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Clinical diagnosis, case examination and the analysis of symptoms online

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The only real, though slight, diagnostic difficulty arises from
the fact that blood shed in the nose or pharynx may actually be
swallowed or coagulate in the nasopharynx itself and be dis-
charged only by a spell of coughing. Under these conditions
the blood is more or less mixed with mucus from the stomach
or nasopharynx and may, upon hasty examination, be deemed to
have issued from the lung or stomach. The opposite mistake,
which consists in carelessly ascribing to the nasopharynx a
hemorrhage actually occurring in the stomach or lung, is much
more serious.

Let it be repeated once again that a careful general examina-
tion — including that of the nasopharynx — will inevitably and


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promptly lead to a correct determination of the source of expec-
torated blood.

The lingual origin of blood expelled from the mouth may be
noted in the event of a bite of the tongue, traumatic or "epi-
leptic," or of a tuberculous or neoplastic ulceration. Mention of
this cause of blood spitting, which could confuse only a very
careless or inexperienced practitioner, is required merely for
the sake of completeness and because it is customary to do so.

Bleeding from the gums is extremely common, even inde-
dendently of scurvy and hemophilia, which are themselves ex-
ceptional disorders. The ubiquitous pyorrhea alveolaris, various
diathetic disturbances, and even abuse of the tooth brush may
induce swelling and "inflammation" of the g^ms and render
them both sensitive and prone to bleed. Under these circum-
stances the least contact with the gums results in oozing which
stains all sputum with blood and gives rise to "pseudo-hemo-
ptysis." A most casual examination of the gums will discover the
actual source of the bleeding to be in these structures.

Hemorrhage in the larynx may result either from traumatism
or from ulceration. The former is readily excluded. Ulcerations
are always either syphilitic, tuberculous, or cancerous ; they are
always attended with hoarseness and local pain ; they are always
preceded by a period during which the attention was drawn to
and fixed upon the larynx. Examination of the larynx with the
mirror will always demonstrate the laryngeal source of the

The only real difficulty in diagnosis is that sometimes met
with in the differentiation of hemoptysifl from hematemesis, which
may constitute a most puzzling problem (see Hemat erne sis).

As a rule, there is little trouble in this connection :

The preliminary symptoms are different, being

Digestive in hematemesis and respiratory in hemoptysis.

The manner in which the blood is expelled is likewise different.

In hemoptysis there are attempts at coughing and the blood
is liquid, red, and foamy.

In hematemesis there is retching and the blood is clotted,
dark colored, without admixture of air, but mixed with food
material; sometimes intestinal hemorrhage coexists.

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All these signs, however, are unreliable.

In hemoptysis there may be dark colored blood (pulmonary
hemorrhage) and in hematemesis red blood (gastric ulcer).

In hemoptysis the preliminary cough may be wanting, while
on the other hand there may be concomitant vomiting and con-
sequently admixture of blood with food material.

In hematemesis the blood may or may not be mixed with bile
or food material.

After careful deliberation and thorough examination the con-
clusion may eventually be reached that hemoptysis has occurred.

♦ ♦ ♦

The diagnosis of "true hemoptysis" having been correctly made
— ^and definitely established, i.e., on the whole, the presence of
blood in the sputum either being obvious or having been demon-
strated by suitable hematologic procedures; the supposition of
hematemesis having been excluded, sometimes a difficult matter,
as the author has seen mistakes in this ccmnection made (and later
proven) by experienced observers; and the oropharynx, gums,
tongue, and nasopharynx being readily eliminated as sources of
bleeding by a mere citrsory examination, provided it is actually
carried out, — ^the cause of the hemoptysis is generally^ very easily
found if the following fundamental propositions are kept in mind :

1. Eleven-twelfths of all instances of true hemoptysis are of
cardiopulmonary origin and are due to one of two following
causes :

(a) Pulmonary tuberculosis in any one of its stages, from the
pretuberculous congestive stage to the stage of cavity pro-

(b) Infarction of the lung, generally secondary either to a
mitral disorder, particularly mitral stenosis; to some cardio-arterial
disorder which has advanced to the stage of decompensation with
stasis, or to phlebitis in any of its stages, from the pre-obstructive
stage to the stage of disintegration of the intravascular clot.

