Secondary hemorrhage may call for ligation of a main trunk not previously attacked, but in a majority of cases will demand reopening of the wound and further search for bleeding points. Should the patient’s condition be materially weakened the effects of position and of pressure may be tried in suitable cases. But the pressure which may be effective to check the hemorrhage may be sufficient to completely shut off circulation from parts beyond, and such pressure should, therefore, be judiciously practised and its effects carefully watched. The signs of secondary hemorrhage will vary with the location of its source. Occurring on or near the surface it will usually stain the dressing; occurring deeply, as in the pelvic or abdominal cavities, it will produce prompt symptoms of shock, i. e., lowered blood pressure, whose degree will indicate the extent of the blood loss. In these cases, unless the patient’s condition contra-indicate the measure, the wound should be opened under anesthesia, and the source of the bleeding sought out and mastered. The surgeon should never overlook the fact that after the gradual restoration of the force of the heart’s action, as the patient recovers from anesthesia and becomes uncontrollably restless, vessels may bleed which upon the operating table scarcely emitted a drop of blood. Experiences of this kind teach the value of hemostasis during operation, and even of absolute rest induced by an opiate, immediately after.
There are certain conditions in which the surgeon is led by experience to anticipate liability to unusual hemorrhage; such as cases of hemophilia, or anything that savors of it or of scurvy. In patients who claim to be “bleeders,” the surgeon should be extremely chary and careful during his operative work. There are, furthermore, certain toxemias, especially that of cholemia, during which the blood is slow in coagulation. When the time for preparation is afforded no cholemic patient should be operated without a few days’ previous preparation by four or five daily doses of calcium chloride, 20 to 30 grains given in plenty of water. This is known to greatly increase blood coagulability, and thereby to measurably protect the patient against the danger of an oozing of blood difficult to control.
The other measures needful in the treatment of secondary hemorrhage are those described in Chapter XVIII.
TREATMENT OF WOUNDS.
The general consideration of wounds in the previous chapters necessarily included many suggestions concerning their treatment. The first essential in the treatment of open wounds is exact hemostasis; the next is the removal of dirt and foreign material of all kinds, i. e., visible and invisible. Accidental wounds are practically never received upon surgically clean surfaces, and it may be always assumed that the possibility of infection is present. It becomes then a question to what extent the surgeon should go in removing or avoiding danger. Obviously all visible foreign material should be carefully removed and all dirt should be scrupulously washed away. Emergency treatment of a bleeding injury in a well-regulated hospital is one thing, and the exigency of a railroad accident or casualty away from civilization is quite another. The canons of antisepsis and asepsis have been elsewhere sufficiently well laid down to indicate what should be done at the time when it can be done.
The protective vitality of the human tissues permits them to bear frightful injuries or resist infection in a surprising way. But occasional escapes from severe accidents by no means justify carelessness when caution can be taken, and cannot be held as excusing the surgeon for any neglect in antisepsis.
A bruise or contusion accompanied by a slight abrasion may seem a trifling injury, and yet by virtue of the injury the resisting powers of the tissues may be rendered insufficient to protect them from infection through a break of the surface. No relatively small lesions of this kind can be safely neglected, but should be cleaned and covered with an antiseptic compress, either wet with some suitable solution or smeared with a protective ointment, or used dry with a suitable antiseptic powder, as, for example, bismuth subiodide. Injuries followed by considerable swelling should be treated according to the time which has elapsed since their reception. If, for instance, a bruise or sprain be seen early and before much swelling has occurred, ice-cold applications can be made in the hope that, by limiting the flow of blood, the outpour of fluids may be prevented. This effort should be seconded by position, and perhaps by gentle pressure. Conversely when a case is seen late, after the tissues have become waterlogged with fluids, heat should be applied in order that by stimulating the circulation reabsorption may more speedily take place. In this case, also, suitable pressure may be of service.
When there is actual hematoma, and the exuded fluid fails to disappear, an incision properly made and in the right place may permit the clot to be turned out, and then speedy recovery secured by coaptation with sutures and pressure.
Poultices are nauseous applications to make to the human body. By their indiscriminate use much harm has been done and suppuration encouraged or brought about, which but for them would not have occurred. There are occasions when a hot flaxseed poultice may be of use, but they are very few and far between. With regard to such remedies as arnica, witch-hazel, etc., the best that can be said of them is that they may be of some use by virtue of the alcohol which they contain; they serve the purpose, then, of a diluted alcohol and nothing else.
There is virtue in the use of a cold wet pack, or compress, especially in the treatment of chronic affections of the joints, and their value can be perceptibly enhanced by using solutions of sodium, or preferably ammonium chloride, and the addition of a little alcohol. Absorbent material wet in such a solution, wrapped around the part, covered with oiled silk or some impervious material, while the part is kept at rest, will render valuable service in conditions of this kind.