tubercle, whether it come from the bronchioles, the blood-vessels, or
alveolar walls. Trasbot[48] says: "A tubercle is found to be developed
along a small artery, most frequently at the angle formed by a terminal
division of the vessel--some around a capillary, around which it forms
a kind of bead, or in the network of an anastomosis, which envelops it
on every side. Vessels are more numerous in the tissues round the
nodules and in the septa or interstices of the large masses than in the
healthy connective tissue: there the vascularity is often so great as
to be mistaken for inflammation."
[Footnote 48: Quoted by Creighton Bevine, _Tuberculosis in Man_, p.
133.]
Hamilton,[49] speaking of the formation of tubercle in the alveolar
wall and cavity, says: "Capillary blood-vessels, filled with
blood-corpuscles, are drawn into it, and in this stage are distinctly
visible. They are all much engorged, and occasionally minute
extravasations are visible, the blood-corpuscles being thrown into the
alveolar cavity." The chance of an earlier obliteration of vessels is
greater under these circumstances than where the process begins in any
other structure. The final result is that combination of catarrhal and
tubercular products characteristic of mixed phthisis.
[Footnote 49: _The Pathology of Bronchitis, Catarrhal Pneumonia,
Tubercle, etc._, 1883.]
As increased vascularity accompanies and surrounds the nascent
tubercle, so vascular neo-formations accompany or are intermixed with
the obliterated zone of vessels, as long since described by Guillot and
recently substantially confirmed by Ewart. The former says:[50] "There
result numerous and inextricable anastomoses, which extend incessantly,
and of which the whole forms a mass of vessels proportional in extent
to the age of the tubercles and cavities that they entirely surround."
[Footnote 50: _L'Expérience_, vol. i. p. 553.]
{281} There ensues a connection between this system and that forming on
the false pleural membranes, and a supplementary function of supply for
regions outside of the area of obliterated vessels and for walls of
cavities is established. Considering the want of vitality of new
formations generally, it is quite probable that these become sources of
hemorrhage occasionally. Successive extensions of the diseased regions
reduce the amount of this supply, so that the converse
follows--comparative anæmia of the lung involved and diminished
tendency to hæmoptysis in some of its forms.
These observations, involving considerations of predisposition and its
tangible forms, do not apply to the important class of cardiac
hæmoptysis. The factors here are increased venous tension, pulmonary
hyperæmia of mechanical rather than vital origin, sclerosed or
atheromatous vessels, capillary ectasis, and embolic obstruction of the
pulmonary artery with resultant infarction, etc.
SYMPTOMS.--The definition requires that the blood be pure or unmixed,
yet the coarse physical appearances may vary a good deal. The color is
usually a bright red, but may be dark or venous in hue. There is
sufficient inconstancy in color to prevent its being reliable in
distinguishing the special source of the bleeding, though usually the
bright color is of bronchial and the dark of pulmonary origin. If
bright red at the onset, it loses some if not the whole of its
brightness as the attack progresses or is subsiding, sometimes because
of retention in the air-passages. The mass is more or less frothy, and
varies in density and specific gravity, in diffluence or adhesiveness,
the latter quality increasing in proportion to congestive or
inflammatory conditions, whether in the early or later stages. This is
dependent on the increase of the plastic, fibrinous, or reactive
elements in the blood and adjoining tissues. The mass may lie in a
circumscribed or in a splashy form in the bottom of the vessel,
circumstances of distance and force of ejection, as well as of physical
quality, producing the variations. The quantity varies greatly, both as
to the amount at each act of expectoration and as to the amount during
all of them. The whole amount throughout an average attack of initial
hæmoptysis might be placed at about one and a half to two ounces. Such
would be called moderate but decided hemorrhage. The extremes would
range between a teaspoonful and several pounds, and the time consumed
in the attack may vary between the time taken up by one or two
ejections and several months. The intervals between the successive
ejections will vary from a few minutes to twenty-four hours or more in
a case lasting a week. The manner of ejection is sometimes by a single
effort of hawking or throat-scraping or clearing, sometimes by a slight
hacking cough or by a vigorous effort of expulsion; at other times the
outflow is so rapid through the mouth and nostrils that it resembles
vomiting and may suggest a hemorrhage of the stomach.
The effect which a severe attack may have on the patient is often
notable. He becomes pale out of proportion to the amount of blood that
he has lost; the pulse is full, bounding, and corresponds to what is
called the hemorrhagic pulse. This is sometimes due to the mental
shock, but again it is independent of any excitement on the part of the
patient, or of even any sort of constitutional disturbance, as fever.
