Let these great experimenters who have many cases at their disposal place a number of them, say a hundred, in finely ventilated apartments, giving them good diet, and see if they will not progress pretty much in the same way as a hundred others under the same conditions, having in addition any of the so-called cures suggested to date.

It is the opinion of the writer that a better knowledge of the natural history of the disease would not only give some new suggestions as to the means of prophylaxis and cure, but also would prevent these, to say the least, undignified announcements of untested cures.

LOUISVILLE.

In the pelvic cellular tissue, behind the rectum and between it and the sacrum, was an abscess containing about 100 c. c. of pus. There was purulent infiltration of the connective tissue surrounding the abscess. Projecting venous thrombi were found over the placental site.

As evidence of direct infection of tetanus, it seemed probable that the disease lad arisen from absorption of ptomainės developed in retained and decomposing portions. of the placenta. Somewhat in favor of this view appears the fact that there was temporary arrest of the disease after the uterus had been thoroughly washed out.

TWO CASES OF PUERPERAL TETANUS.*

BY JOHN A. OUCHTERLONY. A. M., M. D. Professor of the Principles and Practice of Medicine and Clinical Medicine, University of Louisville.

CASE 1. Patient twenty-three years of age. Three years before she had her first child; labor natural. One year ago she had a miscarriage. The last labor took place at full term, and was perfectly natural. Ten days later she got up, but did not feel well; she had rigors, and took to bed again. There was no pain or tenderness in the lower part of the abdomen; urine somewhat scanty; lochia abundant and offensive. The next day she complained of soreness in the muscles of mastication, and trismus and tetanus developed, which rapidly terminated in

death.

CASE 2. This patient was twenty-four years of age. Her first labor, which was normal, occurred three years before; one year before she was again delivered, but with forceps. In the last labor there was transverse presentation; delivery was accomplished by version, and completed by the use of forceps under chloroform. On the fifth day she had chilliness; lochia offensive; difficulty in micturition. Five days later there was suffness in the masseter muscles in both sides, with tenderness; trismus and tetanus ensued, terminating in death three days later.

* By Dr. Lasberg. Translated from Hosp. Yidence, Nord. Med. Arkiv., and red before the Louisville Clinical Society, December 3, 1889. See p. 35.

BOTHRIOCEPHALUS LATUS AND PERNICIOUS ANEMIA.*

BY JOHN A. OUCH ERLONY, A. M., M. D. Professor of the Principles and Practice of Medicine and Clinical Medicine, University of Louisville.

Dr. J. W. Runeberg has recorded nine cases of pernicious anemia at the Medical Clinic in Helsingfors. At the autopsy he found the bothriocephalus latus in the intestinal canal of most of these. He suggests that possibly this intestinal parasite is the cause of the anemia. Every case of this disease admitted to the Medical Clinic since 1883 has been investigated with the view of ascertaining the presence of bothriocephalus latus, and anthelmintics were pre-cribed wherever it had been found. The results of treatment of pernicious anemia have been much more favorable since this measure was adoptéd. Nineteen cases of pernicious anemia have been observed since 1883. Among these there was but one death, which oecurred the day after the patient's admission to the hospital. The bothriocephalus latus was found in twelve out of these nineteen cases; there was ascaris lumbricoides in one. Pernicious anemia had arisen in one case during pregnancy, and recovery took place after delivery. In four cases no causes of the disease could be traced. In one case it was not mentioned whether the bothriocephalus was present or not.

Trans. Med. Assoc. of Finland, and read before the Iouisville Clinical Society, December 3, 1888. See p. 38.

It is thus found that sixty to seventy per cent of the cases had helminthiasis. An investigation was also undertaken by Dr. Runeberg to determine the presence of bothriocephalus latus in persons who were not suf fering from pernicious anemia. It was found to occur in fourteen per cent of the cases. The author does not regard the bothriocephalus as having any specific effect, but rather that its pathogenic significance depends upon the disturbance of intestinal functions which it excites, and perhaps, principally, upon the irritation of the nervous system occasioned by the presence of this intestinal parasite.

PREGNANCY ASSOCIATED WITH GLYCOSURIA.*

BY J. G. BROOKS, M. D.

January last I was called to attend a lady who had for six months been under the treatment of a homeopath for suppression of menstruation.

