modifications of the Hippocratic doctrine in regard to the pathogenetic
relations of hæmoptysis and phthisis. There is a decided rejection of
the causative influence of tubercle in producing hæmoptysis.[13] "The
connection between pulmonary hemorrhage and tubercle stands on no
pathological proof;" "From all the evidence I have been able to obtain
on this point, tubercle seems to have been very unjustly credited with
hemorrhage."[14] He differs from others in attributing much more to the
hæmophilic constitution in the production of hæmoptysis. Other phases
of the history of hæmoptysis might be given. We shall allude to two
only: one is the classification of the varieties. Alexander of Tralles
treats of hæmoptysis under three heads: 1, Hæmoptysis by rupture; 2, by
erosion; 3, by dilatation. Bricheteau[15] makes four divisions: 1,
constitutional; 2, accidental; 3, succedaneous; 4, critical and
symptomatic. These two classifications show in themselves their origin,
in that the one is representative of a local, and the other of a
constitutional, pathogenesis.
[Footnote 12: _On Pulmonary Hemorrhage_, Reginald E. Thompson, London,
1879.]
[Footnote 13: Page 32, _op. cit._]
[Footnote 14: Page 33, _op. cit._]
[Footnote 15: _Maladies chroniques de l'Appareil respiratoire_, Paris,
1851, p. 523.]
The last historical phase is the therapeutic one. We find in the
practice of the present day survivals from the ancient authors. Morton
recommended ligatures around the limbs to arrest hemorrhage, and bark
to prevent hæmoptysis from becoming phthisis.[16] Venesection, which to
some extent is a modern remedy, was frequently practised by the older
physicians. Erasistratus[17] recommended ligatures, applied to the
limbs in several places, to prevent the return of the blood to the
lungs; Asclepiades thought this practice founded on an erroneous
theory, but experience is in its favor. The head should be kept high,
the face wetted with water, the room cool, and the patient perfectly at
rest. Lietaud (1765) is cautious of employing astringents or
purgatives, but recommended ligatures to the limbs and cold to the
scrotum. A drachm of rhubarb was given by Fernelius in hæmoptysis.
Bryan Robinson[18] (1752) relates a case in which an emetic of
ipecacuanha, taken three times a week, kept off hæmoptysis for eight
years, while tar-water constantly brought it on. Marryat (1758, London)
"advises two grains of tartarized antimony, and as much of the sulphate
of copper, in half a spoonful of water." Ipecacuanha was frequently
employed in hæmoptysis by the practitioners of the centuries preceding
the nineteenth.
[Footnote 16: Young, pp. 201, 202.]
[Footnote 17: _Op. cit._, p. 128.]
[Footnote 18: _Op. cit._, p. 156, ed. 1660.]
As an important preface to the subjects considered in this article we
introduce an account of the vascular supply of the lungs.
{269} Before entering into a statement of the distribution of the
minute vessels to the lungs it is desirable, in view of the possible
diseased connections between the larger bronchial and vascular trunks,
to recall some points of the topographical anatomy of the latter. "The
root of the left lung passes below the arch of the aorta and in front
of the descending aorta. The bronchus, together with the bronchial
arteries and veins, the lymphatics and lymphatic glands, is placed on a
plane posterior to the great blood-vessels. The pulmonary artery lies
more forward than the bronchus, and to a great extent conceals it,
while the pulmonary veins are placed still farther in advance." The
left bronchus "in passing obliquely beneath the arch of the aorta is
depressed below the level of the pulmonary artery, which is the highest
vessel."[19] Practically, the chances of abnormal communications lie in
the relations of the aorta, more especially the different parts of the
arch, to the left bronchus and pulmonary artery, and to the trachea, of
the innominate artery to the trachea, and of the glandular structures
at the root of lung to the pulmonary artery.
[Footnote 19: Quain's _Anatomy_, vol. ii. pp. 897, 898.]
The encroachment of aneurism of the subclavian artery on the lung, and
consequent communication between it and the bronchus, is another form
of accidental or extraneous hæmoptysis.
A recognized classification of the vascular systems of the lungs is
into--1st, functional; 2d, nutritive. To the first belong the pulmonary
arteries and veins, and to the second the bronchial arteries and veins.
Both physiological and pathological experience justifies this division.
