Hæmorrhage in Surgical Operations

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 by digital compression of 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 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 hæmorrhage—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 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 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 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.

Hæmostatics or Styptics.—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 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 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.

Reactionary Hæmorrhage.Reactionary or 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 the distal side 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 more warning hæmorrhages before the leakage on a large scale, which is rapidly fatal.

The appearances of the wound in 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.

The general symptoms of 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. The prognosis therefore in cases of secondary hæmorrhage 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 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 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 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 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 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.

Amputation is 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.

The counteraction of the toxæmia and the treatment 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-called post-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, 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 anæsthetic.

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