Injuries of Veins

Gunshot Wounds of Blood Vessels.—In the majority of cases injuries of large vessels are associated with an external wound; the profusion of the bleeding indicates the size of the damaged vessel, and the colour of the blood and the nature of the flow denote whether an artery or a vein is implicated.

When an artery is wounded a firmhæmatomamay form, with an expansile pulsation and a palpable thrill—whether such a hæmatoma remains circumscribed or becomes diffuse depends upon the density or laxity of the tissues around it. In course of time atraumatic arterial aneurysmmay develop from such a hæmatoma.

When an artery and its companion vein are injured simultaneously anarterio-venous aneurysm(p. 310) may develop. This frequently takes place without the formation of a hæmatoma as the arterial blood finds its way into the vein and so does not escape into the tissues. Even if a hæmatoma forms it seldom assumes a great size. In time a swelling is recognised, with a palpable thrill and a systolic bruit, loudest at the level of the communication and accompanied by a continuous venous hum.

If leakage occurs into the tissues, the extravasated blood may occlude the vein by pressure, and the symptoms of arterial aneurysm replace those of the arterio-venous form, the systolic bruit persisting, while the venous hum disappears.

Gangrenemay ensue if the blood supply is seriously interfered with, or the signs ofischæmiamay develop; the muscles lose their elasticity, become hard and paralysed, and anæsthesia of the “glove” or “stocking” type, with other alterations of sensation ensue. Apart from ischæmia,reflex paralysisof motion and sensation of a transient kind may follow injury of a large vessel.

Treatmentis carried out on the same lines as for similar injuries due to other causes.

Veins are subject to the same forms of injury as arteries, and the results are alike in both, such variations as occur being dependent partly on the difference in their anatomical structure, and partly on the conditions of the circulation through them.

Subcutaneous ruptureof veins occur most frequently in association with fractures and in the reduction of dislocations. The veins most commonly ruptured are the popliteal, the axillary, the femoral, and the subclavian. On account of the smaller amount of elastic and muscular tissue in the wall of a vein, the contraction and retraction of its walls are less than in an artery, and so bleeding may continue for a longer period. On the other hand, owing to the lower blood-pressure the outflow goes on more slowly, and the gradually increasing pressure produced by the extravasated blood is usually sufficient to arrest the hæmorrhage before it becomes serious. As an aid in diagnosing the source of the bleeding, it should be remembered that the rupture of a vein does not affect the pulsation in the limb beyond. The risks are practically the same as when an artery is ruptured, excepting that of aneurysm, and the treatment is carried out on the same lines, but it is seldom necessary to operate for the purpose of applying a ligature to the injured vein.

Woundsof veins—punctured and incised—frequently occur in the course of operations; for example, in the removal of tumours or diseased glands from the neck, the axilla, or the groin. They are also met with as a result of accidental stabs and of suicidal or homicidal injuries. The hæmorrhage from a large vein so damaged is usually profuse, but it is more readily controlled by external pressure than that from an artery. When a vein is merely punctured, the bleeding may be arrested by pressure with a pad of gauze, or by a lateral ligature—that is, picking up the margins of the rent in the wall andsecuring them with a ligature without occluding the lumen. In the large veins, such as the internal jugular, the femoral, or the axillary, it is usually possible to suture the opening in the wall. This does not necessarily result in thrombosis in the vessel, or in obliteration of its lumen.

When anartery and vein are simultaneously wounded, the features peculiar to each are present in greater or less degree. In the limbs gangrene may ensue, especially if the wound is infected. Punctured and gun-shot wounds implicating both artery and vein are liable to be followed by the development of arterio-venous aneurysm.

Entrance of Air into Veins—Air Embolism.—This serious, though fortunately rare, accident is apt to occur in the course of operations in the region of the thorax, neck, or axilla, if a large vein is opened and fails to collapse on account of the rigidity of its walls, its incorporation in a dense fascia, or from traction being made upon it. If the wound in a vein is thus held open, the negative pressure during inspiration sucks air into the right side of the heart. This is accompanied by a hissing or gurgling sound, and with the next expiration some frothy blood escapes from the wound. The patient instantly becomes pale, the pupils dilate, respiration becomes laboured, and although the heart may continue to beat forcibly, the peripheral pulse is weak, and may even be imperceptible. On auscultating the heart, a churning sound may be heard. Death may result in a few minutes; or the heart may slowly regain its power and recovery take place.

Prevention.—In operations in the “dangerous area”—as the region of the root of the neck is called in this connection—care must be taken not to cut or divide any vein before it has been secured by forceps, and to apply ligatures securely and at once. Deep wounds in this region should be kept filled with normal salt solution. Immediately a cut is recognised in a vein, a finger should be placed over the vessel on the cardiac side of the wound, and kept there until the opening is secured.

