Hematoma

“ Further, a hemorrhage during life is an active and not a [484] passive one; the blood is forced into the interspaces of the tissues in the vicinity of the wound, and is found infiltrated in the cellular tissue, the muscles, the sheaths of the vessels, etc. It is here incorporated, as it were, with the tissues so that it cannot be washed away. In an ante-mortem wound the arterial nature of the hemorrhage may show by the marks of the jets of blood about the wound or on the clothes or surrounding objects. ”

“ Would you bleed to arrest a hemorrhage from rupture? undoubtedly not; but you would bleed to check an active hemorrhage by exhalation, because by diminishing the mass of blood, you diminish the excess of organic sensibility which produces the hemorrhage; it is nearly the same as when we bleed for inflammation. It is certainly necessary that the hemorrhage should be stopped as it has been produced; it is necessary that the sensibility of the exhalants should return to its natural type before the blood ceases to flow. We do not bleed to draw the blood to another place, as has been said ”

“ It matters not what form of tumor presents itself for treatment, whether of the capillary variety, distinguishable in being of small size, flat or sessile, made up of the terminable branches of the arteries, the beginning of the veins and the capillaries which join them, punctated, granular surface with thin covering and likely to bleed on the least provocation, or the arterial hemorrhoid with the arteries and veins freely anastomosing, larger, and presenting the glazed appearance of a very ripe strawberry, liable to inflammation, erosion, prolapse and hemorrhage ”

“ If an artery is only _partly cut across_, the divided fibres of the tunica muscularis contract and those of the tunica externa retract, with the result that a more or less circular hole is formed in the wall of the vessel, from which free bleeding takes place, as the conditions are unfavourable for the formation of an occluding clot. Even if a clot does form, when the blood-pressure rises it is readily displaced, leading to reactionary haemorrhage. Should the wound become infected, secondary haemorrhage is specially liable to occur. ”

“ But serious, even fatal, hemorrhage sometimes occurs without the escape of any blood at all. Such are the so-called cases of concealed, occult, or internal hemorrhage, in which the nature of the malady is only suspected or recognized by the general symptoms attending the profuse loss of blood. Should the hemorrhage be gradual, anæmia slowly supervenes, with hydræmia and subcutaneous dropsy. Traube reports a fatal case of oedema of the glottis from such a cause. Sudden hemorrhage announces itself by pallor and prostration, dyspnoea, vertigo, and syncope. ”

“ The blood vessels of the lymph gland, greatly congested, contain almost exclusively red blood cells. As a rule, the lymph follicles and the lymph cords take little part in the process. If there is any change in these structures, it is a rarefication. Occasionally, hemorrhage is encountered in a follicle or even in a cord, and this hemorrhage may involve not only the cells of the cord, but its supporting reticular structure, and may form the nucleus of a subsequent necrotizing or suppurative focus. ”

“ When this bleeding is spontaneous it comes from the mucous membranes, especially from the nose, but also from the mouth, bowel and bronchial tubes. Slight bruises are apt to be followed by extravasations of blood into the tissues; the swollen joints (knee especially) of a bleeder are probably due, in the first instance, to the escape of blood into the joint cavity or synovial membrane. It is always from the smallest vessels that the blood escapes, and may do so in such quantities as to cause death in a few hours. ”

“ A slight exciting cause is all that is necessary to produce their rupture. The primary cause is the false membrane, and, in some cases, vascular granulations, which have rapidly formed, perhaps in twenty-four hours—conditions eminently favorable to the production of hemorrhage. In cancerous, tubercular, and dyscrasial conditions of the blood, the blood-vessels are especially weak and easily give way, owing to the defective nutritive properties of the blood itself, just as, in typhoid fever, we have nasal and intestinal hemorrhage, and in typhus, petechiæ. ”

