CHAPTER XXIII

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PREVENTION AND CONTROL OF HEMORRHAGE; SUTURES; KNOTS.

The first requisite after the infliction of a wound is to arrest and control the hemorrhage. In many operations upon the extremities precautions are taken to avoid its occurrence, and the so-called bloodless method of operating, which is effected by the use of an elastic bandage of pure rubber, is frequently employed and generally gives satisfactory results. The pure-gum bandage was first introduced into surgery by Martin, of Massachusetts, and its combined use both as an elastic bandage and tourniquet was so promoted by Esmarch that it is generally known as Esmarch’s bandage, and Martin has failed to receive the credit due him.

The _elastic bandage_ used for this purpose should be about three inches in width and five or six yards in length, and made of pure rubber. The operator begins by applying this to the tip of the extremity which is to be made bloodless. It is wound around the limb in spiral turns, with sufficient force to press out the blood from the tissues and to empty the vessels into those of the trunk. It is continued above the site of the operation, and then the limb is either constricted with a _tourniquet_ of the old type or with one of the rubber appliances used for this purpose. A few turns of the rubber bandage may be passed more tightly about the limb at this point and secured with forceps. The rest of the bandage is then unwrapped from the limb, which will be found pale and bloodless. Operation may then be practised without the loss of more than a few drops of blood. All divided vessels should be secured before the constriction is removed and the wound closed.

In septic, tuberculous, and malignant conditions no such pressure should be made, as harmful elements might be forced into the circulation. In such cases the elastic tourniquet is applied high up and no attempt is made to force the blood out of the limb. The limb should be elevated so that its veins may empty before the bandage is applied, and a certain amount of blood will thus be saved.

Care should be taken in graduating the tightness of the constricting band, as well as its narrowness, and in preventing undue pressure upon nerve trunks. Cases are on record of temporary and even permanent paralysis, due to too vigorous application of the tourniquet, and except upon large and stout limbs it is not often necessary to apply it as tightly as is often done. Moreover even a wide rubber bandage when stretched taut becomes little better than a rubber cord or rubber tube and sinks into the tissues. A sterile towel should be folded into a strip and wound around the limb, and then a tourniquet should be applied over it so that pressure may be more equably distributed and danger of paralysis reduced.

Exigencies may require the application of the elastic tourniquet as high as it can be possibly used, either upon the shoulder or the hip. This necessity is usually observed in amputations at those joints, and the special methods required will be more fully dealt with when speaking of these procedures. (See