Bleeding

Bleeding, hemorrhage, extravasation, the process of blood exiting the bloodstream. Bleeding is divided into internal and external; by origin - into arterial, venous, capillary, and parenchymatous (outflow of mixed blood from an organ parenchyma incision). By method of occurrence, the following are distinguished: 1) Bleeding through violation of vessel integrity - from vessel rupture, haemorrhagia per rhexin, and from vessel wall erosion, haemorrhagia per diabrosin (see Arrosia, Diabrosis), for example in ulcerative processes, especially in gangrenous ones; 2) Bleeding in the absence of visible vessel damage, haemorrhagia per diapedesin (see Diapedesis). Special names are given to individual types of bleeding depending mainly on localization (see Apoplexy, Haematemesis, Haematocele, Hematuria, Hemopericard, Haemothorax, Epistaxis, Hemoptysis, Uterus, Melena, Purpura, etc.). At onset (both through rupture and diapedesis), bleeding from small veins and capillars also involves the following factors: a) increase in venous pressure, especially sudden (congestive bleeding), for example small bleedings in the conjunctiva and other mucous membranes, in the skin during severe coughing, convulsions, strangulation, compression of the body; b) decrease in external pressure on vessels, causing both reduction of venous outflow and increase in blood inflow; this includes small bleedings from dry cupping, bleedings from rapid transition from increased pressure to normal [work in caissons, when ascending to heights (bleeding from ears, nose, bronchi, into joints)]; further in serous membranes of thoracic organs in both newborns and generally in suddenly deceased children and adults in death accompanied by strangulation phenomena, convulsions (eclampsia, epilepsy); in the origin of bleeding here, both increased inspiratory stretching of the chest wall and increased blood pressure are significant; c) occlusion of arterial branches (according to the type of hemorrhagic infarct - see Infarct). The basis of neurotic bleeding is vasodilator effects of central nature, expressed especially sharply with general excessive excitability of the nervous-vascular system. On this basis, vicarious bleeding (from nose, stomach, mammary gland, skin) replacing menstrual bleeding may also occur. Neurotic bleeding sometimes occur in hysterical individuals under the influence of suggestion or autosuggestion in a hypnotic state. These cases are closely related to rare cases of hematidrosis (see Haematidrosis). Ricker recently greatly expands the concept of neurotic bleeding, including in them, for example, bleeding in fatty necroses of the pancreas, perirenal hematoma, etc. Neurotic bleeding, like bleeding per diapedesin in general, can, according to Ricker, occur only in the "peristatic" state of blood circulation in capillaries (see Stasis). As is evident even from the example of neurotic bleeding, external triggering factors (vessel damage from trauma, infection, intoxication) as well as predisposing factors are important in the origin of hemorrhages. The latter may be of genotypic nature (for example in hemophilia) or acquired [scurvy, some cases of Werlhoff's disease, poisoning by so-called capillary poisons (phosphorus, benzene, etc.)], as well as in some auto-intoxications (jaundice, uremia). A marked tendency to bleeding (in mucous and serous membranes) is observed in leukemic diseases, especially in acute forms of leukemia, and sometimes also in pernicious anemia. Finally, various acute infections may acquire hemorrhagic forms (hemorrhagic forms of smallpox, scarlet fever, typhus, coccal infections). Consequences of bleeding see Hematoma. Bleeding is called hidden (or occult) if it does not manifest immediately in any external way. Such are bleedings from parenchyma of various organs into surrounding cellular tissue, from ulcers, cancers, along the gastrointestinal tract into its cavity. - Spontaneous cessation of bleeding is a complex phenomenon depending on many factors, not just on formation of a blood clot, as was previously thought. Local factors leading to cessation of bleeding include vessel contraction both in width (spasm) and in length (retraction), twisting and gluing of the edges of the rupture (especially the inner lining), compression of the vessel by surrounding tissues and blood that has flowed into them; finally, the occurrence of nerve impulses in anemic tissue is admitted, transmitted via axon-reflex to afferent vessels and causing their constriction (Krogh, Tannenberg). Vir and Stegemann also attribute significant importance to the suction effect of capillaries in cessation of bleeding. Their activity can direct blood flow from the area where bleeding occurs to adjacent tissue areas (objections of Tannenberg and Hermann). It is possible that in such regulation of blood flow through capillary activity, besides their contractility, the functions of cells that block the mouths of capillaries are also significant (Tannenberg). Finally, general factors are also important in cessation of bleeding: fall in blood pressure, condition of vessel walls, blood coagulability, size of "bleeding time" (Blutungszeit), etc.

