Historical review of emergency tourniquet use to stop bleeding



      Although a common first aid topic, emergency tourniquets to stop bleeding are controversial because there is little experience on which to guide use. Absent an adequate historical analysis, we have researched development of emergency tourniquets from antiquity to the present.


      We selected sources emphasizing historical development of tourniquets from books and databases such as PubMed.


      The history of the emergency tourniquet is long and disjointed, mainly written by hospital surgeons with little accounting, until recently, of the needs of forward medics near the point injury. Many investigators often are unaware of the breadth of the tourniquet’s history and voice opinions based on anecdotal observations.


      Reporting the historical development of tourniquet use allowed us to recognize disparate problems investigators discuss but do not recognize, such as venous tourniquet use. We relate past observations with recent observations for use by subsequent investigators.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to The American Journal of Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Navein J.
        • Coupland R.
        • Dunn R.
        The tourniquet controversy.
        J Trauma. 2003; 54: S219-S220
        • Kragh Jr, J.F.
        • Walters T.J.
        • Baer D.G.
        • et al.
        Survival with emergency tourniquet use to stop bleeding in major limb trauma.
        Ann Surg. 2009; 249: 1-7
        • Husum H.
        • Gilbert M.
        • Wisborg T.
        • et al.
        Prehospital tourniquets: there should be no controversy.
        J Trauma. 2004; 56: 214-215
        • Husum H.
        • Ang S.C.
        • Fosse E.
        War Surgery Field Manual.
        Penang, Malaysia: Third World Network. 1995; 85: 145
        • Neuhaus S.J.
        Ts13 haemostasis in the Australian defence force: the tourniquet controversy.
        Aust N Z J Surg. 2007; 77: A95
        • Parker P.J.
        • Clasper J.
        The military tourniquet.
        J R Army Med Corps. 2007; 153: 8-10
        • Klenerman L.
        The tourniquet in surgery.
        J Bone Joint Surg. 1962; 44B: 937-943
        • Blackwood M.
        • Royal Army Medical Corps, 3rd Corps Medical Society
        Treatment of wounds from fire trench to field ambulance.
        J R Army Med Corps. 2001; 147 (1916) (discussion, 229): 230-235
        • Anonymous
        Editorial: the tourniquet, instrument or weapon?.
        CMAJ. 1973; 109: 827
        • Sanders R.
        The tourniquet: instrument or weapon?.
        Hand. 1973; 5: 119-123
        • Parsons D.L.
        • Walters T.J.
        Tourniquets: lifesavers on the battlefield.
        J Spec Op Med. 2004; 4: 51-53
        • National Association of Emergency Medical Technicians (NAEMT)
        PreHospital Trauma Life Support (PHTLS) Military.
        in: 6th ed. Mosby, St. Louis, MO2007: 501-519
        • Hodgetts T.J.
        • Mahoney P.F.
        The military tourniquet: a response.
        J R Army Med Corps. 2007; 153: 10-13
        • Montgomery H.R.
        • Kotwal R.S.
        • 75th Ranger Regiment Trauma Management Team (Tactical)
        Ranger Medic Handbook.
        Cielo Azul Publications, Las Vegas2007
        • Mabry R.L.
        Tourniquet use on the battlefield.
        Mil Med. 2006; 171: 352-356
        • Moore F.A.
        Tourniquets: another adjunct in damage control?.
        Ann Surg. 2009; 249: 8-9
        • Lakstein D.
        • Blumenfeld A.
        • Sokolov T.
        • et al.
        Tourniquets for hemorrhage control on the battlefield: a 4-year accumulated experience.
        J Trauma. 2003; 54: S221-S225
        • Beekley A.C.
        • Sebesta J.A.
        • Blackbourne L.H.
        • et al.
        Prehospital tourniquet use in Operation Iraqi Freedom: effect on hemorrhage control.
        J Trauma. 2008; 64: S28-S37
        • Kragh Jr, J.F.
        • Baer D.G.
        • Walters T.J.
        Extended (16-hour) tourniquet application after combat wounds: a case report and review of the current literature.
        J Orthop Trauma. 2007; 21: 274-278
        • Kragh Jr, J.F.
        • Walters T.J.
        • Baer D.G.
        • et al.
        Practical use of emergency tourniquets to stop bleeding in major limb trauma.
        J Trauma. 2008; 64: S38-S50
        • Kragh Jr, J.F.
        • Littrel M.L.
        • Jones J.A.
        • et al.
        Battle casualty survival with emergency tourniquet use to stop limb bleeding.
