TORSION. ' 
With Description of an Automatic 
Forceps for Rapid Torsion. 
F. M. BRIGGS, M. D., 
SURGEON TO THE BOSTON DISPENSARY. 
Reprinted from the Boston Medical and Surgical Journal of 
November 19, 1891. 
BOSTON: 
DAMRELL & UPHAM, Publishers, 
283 Washington Street. 
1891. S. J. PARKHILL & CO., PRINTERS 
BOSTON TORSION; WITH DESCRIPTION OF AN AUTO- 
MATIC FORCEPS FOR RAPID TORSION.1 
BY F. M. BRIGGS, M.D., 
Surgeon to the Boston Dispensary. 
Although torsion has several distinct advantages 
over any other method of treating haemorrhage, and 
although with certain limitations it is both safe and 
practicable, it has never found general favor as a 
haemostatic measure and is rarely made use of. 
The method is a very ancient one, having been rec- 
ognized and practiced in the first and second centuries. 
In the early part of the present century it came into 
use in France, but after having been tried for a while, 
was finally abandoned, as being unsafe when applied 
to large arteries. 
Warren 2 states that torsion was brought to the no- 
tice of and was used by Velpeau in 1826; that it was 
also practiced by Amussat, who, in 1829, presented a 
paper on the subject to the Academy of France. 
Ashhurst8 says that in this year (1829) it was 
successfully used in Germany ; but was followed by 
several failures in France, and it was referred to 
Duypuytren for thorough investigation. His report 
was unfavorable to torsion except in the case of small 
arteries. After this the method went out of use, but 
was revived and practiced by Syme. 
Bryant4 speaks of it very highly. In an experience 
of nine years, upon vessels of all sizes, he has never 
had a mishap, and he believes it to be the most perfect 
physiological method at command for the treatment of 
haemorrhage. 
i Read at the meeting of the Surgical Section of the Suffolk Dis- 
trict Medical Society, May 6, 1891. 
2 The Healing of Arteries after Ligature in Man and Animals. 
3 International Encyclopaedia of Surgery. 
« Practice of Surgery. 2 
Warren,6 speaking of its physiological value, refers 
to the experiments of Kocher, who concludes that: 
"Torsion enjoys with acutorsion and acupressure the 
great advantage of favoring a rapid coagulation, and 
also has its own special advantage of producing a much 
more intimate union between the thrombus and the 
vessel wall . . . these advantages are especially true 
of illimited torsion ; when properly done, it is the 
ideal for small arteries." 
Holmes,6 although believing it safe, prefers the car- 
bolized ligature, and thinks, that " even the most expe- 
rienced operator will find that it takes a long time 
to close all the vessels in a large stump by torsion 
. . . and that much more handling of the parts is re- 
quired." 
Gross7 is doubtful as to its safety upon large arter- 
ies, and Ashhurst8 is strongly opposed to it, being of 
the opinion that " the only truly efficacious means of 
arresting the hmmorrhage from large arteries are 
compression and ligation." 
No method of treatment is justifiable which does not 
offer the greatest possible security against the occur- 
rence of secondary haemorrhage. Such an accident is 
too serious to admit of taking any chances, and, with 
opinion thus divided, it would certainly seem better to 
use the ligature upon such vessels as the femoral, car- 
otid and axillary, and to confine the use of torsion to 
the smaller vessels, where the question of safety can 
be disregarded. But, with this limitation, there is 
still a very wide field for its use; for, where the femo- 
ral is tied once, numbers of ligatures are being put 
upon vessels small enough to come strictly within the 
limits of safe torsion. 
Twisting is done in one of two ways. In limited 
5 The Healing of Arteries after Ligature in Man and Animals. 
6 System of Surgery. 
7 System of Surgery. 
8 International Encyclopaedia of Surgery. 3 
torsion the artery' is seized with one pair of forceps, 
drawn out of its bed, grasped at its deepest point by a 
second pair, and the portion between the two forceps 
is then twisted four to six times. 
