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. While aneurysmal dilatations are rarely to be seen, this is probably due in part to the fact that once ruptured they are very difficult to discover. In studying our hemorrhages as they occur in the various pathological anatomical types of tuberculosis, we find that pneumonic forms of the disease bleed less and are associated with fewer frank hemorrhages, although streaking is not uncommon; that in the nodose (chronic ulcerative phthisis) and in the advanced fibrous and cavity types occur most of the hemorrhages often asso- ciated with aspiration and at times death from asphyxiation. In the fibrous forms in particular, fatal results are often due to the inability of the patient to expel the blood, and death from suffocation quickly ensues. The blood is aspirated through the bronchial tree, the bronchi plugged with clots or filled with a bloody foam. The lungs are widely involved, excavated, fibrous, emphysematous and bound down with pleural adhesions so that they have lost their normal elasticity and ability to readily drain themselves. In such cases death from hemoptysis is greatly to be feared. Terminal cases may die in this way because they are too weak to expel the blood, or may bleed out into large cavities before much blood is coughed up. We have witnessed two instances of this kind. One patient died in the toilet with evidence of only a moderate loss of blood when he was found dead. The other bled out into the pleural cavity, a spontaneous pneumothorax having occurred simultaneously with the hemorrhage. In cachetic patients the sudden loss of a large amount of blood may lead to speedy death even though no aspiration occurs. For simplicity and practicability it is best to divide pulmonary hemorrhag,es into two classes, those originating from cavities and those not associated with cavities. This classification is especially significant from the viewpoint of prognosis and treatment. Hemor- rhages without the existence of cavities are not dangerous and stop spontaneously, as a rule, without any special form of treatment. Aspiration is not so common. Hemorrhages from cavities, on the other hand, are dangerous, are severe, tend to recur, and are frequently followed by aspiration and death from aspiration pneumonia and 188 188 ~~~~~E.H. BRUNS asphyxiation. The only treatment that is effective is collapse therapy. Barnesl'7 has showvn that 81 per cent of cavity cases are dead at the end of three years, and, according to our observation, hemorrhage is not an uncommon method of exitus. Hence the necessity of making an earnest effort to obliterate or at least reduce the size of cavities by some form of collapse therapy when they fail to heal sponta- neously. We are too apt to be misled by the good general condition, and mild symptoms of our cavity cases and ignore the danger signals ahead. .Most hemorrhages stop spontaneously and no doubt we are misled in our therapeutic efforts, taking credit for a result which w'ould have occurred without treatment. Hemorrhage patients are ordinarily greatly frightened and their families and friends alarmed, expecting from the doctor encouragement and relief. Therefore, any remedy as long, as it does no harm, at least has a good moral or psychical effect. It is very important to quiet the patient's fears and reassure him. However, we must remember that hemoptysis is not always a trivial complication and can lead to serious and dangerous consequences. The sudden deaths from asphyxiation are unavoidable when the hemorrhage once occurs. The patient is dead or is dying by the time the doctor reaches the bedside. All efforts to prevent death or revive the patient are futile. Aspiration is rather common and one of the most serious results of hemorrhage. The treatment is largely that of prevention. In fact, the preventive treatment of all hemorrhages in tuberculosis deserves careful consideration. Rest in bed, next to collapse therapy, is one of the best methods of avoiding this complication. For the same reason that a successful collapse of the lung will check and avert the recurrence of a hemorrhage, it can be expected to prevent this complication. Doubtless the more frequent and earlier employment of artificial pneumothorax and phrenico-exaeresis has materially reduced the incidence of bleeding among, our phthisical patients. In fibrous type-s of tuberculosis with cavitation, thoraco- plasty will save the patient from hemoptysis, so often serious and even quickly fatal. Collapse therapy may