        J Emerg Med. 2009; ([E-pub ahead of print])
        • Brodie S.
        • Hodgetts T.J.
        • Ollerton J.
        • et al.
        Tourniquet use in combat trauma: UK military experience.
        J R Army Med Corps. 2007; 153: 310-313
        • Majno G.
        The Healing Hand: Man and Wound in the Ancient World.
        in: Harvard University Press, Cambridge, MA1975: 278-279 (403–5)
        • Wilson L.G.
        Erasistratus, Galen, and the Pneuma.
        Bull Hist Med. 1959; 33: 293-314
        • Klenerman L.
        The Tourniquet Manual.
        Springer, London2003
        • Baker P.A.
        Medical Care for the Roman Army on the Rhine, Danube and British Frontiers in the First, Second, and Third Centuries A.D..
        (Oxford, UK)in: 2004: 1286
      1. Salazar C.F. The Treatment of War Wounds in Graeco-Roman Antiquity: Studies in Ancient Medicine. Brill, Boston2000
        • Richey S.L.
        Tourniquets for the control of traumatic hemorrhage: a review of the literature.
        World J Emerg Surg. 2007; 2: 28
        • von Gersdorff H.
        Feldbuch der Wundarzney.
        Wissenschaftliche Buchgesellschaft, Darmstadt1967 (Nachdruck der Edition von 1517) (Accessed: April 13, 2009)
        • Pilcher L.S.
        Treatment of Wounds: Its Principles and Practice, General and Special.
        2nd ed. William Wood, New York1899
        • Packard J.H.
        A Manual of Minor Surgery.
        Lippincott, Philadelphia1863
        • Longmore T.
        Gunshot Injuries, Their History, Characteristic Features, Complications, and General Treatment: With Statistics Concerning Them as They Have Been Met With in Warfare.
        2nd ed. Longmans, Green, New York1895
        • Bailey H.
        Surgery of Modern Warfare.
        in: Livingstone, Edinburgh1941: 273-279
        • Warren E.
        An Epitome of Practical Surgery for Field and Hospital.
        West & Johnson, Richmond, VA1863
        • Hamilton F.H.
        A Practical Treatise on Military Surgery.
        Baillière Brothers, New York1861
        • Blizard W.
        A lecture on the situation of the large blood-vessels of the extremities; and the methods of making effectual pressure on the arteries.
        Cases of Dangerous Effusions of Blood From Wounds. Delivered to the Scholars of the Late Maritime School, at Chelsea. 3rd ed. Dilly, London1798
        • Macleod G.H.B.
        Notes on the Surgery of the War in the Crimea, With Remarks on the Treatment of Gunshot Wounds.
        John Churchill, London1858
        • Chisholm J.J.
        A Manual of Military Surgery.
        in: West & Johnston, Richmond, VA1861: 140-143
        • Gross S.D.
        A System of Surgery: Pathological, Diagnostic, Therapeutic and Operative.
        4th ed. Lea, Philadelphia1866 (Vol. 1)
        • Johnston W.P.
        The Life of Gen.
        Appleton, New York1879
        • Esmarch F.
        First Aid to the Injured: Six Ambulance Lectures.
        6th ed. Smith Elder, and Co, London1898 ([Christian H. R. H. Princess, trans.])
        • Strott G.G.
        History of Medical Personnel of the United States Navy Sixth Regiment Marine Corps American Expeditionary Forces in World War 1917–1918.
        in: Pike N.H. The Brass Hat, ND. Department of the Navy, Washington, DC1947
        • Böhler L.
        The Treatment of Fractures.
        (Vol 1. [Tretter H, Luchini HB, Kreuz F, transl.])in: Grune & Stratton, New York1956: 126-128
        • Böhler J.
        Fresh Arterial Injuries in the Treatment of Fractures.
        in: 5th ed. Grune & Stratton, New York1966: 2672-2689
        • Jolly D.W.
        Field Surgery in Total War.
        in: Paul B. Hoeber, Inc., New York1941: 24-25
        • Committee of Privy Council for Medical Research
        Medical Research in War: Report of the Medical Research Council for the Years 1939–45.
        in: His Majesty's Stationery Office, London1947: 18-56 (252–6, 413–5)
        • Editor
        In memoriam: Sir Reginald Watson-Jones.
        J Bone Joint Surg. 1972; 54B: 569-575
        • Watson-Jones R.
        Fractures and Joint Injuries.
        in: Livingstone, London1955: 121-122
        • Watson-Jones R.
        Traumatic uraemia.
        J Bone Joint Surg. 1948; 30B: 233
        • Wolff L.H.