Treatment.—Little can be done after the air has actually entered the vein beyond endeavouring to maintain the heart's action by hypodermic injections of ether or strychnin and the application of mustard or hot cloths over the chest. The head at the same time should be lowered to prevent syncope. Attempts to withdraw the air by suction, and the employment of artificial respiration, have proved futile, and are, by some, considered dangerous. In a desperate case massage of the heart might be tried.

Primary Hæmorrhage.—The term primary hæmorrhage is applied to the bleeding which follows immediately on the wounding of a blood vessel. The natural process by which such hæmorrhage is arrested varies with the character of the wound in the vessel and may be modified by accidental circumstances.

(a)Repair of completely divided Artery.—When an artery iscompletelydivided, the circular fibres of the muscular coat contract, so that the lumen of the cut ends is diminished, and at the same time each segment retracts within its sheath in virtue of the recoil of the elastic elements in its walls, the tunica intima curls up in the interior of the vessel, and the tunica externa collapses over the cut ends. The blood that escapes from the injured vessel fills the interstices of the tissues, and, coagulating, forms a clot which temporarily arrests the bleeding. That part of the clot which lies between the divided ends of the vessel and in the cellular tissue outside, is known as theexternal clot, while the portion which projects into the lumen of the vessel is known as theinternal clot, and it usually extends as far as the nearest collateral branch. These processes constitute what is known as thetemporary arrest of hæmorrhage, which, it will be observed, is effected by the contraction and retraction of the divided artery and by clotting.

Thepermanent arresttakes place by the transformation of the clot into scar tissue. The internal clot plays the most important part in the process; it becomes invaded by leucocytes and proliferating endothelial and connective-tissue cells, and new blood vessels permeate the mass, which is thus converted into granulation tissue. This is ultimately replaced by fibrous tissue, which permanently occludes the end of the vessel. Concurrently and by the same process the external clot is converted into scar tissue.

If a divided artery isligated at its cut end, the tension of the ligature is usually sufficient to rupture the inner and middle coats, which curl up within the lumen, the outer coat alone being held in the grasp of the ligature. An internal clot forms and, becoming organised, permanently occludes the vessel as above described. The ligature and the small portion of vessel beyond it are subsequently absorbed.

In course of time the collateral branches of the vessel above and below the level of section enlarge and their inter-communicationbecomes more free, so that even when large trunks have been divided the vascular supply of the parts beyond may be completely restored. This is known as the development of thecollateral circulation.

Imperfect Collateral Circulation.—While the development of the collateral circulation after the ligation or obstruction from other cause of a main arterial trunk may be sufficient to prevent gangrene of the limb, it may be insufficient for its adequate nourishment; it may be cold, bluish in colour, and there may be necrosis of the skin over bony points; this is notably the case in the lower extremity after ligation of the femoral or popliteal artery, when patches of skin may die over the prominence of the heel, the balls of the toes, the projecting base of the fifth metatarsal and the external malleolus.

If, during the period of reaction, the blood-pressure rises considerably, the occluding clot at the divided end of the vessel may be washed away or the ligature displaced, permitting of fresh bleeding taking place—reactionaryorintermediary hæmorrhage(p. 272).

In the event of the wound becoming infected with pyogenic organisms, the occluding blood-clot or the young fibrous tissue may become disintegrated in the suppurative process, and the bleeding start afresh—secondary hæmorrhage(p. 273).

(b) If an artery is onlypartly 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 hæmorrhage. Should the wound become infected, secondary hæmorrhage is specially liable to occur. A further risk attends this form of injury, in that the intra-vascular tension may in time lead to gradual stretching of the scar tissue which closes the gap in the vessel wall, with the result that a localised dilatation or diverticulum forms, constituting atraumatic aneurysm.

(c) When the injury merely takes the form of apunctureorsmall incisiona blood-clot forms between the edges, becomes organised, and is converted into cicatricial tissue which seals the aperture. Such wounds may also be followed by reactionary or secondary hæmorrhage, or later by the formation of a traumatic aneurysm.

Conditions which influence the Natural Arrest of Hæmorrhage.—The natural arrest of bleeding is favoured by tearing orcrushing of the vessel walls, owing to the contraction and retraction of the coats and the tendency of blood to coagulate when in contact with damaged tissue. Hence the primary hæmorrhage following lacerated wounds is seldom copious. The occurrence of syncope or of profound shock also helps to stop bleeding by reducing the force of the heart's action.

