The use of gelatin in checking hemorrhage has given some satisfaction upon the Continent, but has not found much favor in this country. It consists of a solution of 2 parts of pure gelatin to 100 parts of normal salt solution, which should be thoroughly sterilized. It is injected subcutaneously to increase the coagulability of the blood, and has also been injected directly into an aneurysmal sac or its immediate vicinity to induce coagulation. It is likely that if the surgeon have a patient with the hemorrhagic diathesis the combined use of gelatin in this way and of calcium chloride internally would give satisfactory results.
A styptic has recently been introduced by Freund under the name “stypticin.” It is a product of the oxidation of narcotin, one of the opium alkaloids, and is a yellowish powder of bitter taste. Chemically it is cotarnin hydrochloride. It has been used especially in the treatment of uterine hemorrhage, with a certain degree of success, regardless of the cause of the hemorrhage. It may also be given in cases of too profuse menstruation. The average dose is 2 to 3 Gr. (0.15 to 0.20) at intervals of two or three hours. When a speedy result is desired twice the above amount in 10 per cent. solution may be given subcutaneously.
4. Destructive Methods
may include the use of the sharp spoon, chemical caustics, or the actual cautery. The curette is usually employed for removal of surfaces which have attained a spongy or easily bleeding condition, as the interior of the uterus, bleeding ulcers in other cavities, etc. When fungoid tissue is scraped to a base of healthy tissue there is usually a cessation of further hemorrhage. Occasionally there are cases of fungating cancer which bleed upon the slightest touch. The most radical way in which to deal with these for temporary purposes is to destroy the spongy tissue which bleeds so frequently. The gross part may be done with the sharp spoon and the cautery may be made to finish the work. Bleeding piles, when it is not permissible to treat them more radically, should be touched with the actual cautery, with stretching of the sphincter. The cautery knife should not be made too hot, as it may act similar to a sharp blade instead of merely searing by its heat.
5. Mechanical Means.
—When vessels of considerable size or masses of tissue containing them can be made accessible, the best means of control of hemorrhage are those which can be applied directly to the vessels. When this is not possible they should be tied en masse. A method formerly in use was acupressure. To effect this a needle was passed through the overlying skin beneath the vessel and out again, and around this a suture was tied to make pressure. Since the introduction of absorbable materials this method has been supplanted by the use of catgut sutures, which may be tied, cut short, and left to absorb.
Under the term “forcipressure” is included the method of seizing vessels before, or as they bleed, in small forceps, which are variously shaped and constructed, and grouped under the name of hemostats. Small vessels seized between the blades of such an instrument will have their walls so crushed that blood clot is so quickly entangled that the forceps can be removed in a few moments with little or no danger of subsequent bleeding. Larger vessels should be ligated.
Torsion is a substitute for ligature, especially with the smaller vessels, and denotes a twisting of the vessel end after its seizure, breaking up its inner coat, and effectually sealing its lumen. Some surgeons rely on torsion for the large vessels.
Angiotribe is the name applied to strong crushing forceps, by which a pressure of several hundred pounds can be made through a lever mechanism. In this a mass of tissue, as the broad ligament, can be secured and such tremendous pressure brought to bear that its vessels are crushed and destroyed beyond possibility of bleeding. Downes has improved upon this mechanism by adapting to it an electrocautery arrangement, by which not only pressure but also heat is brought to bear. His instrument is called an electrothermic clamp. To all of these instruments there are at least theoretical objections, in that they are more or less clumsy or unwieldy and require special equipment. They devitalize a considerable amount of tissue, all of which has subsequently to be removed either by a process of sloughing or by active phagocytosis; but they serve perhaps a useful purpose in the crushing treatment of hemorrhoidal tumors. They have been used only by a few, and have not found wide acceptance.