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by telephone to the hospital at Spark-hill, and found thepatient very faint and sick; her lips were white; her pulse,between the attacks of fainting, when it became indis-tinguishable, was very weak and rapid, being about 136 tothe minute; and her hands were cold. It was not difficultto conclude from these symptoms that dangerous haemor-rhage must be taking place. On opening the abdomen, I founda quantity of venous blood not only filling the pelvis, but ex-tending for some distance among the viscera in the generalabdominal cavity. This was sponged out as carefully as

possible. The stump*of the broad ligament on each sidewas then gently brought to the surface and examined, aswell as thö candlelight and continued haemorrhage wouldpermit. On both sides the ligature still held, but on theright side some of the tissue appeared to have slipped outof the ligature. This was gathered up by catch-forceps, anda fresh ligature applied. This considerably lessened thehemorrhage, but did not stop it, since, on removing thesponges with which 1 had packed the pelvis, blood still camefrom a point low down behind the uterus, the exact localityof which I could not determine. I therefore dipped a spongein a weak solution of perchloride of iron, and pressed itdown into Douglas’s pouch, while I passed the sutures toclose the incision on the abdominal wall. I withdrew thesponge just before tying the sutures, leaving a large drainage-tube in its place. No subsequent hsemorrhage occurred.The patient made a rather slow convalescence, owing toweakness from the loss of blood, but in every other respecta complete and uneventful recovery.The second case was one of Dr. Savage’s. In this case the

appendages of the right side had been removed on the morn-ing of Sept. 29th. On the left side neither ovary nor tubewas distinguishable, although their supposed site was freelyopened up by the fingers. From this situation considerablehaemorrhage occuired at the time of operation. 4 It was, how-ever, controlled by sponge-pressure, and a drainage-tubewas left in the pelvis on closing the abdominal wound.About 4 P.M. I saw the patient (in the absence of Dr. Savage),and found that free and increasing haemorrhage had occurredsince the operation. The bed was saturated with bloodwhich had come from the drainage-tube, and the patientwas pulseless. Having fortunately been present at theoperation, I knew the probable seat of the haamorrhage. I

reopened the abdomen, brought up the stump on the rightside, and found its ligature sound, and then thoroughlysponged out the pelvis. Passing my fingers to the left sideI easily found the somewhat ragged depression from whichthe bleeding came. Having sponged the parts around myfinger as dry as possible, I took a small piece of solid per-chloride of iron, about the size of a " Wyeth tablet," and,guiding it with a pair of forceps to the tip of my finger,pressed it well into the cleft. I replaced the drainage-tubein the pelvis and closed the abdomen. The case gave butlittle further trouble. The hsemorrhage did not stop atonce, but was of course altered in character and rapidlydiminished in amount. No further fainting occurred, andthe patient made a good recovery.Birming’ham.

IMPACTED FRACTURE OF ZYGOMA.

BY ORMOND H. GARLAND, M.B., M.R.C.P.ED.,VISITING MEDICAL OFFICER TO LEITH HOSPITAL, SURGEON TO POLICE, ETC.

THE following case is, I venture to think, of suffi-cient medico-legal interest to warrant its insertion in thecolumns of THE LANCET.

R. B-, aged twenty-one, a wire-drawer, while wit-nessing a public game of football, on the afternoon ofAug. 22nd last, was asked by a fellow-spectator to moveback, which request he declined to comply with. Shortlythereafter, when leaving the field, the man with whom hehad had the slight altercation came quietly up behind, anddelivered one blow with his clenched hand over B sshoulder, forcibly striking his right cheek. °

- BY.ory.—Immediate severe pain felt chiefly in the rightnasal region; bleeding from the right nostril; " felt stunnedand sick, being compelled to lie down for a quarter of anhour before removal home." A short time thereafterswelling occurred over and around the site of injury. Thenose continued to bleed all Saturday, and on Sunday a quan-tity of dark-coloured clotted blood escaped. The lower jaw

could not be approximated to the upper nearer than withinhalf an inch, the attempt giving rise to pain. On the 25thAugust (the fourth day after receipt of injury) I examinedthe patient on behalf of the authorities. One could not butbe struck -with the remarkably flattened appearance theright side of the face presented, due to the absence of theprominence of the malar bone, this appearance being madethe more striking by the unusually high left cheek-bone. Inaturally inquired if both sides of the face had, previous tothe accident, been uniform, which I was assured by thepatient had been the case. There was no external wound.The upper and lower lids and outer aspect of the eyeballwere ecchymosed. Pain on pressure was felt. The bitingpower was feeble, and the jaws could not by exercising forcebe brought quite close together. Ilappily no ill effects fol-lowed the hurt, the power of mastication was graduallyregained, and the man has continued at his work unin-terruptedly till the present time.

I may add the assailant was sentenced to ten days’ im-prisonment, with the option of a moderate fine.

Leith. _________________

A MirrorOF

HOSPITAL PRACTICE,BRITISH AND FOREIGN.

