Bleeding, or HEMORRHAGE, is one of the most serious accidents which can happen to an animal, and constitutes the most anxious complication in surgical operations. As there is but a limited quantity of blood in the body (corresponding to about one-tenth of its weight), and as the sudden escape of a large portion of it is sufficient to cause death, every one should be instructed as to the measures which experience has shown to be the most efficient for preventing a dangerous loss of blood.
Bleeding may be either from a wounded artery or vein, or from a raw surface; and it may be in the form of a general oozing from the surface of a sore or a mucous membrane. We shall consider these varieties separately.
Arterial bleeding is recognised by the florid redness of the blood, and by its issuing from the cut vessel per saltum or by jerks. There are exceptions to this, however. When an artery has been tied, and bleeding occurs from below the ligature, the flow of blood is continuous, and of a dark colour.
If a large artery be severed, the first gush of blood may prove fatal, but more usually the patient faints, which implies a great diminution in the force of the circulation; and nature takes advantage of this respite to place the cut artery in circumstances as favourable as possible to the preservation of life—viz. the artery draws up within its sheath (see ARTERY); the blood, no longer impelled so vigorously by the heart, clots between the cut end of the vessel and the cellular tissue surrounding it; the inner and middle coats not only retract but contract, and another clot forms within the arterial tube. These clots—which, with the faintness and the contraction and retraction of the artery, are termed natural hæmostatics ('blood-stoppers')—are sufficient in many cases to prevent a recurrence of the bleeding; but such a happy concurrence of circumstances is not to be depended on, and we must be prepared to adopt some of the many surgical or artificial means for restraining the flow of blood till Adhesion (q.v.) can occur between the cut surfaces of the coats of the artery. The principal surgical means are :
Immediate pressure, which may be applied by pressing the finger-tip on the place whence the blood is seen to flow. This may be kept up by pads of lint, or a coin of convenient size wrapped in cloth, and secured with a bandage to the part.
Pressure on the artery above, or as it comes to the cut part. This requires some knowledge of anatomy, but not more than any intelligent person may easily acquire. Thus, pressure on the inside of the upper arm, about midway between its front and back, will press the Brachial Artery (q.v.) against the bone, and arrest any bleeding from wounds of the forearm and hand. Pressure on the middle of the groin with a thumb placed crosswise will control the stream of blood in the femoral artery, so that none can escape from any wound of the lower limb below where the pressure is made. This pressure with the finger or thumb is very difficult to maintain with an adequate amount of firmness and continuity; hence it is well to substitute the handle of a door-key wrapped in cloth, for the direct pressure of the finger-tip, which rapidly becomes relaxed by fatigue.
Pressure on the course of the vessel may be very efficiently effected by tying a handkerchief (see BANDAGE) round the limb above where it is injured, and then inserting a stick, and twisting it sufficiently tightly. This is the principle of the original tourniquet, which was invented by Morel, a French surgeon, at the siege of Besançon in 1674. He got the idea from seeing how carriers tightened the ropes which secured bales of goods on their carts. It has been modified from time to time. At present it consists of a strap and buckle, a pad which may be adjusted over the course of the artery wounded, or likely to be cut in an operation, and a screw by which the strap may be tightened as the surgeon may deem necessary. See TOURNIQUET.
Pressure on the main vessel leading to a limb is only a temporary method of stopping bleeding, since it is not only very painful to the patient, but fraught with danger to the limb, which may mortify if it be too long continued. In a healthy man such pressure may be continued for five or six hours with impunity in case of urgent necessity, but a longer suppression of the circulation would almost certainly be followed by partial or complete death of the limb.
'Actual' cautery, or hot iron, is occasionally useful in bleeding from a bone, or at some points where pressure cannot be efficiently applied. It is the oldest method of stopping bleeding, and until the 18th century was much in use; but its abuse, and the natural horror felt for it by both patient and surgeon, have almost banished it from the list of surgical hæmostatics. If used, the iron should be at a dull red heat, pressed for an instant in firm contact with the bleeding vessel. It causes shriveling of the artery; and if the latter be small, it effectually stops the bleeding.
