tourniquet is also a screw tourniquet, is usually considered as the inventor of the latter. The screw tourniquet is most convenient when the upper brassplate is connected by two or four steel rods with the under one, by which the upper plate is steadied whilst the screw is twisted.

Upon the history of the tourniquet and its various modifications—

KELLIE, Observations on the Medical Effects of Compression by the Tourniquet. Edinburgh, 1797. 8vo.

WESTPHALEN, Dissert. sistens Tornaculorum criticem atque novam ex emendatione recentiori speciem. Jenæ, 1800.

KROMBOLZ, Abhandlungen aus Gebiete der gesammten Akologie. Mit 9 lithogr. Tafeln. Prag. 1825. 4to. p. 1--120.

KLEIN and DUPUYTREN'S Compressor.

284. In the application of the tourniquet, the position of the artery must be first ascertained, on the upper arm, at the inner edge of the m. biceps; on the thigh, in the triangular space between the m. addactor and vastus internus; also above the knee in the hollow formed by the tendons of the m. biceps on the outer, and of the semitendinosus and semimembranosus on the inside; the pad is then, at either of these parts, to be closely placed upon the track of the artery, and the bandage having been carried over it, and around the limb, its two ends (which, in MORELL's tourniquet, are to be passed through the slits in the leather plate) are tied upon it, then twisted with the twisting-stick, and the latter fastened by means of small strings. In the screw-tourniquet, however, the bandage is drawn together by means of the buckle; and the tourniquet itself, of which the two plates must be screwed down, so as to touch each other, must be put upon the side of the limb opposite to the pad, where a compress, or piece of leather or pasteboard, should be put to relieve the severe pressure. In twisting the screw, the lower plate must be fixed with the hand, and the slipping of the pad prevented. The degree of compression is to be measured by the cessation of pulsation below the tourniquet, or by the cessation of the bleeding, which may be taking place. A sufficiently stout pad is preferable to a roller or a graduated compress.

[In applying the screw tourniquet, I think it better to adjust the pad beneath the lower plate of the screw, as the pressure is more steady and direct when the one is below the other. It is better also that one end of the tourniquet bandage should have a buckle to fasten by buckling rather than by tying, as there is less chance of the apparatus slipping.—J. F. S.]

285. In cases where a tourniquet cannot be applied, and where pressure may be long continued, without compression of the whole limb, special compressors are proposed, that of LANGENBECK (a) and VERDIER (b) for the external iliac artery; of MOHRENHEIM (c) and DAHL (d) for the subclavian; of WEGEHAUSEN (e) and MOORE (f) for the upper and lower limbs; and of GRAËFE (g) for bleeding from the palm of the hand.

To this subject also belong the different kinds of compressors which have been proposed for wounded brachial artery, at the bend of the elbow, by SCULTETUS, HEISTER, DIONIS, PLATTNER, BRAMBILLA, DESAULT, LEBER, AYRES, and so on; for the temporal artery, by BELL; in bleeding from the veins of the neck, by CHABERT; from the tongue, by (a) Bibliothek für die Chirurgie, vol. i. part ii. plate ii. (b) Mémoire sur un Appareil Compressif de l'Artère Iliaque externe, etc. Paris, 1823.

(c) Beobachtungen verschiedenen chirurg. Vorfalle, Wien, 1780, vol. i. pl. i. fig. 6, 7.

(d) PLATNER'S Zusatze zu seines Vater's Chirurgie, pl. iii. fig. 3.

(e) RUST's Magazin, vol. ii. part iii. pl. iv. v. vi. (f) BERNSTEIN Systematische Darstellung des chirurg. Verbandes, pl. x. fig. 104, 105, 106.

(g) In Journal für Chirurgie und Augenheilkunde, vol. xvii. p. 305.

LAMPE; from the meningeal artery, by FAULQUIER and GRAEFE; for the epigastric artery, by SCHENDLER and HESSELBACK; and from bleeding from the penis, by JOACHIM.

[For the purpose of suppressing the bleeding from arteries CARLISLE (a) proposed the following plan of applying the tourniquet on the lower extremities:-"A hard roll of linen bandage, about four or five inches in width and three in thickness, being provided, and a piece of smooth board, nine inches in length, five in width, and three-quarters of an inch in thickness, with the sides and ends squared at right angles, the roller is to be placed on the ham midway between the external and internal flexor tendons on the under sides of the knee-joint, the leg being extended in a straight line; the piece of board is then to be placed over the roller, which is to act as a pad of compression on the popliteal artery, the length of the board running crosswise, and projecting beyond the kneejoint on each side. The girth of the tourniquet is to go round the knee above (not upon) the patella, and over the projecting ends of the board. The screw should rest at the upper part of the limb above the patella, having a pad interposed between it and the skin. This mode of compressing the popliteal artery is attended with an important advantage; it allows the arterial circulation by the lateral anastomosing vessels to proceed uninterrupted; the large superficial veins also are undisturbed, so that the limb remains in the same state as if the artery alone had been tied." He does not think it applicable at amputation, but "in all cases of hæmorrhage, when there is a chance of saving the limb, it will be found preferable to the total stoppage of circulation by the ordinary methods." (pp. 23, 4.)

