CHAPTER VIL, (Part 1)

CHAPTER VIL, HEMORRHAGE, DEFINITIONS. ? 1, Arterial hemorrhage is duc to wounds of arteries and is character: ized by spurting and the bright red color. 2. Venous hemorrhage is due to wounds of the veins and is character ized by dark color and steady flow. 3. Capillary hemorrhage is characterized by persistent oozing ami spontaneous arrest. 4. Parenchymatous hemorrhage is due to wounds of thase argant and tissues in which the small arteries terminate directly in veins; ae capillaries intervening, as in the erectile tissues. 5. Primary hemorrhage occurs immediately after the injury. 6. Intermediate or reactionary hemorrhage occurs within twenty four hours and is due to the release of clots or the slipping of the ligature. 7. Secondary hemorrhage occurs after twenty-four hours, before the cicatrization of the wound, and is usually due to sloughing oF supple ration or the too rapid absorption of the catgut ligature. 8. Infernal or concealed hemorrhage occurs when the blood © emptied into one of the large cavities; abdomen, thorax oF cranium. o TITUTIONAL EYPECTS OF MEMORRMAGE, ‘The constitutional effects of hemorrhage vary with the amount and the rapidity of the loss of blood. ‘Thus a comparatively small amount of blood poured out rapidly will produce more marked symptoms thas a much larger amount drained away slowly. ‘The constant accompaniments of severe hemorrkege are pallor, digze ness and faintness, rapid and weak pulse, subnormal temperature, s = DIAGNOSIS OF BEMORRAGE, 5s rapid and irregular breathing, frequent yawning or sighing, nausea, and vomiting. Fatal hemorrhage, or one likely to be so, is indicated by livid lips, blue finger nails, dilated nostrils, pallid mucous membranes, dyspnea, ringing in the ears, syncope, collapse and unconsciousness. Subsequent to the arrest of a dangerous hemorrhage, occur rapid and irregular pulse, rise of temperature, asthenia, a disturbed mental con- dition, usually muttering delirium. ‘This is hemorrhagic fever. As the general condition improves, the mind gradually clears up. The lowered vitality following the hemorrhage favors the development of various inflammatory processes, and one must carefully watch for the onset of these. The diagnosis of hemorrhage is not difficult except in the case of internal hemorrhage, or when shock is In the case of bleeding into the cranial cavity, various forms of paralysis and nervous disturbances, together with the general symp- toms, will form the basis of the diagnosis. on the case of bleeding into the thorax and abdomen, the symptoms, the physical signs, and the history of the case will point to the condition. (See Injuries to Thorax and Abdomen.) When shock is also present it may be almost impossible to tell how much of the symptoms are due to the one or the other, for the symptoms of shock and hemorrhage are practically identical. It is useful to remember that the symptoms produced by shock are usually immediate and tend to improve, except in the fatal cases. On the other band, the symptoms of unchecked hemorrhage tend to grow worse. TREATMENT OF HEMORRHAGE. The First Indication és the Arrest of Hemorrhage. Constitutional measures are then applied with a view to supporting the heart's action, In moderately severe cases give 1/2 ounce of whiskey or a hypodermic of strychnia (1/60 to 1/20 gr.), or of adrenalin chloride, and repeat every hour until the symptoms have improved. Apply warm blankets, hot water bottles, or hot irons well wrapped. Do not burn the patient. Keep him quiet, with head lowered, Attend to the ventilation. As 56 soon as possible give warm drinks and a nutritious but easily digest! diet. Do not overstimulate, as the reaction in that case will be ae duly severe.. - In the dangerous cases of hemorrhage, in addition to these measures do not fail to employ normal sai! solution either by enema, subeutaneos! injection, or intravenous infusion. ‘ In the gravest cases, enemas will be of no avail, for absorption bet practically ceased. Hypodermoclysis will be a little better. For this purpose employ R—Soilii chloridi,, Sty Sodii bicarb., RY Aa. destill, To The necessary apparatus: a carefully disinfected fountain syringe ors funnel with rubber tubing, a large needle (an aspiratingneedle). One half pint or more of the solution is injected by this means under the skin over the abdomen or breasts. Intravenous Infusion. In the gravest cases, the same solution by the same means