Tincture of iodine was now applied to the knee daily for a week, but without affording relief. She also had an anodyne at bedtime. The joint was then blistered with vesicating collodion and the pain ceased, unless when an attempt was made to move the knee. The limb gradually assumed the extended position, but painful startings supervening, a gutta percha splint was applied to the ham, which, by securing rest, gave perfect ease. At the end of a fortnight the splint was removed and the joint strapped with soap plaster, and after a few days the patient was enabled to get about. One day, when the strapping was removed, the patient herself discovered a small tumour on the outer side of the joint in the situation of the external lateral ligament. The tumour was movable, as it slipped away when pressed with the finger. She called Mr. Tyrrell's attention to it, and after a few days' observation it was found that when the tumour could be felt the patient could walk without pain, but when it slipped away the joint became fixed and painful. In a short time a second tumour was discovered, the patient being able to secure both at the outer side of the joint. At this time the patient was unable to lie on her right side, for as she herself described, "when she attempted to do so the lumps fell down to the inner side, and then got into the joint."

There being no doubt as to the diagnosis, efforts were made with various appliances to secure the loose bodies at the outer side of the joint, but after a few trials were given up as useless,

Mr. Tyrrell now determined to remove one of the cartilages, and gave directions to have the patient put to bed and to have a wooden splint applied behind her knee.

On the 7th of July (one week after the patient was confined to her bed) he removed a cartilaginous body much resembling a garden bean in size and shape; it had a short pedicle. The wound in the skin was secured by two ligatures and dressed with carbolic oil. No constitutional symptoms followed. The wound was stripped on the third day after the operation, when it was found to have perfectly united. The sutures were removed.

On the 2nd of October he removed the second cartilage, it was like the first, but smaller, and had no pedicle. The wound was treated like the former one, but the operation was followed by some slight pain and tension, and when the dressing was removed on the fourth day pus escaped-a small abscess had formed. However, the patient got well rapidly and was up eight days after the operation.

A slight weakness of the joint remained for some weeks, but in time it wore away, and she was discharged perfectly cured early in December.

I have forgotten to mention that after each operation cold lotions were assiduously applied over the knee until all danger of inflammation had passed.

We all know that there are two methods of removing these bodies. The one by cutting down to them at once: the other by subcutaneously dividing the synovial membrane and pushing the body into the subcutaneous cellular texture, and, afterwards, when time has been given for the wound in the synovial membrane to heal, either to allow the cartilage to remain in its new position or remove it by an incision of proper size in the skin, according to circumstances. This affection is comparatively rare, and it is very seldom indeed that two have been removed from the same joint.

I myself never saw a cartilage removed from the knee-joint until I did so myself.

On reading up the subject before I operated I was led to believe that the operation is a very easy one, that the body can be easily steadied, and that it starts out when a free incision is made over it, and also that it can be easily pushed into any part of the joint you may select.

My case proves the contrary. In the first place, it is most difficult to steady the cartilages; indeed, it was only the patient herself who could do so satisfactorily, and when operated on she did not take chloroform, but most resolutely and efficiently steadied the cartilages between her two thumbs. It did not start out when cut down upon, and was at a much greater depth from the surface than I imagined. Neither could you select the site for operation, as

the upper and external side of the joint was the only place where they could be felt.

As I determined to give the carbolic acid a fair chance, I performed the operation of removing the cartilage by direct incision at once, and dressed the wound as stated, with carbolic oil. The first operation did beautifully; I thought it was owing to the antiseptic plan of treatment, but that could not be so, as in the second operation a superficial abscess formed. Surely, if carbolic acid was the cause of the absence of inflammation in the synovial membrane, it should have prevented suppuration in the part with which it was in nearest relation.

The following deductions may be drawn from the experience gained by this

case:

1st. That foreign bodies may exist for a length of time without giving rise to any symptoms.

2nd. That they are occasionally, even when made most prominent, at a considerable distance from the surface.

3rd. That we cannot always select the situation for removal.

4th. That in cases where the body is at a distance from the surface the subcutaneous removal of it would be attended with much difficulty.

