pressive bandage can be strengthened by an elastic bandage under moderate
tension.

If these rides are observed, a secondary hemorrhage Jieed not be apprehended.

If the surgeon, however, from excessive fear of secondary hemorrhage,
or because he thinks himself not sufificiently skilled in finding smaller divided
vessels, does not venticre to suture the wound and to bandage it before the
constriction is removed, then, after removal of the bandage, with the limb
held in a vertical position, a large compiessive bandage or a sponge must be
firmly pressed for several minutes upon the surface of the wound, and the
vessels which are still bleeding or spirting must next be sought for and tied.
If the parenchymatous hemorrhage, however, continues, it is arrested by
irrigating the wound with a sterile or antiseptic fluid as cold as ice. For
this purpose, an ice douche is used, — that is, a glass irrigator in the middle
of which a glass tube filled with a cold mixture (pounded ice and salt) is



234



SURGICAL TECHXIC



inserted. Digital compression of the principal artery is also useful in arrest-
ing parenchymatous hemorrhage.

The advantages of elastic constriction over former methods, — especially
the advantages of the application of the tourniquet, — are generally known ;
they consist chiefly in the fact : —

1 . That the blood interruption is safe and can be maintained conveniently
for a long time.

2. A displacement during transportation, as is the case with the pad of
the tourniquet, need not be apprehended.

3. The constrictor can be applied on any desirable part of the limb.

4. For applying the constrictor band, no anatomical foiozuledge is neces-
sary.

In contradistinction to these advantages, it is hardly necessary to refute
the assertions again and again made by some persons that the procedure
had the following disadvantages : —

1. More profuse parenchymatous hemorrhage.

2. Gangrene of the margins of the wound, or even of the whole con-
stricted limb.

3. Paral)^sis of the nerves from the pressure of the constrictor.

4. The danger of infection from pus or tumor cells from compression of
the limb.

A^one of these disadvantages exist, if the above simple
7'nles are obseii'ed in applying the bandages.

Only briefly may it be mentioned here
that formerly a successful attempt was
made to interrupt the flozv of blood by
pressu)-e limited to the field of operation.
Desmarres invented his clamp for opera-
tions on the eyelids ; these are clamped
upon the plate by means of the ring (Fig.
415). DieffenbacJi used forceps ending in
two rings, between which he clamped the
cheek, the tongue, or the lip, in order to
remove bloodlessly angiomata, etc. (Fig.
416). In the operation for harelip or the
cutting out of a wedge-like portion in
cancer of the lips, the flow of blood from

iG. 415 ^^ coronary arteries can be arrested on
Desmarres s -'

Clamp both sides of the field of operation with





Fig. 416

Dieffenbach's Rinl;

Forceps



THE TREATMENT OF WOUxNDS



235



two long hemostatic forceps. In the same manner operates the constriction
of the root of the tongue in amputations of the tongue, and the stitching
about of the neighborhood of the wound in tumors of the tongue and
cheek, and in tracheotomy. We may mention here also Ricord's forceps
for phimosis operation. The transverse and parallel forceps for compress-
ing the pedunculated base of many tumors and as an aid in circular gastror-
rhaphy and enterorrhaphy, etc. Finally, may be mentioned the application
of the rubber tube in most recent times, in amputation of the rectum, in
supra-vaginal amputation of the uterus, and in the Caesarean operation.

Compared with the bloodless method, the other blood-saving methods of
former times are used only in exceptional cases, since they are performed
with difficulty and are uncertain in their results. They all have for their
object

THE COMPRESSION OF THE MAIN TRUNK OF THE ARTERY

above the wound.

I. By pressure of the finger (digital compression), the artery can be com-
pressed effectually only in places where a hard base is furnished by the bone
and where the vessel lies not too deeply concealed in the soft parts.

The most suitable places for digital compression are : —

For the common carotid artery, the anterior lateral region of the neck
between the larynx and the
median margin of the sterno-
cleidomastoid, where the finger
presses the artery against the
cervical column (Fig. 417).

For the subclavian artery,
the supraclavicular fossa on the
lateral margin of the sterno-
cleidomastoid, where the artery
is behind the scalenus anticus
muscle and is pressed against
the first rib. The access of the
finger is facilitated by press-
ing forward the shoulder and
the clavicle (Fig. 418). The
subclavian artery also can be
compressed by strong retrac-

•^ ° riG. 417. COxMPRESSION OF THE CaROTID ARTERY

tion of the shoulder m a pos- by Finger Pressure




236 SURGICAL TECHNIC

terior direction and with the aid of the other arm, between the clavicle and
the first rib (like a compression stopcock). The hand is made to grasp
from behind the bend of the elbow of the healthy arm ; the latter is
pressed forward and both arms are tied together in this position by cloths
or bandages (Fig. 419).

