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his death. Ordered a linseed-meal poultice to her left side,four ounces of wine, beef-tea, and fifteen minims of the mu-riated tincture of iron in peppermint-water twice a day.

Dec. 27th.-She was in great pain last night ; felt very weak.She had rigors, was cold all night ; complains also of headache;passed blood eight or nine times during the night. Skin cooland moist; pulse 1:).." moderate in volume ; tongue clean ; noappetite ; bowels open. No relief from the poultice, as itturned cold and made her shiver ; had great pain in the left’Side. Four minims of tincture of opium ordered in each doseof her medicine.30th.-Seems in a very weak state this morning; the haemor.

rhage still continues as copious as ever; she was obliged to getup to pass a clot this morning, and fainted away ; skin cool andmoist; pulse 84, but not so feeble as might be expected; tonguepale, but clean; feels as if she could eat something; bowels.confine; did not sleep at all last night; she had sharp, cuttingpains in the left groin. To have three grains of acetate of leadand half a drachm of oxymel, in peppermint-water, every threehours. The next day this was changed to ten grains of gallicacid every four hours.

Jan. 1st, 1860.-The haemorrhage still continues, with thepassage of large clots. A turpentine draught was orderedevery three hours, and the gallic acid to be continued.5th.-She was put upon alum, which reduced the quantity

.of blood passed in a couple of days. On the 8th, there wasmore haemorrhage; the bowels were well opened. On the 9th,complained of heat about the head, and other symptoms ofansemia; no clots were now passed.12th.-The haemorrhage now seemed to be passive. Ordered

the muriated tincture of iron, with an occasional aromatic-draught, with ten minims of tincture of opium. This, by the16th, wholly arrested the bleeding, but she was very weak.

Feb. 6th.-Progressed in every respect since Jan. 25th. Shewas now put on the same preparation of iron, eight minims, ininfusion of quassia, thrice a day. Had a little diarrhoea yester-- day, and pain in the loin.

13th.-Has been sitting up for some days, and can walk alongthe ward with assistance; is much improved, although weak.18th.-She left the hospital.

UNIVERSITY COLLEGE HOSPITAL.

INJURY TO THE LEFT KIDNEY, FROM CONTUSION OF THEABDOMEN AND THORAX; HÆMATURIA AND

COLLAPSE; RECOVERY.

(Under the care of Mr. ERICHSEN.)THE presence of blood in the urine, following the receipt of

any injury about the loins, clearly points to the kidneyas the source of it, as is illustrated by the following case,the notes of which were furnished by Mr. Berkeley Hill,house-surgeon to the hospital. Notwithstanding the gravityof the general symptoms, the man made an excellent recovery.In proof of the fact that the blood does come from the kidneyin these cases of injury to that viscus, we may refer to an instancewe saw in the same hospital some years ago. A man was ad-mitted, under Mr. Erichsen’s care, who had sustained an injuryin the loins from a railway buffer. He passed much blood inthe urine, and had all the symptoms of injury to the kidney.He survived some weeks, his death being the result of an- attack of pneumonia, and at the autopsy a distinct cicatrixwas found on the surface of the left kidney, where the lacera-tion of its substance had primarily occurred.The reader is referred to a case under Mr. Sands Cox, in

the Queen’s Hospital, Birmingham (THE LANCET, vol. ii. 1845,p. 6S4), to one under Mr. Stanley’s care, at St. Bartholomew’sHospital (ibid., vol. i. 1851, p. 599), and to the case recordedby Dr. Shearman, of Rotherham (ibid., vol. i. 1848, p. 685),as examples in which heamaturia was a prominent sign afterinjury to the kidneys by direct violence.

