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Problem of Pulmonary Embolism : Report of Thirty Nine Cases

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Problem of Pulmonary Embolism : Report of Thirty Nine Cases University of Nebraska Medical Center DigitalCommons@UNMC MD Theses Special Collections 5-1-1935 Problem of pulmonary embolism : report of thirty nine cases Richard Birge University of Nebraska Medical Center This manuscript is historical in nature and may not reflect current medical research and practice. Search PubMed for current research. Follow this and additional works at: https://digitalcommons.unmc.edu/mdtheses Part of the Medical Education Commons Recommended Citation Birge, Richard, "Problem of pulmonary embolism : report of thirty nine cases" (1935). MD Theses. 565. https://digitalcommons.unmc.edu/mdtheses/565 This Thesis is brought to you for free and open access by the Special Collections at DigitalCommons@UNMC. It has been accepted for inclusion in MD Theses by an authorized administrator of DigitalCommons@UNMC. For more information, please contact [email protected]. Report of Thirty-nine Ca••• Richard Birge Senior Thesie tJniversit7 of •ebraslca College of Medicine Omaha, •ebraska 1935 TA:BLB OJ OOl'!lftS Page I. IB'J!IODUC!CllY ••••••••••••••••••••••••••••••••••••••••••••••••••• 1 II. THE OLIBICAL CAO .A.. S711>toma ••••••••••••••••••••••••••••••••••••••••••••••••••• 3 :e. Diagnoa1a •••••••••••••••••••••••••••••••••••••••••••••••••• ., III. MORBID .AD.!.OMY .A.. '1'he J.utopay :rindinga ••••••••••••••••••••••••••••••••••••••• 10 B. The fhroabue ••••••••••••••••••••••••••••••••••••••••••••••• 12 c. The Bm'bolua................................................ 15 D. The Pathological Ja.clr&round •••••••••••••••••••••••••••••••• 17 1. PlQ"aical and Mec:hanical Jactors Concerned in !rhrombosia and Embolism............................. 18 2. Biochemical J'actora Concerned. ill !hromboaia 8lld .,.boliam. •••••••••••••••••••••••••••• 22 3. The Role of Infection.................................. 29 IT. ml INCIDDCE OF POLMOIWlY mmotIS.-CONSIDIRA!IOB OJ' CAD BISTOllDS .A.. General Conaiderationa ••••••••••••••••••••••••••••••••••••• 33 B. Relation of .Age to PulmoDa17 Bmboliam •••••••••••••••••••• ". 34 C. Relation of Sex to Pulmna17 Jlmboliam...................... 35 D. Relation of Race to Palmonar7 lmboliam. •••••••••••••••••••• 35 •· !he Sourcea of Pa.lm:>na.ry Em.boll •••••••••••••••••••••••••••• 35 J'. Relation of PnlmoDa.17 lmboliam to the Pri111a17 Diaeaae. • • • • • 36 G. latal Pulmona.17 Kmbollam ••••••••••••••••••••••••••••••••••• 38 K. Postoperative and Poat Partum Palmnar;r &aboliam. •••••• •••• 41 I. Relation of Heart Diaeaae to Pul.moDar1 Jlmboliam....... • • . • • 41 J. Paln>na?'7 :lm'boliem Complicating Septic !rhromboais •••••••••• 45 x. Relation of Theraw to Pulmona17 lmboliam.......... • • • • • • • • 45 L. Presentation of Case Kiatoriea •••••••••••••••••••••••••••••• 46 V. 1IOTIS 01 'fBEB.APltJSIS ••••••••••••••••••••••••••••••••••••••••••• 92 VI. SUMYA.ttt •••••••••••••••••••••••••••••••••••••••••••••••••••••••• 95 TII. BIBLIOCIRlPBt ••••••••••••••••••••••••••••••••••••••••••••••••••• 96 ..... ,_ 4806?6 THE PROBLIM OF PULMONARY EMBOLISM: Report of Thirt7-nine Cases INTRODUCTORY The question of pulmoDa.17 embolism ha.a become quite recentl7 one of m:>re than usual interest at the University Hospital. In a period of leas than four months, during the latter part of 1934, six cases of fat~l pulmonary embolism came to autopsy. There had been no caaes of fatal pulmonary embolism during the first eight months of 1934, but one case in 1933, and two in 1932. A. review of these cases revealed. nothing which might explain the increased incidence of fatal pulm:>nar7 embolism. It was, however, known to the writer that a quite large percentage of autopsies show evidence of pulmonary embolism, when both fatal and non-fatal cases are considered. It was recalled that, since the occurrence of pulmonary embolism depend.a upon the formation of priiary thrombi in the systemic venous ayatem or in the right heart, the amount of thrombus which might break loose and reach the pulm:>nary arterial system through the blood stream would be the essential factor determining the outcome of a given case. It seemed that one might consider the occurrence of thrombosis as the fundamental pathological chaDge in these cases, and tlle embolic involvement of the l'UJlgs as incidental or accidental. It this conception were proper, leas significance C011ld be attached to an increase in the occurrence of fatal pulm>nary emboliam over a short period of time. The important problem PROBLEM OF PULMONARY EMBOLISM 2 would be to determine whether the increase in fatal cases was actually accompanied by an increase in total cases of pulmonary- embolism, or whether the increaae depended only- upon the fact that, in a small group of' cases, larger than usual emboli had gained access to the pulmonaey arteries. University Hospital records for a three-year period ending December 31, 1934 reveal a smaller n'tllllber of pulmonal7 emboli found at post-mortem examination during 1934 than during either of the two preceding years, although pulmonary embolism aa the primaey cause of death was more frequent in 1934. In the three-79ar period 309 autopsies were performed. In thirty­ nine, the post-mortem diagnosis of pulmonary embolism or pulmonal7 infarction was ma.de, and in nine, pulmonaey embolism was found to be the primary cause of death. !he percentage incidsnce was 12.6 per cent for total cases show­ ing pulmonary embolism or infarction, and 2. 