ESMARCH’S 
t 
BLOODLESS METHOD. 
BY 
HENRY B. SANDS, M. D., 
NEW YORK. 
[REPRINTED FROM THE NEW TORN MEDICAL JOURNAL. JAN., 1875.] 
NEW YORK: 
1). ?APPLETON AND COMPANY, 
1549 & 551 BROADWAY. 
1875. APPLETONS’ JOURNAL, 
FOIR, 1875. 
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D. APPLETON & CO., Publishers, New York. ESMARCH’S 
BLOODLESS METHOD. 
BY 
HENRY B. SANDS, M. D., 
NEW YOEK. 
[.REPRINTED FROM THE NEW TORE MEDICAL JOURNAL, JAN., 1875.] 
NEW YORK: 
1). APPLETON AND COMPANY, 
549 & 551 BKOADWAY. 
1875. ESMARCH’S BLOODLESS METHOD.1 
In April, 1873, at a meeting of the German Surgical Con- 
gress, in Berlin, Prof. Esmarch, of Kiel, announced an im- 
portant discovery. He stated that, after many trials, he had 
ascertained the fact that, by the application of an elastic band- 
age to the extremities, the limbs could be rendered bloodless; 
and that, by the substitution of a piece of rubber tubing for 
the tourniquet, the condition of artificial ahuemia produced 
by the bandage could be maintained, so as to permit opera- 
tions to be performed upon the parts below, with even less 
loss of blood than if performed upon the dead body. Such 
an announcement could not fail to excite surprise; and sur- 
geons, both in Europe and America, hastened to test the ac- 
curacy of the statements made by the German teacher. In 
the present paper I have endeavored to form an appreciation 
of the value of Esmarch’s method, by studying the experience 
which the surgeons of Hew York and its vicinity have had in 
its employment during the year that has passed since it was 
first put upon trial here. And I may remark, incidentally, 
that whatever value the method maybe found to possess, must 
fairly be ascribed to Esmarch himself, and not to his prede- 
1 Read, November 23, 1874, at the anniversary meeting of the Medi- 
cal Society of the County of New York, by H. 13. Sands, M. D., Presi 
dent of the Society. 4 
esmarcii’s bloodless method. 
cessors. Attempts Lave been made, especially in England, to 
prove tliat the method is no novelty, either in principle or in 
detail, and that the same results bad often been obtained by the 
use of an ordinary bandage and a tourniquet. But, although 
it must be admitted that the principle is an old one, the suc- 
cessful application of it is unquestionably due to the employ- 
ment of the elastic bandage, as recommended by Esmarch. 
To any one who compares the action of an ordinary with that 
of an elastic bandage, in the production of artificial anaemia, 
tlio superiority of the latter is at once apparent. Indeed, the 
novelty of Esmarch’s method is shown by the fact, that the 
old method, owing to its imperfections, had well nigh fallen 
into oblivion; while the new one has excited an interest and 
enthusiasm in the surgical world wdiich have not been equaled 
since the introduction of anaesthetics. 
For the information of those wdio are not yet familiar 
with the details of the bloodless method, it will be desirable, 
first, to describe the mode and range of its application. Sec- 
ondly, wre may state its alleged advantages and disadvantages; 
and, finally, endeavor to estimate its value as tested by our 
own experience. 
The bandages are composed of elastic webbing, or—what 
is better—of simple sheet-rubber, which can be more readily 
cleaned than the webbing, when it has become soiled by pus 
or other discharges. The bandages should be about two and 
a half inches wide, and it is convenient to be provided with 
several of them, each three yards in length, rather than to 
employ one long bandage. As a substitute for the tourniquet, 
some surgeons use a piece of the same bandage ; others employ 
a solid rubber cord or rope, about a quarter of an inch in 
diameter; wdiile Esmarch himself recommends for this pur- 
pose a piece of tubing made of non-vulcanized rubber, which 
is softer and more yielding than the other varieties. The ap- 
plication of the bandage, in ordinary cases, is quite simple. 
It is put on with moderate compressing force, and carried 
from the fingers or the toes to any desired height. The con- 
stricting cord or tube, which is to take the place of the tour- 
niquet, is then wound two or three times around the limb, ESMAKCH’s BLOODLESS METHOD. 
5 
immediately above tlie upper edge of tlie bandage, and made 
fast either by a knot, or by a hook and chain, or any similar 
contrivance. The bandage is then removed to expose the 
parts for operation. Some experience is needful to apply the 
bandage with the proper degree of force. Often it is applied 
too firmly, and this mistake is pretty sure to be made by be- 
ginners. On the other hand, it may be applied too loosely, 
and I have several times seen it put on with just sufficient 
force to allow venous congestion of the parts, with consequent 
haemorrhage during the operation. The same remark applies, 
with equal truth, to the use of the constricting cord, which, 
if applied too loosely, will cause venous engorgement, and, if 
too tightly, may do serious damage to the nerves, and proba- 
bly also to the blood-vessels of the limb. 