ST. BARTHOLOMEW’S HOSPITAL.ALVEOLAR SARCOMA OF THE BLADDER REMOVED BY

PERINEAL SECTION ; REMARKS.

(Under the care of Mr. LANGTON).

Nulla autem est alia pro certo noscendi via, nisi quamplnrimas et n-iot -borum et dissectionum historias, turn aliorum tum proprias collectashabere, et inter se comparare.—MORGAGNI De Sed. et Caus. Morb.,lib. iv. Procemiun.

IN all cases of hæmaturia the question as to whether it isdue to the presence of a new growth in the bladder or nothas to be taken into consideration. The history of attacksof hæmorrhage spread over a long time and somewhat

profuse in character, the presence of blood being chieflymarked towards the end of micturition-in fact, the earlierflow being quite normal,-would point strongly to the

presence of a tumour; complaint of pain and increasedfrequency of micturition, the negative result obtained bysounding and examination under ether, would induce thesurgeon to examine the interior of the bladder with his

finger, making, as in the case reported below, a perinealincision large enough to permit the passage of the finger.and in the majority of cases the removal of any new

growth found. We would refer our readers to the remarks

appended to the case. For the notes of this case we areindebted to Mr. George Lee Wells, house-surgeon.Samuel M, aged twenty-five, was admitted into St.

Bartholomew’s Hospital on August 29th, 1885, under thecare of Dr. Duckworth, with the following history. A yearago, when in apparently good health, he suddenly began topass blood in his urine, and has continued to do so eversince. His urine has never been free from blood for morethan a day at a time. Of late he has had an aching pain inhis bladder after micturition, and has been compelled topass his urine every two hours. Clots of blood have beenvoided during micturition, and occasionally afterwards. Hehad always enjoyed good health, and had up to the presentcontinued his work, which is that of a French polisher.On admission he was anaemic, but otherwise well. Ten-

derness was felt on pressure in the hypogastrium and alsoin the loins, but no tumour was detected. His urine wasacid, of deep red colour, sp. gr. 1035, with an abundance ofblood- and epithelial-cells, and some oxalates. Three daysafter admission he was sounded for stone, but none wasdetected.On Sept. 17th he was sounded by Mr. Langton, and it was

found that the sound moved much less freely on the leftthan on the right side of the bladder, and here the surfaceappeared to be convex. A rectal examination, with thesound in the bladder, gave the impression of increasedthickness on the same side. The sounding was followed by

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a!l increased amount of hæmorrhage, but with this ex-ception nothing worthy of note occurred. The patient wastransferred then to Mr. Langton’s ward, and ten daysafterwards he was seen in consultation with his colleagues.Although the consensus of opinion was not general as to theexistence of a tumour in the bladder, yet all agreed that thehsemorrhage was probably vesical in its origin, and that anexploratory examination ought to be made. Mr. Langtondetermined to explore the bladder by a central perineal in-cision, as being less serious than a supra-pubic section, orby one as for lateral lithotomy. If a tumour were present hewas prepared to more fully explore the bladder by a supra-pubic incision, could the growth not be got away by thefirst incision. The examination with the sound at the con-sultation was succeeded by a more profuse hæmaturia, thanhe had ever had, three parts of that which was passed con-sisting of blood. This fact pointed to the existence of alocal cause for the hæmaturia.On Oct. 19th, whilst under an anaesthetic, the hypogas-

trium was more fully examined, and Mr. Langton was con-firmed in his original diagnosis by feeling a fulness in theleft side of the bladder. The urethra was then opened by amedian perineal incision, and a growth about the size of awalnut was felt after the introduction of the finger into thebladder, resistant to the touch, partly sessile and partlypedunculated, growing from the left side of the base of thebladder about an inch and a half behind the prostate. The

upper border of the growth could not at first be satisfactorilymade out, but by pressure above the pubes it was possibleto define the growth. The tumour was so soft and friablethat it was easily separated from the vesical wall with thefinger-nail, and subsequently it was completely removedwith a steel scoop. Some of the larger pieces were removedby this means, but a large quantity of broken-down separateddebris was subsequently evacuated by a Bigelow’s syringe.A tube was then passed into the bladder through the wound.The tumour consisted of a stroma arranged so as to form anoval alveoli,in which cells of round and oval shape were foundclosely packed. From the fourth day after the operationthe urine became quite free of blood, and has remained soever since.Nov. 18th.—The patient passed nearly all his urine per viam

naturalem, only a few drops coming through the perinealincision. He has suffered no pain since the operation, andhe is, practically speaking, well.