On the other hand, there are conditions which retard the natural arrest. When, for example, a vessel is only partly divided, the contraction and retraction of the muscular coat, instead of diminishing the calibre of the artery, causes the wound in the vessel to gape; by completing the division of the vessel under these circumstances the bleeding can often be arrested. In certain situations, also, the arteries are so intimately connected with their sheaths, that when cut across they were unable to retract and contract—for example, in the scalp, in the penis, and in bones—and copious bleeding may take place from comparatively small vessels. This inability of the vessels to contract and retract is met with also in inflamed and œdematous parts and in scar tissue. Arteries divided in the substance of a muscle also sometimes bleed unduly. Any increase in the force of the heart's action, such as may result from exertion, excitement, or over-stimulation, also interferes with the natural arrest. Lastly, in bleeders, there are conditions which interfere with the natural arrest of hæmorrhage.

Repair of a Vessel ligated in its Continuity.—When a ligature is applied to an artery it should be pulled sufficiently tight to occlude the lumen without causing rupture of its coats. It often happens, however, that the compression causes rupture of the inner and middle coats, so that only the outer coat remains in the grasp of the ligature. While this weakens the wall of the vessel, it has the advantage of hastening coagulation, by bringing the blood into contact with damaged tissue. Whether the inner and middle coats are ruptured or not, blood coagulates both above and below the ligature, the proximal clot being longer and broader than that on the distal side. In small arteries these clots extend as far as the nearest collateral branch, but in the larger trunks their length varies. The permanent occlusion of those portions of the vessel occupied by clot is brought about by the formation of granulation tissue, and its replacement by cicatricial tissue, so that the occluded segment of the vessel is represented by a fibrous cord. In this process the coagulum only plays a passive rôle by forming a scaffolding on which the granulation tissue is built up. The ligature surrounding the vessel, and the elements of the clot, are ultimately absorbed.

Repair of Veins.—The process of repair in veins is the same as that in arteries, but the thrombosed area may become canalised and the circulation through the vessel be re-established.

The management of the hæmorrhage which accompanies an operation includes (a) preventive measures, and (b) the arrest of the bleeding.

Prevention of Hæmorrhage.—Whenever possible, hæmorrhage should be controlled bydigital compressionof the main artery supplying the limb rather than by a tourniquet. If efficiently applied compression reduces the immediate loss of blood to a minimum, and the bleeding from small vessels that follows the removal of the tourniquet is avoided. Further, the pressure of a tourniquet has been shown to be a material factor in producing shock.

In selecting a point at which to apply digital compression, it is essential that the vessel should be lying over a bone which will furnish the necessary resistance. The common carotid, for example, is pressed backward and medially against the transverse process (carotid tubercle) of the sixth cervical vertebra; the temporal against the temporal process (zygoma) in front of the ear; and the facial against the mandible at the anterior edge of the masseter.

In the upper extremity, the subclavian is pressed against the first rib by making pressure downwards and backwards in the hollow above the clavicle; the axillary and brachial by pressing against the shaft of the humerus.

In the lower extremity, the femoral is controlled by pressing in a direction backward and slightly upward against the brim of the pelvis, midway between the symphysis pubis and the anterior superior iliac spine.

The abdominal aorta may be compressed against the bodies of the lumbar vertebræ opposite the umbilicus, if the spine is arched well forwards over a pillow or sand-bag, or by the method suggested by Macewen, in which the patient's spine is arched forwards by allowing the lower extremities and pelvis to hang over the end of the table, while the assistant, standing on a stool, applies his closed fist over theabdominalaorta and compresses it against the vertebral column. Momburg recommends an elastic cord wound round the body between the iliac crest and the lower border of the ribs, but this procedure has caused serious damage to the intestine.

When digital compression is not available, the most convenient and certain means of preventing hæmorrhage—say in an amputation—is by the use of some form oftourniquet, such as the elastic tube of Esmarch or of Foulis, or an elastic bandage, or the screw tourniquet of Petit. Before applying any of these it is advisable to empty the limb of blood. This is best done after the manner suggested by Lister: the limb is held vertical for three or four minutes; the veins are thus emptied by gravitation, and they collapse, and as a physiological result of this the arteries reflexly contract, so that the quantity of blood entering the limb is reduced to a minimum. With the limb still elevated the tourniquet is firmly applied, a part being selected where the vessel can be pressed directly against a bone, and where there is no risk of exerting injurious pressure on the nerve-trunks. The tourniquet should be applied over several layers of gauze or lint to protect the skin, and the first turn of the tourniquet must be rapidly and tightly applied to arrest completely the arterial flow, otherwise the veins only are obstructed and the limb becomes congested. In the lower extremity the best place to apply a tourniquet is the middle third of the thigh; in the upper extremity, in the middle of the arm. A tourniquet should never be applied tighter or left on longer than is absolutely necessary.

The screw tourniquet of Petit is to be preferred when it is desired to intermit the flow through the main artery as in operations for aneurysm.

