Chapter LVII

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The elastic bandage should have been unrolled and sterilized with the rest of the surgical equipment required, and even when so protected it would be well to cover the limb with wet sterile towels before applying the bandage, which is usually done at the last in order to avoid contamination. When this is not done the final scrubbing should not be effected until the bandage has been placed, the tourniquet applied, and the bandage again removed.

[Illustration: FIG. 60

Illustrating forced flexion for control of hemorrhage.]

_The first measure, then, in the treatment of a wound is to prevent loss of blood._ This may be done in various ways, and the method should depend upon the circumstances of the case. In emergency cases it may be accomplished either by direct pressure, by constriction of the limb above the injury, or in some instances by mere position. If it be possible to make direct pressure through the medium of some clean--preferably sterile--dressing or material, this of course would be desirable. In all civilized armies soldiers are now equipped with a package of sterile dressing by which an emergency pad for this purpose can be promptly applied. Railroads and steamers are now providing emergency outfits. In injury of the arm or leg advantage may be taken of position, _i. e._, forced flexion, which is maintained by any measure or material which can be made available for this purpose (Fig. 60). _Digital compression_ over a main vessel may also serve a good purpose. Mere elevation of the part, as, for example, the head, when not otherwise contra-indicated, or a hand or foot, will do much to check venous or arterial flow. Moreover, in these positions reflex contraction of arteries occurs, even in those of the head when the arms are elevated. For this reason in cases of serious nose-bleed it is often advisable to keep the arms raised high above the head.

Of other means resorted to may be mentioned:

1. =Extremes of Heat and Cold.=--Water at a temperature of 130° to 160° F. is a powerful hemostatic. It stimulates contraction of the muscular coats of the vessels and produces coagulation of the albuminous portions of the blood upon the surface to which it is applied, and in this way plugs the capillaries and small arteries and so prevents oozing. Heat with pressure will be serviceable in many instances. Cold may be employed by means of ice or iced water and may be made serviceable in cavities like the mouth, the vagina, or the rectum, after patients have recovered from the anesthetic and at a time when hot water could not be borne. Cold has more of a constringing effect but less coagulating property.

2. =Pressure Directly Applied.=--This may be made with a tampon in some cavity, or by a graduated absorbent dressing whose effect may be regulated by pressure of a bandage or an elastic bandage. Care should be always given that pressure be not too long nor too firmly made, and it should be released as soon as there appears edema of the part below or any evidence of insufficient circulation.

3. =Styptics and Chemical Agents.=--There are many substances which contract vessels and cause more or less coagulation of blood, and at one time there were many of these in general use, but they have been supplemented by other products, _i. e._, cocaine, antipyrine, and adrenalin. The effect of cocaine is temporary, but sometimes is sufficient in the urethra or the nasal cavity. Antipyrine, in 5 to 10 per cent. solution, alone or with cocaine, has a similar effect, but is more lasting. Some years ago the writer stated that by mixing 10 per cent. solutions of antipyrine and tannin there was precipitated a gum-like material of extraordinary tenacity. This will check oozing from any part to which it may be applied, but it may adhere so tightly as to make it difficult to later remove the tampon. Of the hemostatic drugs, adrenalin has the most marvellous properties. It can be procured in solutions of 1 to 1000. A solution of this strength, somewhat diluted, may be spread or applied upon an oozing surface with almost instantaneous effect.

_The use of gelatin in checking hemorrhage_ has given some satisfaction upon the Continent, but has not found much favor in this country. It consists of a solution of 2 parts of pure gelatin to 100 parts of normal salt solution, which should be thoroughly sterilized. It is injected subcutaneously to increase the coagulability of the blood, and has also been injected directly into an aneurysmal sac or its immediate vicinity to induce coagulation. It is likely that if the surgeon have a patient with the hemorrhagic diathesis the combined use of gelatin in this way and of calcium chloride internally would give satisfactory results.

A styptic has recently been introduced by Freund under the name “_stypticin_.” It is a product of the oxidation of narcotin, one of the opium alkaloids, and is a yellowish powder of bitter taste. Chemically it is cotarnin hydrochloride. It has been used especially in the treatment of uterine hemorrhage, with a certain degree of success, regardless of the cause of the hemorrhage. It may also be given in cases of too profuse menstruation. The average dose is 2 to 3 Gr. (0.15 to 0.20) at intervals of two or three hours. When a speedy result is desired twice the above amount in 10 per cent. solution may be given subcutaneously.

4. =Destructive Methods= may include the use of the sharp spoon, chemical caustics, or the actual cautery. The curette is usually employed for removal of surfaces which have attained a spongy or easily bleeding condition, as the interior of the uterus, bleeding ulcers in other cavities, etc. When fungoid tissue is scraped to a base of healthy tissue there is usually a cessation of further hemorrhage. Occasionally there are cases of fungating cancer which bleed upon the slightest touch. The most radical way in which to deal with these for temporary purposes is to destroy the spongy tissue which bleeds so frequently. The gross part may be done with the sharp spoon and the cautery may be made to finish the work. Bleeding piles, when it is not permissible to treat them more radically, should be touched with the actual cautery, with stretching of the sphincter. The cautery knife should not be made too hot, as it may act similar to a sharp blade instead of merely searing by its heat.

