Page images
PDF
EPUB

wounds or small lateral wounds of either veins or arteries can be closed successfully with silk sutures, and if a transverse wound includes more than one-third of the circum

[graphic][graphic][merged small][merged small]

ference of the vessel, after the vessel is completely divided the ends can be successfully united.1

Torsion.-By means of torsion the internal and middle coats are ruptured and the external coat is twisted. It is a safe procedure, and is practised upon vessels as large as the femoral by many surgeons of high standing. Torsion has

FIG. 49.-Method of controlling hemorrhage by torsion.

the signal merit of not introducing possible infection in ligatures. The vessel is drawn out by one pair of forceps, and another pair is applied transversely half an inch above the cut end and twisted six or eight times (Fig. 49).

1 See Med. Record., Jan. 16, 1897.

Acupressure is pressure with a pin. The arrest of hemorrhage by acupressure was devised by Sir James Y. Simpson. A pin is simply passed under a vessel (transfixion), leaving a little tissue on each side between the pin and vessel. A needle can be passed under a vessel, and a wire be thrown over the needle and twisted (circumclusion). The needle can be inserted upon one side, passed through half an inch of tissues up to the vessel, be given a quarter-twist, and be driven into the tissues across the artery (torsoclusion). Some tissue is picked up on the needle, folded over the vessel, and pinned to the other side (retroclusion). Acupressure is used for inflamed or atheromatous vessels, in sloughing wounds, and where a ligature will not hold.

Elevation is used as a temporary expedient or as an associate of some other method. It is of use in wounds of the bursæ, in bleeding from a ruptured varicose vein, and is frequently used with compression.

Compression is either direct or indirect—that is, in the wound or upon its artery of supply. In the removal of the upper jaw arrest bleeding by plugging. In injury of a cerebral sinus, plug with gauze. Compression and hot water (120°) will stop capillary bleeding. A graduated compress is often used in hemorrhage from the palmar arch. A compress will arrest bleeding from superficial veins. The knotted. bandage of the scalp will arrest bleeding from the temporal artery. Long-continued pressure causes pain and inflammation.

Styptics. Chemicals are now rarely used. In epistaxis we may pack with plugs of gauze saturated in antipyrin. In bleeding from a tooth-socket freeze with chlorid of ethyl spray, and then pack with gauze soaked in 10 per cent. solution of antipyrin or with styptic cotton (absorbent cotton soaked in Monsel's solution and dried). In bleeding from an incised urinary meatus pack with styptic cotton. Cold water, chlorid of ethyl spray, or ice acts as a styptic by producing reflex vascular contraction. Hot water produces contraction and coagulates the albumin. The temperature should be from 115° to 120° F. A mixture of equal parts of alcohol and water stops capillary oozing. Paul Carnot has recently shown that a solution of gelatin in normal salt solution (116) will arrest capillary oozing even in a hemophiliac. We have recently employed this mixture with satisfactory results for capillary oozing from an incised wound in a victim of leukemia, and for the arrest of epistaxis.

The actual cautery is a most ancient hemostatic. It is

still used in some cases after excising the upper jaw, in bleeding after the removal of some malignant growths, in continued hemorrhage from the prostatic plexus of veins, after lateral lithotomy, and to stop oozing after the excision of venereal warts. We are driven to it in "bleeders "-that is, those persons who have a hemorrhagic diathesis, and who may die from having a tooth pulled or from receiving a scratch. It will arrest hemorrhage, but sloughing is bound to occur, and when the slough separates secondary hemorrhage is apt to set in. The iron for hemostatic purposes must be at a black heat.

Forced flexion is a variety of indirect compression introduced by Adelmann. It will stop bleeding, but soon becomes intensely painful. Forced flexion can be maintained by bandages. Brachial hyperflexion is maintained by tying the forearm to the arm. It is often associated with the use of a pad in front of the elbow. Genuflexion is kept up by tying the foot to the thigh. It is increased in efficiency by placing a pad in the popliteal space.

Golden Rules for Procedure in Primary Hemorrhage.1. In arterial hemorrhage tie the artery in the wound, enlarging the wound if necessary. In tying the main artery of the limb in continuity for bleeding from a point below we fail to cut off the bleeding from the distal extremity, and hemorrhage is bound to recur. If we fail to look into the wound, we cannot know what is cut: it may be only a branch, and not a main trunk. The same rule obtains in secondary hemorrhage (Guthrie's rule).'

