and, with the exception of another hæmorrhagic drain on the 24th, nothing untoward occurred till the 26th; the patient in fact appeared convalescent.

"I must here crave your attention to a few passing remarks on the history of this case, since the 14th, the date of last bleeding. I mentioned that at the consultation of the 5th, a kind of qualified permission was by the majority given, to throw a ligature round the external iliac artery, if hæmorrhage again occurred from the same spot. The qualification was, if the bleeding was distinctly observed to proceed from the trunk of the femoral artery. I need not inform any of you, how much opinions on this point changed, from the 5th to the 14th, or in other words, how eight days of calm and convalescence strengthened the impression, that such a formidable operation was quite unnecessary, and also the opinion that a small arterial branch only had given way, which time and perhaps compression would cicatrize. For this reason I did not proceed to the operation on the 14th, though much inclined, but rather preferred the sanction of another consultation to abiding by my own conviction, and notwithstanding the result of the consultation, as reported on the 15th, I still had the satisfaction of having done my duty. It may be said, that timidity rather than caution prompted me on this occasion, and I am free to confess that I had fearful forebodings of the result, for the reasons which shall hereafter be detailed; but a paramount feeling of duty to my patient, absorbed at this stage of the case, every other consideration. After the consultation of the 15th, however, I as it were resigned the case into other hands, and from this period ceased to look upon it as of the same interest, for I felt that no sooner had I made up my lee-way by the exhibition of tonics and stimulants, than all must again be lost by another and a more fatal hæmorrhage. True it was, I could not positively affirm that it was the femoral artery, in consequence of the soft, friable and sloughy state of the wound-true it was, I could not very satisfactorily, or according to any of the known rules of surgical pathology, explain the meaning of such

long intervals of hæmorrhagic repose, or the process by which, so frequently, nature in this remarkable case, formed for herself a plug, in so large an arterial conduit; still, I was not singular in this opinion, founded as it was on the observation of nature's resources in aneurismal cases, and as the result will show you, I had the misfortune to be right-but you observe, with what diffi culties I had to grapple, and against what odds I had at every step to contend. The application of lunar caustic, and the finger to the soft flabby granulations, over the hæmorrhagic spot, were resorted to, merely to assist in forming a coating of lymph, and prolonging the interval of repose, and from the success which had previously attended these efforts, I meant, (but for the event which I am by and by to detail,) to have continued them for some time longer."

On the 26th these favourable appearances were at once destroyed by another bleeding. At 3 a. m. arterial hæmorrhage again occurred from the sloughy spot already mentioned, but was immediately commanded by the finger, and not above ii. of blood were lost. A consultation was called at 6, a. m. when, compression having been removed that the wound might be examined, the arterial gush instantly took place, apparently from the femoral artery, exactly over the spot whence all previous hæmorrhage had issued, but it was at once arrested by the finger. The vessel and sheath seemed to be in a soft friable state. The pulse was firm, and he was not depressed.

"The consultation, which consisted of Drs. M'Farlane, Weir, and Auchincloss, being unanimously of opinion that the external iliac artery should, without further delay, be secured by ligature, the operation was performed in the following manner :-I made an incision from outer opening of inguinal canal, to about half an inch from anterior superior spine of ilium, about an inch above Poupart's ligament. first incision was straight and carried through skin and cellular substance. The superficial fascia covering external oblique muscle, was then divided upon the director through whole extent of

The

wound, and the fibres of external and internal oblique were thereafter incised in a similar manner, exposing fascia transversalis and peritoneum. I now introduced my finger into wound, and with my nail detached with ease the peritoneum from sheath of external iliac artery, to the extent of about threefourths of an inch, and having now passed the common aneurismal needle under it, from within outwards, armed with a single silk ligature, I secured the vessel by a double knot, carrying the ends on the points of my fore-fingers to the bottom of the wound, which was nearly an inch in depth. Pulsation and hæmorrhage were instantly arrested, and one end of ligature being allowed to remain, lips of wound were approximated by a stitch in centre, and adhesive plaster. He bore the operation well, and though it lasted about twenty minutes, not two ounces of blood were lost."

