Hemorrhage in pulmonary tuberculosis as a surgical emergency.

Fatalities from exsanguination in pulmonary hemorrhage are rare. Immediate fatalities occur as a rule by clot formation within the bronchial tree and asphyxia, but the sequellae with extension of the disease are more to be feared. Homolateral spread involving the lower lobe is favored by posturing the patient on the side from which the hemorrhage comes. Even more serious is contralateral spread which may convert a unilateral problem into bilateral disease with limitation or delay of surgical treatment. Various authors” 2, 3 have listed hemorrhage as one of the indications for pulmonary resection. In 1950 Ryan4 reported a case of tuberculosis in a young man who had repeated episodes of pulmonary hemorrhage over a period of several months and intermittent hemorrhage for about two weeks prior to the decision to do right pneumonectomy. This patient made excellent recovery. Ross5 reported right pneumonectomy for pulmonary hemorrhage in 1953, in a 45 year old woman. The hemorrhage had persisted for four days, bringing the hemoglobin to 51 per cent. Five days later severe hemorrhage began again and pneumonectomy was carried out. Postoperatively the patient was given chemotherapy with satisfactory recovery. Severe pulmonary hemorrhage, when from well localized pulmonary lesions, should be treated as an emergency by surgery whether the basic pathology be lung abscess, tuberculosis or some other condition. Thoracic surgical techniques have now advanced so that under certain circumstances, pulmonary hemorrhage may be treated by resection on the same principle that severe hemorrhage from gastric ulcer has come to be treated by emergency gastrectomy.5 The corollary of the surgical approach to the treatment of severe pulmonary hemorrhage has been too much neglected. The usefulness of chemotherapy has changed the operability of pulmonary tuberculosis so the presence of this infection is not a contraindication to surgical excision of the diseased segment or segments if hemorrhage occurs. Since hemorrhage carries with it the frequent and serious sequellae of spread of the disease into other lobes of the lung, pneumothorax was frequently performed to control it. More recently this therapeutic procedure was replaced by pneumoperitoneum and possibly phrenic phraxis. Thoracoplasty has been done. Lesions which cause hemorrhage are prone to require eventual collapse or resection. It is difficult to prove the efficacy of any procedure or medication in checking hemorrhage, except the eradication of the lesion.