liable to use them to excess as other drinks. Where constipation occurs, the bowels should be kept open with some laxative pill, or with the eccoprotic mixture in small doses. If diarrhœa occurs, it should be restrained by opiates and the cretaceous mixture with mild astringents. If these remedies, and the diet above pointed out fail of arresting the difficulty, the patient must cease nursing before it goes to the extent of endangering her recovery. The avoidance of fluids should be strongly insisted upon where there is sore mouth, and in case of excessive lactation, or all our remedies will prove ineffectual. This is the more important, as the thirst is frequently as great as in diabetes, and very difficult to allay.

Local applications to the mouth rarely do good, unless the condition of the digestive organs is first improved. The most useful remedies are the solutions of sub-muriate of soda, sulphate of copper, and the nitrate of silver.

Rising loo soon from Bed after Confinement.-The uterus and its appendages are always, after confinement, in a state which disposes them readily to disease, and perhaps, no one thing so frequently gives rise to morbid affections of these parts, as the patient being permitted to get on her feet, and walking too soon after delivery. The congested and sub-acute inflammation sometimes affecting the muscular tissue of the uterus, at other times the mucous membrane of the organ, and of the vagina; those painful affections denominated hysteralgia, which several diseases, in popular language, are known under the general term of falling of the womb, are commonly the consequence of this injudicious management, and months and years of suffering are entailed upon the patient by her own folly or that of her attendants. As a general rule, it is better to keep the patient in a reclining posture for ten days or a fortnight after the birth of the child. At the end of which period she should be permitted to sit in a chair, and at the end of three weeks she should be allowed to be on her feet for a short time. If there is a tendency to disease, or if it has previously existed the patient should be kept in a horizontal position till the expiration of a month or six weeks.

PART SECOND.

Critical Analysis.

ART. XIII. Observations on Aneurism and its Treatment by Compression.--By O'BRYEN BELLINGHAM, M. D., Edin., Professor in the School of the Royal College of Surgeons in Ireland, 12mo., pp. 181, London, 1847.

OUR thanks are due to the distinguished author of this very able and comprehensive treatise on the treatment of aneurismal diseases by compression, for sending us an early copy, and we beg to assure him that we have read it with great interest and satisfaction. We present

a brief analysis.

The treatment of aneurism by compression is not of modern origin. Its early history, indeed, is intimately mixed up and associated with that of the treatment of wounds of arteries. In some cases the pressure was applied to the aneurismal sac, and the artery leading to it; sometimes to the capillary side of the tumor, and in some instances the entire limb was at the same time compressed. The pressure was effected, in some cases, by compresses and tight bandages; in others, the compresses were soaked in styptics, and plasters of various kinds were applied; or the compression was maintained by the use of instruments or apparatus of various forms and construction.

These several methods may be comprised under the following heads :

"1. Where the pressure was applied directly upon the aneurismal sac. "2. Where the pressure was applied to the aneurismal sac, and the entire limb was at the same time compressed.

"3. Where the compression was applied to the artery between the aneurismal sac and the heart.

"4. Where the pressure was applied to both the aneurismal sac and the artery upon the cardiac side.

"5. Where the pressure was applied to the distal or capillary side of the aneurismal sac.

"6. Where the aneurismal sac was laid open, and the pressure was applied upon the ruptured or wounded vessel,

7. Where the artery above the aneurism was laid bare, and the pressure was applied directly upon it."

It appears that compression, when first employed, was always applied immediately upon, the aneurismal sac, and undoubtedly originated in the use of compresses, bandages, and similar appliances in cases of accidental wounds of arteries. The first form of aneurism in which compression was employed was traumatic tetanus, as that