be well said to be our best and surest prophylactic measure for pulmonary hemorrhage. Aside from this, the proper hygienic treatment of the disease, inasmuch as PROGNOSIS AND TREATMENT OF HEMORRHAGE 18918 it brings about a healing of the lesions, will reduce its incidence. This entails absolute rest in bed, fresh air and a nutritious diet. The overfeeding of patients by producing a more or less plethoric condi- tion might further the occurrence, but unfortunately, overeating, is still a common practice. However, a nutritious diet as referred to here applies more to quality than quantity. Frequently, however, there is no exciting cause to explain the onset of a hemorrhage at a particular time. Our hospital statistics show that the great majority of our hemorrhage cases were lying, quietly in bed at the time of onset, some were awakened from a sleep. Bang, found that in 69 per cent of his cases the bleeding started when the patient was in bed at rest. This does not minimize the value of rest as a preventative measure, for the explanation of these hemor- rhages can lie in the overacting, heart as the result of a full stomach and indigestion, an uncontrolled fit of coughing during, sleep, or to the summation of many minor causes leading to a progression of the tuberculous process and the erosion of a blood vessel which happens to reach its climax during a period of rest or slumber. Many times, too numerous to be without significance, especially with reference to the initial attack, we obtain a history of some excit- ing cause, suchi as exercise, sudden effort, lifting a heavy object, run- ning, climbingr stairs, straining at stool, scuffling, etc. Again there may be a history of excitement, a fit of coughing or injury to the chest. These etiological factors were noted in the history of about one-fourth of our patients before admission. In the hospital they spend most of their time in bed and are more cautious about over- exertion. There is not much difference regarding the time of day when bleeding occurs, but among, our patients, while under the treat- ment in the hospital, it is slightly more frequent at night; 6 A.M.- 12 noon, 26.8 per cent; 12 noon-6 P.m., 34.3 per cent; 6 P.m.-12 mid- night, 14.8 per cent; 12 midnight-6 A.M., 24.1 per cent. The question of high altitude increasing the incidence of hemoptysis has often been advanced but not borne out by statistics or the observation of doctors treating, tuberculosis in such localities. Lansell reports a series of 1,061 hemorrhage cases of which 761 (30 per cent) only bled in the valleys, 201 (8 per cent) in the valleys and in the mountains, and 99 (4 per cent) in the mountains. Two 190 190 ~~~~~E.H. BRUNS hundred and fourteen of our cases gave a history of hemoptysis before admission to the hospital and 412Z after admission, which can only be interpreted correctly when we consider that patients are in the hospital for long periods as compared to the comparatively brief time between the making of a diagnosis and their transfer to us. Once we are faced with the treatment of a tuberculous patient who is hemorrhaging, we must bear in mind that the greatest danger is aspiration with immediate death from suffocation, or later pneu- monia and bronchogenic spread. The prevention of aspiration is our gravest problem. Realizing this, our statistics have been analyzed and our cases carefully examined to determine the frequency of aspiration and its probable cause. X-ray plates made before and after hemoptysis are our best method of studying this question. For some time many observers have called attention to the fact that injecting oily medication into the lung is not entirely without harm, that a pneumonitis can be produced or certain changes can be broug,ht about in the parenchyma of the lungs, revealed by coughing riles upon physical examination of the chest or manifest by a mottling, in the X-ray filMS.4-5-6 Blood itself in the bronchial tree does not cast shadows in the roentgenogram. This was proven by us in the following experiment. A patient dying, with no disease of the lungs was rayed before necropsy. The larynx was then freed and brought out through an incision in the neck. Into the larynx a catheter was inserted and 500 cc. of human blood was quickly removed from a donor and injected before coagulation into the catheter, filling under pressure the bronchial tree of the cadaver. X-ray plates of the lungs taken with the patient suspended failed to show any increase in the bronchial markings or any mottling of the parenchyma. Autopsy