The skin, when exposed after the removal of the bandage, 
is seen to be blanched and anaemic; and, when the deeper 
tissues are cut into, they are found to be nearly or quite 
bloodless. The vessels, both arterial and venous, are almost 
absolutely empty, so that an amputation of the thigh, for ex- 
ample, can be performed without the loss of more than live 
or ten drops of blood. This bloodless condition remains un- 
altered so long as the constricting band is kept in position. 
Immediately after this has been removed, however—the large 
vessels having been previously secured—the blood returns to 
the parts with considerable force, and, if these are vascular, a 
pretty free oozing commonly takes place from the surface of 
the wound. This bleeding is usually quickly checked by the 
use of cold water, aided, if necessary, by gentle pressure. 
With slight modifications in the adaptation of the appa- 
ratus, the bloodless method is applicable to amputation at the 
hip or the shoulder joint. A case of amputation at the hip- 
joint has recently been reported in the London Lancet, by Dr. 
Gibb, of Newcastle, who states that only two ounces of blood 
wTere lost during the operation—this having escaped from the 
veins when the femoral vessels were divided. It is also stated 
that, in this case, no harm resulted from the pressure of a pad 
which was placed over the abdominal aorta. In operations 
upon the penis and scrotum, and in the removal of large ESMAKCIl’s BLOODLESS METHOD. 
6 
tumors of tlie breast, the method has been successfully ap- 
plied. Langenbeck speaks highly also of its employment in 
extirpation of vascular tumors of the scalp. 
The enumeration I have now given nearly completes the 
list of regions to which the bloodless method is applicable. 
It cannot be employed in operations on the trunk, or on the 
face and neck, where surgeons would gladly, if possible, avail 
themselves of its advantages. 
These advantages, as claimed by Esmarch, are as follow : 
First, the prevention of a great loss of blood during the larger 
operations. It is assumed that this economy of the vital fluid 
will sometimes be the direct means of saving life; that it will 
render more certain and speedy the healing process, and di- 
minish the frequency of septicaemia and pyaemia. The other 
principal advantage of the method is the facility with which 
it enables the surgeon to accomplish deep and difficult dis- 
sections, the tissues not being obscured by blood. It is said 
also to permit the easy extraction of foreign bodies, and the 
thorough examination of diseased bones and joints, with the 
view of deciding upon the extent of operation necessary in 
any given case. 
The following objections have been made to the bloodless 
method. It is alleged that the pressure impairs the vitality 
of the parts, and causes them, in many instances, to slough. 
Also, that it affects injuriously the nerve-trunks, giving rise 
to paralysis, both of sensation and motion. Haemorrhage, 
occurring shortly after the operation, has been ascribed to the 
method. Its employment is also thought to be dangerous, be- 
cause it may induce plethora of the internal organs, by driv- 
ing back into the blood-vessels a larger amount of blood than 
they normally contain. It is feared that the vessels, if brittle 
from disease, might be ruptured from this cause. Lastly, it is 
believed that in cases of gangrene, or unhealthy suppuration, 
poisonous fluids may be pressed into the blood-vessels, or into 
the healthy tissues, by the elastic bandage, and thus occasion 
septicaemia or pyaemia. 
In a second paper lately written by Esmarch, that surgeon 
gives the results of two hundred bloodless operations per- esmaech’s bloodless method. 
7 
formed by liim during the preceding year; and these results 
show the method in a most favorable light. As our own ex- 
perience, however, is that on which we must rely, I proceed 
at once to a brief analysis of the cases which I have been 
able to obtain. They have been collected from the principal 
hospitals of blew York, Brooklyn, and Jersey City, and from 
the private practice of Drs. Wood, Krackowizer, Gouley, Ely 
Weber, Little, Varick, and myself. The records of Charity 
Hospital are not included in my table, as they were so im- 
perfectly kept that no use could be made of them. I have 
also failed to obtain the experience of St. Francis’s Hospital 
in this city, wdiere more than twenty bloodless operations are 
said to have been performed. I have endeavored to present all 
of the hospital cases, both good and bad; and, although some 
of the histories are imperfect, they present many interesting 
and instructive details. The list embraces one hundred and 
forty-three cases, which I have classified as follows: 
Cases. 
Amputation of fingers, primary 4. 
