Hæmoptysis may be simulated, as by scratches or cuts on some part of the internal surface of the throat or mouth. The blood is then likely to be thinned by secretion from the mouth. Inspection would detect the imposture. The chance of blood from an epistaxis being swallowed and afterward ejected by vomiting is to be remembered. Cardiac hæmoptysis is distinguished in most cases by the presence of symptoms and physical signs of valvular, usually mitral, disease in a considerable degree of advancement. These are so pronounced as to exclude phthisical disease. Other and fewer cases occur where the hæmoptysis is the first evidence of the cardiac disease, and they require a careful exclusion of all the features of tubercular disease, so as to be able to arrive at a correct conclusion. There are no conclusive considerations pertaining to the amount and character of the blood. In the severe and copious hemorrhages there is likely to be present a marked shock.
PROGNOSIS.—Hæmoptysis usually implies phthisis existing or imminent, and yet it has in general a favorable effect on its course. This applies more to its first stage than subsequently, and more to the small than to the large hemorrhages. The gravity of the small ones increases in proportion to their frequency. The family and personal equation is of more importance than the mere quantity. We may have a slight hæmoptysis and a large increase of the morbid condition following it, and the reverse, the result depending on the individual tolerance of and susceptibility to reaction. As in the second stage the reactive elements are more potent, the small hemorrhages then are less beneficial. They are the index of activity in the destructive lesions, and yet may relieve the accompanying congestion. The easiest appreciable symptom of the progress of the disease is the fever. We may fail to properly interpret physical signs because of want of familiarity with the individual case before us. If besides more fever there be more cough, dyspnoea, and debility, the prognosis increases in gravity. These remarks will apply with more force to the large hemorrhages than the smaller ones, and are guides for prognosis in all the clinical forms of hæmoptysis. In the special clinical form, the hemorrhagic variety of phthisis, bleedings recur often and in large quantities during years, and some of the cases end with final recovery. The fever and constitutional irritation give way under seemingly very unfavorable conditions. The fact that a great part of them have no history of heredity, and that they come on at a late period of life, may account for this, because they thus escape the influences which heredity and age are known to impose upon the other classes of phthisical subjects. Some interesting conclusions have been drawn from the history of cases of profuse hemorrhages. Pollock70 thinks that they shorten the duration of the first stage and lengthen the duration of the second and third. Out of his 351 cases, 204 occurred in the first three months of illness: 45 had remained in the first stage when examined, 142 having undergone softening, while 164 had cavities. Of 286 cases of profuse hæmoptysis classified by Williams,71 the number of cases in the first stage was 187, and the percentage of deaths was 13.95; 65 cases were in the second stage, and the percentage of deaths was 24.61; 31 were in the third stage, and the percentage of deaths was 67.74, showing increased effect of hemorrhages upon pulmonary structures advancing in destructive processes and upon constitutions being progressively undermined by them. In other clinical varieties the symptom is so clearly subordinated to the general process that it loses its prognostic importance in the established disease. There is an imminence of fatal hemorrhage in many of them, as in fibroid phthisis, cancer, abscess, gangrene, and hemorrhagic infarction of the lungs. In extra-pulmonary hæmoptysis or in that from rupture of pulmonary aneurism there is seldom opportunity for prognosis.
70 Elements of Prognosis in Consumption, p. 139.
71 Pulmonary Consumption, p. 150.
If the condition be recognized, we can but say that the fatal attack is liable to come at any moment. In cardiac hæmoptysis the hemorrhage is an event coming toward the close of organic and obstructive changes which are not much within our control. There are minor degrees, as shown by expectoration of single small masses of dark coagulated blood and by the absence of marked aggravation of the symptoms, which do not prognosticate unfavorably for the immediate, but do show impending dangers of a future, attack. Morbid anatomy shows traces of a recovery from a number of premonitory threatenings. The elements of a serious prognosis are the appearance of a shock, increased dyspnoea, a large amount of hæmoptysis, increased perturbations in the heart-action, and increased areas of dulness or râles at certain parts of the lung other than the usual sites of consumptive disease. These and other evidences of constitutional initiation are not as available as in the other varieties mentioned.
