gination of the internal and middle coats is sufficient to arrest hemorrhage; it is, therefore, applicable where the blood is anæmic, &c. 5th. No foreign body is left in the wound, thus favoring union by the first intention. CAROTID ARTERY OF A HORSE CONSTRICTED IN ITS CON- On the 11th of November, a large-sized horse, in good condition, was placed at my disposal by the kindness of Drs. A. Large and A. Liautard, of the New 6th. There is no risk of pyæmia or phlebitis. 7th. It is applicable to all sizes and to all condi-York Veterinary College, and the following operations fect. tions of the arteries where the external coat is per8th. It is a mechanical appliance which has a uniform effect, and it requires but little skill or practice in its application. pre These are advantages which can be claimed by no other method, and if the instrument sustains itself in the hands of others, as it promises to do, it will be found useful in many cases where neither of the sent modes of closing arteries could be equally well applied. I have had occasion to make the following severe trials of the artery constrictor. The instrument has the same effect upon the dead artery as upon the living, but it acts more perfectly upon the living vessels. EXPERIMENTS UPON DEAD ARTERIES. Applied to the femoral or other large-sized artery of man (post-mortem), it had the effect (represented in the accompanying cut) of perfectly closing the vessel, so that it resisted the flow of water forced into it by means of a Davison's syringe. This experiment I have repeated frequently, and always with the same result. (Fig. 2.) EXPERIMENT UPON A LIVING DOG. The constrictor applied to the abdominal aorta of a living dog, closed the vessel perfectly-no blood escaped from the constricted end-which could be seen pulsating until the animal died from the combined effects of chloroform and the operation. (Fig. 3.) EXPERIMENTS UPON LIVING SHEEP. In the month of December the following operations were performed upon the carotid arteries of full-sized sheep. The common carotid artery was constricted in its continuity as rapidly as possible, and the constricted portion removed at once. This operation was performed to see the immediate effect upon the vessel, and the rapidity with which the coagulum would form. Upon examination of the specimen, a perfect invagination of the internal and middle coats, at the point of constriction, and a firm clot on either side of it (this specimen is represented in the accompanying cut) closing the vessel perfectly. (Fig. 4.) OPERATION ON CAROTID ARTERY OF SHEEP, IN SECTION. After the above operation the artery was, of course, exposed in such a way that it bled freely from both ends; the constrictor was applied to them with the effect of closing them perfectly, and the sheep was allowed to run in the yard while another sheep was operated upon; and then the animal was killed and the artery examined. It was found closed by the invaginated internal and middle coats, and a firm clot covering them (represented in cut). (Fig. 5.) OPERATION ON CAROTID ARTERY OF SHEEP, IN SECTION. On another sheep the carotid artery was exposed and cut entirely across. The constrictor was then applied to both ends of the vessel, with the effect of perfectly closing the vessel. The animal was killed soon after, and the arteries were found occluded by a firm clot (as represented in the cut). Dr. Robt. F. Speir, Dr. Robinson, and a class of stuwere performed in the presence of these gentlemen, dents. Dr. Liautard cut down upon and exposed the I applied the constrictor to the artery in its middle left carotid artery in a very skilful and careful manner. third, in its continuity-the constrictor being put upon the artery, and removed as soon as the screw could be turned to the required extent, which took only one minute and thirteen seconds. tion, and found that there was a diminution in its force, Dr. Large examined the facial artery after the opera as much as could be expected considering the extent of the collateral circulation through the vertebral artery. The wound was closed by Dr. Liautard, and the horse was led to his stall. No untoward event occurred after the operation, and on the 25th the wound had entirely healed, and the animal was ready for the second operation, viz. : CONSTRICTION OF THE CAROTID ARTERY OF A HORSE-THE ARTERY BEING CUT ENTIRELY THROUGH WITH THE On the 25th of November the same horse was operated upon as follows:-Dr. Liautard exposed the right common carotid for about two and a half inches in its middle third. I applied the constrictor at two points, about one inch and a half apart, and then, with the knife, divided the vessel between them. The artery immediately contracted at each end, the distal end being drawn up in the neck. The cardiac end retracted downward, but was at once projected into the wound again by the force of the heart's action, and it could be seen pulsating in keeping with the action of the heart, rising and falling one half inch with every beat of the heart. Not one drop of blood escaped from the end of the artery. On the contrary, the cardiac extremity, which was seen beating in the wound, presented the yellowishwhite color of the inner coats which were exposed by the operation. The wound was kept open and the artery exposed, that it might be observed by a class of veterinary students; and then Dr. Liautard brought the wound together with sutures, and the horse was led to his stall, looking quite sleepy from the effects of the operation. There was no