eased organ is identified, make a lumbar incision, and suture or perform nephrectomy; if not sure which organ is diseased, perform an abdominal nephrectomy. The use of a cystoscope will show from which ureter blood is emerging.

44. Vaginal hemorrhage requires the ligature or the tampon.

45. Severe uterine hemorrhage (unconnected with pregnancy) requires the tampon. Persistent hemorrhage due to morbid growths may require removal of the tubes and appendages, ligation of the uterine and ovarian arteries, or hysterectomy.

46. Hematemesis, or bleeding from the stomach, is treated by the swallowing of ice, giving tannic acid (dose, 20 or 30 grains) or Monsel's solution (3 drops). Never give tannic acid and Monsel's solution at the same time, as they mix and form ink. Opium is usually ordered. Acetate of lead and opium and gallic acid are favorite remedies, and ergot is used by many. Give no food by the stomach. If life is threatened by bleeding from an ulcer, open the belly and excise the ulcer. If severe hemorrhage follows injury, make an exploratory laparotomy.

47. In bleeding from the small bowel give acetate of lead and opium, sulphuric acid, or Monsel's salt in pill form (3 grains), allow no food for a time, and insist on liquid diet for a considerable period. If hemorrhage threatens life, do a celiotomy and find the cause. If ulcer exists, excise it. If violent hemorrhage follows injury, explore to discover the

cause.

48. In bleeding from the large bowel, use styptic injections (10 grains of alum or 5 grains of bluestone to 3j of water). If bleeding is low down, use small amounts of the solution; if high up, large amounts. Do not use absorbable poisons. In dangerous cases perform an exploratory operation to find the cause. (For rectal bleeding see 37, p. 269.)

49. Hemoptysis, or bleeding from the lung, is treated by morphin hypodermatically, by perfect rest, by dry cups or ice over the affected spot if it can be located, and by gallic acid, which drug aids coagulation.' Of late nitrite of amyl by inhalation has given good results.

50. In hemorrhage from wound of the lung do not open

The use of ergot is a general but questionable practice. Bartholow and others hold that this drug does harm; it contracts all the arterioles, and hence more blood flows from an area where there is damage. Purgatives do good in bleeding from the lung by taking blood to the abdomen and lowering blood

pressure.

the chest unless life is threatened. If life is endangered, resect several ribs, find the bleeding point, ligate or employ forcipressure. A small cavity may be packed with gauze. If a large surface is bleeding, fill the pleural sac with gauze and pack more gauze against the oozing surface.1

Reactionary or Recurrent Hemorrhage (called also Consecutive, Intermediate, or Intercurrent).-This form of hemorrhage comes on during reaction from an accident or an operation-that is, during the first forty-eight hours, but usually within twelve hours. It is bleeding from a vessel or vessels which did not bleed during the shock which accompanied operation, but were overlooked and were not tied. It may be due to faultily applied ligatures. It is favored by vascular excitement or hypertrophied heart. The bleeding is not sudden and severe, but is a gradual drop or trickle. The Esmarch apparatus is not unusually the cause. The constricting band paralyzes the smaller arteries, which do not bleed during shock and do not contract as shock departs; hence bleeding comes on with reaction. To lessen the danger of the Esmarch apparatus use a broad constricting band rather than a rubber tube. During reaction after an amputation, if slight hemorrhage occurs, elevate the stump and compress the flaps. If the hemorrhage persists or at any time becomes severe, make pressure on the main artery of the limb, open the flaps, turn out the clots, find the bleeding point, ligate, asepticize, close, and dress. In any severe reactionary hemorrhage open the wound at once and ligate.

Secondary hemorrhage may occur at any time in the period between forty-eight hours after the accident or operation and the complete cicatrization of the wound. Secondary

hemorrhage may be due to atheroma, to slipping of a ligature, to inclusion of nerve, fascia, or muscle in the ligature, to sloughing, to erysipelas, to septicemia, to pyemia, to gangrene, and to overaction of the heart. The great majority of cases of secondary hemorrhage are due to infection, and the application of modern surgical principles has rendered secondary bleeding a rare calamity. If during an operation the vessels are found 1 See author's case, Annals of Surgery, Jan., 1898.

atheromatous, acupressure had best be used, or a thread should be passed, by means of a Hagedorn needle, around the vessel, including a cushion of tissue in the loop of the ligature (this prevents cutting through) (Fig. 53). One great trouble with atheromatous arteries is that their coats cannot contract; another trouble is that the ligature cuts entirely through them. If after an operation the pulse is found to be forcible, rapid, and jerking, give aconite, opium, and low diet. The bleeding may come on suddenly and furiously, but is usually preceded by a bloody stain in wound-fluids which had become free from blood.

Treatment of Secondary Hemorrhage.-The method of treatment, supposing a case of leg-amputation in which, several days after the operation, a little oozing is detected, is to elevate the stump, apply two compresses over the flaps, and carry a firm bandage up the leg. If the bleeding is profuse or becomes so, make pressure on the main artery, open and tear the flaps apart with the fingers, find the bleeding vessel and tie it, turn out the clots, asepticize, close, and dress. If the bleeding begins at a period when the stump is nearly healed, cut down on the main artery just above the stump and ligate. In secondary hemorrhage from a blood-vessel in nodular tissue throw a ligature around the vessel by a curved needle or tie higher up, or, if this fails, amputate. When secondary hemorrhage arises in a sloughing wound apply a tourniquet or an Esmarch bandage, tear the wound open to the bottom with a grooved director, look for the orifice of the vessel, dissect the artery up until a healthy point is reached, cut it across, and tie both ends. If this fails, include tissue in the ligature or use acupressure. In secondary hemorrhage from atheromatous vessels use acupressure or include surrounding tissue in the ligature.

