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over the course of the femoral artery, the centre of the incision being a little above the lower angle of Scarpa's triangle, and corresponding with the point of intersection of two lines, one drawn over the course of the femoral artery, and the other over the track of the bullet. The sartorius having been pushed aside and some further dissections made, the sheath of the vessel was brought into view, when it was discovered that the bullet had perforated the femoral artery, about 14 inches below the origin of the profunda. The artery was not completely severed ; about three-quarters of its circumference was carried away, leaving a rent about two-thirds of an inch long; the distal end was first tied, a second ligature was also applied to the cardiac end as close as possible to the rent, and the vessel cut between the two ligatures, this last fixed ligature was for the purpose of preventing retraction and to manipulate this end of the artery, as it required further dissection to enable it to be firmly tied. A large quantity of coagula and decolorized fibrin were turned out of the aneurismal cavity, which was to the inner side of the artery extending upwards to Poupart's ligament. The distal cut end of the artery was now sufficiently bared and firmly tied with silk, and the cavity formed by the aneurism washed out with carbolic lotion. The edges of the wound were brought together by means of wire suture and a free opening left at the lower end of the wound, a drainage tube inserted and carbolic oil dressing applied. Patient was immediately put under the influence of opium ; watch was constantly kept up for a few days by his bedside to guard against hæmorrhage.
Temperature continued to rise for a couple of days after the operation, when (Aug. 16) it reached 1059.2. For the first time he now (Aug. 16) complained of pain in his right foot ; on the following day this pain was limited to that portion of the foot immediately behind and below the right internal malleolus, over which, on the 17th, a bulla commenced to form. On the 19th this bulla was filled with a dark fluid, and the lymphatics leading from it were inflamed. It continued to increase in size until the 21st August, when it burst, bringing into view a large slough beneath, portions of which separated on the 24th, leaving healthy granulations beneath ; other portions of the slough separated on the 27th August, but the last of the slough did not come away until two days subsequently (August 29).
On the 26th August, seventeen days after the accident, he complained for the first time of his toes being tender ; three days later (29th) there was considerable swelling and fluctuation over the metatarsal bone of the great toe. This was opened, when a large quantity of pus escaped, and the metatarso phalangeal joint was found to be involved. This joint continued discharging more or less every day until the 10th Oct., when Dr. Wilkins decided to resect the joint, but after laying bare the heads of the bones, the metatarsal bone was found to be diseased so very far up it was necessary to amputate the toe close to the tarso-metatarsal articulation, after which the patient did well without a single bad symptom.
During the course of his confinement to bed two sloughs were produced by pressure on the inside of the foot, the integument over the outer malleolus giving way August 26, and that over the outer edge of the base of the fifth metatarsal bone on the 15th of September.
On the second day after the operation (Aug. 16) symptoms of septicæmia made their appearance; profuse perspiration with high temperature, vomiting and diarrhoea. His temperature, which commenced to rise two days before the operation, reached 1059.2 on the second day after, and kept moderately high (103° to 104°) for about six weeks subsequently, occasionally falling three degrees, sometimes a little more, after the administration of a twenty-grain dose of quinine. Stimulants were freely administered; for one period of forty-eight hours he had continuously one ounce of brandy every two hours. Besides aiding the quinine in bringing down the temperature, it materially lessened the frequency of the pulse, which had reached 148° on August 17.
The destruction of the great toe joint so long after the accident I consider to have been due entirely to embolism : the femoral was tied so close to the origin of the profunda (about an inch from origin) that the cardiac end of the thrombus is likely to have projected, in the form of a cone, a little beyond the opening of the profunda, and thus permitted one or more small portions of the plug being detached from it and carried with the current until arrested in the small blood vessels of this joint where suppurative processes were set up.
Case of Dislocation of the Femur into the Foramen Ovale.