5th. That the success of the case was not due to the dressing of the wounds after Lister's method.-Medical Press and Circular, April 13, 1870, p. 286.

ORGANS OF CIRCULATION. .

44.-ON THE BENEFICIAL RESULTS OF UNDESIGNED AND ACCIDENTAL HEMORRHAGE IN CERTAIN CASES.

By SAMUEL HEY, Esq., Senior Surgeon to the Leeds General Infirmary.

Every physician is well acquainted with what are frequently called critical hemorrhages, in which a patient, reduced to the lowest point, from that moment steadily recovers; e. g., in typhus, hemorrhoids, and hemoptysis. The surgeon often meets with cases in many points analogous to those above alluded to, but they have not been prominently noticed by surgical writers.

1. Excessive hemorrhage in severe injuries is often followed by speedy recovery, the higher and destructive results of inflammation are prevented, and sufficient power remains only for the adhesive process and union by first intention. Thus a bad case of cut-throat, whose life was despaired of for many hours,.recovered completely in eleven days. Again, in cases requiring primary amputation, where the loss of blood has been so great that the operation must be deferred for several hours, the patient not unfrequently progresses favourably to recovery without a bad symptom. This has to me often, through a long course of years, been so striking that I have sometimes ventured to predict a happy termination. In these cases the patient seems to be reduced to the more favourable condition of one suffering from chronic disease. For example, about three months ago, I had to operate on two persons during one week for injury of the upper arin. The first, from gun-shot, had no loss of blood. The second, from severe laceration and compound fracture, was, by hemorrhage, reduced to the last extremity. The first died speedily from traumatic gangrene; the last recovered without drawback. They were about the same

age.

Numerous cases of this kind have led me to be little anxious about considerable bleeding during an operation where the antecedent effusion of blood has been slight; having, however, due regard to the constitutional condition of the patient, and his probable powers of restoration.

2. The second class of examples are those in which bleeding is beneficial, though undesigned and unwished for, and, indeed, occurring where it might seem to be the most undesirable.

A gentleman, aged 55, had in the epigastric region a tumour, ten inches in diameter, followed by ascites to the fullest possible extent. The tumour was

connected with the liver, was marked with veins on the surface, and was supposed to be malignant. The skin of the abdomen and the lower extremities were excessively oedematous. Paracentesis was performed three times at intervals of six weeks. After the last operation the patient appeared to be dying for several hours; by the use of stimulants he rallied. On the third day, a catheter was introduced through the wound; serum, very deeply covered with blood, was drawn off, and it was then discovered that a deep-seated vein had been wounded, and its contents poured into the abdomen. From this time, recovery commenced, the dropsy disappeared. and he became again a strong and hale man, and is still living at the age of seventy-five.

3. The most common order of instances where undesigned hemorrhage is not only useful but curative, is to be noticed in large, and deep, and intractable phagedænic ulcerations. I have seen this so often that I am almost at a loss to select examples.

A man suffered from a large and deep burn on the chest, and, after many weeks, appeared to be hopelessly sinking. A considerable venous hemorrhage took place from the flabby granulations, and straightway they became healthy, and cicatrisation and recovery took place rapidly.

Many instances have come under my notice where deep syphilitic ulcers in the groin, vulva, and nates, and on the legs, have at once cleared up on the occurrence of considerable hemorrhage, especially where the patients had previously undergone a course of antisyphilitic treatment.

Two patients are at present under treatment at our hospital, one an in-, the other an out-patient, where the nose, lips, palate, and bones, have been to a great degree destroyed. In both instances, a spontaneous, vigorous hemorrhage has cut short the disease, and in one has led to all but perfect cure of the ulcerations, leaving only the unsightly results of destructive disease.

It was only after I proposed to write a few lines on this subject, that I learnt that my friend Mr. Jessop, formerly our house-surgeon, had, in our journal last December, noticed briefly cases where even the femoral artery had been opened by phagedænic ulceration, and the hemorrhage thence arising had arrested the disease. Mr. Jessop now informs me that he has, in one case of syphilitic ulceration, tested by practice the value of this teaching of the "effort of nature," by opening the arteria dorsalis penis with every good result.

