Controlling Haemorrhage

In 1708, Dionis rejuvenated Paré's work to prevent lethal haemorrhage by vessel ligation and strongly endorsed this over red-hot cauteries and astringents, which he considered not only more painful but more uncertain. He recalled the two methods proposed by Paré, either to isolate and pick up bleeding vessels accurately, for which Dionis advised the "crow's-beak" forceps, self-holding when closed by a spring or sliding ring, combined with a ligature beyond the forceps tip (Fig. 7.1) or,

Controlling Haemorrhage

Fig. 7.1. Amputation equipment, Dionis, from 1708. A, B, C, K, L, various knives for small and large amputations; H, G, tourniquet with double twisting sticks; M, bow saw; N, P, Q, R, arterial forceps and ligatures; also various swabs and dressings. (From Dionis P. Cours d'Opérations de Chirurgie. Paris: d'Houry, 1750:744-745.3)

Fig. 7.1. Amputation equipment, Dionis, from 1708. A, B, C, K, L, various knives for small and large amputations; H, G, tourniquet with double twisting sticks; M, bow saw; N, P, Q, R, arterial forceps and ligatures; also various swabs and dressings. (From Dionis P. Cours d'Opérations de Chirurgie. Paris: d'Houry, 1750:744-745.3)

alternatively, to thread needles at each end of a ligature, pass this around a vessel and then penetrate the adjacent skin to anchor the ligature over a small compress (see Fig. 6.5). Dionis found simple ligatures of the first method often failed being "loosened by arterial pulsation," and preferred the second ligature for its security and certainty, and also for ease of removal; before antiseptic practice, buried ligatures proved to be unsterile foreign bodies always prone to persistent infection and causing fresh bleeding.3 Initially, surgeons were slow to discard cauteries and astringents but, by the end of the 18th century, most surgeons accepted vessel ligation as the only secure method of controlling haemorrhage of major vessels, including John Bell, who wrote against reliance on cautery (see Fig. 10.3) in 1801 as follows:

"Without reading the books of the old surgeons, it is not possible to imagine the horrors of the cautery, nor how much reason Paré had for upbrading the surgeons of his own time with their cruelties." and also, "The horrors of the patient, his ungovernable cries, the hurry of the operator and his assistants, the sparkling of the irons, and the hissing of the blood against them, must have made terrible scenes, and surgery must in those days have been a horrid trade."*

Bell was equally scathing of the application of caustics and corrosives to bleeding vessels, for they proved uncertain, dangerous and often deadly.

Before Petit introduced his revolutionary tourniquet in 1718, temporary control of major vessel bleeding at amputation was achieved by direct digital pressure on vessels or by means of a simple circumferential band around the limb, tightened by twisting a stick, the so-called Spanish windlass,5 also mentioned in detail by Yonge in 1678.6 Although some control was attainable by untwisting the stick to inspect bleeding points for ligature, the method remained clumsy and inefficient. Petit's invention was to control pressure by means of an integral wing-nut screw (see Fig. 5.5) which could be adjusted gently, up or down, ensuring safe visual evidence of bleeding, which could be stopped instantly by turning the screw.7 Originally made of wood, the screw was soon replaced by an efficient brass model which dominated practice for more than two centuries, being still available during World War I. Heister, who wrote one of the most influential surgical works of the 18th century, having studied widely in Europe, described and illustrated Petit's tourniquet in detail, showing its application during amputation in the many editions and translations of his book (Fig. 7.2).

Le Dran, one of the first to analyse how best to disarticulate at the shoulder joint, ligatured the main vessels through an incision in the armpit before making the amputation.8 Charles Bell agreed that this technique might be essential if the soft tissues and bones were damaged in the shoulder region, although when intact he

Charles Bell Amputation

Fig. 7.2. Leg and arm amputations,dripping blood into large containers, with no obvious tourniquets; however, Petit's tourniquet is shown to right, and simple band tourniquets are seen in the leg drawings above. Figs. 3,4, a guillotine amputation and use of the

'valet a patin' artery catch; Figs. 5,6,7,8, Verduin's flap amputation including a healed stump which would be suitable for a kneeling peg-leg. (From Heister L, A General System of Surgery, London: Innys, 1743, plate 14.68)

Fig. 7.2. Leg and arm amputations,dripping blood into large containers, with no obvious tourniquets; however, Petit's tourniquet is shown to right, and simple band tourniquets are seen in the leg drawings above. Figs. 3,4, a guillotine amputation and use of the

'valet a patin' artery catch; Figs. 5,6,7,8, Verduin's flap amputation including a healed stump which would be suitable for a kneeling peg-leg. (From Heister L, A General System of Surgery, London: Innys, 1743, plate 14.68)

advocated thumb pressure by an assistant over the subclavian artery above the clavicle, until the humeral head was exposed when direct occlusion of the axillary artery with the surgeons' fingers was maintained against the humerus, until the divided artery was ligatured.9

Important anatomicropathological research by Jones, in 1805, recorded in his book A Treatise on the Process Employed by Nature in Suppressing Haemorrhage from Divided and Punctured Arteries: and on the Use of the Ligature, indicated that loosely applied ligatures which temporarily suppressed low-pressure bleeding failed to fracture the internal and middle coats of these vessels and often resulted in secondary haemorrhage as the blood pressure recovered; he stated many surgeons believed it was dangerous to ligature tightly and fracture these structures.10 In fact, Jones proved by animal experiments that actual fracture of the inner coats was necessary to obtain secure adhesion of their surfaces, and it was this process which guaranteed permanent occlusion of arteries, assuming infection did not supervene. In parallel, he demonstrated the more elastic external coat did not fracture for its integrity was necessary to secure sound occlusion. He wrote:

.. every operator should be acquainted with the force necessary to cut through the internal and middle coats of an artery:... this force is very slight, and the external coat of an artery is strong enough to allow the ligature to be tied tight, without it being cut through;... nor does there appear to be any reason for fear, that the external coat may ulcerate through before the internal coats have adhered, since we see from experiments, that their union is very soon effected."11

Jones also demonstrated that it was unnecessary to include soft tissues and nerves as anchors for a mass ligature of tape or other thick material, but to apply a single thread tightly and securely around the carefully isolated artery.

From the later 18th century, the hooklike tenac-ulum became a popular instrument for fixing a divided artery and pulling it clear of other tissues before ligature. Greater sophistication was provided by Assalini in 1812, when he devised a

Cross Action Spring Forceps
Fig. 7.3. Early 19th-century artery forceps. E, Assalini pivoting catch with self-holding spring; F, Liston's spring forceps with integral catch; G, cross-action spring forceps. (From Arnold's Instrument Catalogue, London: author, 1876.69)

tenaculum artery forceps consisting of two limbs articulating by means of a pivot and self-holding by an integral spring (Fig. 7.3). By about 1830, the dissecting spring forceps was also adapted to self-hold by means of a variety of catch mechanisms, for the specific purpose of picking up arteries and other bleeding points accurately (Fig. 7.3). True crushing arterial haemostats were not devised until much later in the century.

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