For the axillary artery, the anterior margin of the axillary space (the
anterior border of the axillary hair) where the artery can be compressed
against the head of the humerus when the arm is raised.

For the brachial artery, the internal side of the humerus in its whole
length, where the artery can be everywhere compressed easily against the
humerus along the internal margin of the biceps muscle (Fig. 420).

The abdominal aorta with flaccid abdominal walls and empty intestines
can be compressed at the level of the umbilicus against the vertical column.
In most cases, however, the pressure cannot be tolerated long without
anaesthesia.

The same is to be said of the external iliac artery in its upper part,
where it can be compressed against the lateral margin of the inlet of the
pelvis. It can be compressed more easily and for a longer time a little in
front of its exit from the pelvis above the middle of Pouparf s ligament
against the superior border of the horizontal ramus of the pubis.

The femoral artery is most easily compressed directly below Poupart's
ligament against the iliopectineal eminence (Fig. 421). The vessel is found
in the middle of a line drawn from the anterior superior spinous process of the
ilium to the symphysis of the pubis. In its further course as far as the
lower third of the femur, it can be compressed against the femur ; digital
compression, however, on account of the thickness of the soft parts lying
between, is difficult and unsafe, especially in stout and very muscular
subjects.

Since a successful digital compression can be performed for some time
only by a well-trained and strong hand, but during the transportation of
seriously injured persons, not at all, attempts have been made to supply the
same by various appliances.

2. By artery compressors or tourniquets; they consist essentially of a
bandage with which a hard pad {pclottc) or a roller is firmly pressed against
the trunk of the artery. The tourniquet can be applied correctly only by a
surgeon who is familiar with the anatomic conditions. It must be constantly
watched, for if it becomes displaced by imprudent movements or during trans-
portation, it does not operate any longer and can even become injurious by
causing stasis by pressure on large veins, which always accompany the artery.



THE TREATMENT OF WOUNDS



237




Fig. 418. Cu.MPREysiON of the Subcla\'ian Artekv
BY Finger Pressure



Fig. 419. Compression of Right
SuBCLA'i'iAN Artery





Fig. 420. Compression of Brachial
Artery



Fig. 421. Compression of Femoral
Artery



238



SURGICAL TECHNIC



The tourniquet is applied in the places mentioned above for digital com-
pression selected on the limbs, and of these again, the arm and the thigh
near the trunk, because here the artery can be found rather easily and can
be most successfully compressed (Figs. 422, 423).





Fig. 422. Compression of Brachial
Artery by Tourniquet



Fig.



423. Compression of Femoral
Artery by Tourniquet



Petifs screw tourniquet was most generally used (Fig. 424); in this, the
circular band is stretched by a strong screw, and the pressure exerted by the
pad upon the artery can be increased at pleasure.

The Spanish windlass (Fig. 425 ) consists of a strap with a buckle, to which
a hard pad is fastened, a plate, and a short stick. After the pad has been
appUed over the trunk of the artery, the strap is buckled loosely around the
limb and then firmly drawn tight across the plate by twisting with the stick.

Pancoasfs aorta tourniquet (Fig. 426) is operated with a long screw,
which moves a broad pad against the posterior cushion.

Of similar construction is : —

Von EsinarcJis aorta tourniquet (Figs. 427, 428). Its pad, provided with
a handle, is pressed against the vertebral column by elastic bandages, which
are stretched between the adjustable hooks of the posterior cushion. The
steel handle of the pad is provided with a slit, through which the turns of



THE TREATMENT OF WOUNDS



239





240



SURGICAL TECHNIC



rubber bandage can be drawn, and with two pads of different size. The
upper pad is kept in position by the hand of an assistant, so that the lower
one cannot sHp off from the aorta.



IMPROVISED ARTERY COMPRESSORS

The aorta can also be successfully compressed with a Hnen bandage 8
meters long and 6 centimeters wide, firmly wound around the middle of a

stick as thick as the thumb and a
foot in length. This pad, applied over
the aorta below the umbilicus, is held
in position by an assistant, and is
pressed forcibly against the vertebral
column by a number of turns of a
rubber bandage 6 centimeters broad,
carried around the body (Fig. 429).

