CHAPTER XVI.

HÆMOPTYSIS AND THE HÆMORRHAGIC VARIETY OF CONSUMPTION. BY DR. C. THEODORE WILLIAMS.

Hemoptysis-Its significance-Views of Louis, Laennec, Andral, Watson -Niemeyer's Explanation of large Hemoptysis - His Comparison of Bronchial Hemorrhage with Epistaxis inappropriate.-Differences in the Bronchial and Nasal Tracts-Niemeyer's Views of the Relation of Hæmoptysis to Phthisis discussed—Origin of Phthisis from Hæmoptysis improbable and unproved-Author's Experience-Hæmorrhage of Early Phthisis explained by Fatty Degeneration of Vessels- Of later Stages by Pulmonary Aneurism-Varieties and Pathology of latter-Hemoptysis from Congestion-Influence of Age and Sex in Hæmoptysis-Influence of Stage Illustrative Cases—Influence of Form of Disease-Hæmorrhagic Phthisis— Its characteristic Symptoms and exciting Causes-Examples-Effects of Hemoptysis in Phthisis-General and local Pneumonia-When and why set up-Results-Illustrative Cases-Influence of Hemoptysis on Duration of life.

So many cases of phthisis are accompanied by hæmoptysis in some part or another of their course, most commonly in the early stages, that spitting of blood, or 'bursting a blood vessel,' as it is popularly called, has long been considered by the public, and to some extent by the profession, as an indication of consumption. The connexion of hæmoptysis and phthisis, though simple in the stages of softening and excavation, is by no means always so in the early stages of the disease, and especially in cases where large hæmoptysis takes place, and but slight if any physical signs are detected at the time of its occurrence. Here the existence of consumptive disease is often denied; and when at a later date it developes itself more clearly, its cause is referred by some writers to the blood

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effused into the bronchi during hæmoptysis, which is considered to have given rise to inflammation and destruction of the lung substance. We propose in this chapter to examine the views held by various writers on the relation of hæmoptysis to phthisis, and to state the conclusions which our own experience has led us to adopt on the subject.

What then do authorities say as to the significance of hæmoptysis? Louis states, that excluding cases of amenorrhoea and mechanical injuries to the chest, he did not find a single instance of hæmoptysis among 1,200 cases, unconnected with tuberculous disease of the lung. Laennec holds much the same opinion; and Andral states, that of persons who have had hemoptysis, one-fifth have not tubercles in the lungs; but he does not state whether any cardiac or other lesion existed to account for the hæmorrhage. Sir Thomas Watson' says, 'If a person spits blood who has received no injury to the chest, in whom the uterine functions are healthy and right, and who has no disease of the heart, the odds that there are tubercles in the lungs of that person are fearfully high.'

On the other hand, Niemeyer, after stating that bronchial hæmorrhage is the most frequent cause of hæmoptysis, explains that it proceeds from rupture of the capillaries, caused either by over-distension, or else by a morbid delicacy of the walls, a result of perverted nutrition.' He remarks very justly, that trifling capillary hæmorrhage, such as occur in bronchial catarrh, violent irritation of air-passages, and in the circulatory disorders attending organic disease of the heart, proceed from the first of these

1 Practice of Physic, vol. ii. 200.

Text-Book of Practical Medicine, vol. i. p. 141. Although we cannot subscribe to all Niemeyer's views, we deeply lament the loss which Clinical Medicine has sustained in the recent death of so careful and accomplished an observer.

causes, but that in most hæmorrhages in which large quantities of blood are poured into bronchi to be ejected by hæmoptysis, they are due to the latter condition.' It is much to be regretted that Niemeyer uses such vague terms as 'morbid delicacy' of walls of vessels; but as far as we understand him, in regarding the vascular walls as the seat of disease, and their fragility the cause of large hæmoptysis, we agree with him. Why he should assign such hæmorrhage to the bronchial trunks and capillaries, we are at a loss to understand, as he gives no fact to support his statement, and we know that as yet simple bronchial hæmorrhage has never been demonstrated by postmortem examination. The comparison with the large hæmorrhage from the nasal mucous membrane, which occurs in profuse epistaxis, does not hold good, as may be shown by structural differences in the two tracts. The Schneiderian membrane in parts, as on the septum nasi and over the spongy bones, is very thick, partly through the presence of glands, but chiefly as Todd and Bowman' say, 'from the presence of ample and capacious submucous plexuses of both arteries and veins, of which the latter are by far the more large and tortuous. These serve to explain the tendency of hæmorrhage in case of general or local plethora.' The bronchial mucous membrane, though undoubtedly vascular, cannot be said to present in its structure any explanation of copious hæmorrhage like that of the nasal tract.

