Adrenalin has no anæsthetic power, but its constricting action lessens the tendency of cocaine to be deeply absorbed, increases the latter’s local effect, and allows of a weaker solution being employed.
Another secondary result is the very irritating rhinitis which is sometimes induced. It passes off in 24 to 48 hours.
Uses. The addition of a small quantity of adrenalin to a cocaine solution mitigates the toxic action of the latter, and its use appears to check tendency to collapse, either from shock or chloroform, during serious operations on the nasal cavities. Its chief use is to check hæmorrhage and allow us to perform practically bloodless operations in the nose.
Methods. Adrenalin is employed as described for cocaine. Disappointment in the result obtained is nearly always due to neglect in recognizing that its full effect cannot be obtained in less than 20 to 60 minutes.
BLEEDING AND ITS CONTROL
Bleeding in the nose cannot be controlled as easily and directly as in the operations of general surgery, and there is always the risk of blood passing into the lower air-passages.
Causation. Hæmorrhage is apt to be not only more free, but also more serious, in young children and in patients over 60. The tendency is increased with menstruation or pregnancy, and hæmophilia is to be particularly looked for. In the nose the vascular turbinals bleed freely; a small varicose vessel on the septum is the commonest source of epistaxis,—often very copious. Many vascular growths are met with, and malignant ones are apt to bleed profusely.
Secondary hæmorrhage may occur between the third and eighth day, when clots or crusts become detached.
The prevention of local hæmorrhage. The patient should be prepared more carefully than usual for an operation. Hæmophilia should be inquired after, and if there is any suspicion of it lactate of calcium is administered for three days beforehand, in doses of 15 to 30 grains twice a day. If the patient be an undoubted hæmophilic, an operation should be avoided if possible. It is well to suspend the use of alcohol and tobacco for at least three days beforehand. Many risks are avoided if the operation can be carried out in the home or hospital where the patient has slept, and if he can remain there afterwards.
The arrest of local hæmorrhage. The preliminary use of adrenalin will diminish bleeding in many cases (see [p. 573]). When it does occur, unless the hæmorrhage is serious, it is well not to be too precipitate in efforts to arrest it. Such attempts, by stimulating the patient, detaching blood-clots, or exciting reflexes, may even maintain it. The clothing should be loose, the operating-room should be well aired and cool, and iced water should always be at hand. If freely sluiced over the face, behind the ears, and round the neck, cold water has such a remarkable reflex vaso-constrictor action that it alone is sufficient to arrest hæmorrhage in the majority of operations on the nose and throat. Its stimulating effect on the respiration and circulation is always agreeable to the patient, and may be very valuable when he is under a general anæsthetic.