Secondary hemorrhage may occur after ligation in continuity, the blood usually coming from the distal side. If the dressings are slightly stained with blood, put on a graduated compress. If the bleeding continues or is severe, make pressure on the main artery of the limb, open the wound and ligate, wrap the part in cotton, elevate, and surround with hot bottles. If this re-ligation is done on the femoral and fails, do not ligate higher up, as gangrene will certainly occur, but amputate at once, above the point of hemorrhage. If dealing with the brachial artery, do not amputate, but ligate higher up and make compression in the wound. In a secondary hemorrhage from the innominate tie the innominate again and also tie the vertebral.

2. OPERATIONS ON THE VASCULAR SYSTEM.

Paracentesis auriculi, or tapping the heart-cavity, has been suggested for the relief of an over-distended heart from pulmonary congestion. The right auricle should be tapped. Push the aspirator-needle directly backward at the right edge of the sternum, in the third interspace. This operation is not recommended, as it is highly dangerous and is of questionable value.

Paracentesis pericardii, or tapping the pericardial sac, is only done when life is endangered. Introduce the needle two inches to the left of the left edge of the sternum, in the fifth interspace, and push it directly backward (thus avoiding the internal mammary artery).

Operation for Varix of Leg.-In this operation make, at several points in the course of the long saphenous vein, skin incisions each two inches long and in the long axis of the vessel. Clear the vessel at each incision, apply two ligatures an inch apart, and excise the vein between them. Never operate if the slightest phlebitis exists (Barker). This method of multiple ligation is the plan of Phelps. Another method is as follows: the patient stands for a time before a fire to enlarge the veins. A harelip-pin is pushed into the tissues an inch from the vein, at the upper end of its varicose portion; the pin is passed under the vein and emerges an inch outside of it. A bit of catheter wrapped in gauze is laid over the vein, and a twisted suture is carried around the pin and over the pad. This operation is done lower down in one or two positions; but it is unsatisfactory, and offers grave danger of infection. Trendelenburg, at a point below the saphenous opening, ties the vein in two places and divides it between his ligatures. Some surgeons have advised the removal of the entire length of the long saphenous vein. Madelung cuts down over the varices and ligates. Schede makes a circular cut completely around the leg at the junction of the upper and middle thirds, the incision reaching to the deep fascia. All bleeding points are ligated and the edges of the incision are sewn together. Fergusson ties the saphenous vein near the femoral and removes a section from it. makes the varices clearly evident. A semilunar incision is made to surround the varices, which incision reaches to the deep fascia. The flap is raised and dissected up, the vessels are tied, and the flap is sutured in place. The author of this operation claims that it is most satisfactory and certain.

This

Open Operation for Varicocele.-The open operation

is by far the best procedure for varicocele. The instruments used are a scalpel, an aneurysm-needle, curved needles, a grooved director, a dissecting-forceps, an Allis dry dissector, hemostatic forceps, and scissors.

Operation. The patient is recumbent. He may be anesthetized or Schleich's fluid may be injected. The operator stands on the diseased side. The assistant stands on the sound side and makes pressure over the inguinal ring of the affected side. A fold of skin is pinched up on the scrotum, and the surgeon transfixes it in the line of the cord, so that he will have an incision about one and a half inches long running downward from below the external ring. The skin and fascia are cut with a scalpel, the veins are well exposed by means of an Allis dissector, and the cord is located and held aside. A double ligature of strong catgut or chromicized gut is passed under the veins by an aneurysm-needle. The threads are separated one inch, tied tightly, and the ends are left long. The veins between the ligatures are excised. The two gut ligatures are tied together and cut. This shortens the cord. The scrotum is sewed up with silkworm-gut, a small drainage-tube being used for twenty-four hours. Healing is complete in one week.

Subcutaneous Ligature for Varicocele.-In this operation employ every antiseptic precaution. The patient stands, and the operator, sitting in front of him, holds the veins in a fold of skin away from the vas deferens by means of the thumb and index finger of the left hand. A large straight needle carrying a double piece of strong silk is passed entirely through the scrotum, between the veins and the vas. The needle is again inserted at the puncture from which it emerged, is carried around under the skin and in front of the veins, and emerges at its original point of entry. The veins are thus surrounded by the silk. The patient, who now lies down, is placed under the first stage of ether, and the double ligatures are separated as far as possible from each other, tied, and cut off, the knots slipping in through the puncture. This operation presents certain dangers. The veins may be wounded and the vas or other structures may be included. In an operation it is always best to be able to see what we are doing; and the open operation, being safe, is preferred to the subcutaneous.

Phlebotomy, or Venesection.-The instruments used in venesection are a lancet or bistoury, a fillet or tape, an antiseptic pad, and a bandage. A stick should be at hand. for the patient to grasp.