394 ON AMPUTATION 



this practice has the great advantage that it banishes all risk of reactionary 

 haemorrhage. 



The catgut, of course properly prepared to fit it for surgical purposes, should 

 be used of as slender quality as will bear the strain of tying ; except in the case 

 of advanced atheroma, when the finer kinds may be found to cut through the 

 degenerated tissues of an arterial trunk, and a thicker sort must then be employed 

 for the principal vessels. If the ligature cannot be made to hold when applied 

 round the point of the forceps in the usual way, as w^hen fibrous tissue is con- 

 densed by inflammatory infiltration, the difficulty may always be overcome by 

 threading a fine curved needle with catgut with both ends long, and passing it 

 so as to take a substantial hold of the tissues at the site of the bleeding-point, 

 cutting off the needle, and tying the two pieces of gut one at each side. The 

 bleeding vessel will be sure to be included in One of them. 



Torsion is preferred by some surgeons ; but, though it is admirable for 

 many wounds, particularly about the face, those who have tried both in amputa- 

 tion will, I think, agree that the ligature is more unfaihng and on the average 

 more expeditious. 



In the second edition of this work I recommended a practice which I had 

 adopted for some years with great advantage, viz. raising the limb into the 

 vertical position and pressing it firmly from the extremity towards the trunk 

 with the view of emptying it of venous blood, and then tightening as rapidly 

 as possible a screw tourniquet, previously kept perfectly loose. The contrast 

 between the ' almost bloodless ' division of the tissues under such circumstances 

 and the gush of venous blood wliich attended the operation when the tourniquet 

 had been applied in the horizontal or dependent position of the limb was extremely 

 striking. Soon afterwards Professor Esmarch, of Kiel, published his bloodless 

 method, which consisted of forcing the blood out of the limb by means of an 

 elastic bandage applied continuously from the distal extremity to a point some 

 distance above the site of the intended operation, and then applying another 

 elastic band just above, to serve as a tourniquet and maintain the bloodless 

 condition when the continuous bandage was removed. By these means the limb 

 is rendered absolutely ex-sanguine at the seat of operation. 



There can be no doubt of the great advantage of the upper elastic band, 

 which follows up any yielding of the soft parts and maintains continuously 

 a perfectly effective constriction ; whereas with the common tourniquet, if 

 the operation was protracted, and especially if the tissues were unusually yielding 

 through inflammatory or oedematous infiltration, the inelastic strap had to 

 be further tightened again and again in consequence of recurrence of bleeding. 

 Esmarch's elastic tourniquet has thus entirely superseded the old instrument. 



Ill 