found the bronchi filled with fluid blood. Autopsies made on patients dying of asphyxiation during hemop- tysis always disclose the bronchi and bronchioles filled with clotted or fluid blood, as well as the cavities, but aside from a cloudiness in the cavity ring no other X-ray manifestation of the hemorrhage can be made out. However, if the patient survives, within a short time a mottling like that of bronchogenic tuberculosis is visible in the X-ray plates. That this mottling is to be interpreted as due entirely to pneumonitis is open to question on account of the density of the PROGNOSIS AND TREATMENT OF HEMORRHAGE 19119 shadows. Probably atelectasis of groups of lobules supplied by the plugged up bronchioles, together with pneumonitis, is responsible. In studying, these cases at post mortem it is noticed that the bronchi are not completely obstructed by clots, but many of the bronchioles are. The blood is forcibly aspirated into the bronchioles and their branches, and once wedged in by coagulation is difficult to dislodge, causing small areas of atelectasis associated with more or less pneu- monitis or collateral inflammation. Along, with the blood, -pus and tubercle bacilli are aspirated from the cavities into the bronchial tree. Thus we are converting many bronchioles into tiny culture tubes distended with heavily inoculated blood culture media, and it is no wonder that our tuberculosis spreads frequently after large hemor- rhages. Often, instead of the shadows of aspiration slowly fading away, we see the X-ray development of an ordinary bronchogenetic tuberculosis. Corper5 has shown that blood and also foreign oils of apparent inert nature, when injected intra-tracheally in rabbits produced dis- tinct pathologic changes in the lungs, usually in the form of a proliferative pneumonia. Austrian and Willis,-, believing the mottling seen in the X-ray plates following hemoptysis was caused by the aspiration of tubercle bacilli as well as blood, conducted experiments on rabbits and found that these shadows only resulted when blood and tubercle bacilli were injected intra-tracheally in tuberculous animals. They concluded that the shadows were due in the main to a collateral exudate. Quite often lipiodol will remain in the lungs, producing a mottling which takes months to clear up, which indicates that foreign material in the lungs is not always readily dislodged and expelled. Aspiration is mostly limited to profuse hemorrhages, but it is conceivable that when bleeding occurs during sleep the blood may trickle down into the finer divisions of the bronchi and produce aspiration before a reflex cough can prevent it. It is not an uncom- mon experience following severe hemoptysis to have the patient run a fever for a few days, probably due to the aspiration of blood and the tissue reaction which results. These exacerbations of temperature may be caused by an extension and reinfection with the allergic 192' 192 ~~~~~E.H. BRUNS response, the hemoptysis being another manifestation of the new involvement and its allergic onset. More serious is the aspiration pneumonia as heralded by high fever, dyspnea, cyanosis and rapid heart action, death often being due to failure of the right heart. The physical signs and X-ray findings are those of a bronchial or lobar pneumonia. Very seldom do these cases recover, dying within a week or two as a rule. For this reason, in additi-on to checking the bleeding, the patient should be encouraged to clear the bronchi of blood by easy coughing without too much effort and exertion. He should be placed in a semi-recumbent position in bed, kept quiet and not permitted to change his position without the assistance of a nurse or attendant. If nervous and apprehensive, he should be reassured by the doctor, and if necessary given a seda- tive-sodium bromide 1 gin., to which is added a coagrulant, 1 gin. of sodium chloride. It should be explained to the patient that the loss of blood is not dangerous, but as longr as the bleeding continues the blood must be re- moved from the lungs by gentle coughing, avoiding all unnecessary and hard coughing. Unproductive coughing may have to be restrained by small doses of codeine (.016-.032 gin. doses). Hot drinks should not be given and fluids restricted to a minimum. The diet should be light and all articles of diet restricted in quantity. A bed pan is used and the bowels kept open by salines and enemas. This is, what we refer to as the routine treatment of hemorrhage. In the meantime the patient's X-ray plates