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Nonsurgical Emergencies in Cases of Thoracic Disease
NONSURGICAL EMERGENCIES IN CASES OF THORACIC DISEASE HERlVlAN
J.
MOERscH
THE thorax is heir to many diseases, most of which, under certain circumstances, may necessitate immediate medical attention. It is not always possible to state with certainty what comprises a true medical emergency as distinguished from a surgical emergency, or at what point one blends into the other. With this realization in mind, an attempt will be made to consider primarily the emergency conditions which generally are treated medically. HEMOPTYSIS
To the patient who suddenly expectorates blood for the first time, the experience is indeed alarming and looked upon as very much of an emergency. Hemoptysis also should be viewed by the attending physician as an emergency, at least until its cause has been adequately determined. Of the more common causes of hemoptysis, I shall consider tuberculosis, acute edema of the lung, pulmonary embolism, pneumonia, bronchiectasis, pulmonary abscess, broncholithiasis, carcinoma of the lung, adenoma of a bronchus. and idiopathic bleeding. Tuberculosis.-Tuberculosis is the most frequent cause of hemoptysis, and bleeding may be the first warning of this disease. It is estimated that in approximately a third of all cases of pulmonary tuberculosis hemorrhage occurs before the diagnosis is made. The initial hem orrhage is seldom fatal. It has been estimated that hemorrhage probably occurs in two-thirds of all cases of pulmom:ry tuberculosis at some time during the course of the disease. Men are somewhat more prone to bleed than women, One is not justified in making a diagnosis of pulmonary tuberculosis on the basis of hemorrhage alon'e. There must be other supporting evidence of the disease such as definite roentgenologic signs or the demonstration of Microbacterium tuberculosis in the sputum. The importance of early and prompt diagnosis of pulmonary tuberculosis is self-evident, and hemoptysis due to this disease truly constitutes an emergency until proper and adequate treatment is started. The treatment of pulmonary tuberculosis has been so well established that further consideration of the disease is not warranted at this time. , Acute Edema of the Lung.-Acute edema of the lung comprises one of the most dramatic as well as terrifying of the pulmonary emergencies that must be treated medically. Expectoration of bloody sputum is often one of the most prominent symptoms. The patient mayor may not expectorate copious amounts of sputum. The sputum is generally· thin and watery, often frothy in consistency and pinkish in color. The patient's breathing is generally la bored, noisy and bubbling 837
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in character, and is aptly designated by the term "death rattle." The patient's face and extremities are generally dusky in color and the superficial veins of the face, neck and upper extremities may be distended. As the condition progresses, the extremities become cold and blotchy purple in color. Percussion of the thorax usually reveals increased dullness over the posterior portions of both lower lobes. On auscultation, coarse, bubbling dIes are found scattered over the entire thorax and are most audible over the trachea. As fluid accumulates in the pleural cavity, the breath sounds disappear at the base of the lungs. The patient's condition is usually so critical that it is often impossible to obtain a satisfactory roentgenogram of the thorax. If it is obtainable, it may present a yaried picture, usually resembling an extensive patchy infiltration with greatest density at the bases and in the hilar regions. It often reveals large, more or less circumscrihed areas of increased density, which may occupy a considerable portion of the pulmonary fields. There also may be evidence of pleural effusion. Any suppurative pulmonary disease in which there is an abundance of sputum may produce a clinical picture which simulates that of acute edema of the lung. Care must be exercised to distinguish the two conditions as the treatment to be employed varies greatly. The past history and the character -of the sputum are of considerable importance in the differential diagnosis. If the sputum is purulent in character, the lesion is more likely to be inflammatory in nature. It must be remembered, however, that pulmonary edema may develop secondary to suppurative pulmonary disease, and when this occurs it may be impossible to state where one condition leaves off and the other begins. Acute edema of the lung may be due to many factors. Anything that causes a failure of the left ventricle will bring about such a state. A common cause is the intravenous administration of excessive quan-tities of fluid, especially in the presence of acute renal failure and in cases in which the serum protein has been depleted. It may occur as a result of any condition that gives rise to an increased pulmonary capillary permeability, such as an acute infectious process. It also may result from chemical irritation or severe anoxemia. Early and prompt treatment is imperative if the patient with acute pulmonary edema is to survive. Oxygen therapy is the most important treatment available for incipient or actual pulmonary edema. It should be used promptly and not withheld until cyanosis occurs. Oxygen is best administered by means of a mask; when it is administered in this manner, its concentration. can be more adequately controlled and it may be given in higher concentrations than is possible when an oxygen tent is used. It may at times be of value to combine the oxygen with helium. Barach, Martin and Eckman have pointed out that, theoretically, it should be of value to administer oxygen with positive pres-
NONSURGICAL EMERGENCIES IN THORACIC DISEASE
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sure. Although this may be of some value in certain selected cases, thus far no completely satisfactory apparatus is available for the administration of oxygen in this manner. Venesection often may be of value in cases of acute edema of the lung. Diuretics such as aminophylline, given intravenously, may be of help. Pulmonary Embolism.-Pulmonary embolism is one of the most serious of medical as well as surgical emergencies. Although hemoptysis occurs in pulmonary embolism, it is usually one of the later manifestations. There are certain conditions which seem to predispose to embolism. Among these may be mentioned operations, especially those for malignant lesions. It is most common among patients who are obese, among those suffering of heart disease, and among those who are more than forty years of age. There is very little to do for a massive pulmonary embolism. As a matter of fact, the patient generally has died before aid can be summoned. A great deal, however, can be done in the prevention of pulmonary embolism and in the care of the patient who has had a nonfatal pulmonary embolism. Prompt recognition of a nonfatal embolism is imperative, for the victim is in grave jeopardy, for a time, of a recurrent and even fatal attack. A careful clinical history is of the greatest importance in the diagnosis of pulmonary embolism. Large pulmonary emboli usually are accompanied by sudden severe pain throughout the thorax. The pain is associated with dyspnea, severe weakness and a sense of impending death. The patient usually is drenched in cold perspiration and has a rapid and often imperceptible pulse, a lowered blood pressure and an ashen color, and often appears in shock. Smaller emboli may give rise to a very similar picture, but more often this classic picture is lacking. Pleurisy, especially if associated with dyspnea occurring in the postoperative period, should cause one to suspect the possibility of embolism. Hemoptysis occasionally may be the first manifestation of embolism. Often, the only inkling of a small embolus may be a sense of apprehension and anxiety associated with palpitation and dyspnea. Unexplained fever in the postoperative period may be the only warning of such an accident. Vines found, in his study of postmortem material, that in 15 per cent of cases of pulmonary infarctions there had not been any clinical symptoms. The physical findings in cases of pulmonary embolism are dependent on the site and size of the embolus. If the embolus has occurred close to the surface of the lung, there may be dullness to percussion and a pleural rub may be heard over the consolidated portion of the lung. The roentgenographic findings are only occasionally indicative of embolism and are extremely variable and best described as a unilateral chronic passive congestion with accentuation of the hiIar shadow when compared with the findings on the other side. Electrocardiography oiten may yield highly significant findings which are suggestive of embolism, as has been pointed out by White and Bames.
