Epistaxis

“ The position of the body is of great importance in treating epistaxis. The recumbent position is no doubt to be preferred. The patient often holds one arm elevated or ties a cord about the proximal end of a limb. These innocent accessories to treatment may be permitted, since they are based upon well-known physiological principles, although it must be said that the bleeding can in all instances be checked without their aid. Cold applications to the nape and sides of the neck are often of service. ”

“ Bleeding from the nose, epistaxis, taking place frequently in a middle-aged person, sometimes is an early symptom. The bleeding may be profuse, but is rarely so large as to be positively harmful. In fact, it may do much good in relieving tension. ”

“ In severe cases of purpura the eruption may be very abundant, and with the cutaneous lesions hemorrhage from various mucous surfaces may occur. The gums are usually swollen and bleed easily. Epistaxis is frequent and blood is often noted in the stools and urine. ”

“ The face is congested and swollen. The eyes are injected and present a bleared appearance, but the watery or weeping condition seen in measles is usually absent. The nose is dry, and a sore throat is not uncommon. Epistaxis is frequent.
A very important symptom which sometimes occurs in this stage is a cutaneous efflorescence, which may resemble urticaria, scarlet fever, or measles. ”

“ When in these attacks of ardent fevers there was a proper and copious hemorrhage from the nose, they were generally saved by it, and I do not know a single person who had a proper hemorrhage who died in this constitution. Philiscus, Epaminon, and Silenus, indeed, who had a trifling epistaxis on the fourth and fifth day, died. Most of those taken with had a rigor about the time of the crisis, and notably those who had no hemorrhage ”

“ Epistaxis, or bleeding from the nose without previous work or other apparent cause, is one of the frequent concomitant symptoms in glanders, and such hemorrhage from the nostrils should always be regarded with suspicion. The animal with farcy frequently develops a cough, resembling much that which we find in heaves—a short, dry, aborted, hacking cough, with little or no discharge from the nostrils. With this we find an irregular movement of the flanks, and on auscultation of the lungs we find sibilant or at times a few mucous râles. ”

“ The head and neck appear ecchymosed, the purplish-blue lividity generally ending abruptly at the lower part of the neck or upper part of the thorax, about the level of the clavicles. The conjunctivæ are ecchymosed, and there may be epistaxis. This discoloration does not disappear on pressure by the finger, indicating its petechial character. If the person survive long enough, the discoloration gradually disappears, passing through the colour changes of an ordinary ecchymosis. ”

“ If the urine have not this sediment, nor do the sweats take place, there is danger either that the joints will become lame, or that the tumor called meliceris will form in it. This disease forms in those persons who in their youth had epistaxis, and in whom it had ceased afterwards. They are to be interrogated whether they had discharges of blood in their youth, and if they have pruritus in the breast and back. And the same thing happens to those who have severe pains in the bowels, without disorder of them, or who have hemorrhoids. ”

“ Epistaxis is not uncommon. A very unfavorable symptom seems to be hiccough. Another frequent cause of death and the one against which we chiefly direct our therapeutic measures is anuria with subsequent uraemic symptoms, such as coma and convulsions. At times a nephritis may develop in the course of a blackwater attack and the case subsequently run as one of severe nephritis.
Very striking is the rapidly developing anaemia, some cases showing a loss of two million red cells in twenty-four hours. ”

“ The former takes notice only of fatal coughing of blood; the latter, besides this, notices epistaxis, hematuria, and fluxes of blood from the bowels, as symptoms of such decided and speedy mortality, that those patients in whom they were observed usually died on the same or the following day.
That a vomiting of blood may not, here and there, have taken place, perhaps have been even prevalent in many places, is, from a consideration of the nature of the disease, by no means to be denied; for every putrid decomposition of the fluids begets a tendency to hemorrhages of all kinds. ”

“ Many other irregular symptoms are described in the monographs, some of which have no intimate relation with the disease. The anæmia has, of course, all the features of the traumatic form. Digestive troubles, after the bleeding, are common, and are due to the anæmia. The Buel Brothers173 mention that in two of their cases the patients showed a marked inclination to eat sand and earth. Children with the hemorrhagic tendency pass through the ordinary diseases of infancy like others. Whooping cough is very liable to cause epistaxis. ”

“ Definition.—Infectious jaundice is a spirochaete infection, caused by Leptospira icterohaemorrhagiae. This spirochaete is a common parasite of rats in various parts of the world and man possibly receives his infection from this source. There is a sudden onset with rather high fever, headache and vomiting. The jaundice appears about the third or fourth day when the urine shows albumin and bile. Haemorrhages, especially epistaxis, are common and the liver rather than the spleen shows enlargement. A polymorphonuclear increase is a feature. ”

“ When the abscess is situated at the mouth of the womb, so as that it can be operated upon, we must not be in haste in having recourse to incision, nor until the disease be ripened, and the inflammation has increased to its utmost, and the vascular bodies which surround it have become attenuated, owing to the importance of the uterus in the system. In operating, the woman should be placed on a seat in a supine posture, having her legs drawn up to the belly, and her thighs separated from one another. ”

“ Secondary abscesses are thus formed in those parts, and these in turn may be the starting-point of new emboli which give rise to fresh areas of pus formation. The organs above named are the commonest situations of pyaemic abscesses, but these may also occur in the bone marrow, the substance of muscles, the heart and pericardium, lymph glands, subcutaneous tissue, or, in fact, in any tissue of the body. Organisms circulating in the blood are prone to lodge on the valves of the heart and give rise to endocarditis. ”

