this year have given me considerable anxiety as regards acupressure-one of them more especially, as the pin was kept in seventy-two hours with a view of preventing any hemorrhage, and yet on its withdrawal so feeble was its hold that a sudden gush of blood took place. I should mention that the whole stump had sloughed, and whether the same result might have occurred with torsion (it most probably would eventually have done so with a ligature) I cannot say; probably any means would have failed, but as acupressure was under trial I was disappointed at its failure.

Some length of time must necessarily elapse before surgeons will be inclined to expose their patients to what, in the minds of many is considered a hazardous condition: there is a certain sense of security given in the case of a ligature being applied which affords to the surgeon a guarantee that for the present at least he will leave his patient in a safe state; but he forgets that there is a danger of hemorrhage arising when that ligature is separating, probably as great as on the removal of the pin. Amussat described the inner coat of the vessel as being folded up, and this condition would appear to act as a preventive of bleeding equally secure with the plan of tying a ligature around the artery, and certainly more secure than acupressure.

During the last two years I have in no case used a ligature where any attempt has been made to obtain adhesion in a wound, nor where I have been able to practise torsion. It is thus difficult to see in what cases ligatures need be used at all.-Guy's Hospital Reports, Vol. 14, 1868, p. 172.

45.-ON THE PROCESS OF TWISTING ARTERIES FOR ARREST OF HEMORRHAGE.

By Dr. JAMES D. GILLESPIE, Surgeon to the Royal Infirmary, Edinburgh.

Though it has of late been brought very prominently into notice, there is nothing new in this method. It has long been known, and occasionally practised.

Amussat was a strenuous advocate in its favour, recommending and practising its employment even in large arteries. The idea appears to have been suggested by what has been observed in cases of forcible avulsion of a limb, it being notorious that, as a rule, under such circumstances the arteries do not bleed; and when examined, they have been found with the internal coats curled up and torn, while the external was twisted over them, and drawn out to a point.

It is easy to understand how the suggestion arose,-Why not imitate nature when you are artificially removing a limb? And accordingly twisting an artery of small or even medium size has been repeatedly put into successful practice. Certain little accessories are, however, essential to obtain satisfactory results.

The point of the artery must alone be seized, and it must be slowly twisted till the portion included in the forceps comes away. If this is not done, and as I have repeatedly seen, the teeth of the forceps, after twisting for a little, are unclasped, the artery is sure to unroll itself again and bleed more fiercely than ever.

I have given this method of arresting hemorrhage a fair and ample trial, having, as well as my colleague, Professor Syme, trusted to twisting alone for occlusion of the femoral after amputation, and with entire success. I would not, however, in the present state of our knowledge, advise you to adopt twisting for the largest class of blood-vessels, for I believe that their vital powers are often impaired by disease; and besides, we know that arteries do not always, though generally, when forcibly torn across or twisted, become safely closed orifices; reaction may burst the barrier, and produce serious if not fatal hemorrhage. For the smaller vessels there is nothing better, for neither the slough of the artery nor the pus-absorbing ligature is left in the wound, nor is the patient put to the pain-for he almost invariably expresses much pain at such a time-of having a lot of needles pulled

through a sensitive cut and resisting surface, when it is necessary to have them removed.

Its only failing is, that in extensively diseased parts the artery sometimes breaks instead of twisting, or in some situations the vessel retracts beneath a band of fascia, and all attempts to isolate and twist its orifice may be found ineffectual.-Edinburgh Medical Journal, Jan. 7, 1869, p. 583.

46.-ON TORSION OF ARTERIES.

By Dr. G. M. HUMPHRY, F. R. S., Professor of Anatomy, and Surgeon to Addenbrooke's Hospital Cambridge.

For several months I have used torsion exclusively, with one or two exceptions, after all operations in hospital and private practice. The operations have included three amputations in the thigh, in each of which I twisted the femoral as well as the other arteries; amputations in the leg and forearm, and of the breast; removal of tumours; excision of the knee, &c.; and it has answered perfectly well. The wounds were closed immediately by suture, and there was no after hemorrhage in any of the cases.