“ “ secondary or for disease. 3. 
“ hand, partial primary 3. One fatal from haemor- 
rhage. 
“ at wrist-joint, primary 1. 
“ of forearm, primary 5. 
“ “ secondary 1. 
“ arm, primary 5. Two fatal: one from 
erysipelas, one from 
shock. 
“ “ secondary 1. 
“ toes, primary 2. 
“ foot, partial 1. 
“ at ankle-joint (Syme’s) 4. 
“ “ secondary 5. 
“ of leg, primary 11. Three fatal: two from 
pyaemia, one from 
Bright’s disease and 
exhaustion. 
Double amputation of leg, primary 1. Fatal from shock in 
forty-four hours. 
“ “ secondary 3. One fatal, performed for 
tetanus. 8 
esmarch’s bloodless method. 
Cases. 
Double amputation at knee-joint, primary... 4. One fatal from gan 
grene on fourth day. 
“ of thigh, primary 8. Two fatal from pyaemia. 
“ “ and leg, primary. 1. 
“ “ “ second’y. 9. Three fatal: one from 
phthisis, one from 
exhaustion, and one 
from pyaemia. 
Excision of wrist 3. 
“ “ primary 1. 
“ elbow, disease 3. 
“ “ primary 3. 
“ ankle-joint 2. 
“ knee-joint, disease 1. Fatal from pyajmia. 
“ tarsus 1. Patient has symptoms 
of tetanus. 
“ tibia, primary 1. 
“ femur, for ununited fracture 1. 
Necrosis of “ 11. One fatal from pyajmia. 
“ tibia 11. 
“ fibula 1. 
“ os calcis 3. 
“ scapula 1. 
“ humerus 3. 
“ radius 4. 
“ ulna 1. 
“ metacarpus 1. 
Ununited fracture of leg 1. 
Exostosis of femur 1. 
Removal of tumor from thigh 1. 
“ “ popliteal space 1. 
“ “ leg 4. 
“ “ forearm 1. 
Ligature of wounded uloar arteries 1. Fatal from pyaemia. 
“ “ anterior tibial artery... 1. 
“ “ deep palmar arch 1. 
Tenotomy of hamstring 1. 
Excision of large mammary tumor 1. 
Incision of leg for varicose ulcer 1. 
Fistula of penis 1. 
Trephining abscess of tibia 1. 
Neuroma of stump 1. 
Elephantiasis arabum 1. 
On reviewing the above table, we find G3 amputations, ex- 
cluding those of the fingers and toes. Of these operations, 44 Esmarch’s bloodless method. 
9 
were primary, for injury, and 19 secondary, or for disease. 
Of the primary amputations, 10 cases, or 22.7 per cent., ter- 
minated fatally—the causes of death being the following: 
Pyaemia , 4 
Exhaustion or shock 3 
Spreading gangrene 1 
Erysipelas 1 
Hemorrhage 1 
Of the cases fatal from pyaemia, one patient had the dis- 
ease at the time of the operation. 
Of 8 cases of primary amputation of the thigh, 2 cases, 
or 25 per cent., ended fatally. 
Of 11 cases of primary amputation of the leg, 3 cases, or 
27.3 per cent., were fatal. 
Secondary amputations, 19 cases, give a mortality of 21 
per cent. The causes of death are stated as follows: 
Tetanus (existing at time of operation) 1 
Exhaustion 1 
Phthisis 1 
Pyaemia 1 
Total 4 
Although I have not the means of making an exact com- 
parison, I believe that the percentage of recoveries in these 
primary amputations, which were nearly all performed on 
hospital patients, is somewhat larger than is commonly ob- 
served in such operations. 
Out of 14 cases of excision of the joints, only one proved 
fatal; the cause of death being pyaemia. Another case will 
probably end fatally, however, as the patient was suffering 
from tetanus when last heard from. 
Finally, the list included two more deaths, one following 
an operation for necrosis—the only fatal case out of 36—and 
the other an operation for the ligature of the ulnar artery, per- 
formed for a wound near the wrist. 
