The Treatment of Pulmonary Haemorrhage. BT JOHN WINTERS BRANNAN, M. D., Physician to Bellevue and the Wl'ltW- P5*V*r Hospitals. REPRINTED FRCM THE Neto ¥orfc $aettfcal journal for August 15, 1896. Reprinted from the New York Medical Journal for August 15, 1896. THE TREATMENT OF PULMONARY HEMORRHAGE* By JOHN WINTERS BRANNAN, M. D., PHYSICIAN TO BELLEVUE AND THE HOSPITALS. The subject assigned to me this evening covers so broad a field that I shall not attempt to deal with it exhaustively, but shall limit myself to certain general considerations. Haemorrhage from the lungs takes place in a large number of diseases and pathological condi- tions, but it is chiefly in connection with pulmonary tuberculosis and obstructive disease of the heart that it calls for active therapeutic measures on our part. Many forms of haemoptysis do not require special treatment, and in all varieties direct treatment of the haemorrhage should be promptly followed by treatment of the disease, to which it is due. In haemoptysis occurring in pulmonary tubercu- losis the general indications for treatment are evi- dent. The bleeding comes either by diapedesis from the smaller vessels of the bronchial or pulmonary mucous membrane, or by rhexis from a ruptured or * Read before the Society of Alumni of Bellevue Hospital, April 1, 1896. Copyright. 1896, bt D. Appleton and Company 2 TREATMENT OF PULMONARY HEMORRHAGE. eroded branch of the pulmonary artery. The for- mer condition is probably the source of the haemopty- sis which occurs early in the disease, when there may be no physical signs whatever in the chest. It is customary to speak of this form of pulmonary haemorrhage as bronchorrhagia, and to ascribe it to a congested area of the bronchial mucous membrane. There is, however, so far as I know, no clinical or pathological evidence to prove that such a localized congestion of the respiratory tract ever takes place, unless there is also an acute in- flammatory process.present. And yet it is not very un- common for haemoptysis to occur in an individual who experiences not the slightest sense of discomfort in the chest, either before, during, or after the event. How, then, are we to account for the haemorrhage? I believe that pathology furnishes us with an explanation that is sound, and that also explains the ominous signifi- cance of the occurrence. According to Delafield and Prudden,* " Haemorrhage by diapedesis usually occurs in the smaller veins and capillaries, all the elements of the blood passing out through the cement substance between the endothelial cells. Although no marked morphological changes have as yet been detected which explain this extravasation, it is probable that some change in the nutrition of the walls does occur which renders them more permeable." Ziegler f also states that " under pathological conditions the cement sub- stance between the endothelial cells [of the vessel walls] becomes softened and permits the passage of the red blood-corpuscles." This nutritive change in the walls of the vessels, which permits the extravasation of blood, is, * Pathological Anatomy and Histology, fourth edition, p. 58. f General Pathology, p. 135. TREATMENT OF PULMONARY HEMORRHAGE. 3 to my mind, only a part of the general lowering of nu- trition of the whole organism, by which it becomes less resistant to the invasion of the tubercle bacillus. The haemoptysis in itself is but a symptom, a warning of the danger which is threatening the individual. This view of the occurrence would explain the rarity with which the haemorrhage itself results seriously, and also the frequency with which it is followed' by the development of tubercular phthisis if its significance is not understood and acted upon. The foregoing hypothesis also accords with another clinical fact which has been noted by Flint and other ob- servers of large experience with pulmonary tuberculosis. After an analysis of one hundred and seventy-nine cases of phthisis in which the presence or absence of haemop- tysis was recorded in the histories, Flint concludes as follows:* " It thus appears that cases in which haemop- tysis occurs show a larger number of recoveries and a notably greater proportion of instances of arrest and tol- erance than cases in which haemoptysis does not occur. Under this aspect, therefore, bronchial haemorrhage is to be regarded as a favorable event." Again, he says: f " Moreover, it is to be borne in mind in this connection that the chances of recovery, arrest, and notable toler- ance in cases of tuberculous disease, as our clinical stud- ies have shown, are greater when haemoptysis occurs than when this event is wanting." Flint contents himself with thus expressing his opinion of the prognostic im- port of haemoptysis and does not offer any explanation of the facts upon which his opinion is based. If our view of the pathology of the haemorrhage is correct, there * Phthisis, a Series of Clinical Studies, p. 107. f Loc. cit., p. 114. 