Pulmonary Embolism.
This consists of a mechanical obstruc tion of one or more pulmonary arteries by an embolus or thrombus.
Symptoms.—While a diminutive in farction may pass unnoticed, complete occlusion of a large pulmonary artery may occasion instant death. Symptoms arise when the embolus does not com pletely fill the lumen of the artery in volved, or when the latter is not of suffi cient size to completely disturb the pul monary circulation, even though the vessel be completely occluded. Under these circumstances, dyspncea is experi enced. It gradually increases in se verity, and may be preceded by uncon sciousness and convulsions. The patient gasps for breath and indicates, by his frantic efforts to inhale, the intensity of his suffering. The pulse becomes weak and thready; the skin is cold and clammy and is covered with sweat. Severe lo calized pleuritic pain and a hard and har assing cough are usually present, and the patient expectorates masses of bloody gelatinous mucus. This reveals, upon microscopical examination, peculiar large lymph-cells resembling alveolar cells and embodying blood-corpuscles. These giant cells are thought to transform the blood-corpuscles into pigment-matter. They are seen especially in cases of heart disease, and are known as the "cells of heart-failure" (Whittaker). As the case progresses, local suppuration with meta static abscesses occur, and all the evi dences of pyfemia may appear. Dissolu tion of the thrombus may take place and the abscesses may undergo resolution; but, as a rule, the prognosis is serious.
Diagnosis.—When associated with the symptoms enumerated,—dyspncea, syn cope, bloody expectoration, etc.,—the physical signs assist in establishing the diagnosis. But they are only clearly ob tained when the lesion is not too deeply seated. A localized consolidation giving rise to dullness under percussion, bron chial respiration, increased resonance, and a friction-sound, when the tension is near the pleura, represent the only signs which may be attributed to the embolus, all others being due to condi tions developed secondarily.
Four typical cases of pulmonary em holism in childbed with severe symptoms noted, three ending fatally. The fourth occurred in a woman who had passed through a normal labor and got up on the tenth day; one main branch seems to have been plugged, but the patient re covered. Vogt (Norsk flag. for Liige vid., p. 1, 130, '97).
Etiology and Pathology.—Pulmonary embolism is due to stasis, in the majority of cases, the primary factor being a pul monary or cardiac affection. The infarct generally consists of a mass of leucocytes and red corpuscles. It is usually firm and brownish and varies in size from that of a cherry to that of an entire lobe, since in some cases the entire vascular supply of a lobe is involved. Its velope is formed of a thin film of fibrin.
Hsemorrhagic infarctions often develop near the pleura and at the back of the lower lobe.
11'yders reports 9 cases of fatal pul monary embolism after gynecological operations, several of them of minor character. Four of the patients were suffering from extensive carcinoma and another from septic endometritis. All the other eases were uninfected and un complicated. Mahler had 22 cases of pulmonary embolism-10 postpartum and 12 after gynecological operations. Welch mentions four cases of thrombo -is of the left leg occurring among 131 cases of appendicitis. Biggs reports the condition once subsequent to fracture of the neck of the femur, once to fracture of the acetabulum and spine of the ischium, and thrice to operation. E. L. Keyes (New York Med. Jour., April 5, 1902).
Treatment.—This can only be symp tomatic, the patient's strength being sus tained and the patient's position so ad justed as to facilitate respiration; this is usually best accomplished by elevating the upper part of the body. Gessner (Centralb. f. Gynak., No. G, '97) mends hypodermic injections of ether or morphine.