paroxysms diminished in number, and after December 1st she never had another, and the breathing became tree and easy. The pulse fell to 80, and the cardiac murmur entirely disappeared. The patient remained, however, very weak and feeble, and the debility seemed to increase. Toward the second week in December she became delirious, and died, apparently exhausted, without any fresh chest symptoms, on the 19th of that month. No post-mortem examination was allowed. I have narrated this case, although it terminated fatally, because I hold it to be one of the class I am considering. The death was certainly not due to the obstruction, all symptoms of which had disappeared, but apparently to exhaustion from the severity of the former illness. It illustrates, too, the simultaneous appearance of symptoms of pulmonary obstruction and peripheral thrombosis. The swelling of the neck was a curious symptom, which has not been recorded in any other cases, and may possibly be a further proof of the analogy between this condition and phlegmasia dolens. Such Cases can only Depend on Pulmonary Obstruction.— Now it may, of course, be argued that these cases do not prove my thesis, inasmuch as I only assume the presence of a coagulum. But I may fairly ask in return, What other condition could possibly explain the symptoms? They are precisely those which are noticed in death from undoubted pulmonary obstruction. No one seeing one of them, or even reading an account of the symptoms, while ignorant of the result, could hesitate a single instant in the diagnosis. Surely, then, the inference is fair that they depended on the same cause. In the very nature of things my hypothesis cannot be verified by post-mortem examination; but there is at least one case on record in which, after similar symptoms, a clot was actually found. The case is related by Dr. Richardson.' It was that of a man who for weeks had symptoms precisely similar to those observed in the cases I have narrated. In one of his agonizing struggles for breath he died, and after death it was found that a fibrinous band, having its hold in the ventricle, extended into the pulmonary artery." This observation proves to a certainty that life may continue for weeks after the depositing of a coagulum; and, moreover, this condition was precisely what we should anticipate, since, of course, the obstructing coagulum must necessarily be small, otherwise the vital functions would be immediately arrested. Cardiac Murmurs in Pulmonary Obstruction.-There is a symptom noted in two of the above cases, and to a less extent in a 1 Clinical Essays, p. 224 et seq. third, which has not been mentioned in any account of fatal cases occurring after delivery, viz., a murmur over the site of the pulmonary arteries. It is a sign we should naturally expect, and very possibly it would be met with in fatal cases if attention were particularly directed to the point. In both these instances it was exceedingly well marked, and in both it entirely disappeared when the symptoms abated. The probability of such a murmur being audible in cases of thrombosis of the pulmonary artery has been recognized by one of our highest authorities in cardiac disease, who actually observed it in a nonpuerperal case. In the last edition of his work on diseases of the heart, Dr. Walshe says: "The only physical condition connected with the vessel itself would probably be systolic basic murmur following the course of the pulmonary main trunk and of its immediate divisions to the left and right of the sternum. This sign I most certainly heard in an old gentleman whose life was brought to a sudden close in the course of an acute affection by coagulation in the pulmonary artery, and to a moderate extent in the right ventricle. Similar cases have, probably, been overlooked or misinterpreted. Many seem to have been attributed to shock, in the absence of a better explanation, a condition to which they bear no kind of resemblance. Causes of Death. The precise mode of death in pulmonary obstruction, whether dependent on thrombosis or embolism, has given rise to considerable difference of opinion. Virchow attributes it to syncope, depending on stoppage of the cardiac contraction. Panum,3 on the other hand, contests this view, maintaining that the heart continues to beat even after all signs of life have ceased. Certainly tumultuous and irregular pulsations of the heart are prominent symptoms in most of the recorded cases, and are not reconcilable with the idea of syncope. Panum's own theory is that death is the result of cerebral anæmia. Paget seems to think that the mode of death is altogether peculiar, in some respects resembling syncope, in others anæmia. Bertin, who has discussed the subject at great length, attributes the fatal result purely to asphyxia. The condition, indeed, is in all respects similar to that state, the oxygenation of the blood being prevented, not because air cannot get to the blood, but because blood cannot get to the air. The symptoms also seem best explained by this theory; the intense dyspnoea, the terrible struggle for air, the tion of intelligence, the tumultuous action of the heart, are certainly not characteristic either of syncope or anæmia. preserva Post-mortem Appearances of Clots.