+HEMORRHAGE+
+Definition.+ The escape of blood from the blood vessels in great or
small quantities, is called hemorrhage, and may occur either
spontaneously or because of injury.
+Spontaneous hemorrhage+ occurs in the organs and cavities of the body
as a result of constitutional diseases, such as tuberculosis,
syphilis, cancer, etc., in which erosion of tissue extends into
vessels. It is also a result of a constitutional tendency. Persons
with this, so called hemorrhagic diathesis, are known as hemophiliacs.
In hemophilia, uncontrollable bleeding may occur from trifling
injuries.
+Hemorrhage due to Injury+ may be classified as follows:
a—arterial
b—venous
c—capillary
(_a_) Arterial hemorrhage may be recognized by rapid, spurting jets of
red blood, occurring synchronous with the heart beat.
(_b_) 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 artery is severed,
the inner and middle coats immediately retract and curl up within the
lumen, partially closing up the cut end.
Blood has the property of clotting, if it comes in contact with
anything but the natural endothelial lining of the vessels.
The curling in of the inner and middle coats retards the escaping
stream and facilitates coagulation within the cut end of the vessel
now formed by the outer coat alone. When the hemorrhage is severe,
these processes are reinforced by an increased tendency to coagulate,
and by a weakened heart action.
+The Control of Hemorrhage.+ The object of treatment in every case is to
check the flow of blood, and, though death from ordinary wounds is
rare, yet the loss of much blood is weakening for a long time.
The principle on which we act in our efforts to permanently stop
bleeding, depends on the power which the blood has of clotting, or as
it is called, coagulating.
If by any means the blood can be made to “stand still” in a blood
vessel at the point of injury, it will clot, thus forming a plug which
prevents further escape.
In wounds involving only small veins or capillaries from which there
is no distinct jet of blood (capillary hemorrhage), pressure of the
thumb, a wad of sterile gauze intervening, will usually suffice in a
few minutes. Gauze dipped in hot water applied to such wounds, also at
times effects a stoppage of such bleeding. Often only tight bandaging
is necessary.
Bleeding from large arteries or veins can be controlled temporarily by
pressure directly over the wound.
Temporary control may also be obtained by digital pressure above or
below the wound, if in a leg or arm, depending upon whether the escape
is chiefly from a vein or an artery, for in any wound some of the
bleeding will be capillary. This method, or the application of a
tourniquet, will absolutely control bleeding in an extremity.
The pressure in arterial hemorrhage must be applied at a point nearer
the heart and in venous hemorrhage at a point away from the heart.
A tourniquet may be devised from a handkerchief, a piece of rope or of
rubber tubing wound around the limb and tightened just enough to
arrest the main stream; in addition, pressure exerted over the wound
will control whatever hemorrhage persists. Such a control can only be
temporary, as the arrest of circulation in an extremity below the
tourniquet for more than an hour or two might cause gangrene. However,
there is no great fear of this occurring, as some blood reaches the
parts through deep vessels.
Permanent control of such hemorrhages can only be effected by grasping
the severed vessels in the open wound with artery clamps, and then
ligating below the clamps with cat gut.
Deep-seated hemorrhages, in the abdomen or chest, can often be
controlled by pressure directly over the wound until an open operation
can be performed.
Deep pressure, with the fist upon the abdomen just to the left of the
vertebral column, will compress the aorta and greatly reduce the
escape of blood from any artery supplied by the descending aorta.
+Hemorrhage in Chiropody.+ For the chiropodist, bleeding is an annoying
and especially perplexing occurrence. The feet are the most
bacteria-laden part of the body; here are warmth and moisture,
congenial to bacteria, and a thick epidermis for their safe
concealment. When hemorrhage occurs, therefore, its proper control
along antiseptic lines is imperative.
The vessels severed are rarely of sufficient size to cause the escape
of blood in an actual stream, but rather as a rapid oozing. It is, as
a rule, capillary hemorrhage.
The methods for its control have already been described in this
chapter, and will always stop such bleeding.
In chiropodial practice, however, the degree of bleeding determines
the method of treatment, and, though the extreme may fall short of
actual danger, it still behooves the operator to control it
absolutely before dismissing his patient.
+Easily Controlled Bleeding.+ The degree of bleeding or slight oozing,
as it should be termed, incident to skiving a calloused surface, is
well controlled with styptics.
In employing these substances it should be borne in mind that they are
not usually antiseptic but, on the contrary, may harbor organisms
which may be transferred to the wound and cause infection. The
subsulphate of iron, commonly employed in the form of Monsel’s
solution, is usually employed because of its efficiency as a styptic,
and because of the fact that it is less irritating than others. It,
however, is not antiseptic and should be kept sterile and
uncontaminated by dropping it upon the wound directly from the bottle,
rather than by dipping the cotton-wound applicator into it, as is so
frequently done. Even this does not prevent an originally sterile
bottle of solution from becoming contaminated, exposure to the air,
when the stopper is removed, admitting many bacteria each time.
A superior styptic has been supplied in the form of dry subsulphate of
iron fused to small sticks of wood. These are efficient because of
their cleanliness, each being used but once and at no appreciable
expense.
It is needless to say that the dressing of even so slight a wound
should prevent the admission of infection to the thousands of portals
of infection which are present. A bandage is not indicated nor
justifiable, and the cotton collodion cocoon suffices.
+Persistent Bleeding.+ When bleeding occurs which does not yield to the
effects of a styptic because of its constant washing away when
applied, it becomes necessary to apply pressure to the wound.
Frequently a wad of cotton or gauze, pressed firmly upon the bleeding
area, will almost stop the bleeding in a few minutes, after which it
becomes possible to apply the styptic. Should this, however, be found
impossible and the bleeding resume when the pressure is released,
clotting in the vessel can only be expected by the agency of either
ligation of the tissue or any individual vessel or more commonly by
tight bandaging. The latter procedure usually accomplishes the control
of the hemorrhage incident to a deep dissection for papilloma or
verucca.
A pad of several thicknesses of sterile gauze is placed upon the wound
and held in place by a few turns of narrow bandage, applied quite
tightly. Though blood may be seen to “spot” through this dressing, it
should occasion no alarm unless the hemorrhage has been clearly either
venous or arterial. Under such circumstances the spurting, either
constant or intermittent, will give immediate evidence of its
character. Active hemorrhage of this nature may yield to tight
bandaging, but ligation of the vessel should be done.
+Venous or Arterial Bleeding+ requiring ligation may be easily dealt
with, and every chiropodist should be equipped with a small artery
clamp with which to grasp the tissues; he should also be provided with
sterile catgut, sizes 0 or 00, with which to ligate a bleeding vessel.
+Antiseptic Precautions.+ In dealing with hemorrhage of even the
slightest degree, it should be remembered that portals of entrance for
bacteria upon the feet require every antiseptic precaution, both as to
the treatment of the wound, and as to the instruments and dressings
which come in contact with it.
For open wounds the U. S. P. tincture of iodin, diluted in water to
one-half strength, is antiseptic and not extremely irritating.
Instruments dipped in pure phenol and dried on sterile gauze are
rendered sterile and may be safely employed.
Dry sterile gauze in the dressing of a clean surgical wound is all
that is necessary. Healing in the absence of infection will be prompt.
The habitual use of ointments and wet dressings should be
discountenanced, except in the presence of a real indication.