H. Howse's able assistance; that he has given me valuable aid in examining the vessels of the animals after death, and that the descriptions of the physiological conditions of the arteries are chiefly from his pen, receiving from me only such slight alterations as I deemed necessary. I am also indebted to him for the drawing of some of the preparations.

66

It would be well, however, in limine, to premise that there are two modes of applying torsion; one described by Amussat as free" torsion, the other as "limited."

In free torsion the end of the artery should be fixed by a pair of clasped forceps and twisted freely.

In limited torsion the artery having been drawn out of its sheath, should be fixed transversely about three-quarters of an inch from its divided extremities by a pair of clasped forceps and held steadily; whilst with a second pair the free end of the vessel should be twisted freely as in the former, the object of the first pair of forceps being to fix a limit to the twisting of the vessel and prevent the artery being separated for any distance from its vascular attachments.

[A long series of experiments on the arteries of the dog and the horse are next detailed by Mr. Bryant.]

Experiments upon the arteries of the dead subject. I have made a large number of experiments on the arteries of the dead subject, healthy and diseased, having generally selected the common iliac and external iliac vessels, and have found that in all the same changes have taken place as have been already described. In every instance the retraction and incurvation of the middle and inner tunics were well marked, and in some the latter was most remarkable; it appears also that in the atheromatous vessels this incurvation is equally well seen.

Indeed this incurvation of the inner tunics of an artery, to which torsion has been applied, appears to be a point of peculiar interest, and from a large number of experiments on the dead subject it may be stated to be a very general result of well-applied torsion.

The amount of incurvation in different instances will, however, be found to vary in some it will show itself more as an irregular crowding together of the divided and retracted tunics; whilst in others it appears as a complete valvular incurvation of the divided coats, the incurved portions appearing within the vessel as nipple-like projections; under these circumstances, the incurved portions form the most perfect valves it is possible to conceive, being not unlike the semilunar valves of the heart, and closing as perfectly. In some cases, again, the middle and the inner coats appear to split, and thus to form an additional means for causing coagulation of the blood and obstruction to the artery.

This incurvation is clearly a physical act, and is due to the natural elasticity of the coats of the vessels; it may consequently be confidently expected to take place in all the larger vessels.

I have found also that when a vessel has been efficiently twisted, no legitimate force that can be employed with a syringe, introduced into the vessel above, will unfold the twist in the cellular coat, or undo the retraction and incurvation of the inner tunics, although the artery will frequently rupture above the part which has been twisted; when the extremity of the vessel has been twisted off, leakage, however, frequently follows.

It should be stated that this incurvation of the inner tunics seems unknown after the ligature; indeed it should be stated that in a large number of experiments which I have made, in which a ligature has been applied to an artery, the only change that takes place in its coats is an imperfect and irregular division of its middle and inner coats; in rare cases this division is very complete, in many others it does not take place at all.

There is never any retraction worth mentioning, and no incurvation. I may refer to Dr. Jones's work on 'Hemorrhage,' published in 1810, to further illustrate this point.

Résumé of the physiological effects of Torsion on the vessels.-The results of the experiments made upon animals, and the single observation I have had

an opportunity of making on the human subject, singularly accord; for in the cardiac and distal ends of the arteries which had been treated by torsion, I found the middle and internal coats of the vessels had been divided; that these coats had retracted in the direction opposed to the blood stream, approximated and overlapped; that at the cardiac end in several instances the coats had become partially incurved, as shown in the preparations and drawings of the carotid of the horse, and the brachial of the human subject; and I found also that every vessel contained clot, from the giving off of the first branch to the point of contact of the two inner divided coats; that lymph or organizable blastema was poured out around the divided extremities of the coats, and between them and the external cellular coat; also that a second smaller clot often existed between the distal end of the two divided inner tunics, and that portion of the cellular coat which had been twisted.