George W-, aged twenty-eight, a carman, admitted onthe lst of May last. under the care of Mr. Erichsen ; on

which day, whilst driving his van, he slipped off his seat, and,fell.under the wheel, which rolled against his side, and probably over his body. On admission, the patient was almostunconscious, suffering under great collapse, being pale, coldcovered with clammy sweat, and with a very feeble pulse.Shortly after admission, he vomited repeatedly biliary matte].and mucus. No blood, however, was detected under the microscope. He complained of great pain and tenderness over th

left hypochondriac and lumbar regions, where the ninth andtenth ribs were fractured; some indistinct emphysema existedhere also. The vomiting and prostration continued until thefollowing evening, when he became flushed, thirsty, his pulsehard and rapid, and his bowels constipated. Some cough alsoset in, and friction sound was audible at the base of the leftchest. The urine during the first three days was dark-brownin colour, and opaque, the discoloration being due to blood-discs, and also to fine granular blood-casts of the uriniferoustubes. After the third day, the urine no longer retained itsdark appearance, though some blood-discs were visible underthe microscope, and some traces of albumen remained. At theend of a fortnight, the man could sit up in bed without pain.By this time all abnormal appearance in his urine had ceased.On the 25th of May he was discharged, quite able to walk andtake a long breath without pain, and having no tenderness onpressure over the left kidney. The urine also was perfectlyfree from albumen, pus, blood-discs, or casts of uriniferoustubes.

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ROYAL FREE HOSPITAL.

EPISTAXIS, GIVING RISE TO HÆMATEMESIS, THE HÆMOR-RHAGE PROCEEDING ALMOST TO FATAL SYNCOPE.

(Under the care of Mr. WEEDEN COOKE.)WHEN bleeding from the nose and vomiting of blood are

co-existing symptoms, it is important to ascertain if their

origin is distinct; for whilst attention is directed towards

arresting the latter, so much time may be lost as to bring abouta fatal result from the former. The occurrence of a double

bleeding of this kind is probably one of the rarest complicationsto be met with. In the present example, the simulation ofreal hsematemesis was so natural as at first to mislead; a care-ful examination of the fauces, afterwards, showed the blood tobe trickling down the pharynx from the back of the nose,coursing onwards to the stomach, whence it was vomited. Thetrue nature of the case being thus apparent, the nostrils wereplugged with success, but not before a large quantity of bloodhad been lost. We are favoured with the notes of the case byMr. John D. Hill, house-surgeon to the hospital.Thomas G-, aged twenty-three, a strong, healthy-looking

man, was admitted on the ]Oth of February, at ten A.M.,vomiting blood and bleeding from the nose. It was statedthat he had been fighting, and had been considerably knockedabout by his opponent, as his appearance would testify. Itwas also said that his antagonist had, after having knockedhim down, jumped upon his body; and, with regard to hisprevious history, it appeared that he was subject to attacks ofepistaxis, particularly after inebriation. These circumstances

having been taken into consideration after the examination ofthe patient, it was determined to administer the acetate oflead and opium combined, with the local application of cold tothe epigastrium. The blanched condition of the patient, toge-ther with the state of collapse and vomiting, at first indicatedtreatment for boamatemesis, which was accordingly adopted.

Had this not been so, the bruised and swollen condition of thenose and face, with the epistaxis (which, upon examination,was not considered at first to be the source of the hsematemesis),would have suggested the propriety of plugging the posteriornares. The epistaxis subsided in a short time, but the vomit-ing continued at intervals, although not so great in quantity,

after the second dose of the medicine had been taken. At twoo’clock the epistaxis returned, as well as the vomiting. More

than a pint and a half of blood was ejected from the stomach,and the patient appeared M articulo q)orti3, the pulse andbreathing being almost imperceptible. The house-surgeon was

summoned immediately, and the patient again carefully exa-mined. Upon exposing the fauces to a good light, the true’ source of the haemorrhage was discovered. The blood was

seen trickling down into the pharynx through the posteriorL nares, which were immediately plugged, as well as the ante-L rior. Brandy, combined with twenty-minim doses of spirit ofl turpentine, was given every twenty minutes. The baemor-. rhage ceased immediately after the operation, and in twenty-; five minutes the circulation began to recover itself. The, patient progressed favourably for twenty-six hours, when re-, action set in rather briskly. On the third day the secretionsr were attended to, and the digestive apparatus restored to- health. The plugs were removed without the least dispositionto the recurrence of hmmorrhage. The patient upon the fourth

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day took food (animal), and continued daily to improve andregain his strength. He was discharged convalescent on the16th February.