A much better apparatus for keeping up pressure than that of CARLISLE'S is the ring tourniquet, which was first introduced at St. Thomas's Hospital by TYRRELL (b), though I am doubtful whether he was the inventor. It has often been employed since, and is a very good instrument for the purpose.

"The ring tourniquet consists of a metal ring, having a diameter larger than that of the limb to which it is to be applied, and a width of about an inch; the circumference is tapped at one point so as to admit a screw, to the inner extremity of which a pad is fixed, and to the outer end a small handle to turn the screw with, by the action of which the pad can be carried to or from the centre of the circle. When applied, this instrument makes pressure only on two parts; by the pad on the site of the artery, and by the portion of the ring immediately opposed to the pad, on the surface of the limb directly opposed to the position of the artery: thus it does not interfere with the lateral circulation." (p. 20.)

On much the same principle is the arch tourniquet of Dr. OKE (c), of Southampton, The flanks of the arch are perforated which "consists of an arch, a pad, and screw. with holes for the action of the external screw, which is worked by a short handle, as in the common tourniquet. The pad is of the ordinary size, flat on one side and convex on the other. Upon its flat surface there is a smooth cavity for the reception and working of the point of the screw. Mode of application:—Let the arch embrace the limb, so that one of the perforations of the flank may be exactly opposite the cavity on the flat side of the pad, previously applied over the trunk of the artery to be compressed; then fit the external into the internal screw, and work it upon the pad till sufficient pressure be made to stop the circulation of the artery." (p. 151.)]

286. The compressing apparatus, which is applied directly upon the wounded part, consists either in the application of special compresses, as mentioned in the former paragraph, or in the application of a bandage enclosing the whole limb. The application of the compressor has great disadvantages, as, on account of the pain and inflammation, it commonly cannot be worn sufficiently long; the flow of blood through the whole limb is checked, or a complete flattening of the artery, if it be not very superficial, and lie immediately on a bone, cannot be effected. For this reason, therefore, if the compressing apparatus is to be used, especially in wounds of the elbow, bandaging the limb is preferable to the use of compressors. After the bleeding has been arrested, by pressure on the artery between the wounded part and the heart, the wound is to be cleansed,

(a) A New Method of applying the Tourniquet, &c.; in Medical and Physical Journal, vol. i. London, 1799.

(b) St. Thomas's Hospital Reports.
Provincial Medical Journal, 1843.

any extravasated blood is to be removed by gentle pressure, the edges of the wound are to be brought into pretty close apposition, and connected with sticking plaster, which is to be wound round the limb, or a small compress is to be placed on the wound, and a sufficiently long bandage turned eight times round the joint, a graduated compress is to be put along the track of the artery, and the whole finished by wrapping up the entire limb. The bandage is to be left alone till it loosens, when it must be reapplied in the same way. The wound may close very easily in six days, when a hard swelling is commonly to be perceived, which is caused by the loosening up of the cellular tissue, and more or less extravasation of blood; this is dispersed by the continued use of a tightly applied bandage. The observations of VON WINTER (1) have especially shown, that, under this treatment, which is applicable only to small longitudinal (punctured) wounds of arteries, the healing may take place, and, perhaps, usually does take place with preservation of the canal of the artery.

(1) VON WINTER recommended that this apparatus should consist of bandages made up of linen four times folded, two inches wide, and of the length of a sheet, and that over this the circular bandage should be rolled, inasmuch as such an apparatus sits closer, and does not so easily get loose as the common bandage, applied according to THEDEN's plan.

287. Immediate or direct compression consists in laying some charpie, rolled together, or pieces of agaric, sprinkled or moistened with styptic remedies, upon the mouth of the bleeding vessel, and fixing it tightly by a suitable bandage. This kind of blood-stanching is less certain, and, as regards the healing of the wound, very injurious (1). It must, therefore, be employed only in those cases where tying the bleeding artery is not possible; for instance, if the blood wells up from the whole surface of a wound, in wounds of the meningeal artery (2), in severe bleeding from the nose (3), after the operation of cutting for the stone (4), and so on. This compression most certainly stops the bleeding when the artery can be compressed against a bone (5).