Notwithstanding the great attention and labor bestowed upon the
circulation of the lungs, there are still unsettled some important
points. We adopt from Küttner[20] some of the anatomical data
applicable to our subject. The branches of the pulmonary artery follow
uninterruptedly the bronchial ramifications. The mutual relations of
the artery and bronchus are such that the larger vessel lying in any
preparation of the lung directly next to the bronchus, and running in
the same direction, can be pronounced to be a branch of the pulmonary
artery. In the lungs of the embryo both lie in the same
connective-tissue sheath that originates at the root of the lung,
enters with them into the root of each lobule, and there spreads out.
In the lobules both run not only closely alongside of each other; there
appear also branches of the pulmonary artery on the bronchus itself,
and press on to the mucosa of the same.
[Footnote 20: "Beiträge zur Kentniss der Kreislaups-verhältnisse der
Saugethierlunge," _Virchow's Archiv_, vol. lxxiii. p. 476, etc.]
With the appearance of the terminal bronchiole this relation is
changed. The bronchial artery, as such, ceases; the pulmonary
artery--or rather its lateral branches--exclusively surround the
alveolar diverticulæ on their external surfaces. At the point where the
terminal bronchiole is developed into the infundibula the corresponding
trunk of the pulmonary artery divides into a number of
branches--"pinselförmig;" each infundibulum receives its stem, which
spreads itself after the manner of a feather on its external surface.
The terminal branches of the pulmonary artery cover the terminal
alveoli. On every lung in which the infundibula and lobules are well
distributed the terminal branches of the pulmonary artery extend beyond
the borders of the infundibula and lobules into the interlobular and
subpleural connective tissue, and here either lose themselves in a
capillary distribution or extend to the periphery of an adjoining
acinus, being lost in its capillaries.
One peculiarity of the pulmonary artery is that from a large trunk
relatively fine lateral branches come. From a vessel of 0.136 mm. come
branches of 0.033, 0.016, 0.011, 0.010 mm. The finest disappear
immediately as vasa vasorum; the larger pass to the perivascular or
peribronchial connective tissue {270} and become capillary, or they
appear on the surface of the immediately adjoining lobules and
disappear in the capillary paths of the alveoli.
The terminal branches of one and the same principal artery behave
differently according as they are distributed to the connective tissue
or to the alveoli. In the first case they form wide meshes and narrow
tubes, and are not different from the capillary terminations of the
body in general. In the other case the meshes are narrow; the vessels
in all of the pulmonary capillaries are wide. If these vessels are
followed from their origin to their final termination, it will be seen
that a considerable part of the pulmonary artery is spread in the
interlobular connective tissue; that it is not exclusively a secretory
vessel; that the capillary network of all the lobuli are in anastomotic
connection.
An anatomical investigation shows that between the branches of the
pulmonary artery no anastomoses exist. It is, however, proved that
under certain conditions connections between the larger branches of the
artery may occur. This artificial connection is favored through
peculiarities of terminal branching: wherever two parallel branches of
the pulmonary artery are followed, it will be seen that the terminal
branches lie alongside of each other without anastomosis. One can be
convinced of that, and, further, that the capillaries of only one or
two alveoli separate them. These unusually short capillaries between
two arteries are those in which differences of pressure in one or the
other artery produce wide connections. Küttner agrees so far with those
observers who think that between the larger branches of the pulmonary
artery no wide anastomoses exist already formed. In this sense the
pulmonary artery can be designated a terminal artery; on the other
side, however, it must not be forgotten that such connections can arise
at any time, and the artery there loses the type of a so-called
terminal artery.
He further remarks that the vascular-district supply of the pulmonary
artery is not so limited as Cohnheim and Litten believe; that, more
than that, some branches of it pass from one lobule to the adjoining
one; that others are distributed in the subpleural and interlobular
connective tissue and in the bronchial wall.
If the lung of an animal be injected from the pulmonary artery, there
is produced a complete filling of the vessels of the bronchial wall and
into the subepithelial layer--a fact the more interesting that a
similar event can scarcely be produced by a filling of the bronchial
artery.
