over the pad, and then carrying the ends ai'ound the pelvis and securing
them.
To make pressure on the axillary artery the compress should be
placed in the axilla, and the middle of the tube is placed over this to
hold it in position ; the ends of the tube are then carried over the
shoulder and crossed, and then carried to the opposite axilla and
secured.
In amputation of the shoulder-joint, to make pressure upon the
subclavian artery, which is difficult to compress by an ordinary tourni-
quet, the handle of a large key well padded may be used ; it is firmly
pressed against the vessel above the clavicle and held by an assistant,
and proves a very satisfactory means of controlling circulation in this
vessel. Wyeth's pins with an elastic strap or tube are now often
GEXERAL TREATMENT OF HEMOBBHAOE.
129
eniploved tu control hemorrhage during amputation at or near the
shoukier-joiut.
Hcemostatic Forceps. — The temporary control of arterial hemorrhage
by the use of haemostatic forceps is now tlie common practice in
surgical operations, and their use has done much to diminish the shock
from the ktss of blood following operations. The hijemostatic forceps
Fig. lOo.
Ha-niostntic forceps.
in general use is self-retaining ; it is clamped upon the bleeding vessel,
and is allowed to remain until the operation is completed, when the
vessel is secured jiermanently by the ajiplication of a ligatui-e and the
forceps is removed. The use of this instrument will be found very
satisfactory in controlling hemorrhage during the removal of tumors
and in cases of amjiutation, and for the temporary control of bleeding
during the operation of tracheotomy it will be found most efficient, as
also in abdominal operations, in which its utility was first demonstrated
(Fig.^ 163).
Esinarch's Bandage and Tnhe. — Esmarch's ujiparatus, which is
applied to the limbs to render them bloodless during ojierations, con-
sists of a rubber bandage two and a half inches in width and three
or four yards in length, and a rubber tube two yards in length, to one
Fi(i. 164.
Esmarch's bundagc and tulx- Mp7)Iiod.
end of which is attached a chain and to the other end a hook, or, better,
a rublier strap one inch in width and one yard in length, with a hook
and chain. The bandage is applied to the extremity of the linil), and is
VuL. II.— 9
130 MIX on SUIiOERY.
carried up the limb to a point some di.staiiee above the .-^eat of ])ropose<l
operation : the bandage i.s applied Hrndy, each turn overhippinii' one-
t'ourth of the preceding one, and wiien the last tui-n has been made the
rubber tube or strap is woiuid tirmly around the limb, and is secured by
fastening the hook into one of the links of the chain (Fig. 164). After
securing the tube or straj) the rubber bandage is removed from the limb,
and if the tube has been tirmly enough apjjlied the limb will be foimd
to be blanched, and should be free from Idood during the operation.
Cai'e should be taken not to apply the tube or strap too tightly in
poorly-developed limbs or on parts of the limb where large nerve-
trunks approach the surface, as they may be subjected to an amount
of pressure which will interfere with their functions subsequently : the
writer has knowledge of one case of this nature in which jicrmanent
paralysis of the limb followed the use of Esmarch's a2)paratus. The
tube should be applied with just enough firmness to control the circula-
tion. As the strap, when hrndy aj)]ilied, completely cuts off the circu-
lation of the parts below, it should be allowed to remain for as short
a time as possil)le as gangrene has resulted from its prolonged use.
After the removal of the tube there is generally tpiitc free capillary
hemorrhage, due to j)aralysis of vasomotor nerves from pressure, but
this in a short time stops, esjjecially if hot water is used to irrigate the
wound. This apparatus is of the greatest service in controlling hemor-
rhage at the time of operation, and in amputations and remo\-al of vas-
cular tumors from the lind)s will be found most satisfactory. In
operations upon l)one, either osteotomy or sequestrotomy, it is espe-
cially useful, as it allows the surgeon to have a view of the parts
unobscured by hemorrhage. In operations for the removal of foreign
bodies, such as needles imbedded in the hands or feet or extremities,
Esmarch's bandage is most useful.
Permaxent Control of .Vrteriai> Hemorrh.vge. — For the per-
manent control of arterial hemorrhage the surgeon may resort to the use
of position, cold, heat, styptics, pressure, cauterization, ligation, torsion,
or acupi'essure.
Position. — In arterial hemorrhage from wounds of the extremities
elevation of the parts will bo found to materially diminish the amount
of bleeding; in hemorrhage from wounds of the hand, forearm, foot, or
leg fbrcilde flexion of the forearm on the arm or of the leg on the thigh
will be fdund useful in diminishing the force of the blood-current.