are studied and every effort made, by a careful physical examination and symptoms, to determine the location of the hemorrhage. The patient's sensations cannot always be depended upon to fix the site of the bleeding. This was shown in the follow- ing case. After a left upper stage posterior thoracoplasty in which the cavity was only partially collapsed, a patient had a series of severe pulmonary hemorrhages. As there was also medium sized cavity in the right lung, it was thought that the blood might be coming from this side, especially as the patient was certain that he felt blood bubbling in the bronchi of this side at the onset of each hemoptysis. However, we succeeded in inducing a localized pneumothorax over this cavity without any effect, and examination over the cavity in the PROGNOSIS AND TREATMENT OF HEMORRHAGE 19193 left upper lobe elicited bubbling and gurgling, rales. It was finally -decided that the bleeding was from this cavity, and the cavity was unroofed and tightly packed. Exposure of this cavity showed the bleeding vessel. Physical signs are likewise unreliable, and all diagnostic aids are frequently necessary to come to a decision. If a cavity is present, this is the probable source of the bleeding. If more than one cavity exists, the more recent cavity is generally to blame. If no X-ray plates are available or none have been taken recently, bedside plates can be made without unduly disturbing the patient. Look for X-ray signs of aspiration. This is more prone to occur in the lung that is bleeding. Having located the side of the hemorrhage, we are pre- pared to use some form of collapse therapy, as artificial pneumo- thorax or phrenico-exaeresis, in case a recurrence of the bleeding or a severe hemoptysis, makes such a step advisable. Artificial pneumo- thorax may not be possible or successful on account of pleural adhe- sions. In such a situation phrenico-exaeresis is indicated. Failure to check the hemorrhage may be due to an incomplete collapse or compression of the wrong lung. This can often be deter- mined by additional bedside plates, from which a decision has to be made as to the best procedure to follow. This may entail increasing the intrapleural pressure withi refills, performing a phrenico-exaeresis or withdrawing air and inducing an artificial pneumothorax on the opposite side. As long as the recurring hemorrhages are not severe, it is better to proceed slowly, watching the patient closely and not be too hasty in altering the original plan of action. Collapse therapy is our best means of stopping and preventing the recurrence of severe hemor- rhages.S 9 10 11 There can be no doubt about this, especially if the case is largely unilateral and the bleeding is from the worst side. Its limitation lies in our inability always to accurately fix the side of the bleeding; the failure to obtain a collapse or a sufficient compression on account of pleural adhesions, and to the fact that the patient has aspirated blood and has a bronchopneumonia in the better lung. We have employed artificial pneumothorax to check hemoptysis in 46 cases. In 32 the hemorrhage was checked, in two diminished, and in 12 no effect was obtained due to an unsuccessful collapse. 194 194 ~~~~~E.H. BRUNS Thoracoplasty has been employed four times and in each instance succeeded in checking the bleeding. Two patients, however, are now dead. One died one month following the second stage of a posterior thoracoplasty, hemorrhaging profusely from the contralateral lung, and suffocating. The other also died of asphyxiation six months fol- lowing operation, bleeding from a cavity in the uncollapsed lung. At times pneumothorax has to b,e abandoned for various reasons, and other means used to control bleeding, however unreliable they may be. In fibrous cases, thoracoplasty can be used as a last resort; an upper stage thoracoplasty or an external pneumolysis and pack over the cavity. Aside from collapse therapy, we, feel reasonably certain that bandaging the extremities is of assistance. Both lower extremities are firmly bandaged or tourniquet applied to the thighs. These constrictions should be removed within an hour, gradually loosening one at a time and then constricting the upper extremities.3 By alternating this procedure, a firm clot may form around the bleeding vessel, preventing a repetition of the hemoptysis. Various coagulants and hemostatics are often employed, but their efficiency is questionable and open to scepticism.3-8 12 13 Among those we usually employ are sodium chloride, calcium