Pulmonary Vein.--Only at the root of the lung do the bronchus,
pulmonary artery, and pulmonary vein lie close to each other. In the
continuance of the same the artery and the bronchus remain close by
each other, but the vein pursues its own course. The branches of the
same are, from the hilus to their capillary termination, situated in
the interlobular connective-tissue paths. They form on the external
margins of the lobules wide blutbuchten, in which the veins of the
infundibula enter with short stems. The artery lies intralobular--the
vein interlobular. The bronchial veins connect not only with branches
of the azygos and superior cava, but also with those of the pulmonary
vein.
Bronchial Vessels.--The variety of origin of the bronchial arteries is
notable. Whatever their origin, they follow with their chief trunk the
bronchus into the parenchyma of the lung, and give off insignificant
lateral branches to the connective-tissue layers. There is still
another kind of artery, which divides independently in the connective
tissue of the lungs, without resting on the bronchial walls; they come
from the oesophageal, mediastinal, and pericardial arteries, branch in
the mediastinal pleura, appear with these at the hilus of the lung, and
form partly an independent mesh of pleural arteries, and partly spread
themselves in the interlobular connective tissue.
All the vessels of the serous membranes of the diaphragm can contribute
{271} in many ways blood to the hilus of the lung: the unusually
fine-branched arteries appear in this way to be in condition to
compensate for obstructions (or lesser). The bronchial arteries in
comparison with the other vessels of the lungs give off sparingly
lateral branches; among the most interesting are the branches which
spring directly from the trunks of the bronchial artery, pass through
the peribronchial connective tissue, appear at the adjoining
infundibula, and lose themselves in capillary terminations.
The capillary districts of the bronchial arteries pass immediately into
those of the pulmonary. It is a fact that besides the pulmonary artery
the bronchial artery provides the infundibula and alveoli with blood.
If the bronchial artery springing from the intercostal and internal
mammary arteries be ligated or cut, leaving open the vessels of the
mediastinal pleura, and the lung be injected from the abdominal aorta,
a mere inspection will show a filling of the parenchyma of the lung;
anastomoses between the pleural arteries and the intra-acinous trunks
of the pulmonary arteries can be recognized. There is an anastomotic
connection between the pleural branches of the pulmonary and bronchial
arteries.
The bronchial, as also the pulmonary, artery can be filled by means of
the fine arterial branches from the mediastinal pleura.
The principal branches of the bronchial arteries go to the bronchi; at
the alveolar passage they here stop as such; their capillaries become
continuous with those of the pulmonary artery. The greater part of the
few collateral branches nourish the submucous peribronchial and
perivascular connective tissue, the nerves, the lymphatic vessels; the
smaller part enter the alveoli of other bronchial systems and become
capillary.
The branches going to the lung with the mediastinal pleura spread
themselves in the pleura and interlobular connective tissue, nourish
the large subpleural and interlobular lymphatic vessels, but lose
themselves in capillary distribution on the alveoli and infundibula.
The pleural and bronchial arteries anastomose partly with each other
and partly with branches of the pulmonary artery.
With reference to the branches of the pulmonary artery going to the
bronchi, it may be said that they, without giving special branches to
the external layer of the bronchi, press on to the basal membrane and
form a compact capillary network in common with the proportionately few
branches of the bronchial artery.
Amidst differences of opinion, as between Küttner, Lalesque, and
Cohnheim and Litten, there is a concurrence as to the chances of
supplementary function by anastomoses between channels that are
ordinarily separate. Küttner admits a modified form of terminal
arrangement in the pulmonary artery, but at the same time claims an
amount of potential connection that is liable to come into actual
operation and suspend, if not destroy, the terminal type.
The correlation of both functional and nutrient vessels is so intimate
that we believe there is no conclusive argument against the actual
transfer of office from one to the other in certain strained conditions
of disease; Virchow's experiment proves it.
The wonderful delicacy and distensibility of the enormous network of
pulmonary vessels (relation of uncovered space in the alveoli to that
covered by the vessels being 50 out of 200, Kuss); their capacity of
response to great variations of supply and tension; the prompt
supplementary function proven by Litten[21] to belong to the
tracheo-oesophageal, pericardial, phrenic, and pleuro-mediastinal
arteries, and their equilibrium under the sensitive changes of the
aortic system; the slower submission of the lesser circulation to the
peripheral impressions, which markedly affect the aortic system; the
facts {272} verified by Lichtheim[22] that on closure of any portion of
the pulmonary artery the same quantity of blood will pass through the
portion remaining open as before; that this is brought about through
increase of pressure in the sections still open, and through the
simultaneous increased rapidity of circulation and distension of the
vessel walls; and that this mechanism is able to compensate for
obstruction of three-fourths of the pulmonary artery,--are important
factors in the anatomical and physiological relations of hæmoptysis.
