Hæmoptysis

“ The attempt to prove that it is hæmophilic rests upon the application of a few histological examinations of hæmophilic vessels to the phenomena of phthisical hæmoptysis. The assumption of identity has only the doubtful force of analogy. Histological examinations of the vessels in the earliest stages of phthisis and hæmoptysis are too rare to afford sufficient data. ”

“ Analogous cases occur in which epistaxis has persisted during pregnancy, during the puerperium, and at the climacteric period, replacing the physiologically suppressed menstrual flow. Similarly Liégois has observed vicarious hæmoptysis during pregnancy. According to Baumgarten, in vicarious epistaxis the bleeding almost always proceeds from the region of the cartilaginous septum, and may become very violent; vicarious hæmorrhage from the larynx proceeds from the true and false vocal cords. Tracheal hæmorrhage is a much rarer occurrence. ”

“ As regards exemption, it is stated that of the cases of decided phthisis which had been free from hæmoptysis, about five-sevenths were males, and under two-sevenths females. In general it may be said that females are more liable to small and males to the larger hemorrhages. ”

“ The term hæmoptysis (αιμα, blood, πτυω, I spit,) is now entirely restricted to bleeding from the lungs and lower air passages. It is a very rare complaint in the lower animals, but is sometimes seen in both horse and ox. In very plethoric subjects the overloaded circulatory organs give way in the delicate membrane, lining the ultimate bronchial tubes and the air cells. The exciting cause in such cases is usually some severe effort of draught, a violent gallop, or other unwonted exertion. It occurs in glanders from rupture of caseated pulmonary nodules. ”

“ In cardiac hæmoptysis the hemorrhage is an event coming toward the close of organic and obstructive changes which are not much within our control. There are minor degrees, as shown by expectoration of single small masses of dark coagulated blood and by the absence of marked aggravation of the symptoms, which do not prognosticate unfavorably for the immediate, but do show impending dangers of a future, attack. ”

“ When serum is effused, a pituitous or purulent expectoration alone takes place; when blood is discharged, a disease is produced which has been called hæmoptysis. An effusion of blood in the brain, brought on by the operation of general debility, has been called by Dr. Hoffman, with equal propriety, a hæmorrhage of the brain. The effusion of blood in the lungs, in consequence of the rupture of a blood-vessel, is less fatal than the same accident when it occurs in the brain, only because the blood in the former case is more easily discharged from the system. ”

“ In case of wounds of the contused variety a laceration of parenchyma occurs at times sufficient to produce marked hæmoptysis. If the blood be not ejected, there are no certain indications of what has happened. If the case be seen immediately after the accident, such physical signs as moist bubbling râles on the margin of an area of feeble or suppressed vesicular murmur, possibly attended with a dull, high-pitched percussion note over that area, would afford a strong presumption in favor of ruptured lung and consequent hemorrhage. ”

“ 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. ”

“ Hæmatemesis may carry off a patient early (Case II.) , or even before the nature of the trouble is suspected (Case VI.) . Hemorrhage from the bowel is common. Hæmoptysis and hæmaturia are rare. Bleeding from the gums may be present (Cases V. and VII.) . In women there may be profuse menstruation. Petechiæ on the skin are frequent; occasionally there are large extravasations beneath the skin or between the muscles. Hemorrhage into the brain may prove quickly fatal (Case X.) , and the extravasations into the retinæ may impair vision.
The respiratory system offers few special symptoms. ”

“ Hæmoptysis occurring in persons not predisposed to Consumption, except the quantity of blood lost be so great as to produce it by mere debility, very frequently may be easily cured without danger of any consequent disease. Indeed not only in such cases consumption is not induced by it, but that disease has actually been prevented, by the occurrence of hæmorrhage from the lungs, relieving that inflammation, which the inert physician, by withholding the lancet, would have suffered to destroy his [Pg 23] patient. ”