These cases are not sufficiently numerous to possess much 
statistical value, and they do not, as I think, warrant any 
definite conclusions respecting the general efficiency of the 
bloodless method in diminishing the mortality which usually 
attends the larger operations. Certainly, pyaemia is not pre- 10 
Esmarch’s bloodless method. 
vented by it, for the greatest number of deaths are reported 
as due to this cause. On the other hand, it must not be as- 
sumed that the elastic bandage is responsible for the pyaemic 
cases, for, so far as I have been able to learn, the application of 
the bandage to gangrenous and putrefying parts has been care- 
fully avoided. It is interesting to observe that no serious re- 
sults appear to have ensued from the forcing back of blood into 
the vessels of the trunk, although the quantity of blood thus 
added, as it were, to the circulation, must, in the cases of am- 
putation of the thigh, have been considerable. In a physio- 
logical point of view, this fact is remarkable, and shows that 
the blood-vessels can bear a suddenly-increased internal press- 
ure, without any appreciable shock to the system, and with- 
out rupture of their walls. Further and more exact observa- 
tion is needed, however, to conclusively determine the safety 
of the bloodless method in this respect; and it will perhaps be 
found that this distention of the vessels may be dangerous to 
persons suffering from organic diseases of the thoracic and ab- 
dominal viscera. 
Although the cases in the table are too few for statistical 
purposes, they are numerous enough to settle many questions 
relating to Esmarch’s method. And, in the first place, I may 
remark that it is perfect in its results, so far as the bloodless 
character of the operation is concerned. In an amputation of 
the thigh, for example, the limb can be removed, and the prin- 
cipal arteries secured, with the loss of only a few drops of 
blood; and, although the haemorrhage from the smaller vessels 
may be tolerably free when the constricting band is unfastened, 
the bleeding is very trifling when compared with that which 
occurs during an amputation performed according to the ordi- 
nary method. In any case, the amount of blood lost to the 
general circulation can never equal that which has been 
gained by the employment of the bandage, so that, after the 
operation, the patient will have proportionately more blood 
than before. That this saving of the sanguineous fluid must 
be salutary in certain conditions, can hardly be doubted, and 
one of my own cases may be quoted as an example. A man 
was brought to the Bellevue Hospital, twelve hours after hav- 
ing had his foot crushed by the wheels of a railway-car. The esmarcii’s bloodless method. 
11 
anterior tibial artery was wounded, and bad bled so freely 
that the patient was in a fainting condition, and had no pulse 
at the wrist. Having administered stimulants by the rectum, 
I performed amputation of the leg by the bloodless method, 
and the patient made an excellent recovery. It is reasonable 
to infer that, if the operation had been attended with the usual 
loss of blood, the result might not have been so fortunate. 
Patients with compound fractures are often brought into 
our hospitals while bleeding severely from injured blood-ves- 
sels ; and the ordinary bandage, which is lisually employed 
before they are brought to our notice, rarely suffices to check 
the haemorrhage. The application of the elastic roller, in such 
cases, would frequently be the means of saving life; and a 
supply of these should be furnished to the ambulance-sur- 
geons, and to those in charge of the police-stations, as they 
could be used with efficiency, even by the most inexperienced. 
Ho argument is needed to prove the excellence of the 
method, in enabling the surgeon to have a clear and unob- 
structed view of the tissues that come under his knife; and 
this feature of bloodless operations is, to my mind, the one ol 
greatest value. Every one has remarked how much easier it 
is to expose an artery or a nerve in the dead than in the liv- 
ing body. How, this difference depends almost entirely upon 
the fact that, in the latter, the tissues are stained and altered 
in their appearance by the blood which escapes from the di- 
vided vessels. While the blood is still flowing, the parts are 
often completely concealed from view; but, even after the 
hminorrhage has ceased, the tissues are not unfrequently so 
uniformly stained as to make their recognition a difficult 
task. In these circumstances, especially if the dissection is a 
deep one, precision in operating is often impossible, and in- 
juries, both unavoidable and serious, are not seldom inflicted 
upon blood-vessels and nerves, even by skillful and cautious 
operators. In a bloodless operation, however, these difficulties 
vanish, as if by magic, and dissections may be made upon 
the living body, with a degree of precision heretofore unknown. 
The aid thereby afforded to the surgeon is incalculable, and 
the advantage to the patient is great and obvious. To one 
who has never before witnessed a bloodless operation, that for 12 
ESMARCH’S BLOODLESS METHOD 
necrosis of the femur in the popliteal space is, perhaps, one 
of the most striking. Instead of groping among tissues ob- 
scured by venous blood, and needlessly sacrificing the living 
bone, to permit the removal of the sequestrum, the operator 
can use his eye to guide the instrument at every step, distin- 
guish at a glance the diseased from the healthy bone, and com- 
plete the operation with the least possible damage to the sur- 
rounding tissues. A medical friend, being present at such an 
operation, remarked to me that he had attended many opera- 
tions for necrosis, but that this was the first one he had ever 
seen. In operations for caries of the joints too, particularly 
those of the hand and the foot, the bloodless method permits 
the surgeon to inspect the diseased parts with ease and satis- 
faction, and to determine, to a nicety, the extent to which 
these require to be removed. In doubtful cases, we may thus 
often substitute for an amputation the minor operation of 
excision, or even an exploratory incision into the affected 
tissues. 