In illimited torsion the artery is seized and twisted 
with one pair of forceps, without the aid of the second 
pair - the fixed point against which the twisting is 
done being found in the tissues in which the vessel is 
embedded. 
After having tried illimited torsion upon small ves- 
sels, some time ago, it seemed to me, that probably one 
reason why it is not in more common use, is because, 
with our present forceps and method of performing 
it, torsion is a slow and clumsy proceeding; and it 
occurred to me, that if an instrument could be made 
which would twist quickly and effectively, and which, 
at the same time could be easily handled, that such an 
instrument might be found useful as a general heemo- 
static for the smaller vessels. 
My first models had a box of gearing wheels con- 
nected with a rod, to which the forceps were attached ; 
by turning a small handle the wheels were set in 
motion, and the forceps made to revolve rapidly. I 
abandoned this model for its use required both hands, 
and it needed too much manipulation. These difficul- 
ties have been overcome in the model as shown in the 
accompanying cut. This instrument has the very 
great advantage of being wholly under the control of 
one hand, and its mechanism is such, that by a simple 
up-and-down motion of the box (g) over the spiral 
rod (e) the vessel is seized, twisted and released. 
Inspection of the cut will show the principle upon 
which it works, and this can be made clear by a few 
words of explanation. The instrument is taken with 
the thumb in the ring at the top, and the first and 
second fingers in the rings on the box (y). The hand 4 
is opened and the box pushed firmly down. The 
arms (/*) drop over and grasp the ring (c), carry it 
down, and the forceps spring 
open (as is shown in the smaller 
drawing). 
It is then ready for use. 
The forceps are placed over 
the vessel and the box (y) is 
drawn up. The arms (/) pull 
up the ring (c) which presses 
against the upper ends of the 
forceps and closes them over the 
vessel. The arms then strike 
the projection at (tZ), spread 
open, and leave the ring (c) in 
situ, holding the forceps firmly 
locked. The forceps cannot be 
again opened until this ring has 
been pushed down. Torsion is 
performed by pulling up the box 
(y) three or four times, over the 
whole length of the spiral rod, 
that is to say, by closing and 
opening the hand three or four 
times. Drawing it up three 
times gives six full twists, which 
ought to be sufficient. When 
the torsion is completed, the 
vessel is released by again push- 
ing the box firmly down.. The 
arms (/) push down the ring 
(c) and the forceps spring open. 
This whole performance, 
namely, seizing the vessel, twisting and releasing it, is 
perfectly simple and very rapid, as it takes only three 
to four seconds. 
Three-fifths of actual size. 5 
This instrument checks the bleeding, not only from 
those vessels which have a distinct vessel wall and 
can be easily isolated, but also from small bleeding 
points, provided they are seated in tissue which will 
allow them to be twisted. But in old cicatricial tis- 
sue, in the skin, etc., they are bound down, and tend 
to break off instead of twisting. 
Regarding the instrument, it is to be noted that 
there is no backward rotation. When the box (g) is 
drawn up, the forceps revolve. When it is pushed 
down, the forceps are stationary. Of course, if the 
motion were reversed, the vessel would be untwisted, 
and the torsion of no value. A small ratchet in the 
thumb piece allows the spiral rod to turn in one 
direction, but acts as a brake to prevent it from turn- 
ing in the opposite direction. The box (g) contains 
a brass cylinder, fitting closely upon the grooves of 
the spiral rod, and toothed at its lower end. When 
the box is drawn up the teeth engage, making a solid 
body of the box and cylinder, and the spiral rod re- 
volves ; but when the box is pushed down the teeth 
disengage, and the brass cylinder revolves around the 
rod which is then stationary. 
It is also to be noted that the opening and closing 
of the forceps is wholly automatic. This mechanism 
is plainly shown in the cut and needs no explanation. 
The forceps (a) are the ordinary hasmostatics with 
short upper ends. They are pivotted on a pin at (6) 
and are held open by a small spring, which cannot be 
seen in the drawing but which is just below this pivot. 
