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this of the pelvic viscera. Kussmaul' made an autopsy upon a man who had died after becoming paraplegic during chronic cystitis, and found atheromatous degeneration of the hypogastric arteries and fatty transformation of most of the nerve tubules of both sciatics. Leyden' has reported two cases of paralysis consecutive to vesical disease, in one also accompanied by urethral strictures of long standing, in which the cord was extensively softened, there being also cerebral foci of disease, the myelitis having begun at the points of exit and entrance of the vesical nerves. Two of Stanley's cases, and five out of forty-one cases collected by Leroy d'Etiolles, apparently came from gonorrheal implication of the urethra. G. Hirsch relates another such case. Leroy d'Etiolles has several cases of paralysis following urethral stricture. Leyden gives the following interesting history:

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Patient, 30 years old. Suffered from strictures, following which he had a vesical fistula, which was operated upon, but primary union was not obtained. Shortly afterward lancinating pains began in the lower limbs, and sensation became impaired. These symptoms grew worse, so that the patient was finally paralyzed completely in motion and sensation. In five days more, the arms could scarcely be moved, respiration became difficult. In two days, the dyspnea was increased, and there was dysphagia and difficulty of speech, and complete paralysis of the arms. Death followed. The dura and pia were adherent, spinal fluid cloudy. The pia posteriorly up to the middle of the dorsal cord was infiltrated with pus. The cord itself was greatly softened in the cervical and lumbar enlargements. Small hemorrhages were found. There was a filbert-sized focus of softening in the brain.

Leyden gives the history of three similar cases, one seen by him in conjunction with Dr. Basler, of Offenburg, the others narrated to him by Professor Lücke, in all of which the cause. was a hydrocele. One of these died, another passed from observation, and another made an excellent recovery. In the fatal case, the hydrocele was operated upon by electro-puncture; in the case of recovery the hydrocele was also operated upon by incision; in the other no operation whatever was performed. Experimentally, it has been demonstrated that a myelitis or pachymeningitis can be set up by a peripheral neuritis. Tiesler* 1 Würz. Med. Zeitschr., iv., 56, 63. I know this only by the quotation in Leyden and Jaccoud.

2 Op. cit., Bd. ii., 1 Abth.

3 Quoted by Leyden.

"Ueber Neuritis," Königsberg, 1869.

induced a sciatic neuritis in a dog, which was followed by paraplegia and speedy death. A collection of pus was found in the spinal cord, at the point of exit of the sciatic nerve. This purulent collection was three-quarters of a centimetre in length, and extended throughout the entire thickness of the cord. Feinberg,' of Kowno, has performed corroborative experiments. Setting up sciatic neuritis in rabbits by irritation with caustic soda, he found that this neuritis generally extended into the cord, and in a number of cases he observed a consecutive myelitis, sometimes of enormous extent, mainly in the gray substance, once extending to the medulla oblongata. Klemm,' of Strasburg, producing sciatic neuritis in rabbits by injection of arsenical solution beneath the neurilemma, regularly obtained ascending and descending neuritis, generally disseminated, which dissemination was characterized by intense injection and swelling of the neurilemma. The neuritis usually extended to the cellular tissue surrounding the dura (peripachymeningitis). This neuritis was of varying intensity and extent, sometimes involving the whole cord and even the brain. It would occasionally involve an opposite or other limb. Klemm, although not denying the supervention of myelitis in these experiments, claims that it is infrequent.

The two following cases, therefore, being the only ones which I have ever seen or heard of, are of interest.

CASE I. I saw this patient in consultation with Dr. Samuel Santoire, who has kindly given me the following history: "I first saw the patient on October 16th, 1882. She had menstruated at fourteen, but was extremely chlorotic. Menstruation was always irregular and painful. Married at eighteen. For two years her condition was the same. I was informed that a sound had been introduced some six or seven times by her medical attendant, to dilate the internal os, and soon afterward inflammatory symptoms developed. When I first saw her, she had been ill six weeks. I made a digital and specular examination. The whole pelvic cavity was found to be completely filled with inflammatory products, the abdomen considerably swollen and very painful to pressure. The pain was along the round ligaments, the whole pelvic circumference, and down the sciatic nerves to the kneejoint, so that the patient could not turn on either side, and could only be partially raised in bed. The gastric disturbance, which had been alarming in the first stage, had somewhat subsided. The patient was well nourished, but was in constant pain. The cervix could be seen with difficulty and much pain with the

1 Berlin. Klin. Wochenschr., 1871, No. 41 and 1874, Nos. 44, 46.
Ueber Neuritis Migrans," Strasburg, 1874.

211

speculum. The os could not be entered with ease, although drawn above the cul-de-sac. The cavity of the uterus was somewhat shortened by long pressure, but was otherwise normal. I diagnosed the disease as peri-uterine cellulitis, well advanced in the second stage.