2

Niemeyer sums up his views on the relation of hæmoptysis to phthisis in the following paragraphs :

1. Bronchial hæmorrhage occurs oftener than is generally believed in persons who are not consumptive at the time of the bleeding, and who never become so.

2. Copious bronchial hæmorrhage frequently precedes consumption, there being, however, no relation of cause

1

1 Physiological Anatomy, vol. ii. p. 3.

2 Op. cit. p. 144.

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and effect between the hæmorrhage and pulmonary disease. Here both events spring from the same source -from a common predisposition, on the part of the patient, both to consumption and bleeding.

3. Bronchial bleeding may precede the development of consumption as its cause, the hæmorrhage leading to chronic inflammation and destruction of the lung.

‘4. Hæmorrhage from the bronchi occurs in the course of established consumption more frequently than it precedes it. It sometimes, although rarely, appears when the disease is yet latent.

5. When bronchial hæmorrhage takes place during the course of consumption, it may accelerate the fatal issue of the disease, by causing chronic destructive inflammation.'

With regard to the first class, Niemeyer states that hæmoptysis occurs, though rarely, in young persons in blooming health and of vigorous constitution, and that there is absolutely no explanation of the disorder, which is often followed by such sad results. Here we question the facts, both of the hæmorrhage being really bronchial, for the reasons we have given above, and of the health of these persons being really sound. In few such cases have we failed to find signs of disease, limited, it is true, and generally confined to the inter-scapular regions of the chest. Niemeyer admits that exceptional instances occur in which tubercles and inflammatory processes form in the lungs in a manner so latent that no tokens of disease are manifested by the individual affected, until he is suddenly attacked by a fit of hæmorrhage; but he denies that this is the case in the great majority of instances, where the first attack of hæmoptysis has not been preceded by cough, dyspnoea, or other sign of pulmonary disorder. How he distinguishes between these two classes, or on what grounds he supposed that they are separate

classes, does not appear; but he continues, that bronchial hæmorrhage is by no means so rare an event where there is no grave disease of the lungs, is shown, moreover, by the tolerably numerous cases in which persons, after suffering one or more attacks of pneumorrhagia, regain their health completely, and indeed often live to an advanced age, and after death present no discoverable traces of extinct tuberculosis in their lungs. Unfortunately, none of these tolerably numerous cases' is given to support this statement, which can hardly therefore be considered to be supported by satisfactory evidence.

Our own experience is exactly the reverse; and we have generally been able to detect signs of disease during life in the lungs of all those patients who have had extensive hæmoptysis, unconnected with heart disease, injury to the chest, or disorder of the menstruation.

Niemeyer also finds a strong tendency to profuse capillary hæmorrhage from the bronchi in young persons between fifteen and twenty-five, whose parents have died of consumption, and who have suffered in infancy from rickets or scrofula, have often bled at the nose, and grown rapidly tall. He is tempted to refer the remarkable frequency to a deficiency of vital material which has been immoderately expanded in the maladies of childhood or in the process of growth; and therefore does not leave sufficient to maintain the normal nutrition of the capillary walls. He remarks that this does not explain why the seat of the hæmorrhage should be, first in the nose, and secondly in the bronchi, &c. Now we would ask our readers, could a case for probable consumptive origin of hæmoptysis be more clearly made out than it is here by Niemeyer himself? The family history, predisposing influences and diseases, and structural features are complete. Some exciting cause, like catarrh, only is wanting to determine the outbreak of disease in the lung, and those