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Frank Hemorrhages, Not Including Cases of Blood Tinged And PROGNOSIS AND TREATMNENT OF HEMIORRHAGE IN PULMONARY TUBERCULOSIS. By E. H. BRUNS, M.D., DENVER, COLO. The purpose of this paper is not to put forward anything newv concerning hemoptysis in pulmonary tuberculosis, but to give some impression regarding this common accident am-ong tuberculous patients, and to discuss certain phases of its occurrence and treat- ment, based largely on personal observations and a series of 626 cases among 7,356 tuberculous patients admitted and treated at the Fitz- simons General Hospital since it became an army tuberculosis institu- tion in 1918. In studying, the statistics of others, as, for instance, those of Lansel, 1,061 among 2,500 patients, it would seem that we have had comparatively few hemorrhage cases. This can probably be explained by the fact that in order to avoid confusion we have only considered frank hemorrhages, not including cases of blood tinged and blood streaked sputum, and also the policy in vogue from the very begin- ning of making frequent X-ray chest plates on our patients and attempting to obliterate cavities as soon as possible, if feasible, by means of some form of collapse therapy. There are many silent cavities, and physical signs cannot always be depended upon to detect their presence. Next to properly applied hygienic treatment, collapse therapy is our best means of preventingr bleeding from the tuberculous lung. Statistics would also vary, depending on the length of time the patient remains in an institution or how long he is under the observation of the one studying the clinical course of his disease. Pulmonary hemorrhage, much as it is to be dreaded in advanced cases, is often a blessing in disguise as an initial symptom in chronic pulmonary tuberculosis. Nothing convinces a patient more that he has the disease and places him in the right frame of mind for begin- ning, the cure than this striking evidence of the activity of the tubercle bacillus. Cough, loss in weight, fatigue and even fever often 183 184 184 ~~~~~E.H. BRUNS go unnoticed at first, but once blood appears in the sputum the patient wastes no time in consulting a doctor. Tuberculosis, insidious in onset, frequently reaches an advanced stage before it is discovered unless an early hemoptysis occurs. Tuberculous broncho-pneumonia, caseation and cavity formation may often be present before the patient realizes something serious is going on in the lungs. At a time when much depends on the immediate institution of proper treatment, the disease is permitted to go unchecked or even fanned into greater activity through lack of diagnosis unless a timely hemoptysis, like 'a bolt from the blue, reveals the truth. Tuberculosis carries with it a deep sense of fear which influences the patient into carrying out a prolonged and tedious form of cure. This fear complex, however, is often suppressed into the subconscious mind by means at times contrary to the best interests of treatment. A pulmonary hemorrhage makes a profound mental impression, re- turning the consumptive to a true sense of the seriousness of his condition and the necessity of "chasing the cure" with more care. Thus bleeding, does not only lead to an early diagnosis, but may act as a restraint to a rebellious consumptive. It has often been said that improvement not infrequently follows hemoptysis. In fact we use this as an argument in allaying the fears of our hemorrhage cases. This is true to a certain extent, as it is conceivable that bleeding may relieve a congestion in the lungs or diminish toxemia by getting rid of some caseous and broken down tuberculous tissue.2 It is not always easy to say what the improve- ment is due to. It can all be psychical. It may be the result of increased codperation, longer hours of bed rest, reconciliation and better mental adjustment. We have found this point very difficult to estimate from our statistics. Proper treatment for the first time usually follows the initial hemoptysis, which is seldom severe or difficult to control. The patient's word cannot invariably be accepted on its face value and symptoms are not reliable in every instance. The most we can determine is that the patient has not been made worse, as carefully reckoned by physical signs, X-ray plates and other clinical findings, and that no extension or change in the lesions has occurred. If no damage has resulted, it has placed the patient in a more receptive frame of mind for "taking the cure," and that PROGNOSIS AND TREATMENT OF HEMORRHAGE 15185 much at least has been accomplished. How often do we find, unfor- tunately, that the next X-ray plate, made after an hemoptysis, reveals definite changes in the form of a perifocal reaction, extension, cavities