Pulmonary tuberculosis is a far more frequent cause than in-
farct of the lung. As for the latter, its cause is nearly always
obvious upon any sort of careful examination (mitral stenosis,
heart failure, puerperal, infectious, or post-operative phlebitis, etc.) ;

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frequently, moreover, infarction is marked by a sudden pain in the
side with cough, dyspnea, and even orthopnea, an area of fine
rales, etc.

Thus, any case of hemoptysis unattended with cardiovascular
disease (heart disease or phlebitis) may be considered to be in
all likelihood tuberculous. Furthermore, the hemoptysis of ad-
vanced tuberculosis, in the stages of softening or cavity forma-
tion, cannot fail to be recognized, as its source is quite obvious.

Doubt may arise only in connection with the premonitory

Fig. 745. — Diagram of pulmonary infarction. The embolus, having
become detached at some point in the inferior vena cava {v, c. i.) or its
tributaries, or in the superior vena cava {v. c. s.) or its tributaries, passes
through the right auricle {o. rf.), is discharged into the pulmonary artery
(a. />.), and lodges in one of the lobes of the lung, giving rise to an infarct
which finds its clinical expression in : 1. A sudden sharp pain in the side.
2. Blood-spitting (hemoptysis). 3. The physical signs shown in Figs. 746
and 747.

hemoptysis at the very beginning of tuberculosis, accompanied
by little in the way of general or auscultatory evidences, or even
occurring at a time when the disease is as yt^t entirely latent.
Any true hemoptysis of obscure, cryptogenic origin should be
considered of tuberculous nature imtil proof to the contrary is
obtained, and the patient kept under careful observation as re-
gards body weight, temperature, general health, and examina-
tion of the lungs ; this is a clinical axiom from which the practi-
tioner should never depart, lest he take upon himself a most

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serious responsibility and meet with egregious disappoint-

The only real difficulty in these cases lies in the possibility of
simultaneous mitral stenosis and pulmonary tuberculosis; only
rarely, however, will careful observation of the patient's general
condition and temperature and systematic, repeated ausculta-
tion of the lungs fail sooner or later to afford a distinction be-
tween the manifestations appertaining to one or the other of
these disorders.

Certain instances of hemoptysis, due exclusively to mitral
stenosis and associated with marked and persistent hyperemia of

Phjrsical signs.

■^ Weakened or muffled breathing.
Ck^ Surrounding area of crepitant rales.

Figs. 746 and 747. — Pulmonary infarction.

a pulmonary apex, may, however, hold the diagnosis in suspense
for a time.

2. One twelfth of all instances of true hemoptysis may be
referable to exceptional or obvious or, on the other hand, with
difficulty detected causes.

Among the obzious causes, traumatism is the most important;
thus, a chest wound or contusion, a fractured rib, or gas poisoning
are obvious conditions.

The majority of acute and, particularly, chronic affections of
the lungs may ultimately be associated with hemoptysis. Ac-
cordingly, hemoptysis may be met with in pneumonia, chronic
bronchitis with dilated bronchi, abscess of the lung, broncho-

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pulmonary gangrene, and syphilitic or cancerous involvement.
Frequently the clinical evidences present in conjunction with the
hemoptysis are such, especially in bronchiectasis and pulmonary
abscess or gangrene, as to make the diagnosis perfectly plain ;
syphilis and cancer, however, require a painstaking examination
for their detection, and especially, the actual thought of their
possible presence on the part of the physician.

Fig. 748. — Aneurysm of the pulmonary artery {Letulle and Natlan-
Larrier. Microphotogr. by E. Normand. X5). n, ruptured wall of the
affected artery; c, tuberculous cavity bounded by a layer of caseous
material; x, a diverticulum of the aforesaid cavity; />, pulmonary vein,
occluded and included in the caseous layer about the cavity.

Hemorrhagic disorders, including the infectious purpuras, in-
fectious jaundice, hemophilia, leukemic conditions, etc., as well
as some severe forms of typhoid fever and malaria, may likewise
lead to hemoptysis, but in these disorders the hemorrhage takes
place in the presence of a clinical picture so definite as to leave
little chance of any actual difficulty in diagnosis. One of the
author's patients with arteriosclerosis and high blood-pressure

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developed every spring, in April and May, for over ten years, a
varied assortment of hemorrhages, usually in the form of epi-
staxis, sometimes as hemoptysis and less frequently as hemor-
rhoidal hemorrhages of almost alarming extent ; the tenth year,
he developed a severe cerebral hemorrhage resulting in perma-
nent hemiplegia.