caused by the accidental wound of an artery in venesection. This was a very frequent accident in former times, as in the 16th century surgeons were compelled by law, in France, to pension those whose arms they had injured in bleeding. We find John Bell using the following language also, in his "Principles of Surgery:" "Our Legislature does not prevent the most ignorant from meddling with a profession which should be sacred as the priesthood. Masons, butchers, gardeners, cowherds, are among the chief phlebotomists in this country; and it is to them we are indebted for the various specimens of aneurism." If we consult the older writers in respect to the treatment of wounds of the brachial artery in venesection, we find them recommending compresses, bandages, styptics, plasters, &c., and copious directions are laid down as to the mode of applying them. According to Sprengle, Jean de Vigo, a physician of Genoa, was the first to conceive the idea of curing aneurisms by compression. He used compresses of charpie wet with styptic solutions, which were applied to the aneurismal tumor, and maintained by bandages rolled tightly round the limb. Galen, however, speaks of having cured an aneurism at the bend of the arm by means of sponge and bandages, and there is good reason for believing that this mode of treatment was successfully employed at a still earlier period.

Compression was, however, limited to traumatic aneurism as a mode of cure, until the end of the 17th century; and it seems to have been employed, moreover, only in cases where the tumor was small, the aneurism recent, its contents fluid, the skin uninflamed, and the disease located in the brachial artery, or some of its branches. The pressure was always applied directly upon the aneurismal sac, and the arm was firmly bandaged; styptics and plasters were generally used at the same time; the arm was confined to the side, and the patient was kept upon a cooling regimen, and occasionally bled. Surgeons formerly supposed that the pressure not only prevented the further dilatation of the artery, but pressed the blood contained in the sac again into the vessels; that the edges of the wounded artery were also brought into apposition, and adhesion took place; so that the channel of the artery was preserved, and on the discontinuance of the compression, the blood passed down the artery as before the injury. The tourniquet was invented about the beginning of the 18th century, and since that period many new forms of compressing instruments have been introduced, an account of several of which was given in the last (May) No. of our Journal, pp. 385-6. Besides these, various forms of compressing bandages were introduced, and all were employed as well in recent wounds of arteries as after the formation of an aneurism; but down to the middle of the 18th century, this mode of treatment was limited to the brachial artery and its branches, or to small arteries in other situations, and to cases where the aneurism was small and of recent occurrence. If the tumor was large, the sac was laid open through its entire length, the coagula and fluid blood removed, the artery tied above and below the opening, the wound filled with charpie, and bandages and compresses applied.

The treatment by compression was extended to popliteal aneurism, by Heister, who cured an aneurism of the femoral artery, produced by a punctured wound, by filling the wound with charpie, laying a number of thick compresses over it, placing another compress along the course

of the femoral artery, and then bandaging the whole limb tightly; an oval metallic plate being applied over the compresses and retained for two months.

Guattani, an Italian surgeon, was the first (about the middle of the last century) who succeeded in the attempt to cure popliteal aneurism by compression; and he was induced to revert to it, partly from the success which attended the employment of pressure in aneurism at the bend of the arm, following venesection; and partly, from his having witnessed a spontaneous cure in three cases of popliteal aneurism; but principally, from having witnessed the great fatality of aneurism of this vessel, and the unfavorable results of every operation for its relief. In the cases treated by Guattani, the chief pressure was made immediately upon the aneurismal sac, and the entire limb was at the same time compressed by bandages, rollers, &c. The patient was frequently bled, placed upon low diet, and confined to bed during its employment. In short, it was only an adaptation of that in general use in brachial aneurism, combined with the medical treatment proposed by Valsalva and Albertini for internal aneurism. He supposed that the pressure diminished the rapid motion of the blood in the vessel; checked the further increase of the aneurismal tumor, and caused the gradual resolution of the contents of the sac into serum. Thus, as the tumor subsided, the ruptured artery was healed, and became fit to convey the blood to the leg and foot.