If circular constriction of the ab-
domen is to be avoided, the linen band-
age is wound, according to Brandts,
around the middle portion of a longer
stick, and its ends are pressed downward through the turns of the rubber
bandage and passed under the plate of the operating table (Fig. 430).

In a similar manner, a tourni-
quet can be made for compres-
'^/ /'^ sion of the external iliac artery,




Fig. 429. Compression of the Aorta by Pad
AND Rubber Bandage




Fig. 430. Brandis's Method of Compressing
Aorta



Compression of External
Iliac Artery



directly above Pouparfs ligament, with a bandage and a pad firmly pressed
upon the artery by a strong rubber bandage, applied in cross turns (Fig.
43 1 ) for high amputations of the thigh.



THE TREATMENT OF WOUNDS



HI



A stick tourniquet (Spanish windlass) can also be improvised by wind-
ing around the limb a handkerchief or a triangular cloth, which is tied into





Fig. 432. Improvised Spanish Windlass Fig. 433. Compression of the Brachial Artery

a firm knot or in which a flat, smooth stone has been wrapped ; by twist-
ing it with a stick or some similar object (sword, ramrod, key) inserted
under the cloth, it can be firmly constricted
(Fig. 432).

For compressing the brachial artery, a com-
paratively light pressure exerted with a thick
stick against the internal surface of the arm is
sufficient (Fig. 433); this pressure forces apart
the bellies of the muscles in an anterior and
posterior direction, and presses the artery flat
against the bone. The arm is pressed firmly
against the body by a cloth or a bandage. The
arm can also be very effectually compressed
between two sticks tied together on both sides
( Volcker's stick tourniquet — Fig. 434).

3. By position: Adelmaim recommended as
a remedy for arresting arterial hemorrhages
hyperflexion of the limbs. By this, the arteries
become so strongly bent that they do not per-
mit the passage of blood. If, for instance, in

R




Fig. 434. Volcker's Stick
Tourniquet



242 SURGICAL TECHNIC

arterial hemorrhages from the forearm or the hand, the forearm in supina-
tion is strongly flexed and firmly tied against the arm by a bandage or a
cravat, the pulse in the radial artery ceases immediately. In the same
manner, by a forcible flexion of the knee, hemorrhage from the vessels of
the leg and the foot, and, by a hyperflexion of the thigh, hemorrhage from
the femoral artery, can be momentarily arrested. In cases where other
means for arresting hemorrhage are not at hand, hyperflexion can be re-
sorted to successfully. Still, it must not be forgotten that such a strongly
flexed position as is required for safely arresting the hemorrhage cannot,
in most cases, be endured for a long time, and if the bones are broken at
the same time, it cannot be made use of at all.

4. Lastly, the blood supply is very considerably decreased by raising
the limb vertically. At times, venous hemorrhage yields to this simple
expedient, provided all articles of clothing, garters, etc., which tend to
promote congestion have been previously removed.

ARRESTING HEMORRHAGES IN THE WOUND

Violent hemorrhage from injured vessels endangers life directly, and
must be arrested as rapidly as possible. In the simplest manner, at least
temporarily, the hemorrhage is arrested by compressing the wound : —

1. By the finger or the hand, which, of course, must be clean. In some
cases of serious injuries, the injured person may compress the wound with
his own finger. Since, however, the pressure of the finger, for any length
of time, cannot be well continued — for instance, during transportation and
when the hemostatic resources discussed in the preceding section are not at
hand, or cannot be applied — it is necessary that —

2. A dressing be substituted for them, which shall exert suflficient pressure
upon the wound. Before applying such a compressive dressing, the wounded
limb must be bandaged carefully and completely from below upward, to
prevent the dangerous collection of blood in the meshes of the cellular tissue
{dijfiise bloody infiltration). Next, a firm dressing is laid upon the wound,
and fastened in place under considerable pressure by a bandage — prefer-
ably an elastic bandage. In deep wounds, the hemorrhage can be arrested
still more effectively.

3. By tamponade. The cavity of the wound is packed firmly by forcing
with the finger the middle portion of a piece of antiseptic gauze (iodoform
gauze) as deep into the wound as possible, and, after the finger has been
withdrawn, the cavity is firmly packed with sterilized gauze. In tubular



THE TREATMENT OF WOUNDS 243

wounds, first smaller, then larger, tampons can be introduced into the cavity
packed with gauze, until the last reach far beyond the surface of the skin.
The tampons are firmly pressed upon the wound by a bandage, if possible
an elastic bandage ; this, if packed with aseptic material, can remain in
position for many days, until the bleeding vessel or vessels have become
occluded by thrombosis. This is especially the procedure in hemorrhages
from the cavities of the body — for instance, from the nose, vagina, uterus,
rectum. It is necessary to provide these several tampons, or portions of
gauze, with a long thread by which they can be removed again in the
gentlest manner.