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HERMAN
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MOERSCH
Much can be accomplished in the prevention of pulmonary embolism by constantly keeping in mind the prevention of stagnation of circulation. When pulmonary embolism has occurred and the patient has survived the initial shock, a great deal can be done in the care and prevention of further emboli. Barker has recommended the immediate intravenous administration of % grain (0.032 gm.) of papaverine and ){oo grain (0.00065 gm.) of atropine to combat the tendency of reflex constriction of the pulmonary vessels. Barker, Alien and Waugh have demonstrated that dicumarol is of great value in preventing pulmonary embolism and Barker has considered its administration elsewhere in this number. Dicumarol requires twenty-four to thirty-six hours to exert its beneficial effect; should an immediate anticoagulating effect be required, heparin can be administered intravenously until the dicumarol has had an opportunity to take effect. It is important that the coagulating time of the blood be closely watched and kept at between fifteen and twenty minutes while heparin is being administered. Pneumonia.-Since the advent of chemotherapy in the treatment of pneumonia, this disease has come to be looked upon as much less of an emergency than it has in the past. It must, however, be classed as one of the most important of the medical pulmonary emergencies. Expectoration of blood is often one of the cardinal symptoms of pneumonia and may be the first sign to attract the attention of the patient and the physician to the fact that a serious pulmonary disease exists. Early and prompt diagnosis still remains an important factor in the successful treatment of this disease. The possibility of pneumonia must always be considered in any case in which fever, general malaise and coughing are present. It must be remembered that pneumonic processes situated centrally within the lung may present few physical findings and often cannot be demonstrated except on roentgenologic examination. Although bacteriologic studies are of value in the study of pneumonia, since the advent of chemotherapy they are not as essential as they formerly were. Chemotherapy is the procedure of choice in the treatment of pneumococcic pneumonia, and in other types of pneumonia it should be given an adequate trial. Among the most generally used chemotherapeutic and antibacterial agents are sulfadiazine, sulfathiazole, sulfamerazine and penicillin. Pneumonia of the virus type does not, as a rule, respond to chemotherapy. When any reasonable doubt exists as to the type of pneumonia, chemotherapy is indicated. The method of administration, dose and precautions involved have been so thoroughly and completely considered in the literature that they will not be repeated here. It should, however, be pointed out that adequate nursing care and the use of oxygen, where indicated, are still valuable adjuncts in the successful treatment of pneumonia. Bronchiectasis.-One of the most common causes for recurrent hem-
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optysis is bronchiectasis. The initial hemorrhage may be very alarming to the patient until the true underlying cause is established. As a rule, the amount of blood expectorated in cases of bronchiectasis is small and bleeding is likely to occur after overexertion. Occasionally, the volume of blood expectorated may be very large and immediate medical attention may be required. At times, the purulent secretions associated with bronchiectasis fail to drain properly and this gives rise to a clinical picture that closely simulates that of pulmonary abscess or pneumonitis. As a rule, attacks of chills and fever associated with retained secretion are self-limited, but other medical measures such as the use of chemotherapeutic agents or bronchoscopic aspirations of the dammed-back secretions occasionally may be required for relief. The possibility of a metastatic abscess of the brain secondary to bronchiectasis must always be kept in mind. The diagnosis of bronchiectasis usually can be made readily from the history of a chronic cough, the typical character of the sputum, which generally can be produced by inversion of the patient, and from the presence of clubbed fingers and positive roentgenographic evidence of the disease. On physical examination, coarse rales generally can be heard over the site of involvement. At times, difficulty may be experienced in distinguishing bronchiectasis from such lesions as tuberculosis, pulmonary abscess, benign and malignant lesions of the bronchi, foreign bodies, pulmonary stones and other pulmonary lesions. This is in part due to the fact that bronchiectasis frequently accompanies such lesions. Whenever there is any question as to the diagnosis, or whenever surgical treatment is contemplated, bronchoscopic studies and bronchograms should always be employed, as this is the only methfld to determine the exact extent and type of involvement. Early and prompt diagnosis is important in the successful treatment of bronchiectasis. When the disease is limited to one lobe, especially if the patient is young, the lobe can be removed surgically with very little risk and with excellent results. The more extensive the involvement and the older the patient, the greater is the surgical risk and the poorer are the postoperative results. If the disease is very extensive and unsuitable for surgical treatment, postural drainage, avoidance of colds and overexertion, and removal of foci of infection are advisable, and administration of penicillin, by means of a nebulizer, or other chemotherapeutic agent, is worthy of consideration. Pulmonary Abscess.-Pulmonary abscess should always be looked on as a medical emergency as prompt treatment is important. In cases in which a pulmonary abscess is neglected, the mortality rate is extremely high. It is well to recall that the onset of abscess of the lung may be as insidious as that of tuberculosis. Hemorrhage may be a prominent and dramatic symptom. Although the diagnosis of pulmonary abscess usually can be made from the historv, phvs;cal findings and roentgenographic findings, it often is extremely difficult to distinguish this disease
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from other types of suppurative disease of the lung. The etiologic factors involved in the development of pulmonary abscess are numerous indeed. In my experience, abscesses of the lung have been about equally divided between those that follow surgical procedures and those that do not. Tonsillectomy perfotmed with general anesthesia and pneumonia have been the most frequent etiologic factors. Bronchoscopy and bronchography are often of great value in the differential diagnosis. Many pulmonary abscesses will clear up spontaneously under adequate rest in bed, but, as a rule, bronchoscopic aspiration or surgical drainage will be found necessary. The most important factor in the successful treatment of abscess of the lung is its early and prompt recognition. Broncholithiasis.