may be injected into the venous circulation. Select s at the elbow, employ the strictest asepsis, and expose the vein by incision. Loosen it from adjacent tissues by careful blunt dissection and stip three catgut ligatures under it. Introduce the needle, or ele the vein may be opened and a cannula used. ‘The cannula or needle® tobe held in place by tying the middle ligature. Slowly inject a pinter more of the solution, the temperature of which should be 165 to 115: Wi aw the cannula, remove the middle ligature, and tie the twate maining. Close the wound and dress aseptically. Keep the furne full during the injection, so that no air may be carried into the wea Crile recommends direct transfusion from the vein of a well person into that of the patient, but of course this method is scarcely available in emergencies of general practice Parke-Davis & Company market a sterile salt in sterile tuber which needs only to be emptied into a liter of sterile water to form & solution for instant use. The formula used is as follows Calcium chloride, 0.25 Rie Potassium chloride, or gm. Sodium chloride, 90 (Be AMWEST OF HEMORRHAGE. iv] Remember that intravenous infusion is not to be employed until the hemorrhage is arrested. MEMOSTASIS—ARREST OF WEMORRIAGE; GENERAL PRINCIPLES. Spontaneous arrest of hemorrhage is due to several factors; contrac- tion and retraction of the injured vessels, diminishing blood pressure due to weakening heart action, formation of a clot; these are the agents which nature employs, Capillary hemorrhage tends to spontaneous arrest, likewise the arterial hemorrhage of lucerated wounds. Hemostatic measures locally applied are chemical, thermal, and mechanical, (A) Chemical remedies, chicfly styptics, are now very rarely em- ployed. Such as are used are expected to favor the formation of a clot without doing violence to the tissues, In a persistent capillary hemor- thage, dioxide of hydrogen or acetanilid is often useful and harmless, but the most useful remedy locally applied is adrenalin chloride. ‘The 11090 solution is commonly used. (B) Thermal hemostasis is that induced by heat. Hot water or hot normal salt solution alone will usually arrest a moderate bleeding. ‘Use the solution as hot as ean be borne by the hand. Hot solutions are especially useful since they serve the double purpose of antisepsis and hemostasis, The actual cautery may be necessary in spongy tissue where the oozing is persistent but ill defined, The iron should not be hotter than a dull red and must be held in contact for some moments, Cold may be used but is much more likely to lower cellular vitality. (C) Mechanical hemostasis includes (x) direct pressure, (2) com- pression, (3) acupressure, (4) forcipressure, (5) torsion, (6) ligation. (1) Direct pressure is of large service especially in 'first aid" treat- ment. ‘The finger or thumb is pressed directly into the wound, or on each edge of the wound. If the pressure is to be prolonged, the finger will tire and a plug or tamponade of gauze must be substituted. Gauze wrung out of a sterile solution is packed into the wound, Direct pressure is sufficient in the slight hemorrhage of operative wounds, The assistant presses a gauze compress on the bleeding sur- — 36 HEMORRHAGE. face, withdraws it by a gliding movement, and the | coases, Tn general, the larger the vessels, the firmer and more must be the pressure. In severe hemorrhage, direct pres, of ene mre tempor? expedient. Parenchymatous bleeding is checked by direct _ pesteursaukTaa wound of the organ is lined with a layer of gauze. In this gauae eavity, complete the tamponade. This compress should be withdraws within twenty-four to forty-eight hours. It may be painful to pull out Release a little at a time, or soften the adhesions with peroxide. 2. Compression aims to occlude the vessel above or below the wound. In the emergency, a finger is applied to an artery at some con- venient point along {ts course at some distance above the wound Pressure is most effective if the vessel lies closely over bone. Large veins are similarly compressed below the wound. In the case of wounds of the extremities, the main vessels, inclading both the vein and artery or either alone, may be compressed by the fowrniquel, The pressure is made firmest over the vessel by laying over its course a body such as a small roller bandage, before the com stricting band is applied above the wound (Figs. 51, 5a). ‘The simplest and most