THE CONTROL OF HÆMORRHAGE
Hæmorrhage from vessels of the scalp.
All surgeons must have appreciated the difficulty attendant on the application of forceps to, and the ligature of, divided scalp-vessels. The patient may lose a considerable quantity of blood, and much valuable time will be wasted before the more essential part of the operation is commenced. All this can, under ordinary circumstances, be avoided by the use of the scalp-tourniquet. As used by Cushing it consists of a rubber ring fashioned after the style of an Esmarch’s tourniquet, encircling the head and passing from the lower frontal region in front, above the ears, to the lower occipital region behind. A median tape, passing from glabella to occiput, prevents any tendency for the tourniquet to slip down over the eyes, at the same time acting as a convenient landmark for the superior longitudinal sinus.
The tourniquet, when applied with the correct pressure, should, under ordinary circumstances, completely control all hæmorrhage from the divided scalp-vessels. It should be noted, however, that bleeding will be rather increased than otherwise if the tourniquet be so loosely applied as to impede the venous return without compressing the scalp arteries. A little experience will soon enable the operator to gauge the requisite pressure.
Fig. 4. The Scalp-tourniquet. Front View.
Fig. 5. The Scalp-tourniquet. Back View.
There is one other exception to the satisfactory working of the scalp-tourniquet. In the presence of a superficial cerebral tumour, especially when of a malignant nature, the normal communication between the intra- and extra-cranial vascular systems may be so exaggerated that those scalp-vessels which receive diploic and emissary venous communications will give rise to some trouble. This difficulty should be overcome—not by rapidity in the formation and turning down of the flap—but by clipping each vessel as exposed or divided, by the application of pressure and by foraminal occlusion (see also [p. 17]).
I found Cushing’s tourniquet rather inconvenient in its application, and, after various modifications, am accustomed to use the one depicted in the [illustration]. It consists of two flat metal bands connected posteriorly by a strong rubber connecting link, the two bands passing in front through a metal fixation piece possessing a screw which, when tightened up, allows of the maintenance of the desired pressure. The median tape, previously [mentioned], helps to keep the tourniquet in position.
The tourniquet is applied as follows: the whole head is enveloped in gauze—two or three layers thick, and cut to the size and shape of a large handkerchief. The tourniquet is slipped over the head, as low down as possible, and then tightened up. The median tape, having a loop behind through which the tourniquet passes, is laid in the middle line and tied round the screw on the fixation piece.
The gauze should then be moistened with saline solution or some mild antiseptic, so that it clings tightly to the underlying scalp and becomes sufficiently translucent to allow of the recognition of any underlying landmarks that may have been previously mapped out with the scalpel, iodine, silver nitrate, or aniline pencil.
The scalp-flap is then framed by incisions carried down to the bone, through gauze and scalp, in one sweep. The flap is turned down and covered with gauze. By the adoption of this method hæmorrhage from scalp-vessels is efficiently controlled and the risk of wound infection is reduced to a minimum.
After the completion of the operation, the scalp-flap is approximated and sewn into position, first by numerous buried fine silk sutures bringing together the aponeurotic layer of the scalp, and finally by a few silk or salmon-gut sutures passed through the skin itself. Gauze dressings are applied, the tourniquet loosened, and a roll-gauze bandage quickly applied circumferentially around the head, low down over the forehead and occipital region. This roll bandage in reality takes the place of the tourniquet, but is, of course, applied with moderate pressure only.
If the wool and bandage now applied over all should include the ears, these two organs should be well covered with vaseline. Few things are more uncomfortable to the patient than the contact of wool and bandage to the ears.
The tourniquet should be utilized whenever possible. In operations, however, that are conducted near the base of the skull—subtemporal decompression, cerebellar exploration, &c.—the surgeon, in his effort at hæmostasis, must rely on the application of digital pressure on either side of the incision, the more careful exposure of the vessels, and the application of forceps as soon as they are seen or divided, or by the utilization of Vorschütz’s hæmostatic safety-pins.
Other methods of controlling scalp-bleeding are as follows:—
1. Kredel’s hæmostatic sutures, passed with a large curved needle which slides along the bone and emerges about 5 to 7 cm. from the point of introduction. The silk ligatures are then tied over metal plates, so curved as to lie flush with the surface of the skull in the particular region involved. Four of these plates would be used in the formation of an osteoplastic flap, one on the distal side of each of the three scalp incisions, and one along the base of the flap.