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CLINICAL RECORDS.

LIGATURE OF THE CAROTID FOR SUSPECTED

ANEURISM OF THE OPHTHALMIC ARTERY.

WE recollect seeing Mr. Bowman tie the carotid artery(about three years ago) for a supposed aneurism of the

ophthalmic artery, in an elderly woman, at King’s CollegeHospital. The patient had applied at the Moortields Oph-thalmic Hospital for a noise in her head. A pulsation eitherwithin the orbit or the head had been heard for five months byherself, and also by her husband. Its origin, Mr. Bowmanobserved, was somewhat obscure, whether from a blow or

otherwise, he could not say positively; but she had receiveda blow on the lower edge of the orbit, which might have pro-duced a fracture and lacerated the vessel. The lower edge of

Ithe orbit was very uneven; possibly a fracture may have rup-tured the coats of the ophthalmic or the internal carotid itself.He remarked that it was not difficult to determine the realnature of the disease. The eye was prominent and injected,and so were the other structures of the orbit. A pulsation wasfelt over the eye, then over the whole head, but the left sideparticularly, and a strong, loud bruit was heard. The onlything to be done was to tie the vessel; and this was performedon Feb. 27th, after the patient had been a week in hospitalto prepare for it. She was by no means a favourable subject;she had lived a very hard life, subject to considerable excite-ment with her husband, and was frequently drunk. She hadno disease of the heart or other vessela. The upper portion ofthe common carotid was ligatured sufficiently below the bifur-cation to permit the formation of a clot, and was there easilygot at. On the 6th of March the patient was going on well,the noises had disappeared, as also the congestion of the eye-ball, &c. Afterwards she died; and at the autopsy no aneu-rism was found to explain the symptoms present during life.We have been thus particular in mentioning these facts to

show how difficult it is always to make out correctly an aneu-rism within the orbit or head. Very recently another case ofsupposed aneurism of the ophthalmic artery was submitted tothe same treatment, and so far it has been followed by goodresults in every way. Subjoined are the particulars, as kindlyfurnished us by Mr. William Wickham, house-surgeon to King’sCollege Hospital:-Susan L--, aged forty-one, admitted April 13th, 1860,

with supposed aneurism of the right ophthalmic artery. Shestates that she has generally enjoyed good health. On Dec.27th, 1859, whilst washing some clothes, she was attacked bysudden pain in the right side of the head, followed soon after-wards by a "blowing" noise in the same part, both of whichhave continued ever since. The right eye gradually becameprotruded and swollen, with increased vascularity. In March,1860, she was confined. On admission, the right eye is foundto project forwards about a quarter of an inch, and she has aconvergent squint of about two lines. There is complete para-lysis of the right external rectus muscle. When told to looktowards the right hand, there is seen to be a second convergentsquint of the left eye. The conjunctiva of the right eye is veryred and oedematous, the sulcus beneath the orbit being com-pletely filled up. The right eye is presbyopic. She is able todistinguish the figures of a watch held at a distance of fourteeninches, but cannot read, being unable to recognise letters of aword at that distance. On pressing the fingers beneath themargin of the orbit, a faint and obscure pulsation can be felt.The veins of the upper lid are varicose. The supra-orbitalartery beats naturally. On applying the stethoscope over thefront of the eyeball, a loud, blowing murmur, synchronouswith the radial pulsation at the wrist, is heard, as also overthe whole of the right side of the head, though more subduedin character. It is also heard on the opposite side of the head,but in a much fainter degree; also at the right angle of thelower jaw over the course of the common carotid artery downto the root of the neck. The intensity of the murmur is dimi-nished on compressing the common carotid, but the bruit is notaltogether stopped. Heart sounds are quite natural, thoughoccasionally she suffers from violent palpitation. The treat-ment adopted at the commencement consisted in the adminis-tration of tonics and pressure of the carotids by means of thefingers. This pressure was kept up for about ten days, twice

