Hemorrhage

“ 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 ”

“ 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 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. ”

“ When a rather free hemorrhage occurs at a part of the body where there are no nerve trunks and no muscles,—as on the forehead or at the top of the head,—the simplest plan is to apply a cup at some little distance from the source of the bleeding and thus divert the current of the blood from the spot affected. ”

“ There are only four ways of arresting arterial [Pg 126] hemorrhage. First, by cautery; second, by division of the artery, when that is not complete—for then the extremities contract and the blood clots—or by a ligature, or by the application of substances which arrest blood flow, aided by a compressive bandage. Other means are inefficient, and seldom and, at most, accidentally successful. His instruction for first aid to the injured in case of hemorrhage in the absence of the physician, is to apply pressure directly upon the wound itself. ”

“ 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. ”

“ These post-mortem hemorrhages are passive and not active, consequently there is less infiltration of blood into the surrounding tissues, which merely imbibe it, and the stain is less deep and may be washed off the edges of the wound, in contrast to the stain of ante-mortem wounds. After putrefaction has set in the hemorrhage may be more abundant, as the blood is driven to the surface by the formation of gas in the abdomen and thorax. ”

“ In wounds, hemorrhage is the symptom which most alarms the bystanders, and which demands immediate attention; but, to operate successfully, the surgeon must divest himself of all fear, and learn to look boldly on the open and bleeding mouths of arteries. ”

“ 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. ”

“ How are we to ascertain whether a person has died from hemorrhage? This may be more difficult in the case of an open wound, for the body may have been moved from the spot where it lay after the wound was received, and the blood on the body, clothes, and surrounding objects may have been removed. ”

“ SYMPTOMS.—The symptoms are those of perforation into the chest—sudden intense pain on the diseased side, with internal hemorrhage, great pallor, feeble circulation, cold extremities, and syncope. Patients often die in a few minutes. If the hemorrhage is moderate in quantity, they revive and the circulation returns, but they complain of feelings of suffocation and oppression. Slowly the general strength returns and the patient recovers. ”

“ In the cure of hemorrhage, if it be active, that is to say, connected with a state of strong tonic contractility of the blood-vessels, a very different remedy will be required as an astringent, than in cases of passive hemorrhage, in which the vascular fibres are in a state of relaxation or collapse. ”

“ If the wound is seen very shortly after its infliction, hemorrhage is in progress, and the divided arteries show their position by their individual, intermittent jets of blood. The severity of incised wounds depends upon the amount of hemorrhage, which is greater the deeper and larger the wound, and the more vascular the tissues in which it occurs, especially if large and important vessels are concerned. ”

“ 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. ”

“ There may be little blood in and about the wound, but it collects in the right iliac region or in the pelvis and is not wholly coagulated. Unless the wound or rupture involves the vena cava, portal vein, or a large branch of either of these, the hemorrhage is apt to be slow and the [583] victim may survive hours or even days, except for active exertion or repeated violence. Two cases illustrating the slowness of the hemorrhage have occurred in Guy’s Hospital. In one [680] the man, showing no urgent symptoms at the time, was sent away, and died a few hours later in a police-station. ”

“ If the wound was in a very vascular part and of some size, or if a large vessel or many moderately large vessels were divided and the vessels, especially the veins in the neighborhood, are empty, then we may be quite sure of death from hemorrhage. ”

“ The introduction of a fine hypodermic needle enables us to be certain of the nature of the fluid.
The PROGNOSIS is always serious. If the cause of the hemorrhage is the bursting of an aneurism, death supervenes in a short time. Hæmothorax, when caused by penetrating wounds, unless they produce hemorrhage, is not necessarily serious. The blood may entirely disappear in a few weeks. ”

“ It is obvious, then, that it is only when nature has not been interfered with, and the patient has not died from bleeding continued to the last moment, but has, on the contrary, lived some time after the hemorrhage has ceased, that the processes by which its suppression has been accomplished can be fairly investigated. ”