2. The enclosure of the proposed incision by a running suture which, passing down to the bone, emerges about 1 inch further on, then so to speak repeating itself in part until the whole region is surrounded. The ligatures are then tightened up. This method takes some time in its application, and presents no advantages over the scalp-tourniquet.
3. The blocking of the main arterial supply—temporal, occipital, and supra-orbital vessels—by modified safety-pins, mass ligatures, &c. Arterial compression by means of the modified safety-pin as suggested by Vorschütz will be found most useful in those operations in which the scalp-tourniquet cannot be utilized—subtemporal decompression, &c.
Hæmorrhage from the bone.
Severe bleeding may take place from the mastoid and other emissary veins, and from the open mouths of those abnormally dilated diploic and emissary veins so often encountered in the exposure of an underlying dural or superficial cerebral tumour. The foramina in the bone, when exposed, must be occluded as quickly as possible. For this purpose we have the following methods at our disposal—plugging with small bone or wooden pegs, blockage with minute plugs of cotton-wool, and the utilization of Horsley’s wax, smeared over the part and well pressed home.
Hæmorrhage may also occur from the bone during trephining, more especially when the operation is conducted over that part of the anterior division of the middle meningeal artery which runs through a channel in the spheno-parietal region. Here the disk of bone should be removed as quickly as possible and the channel plugged with pegs, cotton-wool, or wax.
Oozing from the raw surface of the cut bone is controlled by rubbing in aseptic wax, or by the crushing together of the inner and outer tables.
Hæmorrhage from the dural vessels.
In this case the bleeding may occur from three sources, meningeal veins—often of considerable size when related to neighbouring tumour-formation—the middle meningeal artery, and the venous sinuses of the brain.
Hæmorrhage from meningeal veins may be arrested by one or other of the following methods:—
1. Gentle pressure as applied either by dry gauze, or wet gauze soaked in saline solution at a temperature between 110 and 115 degrees Fahrenheit.
2. The application of a piece of muscle to the bleeding-point. This method was, I believe, first introduced by Sir Victor Horsley. Some muscle is usually available for the purpose, usually the temporal muscle. A small portion of muscle is snipped off, spread out as a flat muscular pad, the bleeding area dried, and the graft quickly applied. It soon adheres, and usually arrests the hæmorrhage.
3. The application of a ligature. This method is placed last, being the most difficult. It is usually necessary to underrun the bleeding-point with a fine needle threaded with the finest of silk. It presents the disadvantage in that the needle may perforate the dura mater and puncture one of the superficial cerebral veins.
Fig. 6. Cushing’s Clips. A, The holder of the clips; B, A clip ready to be applied; C, Two clips applied to the middle meningeal artery.
Hæmorrhage from the middle meningeal artery may be controlled by ligature or torsion, and added to these methods we have one other, recently introduced by Cushing—silver wire ‘clips’. These clips are U-shaped, loaded on a magazine, picked up as required in the jaws of a specially indented forceps, and clipped on to the vessel—usually one on either side of the bleeding-point.
Hæmorrhage from venous sinuses is dealt with on [p. 150].
Hæmorrhage from the superficial vessels of the brain.
This form of hæmorrhage, one of the most troublesome complications arising in head-operations, most commonly results from hasty or careless opening of the dura mater. Thus, when the dura is incised in a case of greatly increased intracranial pressure, the brain herniates suddenly outwards, and the incautious use of the knife will damage one of the dilated superficial cortical veins. The dura should always be opened with the greatest care, the knife being passed lightly over the membrane till the pia-arachnoid is exposed, when the dural margins are lifted up with small tenaculum forceps and the membrane slit up with blunt-pointed scissors or on a grooved director.
In the event of injury, the bleeding may often be controlled by light pressure with dry gauze, or wet gauze wrung out in hot saline solution as described [above]. If this fails, a very fine silk ligature may be passed beneath the vessel on either side of the site of bleeding. This procedure is not easy to accomplish, the tissues are so soft and friable. However, every effort must be made to arrest the bleeding, for not only does the hæmorrhage obscure the field of operation, but the presence of a blood-clot beneath the dura mater will lead at a later date to the formation of adhesions between the various membranes of the brain—a potent cause of headache, epilepsy, &c.