In addition to these hemorrhagic disorders mention should be
made of the congestive hemoptysic attacks of gouty patients; the
author has seen several instances of this condition. The history of
gout, the congestive nature of the pulmonary attack — ^which gen-

Fig. 749. — Diagram of a pulmonary lobule {Miller). B, terminal bron-
chus; y, vestibule; At, atrium; S, air-sac (infundibulum) ; C, air-cell
(alveolus) ; Ar, artery; V (at the right), vein.

erally involves the bases of the lungs and sometimes assumes the
appearances of acute edema — and the ovemourished aspect of the
patient directly suggest the diagnosis in such cases. Uremia may
give rise to a similar condition, the source of which is ascertained
by blood-pressure estimation and determination of the blood urea.

Aortic aneurysm may likewise lead to hemoptysis, under two
very different groups of circumstances. There may occur either
slight, intermittent hemoptysis, due to the presence of a slight
fissure at an area of adhesion of the aneurysm to the trachea and
sometimes compatible with life for a more or less prolonged
period, or else rupture of the aneurysm into a bronchus or the
trachea with fatal hemorrhage. From the diagnostic standpoint,
either the presence of aneurysm will already have long been

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known at the time of the hemoptysis, the significance of which
will therefore be obvious, or the aneurysm will have up to that
time remained latent, either because of insufficient clinical ex-
amination or on account of a remarkable degree of tolerance of
the disease by the patient, who has not as yet consulted a physi-
cian. In no case of this type, to the author's knowledge, has
careful clinical examination failed to elicit some sign or other
of a mediastinal mass (bronchial murmur, collateral circulation
over the upper part of the thorax, pressure manifestations, pupil-
lary inequality, elevation or broadening of the arch of the aorta,
inequality of the right and left pulse, etc.).

Few symptoms, the reader will note, are of such definite
semeiologic significance as hemoptysis. Almost constantly it
constitutes an external expression of some pulmonary or cardiac
disorder, hemorrhagic diathesis, or manifest or latent congestive

Does Vicarious Menstruation in the Form of Hemoptysis Act-
ually Occur? — Before concluding this section, mention may be
made of a very exceptional form of hemoptysis which has been the
subject of prolonged discussion and the diagnostic and prognostic
significance of which may be altogether different, vis., vicarious
menstruation through the lungs.

The reader's indulgence is requested by the author for de-
voting a disproportionate amount of space to this subject, but
the condition is a very peculiar and as yet variously regarded
one, and the following brief contribution to its study seems war-
ranted on condition that the reader makes good note of the fact
that this constitutes only a very exceptional form of hemoptysis.

According to many observers, particularly phthisiologists,
vicarious menstruation through the lungs is almost invariably
evidence of a manifest or threatening tuberculosis of the lungs.

The condition is, as a matter of fact, met with either singly
or repeatedly in not a few cases of pulmonary tuberculosis in
women. But the writer has also seen it in cases in which all
idea of an organic disease could be clinically excluded and in
which very prolonged later observation failed to show the exist-
ence of any morbid manifestation.

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One case, among others, may be here referred to because the
period of observation was sufficiently prolonged to carry con-
viction. The patient was a young lady about twenty years of
age, free of any history of general disease, apparently in robust
health, having one child eighteen months old and another three
months old which she was nursing, and who, in November, 1901,
saw her menstruation stop suddenly on the second day and a
copious hemoptysis set in which continued for two days and
then ceased as it had come on, without apparent cause. The
patient, with whom the author had been acquainted for three
years, had had no discomforts during that time; her pregnancies
had been normal and unattended with any noteworthy difficul-
ties. The attack of hemoptysis referred to, aside from some
justifiable but temporary anxiety, was not associated with any
marked disturbance ; there was no rise of temperature nor of the
pulse rate, nor any dyspnea. Very careful auscultation gave
negative results.

Lactation was not discontinued and no special treatment was
instituted. Although kept under careful observation for a long
period, the patient showed no further untoward symptom. The
author has been seeing her at somewhat irregular intervals for
almost eighteen years, on account of illnesses of her husband or
children, and has not seen her health in the least impaired at
any time. No recurrence of the hemoptysis ever took place.
It would seem difficult to supply any more positive clinical evi-
dence than this.