hemorrhage from the wound or the artery; and in twenty-two hours the horse died from the effect of the operation, the other carotid having been tied previously. Dr. Liautard removed the arteries, and we examined them together. The first specimen, from the left carotid tied in its continuity, exhibited the effect of the constrictor upon an artery when applied in its continuity, viz.: division of the internal and middle coats, with a continuous and uninjured external coat. The clots in this artery were small and easily washed out by a current of water. This operation was such as would be appropriate in the treatment of aneurism. The second specimen-right carotid constricted in section-exhibited the effect of the constrictor upon the artery when applied to it in section-as would be appropriate in amputations. The divided artery was found separated about one and a half inch--both ends were closed and occupied by a firm clot, which, with the invaginated internal and middle coats, had effected a complete occlusion. There had been no hemorrhage from either end of the artery. (Fig. 6.) Considering the large size of the carotid in the horse, I think this test may be fairly considered a very severe one. The appearance of the artery is well shown in the accompanying cut. (Plate 8.) I am not aware of any other means by which so large a vessel could be closed so rapidly and perfectly. The advantage of leaving the wound free from foreign bodies was plainly indicated in the rapidity with which the wound healed after the first operation-a part of the wound closing by the first intention-a rare occurrence in the horse. AMPUTATION AT THE HIP-CONSTRICTION OF THE FEMORAL AND PROFUNDA ARTERIES. On the evening of Saturday, October 8th, 1870, a boy was run over by a street car and taken to the Brooklyn City Hospital. Dr. Cochran, the surgeon then on duty, being sick, requested me to see the patient for him. I found the left limb terribly crushed; the knee-joint was disarticulated and the soft parts of the thigh lacerated to such an extent as to allow the femur to project from the wound several inches, the leg being attached to the thigh by a band of skin and a few shreds of bruised tissue. The only chance for the boy seemed to be amputation at the hip, which I performed at once. As soon as the anterior flap was made, the femoral artery and the profunda artery were taken up and the artery constrictor applied to them, the effect of which was to arrest the hemorrhage from these vessels entirely. They were left in this condition until the remainder of the operation-the formation of the lower flap and the disarticulation of the head of the bone-was completed, and the wound washed and ready for coaptation. All this time the ends of the arteries constricted could be seen pulsating in the wound; those present of the resident staff of the hospital and myself were satisfied with the security of the vessel. However, considering the circumstances in this case, I was not willing to trust to the constrictor, feeling that it would be injudicious to do so in the absence of any of my colleagues, and especially as I knew of the objections of Dr. George Cochran, for whom I operated, to any method of closing arteries other than by the ligature. This, added to the fact that it was an accident case which might involve litigation, induced me to finally apply ligatures and close the wound as usual in such cases. I removed a portion of the profunda artery which had been constricted, and it will be seen among the cuts. The femoral artery being short, I did not feel at liberty to remove a portion of that vessel. AMPUTATION OF THE THIGH-CONSTRICTION OF THE FEMO RAL ARTERY. On the 8th of December, C. W., æt. 54, was brought to the Brooklyn City Hospital with a compound comminuted fracture of the leg. Dr. D. E. Kissam, visiting surgeon then on duty, hoped to save the leg, and treated it with this end in view; but symptoms of gangrene appearing, it was decided to amputate at the thigh. On the 12th of December this operation was performed by Dr. Kissam amputating the thigh at its lower third, after the circular method. At the request of Dr. Kissam I closed the femoral artery with the constrictor, this vessel being the only artery exposed. The femoral vein, which bled more than usual, was also closed by the constrictor. The result gave the same satisfaction as in the other cases. The wound was then washed and left open for a few moments to see if all was secure. Meantime the artery was seen pulsating in the wound perfectly occluded, not a drop of blood having passed from it after its constriction. The wound was then closed by sutures after the usual manner. The condi tion of the patient being bad, and reaction after the operation being difficult, but little hope was entertained of his recovery, a condition of things which created considerable anxiety as to whether this might not be too severe a test for the constricted artery. Finally gangrene set in in the stump, notwithstanding which, and the "open" condition of the wound which followed such a condition, there was no hemorrhage. The patient died three days and sixteen hours after the amputation. The artery was removed from the stump, and it was found perfectly closed by the invaginated internal and middle coats, and a firm clot, as represented in (Fig. 7). In 1793, Deschamp invented his instrument for the nmediate compression of arteries, "by which the artery was to be compressed against a horizontal bar by the tightening of a ligature, the ends of which were