[Footnote 21: "Ueber den Hämorrhagischen Infarct," _Zeitschrift für
klinische Medicin_.]
[Footnote 22: _Die Störungen des Lungenkreislaufs_, by L. Lichtheim,
Berlin, 1876, p. 65.]
ETIOLOGY.--The natural history of hæmoptysis is practically that of
phthisis: exceptions to this will be noted hereafter. As heredity is
largely a determining influence in the latter, it may be assumed that
it qualifies its principal symptoms. More or less uniformity prevails
in the transmission of normal or abnormal conditions, and we seem to
find an illustration of the latter in the correspondence between the
percentages of hereditary phthisis and those of hæmoptysis in such
cases. Reginald Thompson[23] says that "out of 1064 cases of
well-marked inherited phthisis, 426 suffered from hæmoptysis." In his
calculation he omitted all those in which the disease began with
hæmoptysis. Had these then been included, they would have raised the
percentage over that shown by the figures, which is slightly above 40.
The rate would not then be much below that given as an average of cases
of hereditary phthisis. This percentage of cases of hæmoptysis in
hereditary phthisis is a sufficiently uniform transmission to prove the
influence of heredity. Its influence is shown not only in the number of
transmissions, but in the transmission of types; so that, as we have a
family type of phthisis, we may have a family type of hæmoptysis, such
as the cases where all the phthisical members of a family are subject
to hæmoptysis of uniform characteristics, instances where the same
uniformity in type is transmitted, and instances where the phthisical
heredity appears to have its survival in moderate and transient attacks
of hemorrhage.
[Footnote 23: _The Causes and Results of Pulmonary Hemorrhage_, p.
110.]
Atavism is also seen in some family histories. We have in view such an
instance, where the marked hæmoptysical tendencies of one generation
skipped the next to reappear in the third.
A special study of the relation of cases of copious hæmoptysis to
different forms of heredity has been made by Reginald Thompson. His
table is as follows:
COPIOUS HÆMOPTYSIS.
+-------------------+----------------------------------+
| | Cases. |
+-------------------+--------+--------+----------------+
| Age at which | Mother | Father | Non-hereditary |
| attack commenced. | 123 | 102 | 105 |
+-------------------+--------+--------+----------------+
| 5 | ... | 1 | ... |
+-------------------+--------+--------+----------------+
| 10 | ... | 4 | 2 |
+-------------------+--------+--------+----------------+
| 15 | 27 | 16 | 14 |
+-------------------+--------+--------+----------------+
| 20 | 30 | 22 | 20 |
+-------------------+--------+--------+----------------+
| 25 | 34 | 24 | 24 |
+-------------------+--------+--------+----------------+
| 30 | 18 | 19 | 16 |
+-------------------+--------+--------+----------------+
| 35 | 8 | 9 | 12 |
+-------------------+--------+--------+----------------+
| 40 | 2 | 4 | 8 |
+-------------------+--------+--------+----------------+
| 45 | 3 | 1 | 5 |
+-------------------+--------+--------+----------------+
| 50 | 1 | ... | 2 |
+-------------------+--------+--------+----------------+
| 55 | | 1 | |
+-------------------+--------+--------+----------------+
| 60 | | 1 | |
+-------------------+--------+--------+----------------+
| 65 | | | |
+-------------------+--------+--------+----------------+
He claims that this table shows that of the cases of direct heredity,
cross-heredity, and non-heredity, those who were the subjects of
cross-heredity--that is, those from the mother--were more liable to
copious hæmoptysis than either the cases of direct heredity or of
non-heredity; and the numbers of the two latter so closely correspond
as to show that heredity from the father has little influence as
regards hemorrhage. The conclusion he draws from the table is that "an
heredity is drawn from the mother which differs from that derived from
the father, and to this must be attributed the excess of cases of
copious hæmoptysis."