Cold. — The application of cold by means of a stream of cold water
or of an ice-bag or piece of ice will often be found an efficient means
of controlling arterial hemori'hage from vessels of smaller calibre ; it is
especially applicable to lienKu-rhage from wonnds of the vessels of the
mouth, nostrils, vagina, or rectum.
Hot Water. — Hot water will be found a very efiieient means of con-
trolling hemorrhage from small vessels, and it may be used in the form
of a hot antiseptic solution. It is of especial value in capillary or
parenchymatous hemorrhage ; it is employed in the form of a douche
or by means of sponges dipped in the hot solution and packed into the
wpund. Injection of hot water is the most satisfactory means of con-
trolling uterine hemorrhasre.
Styptics. — These agents are sometimes employed to control capillary
GENEBAL TREATMENT OF HEMORRHAGE. 131
bleeding or lieiuorrhage from small vessels, but, although their use is
found satisfactory as regards the control of the bleeding, they have the
disadvantage of interfering with the primary union in wounds, and since
the value of asepsis in wound-treatment has been demonstrated they are
now very seldom employed. The most valuable styptics which are used
are alcohol, alum, oil of turpentine, perchloridc of iron, persulphate of
iron (or Monscl's solution), acetic acid, or vinegar.
Pressure. — For the permanent control of arterial hemorrhage pressure
may be applied directly to the bleeding point or surface by means of a
compress of antiseptic or sterilized gauze or by strips of gauze packed
into the cavity from whose surface the bleeding arises.
Compresses are used with the best results where tlie proximity of a
bone gives a firm substance upon which the vessel may be compressed,
as is the case in the vessels of the scalp. Pressure applied by means of
packing with strips of gauze will be found most efficient in controlling
hemorrhage from cavities such as the nose, vagina, or rectum, and in
the cavities resulting from the removal of necrosed or carious bone.
Pressure may be indirectly apiilied by flexing the proximal joint over
a compress or by firm bandaging of the limb. In controlling bleeding
from a divided artery in a bony cavity, such as the inferior dental canal,
a piece of catgut ligature may be forced into the canal, and it will con-
trol the bleeding in a most satislactorv manner.
Halsted has recently introduced the use of a material known as r/iit-
ironl, which is prei>ared from the subnuicosa from which catgut is made ;
this is moistened witli alcohol, and cut into fine shreds. The wool
is preserved in an alcoiiolic solution of corrosive sublimate, 1 : 1000,
and is used for stopping excessive hemorrhage from bone, a small quan-
tity being pressed into the cavity or opening in the bone from which the
bleeding arises.
The troui)lcsome hemorrhage sometimes occurring after the removal
of a tooth may be controlled by }>acking the alveolar cavit}' with a strip
of sterilized gauze or by introduciug a wedge-shaped piece of cork into
the cavity and holding it in place by fastening the jaws together by
means of a bandage.
Caniirizatioii. — The use of cauterization by means of a hot iron is a
s;itisfaetory manner of arresting hemorrhage. Care should be taken to
have the iron only of a dull-red or black heat, as the result desired is not
the destruction of the tissues, but the coagulating effect of heat upon
them. The form of cautery-iron employed will de])cnd upon the posi-
tion of tlie vessel. Pa(iuelin's cautery is a very satisfactory apparatus
to Use for the conti'ol of hemorrhage.
Control of arterial hemorrliage by cauterization is often resorted to
in o])erations upon the jaws and in the removal of tumors from the
mouth or ])harvnx, or of the tonsils; it is also frequently employed to
control hemorrhage in operations upon the uterus and the rectum, and
also tliat resulting from the removal of abdominal tumors where the
ap])lication of a ligatiu'c is difficult and often inqmssiblc.
Torxiou. — This method of controlling arterial hi^morrhage consists in
seizing the end of the artery, drawing it slightly out of its sheath, and
twisting it : it may be accomplishctl by a single pair of forceps or by
two pairs of fiirceps. In the latter method the artery is held by one
132
MINOR SURGERY.
pair of forceps and twisted In- tiie second pair. Torsion of arteries in
accidental wounds is (piitc common, and in many cases controls the
hcmorrliaiie until surgical aid is rendered. The
Fig. 165. femoral artery in Scarpa's triangle has been com-
pletely conti'olled in this manner in the case of
an avulsion of the thigh from railway injury.
In vessels of moderate size it may he practised
with one pair of forceps, and the ordinary double-
FiG. 16(;.