passed through openings in the bar, and secured at the top of a vertical stem of the instrument." Since this time there have been many attempts to produce a reliable substitute for the ligature. In the present paper it is not intended to enumerate these methods, but it may be stated that they have nearly all been based upon principles which depend for their success upon a force applied to the artery for a considerable period of time, and requiring to be withdrawn subsequently. One of the methods noticed in this paper-torsion-is an exception to this statement. Webber's intracisor and antiligature forceps are also exceptions to this statement. Whether or not there are others I am not aware; certainly none have been presented to at all compare with torsion in this respect. The fact that such efforts have been made to secure the advantages of the ligature without any of its disadvantages, shows plainly that the minds of practical surgeons have long been impressed with the possibility of closing arteries by some method better than the ligature. Certainly no unprejudiced surgeon would deny that the ligature often interferes greatly with the healing of wounds, maintains suppuration by acting the part of a seton, increases the chances of pyæmia, and sometimes causes secondary hemorrhage. The primary effect of the ligature is so satisfactory, and it appeals to one's sense of present security to such a degree, that we are very likely to overlook the accidents which sometimes follow as the direct consequence of its use, but which are often attributed to other causes. The surgeon is not likely to feel any great responsibility rest upon him should a patient upon whom he had operated die of pyæmia or secondary hemorrhage after the amputation of a limb, although it might be traced directly to the use of the ligature. The same surgeon would view his responsibility in a very different aspect should he find that by the employment of some other means of closing the vessels secondary hemorrhage followed. Secondary hemorrhage following, with equal frequency, the use of any other method of closing vessels would be considered sufficient ground for its rejection. Doubtless it is for this reason that many of the methods which have been presented to the profession for trial have failed to sustain themselves as reliable methods, and it is probable that many or most of them were worthy of a better fate than that which befel them. Acupressure and torsion can scarcely meet with the same fate, and they will probably be supported, notwithstanding the objections to them, whether better means are offered or not. We have now learned that it requires but very little force to effect the closure of arteries. The satisfactory results sometimes obtained by the use of acupressure and torsion have taught us that the perfect occlusion of arteries may be effected by a much less degree of force than was formerly supposed to be necessary. In view of these considerations it seems unreasonable to cling to the ligature with prejudiced tenacity; and those objections which are common to the ligature, and other methods also, ought not to be used exclusively to suppress the claims of the rival method, but ought also to be placed to the account of the ligature. The peculiar effect of the artery constrictor upon the coats of the artery-rupturing and invaginating the internal and middle coats, while it preserves the integrity of the external coat-appears to offer a more substantial ground for confidence than any method based merely upon pressure or an internal coagulum. This, added to the fact that the instrument is instantly withdrawn from the vessel, seems to offer all the advantages which can be expected of any method. The advantage which the artery constrictor offers for fulfilling the indications necessary for the union of wounds by the first intention, will be seen when it is noticed that absolutely nothing is left in the wound to act as a foreign body; although probably the same apparent objection will be raised against the artery constrictor which has been offered against the operation of torsion, viz.: that the bruised end of the artery acts as a foreign substance in the wound, and must be removed by suppuration. It seems to me that those who have raised this objection to the use of torsion must have had very little practical experience with it, or else have performed the operation very carelessly or imperfectly. From my own observation of the effects of torsion, and from a considerable experience in the crushing of tissues by the écraseur, I have concluded that the effect of torsion, or of crushing the extremity of the artery, even to a considerable extent, provided it be done rapidly, is not incompatible with the union of wounds by the first intention. In order for the crushed portion of an artery, or other tissues left in a wound, to become a slough, or to act as a foreign body, it is necessary that the pressure should be continued until sloughing or inflammation begins, or else that the portion crushed be separated from contact with the other living tissues, and exposed to the influence of atmospheric air or other deleterious influences, as inflammation, etc. None of these conditions are present in the case of operations as usually performed, for the wound is brought together immediately, and any lost vitality is restored by the close contact with the living tissues and the blood. Besides, the greatest pressure made by the artery constrictor is not sufficient to injure the external coat of the