If the wound involves one of the extremities, it may be useful; and it imparts confidence to the nurse, and, it may be, to the patient, if a Petit’s tourniquet is loosely applied above the wound, which the nurse is instructed to tighten up in the event of bleeding taking place.

Ligation of the Artery.—­If the haemorrhage recurs in spite of packing the wound, or if it is serious from the outset and likely to be critical if repeated, ligation of the artery itself or of the trunk from which it springs, at a selected spot higher up, should be considered.  This is most often indicated in wounds of the extremities.

As examples of proximal ligation for secondary haemorrhage may be cited ligation of the hypogastric artery for haemorrhage in the buttock, of the common iliac for haemorrhage in the thigh, of the brachial in the upper arm for haemorrhage from the deep palmar arch, and of the posterior tibial behind the medial malleolus for haemorrhage from the sole of the foot.

Amputation is the last resource, and should be decided upon if the haemorrhage recurs after proximal ligation, or if this has been followed by gangrene of the limb; it should also be considered if the nature of the wound and the virulence of the sepsis would of themselves justify removal of the limb.  Every surgeon can recall cases in which a timely amputation has been the means of saving life.

The counteraction of the toxaemia and the treatment of the bloodless state, are carried out on the usual lines.

#Haemorrhage of Toxic Origin.#—­Mention must also be made of haemorrhages which depend upon infective or toxic conditions and in which no gross lesion of the vessels can be discovered.  The bleeding occurs as an oozing, which may be comparatively slight and unimportant, or by its persistence may become serious.  It takes place into the superficial layers of the skin, from mucous membranes, and into the substance of such organs as the pancreas.  Haemorrhage from the stomach and intestine, attended with a brown or black discoloration of the vomit and of the stools, is one of the best known examples:  it is not uncommonly met with in infective conditions originating in the appendix, intestine, gall-bladder, and other abdominal organs.  Haemorrhage from the mucous membrane of the stomach after abdominal operations—­apparently also due to toxic causes and not to the operation—­gives rise to the so-called post-operative haematemesis.

#Constitutional Effects of Haemorrhage.#—­The severity of the symptoms resulting from haemorrhage depends as much on the rapidity with which the bleeding takes place as on the amount of blood lost.  The sudden loss of a large quantity, whether from an open wound or into a serous cavity—­for example, after rupture of the liver or spleen—­is attended with marked pallor of the surface of the body and coldness of the skin, especially of the face, feet, and hands.  The skin is moist with a cold,