-The erosion of a calcareous lymph node into the tracheobronchial tree may give rise to alarming pulmonary symptoms, including hemoptysis. The symptoms of broncholithiasis are dependent on the size and shape of the calculus and the degree and duration of bronchial obstruction. The extension of the calculus into the tracheobronchial tree is generaIiy manifested by a sudden, severe, paroxysmal cough, usually associated with· thoracic oppression, substernal constriction or a severe tearing sensation. The cough may be accompanied by a so-called asthmatoid wheeze, to which the term "stone asthma" has been applied. At times, the symptoms are not as dramatic and consist of attacks of chills, fever, recurrent pneumonitis, malaise and loss of weight. Unless the patient has expectorated a piece of calcareous material, the clinical history and physcial examination are of little value in arriving at a correct diagnosis. Roentgenographic demonstration of calcified material in the tracheobronchial tree is of considerable aid in suggesting a correct diagnosis. Bronchoscopic visualization of the calculus or calculi, or the expectoration of such material is essential for a positive diagnosis. Broncholiths should be removed as soon as possible, for if they are allowed to remain they may lead to serious sequelae. This was well illustrated in a case of broncholithiasis that recently came under my observation. Bronchiectasis and a metastatic abscess of the brain developed and the patient died. Broncholiths are best removed bronchoscopically. Carcinoma of the Lung.-Carcinoma of the lung properly should be classified as a surgical rather than a medical emergency. Inasmuch as early diagnosis is paramount for successful treatment and since the symptoms of carcinoma of the lung closely simulate those of other inflammatory diseases of the lung it is essentially the physician who must discover its presence. Hemoptysis is a common and often an initial symptom of the disease. In my experience, approximately half of the patients with carcinoma of the lung will expectorate blood and the amount of blood expectorated varies considerably. It is not uncommon for the clinical history of carcinoma of the lung to simulate that of pneumonia, and the expectoration of blood may be regarded as part
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of the pneumonic process. In half of the cases of carcinoma of the lung that have been observed at the Clinic, a diagnosis of pneumonia had been made at some time during the course of the disease. The possibility of carcinoma of the lung must always be considered in any case in which a patch of so-called pneumonia does not clear up within three weeks. The cardinal symptoms of carcinoma of the lung are cough, hemoptysis, expectoration and recurrcnt attacks of fcver. The most significant physical findings are lagging of the involved side of the thorax and suppression of breath sounds. The roentgenographic findings are of considerable value. Bronchoscopy probably offers the most valuable aid in arriving at an early and accUrate diagnosis. Adenoma of a Bronchus.-Recurrent attacks of hemoptysis, usually of some intensity, occurring in a case in which the patient is less than forty years of age, either with or without associated physical or roentgenographic findings, should cause one to suspect the possibility of adenoma of a bronchus. Adenoma of a bronchus, if uncomplicated, usually can be treated successfully either bronchoscopically or by operation without a high degree of risk. . Idiopathic Bleeding.-A group of patients consults a physician because of pulmonary hemorrhage, sometimes of severe degree, for which no adequate explanation is apparent. The clinical history and the results of physical examination and of roentgenologic and laboratory examination are to all purposes negative. There is no evidence to suggest a blood dyscrasia or vitamin deficiency. On bronchoscopic examination, no organic lesion can be found, but it will be detected that the least manipulation of the bronchial mucosa is followed by the oozing of blood. As a rule, curettage of the bronchial mucosa followed by the insufflation of sulfanilamide or one of its derivatives usually will cause a subsidence of bleeding. The factors involved in the production and relief of this condition are not clearly understood. DYSPNEA
A large number of patients have sudden and often severe attacks of dyspnea of pulmonary origin and this condition must be looked upon as a true medical emergency. Among the more common pulmonary disturbances that cause such dyspnea I shall consider asthma, pneumothorax, massive atelectasis, cystic disease of the lung and pleurisy. Asthma.-The most frequent pulmonary cause of acute dyspnea is asthma. An acute severe attack of asthma, "status asthmaticus," truly represents a medical emergency. At the time of the acute attack it may not be possible or wise to attempt a complete investigation of allergens, but attention must be directed to the immediate relief of the patient. If there is obvious evidence of the presence of an allergic factor, it should be eliminated promptly. Various agents are available in dealing with acute asthma. Epinephrine administered hypodermically remains one of the most
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useful aids in relieving acute asthma. A dose of 7 min\ms (0.46 c.c.) of solution of epinephrine hydrochloride is usually administered. This dose may be repeated as often as required. Epinephrine also may be administered as a spray or in oil, but when the drug is administered in this manner the dose is more difficult to gage than it is when a solution of epinephrine is administered hypodermically. Aminophylline and ephedrme aiso have proved of great value in relaxing bronchial spasm. In cases of acute and severe asthma, the administration of oxygen or of oxygen in combination with helium may afford a great deal of relief. Pneumo+horax.-Spontaneous pneumothorax is a cause of sudden acute dyspnea. The degree of dyspnea is dependent in part upon the degree of collapse of the lung. Patients may have complete collapse of one lung with no appreciable dyspnea, while at times a partial collapse will cause considerable distress. Bilateral complete collapse of the lungs produces severe dyspnea and will terminate fatally if not promptly relieved. Pain over the affected lung is usually an early symptom" and varies considerably in character and degree. The pain may be referred to the abdomen or shoulder and may simulate the distress produced by an acute abdominal disease. Cough mayor may not be present; if present, it is usually nonproductive. There may be a slight elevation of the temperature and a slight increase in the pulse rate. Classically, the physical findings should consist of absence of tactile fremitus and diminution or absence of voice and breath sounds over the involved side. Lagging respiration on the affected side frequently can be detected. A positive coin test is of value. All too frequently, even when a patient may be known to have a pneumothorax, it may be impossible to establish the side of involvement 0'0 the basis of the physical findings alone.· Roentgenologic examination of the thorax is the most valuable method of diagnosis. In most cases of pneumothorax, the condition will clear up without treatment other than rest in bed. If the pneumothorax is due to tuberculosis, treatment should be directed to this end. Moorman recommended converting the spontaneous pneumothorax into an artificial pneumothorax for relief of pain, and if the condition should accidentally be due to tuberculosis this would constitute good treatment. He also expressed the opinion that this procedure tends to aid in the formation of adhesions so that the pneumothorax will be less likely to recur. If pneumothorax is associated with severe dyspnea, the use of oxygen may be of value. As a rule, it is necessary to use the oxygen for only a few days, for the patient tends to adjust himself rapidly to the pneumothorax. In case of bilateral pneumothorax or tension pneum'lthorax, immediate aspiration of air from the pleural cavities in addition to oxygen therapy may be necessary. Massive A+elec+asis.-One of the most dramatic lesions of the lung
NONSURGICAL EMERGENCIES IN THORACIC DISEASE
