HEMORRHAGE.
The treatment of all internal hemorrhages may be carried out on the lines laid down in the preceding article on Ilainoptysis. When the bleeding is due to rupture of a vessel in the stomach, the agents mentioned under Iliematemesis are admissible; the question of surgical interference is discussed under Gastric Ulcer. Intestinal haemorrhage is usually due to duodenal ulcer, and its treatment will he found detailed under its own subheading. Tuberculous ulceration of the bowel when causing severe haemorrhage must be met by internal h;emostatics when laparotomy is contra-indicated. The occurring during typhoid fever will be dealt with under the name of the primary disease. I I mnorrhage from the urinary tract has its treatment discussed in the article on ILematuria. Under I liemophilia, Lpistaxis, Synovitis, lizematocele, the treatment of other forms of bleeding will be found. Ilxmorrhage into the peritoneal cavity can only be treated by laparotomy and the surgical procedures indicated in each case.
The treatment of external haemorrhage when this is severe will include the use of all the internal or constitutional remedies indicated in internal bleeding- viz., saline solution, gelatin solution, lime salts given by the rectum, veins, or by hypodermic injection—together with such agents as ligatures to the limbs, blood transfusion and remedies to combat shock.
Accidental external Iliemorrhage must be promptly arrested by occlu of the severed vessels, but as this is not always possible at the moment pressure applied by the fingers over a pad of lint is often sufficient to stop it for the time, and when long continued the mouth of the divided vessel may become sealed up by a clot, so that further interference may be un necessary when the artery is it small one or where the severed vessel is a vein: the elevation of clue part materially assists in the control of the liamiorrhage.
In bleeding from a large vessel a tourniquet should be extemporised, whilst digital pressure is maintained over the trunk of the main vessel on its proximal side; a bandage being loosely applied in the neighbourhood of the finger-tips, this may he tightly twisted by inserting a piece of stick so as to ligature the limb, a firm pad of lint being placed over the vessel as the fingers are withdrawn. Afterwards, as soon as instrumental aids are procurable, the wound should be opened up, thoroughly cleansed, and the vessel ligatured with silk or catgut, or its lumen may be closed by torsion. Should the artery or vein he only partially divided without being severed, it must be cut across and the vessel ligatured. When an artery has been severed in the middle of a wound, it will be necessary to ligature both its distal and proximal ends.
Where the vessel cannot he easily isolated for ligaturing, acupressure may be employed by compressing it between the tissues and a hare-lip pin with a figure-of-eight ligature. lImmorrhage from wounds of the scalp or mesentery may be controlled by simply involving the bleeding, vessel in a stout suture which, when tied, will stop the flow of blood above the cut extremity.
The cautery at a dull red heat may be passed over the bleeding surface when several small vessels are spouting which cannot he seized by forceps, but such a procedure prevents primary union.
Normal horse serum may be used as a local application in, for example, epistaxis where it can be used on the bleeding-point, or it may he injected subcutaneously or intramuscularly where this is not possible, as in gastric haemorrhage.
Styptics are only to be used under similar circumstances, and Adrenalin solution is the one generally employed. Water at a temperature of is a very efficient hremostatic when directly applied to oozing surfaces. Puff Ball is also most efficacious, but it cannot be easily sterilised. A corrosive liquid like Perchloride of Iron should never be employed as a styptic to aseptic wounds, as it destroys the tissues and produces a superficial slough or eschar; it may, however, be advantageously used to plug the cavity from which a tooth has been extracted. As routine styptics for minor fresh wounds Friar's Balsam and rectified Oil of Turpentine are most convenient and reliable, being antiseptic in their action.
The prevention of primary limorrhage in surgical operations may be carried out by digital compression, by a tourniquet, Esmarch's bloodless method, or in some cases by the application of a ligature to the main vessel supplying the part, as to the subclavian or external iliac arteries when amputation is to be performed at the shoulder or hip joint. This ligature may be a permanent or temporary one, or a clamp or steel skewer may be employed to compress the vessel. It is possible in thin subjects completely to control the haemorrhage in the lower extremities by power fully curving the spine anteriorly with a firm object placed behind the vertebral spines, the patient's thighs being permitted to hang over the edge of the operating table as firm pressure is made on the abdominal aorta by the clenched hand of a reliable assistant, the artery being powerfully compressed against the prominent bodies of the lumbar vertebra- below the umbilical region. Minor operations may be rendered bloodless by the use of the infiltration anmsthesia method, or by combining infiltration with a weak solution of adrenalin.
In secondary hi•morrhage, the cause being almost invariably due to some septic change interfering with the reparative process in the occluded cr ligatured vessels, the best routine procedure is to open up the wound, thoroughly cleanse it with a hot solution of an unirritating antiseptic solution, and plug it firmly with iodoform gauze. Should a large vessel be suspected to be leaking, the main vessel should be ligatured through a wound made under strict aseptic precautions at some distance above the site of the primary operation.
The treatment of the resulting acute amemia following hemorrhage will be found in the article on Anaemia.