bruit were reduced nearly to one-half their former intensity, and in some places could not be felt or heard where they previously existed. At this point digital compression was abandoned from scarcity of assistants; instrumental compression being substituted. The apparatus used was constructed upon the principle of a lever of the first kind; the fulcrum resting upon the artery and forming the compressor.

With the pad in position and the power applied, no movement on the part of the patient could displace it; remaining fixed until the power was relaxed. The irritation of the pad was less than that caused by the frequent changing of the thumbs of the assistants while making digital compression-causing after a time the excoriation of the skin. This was continued for period's of six hours, alternating with six hours' intermission for seven days, causing the pulsation and bruit to become reduced to one-fourth of their greatest intensity. The circulation as before was not completely shut off from the sac.

The area of surface to which pressure could de applied was one inch in breadth by two and one-half inches long, which was insufficient to allow of a requisite amount of rest to the parts in the intervals. The space had become very irritable and inflamed at the end of this time, and it was necessary to suspend pressure for two days, the effect of which was to lose nearly one-half of the advantage gained, which appeared very promising at the time of the discontinuance.

Pressure was resumed at the same point, but could not be made to the same degree from tenderness of the integument, and was only sufficient to prevent a complete relapse.

Pressure was now removed to the external iliac artery where it crosses the pectineal eminence. It required, however, a greater amount of power to produce the same effect, increasing thereby the danger of sloughing.

The principle kept in view thus far had been to retard the current through the sac, that the deposition of laminæ of coagulum might take place gradually. This failing to occlude the sac, after having been fairly tried, and it now being evident that pressure could be maintained but for a short time, it was decided io try the effect of stopping the circulation through the aneurism. The increased pressure caused severe pain, and required large doses of morphia to enable the patient to bear it, which he did for fifteen consecutive hours.

The cedema of the limb increased, and upon the removal of pressure the bruit could be heard faintly at the upper part of the tumour, nearly over the mouth of the sac; but pulsation was not apparent, the tumour being hard and elastic. At the expiration of the following twenty-four hours the pulsation returned, though pressure had been continued at intervals sixteen hours of this time. Forty-eight hours from the time when pulsation ceased

pressure was abandoned from the irritability of the compressed surfaces. This is to be regretted, as more progress had been made during that time than in the eleven previous days.

As a last resort before operating, flexion of the thigh upon the abdomenn was tried. This controlled the circulation completely, but it also had to be abandoned after six hours, the patient suffering more during this period than from any of the previous methods employed. These forms of treatment had been continued for twelve days, and during more than half of this time the arteries were undergoing compression.

The patient complaind of no pain in the tumour or limb at this time, and his general condition was even improved. The measurement around the thigh over the site of the tumour was twentytwo inches, no diminution having followed the treatment. The amount of effusion around the lower part of the tumour increased out of all proportion to that in the remainder of the limb, and it was considered certain by some who examined it that the aneurism had become diffused. Nothing in the appearance of the patient occurred to indicate so grave an accident other than the enlargement, which subsequently disappeared, showing the circumscribed character of the tumour.

April 14, 1874. Dr. Gay, in the presence of a large number of medical gentleman, ligated the external iliac artery. The "operation from below" (Cooper's) was the one chosen. When the peritoneum was reached it very much resembled the transversalis fascia, being thickened and opaline in colour, due to the pressure made upon the external iliac artery, giving rise to circumscribed inflammation at that point; owing to this abnormal appearance the peritoneum was wounded. The pulsation and bruit ceased immediately after the ligature was tightened.

The wound was closed by a few interrupted sutures, none of which, however, included the peritoneum where it was wounded. Patient rallied well from the operation; felt a pricking or tingling sensation in his instep and ankle, extending to the knee; the limb did not change its colour, and only half a degree difference in temperature was shown by the thermometer in the popliteal spaces; no increase of the ædema followed; warmth was applied to the limb by means of bottles of hot water, which was grateful to the patient; the whole surface of the abdomen was covered with a poultice of hops; opium and stimulants being freely administered. No tympanitis or signs of general peritonitis followed; around the margins of the wound it was very tender, showing the existence of circumscribed inflammation. Primary union was obtained in the upper part of the wound; sutures were removed the fifth day; lower portion of wound gaped; the edges were approximated by flexing the thighs and raising the shoulders, which also allowed a more free escape of pus.

Two days after operation, the measurement around thigh, over

the tumour, was eighteen inches, being a reduction of four inches. in circumference. No pulsation could be distinguished in any of the arteries of the limb. The pricking and burning sensations continued throughout the treatment, being at times actually painful. The ligature came away on the fourteenth day, after which the wound rapidly healed.

Five weeks after operation, patient was able to be out of doors, but was obliged to use crutches on account of a slough upon the the back of the heel, the size of a silver dollar, and another upon the great toe. The former penetrated to the bone, and it was, on this account, four months before he could walk without the assistance of crutches.

No signs of suppuration of the contents of the sac followed the ligation; the sac being of a firm, elastic consistence, and free from pain. The measurement of the thigh, at the site of tumour, further diminished to 17 inches in circumference, being the least it reached; the thigh after this became more fleshy.

The tumour itself continued to be absorbed, so that its circumscribed form could be more distinctly defined. When patient left hospital, October 1, 1874, it was of the dimensions and shape of the umbrella portion of a moderate sized mushroom. It caused but slight enlargement at that part of thigh, and would not be noticed in a casual observation.

