65 Zeitschrift für klin. Med., vol. i. p. 148, Berlin, 1880.
Other fatal cases find their anatomical basis in the softening and ulcerating processes, which while forming cavities are liable to open vessels of greater or less size in their walls or trabeculæ.
The condition of the heart in phthisis is one which has an effect in influencing the occurrence of hæmoptysis. The general statement by Peacock, that the weight of the heart in phthisis, though less than in acute diseases, is greater than that in other chronic diseases, needs to be modified somewhat, as he did not make a distinction between different forms of phthisis. The more the case approaches the fibroid variety the more likelihood of some increase of size, particularly in the right ventricle. Spatz,66 a later authority, gives as the result of his examination that phthisis diminishes the size of the left ventricle—that an absolutely compensatory hypertrophy of the right ventricle, which is apparent in special cases, does not as a rule exist, although the resultant decrease does not throughout stand in relation to the decreased weight and volume of the whole body in phthisis. The ratio between the depth of the left ventricle and circumference of the aorta is diminished; and, as this is not compensated for by hypertrophy of the walls of the ventricle, arterial tension diminishes and the pulse becomes soft and small. The chance of rupture of weak vessels by relatively excessive tension is thus much weakened in the later stages of phthisis.
66 Deutsches Archiv für klinisch Med., vol. xxx. p. 154.
Another element capable of modifying the hæmoptysical features of phthisis is claimed by Jaccoud67 as existing in the insufficiency of the tricuspid valve, which compensates the increased tension in the field of the pulmonary artery arising from obstruction of a considerable part of it. The amount of blood passing from the right ventricle is thus, by a reflux, proportioned to the area of obstruction in the artery, and the tension is reduced so as to prevent rupture of the weak vessels. His conclusions are based on 18 cases of measurements of the tricuspid orifice. They varied from 111 to 130 millimeters. The evidence obtainable during life was a systolic murmur heard at the ensiform cartilage and cervical venous reflux.
67 Clinique médicale, vol. ii. p. 346, etc.
DIAGNOSIS is mostly called for with regard to the chances of hæmatemesis. Inspection of the blood is naturally an early point for attention. Its bright-red color, frothy look, freedom from extraneous matter, and its coming up by coughing are strong evidences easily acquired of its pulmonary origin. Corroborative circumstances are the family history of phthisis or hæmoptysis, the presence of pulmonary, or in fewer instances of cardiac, physical signs, the immediately premonitory symptoms spoken of before. Fever, the age of the patient, and the continuance of the discharge of blood in its later gradations of color and mixture of catarrhal elements, inspection of the mouth, fauces, and larynx, would exclude those possible sources. Each has its limitations, but together they are conclusive as against hæmatemesis. Recent and accumulating experience attributes some diagnostic value to the presence of bacilli tuberculosis in the expectorated blood. Hiller68 reports 6 cases of hæmoptysis in which the blood showed in bacilli: 3 were completely initial. The bacilli were easily demonstrated by preparations and also by inoculation on guinea-pigs. They have also been found in the blood of cases of acute tuberculosis by Weichselbaum.69 Resort may be had to the well-known tests for the presence of the elastic tissue of the lung in sputum.
68 Centralblatt für die med. Wissenschaft, March 24, 1883.
69 Wiener med. Wochenschrift, No. 13, 1884.
As positive data for hæmatemesis we have the dark color of the blood, its firmer clotting, greater density and want of aëration, acid reaction, the presence of extraneous matters of food and drink, their ejection by vomiting, and pain or uneasiness at the epigastrium. As corroborative we have the less frequent occurrence of hæmatemesis, the individual history of gastric disease, such as ulcer of the stomach or presence of hepatic cirrhosis from intemperate habits, and the history of a blow on the abdominal surface: discharges of blood from the bowels are more likely to occur in hæmatemesis.