“ It not infrequently happens that such haemoptysis may be the first symptom that seriously attracts attention. At a later period hemorrhage frequently takes place in large or small amounts from the rupture of vessels, which frequently are dilated and form small aneurysms in the walls of cavities. ”

“ It must not be used to check hemorrhage from the kidneys (haematuria) owing to its irritant action on those organs, but in haemoptysis (hemorrhage from the lungs) it is often an invaluable remedy. In large doses it has a depressant action on the nervous system, leading even to coma and total abolition of reflex action. ”

“ Hypertrophy, hæmoptysis, inflammatory affections of the heart and lungs, are the consequences in the young; valvular incompetency, rupture of the valves or of the muscular fibres of the heart, pulmonary apoplexy, and cerebral hæmorrhage, are too frequently the immediate consequences in those of more mature years. ”

“ Those persons who have been early instructed in vocal music, and who use their vocal organs moderately through life, are seldom affected by a hæmorrhage from the lungs.
2. Lawyers, players, public cryers, and city watchmen, all of whom exercise their lungs either by long or loud speaking, are less affected by this disease, than persons of other occupations.
I acknowledge I cannot extend this observation to the public teachers of religion. I have known [193] several instances of their being affected by hæmoptysis ”

“ Journal of Obstetrics and Gynæcology of the British Empire, 1907, xii. 335.
Wallace, Arthur J. On Repeated Cæsarean Section. Ibid., 1902, ii. 555.
CÆSAREAN SECTION IMMEDIATELY AFTER THE DEATH OF THE MOTHER
It occasionally happens that a woman in whom the course of pregnancy is nearly complete dies suddenly from disease, such as hæmoptysis, hæmatemesis, cardiac trouble, or uterine hæmorrhage in the preliminary stage of labour; or is killed by accident. In some such circumstance attempts are sometimes made to rescue the unborn child, by performing Cæsarean section. ”

“ One individual may himself yield to the same degenerating influences, and live with more or less of an acquired predisposition until similar exciting causes reveal his specific weakness. Another may find that he has a phthisis directly acquired from a single attack of severe illness without the aid of any element of heredity or of the acquired predisposition. The gradation would then be inherited predisposition, acquired predisposition, and acquired phthisis. Hæmoptysis may find its origin in these several relations of heredity. ”

“ Usually, the progress of the disease is slower in syphilitic than in tubercular phthisis, but when the systemic poisoning is grave and many other organs are coincidently involved, the progress is more rapid; but the process peculiar to syphilis is often past, and the patient suffers from simple catarrhal phthisis with formation of cavities and softening gummata. Diarrhoea and night-sweats are said to be less frequent than in ordinary phthisis, and the pulse is slower. Hæmoptysis occurs infrequently, because the process in the lungs is chiefly fibroid ”

“ Hæmophilic or Bleeder's Joint.—This is a rare but characteristic affection met with chiefly in the knee-joint of boys who are the subjects of hæmophilia. After some trivial injury, or even without apparent cause, a hæmorrhage takes place into the joint. The joint is tensely swollen, cannot be completely extended, and is so painful that the patient is obliged to lie up. The temperature is often raised (101° to 102° F.) , especially if there are also hæmorrhages elsewhere. The blood in the joint is slowly re-absorbed, and by the end of a fortnight or so, the symptoms completely disappear. ”

“ In certain cases the inheritance is transmitted by the female alone. This is the case in the hæmophilia, the unfortunate subjects of which are known as bleeders. There is in this a marked tendency to hæmorrhage which depends upon an alteration in the character of the blood which prevents clotting. This, the natural means of stopping bleeding from small wounds, being in abeyance, fatal hæmorrhage may result from pulling a tooth or from an insignificant wound. ”

“ How distinguished from ecchymosis?—Effused or coagulated blood is found when an incision is made in a true ecchymosis, however small, whereas a few bloody points are alone seen on a slight or deep incision into a post-mortem stain or true hypostasis. The seat of hypostasis is the superficial layer of the true skin. ”

