For an antiseptic dressing that is intended to be changed from time to time, perfect absence of adhesiveness is a most valuable property; not only because it permits all discharge to escape beneath it into the porous material placed outside to absorb it, but because it avoids traction upon any deeper dressing or upon the skin during the process of withdrawing it, with the concomitant risk of regurgitation of air or liquid charged with living putrefactive organisms.

But for the permanent dressing in compound fracture this complete want of adhesiveness is the converse of what we desire. Here, the material employed, being designed to form part of the scab, should stick to the skin or to anything else that lies beneath it. The lac prepared as above described may, however, be readily made suitable for this purpose, by rubbing off the film of gutta percha by firm friction with a dry cloth, and then brushing the surface over with liquid carbolic acid. It then, at once, assumes a sufficient degree of adhesiveness.

In order to ensure healing without suppuration, it is requisite, as we have seen, not only to prevent the spreading of putrefaction into the wound, but also to protect the raw surface from perpetual stimulation by the carbolic acid. In the mode of dressing above described, in which the putty was employed, the latter object was attained by means of layers of lint forming a crust too thick to be penetrated by the acid supplied externally; and the same plan would no doubt, succeed as well with the lac. But to trust to the mere thickness of a penetrable crust, is not altogether satisfactory. It would clearly be better, if possible, to protect the exposed tissues from the stimulating antiseptic in the lac by a layer of some substance chemically impermeable to carbolic acid. A metallic plate possesses this property; and in its more flexible forms, such as thin block tin or sheet lead, it seems likely, at least in ordinary cases to answer well. I have, as yet, only had an opportunity to try this method in two cases, but both of these have presented points of interest which make them deserving of mention.

Case of Contused Wound treated with Block Tin and Antiseptic Lac.-The first was a contused wound, three inches long, over the lower part of the tibia, with some undermining of the skin, in a young man of 20, occasioned by the limb being violently squeezed between a heavy iron pipe and a fixed piece of machinery. Happening to be at the Infirmary soon after his admission, I dressed the case myself, washing and syringing out the wound with a saturated watery solution of carbolic acid, and covering it with a well-fitting piece of thin block tin of rather larger size, washed with the watery solution, and then applying a piece of lac-plaster, deprived of its gutta percha layer, overlapping the tin freely on all sides. A piece of calico was placed outside the lac-plaster, to prevent adhesion of its edges to a dry cloth, which was wrapped round the leg to absorb discharge, and was intended to be changed. Next day, there was a good deal of sero-sanguineous effusion on the cloth, for which another was substituted, moistened with a solution of carbolic acid in four parts of olive oil. The same was afterwards done daily; the discharge diminishing rapidly, and the limb remaining free from swelling or pain, and the constitution from disturbance, till, on the fourth day, the patient, who was a silly youth, was seized with a desire to see the injured part, and tore off all the dressings. This foolish proceeding on his part gave us the opportunity of making an interesting observation. The wound was found perfectly level with the general surface of the skin, being filled with a clot of smooth surface corresponding to that of the tin which had covered it, while the edges of the skin were pale and natural in appearance. The dressing was re-applied as before, the wound being superficially washed with carbolic acid lotion in the process. Two days later the patient again without any reason, laid bare the wound, which still presented the same characters, except that the surface of the smooth clot showed, here and there, some minute whitish specks, probably in consequence of the action of the watery solution of carbolic acid with which it was washed two days previously. A similar dressing was again employed, the use of carbolic lotion being again necessarily involved. After two more days, that is to say a week after the accident, the patient, though free

from symptoms, having again removed the dressings, the wound was again examined. It was free from pus or odour of putrefaction, but its surface was mottled with red and yellow spots, and was not quite level. The dressing was continued one day longer, when it was abandoned, as the patient could not be induced to leave it alone, water-dressing being used instead, and on the following day the wound presented the characters of a healing superficial granulating sore. Two days later he was so unruly that he was discharged for misconduct.

In the following case we have had the opportunity of seeing the effects of this mode of dressing when left undisturbed.