The cicatrix of the upper part of the wound, at which point the peritoneum was divided, appears weak. Patient wore a compress and bandage while in hospital, but was advised on going out to wear a truss, as a precautionary measure to prevent hernial protrusion. Some authors refer this sequel to not including the peritoneum in the sutures, which, as before mentioned, was not done in this case. Hernia followed from a similar cause, in an otherwise successful case, where the external iliac artery was tied by Mr. Kirby.*

The results of this case show the beneficial influence of pressure, and furnish evidence of its value, and sufficient reason why it should be employed in all cases of aneurism when practicable. Had this aneurism been of smaller size compression would probably have superseded the necessity of ligating the artery; or, with an aneurism of the same size, and a greater area upon which to make a pressure, there is reason to believe that compression alone would be attended with success.

It corroborates the views of Holmes in regard to the influence of compression in more speedily promoting the new circulation. The apparatus used in this case answers the purpose of the various and expensive contrivances used, and is within reach of any one of moderate mechanical ability.-American Journal Medical Sciences, January, 1875.

* Manual of Operations of Surgery, by Joseph Bell, F, R. C. S.

Report of a Case of Inversio-Uteri of Two Years' Standing, Reduced by Taxis; with Remarks.

BY B. F. DAWSON, M. D.

On the 6th of January last, Mrs. R. was sent to me by Dr. Jeffrey Bourke, of this city, with the view of confirming his diagnosis of her case, and for advice as to her treatment. The pa tient was a naturally strong woman, aged thirty-eight years, and the mother of five children. Her illness dated from the birth of her last child, two years ago, of which the following is the account, as given by herself and husband:

On February 5, 1873 (two years ago), she was taken in labor with her fifth child, which was born in four hours without assistance or trouble. In delivering the after-birth, however, her physician caused her considerable pain by pulling upon the cord, of which she complained, and when he persisted she cried out to him repeatedly to stop; at the same time she was losing blood freely. She soon lost consciousness, and her husband and family thought her to be dying. For several days after she was so prostated that she was not expected to recover, even by her physicians. She continued to lose blood freely, and a large mass or tumor protruded from the vulva, requiring repeated efforts at reduction. Her water, also, had to be drawn off for a couple of weeks. In about three weeks after the birth of her child she began to improve, losing less blood, and having less pain. In the mean time she had used vaginal washes and injections ordered by her physicians, and which seemed to control the bleeding considerably. Thus matter remained for about a year, with, however. a yellowish discharge throughout, and occasionally clots of blood. The protruding tumor also gave her considerable trouble, coming down repeatedly on the slightest effort, and requiring her to lie down and have it replaced by her husband. In February, 1874, a year after the birth of her child, the hæmorrhage returned with great severity, and continued without abatement until April, when it intermitted for a few days; again recurring, however, profusely for several weeks. The patient in consequence became rapidly exhausted to such a degree as to be unable to raise her head off her pillow. Her physicians again attempted to control the hæmorrhage by injection and tamponing the vagina with cloths, but to no avail. Her condition continued thus until last November (1874), when she was seen by Dr. Jeffrey Bourke, of this city. After an examination of her, he expressed to her physicians his opinion that she was undoubtedly suffering from inversion; and again in December he adhered to the same opinion, and advised a consultation with others for treatment. With this object he consulted me about her, and at my suggestion and advice she came to this city. From the time we saw her in November to the date of my first visit she continued to lose blood, but had gained some

what in strength. As already stated, she was seen by me January 6, 1875, and on careful examination I found her suffering from complete inversio-uteri. The uterus occupied the entire vagina, was firm to the touch, bled readily, and was exceedingly sensitive. The ring formed by the vaginal portion of the cervix was thin, and did not constrict the tumor to any great degree. In all respects the case seemed one not likely to afford great trouble at reduction, and accordingly I felt safe in expressing my opinion to the patient and her husband that she could be cured if she would submit to treatment. The diagnosis and above opinions were concurred in by my friend Dr. Munde, who saw her at the same time with me. After some persuasion she consented to place herself under my treatment, notwithstanding her friends urged her strongly not to risk her life by an operation. The following day, at my request, my friend Prof. T. G. Thomas examined the case, and expressed the opinion that it was a case favorable to success in all respects, notwithstanding the existence of the inversion for so long a time as two years.

On January 13th, the patient being etherized, and having used hot vaginal injections for the previous week, I made my attempt. My efforts I had determined to confine wholly to taxis, one hand in the vagina embracing the tumor within the fingers, and thus forcing them up within the ring, dilating the latter and carrying the cervix uteri up, at the same time making counter-pressure through the abdominal walls, as a centre to press against as well as to guard against rupture of the vagina. In these efforts I was relieved when tired by Drs. Bourke and Henry Nicoll. After two and a half hours no success of any amount attended our efforts, and accordingly the patient was replaced in bed, it being decided best not to subject her too long to the influence of anæsthasia, or the uterus to prolonged manipulation.

On January 16th, three days after, I prepared for a second attempt, but, after manipulating for two hours, the uterus became oedematous, and, with the concurrence of Drs. Nicoll and J C. Jay, Jr., it was deemed best to desist, and give the patient a few days' rest, and subject the parts to the influence of a constant use of hot vaginal douches. After both these attempts there was a slight elevation of temperature, some pain, very slight discharge, and no vomiting. By the use of quinine and morphia the fever and pain were controlled, and nourishing diet kept up the patient's strength.

On January 18th, I essayed a third attempt, but soon found it would be to my advantage, as well as to the patient's, to subject the uterus still longer to the action of hot water, as it was still coriaceous and doughy in feeling. A full week was given the patient, and on January 25th, efforts were again renewed, in like manner as before, excepting that I essayed the use of Dr. White's inversion repositor, but laid it aside for reasons to be hereafter