QOi
.spring artery forceps (Fig. 1C6) or hiemostatic for-
ceps will be found satisfactory for such cases. In
larger arteries two forceps should be employed,
or some of the numei'ous forms of torsion forceps
(Fig. 165) which have been devised for this pur-
pose.
Lif/aiion. — The use of the ligature is by far
the mo.st generally employed method of control-
ling arterial hemorrhage. Tlie materials used for
ligatures are silk, hemp thread, catgut, horse-
hair, iron or silver wire. Catgut or silk is the
material most generally employed. The vessel is
seized with a pair of artery or hiemostatic forceps
or a tenaculum, and drawn out of its sheath, and
a ligature of prepared catgut is thrown around
it and secured by a surgeon's knot or by a reef
knot and surgeon's knot combined, and when
firmly tied the ends of the ligature are cut short
Fig. 16'
HewBon's torsion forceps.
Aneurism necrlle armud with ligature.
in the wound. Silk ligatures which have been rendered aseptic are
applied in the same manner, and the ends may be cut short in the
wound.
When ligatures are ajiplied to vessels in their continuity they may
be threaded into an eved prolie or aneurism needle (Fig. 167), and carried
around the vessel and secured. A convenient method of ap]ilying a
ligature to a bleeding point in a deep wound or to a vessel in tissues
■which are of such a nature as not to permit of the isolation of the vessel,
GEXEEAL TREATMENT OF HEMORRHAGE.
133
Fig. 168.
Artery occluded by suture (Esmarch),
i.s to use a ourxcd needle threaded with a catgut ligature, which is passed
deeply into the tissues near the vessel and brought out at the opposite
side ; the ligature thus placed is then
firndy tied and tlie ends are cut short
in the wound (Fig. KJSj.
Constriction or Crushing of Arteries
for the Arrest of Hemorrhage. — This
procedure has been adopted for the clos-
ure of arteries without the use of liga-
tures or other foreign substances to be
left in the wound. It was employed l)y
the use of an instrument known as the
artery constrictor, whieii grasj)ed the
artery and constricted it in such a way
that the inner and mi<ldk' coats gave way, but the external coat was
preserved intact.
^irterirrrxioii. — This nietlicid of controllintr hemorriiaiie consists in
constricting the mouths ot arteries divided in amputations by turning
over the cut ends with a little instrument called an arteriverter : with
this instrument the ends of the diN'ided arteries may be retroverted, and
the cut extremity of tjie artery is reinforced by tlie duplicature of its
walls, thus surrounding its open mouth with sucli a (juantity of arterial
nuiscular and elastic fibres as to effectually close it against the impulse
of the heart's action. This procedure has been practised in a few cases,
but has never come into general use.
AcrPRESSURE. — In this mctliod of controlling arterial hemorrhage a
needle or pin is used whicli is thrust through the tissues in such a way
as to compress the artery. There are a number of methods of using the
needle or pin.
First Method of Acupressure. — In this method the surgeon places
a finger of his left hand u]ion the mouth of the bleeding vessel, and with
his right hand introduces the needle from the cutaneous surface, and
passes it through the thickness of the flap until its point projects for a
couple of lines or so from the surface of the wound a little to the right
side of the tube of the vessel. By forcibly inclining the head of the
needle toward the right he tarings the projecting portion of its point
firmly down on the side of the vessel, and after seeing that it occludes
Fie. 169. Fig. 170.
Acupressure— first method :
surface (Erichsen).
Acupressure— first iiietliml: < utaneous
surface (Erichsen).
the artery he makes it re-enter the flesh as near as possible to the left
side of the wound, and pushes the needle through the flesh till its point
comes out again at the cutaneous surfoce (Figs. 169, 170).
134
MINOR SUBOEEY.
Second Method of Acupressure. — A straight needle threaded witli a
sliort ])iei'e of iron or silver wire, for the purpose of afterward retraetiiig
and ri'iuoviiig' it, is passed down through the soft })arts a little to one
side of the vessel ; its point is tiieii raised up and j)assed over the artery,
and is then turned do\\ii again and thrust into the soft tissues on the
other side of the vessel (Fig. 171).
Fiu. 172.
,, J
Fig. 171
fh
f|||:j
Acupressure— second method
(Erichsen).
Acupressure— third method
(Erichsen).