convenient tourniquet is a rubber band or tube. After being tightened, the crossed ends are caught and held in place by an artery forceps. It must always be remembered that the tourniquet is likely to cut off all the blood supply to the extremity and {f too long applied will produce gangrene. Paralysis may follow | from pressure on the nerves. “Wrap the arm with towel and apply || the tourniquet over that. | Capillary oozing is frequently troublesome after the constriction i= removed. Constriction is objectionable on that account, 3. Acupressure is now seldom used and yet, under certain eieume stances, may render great aid. ‘The artery may be deep and retracted: or imbedded in scar tissue or aponeurosis and cannot be seized by the: forceps. In such a case a needle passed under the artery and Secured with a Ggure-of-eight ligature wound around its protruding ends wall) press the artery between it and the tissues and stop the How (Fig. 49}: | = ARREST OF IEMORRUAGE, 59 4. Forcipressure, the control of hemorrhage by seizing the ends of the bleeding vessels with forceps, is the expedient most commonly em- ployed in operative wounds. In the accidental wounds of large arteries, it affords immediate control of the hemorrhage. For the small vessels such pressure is sufficient, the forceps remaining at- tached for a certain length of time. The end of the vessel should be seized with as little other tissue as possible, If it is a large vessel it may be cleared by a moment's dissection, . Torsion is added to forcipressure, if that is not sufficient (Fig. 48). Before removing the forceps, it is given two or three turns on its long axis, The inner coats of the artery are ruptured and con- a 1 | tracted, producing the same conditions favorable to hemostasis as are found in the artery im Jacerated wounds. If the artery is a little larger, it is drawn for 1/2 inch out of its sheath, a second forceps grasps it higher up and is held stationary, while the lower one twists the in- tervening segment, the purpose being to avoid injury to the sheath and the vasovasorum, In making torsion, do not pull at the same time, for fear of tearing the other tissues instead of twisting the artery. ‘Torsion must not be used where the tissues are loose or cellular. Torsion fs of advantage especially in plastic surgery, for it leaves no Tigature behind to interfere with repair; but it is not so certain as ligation. 6. Ligation is finally necessary in bleeding from the larger vessels. Employ eatgut, chromicized or plain, and occasionally silk. 6 HEMORRHAGE, Lift the attached forceps so as to create a pedicle around which pase the thread and tie the first knot (Fig. 49). Tn tying the second knot, (wo things are kept in mind; to the tight enough that the thread will hold when the forceps is removed, amd not to include the tip of the forceps in the ligature, “The forceps is usually removed as soon as the first knot is tied, so that one may be assured the suture Is not badly placed before completing the knots. The first knot is secured by a second if silk is used, and by a third if catgut és used. ‘The threads are then cut short, silk © mm. and catgut 2 or 3 mm Catgut is the preferable ligature and a No. 2 is amply strong for a= Artery the size of the radial. "anSting algae (Vea) Ligation en masse may be employed in parenchymatous hemorrhage, capillary oozing, or bleeding from a deep wound. A eatgut suture carried around the bleeding area by a well curved needle, and all the tissues #0 included are tied; or, in the case of parenchymatous bleeding from a surface, a catgut suture may be carried around the anes and subsequently tightened after the manner of the purse string. HEMOSTASIS IN SPECIAL FORMS OF HEMORRHAGE. (a) Capillary—pressure, hot water, ice, adrenalin, peroxide, acetani id, alum, ligation en masse. : (b) Venous—pressure, compression, forcipressure, ligation, removal of all obstruction to venous flow above the wound, (e) Arterial—pressure, compression, forcipressure, torsion, ligathos, HEMOSTASIS IN SPECIAL FORME OF HEMORRHAGE. 