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applied to the wound with pressure, and succeeded partially in stopping the hæmorrhage.
Between eleven and twelve P.M. I saw him for the first time after the operation, and found him very low from the loss of arterial blood, which had been considerable; but at this time there remained only an oozing from the coagula, lying at the upper part of the wound.--R. lig. plumbi acetat. zi. aquæ zvj. M. Lint and cloths moistened in the above lotion were applied to the wonind, with directions to make pressure with the hand if the bleeding should return; the room was kept cool, and the patient ordered to be perfectly quiet.
June 15, 16, 17, and 18. Bandages were applied round the body to produce different degrees of pressure on the part, but without any apparent advantage, as the bleeding returned at short intervals.
19th. A steel truss was applied with a screw to the pad, by which the pressure could be greatly increased ; ihe pad of the truss was large, and applied immediately over the course of the external iliac artery, the lower part reaching to the edge of Poupart's ligament. This produced great pain, from the pad imbedding itself in the wound, without com. pletely restraining the bæmorrhage, which returned several times during the 20th, 21st, and 22d ; rather profusely on the latter day.
The pad of the truss had, by the 22d, completely embed. ded itself in the soft parts, producing great constitutional irritation.
23d. At eight A. M. the hæmorrhage had been profuse, the stream of blood very large, and evidently arterial : it could not be stopped by pressure.
Five A.M. It was now agreed in consultation to remove the truss, and if possible to expose and secure the bleeding artery.
Pressure was made upon the primitive iliac artery, and the truss removed. The pad had destroyed the integuments, muscles, and tendons, and completely emhedded itself in a large cavity extending nearly to the iliacus internus muscle. The surface of the cavity was a confused mass in a slough, ing state. *
The epigastric artery appeared ulcerated near its origin, having been destroyed by the pressure of the truss.-An in,
* The author of the paper in your last Journal is so little acquainted witb Che real history of the case, that he speaks of the hæmorrhage as occuring « at the expiration of some weeks from the application of the truss." He ought to have informed himself that the truss only remained on between four and fue days
cision of about two inches in length was made through the integuments and muscles, from the upper surface of the wound towards the superior margin of thé ilium in the direction of the fibres of the external oblique muscle.--Little hæ. morrhage followed the complete exposure of the wound. A ligature was now made on the iliac artery, but still some bleeding was observed to come from a small vessel in the di. rection of the spermatic artery. This was taken up with the tenaculum. The ligature which had been passed on the iliac. artery was removed, at which time a tingling sensation was experienced down the thigh in the course of the crural nerve : one suture was passed in that part of the wound where the incision had been made. The wound was dressed with lint moistened in a lotion of some water, acid, and camphor.
The woand suppurated kindly ; the discharge was very considerable; the contused parts separated ; the ligature came away in a few days; the granulations appeared healthy, excepting in one part immediately over the iliac artery, where a kind of downy appearance was seen on the granulations, which were of a pale colour. This disappeared gradually; the wound filled up with healthy granulations, and at the end of three weeks required to be dressed only every second day, the lower part being now completely healed.
During this period a nourishing diet was allowed, some bark had been taken in Port wine, and occasionally an aperient medicine, the general health and strength were much improved, so that on the 15th of July, the patient could be raised in the bed, and held up in nearly a sitting posture for some time. This change of position was repeated several times on the 16th, and seemed to give additional strength, the wounds on the back and lips had become very painful, from lying so long in one position. On the 17th he was lifted out of bed and placed in a chair, the body inclined forwards on a pillow laid on a table.
This change of position agreed well, and was repeated two or three times each day; the general health was much improvedt, but some swelling of the legs took place, parti. cularly about the ancles; pain was felt down the inside of the thigh in the course of the Sartorius muscle ; there was also an irregular, hard, knotty line, extending in the same direction, very painful to the touch ; this line was longest and most painful near the groin.
The wound continued to heal and look healthy, the hardness and pain on the inside of the thigh gradually subsided. A nutritious regimen, bark infused in wine, and aperients were continued; when his cough (to which he was very lia.
ble) was troublesome, he took misturæ ammoniaci cum tinct. digitalis.
On the 5th of August he appeared as well or rather betler than usual, but I observed that the granulations looked pale, and that the edges of the wound had an irregular appearance, which had not been seen before ; he sat op near ten hours during this day, went to bed as well as usual, and had a tolerable night. - On the 6th, soon after he had been lifted out of bed, the wound began to bleed, but not profusely; he was immedia, ately put to bed again, lint and cloths moistened in cold water were applied to the wound; this succeeded in stopping the hæmorrhage, and the qnantity of blood lost (which was arterial) was not more than from 4 to 8 ounces. On removing the cloths and lint there was a small coagulum at the bottom of the wound immediately over the iliac artery, at least two inches from the part where the ligature had been applied on the small artery on the 230 June. Pledgets of lint, moistened in a similar lotion to that ordered on the 14th of June were applied to the wound, he was laid on his back, the knees raised. No bleeding during the remainder of this day.