9 per cent for cases of fatal pulmonaey embolism. Thia series of cases is too small for a critical atu.c!T of the incidence of pulmonary embolism and of the more important factors related to ita occurrence. It is of interest because it demonstrates the total incidence of pulmonary embolism cases at the University Hospital to be comparable to that of other hospitals and clinics where much larger aeries have been acC'Ulll'l1l.ated, and, most important of all, because 1t demonstrates no increase in total pulmonary embolism cases in 1934 corresponding to the increase in fatal pulmonary embolism cases during that -rear. The thirty-nine autopsy cases seen in the University Hospital during 1932, 1933, and 1934 are S'UDllllB.l"ized, and their essential features, in rela• Uon to the comoon finding of evidence of pulmonary embolism, are discuase4 in the following pages. THE CLINIC.AL CASE Symptoms Pulmonaey embolism may be so insignificant as to produce no symptoms whatsoever, or so massive as to result 1n death in a few minutes or hours. It occurs most frequently in middle-aged or elderly patients following some . -1 minor exertion to which the patient has been ilnaccuatomed, as, for example, getting out of bed. The chief symptoms are ~ea, cyanosis or pallor, often precordial or substernal pain, sweating and other evidences of shock, and eometimee anxiety with fear of impending disaster. The severity of the symptoms depends largel.7 on the size and number of emboli and the resultant degree of embarrassment of the pulmonary circulation• .A. sudden and unexpected onset of s;vmptoDB is characteristic. Death ensues within a short time if the common pul:mnary artery is occluded or if multiple small emboli occlude a sufficient amount of the pulmoJla17 arterial system. However, death is not immediate. Of the nine Un1vers1t7 Hospital cases (pages 48 to 58) in which plil.monar;y embolism was the immediate cause of death, the shortest period intervening between onset of &1JU.Ptoms and exitus was seven minutes in case 4 (page 51), and the longest period was two hours and twenty-five minutes in case 5 (page 53) • .A.t necropsy -.sive emboli were found in the common pul:mnar;v arterT, but, because of the length of survival, after the onaet of sYq>toms, it is apparent that occlusion could not have been complete in 8J17 case. In this respect the experimental work of Haggart and Walker (26) on laboratory animals is of passing interest. They found that until from 52 to 66 per cent of the pulm:>nar;v circulation is cut off there ia no significant variation of the circulatory condition of an animal, and that the end-point PRO:BLEM OF PULMOHA.RY EMBOLISM 4 (52 to 66 per cent) is sharply defined, and circulato1"7 collapse is pre­ cipitated by minute increases in pulmona.r;y arterial obstruction be7ond the end-point. Relativel7 small pulmonaey emboli DlaY' cause sudden, sharp pain in the chest, producing signa of consolidation and perhaps a friction rub. The teDg?erature rises, and the leucocyte count is usua.ll;r found to be moderatel;r increased. The respiration is shallow and rapid, due to the pain produced by deep breathing. A.fter a abort time cough 11!81' develop with expectoration of blood-streaked aputum. A.fter a few days the symptoms 11181' resolve and the patient coupletel7 recover. Case 14 (page 63), for example, complained on .A.pril 30, 1932 of sudden onset of pain, exaggerated by deep breathing, over the region of the liver; there was heDDptyt1is in small amounts for three days; and ph1's1cal examination revealed an area of dullness over the right lower lobe. The symptoms of pulmonar;r embolism cleared up and the patient died a week later, a cardiac death. Necrops;r revealed a large intarct in the right lower lobe. There may be multiple and smaller emboli, followed by larger onea. Blood-t i?J88d sputum is usually seen after the lodgement of the earlier emboli, and a patient 1118.7 have apparentl7 recovered when the proceas ia repeated. On August 10, 1934, case 4 (page 51) complained of rather sharp pains over the precordium with only slight difficult7 in breathing. On .A.'1lgll8t 17 the patient had a severe pain in the
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