I do not mean to say that torsion is quite so easily or quickly done as is the application of the ligature. It requires more care and, I think, rather more time. In tying an artery, it is not absolutely necessary for the orifice of the vessel to be included in the grip of the forceps; it is sufficient if it is included in, and the mass tied by, the ligature. But for successful torsion, the artery itself must be held between the blades of the forceps; and it is not always easy to be sure that this is the case. It may not be seized at all, or it may slip on one side as the blades of the forceps are closing. Accordingly, I have often found that the twisting has failed; and I have made, not unfrequently, two or three false attempts, so prolonging of course, the operation. Still I always persevered, and have succeeded at last in every instance; and I have never yet known an artery bleed in the human subject after I could be sure that it had been really twisted. Again, the artery should be held in the forceps in, or nearly in, the direction of its axis: the rotation of the forceps in that axis being necessary to secure proper torsion. If it be seized across its length, as not unfrequently happens unless care be taken to avoid this, it is simply turned upon the rotating blades, and torn across, instead of being twisted.

In accordance with the observations made on the dead body, and recited above, I have simply seized the end of the artery with the forceps, not drawing it out or holding it with a second pair of forceps applied higher up; and have rotated the forceps till they were free, the piece of the vessel included in them being twisted quite off. This may require ten or a dozen rotations of the forceps; and I am careful to go on twisting till the severance is quite complete, not allowing myself to withdraw the forceps till every thread is divided by the twisting, being fearful lest the pulling upon any undivided portion of the outer coat should tear it, or prevent or disturb that complete twist which my experiments have shown to be so important. Lastly, I examine the twisted end well, to ascertain whether there is any leakage.

One advantage of torsion is, that we need not hesitate to apply it to every vessel which bleeds, or which seems likely to bleed after the wound is closed. We are unwilling to leave thirty or forty ligatures in a wound; but we may twist that number of vessels without any compunction, and thus diminish the oozing which sometimes takes place after the closure of the wound, and, by separating its surfaces, prevents their union. This occupies a little more time, which, under chloroform, is of no great consequence; and it may prevent much subsequent trouble, or even danger.

I have observed that the pain suffered after the operation has been less than when ligatures were used.

To form a correct estimate of the effect of torsion, as compared with ligature, upon the healing of the wound, will require more extended experience. My

own observation is, thus far, certainly in its favour. Some of the wounds, in which several vessels were twisted, have healed quite up at once without a drop of pus, which could not have taken place if ligatures had been used. In the last amputation in the thigh, the patient being a man aged 50, the wound healed by first intention, with the exception of a small tract at one part, which soon closed. In two of the amputations in the leg, sloughing occurred from causes quite independent of the torsion; and there was no secondary hemorrhage. In such cases as excision of the knee, torsion promises to be especially valuable, enabling us to secure, without the presence of a foreign body, any small vessels that may bleed or be likely to bleed. I have used it in two cases of excision of the knee, and in both the wound healed up at once.

I think, therefore, that, in amputations and other operations, all vessels short of the size of the femoral artery, as a general rule, may and should be secured by torsion; that the healing of the wounds will be thereby expedited; and that in the greater number of operations, the ligature may with advantage be superseded by torsion.

The femoral artery may also be twisted with success. It was so in the three instances that I have tried; but it must be admitted that my experiments throw a doubt over the applicability of torsion to arteries of large size.— Brit. Medical Journal, Jan. 9, 1869, p. 25.

47. THE USE OF COMPRESSION IN CERTAIN SURGICAL CASES. Ry Dr. C. H. HIGGINS, formerly Surgeon Somerset County and Birkenhead Hospitals. [Any remedy for "sprains" is welcome, if reasonably likely to succeed, for who has not often experienced disappointment in their lingering cure.]

