308 DISEASES OF THE NASAL CAVITIES. 



mortem examination are negative, that is, we neither can find patulous 

 vessels as the source of the bleeding, nor can we, under the microscope, 

 demonstrate any anatomical change in the condition of the vascular 

 walls, to account for their liability to rupture. 



SYMPTOMS AND COURSE. In many instances the haemorrhages 

 are preceded by certain premonitory symptoms. These consist simply 

 in the sensations which are peculiar to hyperaemia and swelling of the 

 nasal mucous membrane, so that, for some time before the bleeding be- 

 gins, the patients complain of stoppage of the nose, or of pressure in 

 the region of the frontal sinus, or else there may be signs of fluxion- 

 ary or obstructive hyperaemia of the brain, or general vascular pleth- 

 ora. In either case, soon after the establishment of the haemorrhage, 

 the prodromal symptoms usually abate, and, as they are often more dis- 

 tressing than the haemorrhage itself, the latter is generally regarded 

 as " critical." 



The symptoms of the actual bleeding, when once it has set in, re- 

 quire no detailed description. Blood flows from both, or (as is more 

 common) from one nostril, either in drops, or in a continuous stream 

 of greater or less profusion. Should the haemorrhage begin while the 

 patient lies sleeping upon his back, the blood readily flows through the 

 posterior nares into the pharynx. Part of it may enter the larynx 

 and excite a cough, and the patient, upon awaking, fancies, to his great 

 terror, that he has had a haemorrhage from the lungs. 



In other cases, the blood is swallowed, enters the stomach, and, 

 when afterward voided by vomiting, may give rise to confusion with 

 gastric haemorrhage. The blood first lost has almost always a some- 

 what dark color, and shows great tendency to coagulate in the vessel 

 into which it is received, or upon the lips, and even within the nose. 

 This coagulation generally checks the bleeding in a short time, acting 

 either as a spontaneous tampon, or by spreading from the effused blood 

 to within the capillaries themselves. In other instances, however, in 

 which the blood shows little tendency to coagulate from the first, or in 

 which the tendency diminishes more and more, the haemorrhage lasts 

 longer, and exhausts the patient, particularly if he already be enfee- 

 bled prior to the loss of blood. 



It is a matter of daily experience that, the longer an epistaxis lasts, 

 the more obstinate it becomes ; and often, after a duration of three or 

 four days, it can only be subdued by means of the tampon. In some 

 cases, it becomes apparent that loss of blood aggravates the haem- 

 orrhagic diathesis more than any other debilitating cause, since, after 

 an exhausting epistaxis of several days' duration, haemorrhages from 

 other mucous membranes and bleedings into the structure of the skin 

 (petectia) supervene. In such cases of abundant and persistent bleed- 



