A system of practical medicine. By American authors. Vol. 3

by Unknown

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.

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. 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's⁵⁹ 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.

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.

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, 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.