I only throw out these few remarks to lead to further observation. To enter into physiological discussion would require rather a book than a short unpretending practical paper.-British Medical Journal, Jan. 29, 1870, p. 101.

45.-ON THE TORSION OF ARTERIES.

By THOMAS BRYANT, Esq., Surgeon to Guy's Hospital.

[Mr. Bryant having removed a number of the larger vessels from various subjects, and twisted the ends freely, had them filled with a vermilioncoloured wax injection. Careful sections were subsequently made of the preparations. The result has been a number of admirable models, displaying most if not all of the modes in which hemorrhage from a twisted vessel is arrested. The physiological facts shown, and the conclusions drawn from a consideration of these modes are as follows:-]

The facts show that by the torsion of an artery, the inner coats are divided, and in the majority of cases turned inwards, and that in the most perfect examples these incurved coats form complete valves, not unlike the semilunar valves of the heart, on the injection of the vessel, either by the blood of the patient during life, or by artificial injection after death.

They show that in other cases-how many it is difficult to estimate-the valvular incurvation of the divided inner coats is not so perfect as to prevent the passage of a small portion of blood or injection with the first rush of fluid, although it is tolerably clear that the valve is subsequently rapidly closed with any increase or continuance of the injecting force.

They prove, likewise, that in some cases this valvular incurvation of the inner coats is exchanged for a general splitting of the tissues, hemorrhage being prevented by the clotting of the blood between the irregular lamine of the divided membrane and the twist of the external cellular coat.

They also prove the great value of the knot formed by the torsion of the external cellular coat; for although in such instances as are shown in figures 1 and 2, the support of such a twist appears to be of secondary importancethe valvular incurvation of the inner coats being apparently sufficient of itself no one can doubt its value in such cases as figures 3 and 4 are meant to illustrate. And even if, in a large number of such cases, the valve formed by the divided recurved inner coat proves to be perfect after the first rush of the blood-current has taken place, the knot formed by the twisted external coat must prove a valuable support, and in doubtful cases, where an imperfect valve exists, it must be of still greater importance. In figure 5 the presence of the twisted external coat is surely of value, not only by forming an obstacle to the immediate escape of blood through the broken-up inner membrane, but by giving time to allow of complete coagulation of the blood which has been caught between the lamina of the inner coats.

We come, therefore, to this conclusion-that although there is no physiological necessity in the most complete examples of torsion of an artery, for the preservation of the knot formed by the twisted external coat, there is in the imperfect examples; and as it is impossible for the surgeon to know during life, in any given case, whether the valvular incurvation of the inner coat has taken place in the most complete way or not, and as it is at least probable that an imperfect incurvation of the inner coat exists, it seems to be more prudent for the surgeon to act on the side of caution, and to preserve this twisted external coat in its integrity in all cases.

I look upon the valvular incurvation of the inner coat as the chief means adopted by nature for the arrest of hemorrhage, and the twist in the external coat as an all-important additional security; the elastic and yet brittle inner tunic, with its tendency to adhesive inflammation, requiring, in all but the most perfect examples, during the first few hours after torsion, the support of the tougher external one.

The more the inner coat is broken up by the twisting of the vessel, the greater is the need of the external coat to give it support.

The more the end of a large artery is twisted, the more is the inner coat broken up and the greater is the danger of disturbing its valvular incurvation. When the end of a healthy vessel is twisted off, the inner coat is, as a rule, greatly broken; when the end of a diseased vessel is so treated, it is split into fragments.

When a limited number of rotations of the forceps-two, three, or fourare applied to a healthy vessel, the valvular incurvation of the inner tunic is, as a rule, complete; and the more diseased the artery, the fewer are the rotations required.

The propriety of twisting off the end of an artery or leaving it on becomes, therefore, a matter of great importance, and a great practical question which has yet to be decided.

