and it may be possible to obtain one. A couple of pairs of elastic suspenders can be constructed into a tourniquet.

Elastic tourniquets are applied by taking two or three turns fairly snugly around the limb and then gradually pulling harder on the long end until the hemmorrhage stops. The remainder of the tourniquet is then wound around over the original turns, stretching it sufficiently so that the proper amount of pressure is maintained. The ends are then tied or twisted together and prevented from slipping by tying a string tightly around them.

FIG.

169.-Course of the

If an elastic tourniquet can not be secured it may be advisable to apply a tourniquet higher up on the limb with a suitable pad over the main artery. A carefully constructed band with a suitable pad properly placed so as to compress the large artery supplying the part controls the hemmorrhage with less pain and damage to the tissues than the simple constricting tourniquet which is applied to immediately stop the loss of blood.

main artery in the arm. Cross show point for applying pressure.

METHOD OF APPLYING TOURNIQUETS TO MAIN ARTERIES.

To apply such a tourniquet properly one should know the location of the large artery which supplies the part. In the arm the main artery runs downward on the inner side and its location corresponds very closely to the inside seam of the sleeve in the upper part of the arm (fig. 169). In the upper part of the thigh the main artery will be found in the front part of the thigh just a little to the inside of the crease of the trousers (fig. 171), and may be easily compressed by pressure directly downward against the thigh bone (fig. 172). All inelastic tourniquets should be fairly broad to avoid bruising the flesh. Where a pad is used it is wise to place a folded towel under the tourniquet on the opposite side of the limb to prevent it from cutting too deeply into the flesh (fig. 173). The band is placed around the limb near the armpit in the case of the arm, or close to the groin for the lower extremity. The exact location of the artery can be determined by searching for it in its proper location by the finger tips, the artery being recognized as a fairly large pulsating cord. The pad which may be a tightly folded

FIG,

171.-Course

of

main artery in the thigh. Cross shows point for applying

pressure.

handkerchief, a smooth stone, wrapped in cloth, a flat cork, or even a watch, is placed over the artery in such a position that the pressure of the band will pull it down on the artery and compress the artery against the bone underneath. The tourniquet is wrapped around the pad and the limb, tied loosely, and then lightly twisted up with a stick or similar object, as above described. The lower provisional tourniquet is now loosened and removed. It may be found that the bleeding has ceased, in which case no tourniquet will be necessary. If the bleeding begins as soon as the lower tourniquet is loosened, the upper one is tightened sufficiently to check the hemorrhage and the stick fastened in the proper location (fig. 167).

Tourniquets can only be used on the extremities or around the forehead. In any case of severe bleeding one should instantly compress the main artery by means of the thumb or fingers and control the loss of blood in this manner while a tourniquet is being improvised or procured (fig. 172). The vessel can not be held with the fingers for more than a few minutes, as the operator will very quickly become fatigued.

Venous hemorrhage from the extremities can also be controlled by a tourniquet if sufficient pressure is applied to close the arteries which are sending the blood to the veins. If the application of the tourniquet between the wound and the heart apparently increases the hemorrhage instead of checking it, it is due to the fact that veins are wounded and the tourniquet is not properly applied so as to completely shut off the arterial blood supply, but is interfering with the venous return, therefore making the hemorrhage worse instead of better. In such a case tourniquet and pad should be readjusted and more pressure applied. If the hemorrhage is of mixed origin, both veins and arteries being severed, as is generally the case, the control of the arteries is all that will be required, and as soon as they are properly compressed the bleeding, both venous and arterial, will cease. In ordinary first-aid work tourniquets are applied simply to check the loss of blood until the doctor arrives to assume charge of the case. If no doctor is available or can not be reached for a considerable time, it will be necessary for the operator to proceed immediately after the application of the tourniquet to consider other means of checking the homorrhage permanently, because it will be necessary, as has been stated above, to remove the tourniquet sooner or later.

If the services of a doctor can not be secured in the immediate future, the case becomes a somewhat difficult one, because tourniquets can not be left in position for an indefinite time. The tissues require the circulation of the blood in order to keep them alive, and if the blood is shut off too long the part will die and gangrene follow. Tourniquets, then, must be classed solely as a temporary expedient

for checking severe hemorrhage until some other means can be employed. It is certainly not safe to allow a tourniquet to remain on longer than three hours. It must also be remembered that the great pressure exerted in twisting up a band with a stick in the manner described may inflict severe injury on the nerves or other structures if continued for too long a period. A case has been recorded in which a heavy cord was wrapped around the wrist and twisted up with a policeman's night stick and so much damage done to the tissues inclosed by the cord that the patient never recoverd the full use of the hand.