TREATMENT.—In the cases of the mildest form very little more need be done than to keep the patient quiet. His apprehensions may require attention. They may be allayed by assuring him that the hemorrhage will be more of a security than a danger, because it is the expression of a local congestion that will be relieved by the discharge. We have found that a large dose of quinine (ten or fifteen grains) will answer the double purpose of a nervous sedative and of controlling the congestion and hemorrhage if the latter object be necessary. This suggestion becomes still more applicable in the severe forms of hæmoptysis. The dose may be repeated within twenty-four hours if needed. If congestion be manifested by its symptoms of substernal heat, soreness, oppression, dyspnoea, and cough to a greater degree, and if the hemorrhage is becoming copious and the hemorrhagic pulse developed, and the temperature elevated, the necessity of a more active interference is evident. Absolute quiet in bed, fresh air, a calm and equable behavior on the part of the family or friends in attendance so that no excitement may be reflected to the patient, are essential. The medicines selected should be such as may control the vascular excitement, and hæmostatics. Ergot will fulfil such indications. It has its limitations in its unpleasant taste, but it should be pushed to the points of tolerance. Of the fluid extract one teaspoonful should be given every hour or two until some effect is observed in slowing the pulse or checking the hemorrhage. If the stomach rebel, ergotin pills may be substituted in doses of three to five grains at the same interval. Should all the resources of ergot medication be required or the above mode of use fail or disagree, hypodermic injections may be added. Two to three grains of the extract of ergotin would form a proper dose, to be repeated every one or two hours. It has been quite the exception in our experience to have serious irritation follow the use of it in this way. Failure in this and other uses of ergot will follow because we do not administer it with sufficient freedom.72 Another most valuable hæmostatic is turpentine. It should also be given freely. From ten to thirty drops in an emulsion or in sugar may be given every two to four hours, according to tolerance and to the threatening character of the case. The ergot and turpentine are best alternated at intervals of one to three hours, according to the requirements of the attack. Some preparation of opium is often required to quiet cough—morphine or codeine, one-fourth grain of the former and one-half grain of the latter, repeated at intervals until their effects are obvious. By adding the use of broken ice and the external application of cold compresses frequently repeated, and, if time and strength permit, the inhalation of persulphate of iron spray twenty or thirty minims in half an ounce of water, we get a plan of treatment adapted to the urgent cases. Some recent reports have confirmed the confidence of the ancients in the use of ligatures. They may be applied to both lower limbs. A dozen dry cups may be applied to the chest. There is no occasion or time for the use of many medicines, but if a general plan, such as the above, must be changed, acetate of lead in doses of two grains every two hours would be an excellent substitute, due regard being had to the possible toxic effects from too long continuance of it in such doses; it is usual to add a little opium to it. Gallic acid is an effectual remedy for the control of different kinds of hemorrhages. Like ergot, it is usually given in too small quantities. Twenty to thirty grains must be given every two to four hours. It is better borne by the stomach, and can often be continued longer, than the medicines above mentioned.
72 A medical friend, T. C. Minor of Cincinnati, has in his own case used three or four drachms of the fluid at a dose, with the effect of reducing his pulse twenty beats in a few hours.
We have already noted ipecacuanha as one of the survivals of ancient practice. It has had warm advocates among modern physicians. Graves places vivisection first and ipecacuanha next in his plan of treatment. Trousseau strongly recommended it. Peter and the French practitioners also strongly endorse its use in the severe forms. We have no doubt of its efficacy. It is important to exclude if possible the existence of a pulmonary aneurism or any such source of blooding, as there are no special means by which this can be done. It is a good rule to use the ipecacuanha in the cases of early or first-stage hæmoptyses. We would give it as it is given in dysentery. Precede its administration half an hour with thirty drops of laudanum, then give ten grains in water. If vomiting comes on, repeat it in an hour, and again, if hemorrhage continue, in two hours. The usual experience is that tolerance is established after two or three doses. It has also an application in small doses of one-quarter to one-half a grain in the milder forms, with irritative cough and slight fever.
Graves calls attention especially to the excellent effect of opium in all kinds of passive hemorrhage, hæmoptysis as well, but insists that it should be given only after vivisection has been performed or when the hæmoptysis has become rather passive, or in scorbutic and similar cases. His direction on one occasion to a physician, in a case of protracted bleeding of the gums, was, "Go home and give two grains of opium immediately, and then half a grain every hour until the bleeding stops." A combination applicable to the persistent bleeding recurring day by day is the sulphate of magnesia made soluble in rose-water by the free use of dilute sulphuric acid—one teaspoonful of the former, fifteen drops of the acid, one-half to one ounce of the rose or plain water. Many other remedies might be mentioned, and among them atropia. After the bleeding has ceased it is necessary to be assured as to the condition in which the lung has been left, and to counteract, if needed, any persistence of irritation. Fever is the most valuable evidence as to this point. If it exist, the use of quinia and ergot had better be continued freely. A three-grain ergotin pill about three times daily, and five grains of quinia morning and evening, can be tolerated two or three weeks. Local irritation should be applied if physical signs or pain warrants it.