An almost similar clinical picture was seen by the author in
a lady of thirty-five years; the ophthalmic test was negative.
From the ISth to 17th of May, 1908, he had occasion to observe
6 spontaneous hemorrhages, including 2 of copious epistaxis in
arteriosclerotic subjects, 1 of cerebral hemorrhage, 1 of hemop-
tysis in a consumptive, the case of vicarious hemorrhage already
referred to, and a case of vicarious epistaxis. In this more than
a mere coincidence was unquestionably involved; the subject
will be taken up again in a later publication.

Were the physician still to harbor any doubts as to the actual
occurrence of idiopathic hemoptysis vicariously substituted for
the menstrual flow, Ventura's case would certainly remove them

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1038 SYMPTOMS. .

(Gas. degli osped,. No. 129, 1907). This author gave the history
of a family in which substitution of periodic hemoptysis for
menstruation took place in three successive generations. The first
generation comprised three sisters; in one of them menstruation
was replaced by hemoptysis at monthly intervals. One of the un-
aflfected sisters had five female children, two of whom presented
the same clinical phenomenon as their aunt. Again, one of the
latter had four female children, two of whom showed the same
inversion of function. In none of these subjects was either
tuberculosis, syphilis, hemophilia, or cardiac disease discovered.

Finally, as an interesting clinical case, reference may be
made, although unrelated to hemoptysis, to a quite typical and
remarkable instance of menstrual substitution recorded by the
author at the Maison municipale de sante while in Danlos's

The patient was a woman about forty years of age, short and
stout, who had had ten years before a child which she had nursed
for a long time (up to about two years) and who had had no men-
strual periods since that time but, on the other hand, had kept
on secreting milk continually, with periodic recrudescences, as
the author had occasion personally to observe. This woman
died of a brain tumor. At the autopsy a normal uterus but
atrophied uterine adnexa were found.

Thus, due recognition should be given to the actual occur-
rence of idiopathic hemoptysis, vicariously substituted for the
menstrual periods, in the absence of any organic disease in the
lungs or heart and of any hemorrhagic disorder of the blood.
The prognostic importance of this fact is self-evident.

4c 4c 4c

Bronchial Spirochetosis. — Castellani in 1905 described a special form of
bronchial infection observed in Ceylon and caused by spirochetes. In 1908,
American observers reported it from the Philippines, and others, in various
tropical lands. Experience during the great war led to the detection of a
considerable number of cases along the shores of the Adriatic and in Serbia,
Switzerland, Egypt, and France. The disorder is commonly mistaken for
tuberculosis, whether acute or chronic in form. The patients generally com-
plain of an obstinate! cough which gets worse at night and in the morning
and is associated with blood-stained expectoration. In the common, chronic
form of the disease, the patient is usually free of fever and the general
health may be slightly impaired. The diagnosis of the disease is based ex-
clusively on examination of the sputum for the organism termed by Castel-
lani Sptrochcpta hronchialis. It stains easily with the basic anilin stains, but
is negative to Gram's method (see p. 527).

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Hiccough or hiccup consists of a clonic contraction of the
diaphragm. Its essential feature is a sudden inspiratory con-
traction of the diaphragm occurring in conjunction with a rapid
closure of the glottis; there result an abdominal spasm, inspira-
tion and sudden expulsion of air, consequent vibration of the
completely or partly closed glottis, and a hiccup sound which
may at times assume the characteristics of a bark.

A diagrammatic representation of the usually reflex patho-
genesis of hiccough is presented below.

The medullary center concerned adjoins that of the pneumo-
gastric and consequently the vomiting and respiratory (cough)

It appears to undergo direct stimulation, possibly through
the circulation, in the course of "grave infections'* and "agonic
states," the resulting condition constituting a terminal form of

The centripetal (afferent) routes of stimulation consist chiefly
of the pneumogastric nerve and secondarily ofJ the sympathetic and
certain cortico-bulbar fibers.