N. Anichkov. Arrest of B. Arrest of B. is carried out either pharmacotherapeutically or mechanically. In this case, either agents acting directly on the bleeding site are used, or those that act on the injured vessel indirectly and thereby promote its closure. In severe B. of various origins, the patient needs maximum rest, especially of the affected part, and elimination of causes for agitation. One of the measures to combat B. is to increase the clotting ability of the blood; for this purpose, ergotin, stiptol, stipticin, calcium', 5-10% gelatin solution, etc., are administered subcutaneously, orally, or intravenously. The most effective method for arresting B. is the introduction into organs (under the skin or into a vein) of blood serum of animals or humans (Barringer, Bra-asch, Allen) 20-100 cm³, and transfusion of whole or citrated blood in the amount of 300-500 cm³; such treatment is especially indicated in hemophiliacs and generally in patients with reduced blood clotting ability (see Blood Transfusion). Among the measures affecting the blood of a general nature, irradiation of the spleen area should be mentioned. For local B., adrenaline is used in a dilution of 1:1,000; it produces strong vasoconstriction and local anemia; but one must keep in mind the sometimes occurring subsequent dilation of vessels and resumption of B. When using adrenaline locally, symptoms of general poisoning have sometimes been observed [fainting state and even convulsions (Kravkov)]. The best local hemostatic agent is a piece of any organ or tissue (muscle) (thrombokinase) applied and pressed to the bleeding site. This method of stopping bleeding is easily accessible. Among local hemostatic agents, some astringent substances are still used to this day. Of the large number of astringent powders, lotions, etc. that were formerly in use, ferric sesquichloride (Liquor ferri sesquichlor.) has remained to this day; it is used undiluted; after moistening cotton with it, it is applied to the wound for several minutes. A scab forms, which Dyakonov evaluates as a good medium for the development of microorganisms, and therefore this agent should be removed from use. Cold acts initially as a vasoconstrictor and therefore can be applied in the form of a bag with ice or cold water; the disadvantage of this method is the difficulty of maintaining asepsis and the possibility of tissue necrosis with prolonged application of ice; moreover, after the initial constriction, the vessels dilate again and B. reappears, and in general, cold can only stop B. from the smallest vessels or even capillaries.-The use of high t° to stop B. has been reduced to just a few devices: Pakelen's apparatus, the galvanocautery loop (see Galvanocautery), and Snegirev's apparatus for vaporization (see). All these devices, by burning tissues, produce a scab; healing occurs under it. For mechanical arrest of B. from damaged vessels, see Blood vessels, surgery. In some, often desperate cases, deep in a wound, in the cavity, for example, of the abdomen, a damaged large vessel cannot be sutured, and ligation of it is incompatible or almost incompatible with life, for example, injury to vena cava inf. during removal of a kidney tumor; one has to apply hemostatic forceps to the wall and leave them in the wound for a long time, for several days (up to 5) (forceps a demeure); by the end of their stay, the vessel thromboses, and the forceps can be removed without B. recurring. The disadvantage of this method is the gaping wound, which creates the possibility of infection. Twisting of the artery is performed by rotating a forceps applied to the severed and freed from connective tissue vessel along its long axis until the captured part of the vessel tears off (Tillaux). This method is applicable only to small and superficially located vessels. Similar to the wall application of forceps a demeure, wall (lateral) ligation of the vessel can be performed: the injured wall of the vessel is grasped with forceps without completely closing its lumen, and a ligature is applied to the captured part; such a ligature can only be applied to a vein, because due to the high pressure in the artery and the elasticity of its wall, the ligature may slip. Instead of wall ligation, a wall or circular suture can be applied (see Vascular suture). In addition to B. from injured arteries and veins, there are also very serious B. from parenchymal organs-liver, spleen, kidney, postpartum atonic B. from the uterus. The source of such B. is small arteries and veins, which cannot be captured individually; in such cases, it is necessary to apply sutures to organs; the mattress suture is most commonly used; or tamponade with the omentum is applied, sewing it in or a neighboring organ (e.g., intestine), transplanting a piece of muscle into the wound; in cases of huge rupture, e.g., of the spleen, complete removal of the organ is resorted to (see Splenectomy). The hemostatic measures applied far from the wound are essentially the same as those applied directly to the wound: these are compression and ligation of arteries along their course (see Blood vessels). Besides fingers, the artery can be compressed with special instruments-tourniquets, but now hardly anyone resorts to such a measure, since it is much simpler to compress the artery by simple bandaging of the limb, e.g., with a bandage, a piece of cloth, a belt taken from oneself, etc. (see Blood vessels, surgery). B. can be stopped by strong flexion of the limb, e.g., at the elbow or knee, but a person cannot tolerate such flexion for any length of time due to pain.

A. Sirotkin. Recognition of death from exsanguination is based on the properties of the injury, on the presence of a large amount of blood near the corpse or in some cavity of the corpse, but mainly on the significant anemia of the corpse: the skin is pale, the postmortem hypostases are barely noticeable. When examining the corpse, a sharp anemia of all organs of both the thoracic and abdominal cavities is noted. Some organs stand out particularly for their anemia (complete bloodlessness and dryness of lung tissue, pallor of the kidneys and cardiac muscle). The cavities of the heart and large vessels are sometimes completely empty. Only in the brain, with sharp anemia of other organs, there is often no anemia. Due to the decrease in the amount of blood in the heart during diastole, negative pressure can develop in the cavity, especially in the left ventricle, as a result of which sometimes hemorrhages appear on the inner membrane (Minakov). In the diagnosis of death from general anemia, it must be borne in mind that in putrefaction of the corpse under the influence of postmortem transudation, all organs become anemic.