The after-treatment of such patients does not differ from that of non-traumatic cases. Abstention from stomach feeding, the judicious use of salines, dependence upon hypodermoclysis and rectal nourishment, and the use of opiates are all matters of importance.

When the bladder has been injured there is usually more or less injury of some of the other pelvic organs. An empty bladder will escape more often than one which is full; while the latter will nearly always leak into the peritoneal cavity or along the bullet track, thus infecting one or both. The appearance of blood in the urine is one of the indications of bladder injury, and sometimes the bladder will fill with blood clot, which will produce the phenomenon of retention. Such a case may rapidly succumb to infection if relief be not promptly afforded, and this may come through abdominal section or a combination of it with exploration through the perineum. Particles of clothing and bone and even the bullet itself have been removed from the cavity of the bladder. It is advisable to open the bladder from below and insert a self-retaining drainage tube, by which, especially when combined with the method of drainage by siphonage, as described in the chapter on Surgery of the Bladder, a satisfactory and continuous emptying of the organ may be maintained.

CHAPTER XXIII.
PREVENTION AND CONTROL OF HEMORRHAGE; SUTURES; KNOTS.

The first requisite after the infliction of a wound is to arrest and control the hemorrhage. In many operations upon the extremities precautions are taken to avoid its occurrence, and the so-called bloodless method of operating, which is effected by the use of an elastic bandage of pure rubber, is frequently employed and generally gives satisfactory results. The pure-gum bandage was first introduced into surgery by Martin, of Massachusetts, and its combined use both as an elastic bandage and tourniquet was so promoted by Esmarch that it is generally known as Esmarch’s bandage, and Martin has failed to receive the credit due him.

The elastic bandage used for this purpose should be about three inches in width and five or six yards in length, and made of pure rubber. The operator begins by applying this to the tip of the extremity which is to be made bloodless. It is wound around the limb in spiral turns, with sufficient force to press out the blood from the tissues and to empty the vessels into those of the trunk. It is continued above the site of the operation, and then the limb is either constricted with a tourniquet of the old type or with one of the rubber appliances used for this purpose. A few turns of the rubber bandage may be passed more tightly about the limb at this point and secured with forceps. The rest of the bandage is then unwrapped from the limb, which will be found pale and bloodless. Operation may then be practised without the loss of more than a few drops of blood. All divided vessels should be secured before the constriction is removed and the wound closed.

In septic, tuberculous, and malignant conditions no such pressure should be made, as harmful elements might be forced into the circulation. In such cases the elastic tourniquet is applied high up and no attempt is made to force the blood out of the limb. The limb should be elevated so that its veins may empty before the bandage is applied, and a certain amount of blood will thus be saved.

Care should be taken in graduating the tightness of the constricting band, as well as its narrowness, and in preventing undue pressure upon nerve trunks. Cases are on record of temporary and even permanent paralysis, due to too vigorous application of the tourniquet, and except upon large and stout limbs it is not often necessary to apply it as tightly as is often done. Moreover even a wide rubber bandage when stretched taut becomes little better than a rubber cord or rubber tube and sinks into the tissues. A sterile towel should be folded into a strip and wound around the limb, and then a tourniquet should be applied over it so that pressure may be more equably distributed and danger of paralysis reduced.

Exigencies may require the application of the elastic tourniquet as high as it can be possibly used, either upon the shoulder or the hip. This necessity is usually observed in amputations at those joints, and the special methods required will be more fully dealt with when speaking of these procedures. (See [Chapter LVII].)

The elastic bandage should have been unrolled and sterilized with the rest of the surgical equipment required, and even when so protected it would be well to cover the limb with wet sterile towels before applying the bandage, which is usually done at the last in order to avoid contamination. When this is not done the final scrubbing should not be effected until the bandage has been placed, the tourniquet applied, and the bandage again removed.

Fig. 60