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There are two circumstances in reference to the circulation in phthisical lungs which are unfavourable to the occurrence of profuse hæmorrhage. In inflamed lung, the blood-vessels, though tortuous, are free, but in tubercular lungs the blood coagulates in the extremity of the vessels. But there is an additional point well worthy of your attention. When you look at this large vomica you observe a considerable band passing across it. Of what does this band consist? It contains no bronchial tube. Bronchial tubes readily ulcerate, and by that process expectoration from cavities is promoted. The band consists mainly of blood vessels and cellular substance. Blood-vessels are inapt to ulcerate, The walls of the pulmonary arteries, when surrounded by tubercular ulcerations, instead of sharing the disorganisation, usually thicken ; by the deposition of fresh material, their calibre gradually lessens ; after a time they cease to be pervious, they are filled with a thin, reddish, fibrinous plug, and transformed into solid cords.
It is probably only in those rare instances in which such a vessel is suddenly torn before the calibre is perfectly closed, that fatal hæmorrhage is at all likely to occur. The popular idea that all bleeding from the lungs is produced by ruptured blood-vessels, is a serious error. The ordinary cause of hæmoptysis is doubtless compression or obliteration of the pulmonary veins by the tubercular deposit ; in consequence of which, blood, interrupted in its natural channels, overflows or exudes into the neighbouring bronchi. If this explanation be correct, hæmoptysis moderate in amount must be regarded rather as beneficial than alarming. By preventing the stagnation of unhealthy blood it must tend to
oppose the extension of tubercular disease; and as far as a conclusion may be drawn from the cases under my care, the influence of hæmoptysis of considerable amount would seem to have been rather favourable than otherwise. You will observe that some of the cases of phthisis recorded in the table, accompanied with copious hæmoptysis, were remarkably slow in their progress. In six of the cases the quantity of blood expectorated at once has excedeed a pint, and the time which has elapsed since the occurrence of the profuse hæmoptysis to the present period has been in these patients, respectively six months, twenty-two months, twelve months, ten months, eight months, and five years. In several of these instances, evidence of pulmonary disease preceded by many months the occurrence of hæmoptysis, and in some the disease has not yet advanced beyond the first stage. These facts are in harmony with my general experience, as showing that this symptom tends more to retard than to accelerate a fatal issue.
The practical bearing of these facts is obvious and important, as impressing the conclusion that undue haste to arrest hæmoptysis should be deprecated, and that, as a general rule, it is better to moderate this symptom by producing determination to other organs, than to employ direct astringents. You will find great benefit in many cases from the administration of a dose of calomel or mercurial pill, with henbane, followed by the use of half-drachm doses of sulphate of magnesia with diluted sulphuric acid, administered twice a day.
This plan has been adopted with a young woman now in the hospital, whose case, as presenting several particulars of interest, I will briefly relate.
E. B., aged sixteen, of sanguineous temperament, and who had lost her mother, an uncle, and two maternal aunts, from phthisis, was admitted on the 26th of December, 1850. Has been subject to pain of chest for ten months, and to cough for fourteen weeks. This cough was at first dry, but latterly accompanied with expectoration. She has been for four years affected with leucorrhea. Catamenia, which commenced fifteen months since, at first profuse for seven months, subsequently irregular, and for the last four months suppressed. Has pain under the left mamma; general appearance delicate, but not very unhealthy.
A fortnight before admission, on awaking in the morning she found the blood flowing from her mouth, and the bed-clothes largely soaked with it. She estimates the quantity at a pint. The flow stopped half an hour after she awoke, but has recurred every night since. She thinks she brought up three or four pints altogether—a pint the first night, and about three ounces every night since.
In the day-time the sputa are not even streaked with blood. Her tongue is furred; appetite bad; bowels much confined ; urine thick and scanty—ten ounces in twenty-four hours, specific gravity, 1037; cough of most distressing character ; sometimes twenty-two fits in ten minutes. Sleeps very badly half an hour at a time, and is then awoke by coughing.
Physical signs.-Slight dulness and imperfect inspiration on right side; prolonged expiratory murmur on both. For a day or two she was treated with sulphuric acid and opium, but on Dec. 28th, the pulse being 135, respirations 48, digitalis and hydrocyanic acid were given.
Dec. 29th.—Pain in the left side relieved by dry cupping, but the hæmoptysis continuing, alum was added to her mixture.
30th.—Hæmoptysis during the night amounted to four ounces. Half a grain of tartarized antimony ; five and a half ounces of water ; half an ounce of syrup of poppies. An ounce of this mixture every four hours. A small blister on each side of the dorsal spine ; six leeches to the vulva.
31st.—Leeches bled freely ; hæmoptysis last night only to the extent of an ounce; incessantly vomiting ; chloroform to be inhaled in order to check the vomiting. Three grains of calomel; five grains of extract of henbane, in two pills, immediately. A drachm of sulphate of magnesia ; an ounce of rose-water ; ten minims of diluted sulphuric acid ; three minims of diluted hydrocyanic acid ; every four hours.
Jan. 3rd.—Hæmoptysis gradually lessening.
On the 6th of January inhalation of turpentine was tried daily, and on the 8th, the same remedy internally, in doses of fifteen minims; under this plan, the spitting of blood was much subdued, but returned in a few days; and, in consideration of the interruption of the catamenia for seven months, tincture of lytta, in half-drachm doses, was administered with decided advantage.
This case is in various ways instructive. It shows you how, even such a symptom as hæmoptysis may be modified, when associated with hysteria, and may indeed partake of the capriciousness of the hysterical condition. It serves also to confirm the statement that considerable expectoration of blood may exist without
any serious consequences, and with relief rather than aggravation of the associated pulmonary disorder.
A. C- , another patient whom you have seen, has had hæmoptysis removed by the use of turpentine, the inhalation of which has also materially diminished the quantity of expectoration.
Let me repeat that hæmoptysis, when slight, is often useful, and should not be hastily checked. When it is considerable, if of an active character, as indicated by full hard pulse, heat and oppression under the sternum, and heaving of the diaphragm, cupping, or even bleeding may be requisite. In less formidable attacks, anticongestive remedies, and small doses of sulphate of magnesia with sulphuric acid may be given, or antimony with nitrate of potash. Ipecacuanha has been recommended, in doses of two grains every quarter of an hour, but this remedy has disappointed me. A strong solution of dinner salt, as formerly recommended by various physicians, especially by our countryman Dr. Percival, and by Dr. Rush of America, is still employed by some practitioners. In the few cases in which I have administered this remedy on account of hæmoptysis, no obvious beneficial result has followed; but circumstances might occur to render the trial of so convenient a remedy desirable, and several medical friends have assured me of its efficacy. Dr. Ross of Madeira, for example, has frequent recourse to it. His plan is to give half an ounce of the salt in two ounces of water at once, and subsequently a drachm three times a day or oftener, while the hæmoptysis continues. If the hæmoptysis be passive, direct astringents may be required, of which alum is one of the best ; and perhaps this re