Third 3fcthnd of Acupressure, or Filo-jrressure. — In this method the
point of the needle is passed into the tissues a few lines to one side of
the vessel, then passed under it, and afterward pushed on, so that the
point again emerges a feM' lines beyond the vessel. A loop of wire is
next passed over the point of the needle, and then, after being carried
over the vessel and jiassed around the o])j>osite end of the needle, it is
drawn suftieientl}' tight to close the vessel, and the ends of the wire are
secured by making a twist around the stem of the needle (Fig. 172).
Fourth Ilethod of Acupressure. — This method is identical with the
third method, except that a long pin is useil in place of the needle ; the
head of the pin remains outside of the wound.
Fifth Method of Acupressure, or Acutorsion. — This method consists in
passing a j>in or needle through the soft tissues close to the artery, and
Fig. 173.
Acupressure— fifth method (Erichsen).
by giving the jiin a quarter or half rotation twisting the vessel upon
itself, and fixing the jiin Ijy thrusting its point deeply into the tissues
beyond (Fig. 173).
Treatment of Venous Hemorrhage.
Bleeding from small veins often stops spontaneouslv unless there is
some pressure upon the wounded veins upon the cardiac side of the
wound. It is, however, very satisfactorily controlled by position, or by
the application of a compress and bandage, or by the use of a ligature :
if the divided vein be a large one, it is well to secure both ends of the
TREATMENT OF SECONDARY HEMORRHAGE. 135
vein by ligatures. Tiie free bleeding arising from ruptured varicose
veins of the leg is easily controlled by a compress and bandage, while
hemorrhage from the larger veins, such as the jugular, should be con-
trolled bv tile application of ligatures as in the case of wounded arteries.
The ap})lication of the lateral ligatures to small wounds of veins of large
size, sucli as tiie femoral, jugular, or subclavian, or to woiuids of the
venous sinuses, lias been recommended and employed with good results.
It consists in pinching up the wall of the vein so as to include the orifice
of the wound and throwing a delicate silk or catgut ligature around it
and tying it firmly. The use of the actual cautery may also be required
for the control of venous hemorrhage in positions in which its arrest by
pressure or the ligature is not feasible.
Treatment of Capillary or Parenchymatous Hemorrhage.
Capillary or parenchymatous hemorrhage is usually arrested spon-
taneously by the expcjsure of the surface of the ^vound to the air, but
it is often so profuse that its arrest becomes a matter of importance.
To control tiiis form of bleeding, pressure may be applied to the sur-
face for a short time, and if this fails to arrest it, sponging the sur-
face witli dilute alcohol will sometimes prove satisfactory ; l)ut the best
application to arrest hemorrhage of this nature is hot sterilized water or
hot water, wjiicii may lie used in the fiirm of a hot bichloride solution.
Acetic acid and vinegar are also sometimes employed for the same pui'-
pose. In cases where the means mentioned above fail to control the
bleeding it may be necessary to pack the wound with strips of antiseptic
gauze : this dressing is most serviceable when the hemorrhage comes
from cavities, such as results from the removal of tumors or excision of
joints ; and for tlie control of l)leeding following the removal of necrosed
or carious bone packing the cavity resulting is the method very generally
employed. To control hemorrhage from mucous cavities, such as the nose,
rectum, and vagina, this method of treatment is sometimes resorted to.
Treatment of Secondary Hemorrhage.
Secondarv hemorrliaa-e folio wino- the use of the liirature or other means
of controlling bleeding is, since the adoption of the aseptic method of
wound-treatment, a much less frecpient com])lication of wounds. The
treatment of this complication is both constitutional and hical. The
constitutional treatment consists in the uscof tliose remedies which were
mentioned as serviceable in primary hemorrhage, and the drugs on which
the most reliance is to be placed are opium and ergot. The local treat-
ment of this form of hemorrhage consists in the use of the various means
of controlling hemorrhage which have been mentioned before, such as
the ligature, hot water, pressure, or the actual cautery. If possible, it is
well to secure the vessel from which tlie bleeding arises in the wound.
If for any reason this cannot be done, the main artery should be ligated
at the point of election above the wound if the hemorrhage be arterial.
Rules for Ligating Wounded Arteries.
In case of ])rimary hemorrhage tlie ideeding artery should be sought
for and secured by a ligature. In applying a ligature to a wounded
136 MINOR SURGERY.
artory the surffcon should out directly down ii])on it at the point from
wliicli it bleeds, and secure it in the wound. This rule holds good lor
both primary and secondary hemorrhage.