-The anatomical character of the clots seems to vary considerably. Ball, by whom they have been most carefully described, believes that they generally commence in the smaller ramifications of the arteries, extending backward toward the heart, and filling the vessels more or less completely. Toward its cardiac extremity the coagulum terminates in a rounded head, in which respect it resembles those spontaneously formed in the peripheral veins. It is non-adherent to the coats of the vessels, and the blood circulates, when it can do so at all, between it and the vascular walls. 1 Walshe: On Diseases of the Heart, 4th ed., 1873. Virchow's Archiv, 1863 Such clots are white, dense, and of a homogeneous structure, consisting of layers of decolorized fibrin, firm at the periphery, where the fibrin has been most recently deposited, and softened in the centre where amylaceous or fatty degeneration has commenced. Ball maintains that if the coagulum have commenced in the larger branches of the arteries, it must have first begun in the ventricle and extended into them. According to Humphry the same changes take place in pulmonary as in peripheral thrombi, and they may become adherent to the walls of the vessels or converted into threads or bands. When the obstruction is due to embolism, provided the case is a well-marked one and the embolus of some size, the appearances presented are different. We have no longer a laminated and decolorized coagulum, with a rounded head, similar to a peripheral thrombus. The obstruction in this case generally takes place at the point of bifurcation of the artery, and we there meet with a grayish-white mass, contrasting remarkably with the more recently deposited fibrin before and behind it. It may be that the form of the embolus shows that it has recently been separated from a clot elsewhere; and in many cases it has been possible to fit the travelled portion to the extremity of the clot from which it has been broken. We may also, perhaps, find that the embolus has undergone an amount of retrograde metamorphosis corresponding with that of the peripheral thrombus from which we suppose it to have come, but differing from that of the more recently deposited fibrin around it. It must be admitted, however, that the anatomical peculiarities of the coagula will by no means always enable us to trace them to their true origin. In many cases emboli may escape detection from their smallness or from the quantity of fibrin surrounding them. Treatment.-But few words need be said as to the treatment of pulmonary obstruction. In a large majority of cases the fatal result rapidly follows the appearance of the symptoms that no time is given us even to make an attempt to alleviate the patient's sufferings. Should we meet with a case not immediately fatal, it seems that there are but two indications of treatment affording the slightest rational ground of hope. 1. To keep the patient alive by the administration of stimulantsbrandy, ether, ammonia, and the like-to be repeated at intervals corresponding to the intensity of the paroxysms and the results produced. In the cases I have above narrated, in which recovery ensued, this took the place of all other medication. Possibly leeches, or dry cupping to the chest, might prove of some service in relieving the circulation. 2. To enjoin the most absolute and complete repose. The object of this is evident. The only chance for the patient seems to be that the vital functions should be carried on until the coagulum has been absorbed, or at least until it has been so much lessened in size as to admit of blood passing it to the lungs. The slightest movements may give rise to a fatal paroxysm of dyspnoea, from the increased supply of oxygenated blood required. It must not be forgotten that in a large proportion of cases death immediately followed some exertion in itself trivial, such as rising out of bed. Too much attention, then, cannot be given to this point. The patient should be kept absolutely still; she should be fed with abundance of fluid food, such as milk, strong soups, and the like; and she should on no account be permitted to raise herself in bed, or attempt the slightest muscular exertion. If we are fortunate enough to meet with a case apparently tending to recovery, these precautions must be carried on long after the severity of the symptoms has lessened, for a moment's imprudence may suffice to bring them back in all their original intensity. Bertin,' indeed, recommends a system of treatment very different from this. In the vain hope that the violent effort induced may cause the displacement of the impacted embolus (to which alone he attributes pulmonary obstruction), he recommends the administration of emetics. Few, I fancy, will be found bold enough to attempt so hazardous a plan of treatment. Various drugs have been suggested in these cases. Richardson2 recommended ammonia, a deficiency of which he at that time believed to be the chief cause of coagulation. He has since advised that liquor ammoniæ should be given in large doses, twenty minims every hour, in the hope of causing solution of the deposited fibrin; and he has stated that he has seen good results from the practice. Others advise the administration of alkalies, in the hope that they may favor absorption. The best that can be said for them is that they are not likely to do much harm. The inhalation of oxygen, which has been used with great success in severe pneumonia,3 is obviously a hopeful remedy in this condition, and is well worthy of trial. Puerperal Pleuro-pneumonia.-This is, perhaps, the best place to mention an important but little understood class of cases which I believe to be less uncommon than is generally supposed. I refer to severe pleuro-pneumonia occurring in connection with the puerperal state, but not distinctly associated with septicemia. Two carefully observed cases of this kind are recorded by MacDonald, occurring in his practice; I myself have met with three very marked examples within the past three years, one of which proved fatal, the other two giving rise to most serious illness, from which the patient recovered with difficulty. So far as my own observation goes there are marked peculiarities in such cases which clearly differentiate them from the ordinary course of pneumonia. The onset is sudden and unconnected with exposure to cold or other cause of lung disease; there is no definite crisis, but a continuous pyrexia of moderate intensity lasting a variable time; and the physical signs differ from those of ordinary pneumonia. Physical Signs.-In MacDonald's case, as well as in my own, they were peculiar in this respect, that there was very slight crepitation, marked rusty sputum, and a wooden dulness, much more intense than in ordinary pneumonia, extending over a large lung space, with a very slight entrance of air into the lung tissue. It is also remarkable that a very large proportion of the cases were associated with phlegmasia 1 Op. cit., p. 393. Heart Disease during Pregnancy, p. 209. 3 "On the Use of Oxygen and Strychnia in Pneumonia," Brit. Med. Journ., January 23, 1892. dolens. Thus it existed in one of MacDonald's two cases, and in two out of my own three. Like phlegmasia dolens, moreover, the disease generally commenced some weeks after delivery; my own cases, for example, occurred respectively fifteen, twenty-eight, and thirty-five days after labor. It is difficult to believe that there is not some connection between these two conditions, and there is much in their peculiar history to lead to the belief that such forms of lung disease depend, in fact, on the thrombotic or embolic obstruction of the minute branches of the pulmonary arteries, caused by conditions similar to those which have produced the phlebitic obstructions in the lower extremities. In the absence of careful post-mortem examination this hypothesis is clearly not susceptible of proof. MacDonald, while admitting that "a limited thrombosis of the pulmonary arteries would no doubt explain the facts of the cases," is rather inclined to "seek the chief explanation of their occurrence in the alterations which the pregnant and puerperal conditions impress upon the blood and the blood-vascular system." I confess that to my mind the former hypothesis is not only the most definite, but the one which most readily explains all the peculiarities of these cases. I cannot, however, do more thau suggest it, in the hope that further observations, and especially carefully conducted autopsies, may throw some light on this obscure and littlestudied subject. Treatment.-As regards treatment, it is obvious that it must be conducted on general principles, carefully avoiding over-severe measures, and supporting the patient through a trial to the system that must necessarily be severe. CHAPTER VII. PUERPERAL ARTERIAL THROMBOSIS AND EMBOLISM. Arterial Thrombosis and Embolism.-The same condition of the blood which so strongly predisposes to coagulation in the vessels through which venous blood circulates tends to similar results in the arterial system. These, however, are by no means so common, and do not, as a rule, lead to such important consequences. The subject has been but little studied, and almost all our knowledge of it is derived from a very interesting essay by Sir James Simpson. As I have devoted so much space to the consideration of venous thrombosis and embolism, I shall but briefly consider the effects of arterial obstruction. Causes. In a considerable number of recorded cases the obstruc 1 Selected Obstet. Works, vol. i. p. 523. |