When a tourniquet cannot conveniently be applied, or when its presence interferes with the carrying out of the operation—as, for example, in amputations at the hip or shoulder—the hæmorrhage may be controlled by preliminary ligation of the main artery above the seat of operation—for instance, the external iliac or the subclavian. For such contingencies also the steel skewers used by Spence and Wyeth, or a special clamp or forceps, such as that suggested by Lynn Thomas, may be employed. In the case of vessels which it is undesirable to occlude permanently, such as the common carotid, the temporary application of a ligature or clamp is useful.

Arrest of Hæmorrhage.—Ligature.—This is the best means of securing the larger vessels. The divided vessel having been caught with forceps as near to its cut end as possible, a ligature of catgut or silk is tied round it. When there is difficulty in applying a ligature securely, for example in a dense tissue like the scalp or periosteum, or in a friable tissue like the thyreoid gland or the mesentery, a stitch should be passed so as tosurround the bleeding vessel a short distance from its end, in this way ensuring a better hold and preventing the ligature from slipping.

If the hæmorrhage is from a partly divided vessel, this should be completely cut across to enable its walls to contract and retract, and to facilitate the application of forceps and ligatures.

Torsion.—This method is seldom employed except for comparatively small vessels, but it is applicable to even the largest arteries. In employing torsion, the end of the vessel is caught with forceps, and the terminal portion twisted round several times. The object is to tear the inner and middle coats so that they curl up inside the lumen, while the outer fibrous coat is twisted into a cord which occludes the end of the vessel.

Forci-pressure.—Bleeding from the smallest arteries and from arterioles can usually be arrested by firmly squeezing them for a few minutes with artery forceps. It is usually found that on the removal of the forceps at the end of an operation no further hæmorrhage takes place. By the use of specially strong clamps, such as the angiotribes of Doyen, large trunks may be occluded by pressure.

Cautery.—The actual cautery or Paquelin's thermo-cautery is seldom employed to arrest hæmorrhage, but is frequently useful in preventing it, as, for example, in the removal of piles, or in opening the bowel in colostomy. It is used at a dull-red heat, which sears the divided ends of the vessel and so occludes the lumen. A bright-red or a white heat cuts the vessel across without occluding it. The separation of the slough produced by the charring of the tissues is sometimes attended with secondary bleeding.

HæmostaticsorStyptics.—The local application of hæmostatics is seldom to be recommended. In the treatment of epistaxis or bleeding from the nose, of hæmorrhage from the socket of a tooth, and sometimes from ulcerating or granulating surfaces, however, they may be useful. All clots must be removed and the drug applied directly to the bleeding surface. Adrenalin and turpentine are the most useful drugs for this purpose.

Hæmorrhage from bone, for example the skull, may be arrested by means of Horsley's aseptic plastic wax. To stop persistent oozing from soft tissues, Horsley successfully applied a portion of living vascular tissue, such as a fragment of muscle, which readily adheres to the oozing surface and yields elements that cause coagulation of the blood by thrombo-kinetic processes.When examined after two or three days the muscle has been found to be closely adherent and undergoing organisation.

Arrest of Accidental Hæmorrhage.—The most efficient means of temporarily controlling hæmorrhage is by pressure applied with the finger, or with a pad of gauze, directly over the bleeding point. While this is maintained an assistant makes digital pressure, or applies a tourniquet, over the main vessel of the limb on the proximal side of the bleeding point. A usefulemergency tourniquetmay be improvised by folding a large handkerchiefen cravatte, with a cork or piece of wood in the fold to act as a pad. Thehandkerchiefis applied round the limb, with the pad over the main artery, and the ends knotted on the lateral aspect of the limb. With a strong piece of wood the handkerchief is wound up like a Spanish windlass, until sufficient pressure is exerted to arrest the bleeding.

When hæmorrhage is taking place from a number of small vessels, its arrest may be effected by elevation of the bleeding part, particularly if it is a limb. By this means the force of the circulation is diminished and the formation of coagula favoured. Similarly, in wounds of the hand or forearm, or of the foot or leg, bleeding may be arrested by placing a pad in the flexure and acutely flexing the limb at the elbow or knee respectively.

ReactionaryHæmorrhage.—Reactionaryor intermediary hæmorrhage is really a recurrence of primary bleeding. As the name indicates, it occurs during the period of reaction—that is, within the first twelve hours after an operation or injury. It may be due to the increase in the blood-pressure that accompanies reaction displacing clots which have formed in the vessels, or causing vessels to bleed which did not bleed during the operation; to the slipping of a ligature; or to the giving way of a grossly damaged portion of the vessel wall. In the scrotum, the relaxation of the dartos during the first few hours after operation occasionally leads to reactionary hæmorrhage.