"On Nov. 1st, fluctuation could be felt in the left side of the vagina. I introduced a large hypodermic needle and filled it with thin pus. The symptoms had become aggravated, the stomachic disturbance had increased, the pains had extended below the knee, especially on the left side, and bed-sores were beginning to develop. During all this time the bowels could be moved only by enemata, each movement containing pus and blood and being preceded by a chill. On Nov. 7th, Dr. T. G. Thomas was called in consultation, and decided that the chronicity of the disease and gravity of the symptoms would render an operation useless. The neuralgic pains had then reached the sole of the left foot, there was complete paralysis of the left lower limb, and incomplete paralysis of the right one." On Nov. 13th I saw the case. She was completely paralyzed in motion in both lower extremities, and the left upper extremity, whilst the right upper extremity was paretic. There was entire loss in the lower extremities of the tactile and muscular senses, marked impairment in appreciation of heat and cold, and there was decided retardation in the conduction of painful sensations. In the upper extremities there was moderate impairment of the tactile sensations only. Tendon-reflex of the quadriceps nil. There were troublesome bed-sores, a well-marked cincture feeling around the abdomen and thorax, and great pains in the lower extremities, this pain being no longer confined to the sciatics, but radiating throughout the limb. There was urinary retention and obstinate constipation. The optic discs were unaffected. The patient was generally emaciated, took scarcely any food, and was in constant pain. She died on Nov. 21st, in a comatose condition, death being preceded by two convulsions. Up to the time of the final coma, the sensorium remained entirely clear. Permission for an autopsy could not be obtained.

CASE II.-K. D., married, aged 30. Admitted to St. Mary's Hospital, Sept. 9th, 1884. Had a miscarriage six weeks before, up to which time she had been in good health. Began to suffer greatly from pain, sense of weight, etc., about the womb. About three weeks before admission, became aware that she was gradually losing power in her lower extremities-could get along fairly well on level ground, but had to be assisted over uneven places, up and down stairs, etc. These symptoms increased until about ten days before admission. She was unable to walk. On admission there was found to be absolute motor paralysis of both lower extremities, such motor paralysis of the upper extremities that she could only flex the fingers slightly, paralysis of the trunk muscles. The tactile, temperature, and muscular senses were almost totally gone in the lower extremities, and greatly impaired

in the upper. The sense of pain in both upper and lower extremities was unimpaired. There was urinary incontinence, but no rectal paralysis. Great sense of constriction about the abdomen up to the height of the sternum. Dr. John Byrne kindly

made a vaginal examination and found evidences of pelvic cellulitis.

Dec. 10th-three months after admission-had regained control over the bladder.

Dec. 20th. Can move the right hand to some extent.

Jan. 5th, 1885. Can sit up in bed. But it was not until July, i. e., ten months after admission, that she could walk about. Soon after she left the hospital, long before she should have done so, for she returned to life in a hovel and abject poverty. Her present condition is as follows: She can walk a short distance. Her upper extremities have regained power, so that she can sew, do household work with them, etc., but the grasp of the hand is still weak. The tactile, temperature, and muscular senses are still greatly impaired. She has regained entire control over the bladder. Dr. A. H. Buckmaster made a vaginal examination for me and finds that there is still a peri-uterine inflammatory condition -indeed, from what the woman tells us, she has probably suffered greatly from this since she left the hospital.

Case I. was, I presume, primarily a case of pachymeningitis with myelitic extension, whilst case II. was a case of myelitis trans

versa.

REPORT ON THE PROGRESS OF OBSTETRICS AND GYNECOLOGY IN GERMANY.

BY

M. HOFMEIER, M.D.,

Assistant at the Gynecological Clinic of the Royal University, Berlin.

NOVEL and interesting contributions to the question of the Cesarean operation have been furnished by Kehrer (Heidelberg) and Obermann (Credé's clinic). Kehrer operated on two parturients according to the method devised by him some years ago (deep transverse incision with accurate peritoneal suture). In one case the pelvis was generally contracted, with a conjugate measuring seven centimetres; fever had set in, and the child was still living; in the other case the pelvis was much narrowed by osteomalacia. The former patient died of sepsis, the other recovered promptly. In Credé's clinic, three Cesarean operations were performed according to Saenger's method (two by Saenger,

one by Obermann). In these three cases, the indication was a relative one, that is to say, the pelves were such that delivery would have been easily possible by craniotomy. In one case with an obliquely contracted pelvis, the diagonal conjugate even measured eleven centimetres. In these three operations, attention was principally directed (aside from rigorous antisepsis) to an accurate uterine suture conjoined with a special suturing of the peritoneal covering. All the patients recovered with hardly any untoward accident. Although it appears somewhat risky, on the strength of the experience gathered from the results thus far reported, to extend the indications for the Cesarean section even now to such cases, it is certain that this will probably take place in future as the results will improve. At all events, it seems to be proved that even the old Cesarean section begins to give better results when the cases are properly selected and the operation is earlier resolved upon.

One of the factors which, aside from contracted pelvis, gives rise most frequently to the Cesarean operation, that is, tumors occluding the parturient canal, has been the subject of a very interesting paper read on January 22d, 1886, before the Berlin Obstetrical Society by Dr. Stratz, who had collated the necessary material from Schroeder's clinic during the time from April 1st, 1876, to January 1st, 1885. The paper comprised all complications of tumors (myoma, carcinoma, ovarian tumor) with pregnancy and labor. The prognosis proved exceedingly variable, depending on whether the patients came under treatment during pregnancy, or not until during labor. There were observed altogether 28 cases of such complications with pregnancy, in none of which the mother died, and in 15 of which the children were saved. On the other hand, among 17,832 labors, there were 25 cases complicated with tumors; of these, 15 mothers died, and 13 children remained alive. The details were as follows:

1. Complication with ovarian tumors.

Ovariotomy was performed 14 times during pregnancy; all the mothers recovered, and, with one exception, went through normal labor (one case of twins). Ovarian tumors were observed 5 times during labor; of these, 1 mother died of peritonitis after rupture of the tumors, 3 children were born living, 2 died during labor.

2. Complication with myomas.

There came under observation 10 pregnancies complicated with myomas; in 4 cases abortion set in spontaneously, in 3 it was induced artificially; in 2 the entire uterus with the myoma was re

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