I found, moreover, that the twist which the cellular coat had sustained was clearly permanent, and that it did not untwist (this can be shown on the dead body). That in no single instance was there any evidence to indicate that the portion of vessel which had been twisted had lost, or was likely to lose, its vitality; or that the parts about the vessel had received any material injury. That in most cases a kind of ampulla tends to form in the cardiac end of the artery, and sometimes in the distal end. The appearance which this presents, varies in every case, and seems to depend on the rapidity with which coagulation takes place in the end of the artery, and upon the amount to which the artery, beyond the point where the clot forms, contracts. those arteries, therefore, in which much muscular fibre exists, and in which it is healthy, it will be most apparent; thus it is scarcely visible in the brachial artery from probable atheroma, and in the carotid of the first horse which was an old worn-out creature.

In

It is not necessary, therefore, to suppose that the force of the heart actually dilates the end of the artery. The diameter of the ampulla is in fact something less than the original cavity of the artery. Fibrin forms here first and prevents that close contraction of the parietes which goes on in other parts, and thus an apparent dilatation is formed. The middle coat in the artery is always much thinner than that in the contracted part of the artery. Thus the appearance of an ampulla is rather due to unequal contraction than to dilatation.

That though "free torsion" was practised in every case except in the horse, yet the twist in the vessel was local, not extending high up the artery. That torsion when applied to large vessels immediately above the giving off of a large branch may be successful; and that when applied to diseased vessels in old subjects it may likewise succeed.

Remarks on the Experiments made on Living Animals. It is to be noticed that in the experiments upon dogs "free torsion" was employed; in the two upon horses "limited torsion" was used. In all the operation was ultimately successful.

In several on the dog, bleeding took place when the torsion had been imperfectly carried out; three revolutions of the vessel being clearly insufficient; in all, however, on the dog four revolutions at once succeeded.

But the arteries of dogs are not large, and although the experiments upon them, as far as they go, must be regarded as satisfactory, they would not be, to my mind, of sufficient value to prove the power of torsion unsupported by others of greater importance.

The experiments on the horse I cannot but refer to with unmixed satisfaction, for no one can look upon the dilated pulsating carotid artery of such an animal during life, without a feeling of astonishment that such a simple act as that of torsion should be found sufficient to arrest hemorrhage from its divided extremity; and yet in both the cases related complete success followed the operation when it had been properly performed.

The temporary failure in the second case which followed upon the imperfect application of the practice must be looked upon with favour, for it went to prove what I confidently anticipated would have been the case-that torsion of the external coat when too much concentrated to one spot must end

in its rupture, and consequently in failure: but the ultimate success of the torsion when carried out in an efficient manner was most satisfactory, for it tended to show that the means employed were such as could be relied on with some confidence.

The fact that torsion was successfully performed on the carotid of a horse, immediately above the giving off of a large branch is a point of great value, for if the permanent safety of torsion depended upon the mere coagulation of the blood in the vessel, success could not have been thus acquired-for as the drawing, model, and preparation well show, there was no room for such an obstruction to the arterial flow to take place between the twist in the cellular coat, and the point at which the branch artery was given off.

It would thus appear that the twist in the cellular coat was the chief cause of the arrest of the arterial hemorrhage in the experiment referred to, and that this twist with the adhesion of the split, retracted, and approximated middle tunic forms the true permanent occluding medium of a divided vessel; that upon such points the main safety of the practice of torsion really rests, the coagulation of the blood in the vessel acting a part of secondary importance.

As mere experiments, these operations on the horse must be looked upon with favour; for they prove practically that torsion of such a large artery as the carotid is to be relied on; and consequently it does not appear unfair to believe that the same practice applied to any smaller vessel would be equally successful. As physiological experiments, however, the observations I have been enabled to make must be regarded in a higher light, for they show that nature's well-known hæmostatic processes act at a far greater advantage when torsion has been applied, than they do after the use of the ligature; and what is of far greater importance, they are allowed to go on undisturbed in their conservative action, for there is no foreign body to set up ulcerative action in the vessel in the seat of its occlusion; nothing to undo at a late period of the case what nature, assisted by art, has done at the beginning for the prevention of arterial hemorrhage. The twist in the vessel remains permanent; the coagulation of the blood in the meshes of the retracted, approximated, and incurved middle coat goes on undisturbed; and the whole becomes, subsequently, rapidly condensed into one homogeneous mass by the effusion of lymph from the exposed surfaces of the divided

tunics.