The table gives eight cases of the removal of tumors from 
deeply-seated parts. The particulars of these cases are some- 
what meagre; but, with the exception of one in the practice 
of Dr. Ely, of JSTewburg, where the extirpation of the tumor 
necessarily involved the division of the large femoral vessels, 
and consequent amputation of the thigh, they all terminated 
successfully. In Dr. Wood’s case, that of a tumor in the 
popliteal space, I presume the dissection was made more easy 
and certain by the employment of the elastic roller. Its ad- 
vantages were plainly shown in a case that occurred in my 
own private practice. The patient, a lady, whom I saw in 
consultation with Dr. Dana, had a sarcomatous tumor about as 
large as a walnut, growing from the periosteum of the radius, 
near the upper extremity of the bone. To remove it, I was 
obliged to turn aside the superficial muscles, and to cut away 
a part of the supinator brevis. In doing this I exposed the 
posterior interosseous nerve to the extent of nearly an inch; 
but with care I dissected out the tumor without injury to the 
nerve. The wound healed in five days, by the first intention, 
and no paralysis followed. I feel confident that, had I not 
been able to avail myself of Esmarch’s method, I should have esmarch’s bloodless method. 
13 
probably either divided the nerve, or excised it. While pur- 
suing this line of remark, I would suggest a caution. The 
bloodless state of the parts, while it favors the recognition of 
most of the textures, renders the blood-vessels themselves, in 
consequence of their emptiness, somewhat liable to accidental 
division. Ordinarily, in operations such as are performed for 
the removal of deep-seated tumors, or for the ligation of ves- 
sels, both the arteries and the veins are easily recognized, the 
former, if at all large, exhibiting pulsation, and the latter re- 
vealing themselves by their size, color, and compressibility. 
But, when the bloodless method is employed, I have found 
that considerable care is required to avoid the unnecessai\y 
division of vessels—the veins, from the thinness of their coats, 
being especially liable to this accident. During the opera- 
tion, therefore, the surgeon should make good use of his ana- 
tomical knowledge, and study the appearance of the tissues 
before he divides them. Otherwise, what is a bloodless opera- 
tion in the beginning, may in the end be a very bloody one ; 
and the operator may be chagrined to find, when the pressure 
of the cord is removed, that he has unwittingly severed one 
or more important vessels. Moreover, in any case, before the 
wound is closed, its surface should be scrupulously examined, 
lest a divided artery escape notice at the time, and shortly 
after prove the source of a more or less copious haemorrhage. 
It is desirable to secure as many vessels as possible, before the 
pressure is remitted, as the capillary bleeding which occurs 
afterward considerably obscures the parts, and prevents the 
recognition of the arteries, unless they are spurting freely. 
With care, a great number of vessels may be secured with a 
trifling loss of blood, as is shown by a case of large mammary 
tumor, removed by Dr. Gouley, who has favored me with the 
following memorandum : “ This tumor, which had been grow- 
ing for eleven years, and was very large—weighing nine 
pounds—proved to be a large-cell sarcoma. Esmarch’s elastic 
bandage was so applied as to make firm pressure upon its en- 
tire surface ; then the rubber tube was securely wound around 
its base, which was somewhat pedunculated. When uncovered, 
the tumor was softer than before, and its surface quite blanched. 
During the extirpation, not more than one ounce of blood es- 14 
ESMAECIl’s BLOODLESS METHOD. 
caped, and throughout the entire operation—thirty ligatures 
having been applied—the total loss of blood did not exceed 
eight ounces. The pressure upon the tumor, and at its base, 
was not continued for more than ten minutes. The patient 
recovered, the greater part of the wound healing by the first 
intention.” 
Our table includes three cases of wounded arteries, in 
which the bloodless method was employed in searching for 
the injured vessel. In the first case, the ulnar artery, in the 
second, the superficial palmar, and, in the third, the anterior 
tibial, was the seat of lesion, and in all the vessel was found 
and secured. There can be no doubt that such operations 
are greatly facilitated by the employment of the elastic band- 
age. In traumatic aneurism also, in which the plan of laying 
open the sac is adopted, the difficulties of the operation, 
which are sometimes very great, must be nearly removed by 
the aid of Esmarch’s method. A case of this character is re- 
lated by Leisrink, who treated successfully a traumatic aneu- 
rism of the anterior tibial artery, situated in the upper third of 
the leg, by opening the sac, and tying the artery as it lay upon 
the interosseous membrane. Those who are aware of the 
great depth at which the artery is placed in the upper part of 
its course, will appreciate the assistance which the bloodless 
method must have afforded in this operation, which is stated 
by Leisrink to have been performed with ease. 