Case of Compound Fracture of the Leg treated with Block Tin and Antiseptic Lac.-On the 3rd of October, 1868, a porter, 25 years old, was unloading a waggon in a warehouse, when a box, weighing about four hundredweight, slipt, and striking him upon the leg, knocked him down over an opening in the floor, through which he would have fallen into the room below had not the heavy box, pressing upon the limb, pinned him down and kept him suspended. When rescued from this situation, he was taken to the Infirmary, where my house-surgeon, Mr. Malloch, found the leg much distended with extravasated blood, with a wound, three-eighths of an inch in length, on the inner side, about midway between the knee and ankle, bleeding freely and communicating with a tranverse fracture of the tibia. A probe smeared with an oily solution of carbolic acid (to prevent the introduction of septic particles) could be introduced beneath the undermined fascia for about three inches in every direction except downwards, and also passed, for the same extent, directly outwards behind the tibia, which was felt to be denuded of its periosteum. Having injected into the wound, with asyringe, several ounces of a saturated watery solution of the acid, and diffused it freely through the limb yb pressure, to mix it with the extravasated blood, Mr. Malloch placed a piece of thin block tin about an inch square over the orifice, and, after pressing out as much as possible of the blood and watery solution, applied a piece of lac plaster deprived of its gutta percha lining, overlapping the tin a couple of inches in every direction, and over this a folded cloth moistened with a solution of carbolic acid in four parts of olive oil. The limb was then put up in lateral pasteboard splints. This treatment relieved the severe pain which he was suffering; but it returned in the course of the next few hours, during which very free hemorrhagic effusion occurred. Next day the discharge became greatly diminished, and in the course of the following day it ceased entirely. The pain also left him about twelve hours after the accident and never returned. The after treatment consisted for the first two days, in renewing the oily cloth once in the twenty-four hours; but from the third day onwards the cloth was left permanently upon the limb and merely brushed over with a mixture of equal parts of carbolic acid and oil, the inner splint being raised for the purpose without disturbing the limb, which lay upon its outer side with the knee bent. After the sixth day, the antiseptic oil was only applied once in forty-eight hours. On the third day, some wrinkling of the epidermis indicated subsidence of the swelling which afterwards fell rapidly till, by the eleventh day, the calf was almost of natural size, having shrunk away considerably from the splint. His pulse never rose above 82, which was its number the day after the accident, and his general health was from that time forward quite unaffected.

Ten days after the receipt of the injury, it was noticed that the oily cloth, which for a week past had indicated complete absence of discharge, exhibited an appearance of additional staining, corresponding to two or three drops of red serum which seemed to have been pent up beneath the lac plaster by inspissation of the blood and serum round its margins, till some accidental cause, such as the shrinking of the limb, cracked the dried exudation. Having been led to disturb the dressing to some extent in investigating the source of this discharge, I thought it best to remove it entirely, protecting the wound at the moment of its exposure with a bit of antiseptic lint. The under surface of the lac gave distinct indications of being impregnated with carbolic acid. The wound presented a very interesting appearance. It had

shrunk considerably; but its margins resembled those of a perfectly recent wound; and its orifice was occupied by a projecting dark clot, which to the naked eye scarcely differed from a fresh coagulum. Hence there seemed reason still to hope for healing without suppuration, if the original mode of dressing were repeated. Accordingly, the tin smeared with carbolic acid was replaced, and overlapping it a fresh portion of lac plaster, rendered adhesive by touching it with carbolic acid after removing the film of gutta percha, except in a narrow space from the centre to one side, where the gutta percha was left, to provide for the escape of discharge. A dry cloth and a splint completed the dressing. Two days later, in order to maintain the lac plaster in an antiseptic condition, two layers of calico, moistened with a solution of carbolic acid in four parts of olive oil, were substituted for the cloth; and afterwards, at intervals of from two to three days, the surface of the calico was lightly brushed over with a mixture of equal parts of the oil and acid. For six days, some yellowish serum, amounting at first to one or two minims in twenty-four hours, but gradually diminishing, exuded from below that part of the margin of the lac plaster where the gutta-percha film had been left, the amount being estimated by changing every day a little bit of antiseptic lint placed at the point of exudation, But, after the sixth day, the piece of lint was left unchanged, as the trifling discharge seemed to have ceased entirely. When eleven days more had passed without any change, I thought it well to ascertain again the state of the wound; and on Oct. 30th, seventeen days after the second application of the deep dressing, and two days short of four weeks after the accident, I pulled off the lac plaster with the tin adhering to it. The plaster was still sticking to the skin, and drew away the hairs along with it, except where the gutta percha film remained. At this part, along the course of the track of exudation, the skin had an orange stain, froin serum mixed with altered hæmatin, and was moist, except near the edge of the plaster. Beneath the tin, also, there was the same kind of orange moisture. The wound appeared at first sight unhealed, having an orange-red aspect; but, on wiping it with a piece of lint, a perfect cicatrix was disclosed, which had been covered with the remains of the little portion of clot seen projecting from the orifice on the former occasion of exposing it. A piece of dry lint was placed upon the scar; and the splints were readjusted, the fragments being in good position. The case was now reduced to one of simple fracture.