5. =Mechanical Means.=--When vessels of considerable size or masses of tissue containing them can be made accessible, the best means of control of hemorrhage are those which can be applied directly to the vessels. When this is not possible they should be tied _en masse_. A method formerly in use was acupressure. To effect this a needle was passed through the overlying skin beneath the vessel and out again, and around this a suture was tied to make pressure. Since the introduction of absorbable materials this method has been supplanted by the use of catgut sutures, which may be tied, cut short, and left to absorb.

Under the term “forcipressure” is included the method of seizing vessels before, or as they bleed, in small forceps, which are variously shaped and constructed, and grouped under the name of _hemostats_. Small vessels seized between the blades of such an instrument will have their walls so crushed that blood clot is so quickly entangled that the forceps can be removed in a few moments with little or no danger of subsequent bleeding. Larger vessels should be ligated.

_Torsion_ is a substitute for ligature, especially with the smaller vessels, and denotes a twisting of the vessel end after its seizure, breaking up its inner coat, and effectually sealing its lumen. Some surgeons rely on torsion for the large vessels.

_Angiotribe_ is the name applied to strong crushing forceps, by which a pressure of several hundred pounds can be made through a lever mechanism. In this a mass of tissue, as the broad ligament, can be secured and such tremendous pressure brought to bear that its vessels are crushed and destroyed beyond possibility of bleeding. Downes has improved upon this mechanism by adapting to it an electrocautery arrangement, by which not only pressure but also heat is brought to bear. His instrument is called an _electrothermic clamp_. To all of these instruments there are at least theoretical objections, in that they are more or less clumsy or unwieldy and require special equipment. They devitalize a considerable amount of tissue, all of which has subsequently to be removed either by a process of sloughing or by

## active phagocytosis; but they serve perhaps a useful purpose in the

crushing treatment of hemorrhoidal tumors. They have been used only by a few, and have not found wide acceptance.

6. =Ligatures.=--These are also mechanical means of controlling hemorrhage, but deserve to be grouped by themselves. Ligation of vessels may be preliminary or may be performed as needed during an operation.

By a _preliminary ligature_ is meant taking such precaution as tying the carotid before operations on the face, the brain, or the femoral artery before amputation at the hip. There is also the method of temporary ligation of vessels by the application of a ligature which should not be drawn too tightly, but simply serve the purpose of gentle constriction for the half-hour or so during which it may be needed, after which the vessel is promptly released. If this ligature has not been too tightly applied the vessel walls will not have been injured and circulation is restored. Crile has effected the same purpose with the carotids by a small clamp whose pressure may be regulated by a thumb-screw.

Ligation of large trunks is made for the purpose of influencing nutrition by diminishing blood supply, as when the femoral is tied for elephantiasis of the leg, or the carotid is tied or excised, as suggested by Dawbarn, to cut off the blood supply from cancer of the face or neck.

Ligatures are usually made of absorbable material, such as catgut, chromicized or not, as may be desired, or of silk, which disappears after a time, but which is not regarded as absorbable. For special purposes other material has been used at times, such as strips of ox aorta. The surgeon has his choice of these, whether he intends to ligate the end of an artery or tie a vessel in its continuity. For the latter purpose the ligature is threaded into an artery needle, or a specially devised curved forceps known as the “Cleveland” needle. When tying the exposed end of a bleeding vessel it is desirable to tie near the cut end, so as not to leave tissue which should be absorbed, and for the same reason to not include unnecessary tissue. One of the forms of knot similar to the “reef” knot, which will not slip, should be used. Silk has the advantage over catgut in that a knot tied with it will rarely become loose, whereas catgut knots, unless carefully tied, will occasionally slip. The ligature knots should be left as short as is consistent with protection against slipping.

=Fate of Ligatures.=--Silk or celluloid thread are the most unabsorbable of ligature materials ordinarily used. Even these usually disappear after the lapse of time. Absorbable ligatures of catgut disappear after a few days or weeks, according to the method of their preparation. Absorption is practically a matter of phagocytosis, the end of the vessel or tissue beyond the ligature disappearing with the latter by the process of tissue digestion.

When vessels of large size are ligated the blood supply is taken up by the collateral circulation. On the possibility or practicability of the latter will depend the success of such operations as ligation of large trunks for the cure of aneurysm. Should the collateral supply prove insufficient, gangrene, beginning at the tip of an extremity, is an assured fact.

The effects of the ligature on the vessel wall will depend upon the security with which it is tied. The damage done to the inner and middle coats by a ligature tied for permanent purposes is usually sufficient to rupture them, after which they roll up inside the outer coat, while the blood contained in that part of the vessel coagulates, the clot extending to the first vessels above and below. This quickly organizes, becomes infiltrated with cells, and brings about the complete obliteration of that part of the vessel and its transformation into a fibrous cord. This can only occur, however, when asepsis has prevailed. Should the ligature prove septic the patient is exposed to two dangers: that of secondary hemorrhage by ulceration and breaking down of the clot instead of organization, and the ordinary dangers of septic infection.

There are circumstances under which it may be well to modify the ordinary methods of ligation and not to tie knots too tightly--_i. e._, when the vessels are greatly weakened by extensive disease, or so stiffened by calcareous degeneration as to cause them to snap under rough handling. It has been suggested to use pieces of ox aorta to prevent these accidents.

The dangers of _secondary hemorrhage_ pertain mostly to septic conditions. In an absolutely aseptic wound, properly cared for, secondary hemorrhage is almost impossible, but as soon as germ activity begins lymph barriers are broken down, tissues softened, and weakened vascular walls may give way.

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