As a rule, reactionary hæmorrhage takes place from small vessels as a result of the displacement of occluding clots, and in many cases the hæmorrhage stops when the bandages and soaked dressings are removed. If not, it is usually sufficient to remove the clots and apply firm pressure, and in the case of a limb to elevate it. Should the hæmorrhage recur, the wound must be reopened, and ligatures applied to the bleeding vessels. Douching the wound with hot sterilised water (about 110° F.),and plugging it tightly with gauze, are often successful in arresting capillary oozing. When the bleeding is more copious, it is usually due to a ligature having slipped from a large vessel such as the external jugular vein after operations in the neck, and the wound must be opened up and the vessel again secured. The internal administration of heroin or morphin, by keeping the patient quiet, may prove useful in preventing the recurrence of hæmorrhage.

Secondary Hæmorrhage.—The term secondary hæmorrhage refers to bleeding that is delayed in its onset and is due to pyogenic infection of the tissues around an artery. The septic process causes softening and erosion of the wall of the artery so that it gives way under the pressure of the contained blood. The leakage may occur in drops, or as a rush of blood, according to the extent of the erosion, the size of the artery concerned, and the relations of the erosion to the surrounding tissues. When met with as a complication of a wound there is an interval—usually a week to ten days—between the receipt of the wound and the first hæmorrhage, this time being required for the extension of the septic process to the wall of the artery and the consequent erosion of its coats. When secondary hæmorrhage occurs apart from a wound, there is a similar septic process attacking the wall of the artery from the outside; for example in sloughing sore-throat, the separation of a slough may implicate the wall of an artery and be followed by serious and it may be fatal hæmorrhage. The mechanical pressure of a fragment of bone or of a rubber drainage tube upon the vessel may aid the septic process in causing erosion of the artery. In pre-Listerian days, the silk ligature around the artery likewise favoured the changes that lead to secondary hæmorrhage, and the interesting observation was often made, that when the collateral circulation was well established, the leakage occurred on thedistalside of the ligature. While it may happen that the initial hæmorrhage is rapidly fatal, as for example when the external carotid or one of its branches suddenly gives way, it is quite common to have one, two or morewarning hæmorrhagesbefore the leakage on a large scale, which is rapidly fatal.

Theappearances of the woundin cases complicated by secondary hæmorrhage are only characteristic in so far that while obviously infected, there is an absence of all reaction; instead of frankly suppurating, there is little or no discharge and the surrounding cellular tissue and the limb beyond are œdematous and pit on pressure.

Thegeneral symptomsof septic poisoning in cases of secondary hæmorrhage vary widely in severity: they may be so slight that the general health is scarcely affected and the convalescence from an operation, for example, may be apparently normal except that the wound does not heal satisfactorily. For example, a patient may be recovering from an operation such as the removal of an epithelioma of the mouth, pharynx or larynx and the associated lymph glands in the neck, and be able to be up and going about his room, when, suddenly, without warning and without obvious cause, a rush of blood occurs from the mouth or the incompletely healed wound in the neck, causing death within a few minutes.

On the other hand, the toxæmia may be of a profound type associated with marked pallor and progressive failure of strength, which, of itself, even when the danger from hæmorrhage has been overcome, may have a fatal termination. Theprognosistherefore in cases of secondary hæmorrhage can never be other than uncertain and unfavourable; the danger from loss of bloodper seis less when the artery concerned is amenable to control by surgical measures.

Treatment.—The treatment of secondary hæmorrhage includes the use of local measures to arrest the bleeding, the employment of general measures to counteract the accompanying toxæmia, and when the loss of blood has been considerable, the treatment of the bloodless state.

Local Measures to arrest the Hæmorrhage.—The occurrence of even slight hæmorrhages from a septic wound in the vicinity of a large blood vessel is to be taken seriously; it is usually necessary toopen up the wound, clear out the clots and infected tissues with a sharp spoon, disinfect the walls of the cavity with eusol or hydrogen peroxide, andpackit carefully but not too tightly with gauze impregnated with some antiseptic, such as “bipp,” so that, if the bleeding does not recur, it may be left undisturbed for several days. The packing should if possible be brought into actual contact with the leaking point in the vessel, and so arranged as to make pressure on the artery above the erosion. The dressings and bandage are then applied, with the limb in the attitude that will diminish the force of the stream through the main artery, for example, flexion at the elbow in hæmorrhage from the deep palmar arch. Other measures for combating the local sepsis, such as the irrigation method of Carrel, may be considered.

If the wound involves one of the extremities, it may be useful; and it imparts confidence to the nurse, and, it may be, to thepatient, if a Petit's tourniquet is loosely applied above the wound, which the nurse is instructed to tighten up in the event of bleeding taking place.

Ligation of the Artery.—If the hæmorrhage recurs in spite of packing the wound, or if it is serious from the outset and likely to be critical if repeated, ligation of the artery itself or of the trunk from which it springs, at a selected spot higher up, should be considered. This is most often indicated in wounds of the extremities.