Ligature, or tying the artery, is a very old method of arresting hemorrhage, and certainly the best. It was not used generally, however, in operations until improved anatomical knowledge and more efficient tourniquets allowed surgeons the time necessary for its application.
Another method was introduced by the late Sir James Y. Simpson of Edinburgh, and was termed by him Acupressure (q.v.), or pressure from a long needle or pin inserted from without, so as to press the artery between it and the tissues. The pins are removed after twenty-four or forty-eight hours. This plan promised to supersede the older kinds of ligature, especially in amputations, where the vessels can be easily secured, and where occasionally they are found so brittle from disease (see ATHEROMA) as to break under the pressure of a thread, but, since the introduction of the absorbable ligature, it has been entirely discarded in surgical practice. This ligature, consisting of catgut, prepared tendon, or silkworm gut, has the peculiarity that when placed around an artery and imbedded in the surrounding textures, it gradually becomes absorbed by the tissues around it, and does not require removal from the wound as was the case with the older silk or thread ligature.
Venous bleeding is recognised by the dark colour of the blood, and its continuous flow. Pressure is generally found sufficient to arrest it, and it should be applied directly over the wounded part. In this case, pressure higher up the limb only does harm, by retarding the return flow of the Circulation (q.v.), and thereby increasing the bleeding from the injured vein. It is hence very important to distinguish venous bleeding from that which occurs from arteries. In both, direct pressure on the bleeding point is the first imperative indication for treatment; in venous bleeding this suffices for the permanent arrest of the bleeding in most cases; in arterial bleeding it must be supplemented by one of the methods already described.
When a very large vein is divided, its two ends must be ligatured; if it be only partially severed, the surgeon can sew up the wound in its walls in many cases, and its function as an organ of the circulation is thus preserved.
Oozing from cut surfaces partakes more of the characters of venous than of arterial bleeding, as there is no vessel sufficiently large to demand the application of a ligature. The actual cautery or cold may be used, or one of the many styptics—e.g. perchloride of iron—may be specially recommended; it may be applied on lint or a sponge; or local astringents, such as alum and tannin, may be employed; there are also the puff-ball, mushroom, agaric, and matico-leaves, cobwebs, felt, &c., which act mechanically, and owe their reputation chiefly to the pressure used in their application. The best remedy for this type of bleeding is the application of a steady stream of very hot water to the injured surface. If continuously applied at as high a temperature as the patient can possibly endure, rapid cessation of the oozing takes place. Some persons have a congenital tendency to bleed (the hemorrhagic diathesis); if such a one have a trifling cut, or have a tooth pulled, he bleeds perhaps to death. A prudent surgeon will not perform cutting operations on one of a hemorrhagic family.
Bleeding from the free surfaces of mucous membranes occurs when they are much congested. One may have fatal hemorrhage from the stomach, and yet no open vessel may be found after death, even on the most careful examination. In such a case, we must trust to cold and internal remedies, such as acetate of lead combined with opium, gallic and tannic acids, and the extract of Witch Hazel (Hamamelis Virginica).
In bleeding, of whatever kind, the posture of the patient is a matter of great importance. The recumbent position is associated with a diminished force of the circulation, and should therefore be adopted in all serious cases. If the bleeding occur in one of the limbs, the raising of the injured part is in itself often sufficient to cut short the loss of blood, and this postural treatment should in all cases be employed in addition to the special local remedies above described.
Bleeding from internal organs, as the stomach or the lungs, is a very serious symptom, and must be immediately and carefully treated whenever it occurs. In any such case, the patient should be placed in the recumbent position in a cool airy room, the dress loosened to allow of cooling of the surfaces of the body, and the application of cold further effected by placing wet cloths over the chest and renewing them as soon as they become warm from contact with the body. All these remedies have the effect of slowing and reducing the strength of the circulation, and the patient therefore loses blood less rapidly. A table-spoonful of turpentine mixed with a little milk should be administered by the mouth at once, and another table-spoonful should be added to a jugful of boiling water, and the patient caused to inhale the vapour from it. This acts directly on the blood-vessels, tending to close them at the bleeding point. Keep the patient very quiet, and summon medical aid as speedily as possible.