FRAGMENT OF SHELL IN THE ARTERIAL CIRCULATION

even then one cannot always be certain of getting at the bleeding point, and-this is particularly true if the vessels h-tave been eroded in the region of the sacro-sciatic ligament andtheir ends have retracted witllin tlle pelvis. It is here, then, that proximal ligature of a lmlain arterial trunk, so.exceptionally justifiable in other parts of the body, has a distinct advalntage over other metlhods of ts:eatment. It effectively controls the haemorrhage, and allows, if necessary, free opening up of the buttock without dangerous haemorrhage, while it does not in any way retard thle healing of the parts involved. The hypogastric -internal iliac artery-is the main trunk of supply to the buttock, and is easily accessible in the pelvis. Ligature of this vessel was performed by Annandale for gluteal haemorrhages. To reach the artery thetransperitoneal route is selected, a rectus incision made, and the patient put into the Trendelenburg position. The common iliac artery is then easily identified, tlle posterior parietal peritoneuim incised, and, with very little dissection, the internal iliac can be found just as it bifurcates from the common trunk. A double chromic catgut ligature is passed under the vessel and tied. The position of the ureter and vein has to be kept in mind, and care must be taker to secure the vessel before it divides. On the left side a little difficulty may be experienced, according to the position of the pelvic colon and its mesentery. The posterior parietal peritoneum is sutured with fine catgut, and the abdominal incision closed in layers. The following cases are illustrative of the condition. A temporary plug was employed for a few hours to control the ha.emorrhage till the patient recovered from the initial shock..