Into Dr. Buchanan's reasons for modifying the operation in the manner in which the well-informed reader will perceive that he did, we need not enter. Until March 1, when pulsation was first perceptible both in the femoral and popliteal arteries, nothing of any moment occurred. The patient was moderately supported. At 7 o'clock of the morning of the 2d, hæmorrhage again occurred from the same spot as before. Only one ounce of blood was lost, the little patient making immediate pressure himself. Till the visit hour at halfpast one o'clock compression was steadily maintained.

"When visited about half-past one o'clock, it was evident that collateral circulation had become completely reestablished, directly through femoral artery upwards to inguinal, from the gush of arterial blood which had taken place at two different periods since 7 o'clock, on attempting to remove the finger from the hæmorrhagic spot; and also from suppression of bleeding and pulsation, by compression of femoral artery, on the distal side of place whence blood issued. On this account, with the concurrence of my colleague, I proceeded to throw a ligature around the femoral artery at the place, where compression arrested the reflux channel. For this purpose, the patient was placed

in the same position as in the operation of the 26th, the finger of my assistant during the performance of the operation being kept firmly applied over bleeding spot. I then made an incision about 14 inches in length, in a slanting direction, from border of fascia lata, towards inner side of sartorious muscle through skin and cellular substance. Femoral fascia was now incised in centre of wound, a director being introduced, first upwards, then downwards, and the membrane divided upon it with a scalpel. Cellular substance between this last and fascia propria was now cautiously cut, the artery separated from the vein, isolated to about onefourth of an inch, an aneurismal needle armed with a single silk ligature passed under it and tied, one end being cut away close to vessel, and lips of wound approximated by straps of adhesive plaster. The operation occupied about ten minutes, and was almost bloodless. Trusting to the report of the young gentleman who made compression with the finger over the bleeding spot, I tightened the ligature, and secured the femoral at the spot above-mentioned, but most unfortunately, on attempting to remove the finger of the assistant, the gush of arterial blood was as copious and furious as before. The application of the actual cautery, button forceps, and pelvis tourniquet were now thought of, but as soon abandoned. Compression having been applied between the ligature, around femoral artery, and bleeding spot, it was found, that both pulsation and hæmorrhage were by this means instantly arrested, though there were not seemingly above two inches between the above situations, and more than the half of this intervening and interesting part of the arterial conduit, was covered with soft blue flabby ulceration. For the above reasons I determined, with the assistance and concurrence of my colleague, to take up the inguinal artery as near the spot where hæmorrhage had appeared as possible, without running the risk of intermeddling with the soft and diseased part of the tube. For this purpose I made an incision from superior termination of former one, upwards through cicatrix of ulceration, and by this means exposed

falx of fascia lata, I now introduced my director under this last and Poupart's ligament, and with my bistoury incised both upwards to the necessary extent; my finger now easily traced inguinal artery to within about half an inch of bleeding spot, and finding it, as I thought, in a sound state, proceeded to isolate it from the vein and anterior crural nerve, and with ease passed the aneurismal needle, armed as before with a single silk thread, on tightening which, pulsation and hæmorrhage were instantly arrested. In this last operation, which did not occupy more than two minutes, as little blood was lost as in the former one, and the after dressing was conducted in the same manner.

It was remarked by the little patient that not only during last night, but on every previous occasion immediately preceding the hæmorrhages, he had a presentiment of what would occur, both from a peculiar restlessness, and also from being annoyed with unpleasant dreams."

During the night, the patient was restless and incoherent. On the 3rd, no pulsation could yet be detected in the femoral or popliteal artery-the left limb was colder than natural-pulse 144 and weak. He took wine and wa ter. On the 4th the pulse was 144, jarring and hæmorrhagic. During the preceding night, he had had a rigor of about a quarter of an hour's duration, a certain harbinger of death. In the night of the 4th he had another rigor, and in the afternoon of the 5th another. On the 6th, pulsation had returned to the popliteal artery. His strength now gradually gave way; there was profuse discharge from an abscess on the dorsum of the ilium, and a sore upon the sacrum, and yet, under quina and support, he again plucked up. The femoral and abdominal wounds produced by the operations rapidly cicatrized. On the 12th (10th day), the ligatures were detached from the inguinal and femoral arteries. On the 13th he began to be affected with dry tickling cough and uneasiness of chest, the pulse was 140, abdomen somewhat tense. In the following evening he vomited his wine

and arrow-root, sank rapidly, and died in the afternoon of the 15th.