        • Adkins T.F.
        Tourniquet problems in war injuries.
        Bull US Army Med Dept. 1945; 87: 77-84
        • Wolff L.H.
        Forward surgeon: the diary of Luther H Wolff, M.D., Mediterranean Theater, World War II 1943–45.
        Vantage, New York1985
        • Butler Jr, F.K.
        • Holcomb J.B.
        • Giebner S.D.
        • et al.
        Tactical combat casualty care 2007: evolving concepts and battlefield experience.
        Mil Med. 2007; 172: 1-19
        • Butler Jr, F.K.
        Tactical medicine training for SEAL mission commanders.
        J Spec Op Med. 2004; 4: 40-51
        • Butler Jr, F.K.
        • Hagmann J.
        • Butler E.G.
        Tactical combat casualty care in special operations.
        Mil Med. 1996; 161: 3-16
        • Walters T.J.
        • Mabry R.L.
        Issues related to the use of tourniquets on the battlefield.
        Mil Med. 2005; 170: 770-775
        • Mallory M.
        Emergency treatment and resuscitation at the battalion level.
        in: Medical Science Publication No. 4: Recent Advances in Medicine and Surgery (19–30 April 1954). Based on Professional Medical Experiences in Japan and Korea 1950–1953. Vol. 1. Office of the Surgeon General Office of Medical History, Washington, DC1954: 61
        • Hughes C.W.
        Medical Science Publication No. 4. Recent Advances in Medicine and Surgery (19–30 April 1954). Based on Professional Medical Experiences in Japan and Korea 1950-1953. Vol. 1. US Army Medical Service Graduate School Walter Reed Army Medical Center, Washington, DC1954
        • Hughes C.W.
        Acute vascular trauma in Korean War casualties: an analysis of 180 cases.
        in: Howard J.M. The Battle Wound: Clinical Experiences. Vol. 3. Army Medical Service Graduate School, Washington, DC1955: 132-139 (Chapter 11)
        • Artz C.P.
        • Howard J.M.
        • Sako Y.
        • et al.
        Clinical experiences in the early management of the most severely injured battle casualties.
        Ann Surg. 1955; 141: 285-296
        • Bellamy R.F.
        The causes of death in conventional land warfare: implications for combat casualty care research.
        Mil Med. 1984; 149: 55-62
        • Bellamy R.F.
        Combat trauma overview.
        in: Bellamy R.F. Anesthesia and Perioperative Care of the Combat Casualty, in Surgical Combat Casualty Care. Part IV of the Textbook of Military Medicine. Borden Institute and Office of the Surgeon General, Bethesda, MD1995: 1-42
        • Bellamy R.F.
        Why is Marine combat mortality less than that of the Army?.
        Mil Med. 2000; 165: 362-367
        • Maughon J.S.
        An inquiry into the nature of wounds resulting in killed in action in Vietnam.
        Mil Med. 1970; 135: 8-13
        • Conzelmann F.J.
        Improvised Esmarch bandage.
        J Assoc Mil Surg US. 1907; 30: 62
        • Mucciarone J.J.
        • Llewellyn C.H.
        • Wightman J.M.
        Tactical combat casualty care in the assault on Punta Paitilla Airfield.
        Mil Med. 2006; 171: 687-690
        • Carey M.E.
        Analysis of wounds incurred by U.S. Army Seventh Corps personnel treated in Corps hospitals during Operation Desert Storm, February 20 to March 10, 1991.
        J Trauma. 1996; 40: S165-S169
        • Mabry R.L.
        • Holcomb J.B.
        • Baker A.M.
        • et al.
        United States Army Rangers in Somalia: an analysis of combat casualties on an urban battlefield.
        J Trauma. 2000; 49: 515-529
        • Walters T.J.
        • Wenke J.C.
        • Kauvar D.S.
        • et al.
        Effectiveness of self-applied tourniquets in human volunteers.
        Prehosp Emerg Care. 2005; 9: 416-422
        • Cain J.S.
        From the battlefield to our streets: how combat medicine is revolutionizing civilian prehospital care.
        J Trauma: War Trauma Suppl. 2008; 3: 16-23
        • Taillac P.P.
        • Doyle G.S.
        Tourniquet first! Safe and rational protocols for prehospital tourniquet use.
        J Trauma: War Trauma Suppl. 2008; : 24-27
        • Dorlac W.C.
        • DeBakey M.E.
        • Holcomb J.B.
        • et al.
        Mortality from isolated civilian penetrating extremity injury.
        J Trauma. 2005; 59: 217-222