As examples of proximal ligation for secondary hæmorrhage may be cited ligation of the hypogastric artery for hæmorrhage in the buttock, of the common iliac for hæmorrhage in the thigh, of the brachial in the upper arm for hæmorrhage from the deep palmar arch, and of the posterior tibial behind the medial malleolus for hæmorrhage from the sole of the foot.

Amputationis the last resource, and should be decided upon if the hæmorrhage recurs after proximal ligation, or if this has been followed by gangrene of the limb; it should also be considered if the nature of the wound and the virulence of the sepsis would of themselves justify removal of the limb. Every surgeon can recall cases in which a timely amputation has been the means of saving life.

Thecounteraction of the toxæmiaand thetreatment of the bloodless state, are carried out on the usual lines.

Hæmorrhage of Toxic Origin.—Mention must also be made of hæmorrhages which depend upon infective or toxic conditions and in which no gross lesion of the vessels can be discovered. The bleeding occurs as an oozing, which may be comparatively slight and unimportant, or by its persistence may become serious. It takes place into the superficial layers of the skin, from mucous membranes, and into the substance of such organs as the pancreas. Hæmorrhage from the stomach and intestine, attended with a brown or black discoloration of the vomit and of the stools, is one of the best known examples: it is not uncommonly met with in infective conditions originating in the appendix, intestine, gall-bladder, and other abdominal organs. Hæmorrhage from the mucous membrane of the stomach after abdominal operations—apparently also due to toxic causes and not to the operation—gives rise to the so-calledpost-operative hæmatemesis.

Constitutional Effects of Hæmorrhage.—The severity of the symptoms resulting from hæmorrhage depends as much on the rapidity with which the bleeding takes place as on the amount of blood lost. The sudden loss of a large quantity,whether from an open wound or into a serous cavity—for example, after rupture of the liver or spleen—is attended with marked pallor of the surface of the body and coldness of the skin, especially of the face, feet, and hands. The skin is moist with a cold, clammy sweat, and beads of perspiration stand out on the forehead. The pulse becomes feeble, soft, and rapid, and the patient is dull and listless, and complains of extreme thirst. The temperature is usually sub-normal; and the respiration rapid, shallow, and sighing in character. Abnormal visual sensations, in the form of flashes of light or spots before the eyes; and rushing, buzzing, or ringing sounds in the ears, are often complained of.

In extreme cases, phenomena which have been aptly described as those of “air-hunger” ensue. On account of the small quantity of blood circulating through the body, and the diminished hæmoglobin content of the blood, the tissues are imperfectly oxygenated, and the patient becomes extremely restless, gasping for breath, constantly throwing about his arms and baring his chest in the vain attempt to breath more freely. Faintness and giddiness are marked features. The diminished supply of oxygen to the brain and to the muscles produces muscular twitchings, and sometimes convulsions. Finally the pupils dilate, the sphincters relax, and death ensues.

Young children stand the loss of blood badly, but they quickly recover, as the regeneration of blood takes place rapidly. In old people also, and especially when they are fat, the loss of blood is badly borne, and the ill effects last longer. Women, on the whole, stand loss of blood better than men, and in them the blood is more rapidly re-formed. A few hours after a severe hæmorrhage there is usually a leucocytosis of from 15,000 to 30,000.

Treatment of the Bloodless State.—The patient should be placed in a warm, well-ventilated room, and the foot of the bed elevated. Cardiac stimulants, such as strychnin or alcohol, must be judiciously administered, over-stimulation being avoided. The inhalation of oxygen has been found useful in relieving the urgent symptoms of dyspnœa.

The blood may be emptied from the limbs into the vessels of the trunk, where it is more needed, by holding them vertically in the air for a few minutes, and then applying a firm elastic bandage over a layer of cotton wool, from the periphery towards the trunk.

Introduction of Fluids into the Circulation.—The most valuable measure for maintaining the circulation, however, isby transfusion of blood (Op. Surg., p. 37). If this is not immediately available the introduction of from one to three pints ofphysiologicalsalt solution (a teaspoonful of common salt to a pint of water) into a vein, or a 6 per cent. solution of gum acacia, is a useful expedient. The solution is sterilised by boiling, and cooled to a temperature of about 105° F. The addition of 5 to 10 minims of adrenalin solution (1 in 1000) is advantageous in raising the blood-pressure (Op. Surg., p. 565).

When the intra-venous method is not available, one or two pints of saline solution with adrenalin should be slowly introduced into the rectum, by means of a long rubber tube and a filler. Satisfactory, although less rapidly obtained results follow the introduction of saline solution into the cellular tissue—for example, under the mamma, into the axilla, or under the skin of the back.

If the patient can retain fluids taken by the mouth—such as hot coffee, barley water, or soda water—these should be freely given, unless the injury necessitates operative treatment under a general anæsthetic.

Transfusion of blood is most valuable asa preliminary to operationin patients who are bloodless as a result of hæmorrhage from gastric and duodenal ulcers, and in bleeders.