In the application of torsion some care is needed, and as two methods have been described, the "free" and the "limited," it may be well to point out as far as possible the conditions under which they should be employed.

"Free" torsion appears to be the more applicable to small vessels, and even to the large trunks of the extremities; the limited" torsion to such arteries as are unsupported by muscles and loosely connected.

It will have been observed that in all my experiments upon dogs, in which both carotid and femoral arteries were treated by torsion, the "free method" was used; and in the single example I have quoted in which I adopted the practice in a large vessel on the human subject-amputation of the arm high up-free torsion was also employed; for in that case I passed one blade of my forceps into the humeral vessel for about half an inch, and, with the other outside, after four complete revolutions the operation was successfully performed. I have, since this paper was written, applied free torsion to the femoral artery of three adult patients with complete success, On the dead subject also this mode of torsion proves successful, particularly on the femoral, brachial, and carotid arteries. It should also be stated that Amussat in his last years employed the limited torsion in all except the very small vessels; whilst Thierry employed the free in every case.

Three or four revolutions of the artery are required for small arteries, five or six for large: when the vessels are atheromatous the former number (three or four) is amply sufficient under all circumstances.

The orifice of the artery alone should be held by the forceps which twis the vessels in both cases.

In no case does it appear necessary, or even prudent, to twist the vesse

till the end is twisted off: for by so doing we do away with the chief safeguard against bleeding, we run the risk of breaking up the valvular incurvation of the inner tunics, and disturb the clot which forms between the retracted ends of the two inner tunics and the twisted cellular coat. In very small vessels this point is not of so much importance. It is probably due to this error of twisting off the ends of the vessels, that the practice of torsion has failed to hold its ground, for in the few cases in which it has been employed, such a mode has been generally, if not universally, adopted.

It seems to be a good rule in every case of torsion, whether free or limited to hold the end of the vessel for a second or two after the twists have been made, to allow of the parts becoming plugged with blood, and the divided tunics to retract and come in contact.

It appears also to be a matter of great importance in twisting large vessels that the whole orifice of the artery should be seized and firmly held; this cannot be well done with the forceps ordinarily sold, but can be by the forceps I have had made for the purpose by Mr. Millikin of Southwark street, the ends of which are broad, and firmly hold the artery, and not having sharp ends do not tear it. The blades are closed by a simple catch. With a small pair of forceps the surgeon is very apt to tear out a piece of the end of the vessel and not twist it securely. I have proved this on many occasions on the dead body.

The forceps I have made for holding the vessel are very simple, they fix it firmly with flat surfaces without injuring the external coat, which the sharply-teethed forceps are apt to do; they are also very well adapted for the twisting of vessels of moderate calibre.

By way of summary the following conclusions may be drawn up.-1. That hemorrhage may be arrested by torsion from even the largest vessels.

2. That it is a safe and judicious practice in all cases in which the vessels are small and of moderate calibre; and that, as far as experiments and practice yet prove, it is equally so in arteries of the first magnitude.

3. That torsion may be "free" or "limited ;" the free method being applicable to vessels of moderate size, and even to the largest of the extremities; limited torsion being more adapted for the large and loosely connected vessels.

4. That in torsion as in the ligature the permanent hemostatic processes are alike due to the sealing of the divided inner and middle tunics; but that in the ligature there is only an irregular division of these tunics, whilst in torsion there is a complete division, separation, retraction, and valvular incurvation.

5. That in torsion the twisted cellular coat forms, with the retracted and incurved middle coat, the direct mechanical obstacle to the flow of arterial blood, in the same way as the compressed cellular coat does in the ligature; but that in torsion the twisted cellular coat and incurved middle coat become subsequently a permanent means of occluding the end of the artery; whilst the ligature of necessity becomes subsequently a source of irritation, and too often a means of undoing what has been done by nature's own hemostatic processes.