"Post-mortem Appearances.-Contents of cranium, thorax and abdomen, having been examined, were found perfectly natural. A wax injection was thrown into left common iliac artery downwards, and into popliteal artery upwards. Abdominal viscera having been entirely removed, peritoneum lining the abdominal parietes was found to be in every part entire, and on sliting it open, from bifurcation of common iliac to left groin, over course of external iliac artery, this vessel was found injected only about two inches in its progress, the remainder of the artery downwards having degenerated into a soft substance, still attached to psoas muscle. The superior portion so far as it allowed the injection to pass, was very much reduced in caliber, not being larger than a crow-quill. The internal iliac was about the size of the little finger, and its gluteal branch was traced through the ischiatic notch filled with injection, and anastomosing freely with the external circumflex, which in this case went on from the profunda; external iliac, from spot where ligature had been applied downwards to seat of hæmorrhage, was completely obliterated, and epigastric artery, which went off about an inch below the tied portion, was so small as to be with difficulty traced. Injection had passed freely upwards, from popliteal artery to within half an inch below the place where lower ligature was applied round femoral; here adhesion of the coats was complete. On tracing the remains of femoral artery, from situation of third ligature, upwards to seat of hæmorrhage, the tube was found in the same state as inferior portion of external iliac, mentioned above. The pouch, which was remarked at the second hæmorrhage, was now well seen, and found to consist of the sheath of main trunk of inguinal artery, and when its soft friable walls were removed, an opening about the size of the point of the little finger was observed at the outer side of main stem, the whole circumference of which, and also the caliber of the vessel, for

the space of more than half an inch, partook of the same morbid appearance as the above portion of the arterial sheath. Profunda could only be traced from below to within half an inch of spot where third ligature was applied; here it was confounded in the general disorganization of parts. On dorsum of left ilium, extending laterally from anterior superior spinous process to sacrum, and inferiorly to tuberosity of ischium, was an extensive abscess, excavated into irregular hollows, occupy ing the whole external surface of left os innominatum. To this abscess there were many openings, the largest of which was situated on the dorsum of left ilium, immediately behind anterior spinous process. On right haunch were two irregular sloughy spots, and on anterior surface of left there were similar marks of disease."

Thus was this long but interesting ease concluded. Without entering into any speculations, or indulging in any criticisms, we cannot but regret that the operation was not earlier performed. We do not clearly understand, from the description of the state of the parts after death, whether the profunda joined the superficial femoral between the second and third ligatures, or above the latter. If it did not unite itself to the femoral between the ligatures, or if no other branch of any size arose in that spot, we are left in the dark as to the cause of the hæmorrhage after the application of the second ligature, and its cessation after that of the third. If it did join the femoral in this situation, another reflection naturally presents itself. When a surgeon is aware of a large artery, like the profunda, taking its rise from the inguinal, he should surely refrain from placing a ligature on the femoral below that origin, in order to arrest hæmorrhage from the ar. tery above. The blood getting back through the profunda into the inguinal, is not arrested in its retrograde course by such an operation. It is no excuse to assert, that ulceration in the groin renders it dangerous to tie the vessel where its tunics are probably unsound. Under such circumstances, it is absolutely necessary to tie the vessel as near

the source of the hæmorrhage, as a healthy condition of its coats can pos sibly permit.

LXVI.

ON THE USE OF THE NITRATE OF IRON IN DIARRHEA. By Mr. W. KERR, of Paisley. Ed. Journal, January, and Glasgow Journal, April, 1832.

THE medicine here recommended is a solution of iron wire, or small pieces of iron, in nitric acid, so as to form a persesquinitrate. This, in moderate doses, has been found very efficacious in diarrhoa, and some other affections of the mucous membrane of the alimentary canal. In our Glasgow contemporary for April, Mr. K. has published some more cases, illustrating the efficacy of the medicine in the premonitory diarrhœa of cholera.