“ Venous bleeding (from a vein) occurs as a steady even stream of dark blood, not affected by the heart beat.
(c) Capillary hemorrhage is in the form of a steady stream oozing from the raw surface of a tissue. The color is intermediary, as both arterial and venous capillaries contribute to it.
Nature’s Efforts to Control Hemorrhage. When an [Pg 52] artery is severed, the inner and middle coats immediately retract and curl up within the lumen, partially closing up the cut end. ”

“ A hemorrhagic tendency also occasionally occurs in affections of a different nature,—a trifling sore pouring out blood on the slightest touch. In some constitutions, leech-bites, trifling punctures, or the extraction of a tooth, have been followed by dangerous hemorrhage. The disposition very often exists in many members of the same family, and is sometimes hereditary. Great trouble has been experienced in staying the bleeding; large vessels have been tied without effect, and some patients have even perished notwithstanding every exertion on the part of the attendants. ”

“ When rupture of the tube into the peritoneal cavity occurs, the danger of fatal hemorrhage is very great. The majority of women die within forty-eight hours after this accident, unless relieved by immediate laparotomy. 318 There is no surrounding pressure to control the hemorrhage, as in the case of rupture into the broad ligament. Sometimes the escaping ovum plugs the rent in the tube, and bleeding is checked in this way.
If the woman survive the effects of hemorrhage, she may die from peritonitis or from suppuration of the hematocele in the peritoneal cavity. ”

“ If the strength admit of bloodletting, we are to abstract blood from the arm immediately and freely; but, if the patient be delirious and will not present his arm, or if there be apprehension of hemorrhage after the bleeding from the patient tearing his arm during the agitation of his delirium, we must open the straight vein in the forehead, and take away at once a sufficient quantity of blood. We are to use clysters [361] and injections of oil, or rose-oil with the juice of ptisan. When watchfulness prevails, we anoint the head with rose-oil, or with vinegar and rose-oil ”

“ Some extend but a little way beyond the subcutaneous cellular tissue, and are consequently attended with but slight bleeding; others penetrate to a greater depth, and occasion hemorrhage from a large vessel, or other alarming symptoms, by having reached some important organ; others, though not of so great a depth as the former, may still, on account of their mere extent, be accompanied with very considerable loss of blood from a number of small branches. It is seldom that fatal effects immediately follow external wounds ”

“ The hemorrhage in the greater number of these cases takes place slowly, and the effused blood depresses the brain by separating the dura mater from the neighboring bone—a process, however, which can hardly occur unless the injury has been so violent as to rupture its attachments to the bone; for the brain generally yields rather than the attachments of the dura mater, and is depressed, the hollow or cavity thus formed being filled up by the coagulum, which becomes thicker and thicker until insensibility is induced. ”

“ On the abdomen the hemorrhage is beneath the skin, causing raised lesions with a sharp border and a flattened top, feeling dense and firm to the touch. In the peritoneum the hemorrhages are extensive.
The constitutional symptoms in this severe form are typhoidal in character. The mind appears at ease, quietly passing into a comatose state. The countenance is pinched and sunken, and the skin is dusky and purplish. The eyes appear bloodshot and listless. The breathing is rapid and superficial. The delirium is of a quiet character, and death comes as a most welcome termination. ”

“ A tumor, properly injected, cannot inflame, because there is nothing to inflame, the circulation is stopped and thus it is as effectually strangulated as by a ligature, with the advantages of the immediate local anæsthetic, antiphlogistic, [17] auterant and antiseptic properties of carbolic acid. The base of attachment heals, while the dead tissue, which is rendered non-inflammatory and antiseptic, disintegrates and is thrown off between the third and fourth day, a process that fortifies against secondary hemorrhage. ”

“ In the irritable and sloughing state of stump alluded to, hemorrhages frequently take place from the small branches, or from the main trunks of the arteries, in consequence of ulceration; and it is not always easy to discover the bleeding vessel, or, when discovered, to secure it on the face of the stump; for as the ulcerative process has not ceased, and the end of the artery which is to be secured is not sound, no healthy action can take place; the ligature very soon cuts its way through, and the hemorrhage returns as violently as before, or some other branch gives way ”