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that may be classified as a medical emergency is massive atelectasis. This occurs as the result of obstruction of a bronchus, usually by a mucous plug. It is especially prone to occur after operations have been performed on the thorax and abdomen or after trauma. It is more likely to occur in cases in which patients have a low-grade infection of the upper part of the respiratory tract or have a tenacious type of nasopharyngeal secretion. Massive atelectasis of the lungs manifests itself by dyspnea and cyanosis. Respiration rapidly becomes labored and is associated with a hacking cough, and the patient experiences difficulty in raising secretions. There is an elevation of temperature with an increase in the pulse rate. The patient may complain of a sense of tightness in the involved side of the thorax. The physical findings in cases of massive atelectasis are usually very striking. There is a sudden respiratory lag on the involved side of the thorax. The apex beat will be shifted toward the side of involvement. Percussion will reveal dullness over the atelectatic area and the breath sounds will be decreased in intensity. Roentgenograms of the thorax are of great value in making the diagnosis. An opacity of the lung will be noted over the involved side, with elevation of the diaphragm, while the mediastinum will be found shifted toward the involved side. The treatment of massive atelectasis is relatively simple and efficacious. Frequently, the patient can be encouraged to cough effectively. If the patient who has undergone an operation can do this by holding the site of the operation firmly, he may expectorate the obstructing bronchial plug. The same thing can at times be accomplished by change of position. Hyperventilation of the lung with carbon dioxide and oxygen and deep breathing exercises will frequently suffice. If prompt relief is not obtained by these methods, bronchial catheterization or, better, bronchoscopic aspiration of the secretions obstructing the bronchus will be followed bv immediate improvement in the patient's condition and by prompt changes in the physical and roentgen findings. The earlier atelectasis is recognized and proper treatment instituted, the less danger there is of the development of secondary pulmonary complications. Chemotherapeutic agents should always be employed promptly when indicated. Cystic Disease of the Lung.-Recurrent attacks of severe dyspnea with cyanosis, nonproductive cough and asthmatic attacks, particularly in cases in which the patients are infants or children, should cause one t@ suspect the presence of cystic degeneration of the lung. In the case of older patients, progressive dyspnea with or without preceding respiratory infection warrants the same suspicion. The attacks of acute dyspnea are caused by a sudden trappIng of air in the cyst owing to a check valve mechanism between the cyst and the bronchus. If there is free communication between the cyst and the bronchus or no communication at all, such attacks do not occur. The symptoms, as might
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MOERSCH
be anticipated, may be fluctuating and progressive and may closely simulate those of spontaneous pneumothorax. The diagnosis is dependent primarily on the roentgenologic findings. In cases of cystic disease, as a rule, in contrast to pneumothorax, the pulmonary tissue contiguous to the cyst usually will be compressed downward and toward the base of the lung. In cases of pneumothorax, it is more likely to be compressed toward the root of the lung. Bronchography may be of value in the differential diagnosis. Artificial pneumothorax may at times be required to distinguish a cystic lesion from pneumothorax or emphysema. If the cyst should contain fluid, difficulty may be experienced in distinguishing it from turn or, abscess and localized empyema. If the pulmonary symptoms become acute as a result of the trapping of air, it may be necessary to aspirate the air as a lifesaving procedure. Lobectomy is the procedure of choice in cases in which the symptoms warrant it. Pleurisy and Pleural Effusion.-The patient suffering from an attack of pleurisy may experience pain of such severity that immediate attention becomes imperative. Care must be exercised to distinguish the pain of pleurisy from pain in the thoracic wall and pain due to diseases of the central nervous system or spinal column. Diaphragmatic pleurisy especially may offer difficulty in differential diagnosis. A characteristic sign of dry pleurisy is the pleuritic friction sound, which is heard either as a fine rub or coarse leather creaking. The friction rub also is usually palpable. Usually, the friction and pain are increased by deep respiration. Roentgenologic examination is of very little value in diagnosis of pleurisy, although it is of considerable value in the determination of its cause. The treatment of pleurisy varies with its severity. Frequently, local pressure over the thorax is all that may be required. The local application of heat in any form is often of benefit. The use of codeine may be necessary to control coughing, which may aggravate the pain. In severe pleurisy that is not controlled by the methods outlined, the blocking, with procaine hydrochloride, of the nerves of the skin overlying the site of pain will generally afford immediate relief. Pleural effusion, which mayor may not be an accompaniment of dry pleurisy, may often become so severe that dyspnea becomes very pronounced and immediate aspiration of fluid is necessary for relief. Careful study of the aspirated fluid is of considerable value in the determination of the cause. It is of interest that, if pleural effusion that is due to cardiac disease or that follows surgical procedures is excluded, if the pleural effusion is found to be bloody in character there is better than a 90 per cent chance that the effusion is due to carcinoma. If the effusion is purulent in character, it may be successfully treated by instillations of penicillin and by surgical drainage in cases in which treatment with penicillin does not prove successful.
NONSURGICAL EMERGENCIES IN THORACIC DISEASE
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OTHER CONDITIONS
There are numerous other conditions, such as aspirated foreign bodies, mediastinal tumors, mitral stenosis, aortic aneurysm and diaphragmatic hernia, which may constitute a medical emergency but they are generally classified as surgical or vascular in type. These will not be discussed at this time. It becomes readily apparent that the thorax, as the abdomen, is the site of many acute diseases and that early treatment is of paramount importance. REFERENCES
1. Barach, A. L., Martin, John and Eckman, Morris: Positive pressure respiration
2. 3.
4. S. 6. 7.
and its application to the treaonent of acute pulmonary edema. Ann. Int. Med. 12:754-795 (Dec.) 1938. Barker, N. W.: The use of dicumarol in surgery. Minnesota Med. 27:102-106 (Feb.) 1944. Barker, N. W., AlIen, E. V. and Waugh, J. M.: The use of dicumarol [3,3' methylenebis (4-hydroxycoumarin) ] in the prevention of postoperative thrombophlebitis and pulmonary embolism. Proc. Staff Meet., Mayo Clin. 18:102-107 (Apr. 7) 1943. Barnes, A. R.: Pulmonary embolism. J.A.M.A. 109:1347-1352 (Oct. 23) 1937. Moorman, J. F.: Spontaneous pneumothorax in apparently healthy young adults. J. Oklahoma M. A. 36:277-281 (July) 1943. Vines, R. W.: Pulmonary infarction: a clinical and pathological study. Thesis, . University of Minnesota, 1943. ~'hite, P. D.: Pulmonary embolism and heart disease: a review of 20 years of personal experience. Am. J. M. Se. 200:S77-581 (Nov.) 1940.
