Esmarch's plan for preventing hemorrhage, during an operation upon a limb, is to apply a very tight rubber bandage spirally from its extremity to a point above the site of the proposed incision. Where this stops, a piece of rubber tubing, with hooks at the end, is wound several times tightly around the limb and fastened. The bandage is then removed, when the circulation will be found to be almost completely cut off.

Flexion of a limb will sometimes be of aid in arresting hæmorrhage. Put in the joint a firm roll of lint against which the pressure will come when the limb is bent. In case of bleeding from the palm of the hand, which will sometimes be profuse, direct the patient to clasp closely a wad of lint, at the same time holding the hand high above the head.

With a secondary hæmorrhage, the first thing to be done is to remove all dressings so as to expose the wound to the air. Make digital pressure upon the wound, if it can be reached, assisted by pressure on the main artery, and notify the surgeon at once.

Besides those named-heat or cold, position, and pressure—there is still another means of arresting hæmorrhage to which a nurse may, in an extremity, resortnamely, use of astringents. Astringents used externally are called styptics. The most useful are the subsulphate or the perchloride of iron, alum, gallic acid, and matico. Wring out a piece of lint in the dilute solution, and, having first wiped out the blood-clots, stuff it into the wound. The mode of action is by increasing the contractile power of the vessels. Nitrate of silver or lunar caustic acts somewhat similarly. Obstinate bleeding from a small point, as a leech-bite, may be checked by touching with this. Lunar caustic is some

times spoken of as the potential cautery, having the effect, though more superficially, of cauterization.

The actual cautery-the application to the wound of a hot iron-is sometimes employed by surgeons, when the bleeding is from many vessels over a large surface, or from a porous part which will not hold a ligature. Both styptics and the cautery prevent primary union, and are only employed when no other means will an

swer.

The method most commonly used by surgeons for the arrest of hæmorrhage from an artery of any size is ligation. The artery is picked up by a pair of forceps, and a ligature tied firmly about it. A ligature should be about eighteen inches long. It is most often made of strong, soft silk, though catgut or wire is some

times used. Test its strength well, so as to leave no chance of its breaking when strained; and, if you have it to tie, be sure and make a firm knot. Surgeons use

generally the "reef knot," a square knot in which both. ends of one string pass either over or under the loop made by the other; if the ends are separated by the loop, you get a "granny" knot, which will slip. The string in the right hand should be held over the other in the first twist, and under it in the second, or vice versa. This knot may be made additionally secure by making the second turn twice instead of once, before drawing it tight. You should practice these knots, and also the "clove hitch," which is often called for. For this, make two loops in the cord from right to left, and put the first over the second. Loops in opposite directions will make, if they hitch at all, the much less reliable" cat's paw."

Another mode of arresting hæmorrhage, frequently employed, is that of torsion, the artery being seized in the forceps and twisted, rendering a ligature unnecessary.

Still another way, though now rarely adopted, is by acupressure; a harelip pin is placed about the open mouth of the vessel, and a wire twisted over it in the shape of a figure 8.

There are then nine methods of arresting arterial hæmorrhage: five-cold, heat, position, pressure, and styptics-which the nurse may employ at discretion; and four others-cauterization, ligation, torsion, and acupressure-which belong exclusively to the surgeon.

The most dangerous form of venous hæmorrhage is that from rupture of large varicose veins. Pressure should be made below the bleeding point, cold or heat applied, and the limb elevated. Pressure above the

point of injury is here useless and absurd. Ligation is avoided, as it is likely to occasion inflammation of the vein. In cases where there is danger of such rupture,

an elastic stocking or bandage should be worn to support and make equable pressure upon the distended vessel. This should be put on before getting up in the morning.

Capillary hæmorrhage is never dangerous, and can easily be checked by cold and position, or by hot water, an especially valuable hæmostatic in such cases. It must be used as hot as it can be borne. Warm water will only increase the flow of blood.

There are some persons who have what is called the hæmorrhagic diathesis, that is, an excessive tendency to bleed, so that even a slight cut or scratch may be followed by hæmorrhage difficult to control. If such a case comes into your hands, you will probably have to resort to styptics. To stop the bleeding after a tooth has been extracted, a good application is a little piece of burnt alum pressed well into the cavity, and packed down with lint.

The constitutional symptoms of extreme hæmorrhage are pallor, coldness of the extremities, clammy sweat, feeble or sighing respiration, small and rapid pulse, restlessness and thirst, vertigo, dimness of vision, ringing in the ears, difficulty in articulation, followed, if the trouble is not before this brought to an end, by unconsciousness, slight convulsive movements, and death. The hæmorrhage usually ceases, or is much lessened, with syncope.

The same effects follow internal hæmorrhage, and may be the only evidence of its existence, though usually the blood will somewhere find an outlet.

If blood comes from the lungs, hæmoptysis, it is usually coughed up, is bright red, and more or less frothy from the admixture of air. It is always a serious symptom, though the quantity of blood lost is rarely

great, but blood supposed to be from the lungs is not infrequently from the mouth or throat.

The vomiting of blood, hematemesis, is usually somewhat less ominous. The patient is likely to have a sense of fullness and oppression in the epigastric region, and then to throw up, without much nausea, a large quantity of dark blood, mixed with food, but containing no air, acid in reaction and incoagulable.

In either case, keep the patient quiet and cool, the head elevated. Give bits of ice, having them swallowed whole if possible, and, if the hæmorrhage is repeated, apply ice-cold cloths externally. Give only fluid food, cold and in small quantities.

In cases of internal hæmorrhage, particularly from lungs, much may be done to arrest it by partially cutting off the venous return from the limbs by means of straps, or bandages, applied tightly around their proximal extremities. This procedure, by diminishing temporarily the amount of blood in the circulation, will diminish its force, and give an opportunity for coagula to form in the bleeding vessels. If the hæmorrhage ceases, the constricting bands should be gradually loosened and removed, but left ready to be instantly re-applied on any re-appearance of it.

When an exhausting hæmorrhage has occurred, after its source has been controlled, the limbs may be tightly bandaged from their distal extremities to the trunk, in order to prevent the circulation in them of blood which is needed by the vital organs. The object in both above procedures is to gain time.

With hematemesis some blood will almost invariably appear in the next defecation as a dark, tarry substance. For hæmorrhage from the bowels, ice-cold injections may be given, and in the same way solutions