This case presents several features of great interest. In the first place, the appearances disclosed on the removal of the dressings on the tenth day after the accident, afford as good an illustration as could be desired of the fact that the surface of a wound is not induced to suppurate, or indeed to undergo any appreciable change by the contact of a foreign body, destitute of chemically stimulating properties. The carbolic acid with which the surface of the tin was washed, like that injected into the wound, was absorbed into the circulation before it had time to bring about those changes in the part which are the essential preliminary to suppuration. The tissues of a recent wound are incapable of forming pus, however much they may be stimulated, whether by nervous (i. e., inflammatory) excitement, or by chemical irritants, such as the products of putrefaction or pungent antiseptics. It is only when they have been gradually changed under the influence of prolonged abnorinal stimulation into that rudimentary form of tissue which, when we see it on the surface of a sore, we term granulations, that they are liable to produce, when still further stimulated, the still more rudimentary pus corpuscle. It is upon this fact that the possibility of obtaining primary union on the antiseptic system depends. The antiseptic applied to the wound in the first instance is a powerful stimulant, but it is absorbed before it has time to bring about granulation in the tissues.

In the second place, it is very satisfactory to see, although theoretically it could hardly have been doubted, that, when a wound has been effectually protected from stimulation and consequent granulation, it may even at a late period after its infliction, be again subjected to the temporary stimulus of an antiseptic application without being made to suppurate; for a knowledge of

this fact will enable us to examine the wound when we think there is a fair prospect of healing being complete, confident that, should the reverse prove to be the case, we can again employ the original mode of dressing without interfering with the process of healing by scabbing.

Thirdly, I may remark that cicatrisation without suppuration beneath a piece of tin, is a novel mode of healing by scabbing. But the ordinary scab is in so far analogous to the metallic plate, that the exudations of which it is composed having dried before they had time to putrefy, the crust is, like the metal, a neutral or unstimulating solid. Further, there is putrescible moisture beneath the scab as beneath the tin; but the mode in which the putrefactive organisms are excluded is essentially different. The scab keeps them out mechanically, by adhering firmly to the surface of the integument; the metallic plate opposes no mechanical barrier to their entrance, but is guarded by a germ poison in the surrounding lac which no less imperatively forbids their access.

Altogether, the case must be regarded as affording great encouragement for giving a further trial to this method, which seems to bring the treatment of compound fracture to something nearly approaching perfection. The lac, being impermeable to discharge, combines the properties of an external antiseptic guard with those of a permanent crust; and, as fresh carbolic acid can be supplied to it as often as may be desired without disturbing its position, the trouble and risk that attended the changing of the putty are entirely got rid of. At the same time the tin protects the raw surface from the acid with absolute certainty, while the tin and the lac constitute together so thin a layer as not to alter the contour of the limb, or interfere with the shape of splints such as would be used for simple fracture; a considerable advantage as compared with the mass constituted by a thick crust, covered with substantial putty. When the wound is large, I would advise the use of two layers of the lac plaster for the sake of additional strength, the outer one overlapping the inner by an inch or two; and the outer, like the inner, rendered adhesive, as above described, so that the two may become incorporated into Also, I would recommend that, as was done in the second dressing of the last case, the film of gutta percha should be left upon a track leading from the tin to what is to be the most dependent part of the edge of the plaster to afford free egress for sero-sanguineous discharge.

one mass.