Remarks.—This case affords an example of the difficultyso often experienced in determining whether the hæmaturiais due to the presence of a vesical tumour or to some othercause. The local indications of its presence are frequentlyso indefinite, that even the introduction of a sound into thebladder does not clear up the uncertainty, It is well inthese cases to put the patient under an anæsthetic, so thata fuller examination can be made by a bimanual explorationof the rectum and the hypogastrium. In this instance adecided fulness was made out on the left side as comparedwith the right, which was corroborated by introducing asound. The persistence and the largeness of the haemor-

shage, increased as it was by the passage of an instrument,pointed to the existence of a tumour, probably highlyvascular, as in fibrous polypi the haemorrhage is often unim-portant. The existence of a tumour can, however, only bedetermined by a digital exploration of the bladder, and inthis case, as in many others, the patient was daily losing somuch blood that there was every reason to determine, ifpossible, the exact cause of the bleeding. The perinealincision is one of little danger, but its distance from thebladder limits very much the full exploration of that viscus.Had the tumour occupied a position an inch further back,or on the fundus of the bladder, it could hardly have beenfelt, still less could it have been satisfactorily removed. Thefirmness and the narrow neck of some vesical tumours willallow of their being removed by a wire ecraseur, but if theyare soft and sessile they arenot so amenable to this treatment.The pedunculated tumours are often fibrous, and these aremost favourable for removal and for non-recurrence. Thepapillomatous tumours frequently involve a considerablearea, in which case their complete removal is oftenimpossible, although if single they may be pedunculated,and so be capable of removal. Myxomatous and canceroustumours are unfavourable for operation as a rule. A supra-pubic incision into the bladder, although more dangerous,enables the operator to have a good view of the interior ofthe bladder, and at the same time affords ample space forthe removal of any tumour. If it can be diagnosed that the

tumour occupies the apex of the bladder, it would be best toremove it ab initio by this incision. Although the opera-tion for the removal of growths from the bladder in maleshas been attended with a high rate of mortality, thereseems to be no reason to doubt that this may be muchlessened by earlier operative interference in cases of vesicalhæmaturia and by a more accurate knowledge of the natureof the growths with which the operator has to deal. Inthis case, as in many others, the examination of the urinedid not throw any light upon the existence or nature of thetumour. Further information seems to be wanted as to therecurrence of vesical tumours after their removal and therelation their recurrence bears to their histological characters.

EDINBURGH ROYAL INFIRMARY.CASE OF PARTIAL PARALYSIS OF THE LEG, WITH

NYSTAGMUS, LOSS OF MEMORY, ETC.

(Under the care of Dr. BYROM BRAMWELL.)A COAL-MINER aged fifty-two presented himself on

Dec. 5th, complaining of difficulty in walking, due, he said,to pain in the left knee and weakness of the left leg. The

patient stated that the symptoms had commenced gradually,and without any obvious cause, five weeks previously. Hishealth before the present illness commenced had alwaysbeen exceedingly good. It was, however, doubtful if thesestatements could be implicitly relied upon, for his memoryand mental faculties were obviously impaired. The difficultyof arriving at the true facts, and of making a full andcorrect diagnosis under such circumstances, more par-ticularly in out-patient practice, where the time allotted tothe examination of each case is necessarily brief, was pointedout to the students.On examination the left knee appeared to be quite

normal, and no obvious cause for the pain which the patientcomplained of could be discovered. When cross-questioned,the patient stated that he also felt pain in the arms,more especially in the right. The patient moved about withdifficulty, and as if he were dazed or stupid. His gaitwas feeble; he walked as a person walks who is recoveringfrom a severe illness, the legs, however, being kept a littlemore apart ; but in addition the left leg was slightly dragged,the balls of the toes at each step tending to catch the ground.The muscular development in both legs was spare, themuscles of the left leg being perhaps a little smaller andsofter than those of the right, and the muscular power inthe left leg somewhat impaired. There seemed to be noparalysis either in the arm or face; the tongue was protrudedstraight. The plantar reflex on the left side was almost absent,that on the right remarkably lively. The knee-jerk on bothsides was much exaggerated, but not more so on the left thanon the right. On both sides there was a tendency to ankle-clonus. The rectal and vesical reflexes were said to benormal; well-marked rotatory nystagmus was present inboth eyes when the patient " fixed " an object. Vision wasvery much impaired, more especially in the left eye, withwhich the patient could not read ordinary pica print. Thepupils were equal and moderately dilated ; they contractedfairly well to light, but hardly at all on efforts of accommo-dation for near objects. This, it was pointed out, was thevery reverse of the Argyll-Robertson condition, in whichthe reflex contraction to light is lost, while contraction onefforts of accommodation remains. On ophthalmoscopicexamination, the whole fundus in both eyes, but moreespecially in the left, was obscured and hazy, the disc andvessels being ill-defined and blurred; the exact cause ofthis obscurity (whether due to an alteration of refraction orto changes in the media or fundus) was not ascertainedduring the brief time that could be allotted to the examina-tion ; the nystagmus and the impaired mental powers of thepatient necessarily rendered the investigation difficult. Thepatient stated that the nystagmus and loss of vision appearedat the same time as the other symptoms. Hearing was saidto be impaired, but when tested with the tuning-fork boththe aerial and skull sounds seemed equally and fairly wellheard on the two sides. The patient stated that he had notsuffered either from headache or vomiting. He had occa-sionally felt giddy. There had been no twitchings, spasms,or fits. On a rough examination through the shirt the heartappeared to be normal. An opportunity of examining theurine was not afforded, but the general appearance of thepatient did not suggest kidney disease.