chloride, cal- cium lactate, thromboplastin, parathormone and horse serum. Whether or not these preparations have the action attributed to them and actually check hemorrhage is difficult to prove definitely. We know that bleeding stops spontaneously in the great majority of cases without medication and without anything, special being done, so that it is very hard to determine the effect of drugs. V"ery often a hemor- rhage only lasts a few minutes, too soon to be the result of treatment. However the patient expects treatment, and his nervousness and anxiety are allayed when medicine is administered. Therefore it is good practice to use one of the various coagulants. In the furtherance of blood coagulation two methods of proce- dure are available. One aims at carrying the patient's tissue fl'uids and therewith thrombokinase into the blood by salt action, and the other supplies coagulants by injection from the outside. An example of the former is sodium chloride given by mouth in 1 to 2 gin. doses, or intravenously 5 cc. of a 10 per cent solution. The explanation of its action is that the salt, by a process of autotransfusion, produces PROGNOSIS AND TREATMENT OF HEMORRHAGE 19195 and maintains a hydremia for an hour or more at the expense of the tissue fluids. In this way thrombokinase is carried from the tissues where is it formed into the blood stream. Of the latter, calcium salts and thromboplastin are good examples. Calcium chloride, 5 to 10 cc. of a 10 per cent solution, may be given intravenously, or calcium lactate in 1 gin. doses may be administered by mouth. Thrombo- plastin (a brain tissue extract manufactured from bovines, a Squibb's and Armour preparation put up in 20 cc. bottles, given hypodermic- ally in 5 to 20 cc. doses and repeated at intervals of a. few days as long, as the hemorrhage continues) has been employed frequently at this hospital with doubtful results. Horse serum is also occasionally used, and at times blood transfusion where there has been a serious loss of blood. Blood transfusions should be small,' not more than 80-200 cc.12 Some endeavor to check hemorrhage by lowering blood pressure by such medicines as the nitrites (sodium nitrite in doses of .13 gin. repeated every two or three hours; inhalations of amyl- nitrite),j Thorwood's tincture of veratrum veride (7-10 gtts.) re- peated every two hours until results have been obtained.'2 The merit of these drugs in the treatment of hemoptysis is dubious, and their employment at this hospital has been only at rare intervals. The stilling of the heart action can be accomplished by reassuring, the patient, quieting his fears and by giving mild sedatives. As we see, there are many remedies for the treatment of pulmonary hemorrhage, and the doctor is too apt to apply most of them at one time so that it is difficult to say what particular remedy accomplishes results. As a matter of fact, a large percentage of hemorrhages stop spontaneously, and about all the good active therapy accomplishes is to appease the patient, including his relatives and friends. Probably the best plan and the one followed by this hospital is only to apply the routine treatment plus one of the coagulants. if the bleeding continues or recurs after giving simple methods a thorough trial, then it is time enough to apply special forms of treatment, such as bandaging the extremities and collapse therapy. In the meantime a good bedside X-r'ay plate of the lungs has been made with the patient sitting up, and fairly definite information regarding the tuberculous lesions obtained. We consider a satisfac- tory X-ray chest plate extremely important, as one cannot depend 196 E. H. BRUNS

DAME OF tIAflOTYS MMON CMSE OF RLIIOARY 11.fRQOSI, F.Gi.. CAES OF PKLflNAY T1ffOLOSIS SINC Ml, 7356 CASES OF HAEMIOTY SIS62 TYPE or rLBEMULOS RESULTS COPUXfONwcanE aim 20 ASPIRATIOM PtCJUIIC TUBELOSAM wu. OK ..c m rmini ASPIRTIRU S 22 msPRIRE 0 OAn" Frw PMAHU 4 FABRO-CASeOU DIMD ea AWTISI85 NODOSE 1'JBRCULA=1 SAnE xw anAh Ah S 289

CASCO-MIROUS 4 ANRKtA0 5 814 HOm fUBCRCULlM SANE A87U"M om £5 OCIq irWOtUS TUBERCULOSi WAe 45 19A3OFCSAm 82 FrM APOLAI10 14 ISSUED a 55*53 FUll MSSAA 20 IOTAL SIIEAN ASPUIIC 341 C34.4%() TOTAL CAVITY CASE 454 (eW.s10 NL SAWS MIRES HASrOFrVS MWON ADIUSON 31