[(1) When direct pressure is employed, as a general rule, it is best not to use any styptic, but trust entirely to the finger, keeping up the pressure, it may be for hours, by a relief of assistants. But very commonly obstinate oozing, where no particular vessel can be observed, or where a score of minute vessels seem to need the application of ligatures, and the surgeon's patience is tired by finding that for every one he ties, two more bleed, may be completely checked, after once or twice gently sponging the wound with cold or tepid water, and carefully removing the smallest portion of clot, and leaving it exposed to the air for three or four hours, during which the whole surface of the wound is glazed with a thin layer of fibrinous exudation and the mouths of the little vessels sealed up. The bleeding in such cases seems to depend on the imperfect closing of the smaller or capillary arteries, which, having in themselves little contractile power, continue to permit the escape of the blood, if the clot first formed in them be disturbed, as is doubtless often the case in cleaning the wound previous to bringing it together; and, indeed, the disturbed clot actually irritates the vessel to bleed till it has been washed off. The objection to styptics, of whatever kind, is that sloughing to a greater extent occurs after their use, than after the mere application of pressure.

In external wounds which continue bleeding, after exposure to the air, if the vessel cannot be found, a piece of cork, or any other hard substance, covered with lint, and bound on tightly with a bandage, is often very useful.

(2) Pressure on the meningeal artery is on no account to be employed, for it would be inconvenient to the brain. Nor indeed is it ever necessary; the removal of all the clot is quite sufficient to stop the bleeding, of which ABERNETHY gives an excellent instance in the case of a man who, having received a blow on the side of the head, had symptoms of compression, for which he was trephined, and, on elevating the bone, the meningeal artery, which had been wounded and formed a clot as big as a walnut, bled furiously, but ceased almost immediately on clearing away the blood.

(3) In bleeding from the nostrils, which is often very troublesome, the best remedy as a compress is a piece of dry sponge, which may be easily introduced in the following manner: A long stout thread having been attached to the extremity of a bougie, the armed end of the bougie is to be passed into the bleeding nostril, and carried back into the pharynx. The surgeon then passes his finger, or a pair of forceps, through the mouth into the throat, and, having found the thread, draws it forwards through the arch of the fauces and out of the mouth, leaving the bougie still remaining in the nose. To the thread thus drawn out a piece of dry sponge slightly greased is to be tied, and then the bougie gently drawn from the nostril, by doing which the thread pulls the sponge back into the throat, and against the hind opening of the nostril. The thread is still to be pulled, and the entrance of the sponge assisted by passing the finger into the pharynx and disengaging the sponge from the soft palate and thrusting it upwards; as soon as it is on a level with the floor of the nose all difficulty ceases, and, by pulling the thread, it can be fixed in any part of the nostril which may be chosen, but about midway is best. For performing this operation there is a clever French instrument (whose invention I do not know) which I brought many years since from Paris; it consists of a short catheter, the stilette of which, double the length of the tube, is a curved flat spring, having at its top, rounded as if it were the end of the catheter, and with an eye in it. The instrument is introduced with its point downwards, along the floor of the nose into the throat, and the stilette being thrust in, the curved spring projects into the mouth, and, being brought between the lips, a piece of thread and sponge is attached to it, after which the stilette is retracted, and with it the sponge, into the throat; the sponge is then pulled up close to the end of the stilette, and is easily introduced into the nostril; after which the instrument is to be withdrawn. With this apparatus the operation is performed in two or three minutes, with but little inconvenience to the patient, and it is far preferable to the bougie.

(4) Occasionally very severe bleeding occurs from wounding the pudic artery itself, or the division of one of its large branches close to the trunk during the lateral operation for the stone. Under such circumstances it is useless to attempt to hook up the vessel with a tenaculum, or to carry a ligature round it with a needle, for it is generally wounded so deeply that the exact situation of the wound cannot be seen. Under such circumstances pressure of the vessel with the finger, which is to be gently shifted till the bleeding is stopped, is the proper treatment to be pursued. I recollect a case of this kind during my studentship, in which either the internal pudic artery itself, or the artery of the bulb close to its origin, was wounded; the bleeding was very severe, and in the course of a few minutes the patient nearly died from the loss of blood. The finger was introduced into the wound, and the artery being found was readily pressed against the ascending branch of the haunch-bone, and the bleeding arrested; but it was necessary to keep up the pressure for fifteen hours.