The term hæmophilia is applied to an inherited disease which renders the patient liable to serious hæmorrhage from even the most trivial injuries; and the subjects of it are popularly known as “bleeders.”

The cause of the disease and its true nature are as yet unknown. There is no proof of any structural defect in the blood vessels, and beyond the fact that there is a diminution in the number of blood-plates, it has not been demonstrated that there is any alteration in the composition of the blood.

The affection is in a marked degree hereditary, all the branches of an affected family being liable to suffer. Its mode of transmission to individuals, moreover, is characteristic: the male members of the stock alone suffer from the affection in its typical form, while the tendency is transmitted through the female line. Thus the daughters of a father who is a bleeder, whilst they do not themselves suffer from the disease, transmit the tendency to their male offspring. The sons, on the other hand, neither suffer themselves nor transmit the disease to their children (Fig. 64). The female members of a hæmophilic stockare often very prolific, and there is usually a predominance of daughters in their families.

Fig. 64.—Genealogical Tree if a Hæmophilic Family.Fig. 64.—Genealogical Tree of a Hæmophilic Family.[Larger image]

Fig. 64.—Genealogical Tree of a Hæmophilic Family.[Larger image]

The disease is met with in boys who are otherwise healthy, and usually manifests itself during the first few years of life. In rare instances profuse hæmorrhage takes place when the umbilical cord separates. As a rule the first evidence is the occurrence of long-continued and uncontrollable bleeding from a comparatively slight injury, such as the scratch of a pin, the extraction of a tooth, or after the operation of circumcision. The blood oozes slowly from the capillaries; at first it appears normal, but after flowing for some days, or it may be weeks, it becomes pale, thin, and watery, and shows less and less tendency to coagulate.

Female members of hæmophilia families sometimes show a tendency to excessive hæmorrhage, but they seldom manifest the characteristic features met with in the male members.

Sometimes the hæmorrhage takes place apparently spontaneously from the gums, the nasal or the intestinal mucous membrane. In other cases the bleeding occurs into the cellular tissue under the skin or mucous membrane, producing large areas of ecchymosis and discoloration. One of the commonest manifestations of the disease is the occurrence of hæmorrhage into the cavities of the large joints, especially the knee, elbow, or hip. The patient suffers repeatedly from such hæmorrhages, the determining injury being often so slight as to have passed unobserved.

There is evidence that the tendency to bleed is greater at certain times than at others—in some cases showing almost a cyclical character—although nothing is known as to the cause of the variation.

After a severe hæmorrhage into the cellular tissue or into a joint, the patient becomes pale and anæmic, the temperature may rise to 102° or 103° F., the pulse become small and rapid, and hæmic murmurs are sometimes developed over the heart and large arteries. The swelling is tense, fluctuating, and hot, and there is considerable pain and tenderness.

In exceptional cases, blisters form over the seat of the effusion, or the skin may even slough, and the clinical features may therefore come to simulate closely those of an acute suppurative condition. When the skin sloughs, an ulcer is formed with altered blood-clot in its floor like that seen in scurvy, and there is a remarkable absence of any attempt at healing.

The acute symptoms gradually subside, and the blood is slowly absorbed, the discoloration of the skin passing through the same series of changes as occur after an ordinary bruise.The patients seldom manifest the symptoms of the bloodless state, and the blood is rapidly regenerated.

Thediagnosisis easy if the patient or his friends are aware of the family tendency to hæmorrhage and inform the doctor of it, but they are often sensitive and reticent regarding the fact, and it may only be elicited after close investigation. From the history it is usually easy to exclude scurvy and purpura. Repeated hæmorrhages into a joint may result in appearances which closely simulate those of tuberculous disease. Recent hæmorrhages into the cellular tissue often present clinical features closely resembling those of acute cellulitis or osteomyelitis. A careful examination, however, may reveal ecchymoses on other parts of the body which give a clue to the nature of the condition, and may prevent the disastrous consequences that may follow incision.

These patients usually succumb sooner or later to hæmorrhage, although they often survive several severe attacks. After middle life the tendency to bleed appears to diminish.

Treatment.—As a rule the ordinary means of arresting hæmorrhage are of little avail. From among the numerous means suggested, the following may be mentioned: The application to the bleeding point of gauze soaked in a 1 in 1000 solution of adrenalin; prolonged inhalation of oxygen; freezing the part with a spray of ethyl-chloride; one or more subcutaneous injections of gelatin—5 ounces of a 2½ per cent. solution of white gelatin in normal salt solution being injected at a temperature of about 100° F.; the injection of pituitary extract. The application of a pad of gauze soaked in the blood of a normal person sometimes arrests the bleeding.