We have seen it in full development in connection with a profuse
hæmoptysis and a temperature of 105°. It has been noted also as part of
the phenomena of hemorrhage produced by septic influences upon the
vaso-motor system. Walshe's dictum is no doubt true, that there is a
calm and excited variety quoad cardiac action.[51] In the former there
is little vascular or mental excitement or debility, and the patient
does not willingly yield to the necessary restraint.
[Footnote 51: _Diseases of the Lungs_, p. 330.]
Feebleness is an accompaniment, sometimes to a degree disproportionate
to the amount of blood lost, and is an element in the shock which the
patient {282} feels at so unexpected an event. The early part of the
attack is usually without fever. This comes on later as a part of the
reaction phenomena, and becomes then a very important prognostic
symptom. We have known it, however, to range as high as 105° before the
hemorrhage appeared, and without any reduction by a most obstinate
continuance of the depletion.
Many cases occur without premonition. In a proportion there are
symptoms precedent to the outbreak. The significance of these is often
not perceived until the hæmoptysis appears. Certain subjective symptoms
are common. A sense of burning, which is substernal or unilateral,
corresponding to that lung which is then or shall afterward show itself
affected; soreness within the same bounds; dyspnoea, rarely grossly
objective; slight hacking cough for variable periods, and, more
immediately antecedent, a salty taste in the mouth,--are some of these.
They have their origin in a state of hyperæmia or irritation which has
its outcome in catarrhal processes or hemorrhage. Which it may be will
depend on certain predisposing as well as the immediately operative
causes already mentioned.
Of the objective states, some importance may be attached to
characteristics of the individual, such as the brunette complexion,
dark hair and eyes, or to external correspondences with others of the
family known to have been similarly affected.
More than the usual care is necessary in the physical examination,
particularly in the use of percussion. Palpation and auscultation can
be safely applied, but there might be greater difficulty in getting the
patient into a good position for the actual examination. In the
hæmoptysis of incipient phthisis the physical signs most usually found
are deficient expansion and resonance and vesicular murmur at either
apex. These are evidences of causes that had been in operation before
the hæmoptysis, and indicate important physical changes at the region
where they may be found. Yet they do not necessarily indicate that the
bleeding has its origin at that place. Add moist bubbling râles, and
the presumption becomes almost a certainty that you have found the
locality of the hemorrhage. If these subside as the amount of blood
expectorated gets smaller, the inference is still stronger. Successive
increments of physical signs would indicate that the bleeding had been
correctly located and that the lesion which gave origin to it was
progressing. A proportion of cases occur where no physical sign can be
found even after careful examination, so that it happens sometimes that
at the period of most importance for diagnosis physical signs are not
available, and when they are most distinct in the advanced cases the
diagnosis is already established. They may even become embarrassing by
their abundance. The true significance of the physical signs cannot be
determined until the attack has subsided entirely. The termination of
an attack is usually by disappearance of the congestion of which the
symptoms related were the expression. The soreness and oppression
beneath the sternum, the dyspnoea and fever, are relieved. The
persistence of cough would not necessarily augur badly, because there
is apt to be some catarrhal secretion which necessitates it. The
general result is relief. If the termination is to be unfavorable,
there will be an evident increase of constitutional symptoms,
especially of fever, as in the case alluded to above with the high
temperature. There will be a slower return to the pre-hæmoptic state
and an increase of the physical signs, and you may have apparently a
case of phthisis ab hæmoptoe. The impetus in a large majority of cases
is from the constitutional elements which initiated the symptoms,
rather than from the local cause, blood within the air-passages.
Clinical experience proves that there are cases where serious and rapid
injury to the lungs has followed closely upon an hæmoptysis. It is
admissible to classify such as phthisis ab hæmoptoe only, in the sense
that the effusion of blood in the remote parts of the lungs has brought
about catarrhal pneumonia, which in those predisposed {283} ends in
phthisis. Sommerbrodt's[52] experiments proved that the healthy animals
recovered from the catarrhal pneumonia.
[Footnote 52: _Virchow's Archiv_, vol. lv. p. 192.]
To determine the genuineness of any such special case, we should be
able to include inherited or acquired predisposition; to prove priority
of the hæmoptysis to cough, dyspnoea, and fever, and that these
followed soon after the bleeding; and to show that the age at the time
of the occurrence was not the phthisical age. If a direct or mechanical
cause can be found for the bleeding, the proof would be still stronger.
