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operations. I requested Dr. Wake* to do me the favour of attending the examination.
We first opened the abdomen, to ascertain the state of its parietes, of the peritonæum, and of the general cavity. There was not any appearance of disease-it was whole and uniform, with the exception of an unimportant degree of thickening, and some slight adhesion of the head of the colon and ileum to the adjacent parts. This uniformity was very apparent, not only to Dr. Wake and to myself, but to Mr. Ward (who had paid the greatest attention to the patient) and to the pupils of the hospital present.
I proceeded to re-open the external wound, which had completely healed (saving where the ligature had protruded), and so to examine the course of the operation.
The cavity on the external part of the peritonæum (the seat of the incision) was completely filled with a grumous pillar, or thrumbus of blood, strong and tenacious. The ligature, on moving a part of this with the sponge, readily followed it, and, without doubt, had been disengaged for some days. The knot of the ligature included a small fragment of (apparently, the artery, which projected in a very trifling degree on each side of it. There was a small portion of coagulum under the cartilages of the ribs; and the pillar reached down to the lower seat of the ligature within the pelvis.
We next turned our attention to the artery, as the subject of the operation. For this purpose, the best mode appeared obviously to dissect and clear the aorta within the abdomen, at a certain distance above the bifurcation; to expose the external and internal iliacs, first on the sound side, then on the diseased, which, being accomplished, we had both sides in open view. We then passed a bougie into the external iliac on the sound side, and down the internal on the same side, to ascertain its direction; and then also passed an instrument into the external iliac on the operated or right side, down to the groin, and there left it. We also passed another into the internal iliac, to the part where it had been tied. The internal iliac being exposed, we found that it had been tied, and had separated about an inch from the bifurcation with the external iliac. . It was broader, flatter, and more enlarged up to the external iliac, than the external iliac of the same side, or the internal of the opposite. This
* This gentleman, I am happy to express, assisted me both during the operation and the whole course of the business, in the most honourable, anxious, and friendly manner,
circumstance had been obvious to me whilst I was endea. vouring to separate it during the operation, and which I no. ticed at the time--for a degree of thickening and of adhesion of its coats was very evident, although it required little force to pass and perforate the internal adhesion of the sides of this artery; and therefore the inside of the mouth or opening, and sides of the internal iliac above where the ligature had been applied, on separating them, had a granulous and greyish coagulated appearance. The
exposure of the respective arteries at the same time on each side, exhibited at once a very clear and satisfactory view of the state of the parts.
A certain space of separation was visible betwixt the upper and lower parts of the internal iliac artery, and now obviously presented to view.
In the lower part of it the artery was wider, and the coats evidently more diseased; and a coagulum of grumous blood was manifest at the mouth of the lower artery, which, being gently removed, exposed this (now more open) mouth, which again, after a short interval, was filled with more fluid ichor from the sac below.
Thus much being satisfactorily ascertained by all present, it was thought expedient to open the glutæal or aneurismas sac, confined to the nates.
It was effected by a free incision, which, dividing the muscle, soon exposed a more membranous surface, the actual sac of the aneurism. From it I cleared away some pounds of coagulum, moistened by a thinner ichorous fluid, and sponged it well, to make all the parts as distinct as their state would permit. I could not perceive any collateral artery opening into it; but a bougie, passed into the lower diseased artery, within the pelvis, in a line with the superior one, was slowly introduced, and easily made way into the exposed sac, from whence the blood Had been eleared ;--so that it became obvious that a regurgitation of blood might easily happen, and which, no doubt, was the case, from the sac up the artery into the pelvis, at a given time after the ligature had separated.
The resistance from so' large a tumour of blood a tergo, confined as it was by the sac, and aided by the pressure and impetus of powerful muscular action, must, I apprehend, force the blood by necessity into any aperture, quâ data portâ ; so that a regurgitation of blood upwards would, in my opinion, possibly supplant, in this instance, the usually supposed effect of aneurism, or a bursting of the sac. In each way, however, it is probable that death would equally be the result to the unfortunate patient.
For the London Medical and Physical Journal. On the Influence of Names, and on the State of the Medical
Profession; by ANDREW BLAKE, M.D. Member of the
Royal College of Surgeons, London. “ Names are the stumbling-blocks of all improvement, and their influence is
always directly proportion to our want of real knowledge.” T is devoutly to be prayed for by this country at large,
that legislative interference may adopt some coercive regulation, restricting the future practice of midwifery to those who, with due pretensions, amply qualify themselves before some professional tribunal for that purpose. It is undoubtedly true, and cannot be sufficiently lamented, that there are an infinite number of worthless pretenders in this country, who, neither by education, talent, nor experience, are adapted to the vital exercise of that momentous duty, who, from the veriest menial capacities, at once assume an office, the eminent functions of which they are really unacquainted with, are daring and obtrusive from the thirst of profit and mistrusted encouragement, and hardened to every sense of conscientious feeling from long inveteracy in the total disavowal of it.
I am urged by no personal animosity or unworthy impulse, and should not, perhaps, here have thus expressed myself, had I not recently been consulted in a case at a moment when all consultation was useless, and in which, I affirm it unhesitatingly, a lady lost her valuable life, a father and children an incalculable treasure, by the perverse and criminal ignorance of an attending man-midwife.
This man was proverbially illiberal to his professional neighbours, he professed all that forward assumption which characterizes little talent, bold conceit, and regardless attention of danger; upon every occasion, however intricate, he so valued his own services, as to hold those of others, when sought for, as contemptible and unnecessary; he had arrived at those years which inspire confidence and carry with them the unerring conviction of supreme infallibility, and he dealt largely in happiness or misery according to the bias of the moment, and the adequateness of nature in her struggles to cast off sickness and disease.
In this instance the family were particularly solicitous, but, by his repeated assurances of safety, they were lulled into a negative satisfaction for the time: the fatal progress, however, of the malady was rapid, and, the general appearance of the patient indicating too plainly to the by-standers