To the Hunterian operation, as practised for idiopathic 
aneurism, the method is not applicable, as the artery can be 
exposed in the usual manner without difficulty, and as the 
pressure of the bandage might cause the rupture or inflamma- 
tion of the aneurismal sac. 
Finally, in this connection, it may be mentioned that, al- 
though there are no cases in the table to prove it, the blood- 
less method has been found serviceable in operations under- 
taken for the extraction of foreign bodies, such as pieces of 
needles or of glass, from the hand or foot. These parts are ex- 
ceedingly vascular, and, when rendered bloodless, must per- 
mit a more precise and satisfactory exploration than could 
otherwise be made. 
Another alleged advantage of the method, which finds no esmaroh’s bloodless method. 
15 
illustration here, is the local anaesthesia which is said to ac- 
company the state of local anaemia. A case is reported by 
Stokes, of Dublin, in which the extirpation of an epithelial 
cancer, from the back of the hand, was accomplished without 
pain. The effects of the ether-spray, when employed as an 
auxiliary, are also said to be very rapidly produced, because 
the arrest of the circulation in the parts prevents their natural 
warmth from being renewed. I am doubtful whether local 
anaesthesia, induced by these methods, can be obtained with- 
out some compensating disadvantage. Both the elastic band- 
age and the ether-spray cause considerable pain; and, when 
combined, would, as I fear, be very apt to occasion sloughing. 
The question, however, is one that will soon be determined 
by experience. 
The table presented contains a number of minor opera- 
tions, which require no comment. A novel application of the 
method, however, was made by Dr. Wood, who applied the 
elastic bandage in a case of elephantiasis of the thigh, with a 
satisfactory result. I hope that Dr. Wood, who is present, 
will communicate the particulars of this interesting case. 
Ilaving considered the advantages of Esmarch’s method, 
as shown by the facts which I have collected, let us now try 
to determine whether they prove it to have any disadvan- 
tages. What I have to say may be put under three heads, 
namely, sloughing, secondary haemorrhage, and paralysis. 
Sloughing is reported to have followed in eight of the 
operations recorded in the table. Six of these operations were 
performed in the Bellevue Hospital, one in the Brooklyn City 
Hospital, and one in the Mount Sinai Hospital. It will be 
profitable to present you with an abstract of each one of these 
cases: 
Case I. Bellevue Hospital.—Male, aged fifteen. Primary 
amputation at knee-joint, for lacerated wound of leg. Slight 
sloughing of each flap, but not enough to prevent healing. 
Case II. Mount Sinai Hospital.—Boy, aged three years. 
Primary amputation, according to Syme’s method, for a rail- 
way injury of the foot. A small part of the flap sloughed, 
but not enough to prevent the covering of the stump. 
Case III. Bellevue Hospital.—Male, forty-nine. Primary 16 
esmaecii’s bloodless method. 
amputation for lacerated wound of hand. The parts removed 
were the thumb and first metacarpal bone, the entire index- 
finger, and the second and third phalanges of the middle and 
ring fingers. Slight sloughing of the stump of the thumb and 
index-finger, but not enough to prevent healing, which was 
complete on the forty-second day. 
Case IY. Bellevue Hospital.—Male. Compound, com- 
minuted fracture of tibia and fibula, with simple fracture of 
femur of same side. Amputation through condyle, by long 
anterior and short posterior flaps, close to the line of lacera- 
tion. Severe haemorrhage had preceded the operation. About 
an' inch and a half of the anterior flap sloughed, but the stump 
finally healed. 
Case Y. Brooklyn City Hospital.—Male, aged twenty- 
eight. Partial excision of carpal bones, for necrosis, resulting 
from a crushing injury received ten months previously. Two 
days after the operation, phlegmonous inflammation followed, 
with profuse discharge and sloughing, necessitating amputa- 
tion of the arm. This was performed, and the patient re- 
covered. 
Case YI. Bellevue Hospital.—A feeble woman, aged sev- 
enty. Primary amputation of arm, for compound, commi- 
nuted fracture of forearm. Some sloughing of one flap ; ery- 
sipelas on seventeenth day; bed-sore, and death from ex- 
haustion. 
Case YII. Bellevue Hospital.—Male, aged thirty-eight. 
Primary amputation at knee-joint, for compound fracture of 
bones of leg. The flaps were taken from parts infiltrated and 
contused. Spreading gangrene, which extended as high as 
the nipple ; destroyed the patient on the fourth day. 