4 TREATMENT OF PULMONARY HAEMORRHAGE. would seem to be a twofold cause for the comparatively favorable course of these cases. Regarded as the first recognized symptom of the threatened invasion of tuber- culosis, the haemoptysis should often justly be assigned to the pretuberculous period of the disease. Tubercles may already exist in the lungs, but in many cases they apparently are not present, as shown by the lack of fur- ther symptoms or physical signs. Our treatment, there- fore, of such cases is really preventive in its character, in that it anticipates and checks in its incipiency the de- velopment of the disease. When, however, haemoptysis is wanting, the pulmonary process is usually well ad- vanced before our attention is attracted by the less strik- ing symptoms, such as cough, expectoration, and loss of flesh and strength. The lungs being already the seat of tuberculous deposit, our therapeutic measures meet with but partial success. A second reason for the effect- iveness of our treatment of cases characterized by hae- moptysis lies in the fact that it is apt to be more thorough. Bleeding from the lungs is such an alarming occurrence that the patient as well as the physician needs no argu- ment in favor of prompt and radical action. Our advice, therefore, is not only given at a time when it can accom- plish the greatest good, but it also usually meets with ready acceptance on the part of the patient and his friends. The treatment of this form of haemoptysis follows from what has been said of its aetiology. The haemor- rhage itself usually requires little direct treatment be- yond rest in bed for a few days, with restricted diet, and opium, if necessary, to relieve cough and allay excite- ment. As soon as the danger of a recurrence of the bleeding appears to be over, all possible measures should TREATMENT OF PULMONARY HEMORRHAGE. 5 be employed to fortify the patient against the develop- ment of tuberculosis. A complete change of surround- ings is usually required, at least for a time. The patient should take up his residence in a climate which will allow of his passing a large portion of the day in the open air. If this is impossible, he should be instructed to practise respiratory exercises for the purpose of deepening the breathing and thus improving the pulmonary circula- tion. The exercises should be especially designed to expand the apices of the lungs. The tubercle bacillus does not thrive in organs which are in full functional ac- tivity and whose tissues are nourished by a constant and vigorous blood supply. These respiratory .movements not only increase the capacity of the chest, but also have a marked effect upon the general nutrition of the patient. Deeper and fuller breathing leads to increased oxygenation of the blood. The appe- tite and digestion are improved, and the patient is enabled to assimilate more food. I have seen patients take with benefit four to five glasses of milk a day, in addition to three good meals, under the stimulating im- pulse of these so-called pulmonary gymnastics. Strych- nine, iron, cod-liver oil, and other tonics are all of value in these cases, but I desire to lay especial stress upon the hygienic treatment. If the above measures are faith- fully and persistently carried out, the patient will often have no further symptoms of pulmonary disease and the initial haemoptysis may indeed " be regarded as a favor- able event." Haemorrhage by rhexis, from a perforated artery, usually takes place at a time when the tuberculous lesions in the chest are more or less advanced. It demands, as a rule, much more energetic treatment than the form just 6 TREATMENT OF PULMONARY HEMORRHAGE. considered. Our first aim is to quiet the action of the heart and to lower the blood pressure in the pulmonary circulation as much as possible. Absolute rest in bed must be enforced, with avoidance of conversation and all excitement. A hypodermic injection of morphine at this time promotes calm of both mind and body. If the pulse be full and strong and the haemorrhage profuse and persistent, ligatures may be applied to the four extremi- ties to prevent the blood reaching the pulmonary circuit. Other means to accomplish the same end will readily sug- gest themselves, suoh as the employment of purgatives and emetics. The induction of vomiting seems rather a heroic measure, but it will often stop a haemorrhage most effectually. The food should be cold and taken in small quantities at frequent intervals to attract blood to the alimentary canal. Of the direct cardiac sedatives I have always pre- ferred aconite. Physiological experiment and clinical evidence unite in its favor. Andrew * has shown in the Harveian oration of 1890 that in animals aconite pro- duces a fall in the pressure in the pulmonary artery. Al- though pulmonary vasomotor nerves have never been demonstrated in man, it is probable that they do exist. At all events, judged by its effect in haemoptysis, it would seem that aconite acts upon the pulmonary circulation in man in a manner similar to its action in animals. Nature's method of stopping haemorrhage is by coagulation of the blood at the point of bleeding. The blood of tuberculous patients is, however, watery and deficient in clot-forming elements. We have recourse, therefore, to remedies which are believed to increase the coagulability of the blood. Among the drugs recom- * Brit. Med. Journal, 1890, vol. ii, p. 94'2. TREATMENT OF PULMONARY' HEMORRHAGE. 