N AMMIRAWU NAIPITUI AriU AIRSfhl 4a upon symptoms or physical signs if some form of collapse is to be attempted. Since the Fitzsimons General Hospital was op4ened, October 13, 1918, it has afforded treatment for 7,356 different patients suffering from chronic pulmonary tuberculosis. See Chart 1. Of these, not counting blood tinged or streaked sputum, 626 (8.5 per cent) had frank hemorrhages, 454 (85.1 per cent) had pulmonary cavities from which the bleeding no doubt came. It has been our policy during the past two years to take bedside plates in each case as soon as the hemoptysis is checked. These plates are taken with the patient sitting up on the edge of the bed with the plate casette hugged in front of the chest. This gives clear pictures. Two plates are always made, one slightly overexposed. Plates are also taken several weeks after the hemorrhage has ceased. By this means we are able to determine what change in the pathology of the lung has resulted therefrom, especially regarding aspiration and exten'sion. In 341 (54.4 per cent) of our cases aspiration occurred, as shown by a mottling in the lower part of the lung on the side of the hemorrhage, which is gen- erally from a cavity; 299 (87.6 per cent) of the 341 showing aspira- PROGNOSIS AND TREATMENT OF HEMORRHAGE 19197 tion were cavity cases. The aspiration pneumonia at times gradually cleared up, leaving behind scattered areas of fibrosis, but when severe were not an uncommon mode of exitus. One hundred and one deaths occurred as a result of hemorrhage, 43 being due to asphyxiation, 56 to aspiration pneumonia, and two to sudden loss of blood. Autopsies were performed on 40 of our fatal cases, 20 due to asphyxiation, 18 to pneumonia, and two to loss of blood. Of the 101 deaths, 20 (19.8 per cent) died immediately during their first hemorrhage, 25 (24.7 per cent) during succeeding hemorrhages or immediately after having had multiple hemorrhages; 12 (11.9 per cent) died from aspiration pneumonia following the first hemorrhage; 44 (43.6 per cent) after having repeated hemorrhages. These statistics point to the interesting fact that of those having repeated hemorrhages, twice as many died of aspiration as of asphyxiation, while of those who died during their first hemorrhage only two-thirds as many died of pneumonia as of asphyxiation. All deaths occurred in cases with cavities. Twenty- five (20 per cent) were predominantly fibrous types of tuberculosis.

CONCLUSION. 1. The incidence of hemoptysis as a symptom and complication of pulmonary tuberculosis is not increased by treatment in institu- tions located in high altitudes. 2. Hemoptysis, especially the, initial bleeding, frequently occurs as the result of some physical strain or effort, or accompanies hard coughing. In sanatoria it very often comes on during sleep or while the patient is at rest in bed. 3. Hemorrhage in pulmonary tuberculosis is one of our greatest means of making a diagnosis, which, while not always early, leads to the disease being discovered frequently before it is advanced and widespread. 4. It may be of value during treatment, causing the patient to realize the seriousness of his condition, acting as a restraint to a refractory patient and leading to better coi5peration in treatment. 5. The bleeding of tuberculosis of the lungs stops spontaneously in the majority of cases under rest and quiet, but the patient's anxiety makes some form of medication advisable. Some sedative, excluding opiates, should be included in the rou'tine treatment, and 198 E. H. BRUNS perhaps one of the coagulants. Binding of the extremities is efficacious in severe hemorrhages. Collapse therapy is our best and probably our only means of checking and preventing the recurrence of hemoptysis. 6. The danger of hemoptysis does not lie in the loss of blood, but in the aspiration of blood and the contents of cavities. In cases with wvidespread involvement, as fibrous form of tuberculosis with large cavities, extensive fibrosis emphysema and pleural adhesions, hemoptysis not infrequently causes immedilate death from asphyxia- tion, or a fatal termination in a short time caused by aspiration tuberculous pneumonia. In the latter failure of the right heart plays a prominent part. 7. With reference to prognosis and treatment, it is best to divide hemoptysis into two classes, those occurring from cavities and those not associated with cavities. The latter as a rule stop spon- taneously, are not dangerous and require no special treatment. They rarely cause death by asphyxiation, and aspiration is infrequent. The former, or cases originating from cavities, however, are dangerous; are little affected by any form of treatment except collapse therapy; are severe; tend to recur and are apt to lead to aspiration and death from pneumonia or asphyxiation. REFERENCES. 