Manual of Surgery Volume I Part 30

#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 dyspna.

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 r.e.c.t.u.m, 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. (Lancas.h.i.+re) 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 circ.u.mcision. 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 haemophilia families sometimes show a tendency to excessive haemorrhage, but they seldom manifest the characteristic features met with in the male members.

Sometimes the haemorrhage 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 haemorrhage into the cavities of the large joints, especially the knee, elbow, or hip. The patient suffers repeatedly from such haemorrhages, the determining injury being often so slight as to have pa.s.sed un.o.bserved.

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 haemorrhage into the cellular tissue or into a joint, the patient becomes pale and anaemic, the temperature may rise to 102 or 103 F., the pulse become small and rapid, and haemic 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 pa.s.sing 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.

The _diagnosis_ is easy if the patient or his friends are aware of the family tendency to haemorrhage 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 haemorrhages into a joint may result in appearances which closely simulate those of tuberculous disease. Recent haemorrhages 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 succ.u.mb sooner or later to haemorrhage, 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 haemorrhage 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 2 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 haemophilics, 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 haemophilic 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 quant.i.ties of milk, which also increases the coagulability of the blood. Monro has observed remarkable results from the hypodermic injection of emetin hydrochloride in -grain doses.

THROMBOSIS AND EMBOLISM

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

#Thrombosis.#--The term _thrombus_ is 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 as _thrombosis_. 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 toxaemias, 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 a _white thrombus_ or 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 coagulates _en ma.s.se_, and the clot consists of all the elements of the blood, const.i.tuting a _red thrombus_ (Fig. 66). Sometimes the thrombus is _mixed_--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 a _phlebolith_; 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--pyaemic abscesses.

#Embolism.#--The term _embolus_ is applied to any body carried along in the circulation and ultimately becoming impacted in a blood vessel. This occurrence is known as _embolism_. 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 pyaemia; 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.

ARTERITIS

_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 haemorrhage. If the vessel ruptures into an abscess cavity, dangerous bleeding may occur when the abscess bursts or is opened.

_Syphilitic._--The inflammation a.s.sociated 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 diminis.h.i.+ng 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 in _tuberculous_ lesions.

#Arterio-sclerosis# or #Chronic 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 or rings over a considerable area of the vessel wall. To this stage in the process the term _atheroma_ is 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.

The primary cause of arterio-sclerosis is not definitely known, but its almost constant occurrence, to a greater or less degree, in the aged suggests that it is of the nature of a senile degeneration. It is favoured by anything which throws excessive strain on the vessel walls, such as heavy muscular work; by chronic alcoholism and syphilis; or by such general diseases as tend to raise the blood-pressure--for example, chronic Bright's disease or gout. It occurs with greater frequency and with greater severity in men than in women.

Atheromatous degeneration is most common in the large arterial trunks, and the changes are most marked at the arch of the aorta, opposite the flexures of joints, at the mouths of large branches, and at parts where the vessel lies in contact with bone. The presence of diseased patches in the wall of an artery diminishes its elasticity and favours aneurysmal dilatation. Such a vessel also is liable to be ruptured by external violence and so give rise to traumatic aneurysm. Thrombosis is liable to occur when calcareous plates are exposed in the lumen of the vessel by destruction of the endothelium, and this predisposes to embolism. Arterio-sclerosis also interferes with the natural arrest of haemorrhage, and by rendering the vessels brittle, makes it difficult to secure them by ligature. In advanced cases the accessible arteries--such as the radial, the temporal or the femoral--may be felt as firm, tortuous cords, which are sometimes so hard that they have been aptly compared to "pipe-stems." The pulse is smaller and less compressible than normal, and the vessel moves bodily with each pulsation. It must be borne in mind, however, that the condition of the radial artery may fail to afford a clue to that of the larger arteries. Calcified arteries are readily identified in skiagrams (Fig. 65).

[Ill.u.s.tration: FIG. 65.--Radiogram showing Calcareous Degeneration (Atheroma) of Arteries.]