Through the pneumogastric (an appropriately named nerve) :

The center may be brought into activity by stimuli starting :

(a) From the abdomen (subdiaphragmatic region) :

1. From the stomach: This is the starting-point of hiccough in
4 out of 5 cases, e.g., very commonly in infants after nursing, in
dyspepsia (especially of the neurotic type), in dilatation of the
stomach, aerophagia, tachycardia, the ingestion of unduly hot or
cold food, and much less frequently in ulcer and cancer of the
stomach. In these cases the hiccough may be either continuous or
intermittent, appearing and disappearing for no evident reason or
when the subject takes food or a little fluid.

2. From the intestine : Helminthiasis.

3. From the peritoneum: Peritonitis, especially when situated
below the liver.


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4. From the female reproductive organs: Genitourinary and
uterine disorders.

(b) From the thorax (supradiaphragmatic region).

1. In diaphragmatic pleurisy: Actually a rare cause, the stimu-
lus being ordinarily inhibited by pain. The same is true in pneu-

2. In car dio pericardial disturbances : Hiccough is observed espe-
cially in pericarditis, particularly at the beginning, when the phe-

Medullanr center. ^^SSdS °'

1^6&r th© "v**"™ '*'•*"■ ««»Ti*oi»" anil thfl "i>oaf\li>atm>tr

center." This c
—possibly throu
tioDS and In age


The stomach
ordinary blccouf
cold, etc.. or t

Fig. 750. — Diagram illustrating the pathogenesis of hiccough.

nomena of irritation are still predominant. Exceptionally the
author has seen it in lesions of the aortic arch, aortitis, and aneurysm.
The same is true of heart disorders, such as acute or chronic endo-
carditis, myocarditis, etc.

The SYMPATHETIC ROUTE may in all likelihood be one of the
afferent routes of stimulation of the phrenic nerve, chiefly in the
presence of heart disturbances.

Finally, the corticobulbar routes of stimulation are those involved
in psychoneurotic states (tic-hiccough), in hysteria (barking hic-
cough), and in meningitis.

The centrifugal (efferent) routes of transmission are chiefly
represented by the phrenic nerve which is the motor nerve to the

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diaphragm and the gross anatomic relationships of which should
always be kept in mind. Issuing from the cervical plexus, it
passes down, crosses the anterior aspect of the scalenus anticus
muscle, runs down along the internal border of this muscle,
enters the thorax, and passes, on the right side, between the sub-
clavian artery and vein, on the lateral aspect of the pneumo-

ScalenuB an

Phrenic d
Subclavian ai

Superior Tena cai

Phrenic nerve.

Fig. 751.— The phrenic nerves {Hirschfeld),

gastric, and along the superior vena cava, and on the left side, be-
hind the innominate artery, crossing the arch of the aorta. It
then courses on either side between the pleura and the pericar-
dium and ends in ramifications over the upper surface of the

It receives the stimuli issuing from the pneumogastric :

1. Through the intermediation of the medullary center of
this nerve and through the anterior gray horns.

2. Through the cervical plexus (whence the phrenic nerve
originates from three roots), being connected with the pneu-


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mogastric through the gangliform plexus by means of one or
two nerve filaments.

It is enabled to receive the stimuli from the sympathetic by
reason of the many anastomotic connections between the cer-
vical plexus and the sympathetic.

The actual cortico-bulbar pathways are not as yet satisfac-
torily known.

Recoftnition of the cause of hiccough is based chiefly upon the
associated symptoms or physical signs, which may indicate gastric
disturbance, peritoneal or meningeal involvement, psychoneu-
rosis, etc.

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Inspection of a sphygmographic tracing of the pulse, such as
that presented herewith (Fig. 752), in which variations of blood-
pressure within the artery under examination are elicited and
recorded, is sufficient to show that this pressure is a variable
quantity and that it exhibits both a high point corresponding to
cardiac systole (the maximal or systolic pressure) and a low
point corresponding to diastole (the minimal or diastolic pres-
sure). There is thus not one single blood-pressure, but several


. Systolic


Fig. 752. — Pulse tracing showing the successive variations of pressure
within the lumen of an artery.

blood-pressures. The maximal pressure corresponds to but a
very brief portion of the cardiac cycle, the point of culmination
of the systole. The minimal pressure, on the other hand, consti-
tutes the permanent, basic pressure below which the pressure
never descends; it will be seen at once that this latter pressure
is at least as important to know, and perhaps even more impor-
tant, than the maximal pressure. The difference between the

Online LibraryAlfred MartinetClinical diagnosis, case examination and the analysis of symptoms → online text (page 26 of 50)