a day, for five minutes at a time, with the effect of completelystopping both the throbbing and the pain for the time being.As this, however, gave no permanent relief, it was discon.tinued, and, for the temporary relief of the patient, irrigationand cold to the parts have been since applied.From the date of her admission till June 15th she continued

in much the same condition; but in the evening the promi-nence of the eye became much more apparent, with an increaseof vascularity and pain to such an extent that Mr. Bowmandetermined at once to ligature the common carotid, and per-formed the operation on June 16th in the ordinary way.The patient has proceeded favourably since the operation,

with a relief to most of the symptoms complained of, and is atthe present time (July 31st) in a fair way of recovery. Theligature came away on the seventeenth day, without haemor-rhage. The eye is still prominent, and the paralysis of thesixth nerve is permanent. A faint bruit is occasionally heard.

CIRCULAR AMPUTATION OF THE THIGH.

ON July 19th, at St. George’s Hospital, Mr. Cassar Hawkinsremoved the leg of a female at the lower third of the thigh,for extensive disease of the knee-joint. The patient had beena sufferer for five years, the mischief slowly progressing untilthe articulation was wholly destroyed, spreading also upwardsinto the shaft of the femur. A large part of the lower end ofthis bone was completely necrosed, as was also the head of thetibia, the surface of which latter was covered by some looseosseous fragments. The cartilages were likewise destroyed,from ulceration and absorption. The present was one of thoseexamples in which the morbid action had become too widelyspread to warrant the expectation that any surgical proceedingshort of amputation would afford relief. This was accordingly-adopted, and successfully carried out by the circular method.The patient is going on most satisfactorily.We may here observe, that the circular amputation is to

some extent superseding the ordinary flap operation in hospitalpractice. It is now mostly employed by the surgeons at St.George’s Hospital, and is preferred also at other institutions. Theadoption of the circular method, or of that by flaps, is solely aquestion of taste and of dexterity on the part of the operatory.for most writers on surgery believe that an equally good stumpmay ultimately be formed by the one as by the other. The

rapidity with which the flap operation can be done is an ad-

vantage over the other; but the circular method gives a firmerand neater stump.

GOOD RESULTS OF THE AMPUTATIONS ATST. GEORGE’S HOSPITAL.

1’VmLS on the subject of amputations, we may refer to thesuccessful termination of the great majority of those recentlyperformed at St. George’s Hospital. For a time, most of thewards of this institution were so unhealthy that a considerablenumber of capital operations ended badly, as we learnt frompersonal observation and from the testimony of some of themedical officers. In consequence of improvements carried outlast year in most of the wards, together with the addition of aconvalescent ward at the top of the building, the generalsalubrity has so much increased that pysemia, which hadheretofore been very prevalent, has now almost entirely disap.peared.

In October last, of six amputations performed within a com-paratively brief period, all the patients were up and conva-lescent within the term of three weeks. This has also beenthe general experience since. At the present time (Aug. 2nd),we can count four amputations of the lower extremity in onefemale ward alone, all proceeding without an untowardsymptom, union having taken place by first intention. Intwo cases of amputation above the knee, performed by Mr.Caesar Hawkins on the 12th and 19th of July, and in one of thesame kind, under the care of Mr. Prescott Hewett, the samefavourable state of things obtains. In the male ward, weobserved a patient, whose forearm was taken off on the 26thult., with the stump healed and the ligatures away, which per-mitted his walking about, without inconvenience, six days afterthe operation.

In all these operations the circular method was adopted.Of ninety amputations recently resorted to in this hospital,sixty were circular, and thirty flap. The mortality amongstthe latter was found to be as great as in the whole of theformer.