The objections to this mode of treatment are sufficiently obvious. The process was very tedious and painful, and the result uncertain. The pressure upon the aneurismal sac tended to cause its rupture, and to convert a circumscribed into a diffused aneurism; or to give rise to inflammation and suppuration in the sac, and perhaps occasion gangrene of the limb. These results often followed, but they were not much dreaded, inasmuch as where suppuration followed, the aneurism was sure to be cured, provided the patient had sufficient stamina to hold up under the tedious process. The chances of recovery were even greater than after the operative proceedings. The frequent occurrence of gangrene was owing to the compression and obliteration of the collateral vessels about the knee, to obliteration of the vein over the sac, and the pressure made upon the large nerves of the part.

This mode of treatment of aneurism, appears to have failed in more than half of the cases. When it failed, the disease seems always to have been the cause of the death of the patient, except in a few instances where the limb was amputated. When the treatment succeeded, the artery at the seat of the aneurism was undoubtedly obliterated, although the main object which the surgeons had in view in employing compression, was to avoid this very occurrence; supposing that the aneurismal sac was a bag distended with blood; that the pressure had the effect of squeezing its contents back into the artery, when the edges of the wounded or ruptured vessels came into contact, and adhered as in wounds of other parts; and that on the discontinuance of the compression the blood returned to its original channel, and the limb was nourished as before its employment.

John Hunter's first operation for popliteal aneurism took place (1785) only thirteen years after the first appearance of Guattani's treatise on this subject; but, in the mean time, several cases of cures

The

by the former treatment were reported by different surgeons. simplicity of Hunter's operation, the facility with which it was performed, and the success which attended it, when contrasted with the ancient method, led, in a great measure, to the discontinuance by British surgeons of compression in aneurism of the large arteries; and to the almost entire discontinuance of the mode in which it had previously been used. Pressure was no longer made upon the sac; when employed at all, it was applied upon the artery between the aneurism and the heart. Compression was, however, never entirely laid aside, as the Hunterian operation sometimes failed, and occasion. ally an aneurism was so situated that an operation was impracticable. The principle on which pressure was applied at this period, was to endeavor to excite inflammation of the coats of the artery, at the seat of its application, so that coagulating lymph might be thrown out, and adhesion of the coats taking place cause an obliteration of the artery. This pathology was established by the experiments of Mr. Freer of Birmingham in 1806, who recommended a trial of compression in all cases of aneurism which admit of its application; the pressure to be made upon the sound side of the artery, for the purpose of causing adhesion of the sides of the vessel. Cases of popliteal aneurism, successfully treated in this way, were reported by Pelletan in 1810, (Clinique Chirurgicale), by Dubois in the same year, (Bull. de la Faculté de Medicine), and Dupuytren in 1818. Similar cases may also be found in Boyer's Surgery, (1818).

Where this treatment was resorted to by British surgeons, the pain from continued pressure was so severe that the patients were unable to bear it, and it was therefore speedily discontinued. Dupuytren concluded, from his experiments and observations, that there are individuals who cannot bear compression, whilst there are others who support it without inconvenience, and that this is the only reason of the different results of compression as applied to the treatment of

aneurism.

Compression, however, as a mode of treating aneurism never had many advocates in Great Britain. Dr. Colles, in his early lectures, recommended amputation, and after Hunter's operation was introduced the ligature was almost solely relied upon, and its superiority over every other kind of treatment was taught and enforced both by reasoning and example. Among the earliest recorded cases, are those of Mr. Todd, in the 3d Vol. Dublin Hospital Reports, 1822. The apparatus employed resembled a truss for femoral hernia, the spring of which was much stronger, and the pad longer, of a more oval form, and more firmly stuffed than in the truss. The pad was furnished with an inner plate of iron, which was connected with the outer iron plate by means of a hinge close to the junction of the outer plate with the spring; and a tourniquet screw, passing through this plate, had the effect, when turned, of making a greater or lesser degree of pressure with the pad on the part to which it was applied. The instru ment was put on like a common truss, the pad being placed in the line of the crural artery, immediately below Poupart's ligament; and it was kept in its place by a strap which passed from the spring of the truss behind, and buttoned in front on the outer plate of the pad. This instrument seems to be that described and employed by Heister, Albers, and others.