“ If an attack of acute appendicitis is allowed to take its course unoperated on, abscess forms in the peritoneal cavity in the region of the appendix, but if already inflammation has happily glued the intestines together around that area, the pus is confined within definite limits. But as the abscess increases in size the demand for its evacuation becomes urgent. The pus, under the influence of a natural law, seeks its escape by the path of least resistance; sometimes this is into the intestine, and occasionally into the bladder. ”

“ This kind of abscess, though not itself dangerous, has given opportunity for the inoculation of venereal matter in the hands of accoucheurs, and of putrid matter from the dissection of diseased bodies; and has thus been the cause of disease and death. When putrid matter has been thus absorbed from a dead body, a livid line from the finger to the swelled gland in the axilla is said to be visible; which shews the inflammation of the absorbent vessel along its whole course to the lymphatic gland; and death has generally been the consequence. ”

“ Active inflammatory action may, however, be excited at any time, as in other chronic abscess, by a new infection, septic organisms entering the abscess by way of the uterine cavity, an adherent loop of intestine, or the bladder. The woman will then have an attack of acute septic inflammation in the old pyosalpinx, and will be exposed to the various dangers that were imminent during the primary acute stages of the disease. ”

“ Any professional man, with the right regard for his patient's welfare, and the judicial understanding that qualifies him for taking the responsibility of directing the treatment of so important a case, would scarcely have laid the weight of his finger on an abdomen in such a dangerous condition. The symptoms and course of the malady up to that time should have told the real diagnostician that there was an abscess and that the abscess would rupture into the cecum if it were not meddled with. ”

“ When pus is present and is deeply seated, the evacuation of the abscess will be aided by the introduction of the forefinger into the bowel, by which means the swelling may be pushed forward, rendered tense, and hence made more apparent.
In opening these abscesses, if possible, ether should be given. The patient should lie on the side on which the threatened abscess is situated; the upper leg should be bent forward upon the abdomen. When pus is present, the operator should stand out of the line of its exit, for when the cavity is opened it often squirts out a considerable distance. ”

“ As regards the treatment of acute peritonitis, the first thing that the surgeon has to do is to assure himself that the disease is not due to some cause which itself should be dealt with, to a septic disease of appendix or Fallopian tube, for instance, or to a toxic condition of the uterus, the result, perhaps, of a criminal or innocent abortion, or to a perforated ulcer of stomach or intestine. ”

“ It is sound surgery, in dealing with abscesses, to find, if possible, the direction nature is taking to evacuate pus and be guided by this suggestion in evacuating a pus cavity.
In order to cure appendicitis you must remove the cause. Cutting off the appendix, opening an abscess, withholding food till the acute symptoms have passed; such treatment is not removing the cause. Nothing short of changing the eating habits of the patient will cure, so the surgeon who knows nothing about food and its action—what part improper eating has to do with bringing on the disease—will never be able to cure. ”

“ Pyæmia is closely allied to septicæmia. It is due to the setting free of bacterial emboli or septic emboli from a broken-down, septic thrombus in the neighborhood of the wound, and the circulation of these emboli in the blood until they are arrested and form the characteristic metastatic abscesses, especially in the lungs, joints, abdominal viscera, and parotid gland. Almost always the source of infection is an infected wound. Granulation does not prevent the occurrence of pyæmia, which, as a rule, commences at a later stage than septicæmia. ”

“ Effusion takes place into the cavity of the tunica vaginalis, and thereby the tumescence is still more increased, this tunic from its great dilatibility readily accommodating itself to the accumulation of fluid within. Sometimes the effusion is bloody, more generally serous, and not unfrequently composed of serum more or less tinged with blood. The epididymis remains enlarged longer than any other part, often during the remainder of life. Sickness, vomiting, and violent fever, attend the progress of the swelling. ”

“ Great swelling, with tension and acute tenderness, takes place; in fact, rapid inflammatory action is kindled in the infiltrated parts, and unhealthy abscesses form; the matter ultimately reaches the surface, but by that time ulceration or partial sloughing has taken place at the wounded part of the vessel; profuse and repeated hemorrhages take place, and are with difficulty controlled. The patient becomes weak and pale. The greater part of the forearm may become involved in the inflammation, terminating in infiltration of the cellular tissue, and the formation of diffuse abscesses. ”

“ PREFERRED ANTISEPTICS ANTISEPTIC SOLUTIONS
These are solutions used for the destruction of and to arrest the progress of microörganisms that have found their way into wounds—the cause of sepsis, as exhibited by fever, suppuration, and putrefaction. These preparations are called antiseptics and are used to render parts aseptic. They vary much in their destructive power, effect on tissue, and toxic properties. ”

“ Such an abscess is most distressing to a patient. It may become chronic, lasting for months, and its drainage is extremely difficult. Why should a simple operation, done in the flash of an eye, result in such injury? Some authorities have offered the explanation that pus is sucked down into the lung, and, recently, Schleuter and Weidlein have been able to reproduce such abscesses in animals. by putting small particles of tonsils into the blood stream. The particles become lodged in the lung arteries and there pro- duce abscesses like those seen in man after the removal of tonsils. ”

“ When pus is formed in a well-maintained system and tissue, the outer layer of the lymph is developed into a fibrous sac enclosing the liquid pus and constituting an abscess. In an unhealthy system, or when the inflammation depends on some injurious poison, like that of erysipelas, this sac may not be formed, and the pus, burrowing into and between different organs, destroys the connections and substance—diffuse suppuration. ”

“ When abscesses form about the ears, after peripneumonic affections, or depositions of matter take place in the inferior extremities and end in fistula, such persons recover. The following observations are to be made upon them: if the fever persist, and the pain do not cease, if the expectoration be not normal, and if the alvine discharges be neither bilious, nor free and unmixed; and if the urine be neither copious nor have its proper sediment, but if, on the other hand, all the other salutary symptoms be present, in such cases abscesses may be expected to take place. ”