(5) But it frequently happens in stabs into the thick fleshy parts of the hand or foot, that pressure is of no avail: it seems to answer the purpose for a time, perhaps for hours, after which the blood begins to find its way out beneath the compress, and free oozing occurs, and will continue to such extent as to blanch the patient's countenance and very seriously reduce his constitutional powers. In such cases some surgeons grope about in the wound, enlarging it or not as may suit their fancy, in search of a little vessel, which can scarcely be expected to be found, and which they rarely do find, but instead they render the disposition to bleeding greater, and also damage the tendinous and nervous structures, so that very serious consequences result. This practice is therefore very bad, and ought not to be pursued. It is quite right at first to sponge out the wound gently and carefully, and, finding the bleeding vessel, to tie it; but, if this cannot be effected, it should not be persisted in, and the edges of the wound having been brought lightly together, a constant application of lint dipped in cold water is to be made, and the hand or foot raised so considerably as to discourage the flow of blood towards the wound, and to encourage it from the wound; the patient being kept in the recumbent position in bed at the same time. This practice is often quite sufficient without anything further being required. Other surgeons, if the wound be in the hand, prefer taking up the radial or ulnar artery at the wrist, according as they believe the bleeding vessel to have its origin from one or other. But taking up one is rarely of much use on account of the communication between the vessels in the palm; and even if both be tied, their interosseal branches often carry sufficient into the hand to keep up the bleeding, so that at last it becomes necessary to tie the brachial artery also, which generally puts an end to the business. But it is a very serious and painful proceeding for the patient, and the practitioner before adopting it should be well assured of its neceessity. When bleeding continues after the use of compression, it very frequently ceases by removing the pres

sure, and after clearing out the clotted blood, placing the hand as first mentioned, raised much above the elbow, and constantly applying cold wet linen over the wound. This practice I have often adopted successfully, and at any rate it should always be employed before cutting upon the arterial trunk above.-J. F. S.]

288. The Tying or Ligature (Ligatura) of a bleeding artery is the most simple, certain, and, in most cases, practicable method of stanching the blood. The operation of the ligature consists in its preventing the current of the blood, and, by its irritation, producing inflammation, exudation of plastic lymph, and union of the coats of the artery. This takes place as well when the arterial coats are kept merely in contact by the ligature, as when the inner and middle coats are torn through by means of the tightening and the small size of the ligature, the outer coat alone remaining undivided.

JONES, supported by his experiments, asserts that the cutting through of the inner and middle coats is necessary to produce such degree of inflammation as is sufficient to effect the union of the apposed arterial coats; and further, that this cutting through of the inner and middle coats, in tying arteries in their course, is sufficient to produce the union of the vessel, even although the ligature be immediately removed. That this cutting through of the inner and middle coats of the artery is not necessary, however, to produce the union of the arterial coats, is proved by the experiments in which arteries were brought to close by continued pressure, or by the use of broad ligaments, without tearing the inner and middle coats. CRAMPTON (a) and SCARPA (b) have proved, by their experiments, that the inner arterial coats, which belong to the class of serous membranes, are well disposed, without requiring division, to adhesive inflammation, and to the pouring out of plastic lymph; and a continued compression suffices to bring the artery to adhesion.

[In brutes not even continued compression is necessary to produce the adhesion and obliteration of an artery, for I remember many years since passing a ligature around the carotid of a dog and tying it so loosely, as not merely to offer no obstruction to the flow of blood, but also to admit the introduction of a probe between it and the artery, without causing any compression, yet in the course of three weeks, at the end of which the animal was destroyed, the artery had become obliterated for two or three inches. I should, however, be sorry to attempt such practice on the human subject.—J. F. S.]

289. Upon this difference in the operation of the ligature depends the variety of its application, as practised by surgeons. Those who hold the cutting through of the inner arterial coats necessary, use a round thread, not very thick, and sufficiently strong, wherewith the artery is so firmly drawn together, that only the latter coat remains undivided. Others who maintain the opposite opinion, endeavour to flatten the artery, and bring its walls into close contact by the broad ligature (in tying arteries in their course, even by means of a cylinder of wood or linen placed beneath it ;) in which case they tie the ligature only so tight as is necessary to prevent the current of the blood. They object to the division of the inner coat on the ground that the division of the arterial coats, effected by means of a ligature, rather resembles a torn and bruised than a cut wound, and is consequently more prone to suppuration; that the ligature does not bring into contact the two divided coats of the artery, but only the puckered walls of the external coat, and that in suppuration, after-bleeding occurs much more readily, inasmuch as the outer coat of the artery is little capable of withstanding the pressure of the blood.

[Although English Surgeons differ as to the size of the ligature to be used for tying arteries, some preferring a thinner and others a thicker one, yet there are few, if any, who do not now tie the vessel sufficiently tight to produce division of the internal coat, for which purpose, however, it is not necessary to employ the vigorous efforts which are (a) An Account of a New Method of operating tion of the Arteries; in the Medico-Chirurg. for the cure of external Aneurism; with some ob- Trans., vol. vii. p. 341. servations and experiments illustrative of the effects of the different methods of procuring the oblitera

(b) Memoria sulla Legatura delle principali Arterie degli Arti; con una Appendice all' Opera sull' Aneurisma. Pavia, 1817.

4to.