Under care of Dr. Reddy. Reported by JAMES BELL,
M.D., Assistant House Surgeon, M. G. Hospital. W. S., a medium-sized, well-built and healthy Englishman, 40 years of age, was admitted to Dr. Reddy's wards on the 23rd of June last, having received an injury to his left hip the evening before. He was wrestling with a friend and threw him, and the latter while down grappled him by the legs and brought him to the ground, at the same time rolling over him. He felt something give way in the fall, and he had to be assisted to his feet. On admission he was suffering great pain, especially over the adductor muscles of the thigh near Poupart's ligament. The body was bent forward in attempting to walk, and in the recumbent position the thigh was semiflexed on the abdomen. The whole limb was abducted and the foot everted,
There was also considerable apparent lengthening of the limb. The buttock was much flattened, and the gluteal fold absent. The trochanten could be felt at the bottom of a deep depression over the outer side of the thigh. There was preternatural fulness of the anterior and inner portions of the upper third of the thigh, and in this situation even slight pressure was very painful. Bryant's Line measured 34 inches on the left side and 2 on the right, and the left leg was half an inch longer than the right. The patient was chloroformed and Drs. Reddy and Fenwick proceeded to reduce the dislocation by the rotatory method. The first attempt threw the bone into the ischicatic notch. It was easily thrown back again into the foramen ovale, and a second attempt was made with a similar result. On the third attempt it slipped into its place without difficulty. The patient's legs were bound together and ice applied to the joint. There was considerable swelling for a few days and his temperature rose a little. It ranged for three or four days between 99° F. and 101° and then became normal. The ice-bags were removed in three or four days and the bandages at the end of a week. The patient was kept in bed for two weeks. He was finally discharged on the 13th of July, feeling quite well and able to walk with the aid of a stick.
LONDON, July 11, 1878, To the Editor of the Canada MEDICAL AND SURGICAL JOURNAL:
DEAR SIR.—At Edinburgh, from the great and long standing reputation of its University, there is always found much to repay any medical visitor. Yet at the present time one cannot but be struck with the absence of any who stand as Syme, Simpson and others stood, head and shoulders above all the rest. London men taunt their northern friends by telling them that every good man there naturally comes to London. That is certainly true ; but the retort which has been thrown back has equal justice, viz., that when a London school is in want of a teacher it is very often to Edinburgh that they look to find the man.
Of course one cannot speak of Edinburgh without being led to speak of Listerism. My impression so far is that the last 12 months does not appear to have made any change in the position of the germ-doctrine. I don't think the full antiseptic teaching and treatment can be said to be gaining ground, and it will apparently be a long time before this matter can be definitely settled. The opponents of Listerism are not confined to such men as Spence, who have grown grey in the practice of now-called old-fashioned surgery, and who obstinately refuse for a moment to entertain the idea of such radical changes in procedure, but number amongst them young men, active, keen and earnest, who have had ample opportunities of studying both, and who will asseverate and maintain and shew cases to prove that as good results can be obtained one way as the other, provided always it be in the same hands and equally carefully
and skilfully managed. Even in Edinburgh itself there are but a few who may be called enthusiastic and thorough antiseptic men. Of these probably Chiene is the chief. Many others, such as Mr. Jas, Bell, for instance, use a thoroughly antiseptic treatment in certain cases, but object to its employment in many others of a similar class.
The new Royal Infirmary at Edinburgh is approaching completion. It is an immense structure, built of stone, on the most approved modern pavilion-plan, and covering several acres of ground. It will surely be much appreciated by the members of the schools and by the public. No stranger can help being struck with the antiquated and wretched condition of the present building, seeing that it is the teaching field of the largest schools in Great Britain.
Nerve-stretching in sciatica continues to be practiced there to a limited extent. Some of the results from it are brilliant but in other cases it has quite failed, and as yet there is no positive means of distinguishing between those which are amenable to this treatment and those which are not. I saw one case there supposed to have been cured but in whom it had speedily returned.
There is a considerable number of Canadian graduates and students here at present. St. Thomas' Hospital is their favorite resort. Dr. Murchison still continues his summer clinics twice a week. There are always to be found in his words an admirable selection of severe and important medical cases. From the severity of the cases admitted also autopsies are frequent. Here probably more than at any other school are the students of the class diligently and systematically instructed by the bedside and made to take a continually active part in the diagnosis of all new cases. Owing of course to Dr. Murchison's great reputation in connection with diseases of the liver and allied organs, great numbers of rare and interesting varieties of abdominal complaints are constantly to be seen. For instance, within two days of each other, I saw two very parallel cases of encephaloid of the testicle combined with secondary disease in the post-peritoneal glands, and one of these in a monorchid, where the disease first attacked the undescended gland.