Alexis Thomson and Alexander Miles - Manual of Surgery

A >> Alexis Thomson and Alexander Miles >> Manual of Surgery

Pages:
1 | 2 | 3 | 4 | 5 | 6 | 7 | 8 | 9 | 10 | 11 | 12 | 13 | 14 | 15 | 16 | 17 | 18 | 19 | 20 | 21 | 22 | 23 | 24 | 25 | 26 | 27 | 28 | 29 | 30 | 31 | 32 | 33 | 34 | 35 | 36 | 37 | 38 | 39 | 40 | 41 | 42 | 43 | 44 | 45 | 46 | 47 | 48 | 49

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
vertebrae 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 the
abdominal aorta 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 haemorrhage--say in an amputation--is by the
use of some form of _tourniquet_, 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 haemorrhage 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 Haemorrhage.#--_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 to surround the bleeding vessel a short distance from its
end, in this way ensuring a better hold and preventing the ligature from
slipping.

If the haemorrhage 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 haemorrhage 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 haemorrhage, 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.

_Haemostatics_ or _Styptics_.--The local application of haemostatics is
seldom to be recommended. In the treatment of epistaxis or bleeding from
the nose, of haemorrhage 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.

Haemorrhage 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 Haemorrhage.#--The most efficient means of
temporarily controlling haemorrhage 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 useful _emergency tourniquet_ may be improvised by
folding a large handkerchief _en cravatte_, with a cork or piece of wood
in the fold to act as a pad. The handkerchief is 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 haemorrhage 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.

#Reactionary Haemorrhage.#--Reactionary or intermediary haemorrhage
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 haemorrhage.

As a rule, reactionary haemorrhage takes place from small vessels as a
result of the displacement of occluding clots, and in many cases the
haemorrhage 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 haemorrhage
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 haemorrhage.

#Secondary Haemorrhage.#--The term secondary haemorrhage 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 haemorrhage, 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 haemorrhage 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 haemorrhage. 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 haemorrhage, and the interesting observation was often made,
that when the collateral circulation was well established, the leakage
occurred on the _distal_ side of the ligature. While it may happen that
the initial haemorrhage 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 more _warning haemorrhages_ before the leakage
on a large scale, which is rapidly fatal.

The _appearances of the wound_ in cases complicated by secondary
haemorrhage 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 oedematous and pit on pressure.

The _general symptoms_ of septic poisoning in cases of secondary
haemorrhage 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 toxaemia may be of a profound type associated with
marked pallor and progressive failure of strength, which, of itself,
even when the danger from haemorrhage has been overcome, may have a fatal
termination. The _prognosis_ therefore in cases of secondary haemorrhage
can never be other than uncertain and unfavourable; the danger from loss
of blood _per se_ is less when the artery concerned is amenable to
control by surgical measures.

_Treatment._--The treatment of secondary haemorrhage includes the use of
local measures to arrest the bleeding, the employment of general
measures to counteract the accompanying toxaemia, and when the loss of
blood has been considerable, the treatment of the bloodless state.

_Local Measures to arrest the Haemorrhage._--The occurrence of even
slight haemorrhages from a septic wound in the vicinity of a large blood
vessel is to be taken seriously; it is usually necessary to _open 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, and
_pack_ it 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 haemorrhage 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 the patient, 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 haemorrhage 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 haemorrhage may be cited
ligation of the hypogastric artery for haemorrhage in the buttock, of the
common iliac for haemorrhage in the thigh, of the brachial in the upper
arm for haemorrhage from the deep palmar arch, and of the posterior
tibial behind the medial malleolus for haemorrhage from the sole of the
foot.

_Amputation_ is the last resource, and should be decided upon if the
haemorrhage 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.

The _counteraction of the toxaemia_ and the _treatment of the bloodless
state_, are carried out on the usual lines.

#Haemorrhage of Toxic Origin.#--Mention must also be made of haemorrhages
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. Haemorrhage 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. Haemorrhage 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-called
_post-operative haematemesis_.

#Constitutional Effects of Haemorrhage.#--The severity of the symptoms
resulting from haemorrhage 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 haemoglobin 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 haemorrhage 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 dyspnoea.

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, is by transfusion of
blood (_Op. Surg._, p. 37). If this is not immediately available the
introduction of from one to three pints of physiological salt
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 anaesthetic.

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

HAEMOPHILIA

The term haemophilia is applied to an inherited disease which renders the
patient liable to serious haemorrhage 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 haemophilic stock are often
very prolific, and there is usually a predominance of daughters in their
families.

FIG 64.--Genealogical Tree of a Haemophilic Family.

Great-Great-Grandmother Great-Great-Grandfather
Mrs D. (Lancashire) F M (History not known
.| | as to bleeding)
.| |
.+----------+-------+
............|
.|
....|
.+---------+--------+
Great-Grandmother .| | |
(Married three .F MB MB
times) .|
.|
.|
By First Husband .| By Second By Third
..............| Husband Husband
+-----------+------------+----------+-------+-------+-----------+------+
| .| | | +-------+-----------+------+
M .F F F | | +------+
| .| | | MB F Died in No
Died Grandmother | | | Childbed Family
aet. .| | +-----------+ +----+---
70 .| +------+ |had family | |
.| | | |but history| |
.| MB MB |not known | MB
.|
.|
.|.............................
+-----+----------+------------+------------+------------+-------------+
| | | | |. | |
| | | | |. | |
M M M MB F. F F
| |. | |
| Mother +--+--+---+--+--+ |
+----+ |. | | | | | | |
| | |. M M MB F F F |
M F |. |
Not Married |. +---+---+---+---+
|. | | | | |
|. MB M MB M M
.............|.
+-----+-----+-----+-----+-----+
| .| .| | | |
| .|* .|* | | |
M MB MB F F F

F = Females. M = Males (not bleeders). MB = Males (bleeders)

** the patients observed by the authors. The dotted line shows the
transmission of the disease to our patients through four
generations.

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 haemorrhage 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.