Case YIII. Bellevue Hospital.—Male, aged thirty. Am- 
putation at middle of thigh, by long skin-flaps, for a large, 
malignant tumor of the femur. The patient was in feeble 
condition at the time of operation, and did not rally well 
afterward. About one-fifth of each flap sloughed, and death 
occurred on the third day. 
Case IX. Bellevue Hospital.—Male. Amputation above 
knee, for compound fracture of leg, caused by the wheels of 
a railway-car. Slight slough of outer flap, which did not 
prevent the healing of the wound. esmarch’s bloodless method. 
17 
On reviewing these cases, we find that seven of them were 
cases of primary amputation. As the whole number of prima- 
ry amputations given in the table is forty-one, it follows that 
sloughing of the flaps occurred in seventeen per cent. So far 
as these figures are concerned, they prove nothing against 
the bloodless method ; for it has been shown, by Dr. Figuera, 
that, at Bellevue Hospital, out of forty amputations, according 
to the old method, the flaps sloughed more or less in twenty- 
four, or sixty per cent. 
Ten cases of sloughing are reported after secondary opera- 
tions, these being nearly twelve per cent, of the entire number 
given in the table. 
After a careful examination of the cases in which slough- 
ing followed in primary amputations, I hardly feel willing to 
attribute the accident to the method employed. When we 
consider that some of these patients were intemperate, or 
feeble from loss of blood, that their injuries were severe, and 
that the flaps, which, in some cases, were very long, were 
generally taken from parts not far from the line of laceration, 
we are strongly inclined to regard these circumstances as the 
most important factors in the production of gangrene. It is, 
however, impossible to deny that the application of the elastic 
bandage may have had some share in causing this untoward 
event; and our suspicions are strengthened by the occurrence 
of gangrene in one case of amputation, which was not primary, 
inasmuch as gangrene, so far as my observation goes, is very 
rare in amputations performed for disease. In this case, ampu- 
tation of the thigh was performed on account of a malignant 
tumor of the femur; and although the patient’s general con- 
dition, prior to the operation, is stated to have been feeble, 
the gangrene of both flaps, which soon followed, compels us 
to suspect that the bloodless method may have been its de- 
termining cause. On the other hand, we must not fail to 
notice that the amputation was performed by long skin-flaps, 
which overhung, loosely, the end of the stump.. 
But the strongest case bearing upon this point is the one 
mentioned as having occurred in the Brooklyn City Hospital, 
and in which extensive sloughing followed an excision of the 
carpus. Dr. Speir, the attending surgeon, has kindly favored 18 
esmaech’s bloodless method. 
me witli his own views respecting this case, and I quote from 
his letter as follows: “ There is no doubt, in my mind, that 
the use of Esmarch’s method was the cause of the sloughing 
that followed the operation, in the case to which you refer. 
I do not hold the method responsible, however, for there was, 
perhaps, unnecessary pressure made by the constricting band, 
although it was not greater than I have used in other cases, in 
which no sloughing occurred. Less pressure wrould probably 
have been followed by a different result; and I find, by later 
experience, that less pressure would have been sufficient to 
have fulfilled the object of Esmarch’s method. Therefore I 
cannot hold it responsible. The proof that the use of Es- 
march’s method was the cause of sloughing in the case 
referred to is, that in the amputation of the arm which fol- 
lowed—performed by Dr. Kissam, my successor in the hospi- 
tal-service—I controlled the brachial artery myself, with the 
view of deciding whether the bloodless method, or the pa- 
tient’s condition, was to blame for the sloughing. After this 
operation, the wound healed almost by the first intention. 
Esmarch’s method is certainly a most excellent one, and I 
should be sorry to have this case bring any discredit upon it. 
It takes a little time to learn how to apply the new method 
properly.” 
With these remarks I cordially agree. Should future ex- 
perience show that the employment of the bloodless method 
is a frequent cause of gangrene, we shall be obliged to aban- 
don it; for this objection, once well established, would be a 
fatal one. It is greatly to be hoped, however, that, by a care- 
ful application of the elastic bandage, we shall be able to 
secure the benefits which it unquestionably confers, without 
any compensating disadvantages; meanwhile it will be pru- 
dent to abstain from its employment in certain cases, and, 
above all, to learn the minimum degree of pressure that will 
accomplish the desired result. The bandage should be soft 
and highly elastic, and the constriction of the limb should be 
made either by a piece of the same material, or, where this 
would be too wide, by a piece of soft rubber tube. The solid 
cord should, I think, be abandoned, as likely to do mischief. 
In applying the constricting band, much less force is needed esmarch’s bloodless method. 