J.
MOERscH
THE thorax is heir to many diseases, most of which, under certain circumstances, may necessitate immediate medical attention. It is not always possible to state with certainty what comprises a true medical emergency as distinguished from a surgical emergency, or at what point one blends into the other. With this realization in mind, an attempt will be made to consider primarily the emergency conditions which generally are treated medically. HEMOPTYSIS
To the patient who suddenly expectorates blood for the first time, the experience is indeed alarming and looked upon as very much of an emergency. Hemoptysis also should be viewed by the attending physician as an emergency, at least until its cause has been adequately determined. Of the more common causes of hemoptysis, I shall consider tuberculosis, acute edema of the lung, pulmonary embolism, pneumonia, bronchiectasis, pulmonary abscess, broncholithiasis, carcinoma of the lung, adenoma of a bronchus. and idiopathic bleeding. Tuberculosis.-Tuberculosis is the most frequent cause of hemoptysis, and bleeding may be the first warning of this disease. It is estimated that in approximately a third of all cases of pulmonary tuberculosis hemorrhage occurs before the diagnosis is made. The initial hem orrhage is seldom fatal. It has been estimated that hemorrhage probably occurs in two-thirds of all cases of pulmom:ry tuberculosis at some time during the course of the disease. Men are somewhat more prone to bleed than women, One is not justified in making a diagnosis of pulmonary tuberculosis on the basis of hemorrhage alon'e. There must be other supporting evidence of the disease such as definite roentgenologic signs or the demonstration of Microbacterium tuberculosis in the sputum. The importance of early and prompt diagnosis of pulmonary tuberculosis is self-evident, and hemoptysis due to this disease truly constitutes an emergency until proper and adequate treatment is started. The treatment of pulmonary tuberculosis has been so well established that further consideration of the disease is not warranted at this time. , Acute Edema of the Lung.-Acute edema of the lung comprises one of the most dramatic as well as terrifying of the pulmonary emergencies that must be treated medically. Expectoration of bloody sputum is often one of the most prominent symptoms. The patient mayor may not expectorate copious amounts of sputum. The sputum is generally· thin and watery, often frothy in consistency and pinkish in color. The patient's breathing is generally la bored, noisy and bubbling 837
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in character, and is aptly designated by the term "death rattle." The patient's face and extremities are generally dusky in color and the superficial veins of the face, neck and upper extremities may be distended. As the condition progresses, the extremities become cold and blotchy purple in color. Percussion of the thorax usually reveals increased dullness over the posterior portions of both lower lobes. On auscultation, coarse, bubbling dIes are found scattered over the entire thorax and are most audible over the trachea. As fluid accumulates in the pleural cavity, the breath sounds disappear at the base of the lungs. The patient's condition is usually so critical that it is often impossible to obtain a satisfactory roentgenogram of the thorax. If it is obtainable, it may present a yaried picture, usually resembling an extensive patchy infiltration with greatest density at the bases and in the hilar regions. It often reveals large, more or less circumscrihed areas of increased density, which may occupy a considerable portion of the pulmonary fields. There also may be evidence of pleural effusion. Any suppurative pulmonary disease in which there is an abundance of sputum may produce a clinical picture which simulates that of acute edema of the lung. Care must be exercised to distinguish the two conditions as the treatment to be employed varies greatly. The past history and the character -of the sputum are of considerable importance in the differential diagnosis. If the sputum is purulent in character, the lesion is more likely to be inflammatory in nature. It must be remembered, however, that pulmonary edema may develop secondary to suppurative pulmonary disease, and when this occurs it may be impossible to state where one condition leaves off and the other begins. Acute edema of the lung may be due to many factors. Anything that causes a failure of the left ventricle will bring about such a state. A common cause is the intravenous administration of excessive quan-tities of fluid, especially in the presence of acute renal failure and in cases in which the serum protein has been depleted. It may occur as a result of any condition that gives rise to an increased pulmonary capillary permeability, such as an acute infectious process. It also may result from chemical irritation or severe anoxemia. Early and prompt treatment is imperative if the patient with acute pulmonary edema is to survive. Oxygen therapy is the most important treatment available for incipient or actual pulmonary edema. It should be used promptly and not withheld until cyanosis occurs. Oxygen is best administered by means of a mask; when it is administered in this manner, its concentration. can be more adequately controlled and it may be given in higher concentrations than is possible when an oxygen tent is used. It may at times be of value to combine the oxygen with helium. Barach, Martin and Eckman have pointed out that, theoretically, it should be of value to administer oxygen with positive pres-
NONSURGICAL EMERGENCIES IN THORACIC DISEASE
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sure. Although this may be of some value in certain selected cases, thus far no completely satisfactory apparatus is available for the administration of oxygen in this manner. Venesection often may be of value in cases of acute edema of the lung. Diuretics such as aminophylline, given intravenously, may be of help. Pulmonary Embolism.-Pulmonary embolism is one of the most serious of medical as well as surgical emergencies. Although hemoptysis occurs in pulmonary embolism, it is usually one of the later manifestations. There are certain conditions which seem to predispose to embolism. Among these may be mentioned operations, especially those for malignant lesions. It is most common among patients who are obese, among those suffering of heart disease, and among those who are more than forty years of age. There is very little to do for a massive pulmonary embolism. As a matter of fact, the patient generally has died before aid can be summoned. A great deal, however, can be done in the prevention of pulmonary embolism and in the care of the patient who has had a nonfatal pulmonary embolism. Prompt recognition of a nonfatal embolism is imperative, for the victim is in grave jeopardy, for a time, of a recurrent and even fatal attack. A careful clinical history is of the greatest importance in the diagnosis of pulmonary embolism. Large pulmonary emboli usually are accompanied by sudden severe pain throughout the thorax. The pain is associated with dyspnea, severe weakness and a sense of impending death. The patient usually is drenched in cold perspiration and has a rapid and often imperceptible pulse, a lowered blood pressure and an ashen color, and often appears in shock. Smaller emboli may give rise to a very similar picture, but more often this classic picture is lacking. Pleurisy, especially if associated with dyspnea occurring in the postoperative period, should cause one to suspect the possibility of embolism. Hemoptysis occasionally may be the first manifestation of embolism. Often, the only inkling of a small embolus may be a sense of apprehension and anxiety associated with palpitation and dyspnea. Unexplained fever in the postoperative period may be the only warning of such an accident. Vines found, in his study of postmortem material, that in 15 per cent of cases of pulmonary infarctions there had not been any clinical symptoms. The physical findings in cases of pulmonary embolism are dependent on the site and size of the embolus. If the embolus has occurred close to the surface of the lung, there may be dullness to percussion and a pleural rub may be heard over the consolidated portion of the lung. The roentgenographic findings are only occasionally indicative of embolism and are extremely variable and best described as a unilateral chronic passive congestion with accentuation of the hiIar shadow when compared with the findings on the other side. Electrocardiography oiten may yield highly significant findings which are suggestive of embolism, as has been pointed out by White and Bames.