For treating the interior of the wound in compound fracture, I employed, till comparatively lately, the undiluted acid, and, as this afforded excellent results, I did not venture to change the practice without having some more substantial basis than hope to found upon. But rather more than a year ago, having observed that the injection of a saturated watery solution (one part of acid to twenty parts of water) among the fibrous tissues in a fœtidsuppurating wound of the palm, completely arrested the existing putrefaction, I concluded, that if the acid so diluted sufficed to destroy the abounding putrefactive organisms which must have been present among the textures in that case, it must surely be trustworthy for compound fracture, We have accordingly employed the saturated watery solution in all the numerous cases of compound fracture that have since come under my care and in no instance has it failed. If it answers equally well, it is obviously superior to the strong acid, since it does not produce the slightest sloughing from caustic action, and, being a less powerful irritant, causes a less copious serous effusion. Besides it may be injected and diffused among the tissues which are the seat of extravasation with a freedom which could not be used with the acid of full strength, and it is to this circumstance that I am disposed to attribute the fact that we have obtained success at a period after the infliction of the injury which I should formerly have thought quite hopeless, in one case, for example, as late as thirty-six hours after the accident. Lastly, we avoid a disagreeable symptom which we used to observe occasionally after applying the undiluted acid freely to large wounds, viz., obstinate vomiting for about twenty-four hours, occasioned, no doubt, by imbibition of a poisonous dose into the circulation.-British Medical Journal, Nov. 14, 1868, p. 515.

43.-ON THE TORSION OF ARTERIES AS A MEANS OF ARRESTING HEMORRHAGE.

BY THOMAS BRYANT, Esq., Assistant-Surgeon to Guy's Hospital.

[The employment of torsion for arrest of hemorrhage from large blood-vessels was suggested to Amussat by the recognised fact that torn wounds do not bleed. Although at once adopted by Boyer, Dupuytren, Majendie and others, it was little noticed by the surgeons of this country until the introduction of chloroform removed any object in hurrying over an operation. Speaking of acupressure, Mr. Bryant says:]

It has, physiologically considered, one point of weakness which has some bearing on my present subject, for the value of the practice of acupressure rests on what has hitherto been looked upon, and what still must be described, as being a temporary mechanical obstruction to arterial hemorrhage; the permanent arrest of bleeding depending in this practice, as in others, on natural processes; now in acupressure the permanent arrest of hemorrhage depends entirely upon the clot which forms in the vessel, for no evidence has yet been adduced to show that any change occurs in the inner tunics of the vessels which have been subjected to the pressure of an acupressure needle, such as is well known to take place after the use of the ligature, and such as also occurs after the application of torsion in large vessels. In these last two forms of practice the two inner coats are divided, and subsequently unite, the permanent arrest of hemorrhage depending materially on such a process; in acupressure there is no evidence whatever to show that any such union takes place between the two surfaces of the vessel which are brought in contact; as a consequence the permanent success of acupressure depends upon the coagulating power of the blood in the occluded vessel, the needle acting as a temporary mechanical obstruction to the flow of blood during the brief period of its presence.

Physiologically, therefore, acupressure is an uncertain process, and when contrasted with the ligature and torsion stands condemned; for its success depends only upon the temporary processes which nature adopts for the purpose of arresting hemorrhage, and not upon the permanent hemostatic changes which nature employs in other cases.

When Professor Syme, therefore, in a short note published in the Lancet of January 4th, drew the attention of the profession back again to the subject of torsion, I must confess to feeling a sense of satisfaction, for it seemed tolerably clear that, if it could be practically proved that hemorrhage from a divided artery could be safely and permanently controlled by such a method, we should have a means at our disposal which would be entirely free from all the objections which the strongest objector to the use of the ligature could possibly adduce, and which in its simplicity and value would without doubt bear favourable comparison with acupressure as well as with the liga

ture.

It was under these circumstances that I was thus led to examine into the question, to try it in practice, and to prove it by experiment; and I now propose to lay the results of my inquiries before the Fellows of this Society, with the hope that they will be induced to test the practice for themselves, and by the aid of experiment gauge its value.

I propose to relate seriatim the experiments I have made upon the dog, horse, and human subject to test the value of torsion, and to observe the process by which the vessels so treated become permanently sealed; having previously described the two methods by which torsion has been practised. I shall pass on to describe the physiological changes which have taken place in the arteries which have been twisted; and drew attention to such special points as it seems necessary to attend to in the application of the practice. Some brief comparison will then be made between the value of torsion and the ligature, and some general deductions drawn up from the consideration of the subject as a whole.

I must add that in most of my experiments I bave bad the benefit of Mr.