To prevent bleeding in hæmophilics, intra-venous or subcutaneous injections of fresh blood serum, taken from the human subject, the sheep, the dog, or the horse, have proved useful. If fresh serum is not available, anti-diphtheritic or anti-tetanic serum or trade preparations, such as hemoplastin, may be employed. We have removed the appendix and amputated through the thigh in hæmophilic subjects without excessive loss of blood after a course of fresh sheep's serum given by the mouth over a period of several weeks.

The chloride and lactate of calcium, and extract of thymus gland have been employed to increase the coagulability of the blood. The patient should drink large quantities of milk, which also increases the coagulability of the blood. Monro has observed remarkable results from the hypodermic injection of emetin hydrochloride in ½-grain doses.

The processes known as thrombosis and embolism are so intimately associated with the diseases of blood vessels that it is convenient to define these terms in the first instance.

Thrombosis.—The termthrombusis applied to a clot of blood formed in the interior of the heart or of a blood vessel, and the process by which such a clot forms is known asthrombosis. It would appear that slowing or stagnation of the blood-stream, and interference with the integrity of the lining membrane of the vessel wall, are the most important factors determining the formation of the clot. Alterations in the blood itself, such as occur, for example, in certain toxæmias, also favour coagulation. When the thrombus is formed slowly, it consists of white blood cells with a small proportion of fibrin, and, being deposited in successive layers, has a distinctly laminated appearance on section. It is known as awhite thrombusor laminated clot, and is often met with in the sac of an aneurysm (Fig. 72). When rapidly formed in a vessel in which the blood is almost stagnant—as, for example, in a pouched varicose vein—the blood coagulatesen masse, and the clot consists of all the elements of the blood, constituting ared thrombus(Fig. 66). Sometimes the thrombus ismixed—a red thrombus being deposited on a white one, it may be in alternate layers.

When aseptic, a thrombus may become detached and be carried off in the blood-stream as an embolus; it may become organised; or it may degenerate and undergo calcification. Occasionally a small thrombus situated behind a valve in a varicose vein or in the terminal end of a dilated vein—for example in a pile—undergoes calcification, and is then spoken of as aphlebolith; it gives a shadow with the X-rays.

When infected with pyogenic bacteria, the thrombus becomes converted into pus and a localised abscess forms; or portions of the thrombus may be carried as emboli in the circulation to distant parts, where they give rise to secondary foci of suppuration—pyæmic abscesses.

Embolism.—The termembolusis applied to any body carried along in the circulation and ultimately becoming impacted in a blood vessel. This occurrence is known asembolism. The commonest forms of embolus are portions of thrombi or of fibrinous formations on the valves of the heart, the latter being usually infected with micro-organisms.

Embolism plays an important part in determining one form of gangrene, as has already been described. Infective emboli are the direct cause of the secondary abscesses that occur in pyæmia; and they are sometimes responsible for the formation of aneurysm.

Portions of malignant tumours also may form emboli, and their impaction in the vessels may lead to the development of secondary growths in distant parts of the body.

Fat and air embolism have already been referred to.

Pyogenic.—Non-suppurative inflammation of the coats of an artery may so soften the wall of the vessel as to lead to aneurysmal dilatation. It is not uncommon in children, and explains the occurrence of aneurysm in young subjects.

When suppuration occurs, the vessel wall becomes disintegrated and gives way, leading to secondary hæmorrhage. If the vessel ruptures into an abscess cavity, dangerous bleeding may occur when the abscess bursts or is opened.

Syphilitic.—The inflammation associated with syphilis results in thickening of the tunica intima, whereby the lumen of the vessel becomes narrowed, or even obliterated—endarteritis obliterans. The middle coat usually escapes, but the tunica externa is generally thickened. These changes cause serious interference with the nutrition of the parts supplied by the affected arteries. In large trunks, by diminishing the elasticity of the vessel wall, they are liable to lead to the formation of aneurysm.

Changes in the arterial walls closely resembling those of syphilitic arteritis are sometimes met with intuberculouslesions.

Arterio-sclerosisorChronic Arteritis.—These terms are applied to certain changes which result in narrowing of the lumen and loss of elasticity in the arteries. The condition may affect the whole vascular system or may be confined to particular areas. In the smaller arteries there is more or less uniform thickening of the tunica intima from proliferation of the endothelium and increase in the connective tissue in the elastic lamina—a form of obliterative endarteritis. The narrowing of the vessels may be sufficient to determine gangrene in the extremities. In course of time, particularly in the larger arteries, this new tissue undergoes degeneration, at first of a fatty nature, but progressing in the direction of calcification, and this is followed by the deposit of lime salts in the young connective tissue and the formation of calcareous plates orrings over a considerable area of the vessel wall. To this stage in the process the termatheromais applied. The endothelium over these plates often disappears, leaving them exposed to the blood-stream.

Changes of a similar kind sometimes occur in the middle coat, the lime salts being deposited among the muscle fibres in concentric rings.


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