6. That in torsion the twist in the cellular coat of an artery; the division and subsequent retraction, incurvation, and adhesion of the middle coat; and the coagulation of the blood in the vessel down to the first branch, are the three points upon which its temporary as well as permanent safety depends; whilst the permanent safety of acupressure rests only upon the last point alone, and its temporary effects upon the pressure produced by the needle. 7. That there is every reason to believe that when torsion has been successful on its first application, the fear of subsequent hemorrhage is altogether groundless; for there is nothing, as there is in the ligature, to interfere with the physiological processes set up by nature to occlude the divided vessel; and, unike acupressure, the temporary obstacle to the flow of blood becomes a permanent one.

8. That upon physiological grounds torsion has decided advantages over the ligature and the acupressure reedle; and that if subsequent experience

confirms what has been hitherto observed in the experiments on animals and the application of the practice in the human subject, we shall have gained a point of no mean importance and simplified surgery in no slight degree.Medico-Chirurgical Transactions, Vol. 51, 1868, p. 199.

44.-ON ACUPRESSURE AND TORSION.

By J. COOPER FORSTER, Esq., Assistant-Surgeon to Guy's Hospita`.

In many cases, torsion has a great advantage over acupressure, but it is not always easy of application; nay, in some instances it is applied with great difficulty, and should a portion of the vessel perchance be torn off and hemorrhage still go on, the further practice of torsion becomes exceedingly troublesome. It is impossible to say why the practice, adopted first by Amussat, was given up by the French surgeons--perhaps the difficulty of its application without chloroform may have been one reason, but I can scarcely imagine such to have been the case. In the few instances where I have used it there has not been any trouble in applying it, and certainly nothing that would induce me to abandon the practice on any such grounds.

The great recommendation for the employment of acupressure has been generally asserted to be that thereby adhesion-entire or almost entire-of the whole of the wound would more frequently occur than at present, but on reviewing the cases which have fallen under my notice, in no one instance has there been an entire absence of suppuration, with such complete adhesion as I had been led to expect and hope for. I must confess here to a certain amount of disappointment. I hear it also stated by the warmest advocate of acupressure that torsion leaves a small piece of sloughy tissue in the wound which acts injuriously by preventing the entire adhesion of the surfaces. Supposing there to be truth in this statement, we are no worse off if we get no more adhesion by acupressure than by torsion, and surely out of forty cases one or two at least might have afforded me a happy result. One of the undoubted advantages of torsion is the absence of a foreign body of any description in the wound. It is even simpler than the use of pins for twenty-four or fortyeight hours, and if it answers equally well I think it should be employed. But there are cases where I think the use of both means for arresting bleeding may be advantageous; the combined plan in the patient upon whom I adopted this double treatment for the arrest of hemorrhage was more successful than torsion alone-indeed, there seems to be a greater trouble in applying torsion to the smaller vessels than to the larger ones.

Professor Syme and Dr. Humphry have now brought forward so many cases in which they have employed torsion that no one can believe for a moment that there need be the slightest fear of trusting a large artery thus treated and from what I have done in the few cases mentioned, I believe it bids fair to realize the hope I expressed at the termination of my last communication, that some plan even more convenient than the pin and wire might be found as a substitute for them: such at present appears to be the result of torsion.

Experiments on animals are of little avail in establishing the security of the torsed vessels-the French surgeons made enough of these trials many years ago to satisfy any one, and with the happiest results; yet the practice of torsion was abandoned by them because (so far as I can gather) suppuration occurred in the human subject along the course of the arteries.

I have not yet heard of any such results following the practice at the present day. The time occupied in the performance of torsion is somewhat longer than that in applying the pin and wire, and in the smaller vessels there is no doubt, considerable trouble sometimes experienced in applying torsion, and it may be advisable to have a pin and needle at hand so as to combine the two plans, as in the vessels of small size the pins can always be removed in twentyfour hours or less.

I have no hesitation in saying that two of the cases which have occurred