1. LANSE.L, P.: Uber Lungenblutungen im Hochgebirge. Beit. z. Klinik der Tuber. Bd. 66, S. 784-791, 1927. 2. POTTENGER: Clinical Tuberculosis. Chapter xxxiii, Vol. 2. Pub. C. V. Mosby Co., St. Louis. 3. RivIERaE: The Treatment of Hemoptysis in Pulmonary Tuberculosis. Tubercle, Vol. ix, No. 11, Aug. 1928. 4. CORPER, KRETSCITMER, and LURIE: An Experimental Study on the Behavior of Extravasated Blood in the Lungs. Am. Rev. Tuber., Vol. vi, No. 12, Feb. 1923. 5. CORPER and ROBIN: The Pulmonary Aspiration of Particulate Matter. Am. Rev. Tuber., Vol. vi, No. 9, Nov. 1922. 6. MULLIN and RYDER: Experimental Lesions of Lungs Produced by Inhala- tion of Fluids from Nose and Throat. Am. Rev. Tuber., 4 :683, Nov. 1920. 7. AULSTRIAN and WILLIS: Studies of Pulmonary Changes Following Hemop- tysis in Tuberculosis of the Lungs. Trans. Asst. of Am. Phys., 41:48-54, 1926. 8. BURRELL: Recent Advances in Pulmonary Tuberculosis. Pub. P. Blakiston's Son & Co., Philadelphia, Pa. PROGNOSIS AND TREATMENT OF HEMORRHAGE 199

9. RANDOLPH: Treatment of Pulmonary Hemorrhage. Southwestern Medicine, 5 :208-2 10, May, 1927. 10. PEARSON: A Study of Initial Hemoptysis. Tubercie, Vol. ix, No. 6, March, 1928. 11. HEBERT: The Classification and Treatment of Hemoptysis in Pulmonary Tuberculosis. British Jour. of Tuber., Vol. xxiv, No. 2, April, 1930. 12. EDEL: Pathogenesis and Therapy of Tuberculous Hemnoptysis. Medizinische Klinik, Berlin, 121 :1139-1174, Aug., 1930. 13. CHANDLER: Treatment of Hemoptysis. L-ancet, 1:588-589, March 15, 1930. 14. Ho1ArAN: The Cause and Control of Pulmonary Hemorrhage. Southwestern Medicine, 4:175-177, April, 1926. 15. BARNES: The Duration of Life in Pulmonary Tuberculosis with Cavity. Trans. Am. Climatological and Clinical Association, Vol. 44, 1928.

DISCUSSION. DR. HUGH M. KiNGHORN (Saranac Lake, New York): Since we have used rest treatment, hemorrhage has become less in evidence. We do not have as many cases now as we used to have. I believe that is due to the rest treatment that we give. I think the figures given by Dr. Bruns are very important. If you will remember the figures previous to this, in the majority of the cases death was due to aspiration, they died in the hemorrhage. The second largest number of deaths were due to pneumonia following the aspiration. The third, and only one, as I remember it, died of loss of blood. That brings up a very important question in the treatment. A solution has been brought to my attention by my friend, Dr. McConkey at the Raybrook Sanitarium. Our usual procedure was to give a sedative in order to stop the coughing. I believe that is entirely wrong. We should encourage these patients to cough. We are afraid that if we, have them cough they will bleed to death. As a matter of fact the majority of the patients died of asphyxiation, and only one died from loss of blood, as I remember it. So we should encourage these patients in their coughing. Another matter that Dr. McConkey has brought to my attention is that if you do not have them cough and relieve the lung of the blood you may have a massive collapse of the lung, the clot will become fibrinous, and you will have the main bronchus occluded, after which you will have a massive collapse of the lung. Of course, you can only determine that in some cases after death. The frequency of finding the source of hemorrhage in post mortems is often a very difficult thing. Last Tuesday, before I left, one of the patients at Raybrook died and we had an autopsy. The patient died of asphyxiation. We were unable to find the source of the hemorrhage. DR. WILLIS ST-URGIs LEmON (Rochester, Minnesota) : In a clinic that is not devoted to the study of tuberculosis essentially, we find that bronchiectasis bleeds much more frequently than tuberculosis, more frequently than mitral disease. We see a larg,e number of unexplained hemorrhages. The greatest pre- 200 DISCUSSION caution that we have to use is that they must he proven non-tubercular before further investigation. All such cases should he bronchoscoped to discover the cause. In the search, such conditions as malignancies, lung stones, bronchiectasis and various other non-tuberculous diseases are then discovered. I think that phase of it has to be kept in mind where one is not dealing entirely with tuberculosis. PRESIDENT PIERSOL: Dr. Bruns, will you close the discussion? DR. E. H. BRUNS: I didn't include hemorrhages from bronchiectasis or mitral disease in those figures. We hiave those, of course. We have figures for those that were autopsied.