vessel. The moment the internal and middle coats give way, the pressure upon the external coat is very slight, on account of the groove in the tongue of the instrument, made on purpose to receive the external coat and protect it from injury. Therefore this objection to the operation of torsion, even if it held good, could not be raised against the artery con strictor. This leads me to mention one of the chief advantages of the artery constrictor over the ligature and acupressure, viz. :-That provision which it promises for the prevention of secondary hemorrhage. When the ligature is used a sinus is formed along the track of the ligature, leading directly to the end of the vessel; and in case of accident to the artery from a too speedy separation of the ligature, or from a failure of the internal coagulum to form, or other cause producing secondary hemorrhage, the blood finds a free and tempting outlet through the sinus or opening thus provided. So also with acupressure, the needle being left in the wound acts temporarily as a foreign body, and also creates a sinus leading to the artery; and in case of the failure of the internal coagulum to form, or on account of the breaking down of the clot from a granular degeneration, or in case of a failure of the wound to unite by the first intention, there is always more or less danger of secondary hemorrhage following the withdrawal of the needles when any of the above circum stances occur. With the artery constrictor, on the contrary, hemorrhage is rendered impossible, under any of these conditions, from the fact that the invagination of the internal and middle coats forms a valve-like projection in the interior of the vessel, which is of itself sufficient to protect the artery from hemorrhage. I desire now to present the artery constrictor to the profession for trial. I am confident that some such method will eventually displace the ligature; if this be not the method, it must be acknowledged that the principles upon which it is based are those which must finally succeed. It may be that the experiments which I have thus far been able to make upon the living human arteries of large size, are not sufficient to inspire those not interested in the success of the instrument with confidence enough to employ it in capital operations. I trust, however, that any necessary proof of its merits may soon be forthcoming. To my own mind the experiments upon the arteries of the horse have covered the whole ground, the first operation proving the possibility of rupturing the internal and middle coats of the artery without injuring the external coat; the second operation proving the possibility of closing a very large artery, in section, without leaving any substance attached to the artery or in the wound. All the other questions connected with the occlusion of arteries have been proved over and over again by the advocates of other methods and pathological investigations. In the meantime there can be no objection to the use of the instrument in a multitude of cases where the arteries are not of large size, and where there is never any danger in the use of even the most crude efforts to arrest hemorrhage. 1 The artery constrictor will often be found useful to control the bleeding in amputation of the breast, and in other operations where it is desirable to secure union by the first intention, and yet where the arteries are not of such a size as to create any fear of failure. If the surgeon has not sufficient confidence in the instrument for this, then I may venture to recommend it as an aid to the performance of operations in general, where it is desirable to keep the wound free from blood after the first incision is made, and yet where the ligature or acupressure needle would be in the way of the operator, and also require subsequent removal. In such cases there can be no danger, and often a great advantage gained by applying the constrictor to the arteries as fast as they are cut; the operation may then go on with one of the most disagreeable accompaniments of larger operations overcome, that is, the presence of blood in the wound. For this purpose a small pocket case constrictor is to be used. In such instances it may supply the place of torsion, than which it is more easily and effectually applied. The artery constrictor offers encouragement for its trial in operations to produce the occlusion of arteries in cases of aneurism. In this use the constrictor is to be applied to the artery in its continuity, the internal and middle coats being ruptured and invaginated on either side of the instrument, and the external coat is left as a connecting band to the vessel, preserving its continuity. The great advantage to be gained in the use of the constrictor in aneurism being the possibility of obtaining union by the first intention, the wound being brought together immediately after the operation, and as the constrictor is always to be withdrawn as soon as it has made its impression upon the artery, there is nothing left around the artery or in the wound to act as a foreign body. The artery constrictor may be found useful also in cutting off the vascular supply of large tumors, in which case it should be applied in the continuity of the vessels in the same manner as directed for aneurism. In the operation of ovariotomy it is very desirable to have some simple means of arresting the flow of blood from the small vessels which are opened during the breaking up of adhesions, etc. Inasmuch as the constrictor acts equally as well upon small