19 
than is commonly imagined, and with every additional turn the 
effect is considerably increased. Finally, the operation ought 
not to be needlessly prolonged. It is not easy to determine, 
however, for what length of time the state of artificial anaemia 
may be maintained with impunity; as, in several cases in the 
table, the elastic bandage wTas applied for an hour, and, in one 
case of amputation of the thigh, for one hour and forty min- 
utes, without injurious consequences. Doubtless, however, 
the danger increases with the length of time the pressure is 
continued; and in amputations—which are shown to be the 
operations most likely to be followed by gangrene—the band- 
age need not be kept on longer than five or ten minutes. As 
bearing on the question of the cause of sloughing after the use 
of the elastic bandage, it may be well to bear in mind that, 
with a single exception, sloughing occurred only in amputa- 
tions. 
I have been unable to discover, in the cases of operation 
that were not followed by sloughing, any failure or imper- 
fection in the reparative process, which could be ascribed to 
the method employed. The wounds have presented the ordi- 
nary character, and many of them have healed by the first 
intention. 
Haemorrhage is reported in four cases in the table, as 
follows: 
Case I. Bellevue Hospital.—Male, aged forty. Operation 
for necrosis of lower end of femur. The wound, which was 
situated on the inner side of the limb, was deep, and bled 
pretty freely when the operation was concluded. It was 
plugged with lint, but the haemorrhage persisted until the 
fourth day, when the wound was reopened, and a bleeding 
artery discovered, -which was supposed to be the anastomotica 
magna. This was tied, and no further haemorrhage occurred. 
Case II. Bellevue Hospital.—Male, aged ten. Primary 
amputation of thigh at junction of lower and middle thirds. 
Shortly after the operation, bleeding took place from the 
medulla, and was arrested by the actual cautery. 
Case III. Bellevue Hospital.—Male, aged twenty-seven. 
Partial amputation of the hand, for a severe crushing injury, 
received four days previously. After the operation, the limb 20 
esmarch’s bloodless method. 
was immersed in hot water. A week later, a lifemorrhage 
occurred, which did not exceed two ounces. The patient was 
terribly frightened, and died three hours after. 
Case IY. Bellevue Hospital.—Male, aged twenty-one. 
Amputation of arm for compound fracture of forearm. Ooz- 
ing of blood for some time after the operation prevented the 
adhesion of the flaps, but the wound healed by granulation. 
In none of these cases, so far as I am able to judge, was 
the bleeding fairly attributable to the employment of Es- 
march’s method, and I am therefore disposed to dismiss, as 
invalid, the assertion that the method predisposes to the 
occurrence of haemorrhage. 
We find in the table only one case of paralysis; but this 
was well-marked, and occurred on the day following an opera- 
tion, performed at the Roosevelt Hospital, for necrosis of the 
humerus. The operation was performed on February 9th. 
The constriction of the arm was effected by a solid rubber cord, 
but the duration of its application is not stated. February 
10th.—Complete motor paralysis in forearm and hand. Tac- 
tile sensibility in finger greatly diminished. March 13th.— 
Examined by Dr. Seguin. Total motor paralysis of forearm 
and hand still remains. Electricity was applied, and the 
patient speedily improved. When he left the hospital, on 
May 10th, he had almost entirely regained the movements of 
flexion and extension, and partly those of supination and 
pronation. 
Besides this case of paralysis, we find one of neuralgic 
pains, continuing for two weeks after an operation, performed 
at the Mount Sinai Hospital, for necrosis of the scapula. 
The above are the only cases in which nerve-symptoms 
followed the employment of the bloodless method, and there 
can be no doubt that the mischief was caused by the undue 
pressure of the constricting cord. Langenbeck has reported 
three cases of paralysis of the median nerve, due to the same 
cause-; and he suggests that an elastic bandage be used as a 
means of constriction, instead of the tubing or solid cord. 
This suggestion is a practical one, and its adoption will, it is 
to be hoped, prevent a repetition of the accident referred to. 
We have no facts to enable us to prove the danger of esmaech’s bloodless method. 
21 
rupture of the blood-vessels, from the pressure of the con- 
stricting cord, and it seems probable that snch danger is no 
greater than when the tourniquet is employed. Finally, the 
caution which has been urged against the application of the 
elastic bandage over gangrenous parts, or over those which are 
the source of putrid discharges, is undoubtedly a wise one, 
and, so far as I can learn, has generally been observed by 
operating surgeons. 
Enough has been said to prove that Esmarch’s bloodless 
method is one of the most valuable surgical expedients that 
have been devised in modern times. It only remains, now, to 
determine the best mode, and the proper range, of its appli- 
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