Manual of Surgery by Alexis Thomson (golden son ebook .TXT) 📕

days. The packing should if possible be brought into actual contact with the leaking point in the vessel, and so arranged as to make pressure on the artery above the erosion. The dressings and bandage are then applied, with the limb in the attitude that will diminish the force of the stream through the main artery, for example, flexion at the elbow in hæmorrhage from the deep palmar arch. Other measures for combating the local sepsis, such as the irrigation method of Carrel, may be considered.

If the wound involves one of the extremities, it may be useful; and it imparts confidence to the nurse, and, it may be, to the patient, if a Petit's tourniquet is loosely applied above the wound, which the nurse is instructed to tighten up in the event of bleeding taking place.

Ligation of the Artery.—If the hæmorrhage recurs in spite of packing the wound, or if it is serious from the outset and likely to be critical if repeated, ligation of the artery itself or of the trunk from which it springs, at a selected spot higher up, should be considered. This is most often indicated in wounds of the extremities.

As examples of proximal ligation for secondary hæmorrhage may be cited ligation of the hypogastric artery for hæmorrhage in the buttock, of the common iliac for hæmorrhage in the thigh, of the brachial in the upper arm for hæmorrhage from the deep palmar arch, and of the posterior tibial behind the medial malleolus for hæmorrhage from the sole of the foot.

Amputation is the last resource, and should be decided upon if the hæmorrhage recurs after proximal ligation, or if this has been followed by gangrene of the limb; it should also be considered if the nature of the wound and the virulence of the sepsis would of themselves justify removal of the limb. Every surgeon can recall cases in which a timely amputation has been the means of saving life.

The counteraction of the toxæmia and the treatment of the bloodless state, are carried out on the usual lines.

Hæmorrhage of Toxic Origin.—Mention must also be made of hæmorrhages which depend upon infective or toxic conditions and in which no gross lesion of the vessels can be discovered. The bleeding occurs as an oozing, which may be comparatively slight and unimportant, or by its persistence may become serious. It takes place into the superficial layers of the skin, from mucous membranes, and into the substance of such organs as the pancreas. Hæmorrhage from the stomach and intestine, attended with a brown or black discoloration of the vomit and of the stools, is one of the best known examples: it is not uncommonly met with in infective conditions originating in the appendix, intestine, gall-bladder, and other abdominal organs. Hæmorrhage from the mucous membrane of the stomach after abdominal operations—apparently also due to toxic causes and not to the operation—gives rise to the so-called post-operative hæmatemesis.

Constitutional Effects of Hæmorrhage.—The severity of the symptoms resulting from hæmorrhage depends as much on the rapidity with which the bleeding takes place as on the amount of blood lost. The sudden loss of a large quantity, whether from an open wound or into a serous cavity—for example, after rupture of the liver or spleen—is attended with marked pallor of the surface of the body and coldness of the skin, especially of the face, feet, and hands. The skin is moist with a cold, clammy sweat, and beads of perspiration stand out on the forehead. The pulse becomes feeble, soft, and rapid, and the patient is dull and listless, and complains of extreme thirst. The temperature is usually sub-normal; and the respiration rapid, shallow, and sighing in character. Abnormal visual sensations, in the form of flashes of light or spots before the eyes; and rushing, buzzing, or ringing sounds in the ears, are often complained of.

In extreme cases, phenomena which have been aptly described as those of “air-hunger” ensue. On account of the small quantity of blood circulating through the body, and the diminished hæmoglobin content of the blood, the tissues are imperfectly oxygenated, and the patient becomes extremely restless, gasping for breath, constantly throwing about his arms and baring his chest in the vain attempt to breath more freely. Faintness and giddiness are marked features. The diminished supply of oxygen to the brain and to the muscles produces muscular twitchings, and sometimes convulsions. Finally the pupils dilate, the sphincters relax, and death ensues.

Young children stand the loss of blood badly, but they quickly recover, as the regeneration of blood takes place rapidly. In old people also, and especially when they are fat, the loss of blood is badly borne, and the ill effects last longer. Women, on the whole, stand loss of blood better than men, and in them the blood is more rapidly re-formed. A few hours after a severe hæmorrhage there is usually a leucocytosis of from 15,000 to 30,000.

Treatment of the Bloodless State.—The patient should be placed in a warm, well-ventilated room, and the foot of the bed elevated. Cardiac stimulants, such as strychnin or alcohol, must be judiciously administered, over-stimulation being avoided. The inhalation of oxygen has been found useful in relieving the urgent symptoms of dyspnœa.

The blood may be emptied from the limbs into the vessels of the trunk, where it is more needed, by holding them vertically in the air for a few minutes, and then applying a firm elastic bandage over a layer of cotton wool, from the periphery towards the trunk.

Introduction of Fluids into the Circulation.—The most valuable measure for maintaining the circulation, however, is by transfusion of blood (Op. Surg., p. 37). If this is not immediately available the introduction of from one to three pints of physiological salt solution (a teaspoonful of common salt to a pint of water) into a vein, or a 6 per cent. solution of gum acacia, is a useful expedient. The solution is sterilised by boiling, and cooled to a temperature of about 105° F. The addition of 5 to 10 minims of adrenalin solution (1 in 1000) is advantageous in raising the blood-pressure (Op. Surg., p. 565).

When the intra-venous method is not available, one or two pints of saline solution with adrenalin should be slowly introduced into the rectum, by means of a long rubber tube and a filler. Satisfactory, although less rapidly obtained results follow the introduction of saline solution into the cellular tissue—for example, under the mamma, into the axilla, or under the skin of the back.

If the patient can retain fluids taken by the mouth—such as hot coffee, barley water, or soda water—these should be freely given, unless the injury necessitates operative treatment under a general anæsthetic.

Transfusion of blood is most valuable as a preliminary to operation in patients who are bloodless as a result of hæmorrhage from gastric and duodenal ulcers, and in bleeders.

Hæmophilia

The term hæmophilia is applied to an inherited disease which renders the patient liable to serious hæmorrhage from even the most trivial injuries; and the subjects of it are popularly known as “bleeders.”

The cause of the disease and its true nature are as yet unknown. There is no proof of any structural defect in the blood vessels, and beyond the fact that there is a diminution in the number of blood-plates, it has not been demonstrated that there is any alteration in the composition of the blood.

The affection is in a marked degree hereditary, all the branches of an affected family being liable to suffer. Its mode of transmission to individuals, moreover, is characteristic: the male members of the stock alone suffer from the affection in its typical form, while the tendency is transmitted through the female line. Thus the daughters of a father who is a bleeder, whilst they do not themselves suffer from the disease, transmit the tendency to their male offspring. The sons, on the other hand, neither suffer themselves nor transmit the disease to their children (Fig. 64). The female members of a hæmophilic stock are often very prolific, and there is usually a predominance of daughters in their families.