Most of the cases depended on to prove phthisis ab hæmoptoe or
hemorrhagic phthisis (Powell) do not answer to these requirements. In
the 8 cases reported by Sokolowski[53] are summarized these features,
and they give strong support to the conception of a phthisis ab
hæmoptoe. The mode of termination by sudden death is by syncope, and
suffocation cannot be said to be very frequent. There have not been
more than 3 suddenly fatal cases (within a half hour) in the Cincinnati
Hospital records in a period of fifteen years: 22 cases are given in
the second medical report of Brompton Hospital, where the cases of
phthisis are very numerous; Powell's table[54] has 15 cases, which
happened at the Brompton Hospital between February, 1868, and November,
1870. The cases which we have collected as occurring since that amount
to about 20. T. Williams[55] says that of 198 patients who died, 4 died
of profuse hæmoptysis. Thompson[56] says that of 383 deaths occurring
in the hospital (Brompton) during three years, 26 were from fatal
bleeding--a percentage ranging between 2 and 6 in the two series.
[Footnote 53: _Berlin. klin. Wochenschrift_, 30 Sept., 1878.]
[Footnote 54: Vol. xxii., _Lond. Path. Soc. Tr._]
[Footnote 55: _Med.-Chir. Trans._, vol. liv.]
[Footnote 56: _Loc. cit._, p. 115.]
The symptomatology given above is a general one. Looked at with
reference to the varieties of hæmoptysis, the assignment would be to
the earliest or initial attacks. Assuming five varieties--1, the simple
or idiopathic; 2, the congestive; 3, the ulcerative; 4, the cavernous;
5, the extra-pulmonary--it would belong to the simple or to the
congestive form.
Under the first may be included those cases which occur without any
heredity or traceable cause, are not accompanied by fever, soreness,
dyspnoea, or physical signs, and which further observation shows are
not followed by pulmonary disease. Such cases are rare, yet clinical
records afford them. Time is so important an element in the diagnosis
that the presumption would be against such a classification at the time
of the call for treatment. They have probably developed the hemorrhagic
element of phthisis, and by otherwise vigorous constitutions are
protected from its further evolution.
The congestive form is the one with which we most often meet, and is
essentially the expression of the predisposing element mentioned as one
of the agencies of heredity. Unlike the idiopathic variety, it has its
positive symptoms, so familiar to the practitioner. Special clinical
forms, as the hæmoptysis of pregnancy, the so-called vicarious cases,
the earliest attacks in the hemorrhagic variety of phthisis, the
hæmoptysis of plastic bronchitis (which has a phthisical element in
it), that of hydatids of the lung preliminary to the opening of the
hydatid, and probably others, such as cancer of the lung, may be placed
in this category. Hysterical hæmoptysis is a term of doubtful
propriety, because facts show that the tubercular diathesis has close
affinities with the neuropathic heredity,[57] and hence that the
hæmoptysis arises from the tubercular and not the neuropathic element.
From this point of view it has its congestive origin, and can be
properly classified under this head.
[Footnote 57: J. Grasset, _Brain_, vols. vi. and vii.]
The ulcerative form is familiar to us in the second stage of phthisis.
It is more subordinated to the constitutional features, fever, hectic,
and debility, to the purulent expectoration, and to the
easily-determined physical signs. {284} Notwithstanding the apparently
increased chance of profuse hemorrhage, the quantity of blood is often
quite small and apt to be accompanied with a mixed sputum. It is not so
florid as in the congestive form. Some of the most copious hemorrhages
in this stage arise from the presence of the hemorrhagic diathesis or
are found in persons of full and plethoric habit. They will recur at
intervals of once or twice a year for many years, and some of them
finally cease, with a remainder of physical signs. The physical signs
usually indicate nothing more than consolidation of the lung for a long
time. They are dulness, bronchophony, bronchial breathing, and mucus or
crackling sounds over a limited area in the upper part of the chest. In
the slow cases of pulmonary fibrosis there is now and then a small
amount of ulcerative action to produce hæmoptysis. We have seen cases
fatal by a suffocating quantity without discovery of the actual source.
In cavernous hæmoptysis there are striking facts which give this class
a great interest. It includes most of the suddenly fatal cases which
shock families or hospital inmates. It comes from rupture of small
aneurisms in the walls of old cavities. A less dangerous form is that
from small granulations or vessels in the walls of recent cavities or
from small vessels in their trabeculæ. The elucidation of hemorrhage
and death from pulmonary aneurism is of the later acquisitions in our
knowledge.[58] A distinction between the ulcerative and pulmonary
aneurism forms is not always practicable. A detection of the aneurism
by auscultation has not been recorded, though it is at times quite
large. In the latter form you may have, as in the former, repeated
attacks of hemorrhage before this fatal one. The most decisive
indication in favor of the aneurismal source of the bleeding, besides
frequent and abundant hemorrhage, would be the proofs of a chronic
cavity. In Powell's[59] 15 cases of fatal hæmoptysis 3 were without
discoverable source; of the other 12, 3 were immediately fatal; in the
remaining 9 the previous attacks of hæmoptysis occurred at periods
varying from eighteen months to two days. The aneurisms were all in the
left lung except 2: 6 occurred in individuals with family histories of
phthisis; 3 with such histories; 2 are negative or doubtful of fatal
hæmoptysis.