The inflation of a small elastic bag, introduced in a collapsed condition,
with air or ice water (Rhineurynter, Colpeurynter, see Fig. 141 2) is likewise
very effective, but it is not so simple as the common tamponade.

MEDICINAL HEMOSTATICS (STYPTICS)

These partly promote the coagulation of the blood, and the contraction
of the vascular walls, partly produce a firmly adhering crust. They should
be used only in case of greatest necessity, when the hemorrhage cannot be
arrested by tamponade, for fresh wounds are more or less irritated, and even
strongly cauterized, by all these agents, so that healing by primary intention
is made impossible. To the oldest agents of this kind belong agaric, the
cautery iron (see page 26), and the soliUion of ferric chloride {liquor ferri
sesqiiichlorati) ; even now the latter is used in the form of a dry, yellow,
styptic cotton, just like Penghawar Yanibi. To this class of agents belong
also vinegar, solution of alum, of creosote (i : 100 — aqua binelli), oil of
turpentine {Bawn, Billroth), chloride of zinc in saturated solution, tannin
(^Graf) in powder form, peroxide of hydrogen {von Nnssbaunt). To the more
modern styptics belong antipyrine in a 20% solution, or in powder form
{Bosworth), 2L 20% cocaine solution, fibrin ferment solution {Wright), cornn-
tine, sclerotinic acid, ferripyrine and gelatine. Irrigation with ice cold or hot
sterile water and the use of steam (vaporization, Atmokausis, Zestokausis)
may be mentioned here.

The best and safest procedure for arresting hemorrhage permanently is : —

LIGATION OF THE VESSELS (LIGATURE)

All bleeding vessels, arteries, and veins in a wound (after operations or
injuries) are grasped and clamped with hemostatic forceps. These instru-
ments are now relied upon exclusively in grasping bleeding orifices, and are



244



SURGICAL TECHXIC



variable in their construction, the principal object of all of them being to seize
and compress the bleeding vessel (Figs. 435-437). In major operations —
for instance, in amputations — large vessels are drawn somewhat forward




Fig. 437
Spencer Well's Artery Forceps



from the surface of the wound with forceps, and are then securely closed by
torsion with the aid of a second transversely applied forceps. If larger
vessels cross the field of operation, they are grasped transversely with two
hemostatic forceps, and divided between them (Figs. 438, 439). As many





Fiu. 439
Ligation between Two Hemostatic Forceps

hemostatic forceps as are required are applied, and allowed to remain in
position. Ligation with catgut does not commence until all the bleeding
vessels have been temporarily secured with forceps (Fig. 440). The pro-
cedure is as follows : —



THE TREATMENT OF WOUNDS



245



Make slight traction on the instrument which grasps the vessel ; pass a

simple knot around its point ; push it with the tip of the forefingers over the

vessel (Fig. 441), draw it tight, place a second knot (" reef knot ") upon it,

next cut off the two threads

closely in front of the knot with

a pair of curved scissors, and

remove the forceps. For ligat-

ing large vessels it is advisable

not to use too heavy catgut,

because its knots loosen more

easily, especially if the threads

have been cut off very closely.

Many surgeons prefer silk for

ligatures.

(The editor has for the last

ten years applied a double

ligature ^ to ^ of an inch apart

in ligating arteries the size of

the brachial. The bloodless

space between the two liga-
tures is securely closed in the

course of 7 days by definitive

obliteration of the lumen of

the vessel. The proximal liga-
ture includes the accompany-
ing vein or veins.)

Ligation. If a bleeding

vessel cannot be well drawn forward from its surrounding tissue, or if it
cannot be grasped — for instance, in the scalp or in
hardened cicatricial tissue — it must be ligated with
an ordinary round curved needle armed with the liga-
ture. The needle is carried through the connective
tissue surrounding the bleeding portion, and with the
loose connective tissue included the ligature is tied
(Fig. 442). If many vessels are found in tough,
broad layers of connective tissue, they can be
grasped separately with care and time. The same
object can be accomplished more rapidly, however,
and with the same degree of certainty by ligating




Fig. 440.



