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artery, and well pressed down upon it. The third step consists in sending the point of the instrument into the tissues beyond the artery for the purpose of securing it in the proper position and retaining the twist."

Second Variety of the Aberdeen Method. This is preferable to the first variety, being more simple, requiring only a quarter

FIG. 12. The appearance of the parts at the termination of the first step of the fifth or Aberdeen method, by the twist, before making the quarter rotation with the needle.

instead of a half rotation of the instrument used. This variety also should be considered as divided into three steps.

In the first step the needle or pin is thrust into the tissues on one side of the vessel to be secured, pressed onward a short distance parallel with the course of the artery, and at its point made to appear in the wound.

The second step consists in giving a quarter rotation to the instrument, which places it above the artery and well pressed down against the small portion of tissues between the instrument and the vessel," and enables the operator to complete the third step by driving the point of the pin into the tissues beyond the artery, thereby securing both the pin and the twist.

One using either of these methods for the first time will be struck with the slight degree of pressure required to stop the bleeding which is all the surgeon need attempt to do.

These methods by the twist are performed with great facility, and give, perhaps, more satisfactory results than any of the others, from the fact that a minimum amount of injury is inflicted on the soft parts, and the pins or needles can be withdrawn with very little pain to the patient.

FIG. 13. Showing the appearance of the parts after the quarter rotation of the needle, and the ultimate insertion of its point into the tissues beyond the artery.

This method was used in one case by Professor Simpson in

1860. In 1864 Dr. Knowles, at that time in the Aberdeen. Hospital, suggested this mode, being ignorant of the fact that it had been devised by Professor Simpson; and Professor Pirrie applied it for the first time successfully to the femoral artery after amputation of the thigh.

One essential point in the Aberdeen method by the twist is, that the artery should not be transfixed, a procedure which has been recommended and practiced, and which I shall explain at a subsequent time.

Sixth Method. This was devised by Dr. Keith of Aberdeen. It requires for its performance a pin and a loop of fine annealed iron wire.

Enter the pin a few lines from the artery, cause it to pass below it, and then push it on so that its point will emerge a few lines beyond the mouth of the vessel, taking care not to transfix the artery.

Now, throw the loop of wire over the point of the pin and cross the two ends behind its stem, and draw upon the wire with sufficient force to compress the bleeding vessel between one side of the loop in front and the pin behind; the ends are then "brought forward and finally fixed by a half twist in front of and close down upon the pin."

FIG. 14.-The sixth method, by means of a pin and loop of iron wire. If more force is used in drawing upon the wire than simply sufficient to stop the bleeding, the mechanism of this method is

FIG. 15.-Skeleton diagram, showing the arrangement of the wire in the sixth method.

changed, and the artery, instead of being compressed between one side of the loop and the needle, is caught in the loop of the wire, and the rationale of its operation in this case is precisely that of the ligature; and, if the force be continued, the internal and middle coats are divided, and it is not acupressure at all.

Dr. Pirrie claims that, "for securing a vessel on a perpendic ular wound, the sixth will sometimes be found a convenient method in circumstances where the performance of the third or fourth would be attended with difficulty."

Seventh Method.-For the performance of this method, a long pin is the only instrument required. Pass the pin from without inward; in the words of Prof. Pirrie, "through the skin, pretty deep into the soft parts, at some distance from the vessel to be secured, making it emerge near the vessel, bridging over and compressing the artery, dipping the pin into the soft parts on the opposite side of the vessel, and bringing out the point of

FIG. 16. The position of the pin in the seventh method. The middle portion of the pin, in front of the integument, bridges over the artery to be acupressed; and the compression is effected between the middle portion of the pin in front and the bone behind.

the pin a second time through the common integument. The soft parts are twice transfixed, and the artery is compressed between the bone and middle portion of the needle, in front of the integument, between the first point of exit and the second point of entrance. Three portions of the needle are left without the integument; namely, its central portion and its extremities."

I have described above the seven methods of acupressure devised by Profs. Simpson and Pirrie, and by Drs. Keith and Fiddes, and extensively used in both hemispheres. These methods are simple, easily understood, and are sufficient to meet all cases where "this most excellent way of suppressing hæmorrhage" is admissible.

Various modifications or combinations of these methods may be contrived; but the principle must ever remain the same; namely, temporary metallic compression of force sufficient simply to close the calibre of the artery without lacerating any of

its coats.

The subject of acupressure has of late attracted considerable attention in the New York Hospital, and Dr. Gurdon Buck, one of my colleagues in that institution, has devised a method for its performance which he desires should be called the New York twist, and which I shall describe as the

Eighth Method, or New York Twist.-For its performance a pair of thumb forceps and a pin or threaded needle are required.

The first step consists in seizing the mouth of the bleeding vessel between the blades of the forceps and rotating the extremity of the artery at least twice on its own axis.

The second step requires that the needle should now be thrust entirely through the twisted artery, near the forceps, and pressed on into the tissues beyond, thus securing both the artery and the needle.

The objection to this method which strikes me is, that it may with truth be said to violate the great principle of acupres