The plan then which I have pursued during the last four or five years in all cases of sprain is as follows:-immediately on seeing the patient and satisfying myself of the nature of his accident, I plunge the injured joint, say the ankle or the wrist, which are the parts most exposed to sprain, into a vessel containing water as hot as can be borne, and keep it there for at least two hours, maintaining the temperature of the water by fresh quantities of the hot. At the end of the time specified, I find the pain of the part considerably mitigated, and it is, of course, very greatly distended and swollen. Having next carefully dried the part, I proceed at once to strap it, (if the ankle, from the toes to the middle of the calf, and if the wrist, from the fingers to the middle of the fore-arm,) as tightly and equally as I can, with common adhesive plaster cut into strips an inch wide, placing each succeeding piece so as to overlap the preceding one by about a quarter of its width. I always put on two such layers, and finally I direct the patient to keep the horizontal position, on no consideration to meddle with the dressing, but if much pain or distress is set up to take an opiate on retiring to rest. Upon visiting my patient on the following day, I usually receive some account of a restless night during the first hours, but subsequently of sleep and diminution of pain, &c. The plasters are generally quite loose from the shrinking of the limb, which is moreover now said to be comparatively free from pain, unless handled roughly-though of necessity much discoloured; having removed the plaster, I immediately replace it by fresh strips laid on as firmly, evenly, and extensive as before; in short, exactly in the same way as on the first dressing, insisting of course on a continuance of the recumbent position. On the third day of the accident I repeat the process, this time, however, allowing two days to intervene, and I perinit some movement about the room. At the end of the two days, I renew the plaster-dressing exactly as on the previous occasions, and generally for the last time, retaining this dressing until it loosens itself off, which usually occurs in three or four days, by which time I find the patient able to use his limb, and free from pain; in short cured. Such is my proceeding in ordinary cases of sprain; where the accident is of unusual severity, I have had recourse to six relays of plaster instead of four, and up to

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the present time with equal success, though the cure is generally delayed three or four days or so longer.

The first case I treated on the above plan was that of a former student of the Liverpool Medical School, residing at the time on this side of the river, and at present a Surgeon in the army. This gentleman took it into his head to leap down the last four or five steps of a common flight of stairs with an adult sister in his arms. He fell with his right foot doubled under him, and suffered a most severe sprain of his ankle. I saw him shortly after the accident and found him in intense agony, &c., and quite unable to move his foot, which was already much swollen. Not having perfect confidence in my plan of strapping, I immediately applied a full number of leeches, and then had his limb well fomented and ultimately enveloped in a bran poultice, and enjoined complete rest in bed. The following morning I repeated the leeches and fomentation, as there were still considerable pain and distention. On the subsequent day, I timidly commenced the plan of compression, using for the purpose a common firm calico bandage, which I applied firmly. As he expressed relief from the support, I rigidly continued the compression, removing and re-adjusting the bandage as the swelling diminished. Three weeks from the date of the accident, he was able to draw on an ordinary Wellington boot and go out shooting; and in a couple of weeks more he reported himself as quite recovered, and resumed his studies.

The next case I was called to was that of a lady, about 45 years of age. She slipped down the kitchen stairs, sustaining a sprained ankle. I saw her three or four hours after the fall, and found her ankle swollen and intensely painful. I caused her to foment the limb for a couple of hours. At the end of that time, having reasoned myself into more confidence of the method, I tightly strapped the foot and ankle, from the toes to the middle of the leg, with strips of ordinary adhesive plaster. She bore the strapping for some hours, but at length, becoming impatient of the distress occasioned by the dressing as she supposed, before my visit on the following day, she had loosened and to a great extent removed it. I re-adjusted the strapping; and on the next day, finding she had again loosened it, I applied, in place of common' adhesive plaster, emplastrum roborans, spread on linen and cut into strips like the former. Seeing me so determined, and not finding it quite so easy to remove the new strapping, she had not meddled with it; and after two or three days more, perceiving that the swelling had greatly diminished and the plaster consequently loose, I applied fresh strips as firmly as I could. The parts were by this time much less painful, and reduced, and my patient, being now convinced of the advantage of the compression, contentedly submitted to two or three renewals of the plastering, and in a month from the accident she was quite recovered, and able to walk about well.