7 mended for this purpose, my own experience is in favor of gallic acid. Wood has called attention to the greenish hue of the blood expectorated after gallic acid has been taken, thus proving that the drug does reach the circu- lation. As the haemorrhage often ceases of itself if the patient remains at rest, it is difficult to determine wheth- er or not our remedies have had any agency in bring- ing about the desired result. I recall one case, however, in which gallic acid apparently had a marked haemostatic effect, in spite of the fact that the patient continued at his work. The case is that of a postman with consolidation at the apex of the left lung, who suffered with rather free haemoptysis from time to time. He did not wish to give up his occupation, and had tried ergot and other reme- dies without relief from the spitting of blood. I gave him gallic acid in ten-grain capsules, and he reported later that the haemorrhages were always promptly checked by its use. This was two or more years ago. I saw him a few weeks since, going his rounds and blow- ing his whistle, and he told me that the capsules never failed to serve their purpose. Of all the drugs employed for the relief of haemop- tysis ergot is probably the one in most universal use. I have given it myself in almost every case of internal haemorrhage that I have been called upon to treat. Its value is, no doubt, dependent upon its power of contract- ing the small blood-vessels. Inasmuch as ergot produces a decided rise in the blood pressure objections have been raised to its use in pulmonary haemorrhage. It has also been urged that as the bleeding vessel is generally more or less diseased, it can not respond to the contractile force of the drug, which is expended upon the sound 8 TREATMENT OF PULMONARY HEMORRHAGE. arteries of the body, which it should be our aim to relax and keep full of blood. These objections would seem fatal to the usefulness of ergot in haemoptysis, were it not that clinical experience furnishes overwhelming evi- dence in its favor. All observers have seen the haemor- rhage cease almost immediately after a hypodermic in- jection of ergotine. Undoubtedly in many cases it fails to arrest the flow of blood; probably, in these cases, the walls of the affected vessels have lost all power to con- tract. "When, however, the ruptured artery still contains muscular tissue, the vaso-contracting effect of ergot ap- pears to be greater than its action in raising the blood pressure. There are many other remedies recommended for the treatment of haemoptysis, but as this paper does not pro- fess to be complete, I shall not even enumerate them. Aconite, morphine, ergot, and gallic acid respond, in my opinion, to all the indications which we can hope to meet by means of drugs. ' When the haemorrhage has definitely ceased, the hy- gienic measures already described should be put in force. So long as fever is present, the patient should remain at rest, but not necessarily in bed. I am convinced that patients are often kept in bed much beyond the time when a renewal of the haemorrhage is the chief danger to be feared. We should always bear in mind that an extension of the tuberculous process is favored by the sluggish circulation and imperfect chest expansion in- cident to a life of confinement. The patient should be taken out of doors as soon as possible. If his occupation has been of a sedentary nature, it should be changed for one involving an active life in the open air. A change of climate is absolutely essential in many cases, so as TREATMENT OF PULMONARY HEMORRHAGE. 9 to completely do away with the conditions under which phthisis was acquired. Years will probably elapse before the disease can be regarded as cured, or even permanent- ly arrested. The treatment of the haemoptysis which occurs in disease of the heart does not call for extended considera- tion. This form of haemorrhage is the result of throm- bosis or embolism of a branch of the pulmonary artery. It is most common in mitral disease, but may occur whenever from any cause the blood current in the pul- monary artery is feeble or the circulation in its branches is impeded. The pulmonary arterioles are non-anasto- mosing terminal arteries, and if one of them is obstruct- ed by a thrombus or an embolus, the tissues of the affected region are deprived of their blood supply and undergo degenerative changes. In the absence of pres- sure from the side of the pulmonary artery, a reflux flow of blood from the veins takes place and the capil- laries are again gradually filled with blood. According to Litten, the refilling of the capillaries is at least part- ly due to an inflow of blood from neighboring unob- structed arterioles. The blood from the adjacent vessels is, however, under very low pressure, which is not suffi- cient to establish a current through the obstructed area into the veins. The blood therefore stagnates, the capil- laries become overfilled, their walls suffer in their nutri- tion, and permit the escape of blood into the surround- ing tissues. A haemorrhagic infarct is thus formed and haemoptysis readily occurs. Owing to the low blood pressure, the effused blood tends to clot and the haem- orrhage usually ceases if the patient remains at rest. After a proper period of rest in bed, the indication is to strengthen the action of the heart to prevent throm- 10 TREATMENT OF PULMONARY HAEMORRHAGE. bosis in other vessels with a recurrence of the haemor- rhage. Strychnine, digitalis, and other cardiac tonics should be prescribed, and all measures taken to improve the nutrition of the patient. The general treatment, in fact, should be sustaining, as in the case of the early haemoptysis of tuberculosis. The New York Medical Journal. A WEEKLY REVIEW OF MEDICINE. FRANK P. 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