— This form of congestion is generally ob served in elderly people who are obliged, through disease, to remain a long while in the dorsal position. The shoulders being raised by the pillows, the blood normally accumulates in the bases. Chronic diseases, long-continued fevers, and cardiac disease attended by weak ness of the heart-muscle may thus favor the development of the disease. Fract ured limbs in the aged may also prove indirectly causative if the patient is al lowed to remain in bed beyond a certain time. The lesions resemble those of a mild lobular pneumonia. The capillaries are enlarged, the air-cells more or less collapsed, and the lung-tissue is dark red, dense, and engorged with blood and serum: a condition which has been termed "splenization." — The prevention of hypostatic congestion should be an im portant feature of the measures adopted in cases of paralysis, protracted tubercu losis, cancer, fracture, typhoid fever, etc., especially when these occur in old subjects. The posture should be fre quently changed, not only from side to side, but also in respect to the elevation of the shoulders. The semiprone posi tion—the patient lying with one side of his abdomen touching the bed—is a use ful one to prevent or relieve the local engorgement, but he should be allowed to leave his bed as soon as at all practi cable. It is important to sustain cardiac action; this may best be done by means of strychnine, nitroglycerin, caffeine, or digitalis.
Pulmonary HTmorrhage.
Pulmonary hcemorrhage or bleeding within the lungs may be caused by vari ous disorders and injuries, and erosion or rupture of the walls of the pulmonary vessels, large or small. It may be most conveniently divided into two forms: the broncho-pulmonary (bronchorrhagia), in which the blood flows into the bronchi and is eliminated through the mouth— constituting Inremoptysis; and pulmo nary apoplexy (pneumorrhagia), in which the blood accumulates in the pulmonary parenchyma, or the lung-tissue and the air-cells.
Broncho-pulmonary Hemorrhage. Although this form of hemorrhage is one of the prominent symptoms of pul monary tuberculosis, it is important to realize that the latter affection is by no means the only one in which hemoptysis may occur. It is a comparatively fre quent accompaniment of cardiac dis orders, diseases of the nasal cavities, pharynx, larynx, and trachea; aneurism; menstruation; arthritism; purpura hrem orrhagica; haemophilia; the Distomum pulmonale, and other disorders.
Symptoms and Diagnosis. — In rare cases the quantity of blood is so great that the flow occurs from the nose and the mouth simultaneously. Again, it may be swallowed as rapidly as it reaches the laryngeal aperture, enter the stom ach, and be regurgitated. But, in the majority of cases, the flow is not great; the patient first experiences a warm, salty taste, then ejects more or less great quantities of bright-red frothy blood. It may be brought up with a
cough, or suddenly fill the mouth and be expectorated. Small quantities may be brought up from time to time and merely permeate the saliva with films or streaks. The first hmmoptysis may prove to be the last; it may recur a few hours later or the next day. When repeated haemor rhages occur, the last sputa assume a dark aspect; this represents blood which has sojourned in the bronchi, and usu ally indicates an early cessation. Dysp ncea and a sensation of heat in the chest are sometimes complained of. If the haemorrhage is great, unconsciousness may occur.
Besides pulmonary tuberculosis (see TUBERCULOSIS), of which pulmonary haemorrhage is one of the prominent earlier symptoms, and the diseases such as purpura licemorrhagica, hemophilia, scurvy, malignant infectious diseases, hepatic cirrhosis, etc., that are often at tended by this symptom, hmmoptysis may occur in the following disorders:— Cardiac Disorders.—Hmmoptysis fre quently occurs when valvular disorders involving stenosis are present, and espe cially when the mitral and aortic valves are diseased. Besides the general symp toms of the cardiac affection, the char acter of the blood assists in establishing the diagnosis. Instead of being bright red and frothy, as in tuberculosis, it is, as a rule, dark and more or less mixed with mucus. It does not present itself in the mouth in sudden jets, but usually comes up as would muco-purulent sputa. Again, the sanguineous expectoration continues several weeks, sometimes with out causing untoward symptoms.
Menstruation.-11mmoptysis some times replaces menstruation in women. The limmorrliages are then periodical; or they may be observed as a sequel to the menopause and occur repeatedly, also at regular intervals. All such cases should be watched, debility and vulner ability of the pulmonary structures be ing at times either concomitant or result ing conditions under such circumstances. Periodical lnemoptysis is occasionally observed after removal of the ovaries.
Xaso-pharyngeal Disorders. — These are frequently attended by slight Inum orrhage; as a rule, the blood is brownish and the symptoms of chronic naso-phar yngitis or other local disorders may be present. Tumors, especially fibroma and sarcoma of the nose and naso-pharynx, may give rise to copious hmmoptysis; hut recurrent epistaxis often attracts at tention to the seat of the disease. In a case of my own, copious recurrent haem orrhage was traced to an ulcer in the pharyngeal vault, which proved to be tuberculous. Varices of the pharynx and lingual tonsil occasionally rupture, and may give rise to a copious flow of blood.