From the remarks I have already made it will be evident that my own opinions tend to support the practice of leaving the twisted extremity of the vessel in situ. Dr. Humphry has, however, come to the opposite conclusion. How it is, therefore, that we differ upon this point may claim some brief notice, for his authority is so high that his opinions are readily accepted and his practice followed.

First of all, Dr. Humphry clearly shows in his paper that he does not attach so inuch importance to the reflection of the inner coat, as a barrier to the flow of blood, as he does to the twisting of the outer coat, forasmuch as by this, he states, "the inner coat is not only forced into, but is held in its new position; accordingly, if a syringe be attached to an artery thus twisted, and water be injected, considerable resistance to the escape of the water is presented; but if the twisted portion of the outer coat be cut through, or dissected off, the water very soon escapes. It has little difficulty in finding its

way through the inner coat, or of separating the surfaces, when the support afforded by the outer coat is withdrawn."

These facts are undoubtedly correct, my own experiments have confirmed them; but the test applied to the inner coat by dissecting off the outer is a very severe one, to say the least of it, and applies to conditions that do not naturally exist. The facts tend, moreover, to prove the value of the twisted external coat rather than the weakness of the inner tunic, and suggests to the surgeon the wisdom of doing nothing to weaken the strength of the twisted external coat. Yet it is to be remarked that Dr. Humphry in most of his experiments twisted off the ends of the vessels, and in doing this, I have little doubt, in a large number of cases he not only destroyed the valvular incurvation of the inner coat, and so broke up the tissues as to render the support afforded by the external coat an absolute necessity, but by the same act of twisting off he likewise weakened the external coat upon which safety under such circumstances absolutely depended; for repeated experiments have proved to me that when a mixture of glycerine and water of the sp. gr. of blood is thrown into a large artery, the end of which has been twisted off, it is far more frequent to find some leaking of the vessel through the divided extremity than when the end of the vessel has been only twisted three, four, or five revolutions.

When the arteries are diseased this fact comes out still more clearly, for in a diseased artery the inner coat is so brittle as to break and incurve on one or two rotations of the forceps. One or two more rotations break up the inner membrane into pieces very like those seen in Fig. 5, and by twisting the end off the artery it is very apt to be destroyed.

The twisting off of the end of a large artery crushes up the inner membrane, and too often lacerates the external, destroying by one act the valvular incurvation of the inner tunic, upon which the arrest of hemorrhage so much depends, and weakening the support which the external coat would otherwise give, and which under such circumstances is so much required.

In a recent amputation of the thigh, where the vessels were much diseased, the truth of these remarks was well illustrated, for when I twisted the femoral artery three complete revolutions, the end became so loose that I thought it was off, and leakage followed, but when I took the vessel up again, having cut off the lacerated extremity and twisted its end two rotations, good success ensued. This case illustrates the practical truth that in applying torsion to a diseased vessel a more limited number of rotations of the forceps should be made than to a sound artery.

What we want to effect by the torsion of an artery is a laceration and incurvation of the inner tunic, and to support this incurved membrane by the twist of the external coat. We do not want to crush up the inner tunic too much, or to weaken in any way or to lacerate the external. By twisting off the end of the vessel I have abundant evidence that we incur a greater risk of falling into both of these errors than by making a limited number of rotations of the forceps and leaving the end of the vessel on. All my experiments and observations tend to prove this in a direct way, and the facts that Dr. Humphry has supplied by his experiments go to support the same views.

If it be generally true, therefore, as a modern writer in the last edition of "Holmes's Surgery" has so dogmatically asserted, "that torsion is unsuitable for diseased arteries, and large vessels, even though healthy, cannot be invariably secured by it, Professor Humphry having found in his experiments on animals that the outer coat is sometimes too much weakened by the rotation," he should have added when rotated off, for it was made true only from the fact that torsion was carried to too great an extent. For all my experiments and nearly two years' experience have convinced me of the following conclusions.:

Το

That torsion may be safely applied to all arteries of the extremities and to all those of the trunk which are in size less than or equal to the femoral. the carotid and the iliac vessels it has yet to be applied.

That it is almost as applicable to diseased as to healthy vessels, the former

requiring fewer rotations of the forceps than the latter.