“ Being always a homoplastic transfer, the new blood is not always tolerated by the old, in which case biochemical changes occur, resulting in hæmolysis, which corresponds to the disintegration of other unsuccessful homoplastic grafts. ”

“ In the peculiarly male disease known as hæmophilia the blood refuses to clot when shed, and there is nothing to prevent great loss from even a superficial scratch. In its general trend the inheritance of hæmophilia is not unlike that of horns among sheep, and it is possible that we are here again dealing with a character which is dominant in one sex and recessive in the other. ”

“ Hypostases are never raised above the surface, as ecchymoses sometimes are. In describing these two conditions, “ecchymosis” and “hypostasis,” it is preferable to describe the former as “discoloration from extravasated blood,” and the latter as “lividity after death.”
10. Cadaveric rigidity.—From the moment of death till the time when putrefaction sets in, the muscular structures of the body may be said to pass through three stages:—
(1) Muscular Irritability.—The muscles flaccid, but still possessing the power of contractility on the application of certain stimuli. ”

“ If hæmostatic effects only are wanted, 100 cc. of blood will be enough. If anæmia is also present, the dosage will be governed by the same considerations as have already been discussed in the section on the treatment of hæmorrhage.
Melæna Neonatorum.—Another hæmorrhagic condition in which blood transfusion is of the very greatest value is that known as melæna neonatorum. Severe hæmorrhage takes place from the bowel of an infant, sometimes only a few hours after birth. The cause is quite unknown, but it is found that absolute hæmostasis is usually brought about by blood transfusion. ”

“ Death occurs primarily through paralysis of the respiratory centre.
Local effects. In many cases considerable help to diagnosis may be obtained by external examination—bruising and ecchymosis, or definite hæmatomata, in the temporal or parietal regions. In some cases the hæmatoma may pulsate, and in others the application of pressure to the hæmatoma will lead to the development of fits involving the face and extremities on the contra-lateral side. Copious [141] hæmorrhage from the ear should always arouse suspicion as to the probability of an extra-dural hæmorrhage (see p. 97) . ”

“ With regard to the persistence of dulness on percussion, it is well to bear in mind that a thin layer of blood apparently produces as serious impairment of resonance as a much larger quantity of serum. The signs appeared to favour the view that the space necessary for the location of the hæmorrhage had been obtained at the expense of the lung rather than by distension of the thoracic parietes, and also, I think, denoted the presence of adhesions. ”

“ If the Echymosis happens in a Nervous Part, Balsam of Peru may be us'd, or, for want thereof, Oleum Lumbricorum & Hyperici, with luke-warm Wine, with which the Bolsters must be soak'd, to be laid upon it.
When the Echymosis is great, and much Blood is diffus'd between the Skin and the Flesh, the safest way is to make an Opening to let it out, lest a too plentiful and dangerous Suppuration should ensue, or even a Gangrene it self. However, a Surgeon ought to proceed in the curing of an Echymosis in the Face with great Circumspection, which must be always prepar'd for Incision. ”

“ An irregular entry wound was situated over the internal tuberosity of the tibia, while a large fluctuating hæmatoma existed in the lower third of the thigh, at the upper part of which a hard elongated body was palpable. As was so often the case with internal hæmorrhages, the patient's temperature rose high, and on the third day the hæmatoma was incised by Major Coutts, R.A.M.C. The core of the bullet was then found in the blood cavity near the surface, but on introduction of the finger a second body was discovered entangled in the quadriceps muscle, and this proved to be the tattered mantle. ”

“ If the blood flows from those veins which are terminated at the neck of the matrix, then it is not called an undue discharge of the menses, but haemorrhoids of the womb. The same remedy, however, will serve for both, only the instrumental cure will be a little different; for in uterine haemorrhoids, the ends of the veins hang over like teats, which must be removed by cutting, and then the veins closed with aloes, fine bole, burnt alum, myrrh, mastic, with comfoly-juice and knot grass, laid upon it like a plaster.
The air should be cold and dry, and all motion of the body should be prohibited. ”