“ When serum is effused, a pituitous or purulent expectoration alone takes place; when blood is discharged, a disease is produced which has been called hæmoptysis. An effusion of blood in the brain, brought on by the operation of general debility, has been called by Dr. Hoffman, with equal propriety, a hæmorrhage of the brain. The effusion of blood in the lungs, in consequence of the rupture of a blood-vessel, is less fatal than the same accident when it occurs in the brain, only because the blood in the former case is more easily discharged from the system. ”

“ The constitutional conditions that produce the tendency to hemorrhage are most important. In individuals of a debilitated condition, it results from the lack of a proper amount of fibrin in the blood. Where the blood becomes thin, or loses a large share of its red corpuscles, the individual is pale, and hemorrhages are frequent from the mucous surfaces of any portion of the body, the nasal mucous surface being especially liable to such attacks. ”

“ The right course is, I apprehend, to remove all the blood which can be evacuated by position, provided it can be done without danger to the patient, rather than to allow it to fill the chest; but as the bleeding vessel in the lung cannot readily be got at, if seen, nor be secured by ligature with advantage, it is advisable, if the bleeding continue, to close the wound, and allow the cavity of the pleura to be filled, until the lung shall be sufficiently com [422] pressed to cause the hemorrhage to cease, if the person survive so long. The first object is to save life ”

“ All hemorrhage of this kind, in women over thirty years of age, demands immediate and careful physical examination. Any bleeding from the vagina in a woman who has passed the menopause should arouse the gravest suspicion. From the slight hemorrhages just described the bleeding increases in intensity and duration, until there is a continuous loss of blood that saps the strength of the woman and produces the profound anemia characteristic 191 of the last stages of cancer of the cervix, Sudden fatal hemorrhage in this disease is rare. ”

“ Generally, however, untoward symptoms result sooner or later in such cases. Hemorrhage occurs from the injured part, and a clot protrudes from the external wound. Or the cerebral substance in the neighbourhood of the wound softens, and becomes converted into a semifluid mass, often mixed with pus; and a fungous growth,233 connected with the disorganised matter, gradually protrudes through the aperture in the cranium, and is repressed with difficulty. If removed by knife or ligature, it is rapidly reproduced. Pressure is the only means left by which to attempt its retardation ”

“ In arresting haemorrhage temporarily the chief thing is to press directly on the bleeding part. The pressure to be effectual need not be severe, but must be accurately applied. If the bleeding point cannot be reached, the pressure should be applied to the main artery between the bleeding point and the heart. In small blood-vessels pressure will be sufficient to arrest haemorrhage permanently. In large vessels it is usual to pass a ligature round the vessel and tie it with a reef-knot. Apply the ligature, if possible, at the bleeding point, tying both ends of the cut vessel. ”

“ PATHOLOGICAL ANATOMY.—Blood is found coagulated to a greater or less degree in the pleural cavity, and the lesion producing the hæmothorax can generally be found; the remains of blood may be found even after it has been some time effused. If the hemorrhage does not prove fatal, it may all be absorbed, or it may by its presence cause local inflammation of the pleural membrane. ”

“ During life they are frequently mistaken for subperiosteal hemorrhages.
Less frequently there are hemorrhages into the internal organs. These, however, play a comparatively insignificant rôle in the symptomatology of this disease. At postmortem examination we find numerous hemorrhages of the pleura, pericardium and peritoneum, which rarely produce symptoms during life. Still records a case with marked abdominal pain and swelling, which he believed to have been due to hemorrhage into the wall of the intestine. ”

“ After hemorrhage from a wound made during life the veins are empty about the wound, especially those situated centripetally, while normally after death the blood is mostly aggregated in the veins. They are the source of post-mortem hemorrhage, but do not empty themselves to any great extent.
The hemorrhage from a wound made after death may be extensive if the blood remains fluid as in the cases mentioned above, i.e., after death from drowning or asphyxia or after the commencement of putrefaction. ”