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 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 ends in phthisis. Sommerbrodt's52 experiments proved that the healthy animals recovered from the catarrhal pneumonia.
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 Sokolowski53 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 table54 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. Williams55 says that of 198 patients who died, 4 died of profuse hæmoptysis. Thompson56 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.
53 Berlin. klin. Wochenschrift, 30 Sept., 1878.
54 Vol. xxii., Lond. Path. Soc. Tr.
55 Med.-Chir. Trans., vol. liv.