If a layman finds that he must assume the after treatment of such a patient, he has two procedures to adopt. The wound may be packed or the bleeding artery tied. If the severed artery is small, packing will probably be successful. If the artery is large, it must be tied. The size of the artery may be estimated by the amount of blood which comes from the wound before the tourniquet was applied. If in doubt as to which course to pursue it is generally best to pack the wound, then if packing fails, an attempt may be made to tie the artery later. It is possible to pack such a wound under practically all circumstances, hence this will be the method of choice if the accident has happened in the woods or some other remote place, when the necessary materials for tying an artery are not at hand and can not be improvised.

TYING ARTERIES.

Arteries may be tied with either silk, linen, or cotton thread. The string used for tying an artery is called a ligature. Surgeons often use specially prepared sterile catgut ligatures because this material is absorbed in time by the tissues and causes less trouble than silk or cotton if the wound becomes infected. The strength of the string selected depends upon the size of the artery. Fairly large arteries should be tied with strong string similar to that used by grocers, while medium-sized vessels can be safely closed with one or more strands of heavy thread such as is used for sewing on buttons.

In order to find the artery and get at it, it will generally be necessary to have an assistant pull the edges of the wound apart with some sort of an instrument. The handles of tea or table spoons can be used for this purpose. Bending the handle at a right angle to the shaft about 2 inches from the end makes a sort of hoe-shaped instrument very suitable for this purpose and enables the assistant to hold the wound open without getting his hands in the way of the operator (fig. 174). For a large, deep wound use tablespoons.

METHOD OF TYING ARTERIES.

Boil 2 tablespoons, 2 teaspoons, a pair of scissors, a hair pin or probe, several artery forceps, if they are available, 4 or 5 stout

needles, and a dozen pieces of stout thread about 12 inches long. If possible, the operator should have two assistants, one to manipulate the tourniquet, the other to sponge the wound. While the instruments are boiling, the operator and one assistant should carefully prepare their hands according to the method described on page 184. Artery forceps are provided with locks so that when the handles are closed the points of the forcep will firmly hold any material which is within their grasp (fig. 175). When the instruments have been boiled and cooled, and the hands sterilized, the operator places them alongside of the patient in the pans and fearlessly scoops out all blood clots from the wound. The edges of the wound are held apart by means of the handles of the tablespoons in the hands of the assistants, so that the interior of the wound can be freely inspected. The wound is dried by pads of sterile gauze. The third assistant now loosens the tourniquet a little. The operator watches the wound carefully, and as soon as the place from which the blood is coming is located, he grasps a small part of the tissues around the opening with the blades of the artery forcep and locks the handles. If the forcep is applied in the proper manner this should check the bleeding from that spot. If other freely bleeding points are noticed they are grasped with the other forceps. The operator may have to make several attempts before he gets the forceps properly applied so that it closes the opening in the blood vessel. The tourniquet can be tightened between each attempt and the blood cleaned out of the wound before making another trial. When the bleeding point has been properly grasped, the assistant makes gentle traction on the forceps so as to raise the tissues slightly from the side or bottom of the wound. One or more of the prepared strands of thread are now placed around the forcep and worked down to the point. The handle is depressed and a single surgeon's knot tied loosely in the thread, which is worked downward with the tips of the fingers so as to grasp the tissues below the point of the forcep. The point must not be included in the ligature or otherwise it will be displaced when the forcep is removed.

Having gotten the ligature in the proper position hold it there with a probe, hairpin, or other narrow instrument while the knot is drawn up tightly and several other knots added for additional security. The first knot should be what is known as the surgeon's knot, which can best be understood by looking at figure 177. When the knots are firmly in place the handles of the forceps are unlocked and it is carefully withdrawn. The ends of the ligature are now cut off about one-third of an inch from the knots. The same procedure is applied to any other forceps which have been in use. In the absence of an artery forcep a needle may be inserted into the tissues under the bleeding point, the tourniquet tightened, the needle