Denison,40 after an analysis of 90 cases of hæmoptysis out of 202 of phthisis, says: "The advantages of high altitudes are pre-eminently for hemorrhagic cases in the first stage, while hemorrhagic cases with excavations, especially if the bleeding has been recent and softening is in progress, should be interdicted from going to great elevations."
40 Rocky Mountain Health Reports, p. 140.
He also quotes Herman Weber41 as recommending "alpine climates, not only as a prophylactic measure against hæmoptysis, but also as a means to promote the cure of the effects of the inflammatory processes resulting from pulmonary hemorrhage."
41 Hæmoptysis as a Cure of Inflammatory Processes and Phthisis, with Remarks on Treatment.
These statements are sufficient to show that the view formerly prevalent, and still more or less so, that high altitudes have the effect of prolonging or favoring hæmoptysis, is not altogether correct. It should be understood as applying to the extreme heights of 10,000 or 15,000 feet, and that rapidity of transfer and unusual exertion are necessary and qualifying considerations. Jourdanet42 places the region of safety in phthisis about the mid-point between the level of the sea and the snow-line. The preservative level is lower in Alpine than in American regions. The line of perpetual snow in Mexico being about 4500 meters, the preservative zone would be 2250 meters. In Switzerland, where the line of snow marks 2700 meters, the same zone would be 1350 meters. No such definite limitations are attainable as regards hæmoptysis, but a correspondence of zones might be conjectured.
42 Influence de la Pression de l'Air, vol. ii. pp. 183, 184, 213.
The belief that pregnancy in some way favors hæmoptysis is a very old one. It has been more or less accepted by modern writers. Trousseau43 gives his observations to the effect that there are women who during pregnancy, and others who during nursing, spit blood. His belief was that such hæmoptyses were not symptomatic of pulmonary tubercle nor of cardiac disease, but he classifies them as cases of hemorrhagic deviation. Peter44 speaks of a gravid pulmonary hyperæmia, proven in part by his determination of increased local temperatures in the lower intercostal spaces. Some of his cases do not sustain his theories, and can properly be referred to puerperal accidents, such as emboli in phlegmasia alba dolens. Such cases as we have met with in connection with pregnancy or lactation have had hereditary or acquired tendencies to phthisis. We have under view a case where hæmoptysis always recurs during pregnancy and where there is a family history of phthisis. A brother has pulmonary hemorrhages preceded by inflammatory attacks, which stand in a relation to him corresponding to the pregnant hyperæmia of the sister. The well-known effects of pregnancy or prolonged lactation in developing phthisis are a sufficient explanation of this class of cases.
43 Clinique Medic. Trans., vol. i. p. 531.
44 Leçons de Clinique médicale, vol. ii. p. 664, 2d ed.
Many exciting causes are assigned by patients in explanation of a dreaded event, and some are otherwise misinterpreted. Their mode of action is not intelligible unless we keep in view the anatomical, physiological, and pathological data heretofore given. Numerous cases occur where no exciting causes can be found, such as those coming on in the quietude of sleep. The insidious agencies of the predisposing causes must be responsible. A study of many cases will show that the alleged causes have become operative only after a considerable time has elapsed, during which a congestive or inflammatory condition has appeared, the expression of a latent tendency. Dancing in a warm room or speaking long in the open air, followed in twenty-four hours by bleeding, are such instances. The physical effort was only so far instrumental as it gave a chance for the development of a potential diathetic condition. It was not the direct cause. Falls, frights, blows on the chest, heavy lifting, playing on wind instruments, and emotional excitement are sufficient to bring on a hemorrhage by direct influence, and by so increasing arterial tension as to overcome the resistance of vessels already weak. It is not intended to maintain the impossibility of rupture of healthy vessels under some circumstances, but the large provision made in the great distensibility of the pulmonary vessels and in the supplementary functions already alluded to make it necessary to be cautious in such admissions. The fact that hemorrhages from the direct causes are sometimes not followed by phthisical effects does not necessarily disprove their diathetic origin.