ON AMPUTATION 395 



But for emptying the limb of its blood the method of elevation seems to me 

 preferable, if it is used in such a way as to obtain its full advantages, with a 

 view to which it is essential to understand the modus operandi. Though I first 

 employed elevation, as others had occasionally done before me, with the object 

 merely of emptying the limb of its venous blood, I saw before long that much 

 more than this was really done. If the elevated position was maintained for 

 a sufficient length of time, the perfectly blanched appearance of the skin implied 

 that arterioles as well as veins were emptied in a manner that could not be 

 accounted for on merely hydraulic principles by the effect of gravity upon the 

 blood ; and being led to inquire into the matter experimentally, I ascertained 

 that when a limb is raised, the first effect of gravity in emptying and relaxing 

 the veins is followed by a gradual contraction of the larger as well as smaller 

 arteries of the limb under the influence of the vasomotor nervous system ; the 

 effect reaching its maximum in about four minutes.^ If, therefore, the limb 

 is kept raised to the utmost for about that length of time, care being taken not 

 to press upon any part containing a venous trunk, and the elastic tourniquet 

 is then rapidly applied, a degree of bloodlessness of the site of operation is 

 obtained which is practically as good as that of Esmarch's method, while it 

 is free from two objections which attend the latter. One of these is referred 

 to by Esmarch, viz. that it is inapplicable in case of putrid infiltration of the 

 tissues, on account of the risk of forcing septic matter into the interstices of 

 sound tissues ; and I may add that I should feel considerable hesitation in 

 applying the continuous elastic bandage to a part affected with soft malignant 

 tumour, fearing the possibility of the disease being diffused by the upward 

 pressure through venous or lymphatic channels. The method by position, 

 on the other hand, is applicable to all cases. The other objection to Esmarch's 

 method which many surgeons have complained of, and which has induced some 

 to abandon it, is a liability to reactionary haemorrhage. From this also the 

 method by position is free. Esmarch's original elastic band, consisting of a tube 

 of caoutchouc about as thick as the finger, or a somewhat thinner solid rod 

 of the same material, is, I believe, the best for the thigh ; because, while it is 

 exceedingly effective, the abrupt constriction which it produces cannot injure 

 the nervous trunks, well protected as they are by an abundant padding of muscles. 

 But in tlie case of the arm, where the soft parts are comparatively scanty in 

 proportion to the bone, serious paralytic effects have followed the use of the 

 elastic tourniquet in tliis form. These are. however, entirely avoided by 

 employing for the u})per limb, in accordance with Von Langenbeck's suggestion, 



' Sec an Address on the Influence of Position on the Local Circulaiuni. British Medical Journal, 

 June J I, 1879 (reprinted in vol. i, p. 176). 



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