“ 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 source of hemorrhage from gastric ulcer is from blood-vessels either in the stomach itself or in the neighborhood of the stomach. Hemorrhages slight or of moderate severity occur from the capillaries and small arteries and veins in the mucous and submucous coats. Sometimes profuse and even fatal hemorrhage comes from arteries or from veins in the submucous coat, especially when these vessels are dilated. Quickly-fatal hemorrhages take place from the large vessels between the muscular and the serous coats, particularly from the main trunks on the curvatures. ”

“ In the treatment of hemorrhages, the Indians pursue a very rational mode of treatment. If a severe hemorrhage follow a wound, which is not unfrequently the case, they plunge themselves into cold water, thereby producing a constriction upon the bleeding vessels. We all know by experience the efficacy of cold to arrest bleeding at the nose. ”

“ If the characters of the hemorrhage and the clotting are still more like those normal to a wound inflicted during life, then, as a rule, it is impossible to say from these two features of the wound, hemorrhage and clotting, whether the wound was inflicted during life or a very short time after death. ”

“ When loss of blood occurs without the lung being wounded, the hemorrhage is probably proceeding from a wound of one of the intercostal arteries, which has been torn by the sharp ends of fractured bone. ”

“ From Bleeding, at least in the{174} London registers, there is petty spoliation. Pulmonary hemorrhage is more frequently the consumptive precursor. Malign omens are an eruptive torrent; ulceration in the lungs; fever renewed; pain in the breast; difficulty of breathing; cough, hoarseness; night sweats; peripneumony; visceral obstructions; cachexy; old age; relapses. But pulmonary hemorrhage from temporary obstructions of the menses, or in pregnancy, or periodical, or without load in the thorax, or fever, are much less mischievous. ”

“ 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. ”

“ The vitality of the injured surface is generally destroyed at once, whence bleeding seldom occurs, even after whole limbs have been shot away; in some cases, however, hemorrhage is profuse, as when a large artery has been wounded by small shot. The effects on the system are extremely various; some persons are affected with tremors, anxiety, and depression from slight wounds; while the most severe injuries are often unaccompanied by any disturbance of the nerves. ”

“ 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 ”

“ If the amount lost be excessive, death results from the diminution in the total volume of blood and general lowering of the arterial pressure. If the hemorrhage is sudden and profuse, as from a large vessel, the loss of four or five pounds of blood, or even less, may be sufficient to induce fatal syncope. In hemorrhage into the pleura or peritoneum from rupture of aneurisms, etc., it is rare to meet with more than three or four pounds of clot and serum ”

“ Applications of heat and cold are common methods of checking [Pg 122] hemorrhages, heat being at all times preferable. Hot water poured on open wounds will encourage coagulation. Bleeding from an ulcer of the leg, which often results from varicose veins, should be stopped by firm pressure over the wound.
Hemorrhage from the Lungs.—A teaspoonful of salt taken internally may stop it. Place an ice-bag over the chest. Morphin, gr. 1⁄8-1⁄4, may be given under the instructions of a physician. In all cases put patient in bed and enjoin complete rest until medical aid arrives. ”

“ The blood in bleeder cases is, as a rule, normal, so far as our present means of investigation enable us to decide. When a hemorrhage has continued for some time, it is thin and watery, but at the beginning of the bleeding the blood is usually rich in corpuscles and fibrin and coagulates firmly. ”

“ Primary hemorrhage.—Primary hemorrhage of a serious nature from gunshot wounds does not often come within the sphere of the surgeon’s observation. If hemorrhage occur from one of the main arteries, it probably proves rapidly fatal; and surgeons, after an action, are usually too much occupied with the urgent necessities of the living wounded to spare time for examining the wounds of the dead, who are mostly buried on the field where they fall. Thus most surgeons speak of primary hemorrhage being exceedingly rare, more rare, perhaps, than it actually is. ”

“ Pressure over the surface of the wound is the most convenient method of Controlling haemorrhage in most cases. Whenever possible, the part should be bandaged heavily with clean cheese cloth or muslin. Before applying the bandage, it is advisable to cover the wound with a piece of sterile absorbent cotton that is well dusted with boric acid. Hemorrhage from wounds that cannot be bandaged may be temporarily stopped by pressure with the hand, or, better, by packing the wound with absorbent cotton and holding this in place with sutures. ”