and tuberculous broncho-pneumonia. Certain real dangers accompany hemorrhage, such as weakness and anemia from loss of blood, aspiration broncho-pneumonia, and even immediate death from asphyxiation. Of the three, the first is the least serious and frequent. Rarely do we see a fatal result from loss of blood, and we should not stress this feature but rather em- phasize the necessity of clearing the bronchi of blood as expeditiously as possible to prevent aspiration pneumonia or asphyxiation. We observe patients who lose pints of blood with surprisingly little immediate and permanent effect, yet others die almost at once before anything, can be done and without much blood ever being coughed up or expelled. Furthermore, following a moderate or severe hemorrhage, patients become acutely ill with symptoms and signs of pneumonia. The greatest danger, therefore, is not from loss of blood, but from inability to cough the blood out to prevent its aspiration into other parts of the lungs. Certainly the sooner a hemorrhage is checked and the less frequent its recurrence, the less is the chance of aspiration, providing, our attempts to stay the bleeding do not favor- aspiration, as by the giving of opiates. Hemorrhages occur from pulmonary capillaries, various sized arteries and veins, due to erosion of the vessel wall or to rupture into a cavity. Certain types of hemorrhages are observed, such as blood tingeing, or streaking, of the sputum. This may be a forerunner of something worse: frank hemorrhages of an ounce or more stopping within a few minutes; the recurrence of the coughing up of varying amounts of bright red blood followed by dark clots-this is a typical small or medium sized cavity bleeding in which a clot fills the cavity, compresses and seals over the bleeding vessel and is renewed when the clot softens or is expelled by coughing; profuse bleeding, which only stops after the patient is fairly well exsanguinated and the blood pressure lowv a large cavity affair or one communicating with a large bronchus; or the bloody tragedy which suddenly happens and the patient is dead by the time the doctor arrives. Most of the frank hemorrhages probably originate in cavities 186 186 ~~~~~E.H. BRUNS due to the exposure of a vessel which dilates and ruptures before it has had time to thrombose. Such hemnorrhagaes are rather character- istic, as they come suddenly, are severe, and cease as soon as the cavity becomes filled with a blood clot, w'hich acts as a tampon and closes the vessel opening. As soon as the clot softens it is expelled as a mixture of dark coagulated and bright red blood. The expulsion of the clot causes a renewal of the bleeding. The severity and char- acter of the hemorrhage depend on the size of the ruptured vessel, the dimensions of the cavity and the caliber of the draining bronchus. Usually the hemiorrhage does not occur from the oldest and largest cavity, but from a newly formed excavation below the older one. In the older cavity the vessels in the trabeculae are well thrombosed, as a rule, and bleeding is no longer to be expected unless an erosion in the base or wall of cavity opens up an artery or vein. Such a vessel may be of small dimensions and the hemorrhage not severe even though from a cavity. However, as just mentioned, our autopsies almost invariably reveal the source of bleeding from a newly formed cavity, as judged by the appearance of the clot and the cavity wall. For years we have been examining the blood vessels of pulmo- nary cavities. at autopsy, and in only one case out of several thousand -has the pathologist been able to demonstrate an aneurysm or dilata- tion of an artery or vein traversing a cavity. In this case the aneurysm was the size of a large hazelnut and partially filled with a fibrous clot. Extremely rarely do vessels in trabeculae fail to completely thrombose. In hemorrhage cases the bleeding vessel is almost in- variably in the cavity wall and not easy to find. Its location may be marked by an organized clot or a thrombus within a clot, which, when removed, leaves a bleeding point. Often the bleeding vessels cannot be found, but by searching for a cavity of recent origin filled with a dense clot, this can be considered as the seat of the hemor- rhage, although the vessel or the bleeding point cannot always be definitely demonstrated. At times, after the blood clots are washed away, liquid blood is seen oozing from the bleeding spot. The blood can be found in the bronchi in a liquid or clotted form and in the alveoli as a dark red stippling, now and then as patches of bloody PROGNOSIS AND TREATMENT OF HEMORRHAGE 18187 infiltration. Most of the blood is on the side of the hemorrhage, the opposite lung being voluminous and emphysematous.
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