Another case was that of a young gentleman, about 20 years old, who severely sprained his ankle in leaping from the landing.stage on to one of the Woodside boats. He was brought home, not being able to put his foot to the ground, and I saw him three or four hours afterwards. He complained of great pain, and his foot and ankle were much swollen and discolored. I had his foot placed for a couple of hours in a bucket of water as hot as he could bear it, and then tightly and evenly strapped the limb in the way already described, from the toes to the middle of the calf, and enjoined the recumbent position; the next morning he reported a somewhat restless night and some distress from the plaster, which, as usually happens, I found loose, from the shrinking of the parts. I restrapped the limb tightly, and he expressed himself easier when the operation was finished. Two days afterwards I applied fresh plaster, and again in two days, as the limb had now nearly returned to its usual size; this was the last application of plaster, for he could now walk tolerably about the room. At the end of ten days I saw him dancing at a party, and in one fortnight from the date of his accident he returned to his office duties, perfectly recovered.

The next opportunity I had of testing my method of treatment was in the case of an officer in one of the Inman line of steamers, who had a fortnight

before sprained his ankle by slipping on the ice at Halifax, i. e., the day before he sailed for Liverpool. He was entirely laid up during the voyage, and when he reached home was quite lame, and suffering from pain in the ankle joint. I pursued the plan I have already so fully detailed in the former cases. He underwent four strappings, and at the end of one week, though still wearing the last dressing, he was able to walk about without pain or limping.

Lately, one of my sons in leaping a gate fell, and sustained a most severe sprain. I pursued precisely the same plan as in the other cases, and though he suffered some considerable discomfort from the first application of plaster, he recovered without a drawback, and in less than a fortnight, though much discolouration continued almost up to the knee, he was able to resume his office duties, which entail on him a great deal of walking, without pain, &c.

A short time ago I had the opportunity of testing my plan upon myself, and, what is more, of contrasting it with the treatment I was subjected to for a similar accident some years previously. I was returning home some months since, late at night, from a patient's house, and stumbled over a large stone carelessly left in the road, and met with a severe sprain of the left wrist-joint. My hand was quite powerless, and extremely painful. I caused straps of plaster, in the usual way, to be tightly applied, from the base of the phalanges to about four inches above the wrist. These were renewed three times, and in five or six days I was free from uneasiness, and could use my hand almost as well as ever, and in a couple of days or so more had quite recovered, and have never felt inconvenience since.

From this accident to myself, I need scarcely say, I had an opportunity of measuring the amount and sort of discomfort occasioned by the first application of the strapping. This I found to extend over only the first six or eight hours, and, though certainly sufficiently distressing, it was by no means so great as I had anticipated, and consequently quite worth undergoing to ensure the after benefits of the treatment, and indeed quite compensated by the sense of security and support it produces, the absolute immobility in short, of the injured structures.

I have lately had an opportunity of proving to some extent the efficacy of compression, by the method I have described, in two or three cases of contusion, also in one case of dislocation of the elbow joint, in a member of my own family; and I may add also in two cases of gout in the foot. Here I delayed the application of the plaster strips until all inflammatory appearances had subsided. The benefit of the compression in both instances was considerable, not only from the support it afforded, but also by inducing absorption of the insterstitial deposits.

When we reflect upon the nature of a sprain,-that it is indeed a kind of subluxation, a more or less partial and temporary displacement, as it were, of all the structures about a joint, accompanied by considerable stretching, and even laceration of its ligaments, its tendons, its fascia, its vessels, and its nerves, I think we shall be safe in acknowledging that a judicious system of compression, early employed, must be a more efficacious method of treatment for its cure than the old temporising plan of leeches, cold lotions, stimulating liniments, &c., &c., with ultimate timid bandaging.

By compression, employed in the manner I have endeavoured to point out, I do believe we can bring about, more surely and more quickly and more comfortably to the patient, the various desiderata in the cure of sprains and similar cases. In the first place, we may ensure the complete, the absolute immobility and repose of all the injured structures. In the next place, we are enabled to restrain the greater amount of the extravasation and effusion which will of necessity be poured out, in and around the joint, unless prevented. And we may also promote at once the re-absorption of all intersti tial outpourings, be they of blood or of serum, which so frequently complicate the recovery in such cases, and compromise the symmetry of the parts, and we can restrain within due bounds the tension and vascular action of the parts. And lastly, I am sure now, from experience in my own person, that