[Footnote 58: Williams says that Peacock and Fearn of Derby were the
first to record instances of pulmonary aneurism in England. Stark in
his works edited by J. C. Smyth, 4th Lond. ed., 1788, p. 31 (quoted by
Young, _loc. cit._, p. 331), relates a case of diseased lungs in which
sudden death took place from the bursting of an aneurism of the
pulmonary artery.]
[Footnote 59: Vol. xxii., _Path. Soc. Trans._, London.]
We have a table of cases collected from reports made since Powell's--in
all 21. In 10 the aneurisms were in the left lung, 8 were in the right,
and in 3 the place of the aneurism was not designated; 16 were in
males, 4 in females, and 2 not noted. The relation of heredity to
phthisis was not noted, except in 1, which was affirmative. In 2 there
was no previous attack of hæmoptysis. The longest interval between the
first and fatal attack was four years: 7 were immediately fatal. From
both collections we have 33 aneurisms of the pulmonary artery in
cavities, 20 being in the left lung; 10 were in the right. Most of the
aneurisms were situated in the upper lobes, as might naturally be
expected. Powell's opinion was that there were good grounds for saying
that the more chronic and quiescent the cavity, and the more unilateral
the disease--the more nearly, in short, it approached the type of
fibroid phthisis--the more probable it was that the hemorrhage, if it
occurred in any quantity, proceeded from a pulmonary aneurism. Taking
15 cases from our list the duration of which could be fairly named, the
average was about seventeen months. The average duration of Powell's
cases was about twenty-four months. Most of our cases were bilaterally
affected, and only 2 were positively stated to have been of the fibroid
variety. Yet, practically, {285} the clinical features enumerated by
Powell form the best standard by which to determine the source of the
fatal hemorrhage. Copious hæmoptysis, with great chronicity and
quiescence of phthisis and cavernous physical signs, points to aneurism
of the pulmonary artery within the cavity.
In the class of extra-pulmonary hæmoptysis are included those cases of
ulceration and rupture of aneurisms of the aorta and its branches into
some portion of the air-passages, and the necessary discharge of blood
therefrom. Experience justifies a classification of this kind. Cases
have occurred where the pulmonary symptoms and signs have been so
prominent as to have obscured those of the coexistent and causal aortic
aneurism until the fatal hæmoptysis revealed the mistake. Still others
of simultaneous tubercular disease of the lungs and aortic aneurism are
reported. J. W. Ogle[60] reports a case where the patient had had cough
for seven years, at first attended with hæmoptysis, dyspnoea, and
palpitation, and afterward consolidation of the left lung, and where
death was produced by rupture of aortic aneurism into the right
bronchus. Bronchitis and pneumonia have been treated without suspecting
the real cause until a similar event occurred. Janeway and Loomis[61]
also give instances of aortic aneurism and phthisical deposits with
doubtful diagnoses in the same persons. We have seen an instance where
illness began with cough, frothy and then purulent expectoration, then
loss of flesh and strength and pain in side, fever to 102, dulness
below right clavicle, and then a number of large hemorrhages, and
finally a fatal one, all of the hemorrhages depending on an aneurism of
the internal carotid artery discharging into the mouth. The chances of
these irregular clinical associations must, then, be borne in mind.
Careful examination only will enable us to eliminate the doubtful
features.
[Footnote 60: _Lond. Path. Soc. Trans._, vol. xvii. p. 104.]
[Footnote 61: _N.Y. Med. Rec._, vol. vii. p. 304.]
In a collection of 33 aortic aneurisms discharged through the
air-passages, 9 had histories of hæmoptysis previous to the last one.
These discharges were more or less copious, and, considering the
physical signs of phthisis obvious in some, and recollecting that
aneurisms were not recognized, the clinical features were such as to
produce if not justify a diagnosis of intrapulmonary hæmoptysis. Of the
33, 16 opened into the left bronchus, 14 into the trachea, 2 into the
right bronchus, and 1 is given without special designation of the point
of communication. Of 2 aneurisms of the arteria innominata, both opened
into the trachea. Aneurisms of the subclavian have also been known to
have discharged through the apex of the lung. These clinical and
anatomical facts point to a large predominance of symptoms and lesions
connected with the left lung where the pulmonary organs are at all
affected. In our own table, while 18 had marked lesions and symptoms
pertaining to the left, only 6 had them connected with the right lung.
These figures are too limited to be decided, but so far as they go they
tend to prove a greater amount of left-lung lesion in extra-pulmonary
than in cavernous hæmoptysis.