Two ligatures should be applied — one to each end of the artery if it
be completely divided, and one on each side of the wound if the latter
has not completely severed the coats of the artery. This procedure is
adopted for the reason that the arterial anastomosis is so free that the
])roximal ligature will not always, even temporarily, arrest the bleeding ;
and if it does accomplish tliis object at the time, after the collateral cir-
culation is establislied bleeding is apt to occur from the distal extremity
of the divided vessel. If the coats of the artery are not completely
severed, their division should be completed either before or after the
ajjplication of the proximal and distal ligatures, thereby favoring the
contraction and retraction of the ends of the divided vessel.
PLASTIC SURGERY.
By GEORGE R. FOWLER, M. D.
Injueies and Inflammations of the Facial Region.
Wounds. — Owing; to the vascularity of the parts, wounds of the
face bleed freely, ^\'itll the exception of some of tlie larger branches
of tlie facial artery, iiowever, the application of a ligature is seldom
required. Tiiis same vascularity also explains the almost invariable
occurrence of healing by first intention of M'ounds in this region. Even
in tissues considerably lacerated and contused, sloughing is a rare cir-
cumstance. Xature's efforts are frequently successful in filling up
defects, hence plastic jirocedures are best deferred until complete cica-
trization takes place.
Burns. — Burns from hot water, caustic li(juids, and chemical sub-
stances driven against the face in laboratory accidents are usually deeper
than at first appear, and frequently involve an unfavorable prognosis so
far as the cosmetic effect and function of the parts are concerned. In
the case of the lower lij) the saliva trickles away and the formation of
labial sounds is interfered with. Ectropion of the lower eyelid permits
the tears to flow over the face, and the globe of the eye suffers in conse-
quence. Extensive formation of cicatricial tissue at the lateral aspects
of the cheeks embarrasses the movements of the lower jaw. Operative
interference is here demanded.
Gunpowder Accidents. — Tlie presence of powder-grains in the skin
of the face involves considerable disfigurement. When recent, the
greater portion of them can be removed by vigorously scrubbing the
face, under an anaesthetic, by means of a coarse and stiff hand-brush
(Richardson). A stiff cataract needle applied to each powder-grain if
the case is not seen, until late will remove these in the course of time,
altliough many sittings are required. According to Hebra, the prolonged
application of a 1 per cent, solution of mercuric chloride is said to facil-
itate the extraction.
Simultaneous "Wound of Skin and Mucous Membrane. — ^^'hen
both skin and mucous membrane are wounded at the same time, sep-
arate suture of the divided structures is required. This is particularly
true of tlie eyelijs. Perforating wounds of the oral cavity, if permitted
to cicatrize, leave fistulous (i]>enings, tlu-ough whicli li(|uids that are
taken into the mouth escape, as well as tlie mucus and saliva. Stenson's
duct may be involved in the injury, and the {>arotid secretion poured
upon the outside of the face.
Traumatic Inflammation. — The extension of septic processes in the
facial region are of rather infrequent occurrence, although tlie extensive
vascularity of the soft jxtrts would tend to favor such extension. This
comparative innnunity from spreading infiammatory conditions is mainly
l."i7
138 PLASTIC SURGERY.
clue to the jicculiar arr;iii.<i'('niciit (if tlie snl)fiitanoons connective tissue,
which passes directly at rioiit angles to the surtace to enihraee the sub-
cutaneous muscles. Altliou<xh wounds in the neijihhorhood of these
muscles gape widely, the peculiar arrangement of the connective-tissue
fibres prevents projjagation of septic inflaniniatory processes. In other
parts, however — as, for iiistanc-e, in the eyelids — the fibres of the con-
nective tissue arc arranged parallel to the fibres of the orbicularis jialpe-
brarum, and phlegmonous infianunation is more ajit to occur. I )estruction
of tissue here may give rise to cicatricial shortening of the integumentary
surface of the lid, and consequent ectropion. Extension of the septic
processes through the medium of the ]ialpcbral fascia and along the
muscles of the globe or sheaths of the nerves into the mass of fat behind
the globe inself, and thence through the superior or inferior orbital fissure
to the brain, may occur.
A characteristic symptom of septic inflammation about the face is
cedematous swelling of the involved parts. This is due, in jiart, to
venous and lym])hatic congestion, and in part to serous infiltration.
Erysipelas infection likewise produces oedema. The occin-rence of ery-
sipelas in the face may lead to an extension to the scalp, and to tlie
peculiar clangers which arise from the presence of infection in that
region. Septic thrombi in the facial and orbital veins may give rise to
serious metastatic pyaemia.
Although the facial region, therefore, is not particularly prone to