Pulmonary Hemorrhage.

Synonyms.—Hemoptysis; Broncho-pulmonary Hemorrhage; Bronchorrhagia; Pneumorrhagia.

Definition.—An expectoration of blood, due to hemorrhage from the mucous membrane of the bronchi, trachea, or larynx, and more rarely from erosion or rupture of capillaries in lung cavities or parenchymatous tissue.

Bronchorrhagia.—When the hemorrhage is from the bronchial tubes, the term bronchorrhagia should be used, while an escape of blood into the air-cells and interstitial tissue is known as pneumorrhagia.

Etiology.—Although hemoptysis is not necessarily a serious condition, occasionally occurring in young persons of seemingly good health, it is usually one of the early symptoms of pulmonary tuberculosis, and should suggest to the physician a thorough examination of his patient.

The hemorrhage may result from congestion of the lungs, due either to pulmonary lesions or from cardiac derangements, especially mitral affections. In capillary bronchitis, not infrequently the distended capillaries give way, and hemorrhage results. Broncho-pneumonia, especially when it is the forerunner of tuberculosis, may also be a cause; severe congestion of the bronchi or ulceration of the larynx, trachea, and bronchi may also give rise to it by erosion of some of the arterial twigs. It may accompany malignant affections, infectious fevers, scurvy, purpura hemorrhagica, hemophilia, and other lesions. Cancer of the lung, gangrene, and abscess must be regarded as causal factors.

Pulmonary apoplexy, or an escape of blood into the air-cells and interstitial tissue, with or without laceration of the parenchyma, may be diffuse or circumscribed. It may be due to penetrating wounds or ruptures of a thoracic aneurism.

Vicarious hemoptysis is most likely an early symptom of tuberculosis rather than a substitute for the menstrual flow.

Pathology.—There is, in most cases, rupture of the capillaries of the bronchial mucous membranes, which at first are swollen and red, but soon become very pale. If tubercular cavities are formed, a ruptured aneurism is sometimes seen, or large bloodvessels eroded by ulceration. If pulmonary apoplexy has existed, the parenchyma may be lacerated; otherwise, the air-cells and interstitial tissue are infiltrated with blood, which gives them a reddish-brown cast.

Symptoms.—Usually the hemorrhage comes on suddenly, generally after some severe exertion, or undue excitement from coughing, or great vocal effort; while at other times it comes on when least expected, as during sleep. One of my cases invariably had his hemorrhage after going to sleep, though during the day his labor was quite severe.

The first evidence of the hemorrhage is a welling up in the mouth of a warm, salty fluid. The quantity varies greatly, though always appearing to the patient much larger than it really is. It may be that a mouthful may be coughed up every few minutes for an-hour or more, then cease for several days or weeks. Again, an occasional mouthful will be expectorated for several days in succession. Where there is a rupture of an aneurysm there may be an alarming gush of blood that proves rapidly fatal. One such case occurred in my practice about ten years ago, when a child, suffering from pulmonary tuberculosis, suddenly startled the mother by a frightful gush of blood, and died within five minutes.

Where the hemorrhage is profuse and prolonged, there is usually more or less dyspnea, the patient assuming a distressed appearance and soon becoming anemic. The blood is usually bright red and frothy, containing air-bubbles, though where the blood wells up in the mouth without coughing, the patient is apt to swallow more or less of it, and when this is spit up or vomited it will be dark and clotted.

Diagnosis.—This consists in determining the source of the hemorrhage. That from the lungs and smaller tubes is bright red and frothy. From the posterior nares and pharynx, the expectoration is streaked with blood and is airless. From the stomach, the blood is dark and clotted.

Prognosis.—Although hemoptysis usually signifies tuberculosis, it is not necessarily of this character, and the patient may live for years, finally dying of other lesions. I have in mind a lady who, thirty-five years ago, had several hemorrhages, and of whom it was said she would die early of consumption, who is still living, and has two grown daughters.

While alarm is usually felt by the patient, immediately fatal results very seldom occur. I have known of only one such case in twenty-five years of practice. The prognosis, then, as to life, is generally favorable, save from the rupture of an aneurysm or erosion of large branches of the pulmonary artery.

Treatment.—The patient should be placed in the recumbent position, and his fears allayed as to the results of his attack. All excitement is to be avoided and the patient encouraged as to the outcome. Small bits of ice may be swallowed, and cold drinks encouraged. Gallic acid in five to ten grain doses may be given every thirty or sixty minutes, or a mixture of oil of cinnamon and equal parts of oil of erigeron may be given, five to ten drops. on sugar, every twenty, thirty, or sixty minutes.

Should the hemorrhage be active, with a full, strong, bounding pulse, add tincture of veratrum ½ drachm to water four ounces, and give a teaspoonful every half hour until an impression is made upon the heart, when the remedy should be given every one or two hours.

If the hemorrhage is passive in character, carbo. veg. will be a good remedy. Dr. Scudder placed great reliance upon this agent, and, from its use in other passive hemorrhages, I would advise its use. Of the first trituration, give two or three grains every hour. Mangifera indica is used where the hemorrhage is passive in character. Dose, three to five drops in water, every one, two, or three hours.

Lycopus Virginicus is a favorite remedy with Eclectics, and may be given as an infusion or the spec. tincture. Where the hemorrhage is due to cardiac lesions, cactus, digitalis, and like remedies, will be given. One must not forget ipecac in these cases. It may be given to arrest hemorrhage, but is especially useful during the interim of attacks. The powder in grain doses or the spec. tincture may be given.

Of the domestic remedies, salt and alum should not be overlooked. Following an attack of hemorrhage, the patient should be kept quiet and in the recumbent position for a few days, especially when the hemorrhage has been severe, and remedies given to counteract the loss of tone due to the hemorrhage.

The administration of iron, the bitter tonics, and a nutritious and easily digested food will be good treatment. The patient, as he gains strength, should take light exercise and be much in the open air. To allay fear of a future hemorrhage, it is well to provide the patient with a few ten-grain gallic-acid powders, with instruction to take one at the first symptom of an attack.

The Eclectic Practice of Medicine, 1907, was written by Rolla L. Thomas, M. S., M. D.