Page:EB1911 - Volume 12.djvu/830

Rh undergo changes. The treatment of a case seen soon after the injury is directed towards keeping the patient at rest, elevating the parts, and applying an evaporating lotion or ice-bag. In chronic cases it may be necessary to lay open the cavity and remove the coagulum.

 HAEMOPHILIA, the medical term for a condition of the vascular system, often running in families, the members of which are known as “bleeders,” characterized by a disposition towards bleeding, whether with or without the provocation of an injury to the tissue. When this bleeding is spontaneous it comes from the mucous membranes, especially from the nose, but also from the mouth, bowel and bronchial tubes. Slight bruises are apt to be followed by extravasations of blood into the tissues; the swollen joints (knee especially) of a bleeder are probably due, in the first instance, to the escape of blood into the joint cavity or synovial membrane. It is always from the smallest vessels that the blood escapes, and may do so in such quantities as to cause death in a few hours.

 HAEMORRHAGE (Gr. , blood, and  , to burst), a general term for any escape of blood from a blood-vessel (see Blood). It commonly results from injury, as the tearing or cutting of a blood-vessel, but certain forms result from disease, as in scurvy and purpura. The chief varieties of haemorrhage are arterial, venous and capillary. Bleeding from an artery is of a bright red colour, and escapes from the end of the vessel nearest the heart in jets synchronous with the heart’s beat. Bleeding from a vein is of a darker colour; the flow is steady, and the bleeding is from the distal end of the vessel. Capillary bleeding is a general oozing from a raw surface. By extravasation of blood is meant the pouring out of blood into the areolar tissues, which become boggy. This is termed a bruise or ecchymosis. Epistaxis is a term given to bleeding from the nose. Haematemesis is vomiting of blood, the colour of which may be altered by digestion, as is also the case in melaena, or passage of blood with the faeces, in which the blood becomes dark and tarry-looking from the action of the intestinal fluids. Haemoptysis denotes an escape of blood from the air-passages, which is usually bright red and frothy from admixture with air. Haematuria means passage of blood with the urine.

Cessation of bleeding may take place from natural or from artificial means. Natural arrest of haemorrhage arises from (1) the coagulation of the blood itself, (2) the diminution of the heart’s action as in fainting, (3) changes taking place in the cut vessel causing its retraction and contraction. In the surgical treatment of haemorrhage minor means of arresting bleeding are: cold, which is most valuable in general oozing and local extravasations; very hot water, 130° to 160° F., a powerful haemostatic; position, such as elevation of the limb, valuable in bleeding from the extremities; styptics or astringents, applied locally, as perchloride of iron, tannic acid and others, the most valuable being suprarenal extract. In arresting haemorrhage temporarily the chief thing is to press directly on the bleeding part. The pressure to be effectual need not be severe, but must be accurately applied. If the bleeding point cannot be reached, the pressure should be applied to the main artery between the bleeding point and the heart. In small blood-vessels pressure will be sufficient to arrest haemorrhage permanently. In large vessels it is usual to pass a ligature round the vessel and tie it with a reef-knot. Apply the ligature, if possible, at the bleeding point, tying both ends of the cut vessel. If this cannot be done, the main artery of the limb must be exposed by dissection at the most accessible point between the wound and the heart, and there ligatured.

Haemorrhage has been classified as—(1) primary, occurring at the time of the injury; (2) reactionary, or within twenty-four hours of the accident, during the stage of reaction; (3) secondary, occurring at a later period and caused by faulty application of a ligature or septic condition of the wound. In severe haemorrhage, as from the division of a large artery, the patient may collapse and death ensue from syncope. In this case stimulants and strychnine may be given, but they should be avoided until it is certain the bleeding has been properly controlled, as they tend to increase it. Transfusion of blood directly from the vein of a healthy person to the blood-vessels of the patient, and infusion of saline solution into a vein, may be practised (see ). In a congenital condition known as (q.v.) it is difficult to stop the flow of blood.

The surgical procedure for the treatment of an open wound is—(1) arrest of haemorrhage; (2) cleansing of the wound and removal of any foreign bodies; (3) careful apposition of its edges and surfaces—the edges being best brought in contact by sutures of aseptic silk or catgut, the surfaces by carefully applied pressure; (4) free drainage, if necessary, to prevent accumulation either of blood or serous effusion; (5) avoidance of sepsis; (6) perfect rest of the part. These methods of treatment require to be modified for wounds in special situations and for those in which there is much contusion and laceration. When a special poison has entered the wound at the time of its infliction or at some subsequent date, it is necessary to provide against septic conditions of the wound itself and blood-poisoning of the general circulation.

 HAEMORRHOIDS, or (from Gr. , blood, and  , to flow), commonly called piles, swellings formed by the dilatation of veins of the lowest part of the bowel, or of those just outside the margin of its aperture. The former, internal piles, are covered by mucous membrane; the latter, external piles, are just beneath the skin. As the veins of the lining of the bowel become dilated they form definite bulgings within the bowel, and, at last increasing in size, escape through the anus when a motion is being passed. Growing still larger, they may come down spontaneously when the individual is standing or walking, and they are apt to be a grave source of pain or annoyance. Eventually they may remain constantly protruded—nevertheless, they are still internal piles because they arise from the interior of the bowel. Though a pile is sometimes solitary, there are usually several of them. They are apt to become inflamed, and the inflammation is associated with heat, pain, discharge and general uneasiness; ulceration and bleeding are also common symptoms, hence the term “bleeding piles.” The external pile is covered by the thin dark-coloured skin of the anal margin. Severe pressure upon the large abdominal veins may retard the upward flow of blood to the heart and so give rise to piles; this is apt to happen in the case of disease of the liver, malignant and other tumours, and pregnancy. General weakness of the constitution or of the blood-vessels and habitual constipation may be predisposing causes of piles. The exciting cause may be vigorous straining at stool or exposure to damp, as from sitting on the wet ground. Piles are often only a symptom, and in their treatment this fact should be kept in view; if the cause is removed the piles may disappear. But in some cases it may be impossible to remove the cause, as when a widely-spreading cancerous growth of the rectum, or of the interior of the pelvis or abdomen, is blocking the upward flow of blood in the veins. Sometimes when a pile has been protruded, as during defaecation, it is tightly grasped by spasmodic contraction of the circular muscular fibres which guard the outlet of the bowel, and it then becomes swollen, engorged and extremely painful; the strangulation may be so severe that the blood in the vessels coagulates and the pile mortifies. This, indeed, is nature’s attempt at curing a pile, but it is distressing, and, as a rule, it is not entirely successful.

The palliative treatment of piles consists in obtaining a daily and easy action of the bowels, in rest, cold bathing, astringent injections, lotions and ointments. The radical treatment consists in their removal by operation, but this should not be contemplated until palliative treatment has failed. The operation consists in drawing the pile well down, and strangling the vessels entering and leaving its base, either by a strong ligature tightly applied, by crushing, or by cautery. Before dealing with the pile the anus is vigorously dilated in order that the pile may be dealt with with greater precision, and also that the temporary paralysis of the sphincter muscle, which follows the stretching, may prevent the occurrence of painful and spasmodic contractions subsequently. The ligatures by which the base of the piles are strangulated 