LXVII.

A PRACTICAL TREATISE ON UTERINE

HÆMORRHAGE, IN CONNEXION WITH PREGNANCY AND PARTURITION. By JOHN T. INGLEBY, Member of the Royal College of Surgeons in London, one of the Surgeons to the General Dispensary, Surgeon to the Magdalen Asylum, and Lecturer on Midwifery at the School of Medicine in Birmingham. One Plate, 8vo. pp. 276. London, 1832.

THAT the art of midwifery, on the scientific and successful practice of which the lives of the most interesting portion of our species often depend, should have received no legal protection, and been controlled by no authorized regulations in Great Britain, a country so pre-eminently distinguished for humanity, appears almost incredible. The commercial spirit which pervades every part of the empire, and appreciates every pursuit in proportion to the pecuniary advantages it may afford, seems to have penetrated into the sanctuaries of physical science. Hence our great chartered bodies, having relinquished this branch of the profession, and being no longer competent to ascertain the

qualifications of candidates, the most ignorant adventurers are permitted to abuse the public confidence, and endanger the lives of His Majesty's subjects, without incurring any fine or penalty. To this neglect and degradation of the obstetrical art, we may trace the constant occurrence of disgraceful and fatal errors in practice and the paucity of publications, in comparison with those in other departments of therapeutic sci

ence.

"Questions, it is true (observes the author), are sometimes proposed to the candidate for diploma at Apothecaries' Hall, although not forming a necessary part of the examination, whilst examiners at the College of Surgeons take no cognizance whatever of the obstetrical qualifications of the student, a circumstance which sufficiently accounts for the indifference, not to say contempt, with which many regard this study." Preface, p. viii.

He might have added, that licences to practise midwifery were formerly sold at the Royal College of Physicians in London; but, after it was discovered that the Fellows of that learned body were, by their own bye-laws, restricted from acquiring any practical information on the subject, their licenses became obsolete and despised.

To remedy one of the vicious consequences arising from those minute and arbitrary subdivisions of the profession, which were the offspring of academical pride and popular prejudice, an attempt was made to form an obstetrical society in this metropolis; and it is much to be regretted that such a needful institution was not supported and extended by legal enactment, as no branch of the healing art is so fit for, or so likely to be promoted by, separate cultivation. We would, however, on no account recommend the study of one branch to the exclusion of the whole; for we believe that any one, understanding every portion of a science, must be best adapted for exercising or improving any distinct part. Whoever, therefore, may expect to refine and improve his practice by contracting his education, would be like an agriculturist, who, instead of cultivating all his land with a view of produc

ing cheap and wholesome food, of which all may partake, confines his attention to his greenhouse, that he may excel his neighbours in the propagation of expensive and useless flowers. In this respect, the mere physician or surgeon is often found to labour under a decided disadvantage, where his limited education is brought into practical competition with the omniscience of the general practitioner, “omnia scire; non omnia exsequi.”—Tacitus.

The neglect with which the midwifery department has been treated by the Colleges of Physicians and Surgeons in Great Britain, has not escaped the notice of the profession at large; and we hope the time is not far distant, when the obstetrical professors will combine their efforts for the purpose of establishing a national institution, which may improve and regulate the cultivation and exercise of an art so useful to the public.

In the preliminary observations, with which the able work under review commences, the author reminds the young practitioner of the absolute necessity of obtaining an intimate knowledge of the various duties he may be suddenly called upon to discharge; as time and circumstances, especially in remote parts of the country, will often not admit a consultation.

"In the graver hæmorrhages, whether antecedent or subsequent to delivery, alacrity and promptitude are indispensable; hesitation is often fatal in its consequences, life is fluttering away, and, when time does not allow of a second opinion, the practitioner is at once thrown upon his own resources."

"If the student is not impressed with the value of human life, his own selfinterest, so closely interwoven with his success in the obstetric art, paramountly demands an intimate knowledge of these very duties."

The infrequency of death, during or connected with the process of parturition, in the country in comparison with the metropolis, is accounted for by the author from the superior salubrity of the atmosphere and moral and physical condition of the patient, which, in preventing disease, and promoting reco