as upon large arteries, the same advantage may be gained by its use in this operation as in those already mentioned, the abdomen being left free from ligature or other foreign substances usually found necessary. ETC. SURGEON TO CHARITY HOSPITAL, LECTURER ON SURGERY, ETC., Examination elicited a history of diphtheria, and exploration revealed patches of false membrane extendIn the application of the constrictor for the closure ing over the fauces, soft palate, and tonsils, all the signs of large vessels after amputation, etc., there need be no of laryngeal obstruction, accompanied by loud bubbling fears entertained of immediate hemorrhage, because the râles audible over most of the heaving chest, and assousual pressure which is made upon the artery above the ciated with dulness on percussion posteriorly and inpoints of operation (by the tourniquet or otherwise) is feriorly. The countenance was livid, the extremities always sufficient to arrest the flow of blood into the ex- cold, the pulse weak and rapid-death was impendtremity of the artery and cause the formation of a clot. ing. I gave a discouraging prognosis, but advised This pressure is usually made for safety and convenience tracheotomy as a last resort, in which I was cordially sake; but should it be made designedly for the object of sustained by the attending physician. With much reobtaining a clot in the artery, of course the effect would luctance and after considerable delay consent was be more perfect. given, and at 12 o'clock, assisted by Dr. Thomas Addis Emmet, Dr. Johnston, and in the presence of several other medical gentlemen, I performed the operation upon the almost lifeless child. The light was fortunately good, and conveniently placed. Ether was cautiously given in small quantity. Little blood was lost, notwithstanding the distension of the thyroid veins. An immense quantity of viscid, frothy, bloody mucus and fluid diphtheritic material issued from the opening into the trachea, and for many seconds respiration was entirely suspended. The trachea was cleared out by suction, compression of the chest practised, and finally breathing recommenced, and the tube, a double one, kindly lent me by Prof. Van Buren, introduced and secured. DIRECTIONS FOR THE APPLICATION OF THE ARTERY CON STRICTOR. (See Figs. 8, 9, 10.) The application of the constrictor is very simple. The artery is to be caught up by a tenaculum or a pair of forceps (which answers better), and the tongue of the constrictor placed around the vessel; the tongue is then drawn tightly upon the artery by means of the vice arrangement at the upper end of the instrument. As soon as the screw turns with a considerable degree of resistance, or the internal and middle coats are seen to be invaginated, by noticing their movements in the end of the artery, the instrument is to be detached from the artery and the operation is completed. In large arteries the tongue of the constrictor must be drawn into the sheath further than is necessary for small arteries. This is the one point which it is necessary to attend to in the closure of large arteries;-there can be no harm done to the vessel by being drawn well into the tube, and a thorough invagination secured. The invagination of the internal and middle coats may be made as thorough as it is desired, by drawing the artery into the tube as far as needed to effect the object. Some of the instruments have been made with stops, to indicate when a proper invagination was reached; but by further experience it was found that the touch was the best guide for the operator. By a continued traction upon the external coat of an artery, after the invagination is once commenced, the internal and middle coats may be peeled up and pushed entirely out of the external coat, and this latter coat be drawn out through the sheath, entirely freed from its inner coat, so that the operator has it in his power to produce an invagination to any desired extent. It is well always to permit the blood to flow into the artery (if it has been controlled by tourniquet or otherwise during the operation) before removing the constrictor; this secures a perfect clot upon the invaginated coats, which can hardly be displaced afterwards. For convenience's ake the constrictor may be made Every vicissitude characterized the subsequent progress of this case. The temperature of the apartment was frequently allowed to sink to a level with the external air of a very cold season. I sometimes found the little patient sitting up uncovered in his bed, with the tube choked by bronchial excretions, gasping, coughing, and breathing through the tracheal wound by the sides of the tube in a hissing, bubbling, and altogether most distressing manner. In spite of these untoward circumstances, and one or two occasions of collapse in which life was apparently extinct, the case made a good recovery, and the boy is now living and in good health. The tube was worn about fourteen days. The wound healed on the twenty-fifth day. Šix weeks sufficed for the restoration of natural voice and normal strength and activity. I attribute the recovery of this apparently hopeless case, after operation, to an almost unlimited administration of stimulants. Hot whiskey and brandy punch were freely and constantly given, and for days together the tube exhaled an ethereal odor. Diminution in quantity or frequency in this respect was immediately resented by signs of sinking. My own accidental but most opportune visit at 4 o'clock of an exceedingly cold morning on the occasion |