840
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Much can be accomplished in the prevention of pulmonary embolism by constantly keeping in mind the prevention of stagnation of circulation. When pulmonary embolism has occurred and the patient has survived the initial shock, a great deal can be done in the care and prevention of further emboli. Barker has recommended the immediate intravenous administration of % grain (0.032 gm.) of papaverine and ){oo grain (0.00065 gm.) of atropine to combat the tendency of reflex constriction of the pulmonary vessels. Barker, Alien and Waugh have demonstrated that dicumarol is of great value in preventing pulmonary embolism and Barker has considered its administration elsewhere in this number. Dicumarol requires twenty-four to thirty-six hours to exert its beneficial effect; should an immediate anticoagulating effect be required, heparin can be administered intravenously until the dicumarol has had an opportunity to take effect. It is important that the coagulating time of the blood be closely watched and kept at between fifteen and twenty minutes while heparin is being administered. Pneumonia.-Since the advent of chemotherapy in the treatment of pneumonia, this disease has come to be looked upon as much less of an emergency than it has in the past. It must, however, be classed as one of the most important of the medical pulmonary emergencies. Expectoration of blood is often one of the cardinal symptoms of pneumonia and may be the first sign to attract the attention of the patient and the physician to the fact that a serious pulmonary disease exists. Early and prompt diagnosis still remains an important factor in the successful treatment of this disease. The possibility of pneumonia must always be considered in any case in which fever, general malaise and coughing are present. It must be remembered that pneumonic processes situated centrally within the lung may present few physical findings and often cannot be demonstrated except on roentgenologic examination. Although bacteriologic studies are of value in the study of pneumonia, since the advent of chemotherapy they are not as essential as they formerly were. Chemotherapy is the procedure of choice in the treatment of pneumococcic pneumonia, and in other types of pneumonia it should be given an adequate trial. Among the most generally used chemotherapeutic and antibacterial agents are sulfadiazine, sulfathiazole, sulfamerazine and penicillin. Pneumonia of the virus type does not, as a rule, respond to chemotherapy. When any reasonable doubt exists as to the type of pneumonia, chemotherapy is indicated. The method of administration, dose and precautions involved have been so thoroughly and completely considered in the literature that they will not be repeated here. It should, however, be pointed out that adequate nursing care and the use of oxygen, where indicated, are still valuable adjuncts in the successful treatment of pneumonia. Bronchiectasis.-One of the most common causes for recurrent hem-
NONSURGICAL EMERGENCIES IN THORACIC DISEASE
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optysis is bronchiectasis. The initial hemorrhage may be very alarming to the patient until the true underlying cause is established. As a rule, the amount of blood expectorated in cases of bronchiectasis is small and bleeding is likely to occur after overexertion. Occasionally, the volume of blood expectorated may be very large and immediate medical attention may be required. At times, the purulent secretions associated with bronchiectasis fail to drain properly and this gives rise to a clinical picture that closely simulates that of pulmonary abscess or pneumonitis. As a rule, attacks of chills and fever associated with retained secretion are self-limited, but other medical measures such as the use of chemotherapeutic agents or bronchoscopic aspirations of the dammed-back secretions occasionally may be required for relief. The possibility of a metastatic abscess of the brain secondary to bronchiectasis must always be kept in mind. The diagnosis of bronchiectasis usually can be made readily from the history of a chronic cough, the typical character of the sputum, which generally can be produced by inversion of the patient, and from the presence of clubbed fingers and positive roentgenographic evidence of the disease. On physical examination, coarse rales generally can be heard over the site of involvement. At times, difficulty may be experienced in distinguishing bronchiectasis from such lesions as tuberculosis, pulmonary abscess, benign and malignant lesions of the bronchi, foreign bodies, pulmonary stones and other pulmonary lesions. This is in part due to the fact that bronchiectasis frequently accompanies such lesions. Whenever there is any question as to the diagnosis, or whenever surgical treatment is contemplated, bronchoscopic studies and bronchograms should always be employed, as this is the only methfld to determine the exact extent and type of involvement. Early and prompt diagnosis is important in the successful treatment of bronchiectasis. When the disease is limited to one lobe, especially if the patient is young, the lobe can be removed surgically with very little risk and with excellent results. The more extensive the involvement and the older the patient, the greater is the surgical risk and the poorer are the postoperative results. If the disease is very extensive and unsuitable for surgical treatment, postural drainage, avoidance of colds and overexertion, and removal of foci of infection are advisable, and administration of penicillin, by means of a nebulizer, or other chemotherapeutic agent, is worthy of consideration. Pulmonary Abscess.-Pulmonary abscess should always be looked on as a medical emergency as prompt treatment is important. In cases in which a pulmonary abscess is neglected, the mortality rate is extremely high. It is well to recall that the onset of abscess of the lung may be as insidious as that of tuberculosis. Hemorrhage may be a prominent and dramatic symptom. Although the diagnosis of pulmonary abscess usually can be made from the historv, phvs;cal findings and roentgenographic findings, it often is extremely difficult to distinguish this disease
842
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from other types of suppurative disease of the lung. The etiologic factors involved in the development of pulmonary abscess are numerous indeed. In my experience, abscesses of the lung have been about equally divided between those that follow surgical procedures and those that do not. Tonsillectomy perfotmed with general anesthesia and pneumonia have been the most frequent etiologic factors. Bronchoscopy and bronchography are often of great value in the differential diagnosis. Many pulmonary abscesses will clear up spontaneously under adequate rest in bed, but, as a rule, bronchoscopic aspiration or surgical drainage will be found necessary. The most important factor in the successful treatment of abscess of the lung is its early and prompt recognition. Broncholithiasis.