2. We can safely ligate veins as we would arteries.

3. In a wound of the superficial palmar arch tie both ends of the divided vessel.

4. In a wound of the deep palmar arch enlarge the wound, if necessary, in the direction of the flexor tendons, at the same time maintaining pressure upon the brachial artery. Catch the ends of the arch with hemostatic forceps and tie both ends. If the artery can be caught by, but cannot be tied over the point of, the forceps, leave the instrument on for four days. If the artery cannot be caught with forceps, try a tenaculum. If these means fail, insert a small piece of gauze in the depth of the wound, put over this a larger piece, and keep on adding bit after bit, each one larger than its predecessor, until there is constructed a conical pad the apex of which is against the extremities of the cut arch and the base of which is well external to the palm. Bandage

1 For Murphy's observations on anastomosis of vessels, see page 261.

each finger and the thumb, put a piece of metal over the pad, wrap the hand in gauze, place the arm upon a straight splint, apply firmly an ascending spiral reverse bandage of the arm, starting as a figure-of-8 of the wrist, and hang the hand in a sling. Instead of applying a splint, we may place a pad in front of the elbow and flex the forearm on the arm. The palmar pad is left in place for six or seven days unless bleeding keeps on or recurs. If bleeding is maintained or begins again, ligate the radial and ulnar. If this maneuver fails, we know that the interosseous artery is furnishing the blood and that the brachial must be tied at the bend of the elbow. If this fails, amputate the hand. A plan which might obviate these radical procedures is to incise on a line with the injury from the web of the fingers to above the carpus, separating the metacarpal and carpal bones until the artery is exposed (this is really Mynter's incision for excision of the wrist).

5. In primary hemorrhage, if the bleeding ceases, do not disturb the parts to look for the vessel. If the vessel is clearly seen in the wound, tie it; otherwise do not, as the bleeding may not recur. This rule does not hold good when a large artery is probably cut, when the subject will require transportation (as on the battle-field), when a man has delirium tremens, mania, or delirium, or when he is a heavy drinker. In these cases always look for an artery and tie it.

6. When a person is bleeding to death, arrest hemorrhage temporarily by digital pressure in the wound and apply above the wound a tourniquet or Esmarch bandage. Bring about reaction and then ligate, but do not operate during collapse if the bleeding can be controlled by pressure.

7. If a transverse cut incompletely divides an artery, it may be found possible to suture the cut if it does not include more than one-third of the circumference of the vessel. Longitudinal cuts can be sutured (Murphy). If suturing is impossible, or if the surgeon prefers not to attempt it, apply a ligature on each side of the vessel-wound and then sever the artery so as to permit of complete retraction.

8. If a branch comes off just below the ligature, tie the branch as well as the main trunk.

9. If a branch of an artery is divided very close to a main trunk, tie the branch and also the main trunk. If the branch alone be tied, the internal clot, being very short, will be washed away by the blood-current of the larger vessel.

10. If a large vein is slightly torn, put a lateral ligature

upon its wall. Gather the rent and the tissue around it in a forceps and tie the pursed-up mass of vein-wall. It is a wise plan to pass the suture through the two outer coats by means of a needle and tie the knot subsequently. This expedient

007

FIG. 50.-Application of lateral ligature to a vein.

prevents slipping. If a longitudinal wound exists in a large vein, take an intestinal needle and fine silk and sew it up with a Lembert suture.

11. When a branch of a large vein is torn close to the main trunk, tie the branch, and not the main trunk. Apply practically a lateral ligature.

12. If, after tying the cardial extremity of a cut artery, the distal extremity cannot be found even by a careful search after enlarging the wound, firmly pack.

13. In bleeding from diploë or cancellous bone, use Horsley's antiseptic wax or break in bony septa with a chisel.

14. In bleeding from a vessel in a bony canal, plug the canal with an antiseptic stick and break the wood, or fill up the orifice of the canal with antiseptic wax; or, if this fails, ligate the artery of supply.

15. In bleeding from the internal mammary artery the old rule was to pass a large curved needle holding a piece of silk into the chest, under the vessel and out again, and tie the thread tightly, but it is better to ligate the artery.

16. In bleeding from an intercostal artery make pressure upward and outward, or throw a ligature by means of a curved needle entirely over a rib, tying it externally, or, what is better, resect a rib and tie the artery.

17. In collapse due to puncture of a deep vessel, the bleeding having ceased, do not hurry reaction by stimulants. Give the clot a chance to hold. Wrap the sufferer in hot blankets. If the condition is dangerous, however, stimulate to save life. 18. In punctured wounds, as a rule, try pressure before using ligation.

« PreviousContinue »