{273} This difference will be seen in the following table, which shows
the number of cases occurring before and after thirty:
+-----------------+-----+-------------------+------------------+
| Cases. | | Before age of 30. | After age of 30. |
+-----------------+-----+-------------------+------------------+
| Mother | 123 | 91 | 32 |
+-----------------+-----+-------------------+------------------+
| Father | 102 | 65 | 37 |
+-----------------+-----+-------------------+------------------+
| Non-hereditary | 105 | 60 | 45 |
+-----------------+-----+-------------------+------------------+
He thinks the explanation is to be obtained from the statistics of
hæmophilia, which show a large proportion of transmissions from mothers
to sons, and that we have here a strong argument connecting copious
hæmoptysis, not with tubercle, but with hæmophilia.
His next table is one of 125 cases of double heredity, calculated upon
the same basis as the others, that of 400:
+----------+-------------------------+
| | Cases. |
+----------+------------+------------+
| | Double | Calculated |
| | heredity | to |
+----------+------------+------------+
| | 125 | 400 |
+----------+------------+------------+
| 5 | ... | ... |
+----------+------------+------------+
| 10 | 3 | 10 |
+----------+------------+------------+
| 15 | 20 | 74 |
+----------+------------+------------+
| 20 | 40 | 128 |
+----------+------------+------------+
| 25 | 23 | 75 |
+----------+------------+------------+
| 30 | 15 | 48 |
+----------+------------+------------+
| 35 | 12 | 37 |
+----------+------------+------------+
| 40 | 9 | 29 |
+----------+------------+------------+
| 45 | 1 | 3 |
+----------+------------+------------+
| 55 | 1 | 3 |
+----------+------------+------------+
| 60 | 1 | 3 |
+----------+------------+------------+
| 65 | | |
+----------+------------+------------+
which shows a close approximation to the table of cases of
cross-heredity from the mother, and that the calculated number for 400
cases of double heredity are almost identical with that of the actual
number of 400 cases of cross-heredity between the ages of fifteen and
twenty-five--in the first case being 202, in the second 203--and the
calculated number of cases before thirty amount to 287, not quite equal
to actual number for cases of cross-heredity, which is 294. He
concludes that these cases do not show a greater tendency to hemorrhage
than is shown in cases of direct and non-heredity. We may accept these
figures and calculations as important without endorsing the conclusion
which they are intended to sustain--viz. that such hæmoptyses are
essentially of hæmophilic origin. It may be stated as a general opinion
that hæmophilia does not especially manifest itself in pulmonary
hemorrhages, and that hæmophilic families are not specially liable to
phthisis.
The hemorrhagic diathesis, as distinguished from the specific bleeders'
heredity, does not often manifest its activity through the lungs, and,
as correlative, phthisis does not often show hemorrhages in other
organs than the lungs.[24] Leudet has met in 244 cases of phthisis 9
times hemorrhages in other organs than the lungs; oftenest by the
intestine, the skin, the nasal mucous membrane; more rarely by the
brain and urinary organs; 10 times between the muscles of the abdominal
walls. These considerations suggest that the phthisical hæmoptysis is
distinct from that of hæmophilia or the hemorrhagic diathesis, and has
an independent origin.
[Footnote 24: "Rémarques sur la Diathese hémorrhagique," _Mém. Soc. de
la Biologie_, 1859, p. 179.]
Some facts in regard to the previous diseases of patients admitted into
the Brompton Hospital with phthisis are given in the second medical
report of that institution, which may have a bearing on the special
features, such as hæmoptysis. Among 1973 patients admitted, 275 were
found to have suffered with well-marked attacks of rheumatism, and 16
had acute symptoms of it while in the hospital, making a larger number
than of any other disease, fevers coming next with 238. The connection
of forms of hemorrhage with {274} so-called rheumatism suggests a
possible influence of that kind in favoring hæmoptyses during the
evolution of phthisis. We know of no facts collected with the view of
studying this relation. If such a conclusion were sustained, it would
tend to confirm the view connecting hæmoptysis with hæmophilia or the
hemorrhagic diathesis.
Williams[25] gives a statement qualifying the assumption that the
hemorrhagic variety of consumption specially originates in family
predisposition, for in 72 cases out of 1000 tabulated cases of phthisis
family predisposition was present in only 25 instances. This percentage
is scarcely small enough to exclude a predisposition.
[Footnote 25: _Pulmonary Consumption_, p. 157.]