-The erosion of a calcareous lymph node into the tracheobronchial tree may give rise to alarming pulmonary symptoms, including hemoptysis. The symptoms of broncholithiasis are dependent on the size and shape of the calculus and the degree and duration of bronchial obstruction. The extension of the calculus into the tracheobronchial tree is generaIiy manifested by a sudden, severe, paroxysmal cough, usually associated with· thoracic oppression, substernal constriction or a severe tearing sensation. The cough may be accompanied by a so-called asthmatoid wheeze, to which the term "stone asthma" has been applied. At times, the symptoms are not as dramatic and consist of attacks of chills, fever, recurrent pneumonitis, malaise and loss of weight. Unless the patient has expectorated a piece of calcareous material, the clinical history and physcial examination are of little value in arriving at a correct diagnosis. Roentgenographic demonstration of calcified material in the tracheobronchial tree is of considerable aid in suggesting a correct diagnosis. Bronchoscopic visualization of the calculus or calculi, or the expectoration of such material is essential for a positive diagnosis. Broncholiths should be removed as soon as possible, for if they are allowed to remain they may lead to serious sequelae. This was well illustrated in a case of broncholithiasis that recently came under my observation. Bronchiectasis and a metastatic abscess of the brain developed and the patient died. Broncholiths are best removed bronchoscopically. Carcinoma of the Lung.-Carcinoma of the lung properly should be classified as a surgical rather than a medical emergency. Inasmuch as early diagnosis is paramount for successful treatment and since the symptoms of carcinoma of the lung closely simulate those of other inflammatory diseases of the lung it is essentially the physician who must discover its presence. Hemoptysis is a common and often an initial symptom of the disease. In my experience, approximately half of the patients with carcinoma of the lung will expectorate blood and the amount of blood expectorated varies considerably. It is not uncommon for the clinical history of carcinoma of the lung to simulate that of pneumonia, and the expectoration of blood may be regarded as part
NONSURGICAL EMERGENCIES IN THORACIC DISEASE
843
of the pneumonic process. In half of the cases of carcinoma of the lung that have been observed at the Clinic, a diagnosis of pneumonia had been made at some time during the course of the disease. The possibility of carcinoma of the lung must always be considered in any case in which a patch of so-called pneumonia does not clear up within three weeks. The cardinal symptoms of carcinoma of the lung are cough, hemoptysis, expectoration and recurrcnt attacks of fcver. The most significant physical findings are lagging of the involved side of the thorax and suppression of breath sounds. The roentgenographic findings are of considerable value. Bronchoscopy probably offers the most valuable aid in arriving at an early and accUrate diagnosis. Adenoma of a Bronchus.-Recurrent attacks of hemoptysis, usually of some intensity, occurring in a case in which the patient is less than forty years of age, either with or without associated physical or roentgenographic findings, should cause one to suspect the possibility of adenoma of a bronchus. Adenoma of a bronchus, if uncomplicated, usually can be treated successfully either bronchoscopically or by operation without a high degree of risk. . Idiopathic Bleeding.-A group of patients consults a physician because of pulmonary hemorrhage, sometimes of severe degree, for which no adequate explanation is apparent. The clinical history and the results of physical examination and of roentgenologic and laboratory examination are to all purposes negative. There is no evidence to suggest a blood dyscrasia or vitamin deficiency. On bronchoscopic examination, no organic lesion can be found, but it will be detected that the least manipulation of the bronchial mucosa is followed by the oozing of blood. As a rule, curettage of the bronchial mucosa followed by the insufflation of sulfanilamide or one of its derivatives usually will cause a subsidence of bleeding. The factors involved in the production and relief of this condition are not clearly understood. DYSPNEA
A large number of patients have sudden and often severe attacks of dyspnea of pulmonary origin and this condition must be looked upon as a true medical emergency. Among the more common pulmonary disturbances that cause such dyspnea I shall consider asthma, pneumothorax, massive atelectasis, cystic disease of the lung and pleurisy. Asthma.-The most frequent pulmonary cause of acute dyspnea is asthma. An acute severe attack of asthma, "status asthmaticus," truly represents a medical emergency. At the time of the acute attack it may not be possible or wise to attempt a complete investigation of allergens, but attention must be directed to the immediate relief of the patient. If there is obvious evidence of the presence of an allergic factor, it should be eliminated promptly. Various agents are available in dealing with acute asthma. Epinephrine administered hypodermically remains one of the most
844
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useful aids in relieving acute asthma. A dose of 7 min\ms (0.46 c.c.) of solution of epinephrine hydrochloride is usually administered. This dose may be repeated as often as required. Epinephrine also may be administered as a spray or in oil, but when the drug is administered in this manner the dose is more difficult to gage than it is when a solution of epinephrine is administered hypodermically. Aminophylline and ephedrme aiso have proved of great value in relaxing bronchial spasm. In cases of acute and severe asthma, the administration of oxygen or of oxygen in combination with helium may afford a great deal of relief. Pneumo+horax.-Spontaneous pneumothorax is a cause of sudden acute dyspnea. The degree of dyspnea is dependent in part upon the degree of collapse of the lung. Patients may have complete collapse of one lung with no appreciable dyspnea, while at times a partial collapse will cause considerable distress. Bilateral complete collapse of the lungs produces severe dyspnea and will terminate fatally if not promptly relieved. Pain over the affected lung is usually an early symptom" and varies considerably in character and degree. The pain may be referred to the abdomen or shoulder and may simulate the distress produced by an acute abdominal disease. Cough mayor may not be present; if present, it is usually nonproductive. There may be a slight elevation of the temperature and a slight increase in the pulse rate. Classically, the physical findings should consist of absence of tactile fremitus and diminution or absence of voice and breath sounds over the involved side. Lagging respiration on the affected side frequently can be detected. A positive coin test is of value. All too frequently, even when a patient may be known to have a pneumothorax, it may be impossible to establish the side of involvement 0'0 the basis of the physical findings alone.· Roentgenologic examination of the thorax is the most valuable method of diagnosis. In most cases of pneumothorax, the condition will clear up without treatment other than rest in bed. If the pneumothorax is due to tuberculosis, treatment should be directed to this end. Moorman recommended converting the spontaneous pneumothorax into an artificial pneumothorax for relief of pain, and if the condition should accidentally be due to tuberculosis this would constitute good treatment. He also expressed the opinion that this procedure tends to aid in the formation of adhesions so that the pneumothorax will be less likely to recur. If pneumothorax is associated with severe dyspnea, the use of oxygen may be of value. As a rule, it is necessary to use the oxygen for only a few days, for the patient tends to adjust himself rapidly to the pneumothorax. In case of bilateral pneumothorax or tension pneum'lthorax, immediate aspiration of air from the pleural cavities in addition to oxygen therapy may be necessary. Massive A+elec+asis.-One of the most dramatic lesions of the lung
