I usually know the complaint before the patient opens his mouth. It is preceded by fits of hesitation, mentioning other complaints before coming to the main problem. And when it’s time to say it, it is again preceded by gestures that make it all the more vague, gestures that suggest vomiting or coughing. Until finally, the patient is left with no choice but to say it in the mutest voice it’s almost a whisper. “Dumudura ako ng dugo.”
To cough out blood or in medical parlance, hemoptysis, has become so stigmatized that it almost ranks as high on the list of “untouchables” with AIDS, leprosy, or any sexually transmitted disease. Its stigma has been etched so deep that even medical personnel sometimes ignore their own medical knowledge and choose to get carried away by the fear of seeing that bright red fluid coming out of a patient’s mouth.
Hemoptysis (coughing of blood) must be distinguished from vomiting of blood (hematemesis) as the former comes from the lungs while the latter, from the stomach. In the Philippines where Tuberculosis has a very high incidence, hemoptysis has become synonymous with “pthisis” or “tisiko” as description of an emaciated TB patient.
Twenty-five years ago today at the San Lazaro Madical Center, I was standing in front of a big muscular man sitting on the ER bed, holding a large pail coughing bright red blood into it. It was half full when he lost consciousness. And in spite of the blood transfusions, he died 30 minutes later. He was a “kargador” at the North Harbor in the “prime” of his life. And although he smoked 2 packs a day and drank gin every night, his family never expected him to be taken away so soon.
Although we know of tuberculosis as a highly contagious infection of the lungs, it is actually a slowly progressive infection that targets almost every organ of the human body. The lungs are its favorite hangout, but when it gets too crowded there, they search for greener pastures in lymph nodes, the liver, the intestines, the brain, and even the ovaries and testicles. These extrapulmonary infections however are not as obvious as infection of the lungs.
TB of the liver would present with jaundice and itching. TB of the intestines may cause intestinal obstruction or perforation. A patient with TB of the brain or meninges will present with coma with fever. Lastly, TB of the genitalia would certainly affect ones capacity to procreate not to mention inability enjoy the process.
Infection in the lungs becomes obvious since the lungs are an important part of our moment to moment “will to live”. So patients initially complain of chronic cough, weight loss, and later, difficulty of breathing. And when the lesion eats into a part of the lungs with a large blood vessel, the blood will naturally flow out with the cough.
Those lucky enough not to cough out blood in their lifetime despite lack of treatment will bear the brunt of the slow but sure demolition of the lung tissue. They will suffer from progressive difficulty of breathing and cough unresponsive to ordinary cough preparations. They will lose appetite, lose weight and grow old to a ripe old age when they can no longer walk, talk or even get out of bed, tubes carrying oxygen to their nose, food to their stomach, and God forbid, air into their trachea.
On the other hand, my patient as the San Lazaro was probably a lot luckier.