Ligation with Numerous Hemostatic
Forceps




Fig. 441. Ligation of
Blood Vessel



246



SURGICAL TECHNIC



tissues, including the vessels, in sections by indirect ligatures. Thinner
layers are clamped with hemostatic forceps, and secured with a double
ligature (Ligature en masse).

If only a few or no ligatures are on hand, smaller arteries can also be
closed by torsion. Grasp the artery with torsion forceps, draw it forward,





Fig. 442. Ligation of Artery
BY Indirect Ligature



Fk;. 443. Closing Artery by Torsion



and, according to its thickness, twist it from six to eight times around its
axis, holding the central end of the projecting portion with the fingers or,
better, with another pair of forceps {Ajmissafs clamp forceps — Fig. 443).
By this procedure, the inner coat of the artery (tunica intima) is torn,
and is rolled up in an upward direction, thereby forming a very safe
valvular occlusion, strengthened by the twisted tissues.
The same effect is produced by a veiy strong press-
iire exerted upon the artery. Kdbcrle
and Pcan have devised for this purpose
clai)ip or pressure forceps (Fig. 441)
similar to small dressing forceps, which
greatly contuse the grasped tissue by
the fixation of its compressed ends.
After a quarter of an hour the forceps
may be removed without any previous
ligature, since the contused inner coat
(tunica intima) is rolled up like a cuff in
the lumen of the vessel, and the tissues,
from the strong pressure, become as
desiccated as if they were burned {forci-
pressui'e). The clamp forceps are used
especially in places where a ligature can




444. KOBERLfe-



„, , „ c- ' be applied only with difficulty or not at
Pkan's Clamp For- ' ' -^ _ -' _

cEPs all, and as a substitute for the ligatures




Fig. 445. Doyen's
Angiotribe



THE TREATMENT OF WOUNDS 247

en masse. As the contused tissue does not become necrotic, forcipressure
has the advantage over the ligature of not introducing any foreign substance
into the wound. When applied to large arteries the forceps must remain
in situ from 12 to 24 hours.

A still greater effect is produced by angiotripsy {Doyen). Bv means of
it, with YQxy strong forceps (vasotribe, Fig. 445 ) under an immense pressure
(up to 2000 kilometers), not only the vessels, but also all tissues grasped by
the forceps (as in hgations of pedicles and "en masse"), are crushed to
plates as thin as paper, from which no hemorrhage can occur any more.

HEMORRHAGE FROM PUNCTURED AND GUNSHOT WOUNDS

If the injury in question is a hemorrhage from a larger vessel which, in the
depth of a punctured or a gunshot wound, manifests itself directly or after
some time by a continued oozing of blood through the bandages, or which
occurs in the subsequent course of the wound from erosion of the vascular
wall or from thrombosis of the veins (phlebostatic hemorrhage, Styo7neyer),
no time should be lost in exposing at once the bleeding vessel at the place
of ijijnry and in ligating it in the wound itself (direct ligation).

Before this often very difficult task is attempted the anatomical posi-
tion of the trunks of the vessels should always be called to mind. Figs.
446-450 may serve to recall the anatomical locations and surgical relations
of the principal arterial trunks.

The paramount condition for executing such operations easily, rapidly,
and thoroughly is a la^-ge external i?icisioTi, which is made from the wound in
an upward and downward direction and longitudinally to the limb in such a
manner that it corresponds to the course of the injured vessel. Where it is
a matter of Hfe it is indifferent whether the incision is an inch or a foot in
length. If arresting the hemorrhage meets with success and the wound
remains aseptic, the large incision heals as well and as rapidly without
suppuration as a small one.

As to the rest, the procedure is exactly the same as that described in
secondary antiseptics (page 57). Ha\-ing incised the skin to the requi-
site extent, the operator penetrates in the depth of the wound with the
left forefinger, divides with a probe-pointed knife the deeper layers, the
cellular tissue, the fascias and muscles as far as necessary ; the divided
parts are then retracted with large sharp or blunt retractors.

Next, the blood clots filling the whole cavity of the wound (the so-called
aneurysma traumaticum diffusum) are quickly and thoroughly removed with



248



SURGICAL TECHNIC



the fingers and sponges, and in most cases in the depth of the wound the
injured vessel or at least a bloody infiltrated layer of tissue is found, in





27^-3? ^â– â– â– "â– ^ â–  n






<.''- — ••^-.Mmaxf^^^:-



\



Fig. 446. Arteries of Head, Neck, and Axilla



which the artery, veins, and nerves can eventually be found and identified.
The operator should try to separate these several parts by careful dissection.
The finding of the injured vessels is essentially facilitated by making use