NONSURGICAL EMERGENCIES IN THORACIC DISEASE
845
that may be classified as a medical emergency is massive atelectasis. This occurs as the result of obstruction of a bronchus, usually by a mucous plug. It is especially prone to occur after operations have been performed on the thorax and abdomen or after trauma. It is more likely to occur in cases in which patients have a low-grade infection of the upper part of the respiratory tract or have a tenacious type of nasopharyngeal secretion. Massive atelectasis of the lungs manifests itself by dyspnea and cyanosis. Respiration rapidly becomes labored and is associated with a hacking cough, and the patient experiences difficulty in raising secretions. There is an elevation of temperature with an increase in the pulse rate. The patient may complain of a sense of tightness in the involved side of the thorax. The physical findings in cases of massive atelectasis are usually very striking. There is a sudden respiratory lag on the involved side of the thorax. The apex beat will be shifted toward the side of involvement. Percussion will reveal dullness over the atelectatic area and the breath sounds will be decreased in intensity. Roentgenograms of the thorax are of great value in making the diagnosis. An opacity of the lung will be noted over the involved side, with elevation of the diaphragm, while the mediastinum will be found shifted toward the involved side. The treatment of massive atelectasis is relatively simple and efficacious. Frequently, the patient can be encouraged to cough effectively. If the patient who has undergone an operation can do this by holding the site of the operation firmly, he may expectorate the obstructing bronchial plug. The same thing can at times be accomplished by change of position. Hyperventilation of the lung with carbon dioxide and oxygen and deep breathing exercises will frequently suffice. If prompt relief is not obtained by these methods, bronchial catheterization or, better, bronchoscopic aspiration of the secretions obstructing the bronchus will be followed bv immediate improvement in the patient's condition and by prompt changes in the physical and roentgen findings. The earlier atelectasis is recognized and proper treatment instituted, the less danger there is of the development of secondary pulmonary complications. Chemotherapeutic agents should always be employed promptly when indicated. Cystic Disease of the Lung.-Recurrent attacks of severe dyspnea with cyanosis, nonproductive cough and asthmatic attacks, particularly in cases in which the patients are infants or children, should cause one t@ suspect the presence of cystic degeneration of the lung. In the case of older patients, progressive dyspnea with or without preceding respiratory infection warrants the same suspicion. The attacks of acute dyspnea are caused by a sudden trappIng of air in the cyst owing to a check valve mechanism between the cyst and the bronchus. If there is free communication between the cyst and the bronchus or no communication at all, such attacks do not occur. The symptoms, as might
'846
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J.
MOERSCH
be anticipated, may be fluctuating and progressive and may closely simulate those of spontaneous pneumothorax. The diagnosis is dependent primarily on the roentgenologic findings. In cases of cystic disease, as a rule, in contrast to pneumothorax, the pulmonary tissue contiguous to the cyst usually will be compressed downward and toward the base of the lung. In cases of pneumothorax, it is more likely to be compressed toward the root of the lung. Bronchography may be of value in the differential diagnosis. Artificial pneumothorax may at times be required to distinguish a cystic lesion from pneumothorax or emphysema. If the cyst should contain fluid, difficulty may be experienced in distinguishing it from turn or, abscess and localized empyema. If the pulmonary symptoms become acute as a result of the trapping of air, it may be necessary to aspirate the air as a lifesaving procedure. Lobectomy is the procedure of choice in cases in which the symptoms warrant it. Pleurisy and Pleural Effusion.-The patient suffering from an attack of pleurisy may experience pain of such severity that immediate attention becomes imperative. Care must be exercised to distinguish the pain of pleurisy from pain in the thoracic wall and pain due to diseases of the central nervous system or spinal column. Diaphragmatic pleurisy especially may offer difficulty in differential diagnosis. A characteristic sign of dry pleurisy is the pleuritic friction sound, which is heard either as a fine rub or coarse leather creaking. The friction rub also is usually palpable. Usually, the friction and pain are increased by deep respiration. Roentgenologic examination is of very little value in diagnosis of pleurisy, although it is of considerable value in the determination of its cause. The treatment of pleurisy varies with its severity. Frequently, local pressure over the thorax is all that may be required. The local application of heat in any form is often of benefit. The use of codeine may be necessary to control coughing, which may aggravate the pain. In severe pleurisy that is not controlled by the methods outlined, the blocking, with procaine hydrochloride, of the nerves of the skin overlying the site of pain will generally afford immediate relief. Pleural effusion, which mayor may not be an accompaniment of dry pleurisy, may often become so severe that dyspnea becomes very pronounced and immediate aspiration of fluid is necessary for relief. Careful study of the aspirated fluid is of considerable value in the determination of the cause. It is of interest that, if pleural effusion that is due to cardiac disease or that follows surgical procedures is excluded, if the pleural effusion is found to be bloody in character there is better than a 90 per cent chance that the effusion is due to carcinoma. If the effusion is purulent in character, it may be successfully treated by instillations of penicillin and by surgical drainage in cases in which treatment with penicillin does not prove successful.
NONSURGICAL EMERGENCIES IN THORACIC DISEASE
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OTHER CONDITIONS
There are numerous other conditions, such as aspirated foreign bodies, mediastinal tumors, mitral stenosis, aortic aneurysm and diaphragmatic hernia, which may constitute a medical emergency but they are generally classified as surgical or vascular in type. These will not be discussed at this time. It becomes readily apparent that the thorax, as the abdomen, is the site of many acute diseases and that early treatment is of paramount importance. REFERENCES
1. Barach, A. L., Martin, John and Eckman, Morris: Positive pressure respiration
2. 3.
4. S. 6. 7.
and its application to the treaonent of acute pulmonary edema. Ann. Int. Med. 12:754-795 (Dec.) 1938. Barker, N. W.: The use of dicumarol in surgery. Minnesota Med. 27:102-106 (Feb.) 1944. Barker, N. W., AlIen, E. V. and Waugh, J. M.: The use of dicumarol [3,3' methylenebis (4-hydroxycoumarin) ] in the prevention of postoperative thrombophlebitis and pulmonary embolism. Proc. Staff Meet., Mayo Clin. 18:102-107 (Apr. 7) 1943. Barnes, A. R.: Pulmonary embolism. J.A.M.A. 109:1347-1352 (Oct. 23) 1937. Moorman, J. F.: Spontaneous pneumothorax in apparently healthy young adults. J. Oklahoma M. A. 36:277-281 (July) 1943. Vines, R. W.: Pulmonary infarction: a clinical and pathological study. Thesis, . University of Minnesota, 1943. ~'hite, P. D.: Pulmonary embolism and heart disease: a review of 20 years of personal experience. Am. J. M. Se. 200:S77-581 (Nov.) 1940.