The instrument is cleaned as follows : The pin at (5) 
which pivots the forceps is fastened to a plate. By 
turning this plate half round, the pin can be pulled out 
and the whole instrument taken apart. There is no 
point which cannot be easily reached and thoroughly 
cleaned. The forceps pull out of the shaft, the ring (c) 6 
slides off, the shaft is taken off the spiral rod, the box 
(y) removed, and by unscrewing the cap from its upper 
end, the brass cylinder can be taken out. The arms 
(/*) can be taken off, and, if desired, the thumb ring 
can be unscrewed. To allow of thorough cleanliness 
the number of different parts has been purposely 
made large. Some difficulty may be found in putting 
it together again. To do this: First, put the brass 
cylinder, with the toothed end downy into the box (y) 
screw the cap on, and slide the box upon the spiral 
rod; second, put the shaft on the rod ; third, put the 
ring (c) on the shaft; fourth, push the forceps into 
place ; fifth, re-insert the pin (6) and turn the plate 
to which it is attached back into position. 
When taken apart it is complicated. When put 
together and ready for use, it is not complicated. It 
is simple, compact and strong. 
The instrument has been made for me by Tiemann 
& Co., of New York. Mr. L. G. Pfarre, of this firm, 
has taken great pains in the details of its construction, 
which was very difficult on account of the tendency 
to friction between the various parts. 
It is intended for illimited torsion, and can be 
safely used upon all vessels cut in any operation: 
(1) Upon the forearm and hand. 
(2) Upon the leg below the upper third, and the 
foot. 
(3) About the head and face. 
(4) Upon the surface of the body generally, as for 
the removal of tumors, for the radical cure of hernia, 
for plastics, etc. ; and this class includes a very large 
proportion of all operations performed. 
In comparing torsion with the ligature, it can be 
stated that every ligature is a foreign body in the 
wound at the time it is applied. Until recently, liga- 
tures were treated as foreign bodies, and were removed 7 
at a later period of the case. We now know that this 
is not necessary; that an aseptic ligature can be left 
in the wound, and that it ought to be taken care of in 
the healing process, being either absorbed or becom- 
ing encysted. 
Notwithstanding this great advance in surgical 
detail, it would certainly be better if all wounds could 
be closed without containing any knots of foreign 
material; there is always the possibility that ligatures 
apparently aseptic, are not so ; and, if aseptic, the 
wound has an extra amount of work in disposing of 
them. Where only one or two ligatures are applied, 
this work may be insignificant, but where any number 
are necessary, it must become an appreciable factor. 
In torsion, however, no foreign substance is left in 
the wound. After torsion by this rapid method, the 
twisted ends are seen as small, compact knots, and 
these are apparently no greater hindrance to healing 
than are the ends of the vessels which project beyond 
the ligatures after tying. 
Asepsis is more certain than with any form of liga- 
ture. The only object which comes in contact with 
the wound is the forceps ; while in tying, in addition 
to the forceps, we have the ligature itself and the 
hands of the operator or assistant in tightening the 
knot. 
Primary union ought to be facilitated, for it is ob- 
vious that where ligatures are aseptic and therefore 
innocuous, still, there can be no union of the cut sur- 
faces at the points were they are applied until the for- 
eign element has been removed by absorption or by 
encapsulation; and this must take a longer time than 
is needed in disposing of the small knots left by this 
instrument. 
The writer wishes to express his indebtedness to 
Dr. J. C. Warren, to whom he is under very great 8 
obligations for his kindness in giving an opportunity 
to use the instrument, and to test the method at a 
number of his operations at the Massachusetts Gen- 
eral Hospital, last March. At these trials, which 
were upon cases where no large trunks were involved, 
bleeding was successfully and permanently checked. 
Several defects in the instrument, which prevented 
it from working smoothly, were made apparent, and 
the experience obtained through this courtesy on the 
part of Dr. Warren, has been of the greatest assist- 
ance in perfecting these defects.  THE BOSTON - - 
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