6: (d) Parenchymatous—pressure (tamponade), heat, ligation en masse. (©) Intermediate hemorrhage—reopen the wound, turn out the clots and treat hemorrhage us if it were a primary one. ©) Secondary hemorrhage—reopen the wound, turn out clots, and apply compresses, If possible.catch the ends of the bleeding vessels, Lf the hemorrhage is alarming and it is impossible to control it by com- presses or forcipressure, apply the tourniquet, in the case of an ex- tremity, and ligate the artery in its continuity above the wound. ff this fails and the artery cannot be tied higher up, amputate. Pro, 50. (g) Operative hemerrkage—In spite of artery forceps, the bleeding remains to the unexperienced one of the bugbears of operative work. In many operations it is the chief drawback to rapid work; more time is lost in catching and tying bleeding points than in doing the actual operation, Oftentimes the field is masked by a general oozing, and the procedure must halt until the wound can be packed with hot com- presses, which will usually be all that is necessary. Gentle and momentary pressure with a gauze compress is usually all that is necessary in capillary bleeding, Tn operations in the various cavities, as the nose, mouth, rectum, in the mastoid operation, etc., the hemorrhage, even if not disconcerting, is often very troublesome and some special measures are required. Under the circumstances, Parke Davis’ adrenalin gauze, which is cut in narrow strips, may be packed in the cavity for a moment and on its removal the operation may proceed (Fig. so). 62 HEMORRHAGE, FIRST ALD IN DANGEROUS HEMORRHAGE. It is rare that the regulated measures for hemostasis cam be appliol first hand in a dangerous hemorrhage. ‘There are certaim temporary and makeshift but extremely useful procedures which the surges should keep in mind, if for no other reason than that he may give pre cise and definite instruction to the layman who may have to play the part of surgeon for the time being. Intelligent first aid is the chief factor in saving life in most cases of dangerous hemorrhage both in military and civil practice. Whoever has to meet these emergencies must keep cool. He must remember how to apply three principles of treatment, position, direct presere, compression. 1, Porition.In case the upper extremity és wounded: hold the arm above the head. If it is the lower extremity: put the patient on his back and clevate the limb. If it is the face or scalp; place the patient in a sitting position. 2. Direct Pressure —The wound is small, the bleeding is dangerous plug the wound directly with the thumb or finger, or press firmly on each edge of the wound; or, in any case and better still, if supplied with a first aid packet, stuff the wound tightly with gauze and bandage firmly. It should be emphasized that a finger must never be thrust into a wound except in cases of greatest urgency and where other means less likely to cause sepsis are not at hand 3. Compression.—The bleeding vessel is recognized and its course is familiar: compress it with the fingers at some convenient point of in the case of the extremities, by constricting the limb. In liew of the tourniquet, knot a handkerchief, apply the knot over the artery and tie the handkerchief tightly around the timb, If am not tight enough, a stick may be slipped under the handkerchief amd given a few turns, end for end. A suspender, a rope, OF a Wine may, Wf necessary, be similarly employed. It must be remembered that on the whole, circular constriction is mot without its dangers, and it mum not be recommended without reserve to the layman, “ * See also “Firs Ald on Battletie COMPRESSION OF PRINCIPAL ARTERIES. 63 The principal arteries near the surface have cach certain points where compression is most effective, ‘The temporal and occipital furnish most of the dangerous bleeding in scalp wounds, The temporal may be compressed just in front of the upper part of the ear. ‘The occipital may be compressed in its course from the tip of the mastoid upward toward the occipital protuberance. ‘The entire blood supply of the scalp may be shut off temporarily by a bandage encircling the head, passing from the forchead, above the ear, to thebase of the skull and thence upward, just above the other ear, to the forehead again. ‘The facial is compressible as it crosses the body of the jaw just in front of the masseter muscle, The coronary arteries, supplying the lips, are compressed by seizing the lip between the forefinger and thumb. ‘The carotids are controlled by compression of the common carotid over the transverse process of the sixth cervical vertebra. Wounds of the vessels of the neck, however, are of such extreme danger, including, as a rule, both arteries and veins, that bleeding should be controlled by direct pressure in the wound, Nothing can be so well trusted here as the