In the evening, on removing the lint the coaguluin was separated and a small sinus observed at the bottom of the wound over the iliac artery. A probe introduced about an inch deep in a direct line to the artery had a distinct pulsating motion communicated to it.
The pulsation in the femoral artery through its whole course had continued the same as in the other thigh during the whole confinement.
August 7. He had slept a little during the night, but suf. fered much this morning from the position of the body, which had not been changed, he had also great pain in his left side with difficult respiration.
Bottles of warm water were ordered to be applied to his side, and a mixture of the liquor ammoniæ acetat. cum syrup..' papav. alb. to be taken frequently.
August 8. From this time to the 26th September the ori. ginal wound often granulated in a healthy manner, and even, seemed disposed to cicatrize, yet his general health gradually declined, he became bectic and even anasarcous, with those deceitful intermissions which so often occur in these cases. The wounds in his back assumed an unfavourable aspect, and bis cough and expectoration encreased. From the 26th to the 30th he became much worse, respiration was short and painful, the granulations looked flabby and pale, and the edges a little irregular, the hands were somewhat swelled.
October Ist. Much worse, respiration very short and painful, the countenance indicated a speedy dissolution.
October 20.-2 A. M. After a restless night he is a little revived, but in the whole much worse than he was yesterday. Died at 1 P: M.
Examination after Death. October 3d. The abdominal viscera were healthy, ex:' cepting some adhesions between the intestines and the peritoneum : in the left inguinal and iliac regions, the peritonelim, iliac artery and vein were united by a dense substance, evidently the effects of extensive and active inflammation The iliac'artery was obliteraied from within halt an inch of the internal iliac to the under part of Poupart's ligaient about Si inches in extent.--The arteria profunda was given off, high up, near Pou part's ligament, and neither that nor the femoral artery appeared to have undergone any change at that part.
• What appears to me to deserve particular attention is, that the pulsation of the femoral artery at the under edge of Poqpart's ligament, and below, never suffered any change in strength or frequency from that which was observed in the artery of the right thigh.
The iliac vein 'was obliterated from a little above Poupart's ligament for one inch and balf downwards, which was the part where the vessel was divided, bence it could not be as.. certained how low the obliteration was contingel.
Is it not probable that the obliteration extended along the femoral vein, and that the pain, and the irregular knotty line, wbich was observed on the 17th of July, and following days, in the direction of the Sartorius muscle, were occasioned by the obliteration of this, and the Saphenæ major veins ? : The experiments of Dr. Jones tend to prove, that the obliteration of an artery must be preceded by inflammation. Whether this inflammation is produced by injury done immediately to the artery itself, or to the surrounding parts, and from them communicated to the artery, cannot be of importance, if, as Dr. Jones supposes, the whole effect is produced by inflammation. · In this instance there cannot be any reasonable grounds for attributing the obliteration to the ligature, especially as the iliacand femoral veins were obliterated without any ligature, and also as the inflammation, ulceration, and destruction of parts produced by the pressure of the truss in the neighbourhood, and upon the obliterated Vessels, were much more than sufficient to explain the event. It is very far from my wish to undervalue Dr. Jones's labours, or the conclusions he draws from them, they are supported by experiments, and, in my opinion, would not receive aid from any inference drawn from the preceding case.
I Request you will insert, in your widely circulated Joure nal, the following statement. It is meant merely to put in my claim to a discovery, 'without the least oftence intended to Mr. Ramsden.
Yours, &c. Dean-street, Soho, Dec. 15, .
JESSE FOOT. 1810.
· ON perusing the Table of Contents in Mr. Ramsden's late Publication, my attention was particularly arrested by the following article. « Description of a Membranous Fence at " the Aperture of the Urethra hitherto UNNOTICED; a com. mon cause of elerangement of the Urethra.” And on coming to page 36 of the work, which is referred to by the Table of Contents, the explanation of the discovery, so important in Mr. Ramsden's opinion, commences with the following paragraph :
.* There is, however, another cause which is very commonly productive of that derangement of the urinary passage now under consideration, and which I believe has not been noticed, viz. an unnatural diminution of the external opening of the urethra.
" In the majority of persons who apply for assistance under complaints of the testicle or of the urethra, which are not to be traced to gonorrhæal inflammation, the urethra will be found to be more contracted at its orifice than at any other part of the canal. This state of its extremity is very different from the stricture which is sometimes situated iminediately within the aperture, as well as from that appearance of this part, which is called the blind urethra. i « The diminution of thic orifice of the urethra is occasioned by a membranous fence, which partially closes up the lips of the extremity of the canal; it may sometimes be an original mal-formation : yet I apprehend it is for the most part produced by cohesion during infancy, and is analogous to the union we sometimes see between the prepuce and glans penis of the male child, and between the nymphæ in the fomale. .
“ Unimportant as this diminution of the extremity of the urethra may at first appear, many valuable facts may be deduced from it. It is the only instance, I believe, in which
an immediate cause of spasmodic stricture in that canal can .: (No. 1:13.)