I found the patient very much emaciated and extremely weak, a condition which she claimed was brought about by a constant nausea and vomiting, associated with an insatiable thirst. She had frequent urination, which varied much as to quantity as well as quality. Finding nothing at this visit particular upon which to base a diagnosis, I asked that a sample of her urine be sent to me for examination. I found it heavily laden with sugar, and concluded that I had a case of diabetes mellitus, and that it was upon this disease that all the above distressing symptoms depended.

I prescribed lithia. carb. gr. iij, soda, arseniate gr.. in aerated water thrice daily.

There being no improvement, after ten days another examination of the urine was male, revealing sugar in great quantities. I now recommended diet, gradually withdrawing saccharine and starchy substances; but this was contrary to my judgment, as I felt confident that all symptoms would be aggravated save probably a falling off in

1880

*Read before the Kentucky State Medical Society, May,

At this juncture I became very much concerned in the case, and made more frequent visits and closer inquiry, finding that all these symptoms came on simultaneously with a cessation of menstruation about seven months previously, and that all this time a tumor had been growing in her side.

On examination a tumor as large as six inches in diameter by ten inches in length occupied the right inguinal region, mounting up on a level with the umbilicus, and was freely movable in all directions save toward the left side. Digital examination per vaginam tound the tumor well down below the pelvic rim, the os uteri being displaced to the extreme left side and above the lower border of the tumor.

After prolonged and careful examination I concluded that I had unquestionably a case of ectopic gestation, and that the diabetes was only a concomitant trouble. The next day, after a careful examination, in which the fetal heart-beat was clearly made out, I informed the lady that her tumor was a pregnancy, but not a normal one. This she positively denied, and asked me to bring counsel the next day, which I did.

I invited Drs. Elliott and Murrell, two of my colleagues, who, after they had examined the patient, agreed with me that it was a pregnancy and certainly extra-uterine.

By this time the condition of my patient was truly alarming, rendered so by loss of sleep and inanition. Prompt and decisive measures were now demanded, and the question was, what should they be?

Unquestionably the diabetes was rapidly sapping the life of our patient, and was only the proximate cause, the pre naney being the remote cause, for prior to conception she had no diabetic symptoms.

We decided that the only means of relief

was to remove the child, and began making ready for a laparotomy. Pending this preparation, however, we explored the uterine cavity in order to settle beyond question as to whether this organ contained the child, and that, in the event it did, to rupture the membranes and bring on premature labor, notwithstanding the lack of authoritative clinical experience to back our judgment.

I failed to pass the sound over three inches, although I used considerable force. I was now more than ever convinced that we had an ectopic gestation, probably tuboabdominal. A few hours after using the sound I was hurriedly summoned to her bedside. The sac had ruptured and labor was in progress. By this time the woman was eight months pregnant. The pains came on regularly, but there was no progress until after about six hours, when I could get my finger in the mouth of the womb, and when, as pains came on, I would pull the neck toward the median line.

Finally, finding my patient rapidly becoming exhausted, I gave chloroform and delivered with forceps, while my assistant, with one hand on the abdomen, literally forced the child from its lodgment in the right side. The placenta was removed by passing the hand into the womb and well over to the right inguinal region, withdrawing it in a line of the segment of a circle.

My patient rallied promptly from the operation and the anesthetic, and had no more vomiting or thirst.

The glycosuria rapidly disappeared, and, considering the extreme debility, she had a good getting up. The baby was very thin, weighed only two and one half pounds and was diabetic, but has since thrived and is now well.

The mother was put on a generous diet, especially fruits, wine, pastry, and sweetmeats, for the simple reason that she craved such food. Notwithstanding this course, the urine showed a rapid diminution of sugar as the examinations from time to time were made.

Unquestionably our diagnosis as to the form of gestation was incorrect, and, had

labor not come on as it did, we would have made a terrible blunder in opening the abdomen, which would have been done the next day. To us now it was clearly a case of one of those rare forms of pregnancy known as lateral dilation of the womb, and a condition seemingly upon which little is either said or written.

The termination of the case was indeed good, and a deal better than could have been expected. I am not ashamed to acknowledge the mistaken diagnosis, inasmuch as two very important lessons were learned, facts developed, I will say, at least so far as this case is concerned, viz:

1. That in grave cases of glycosuria associated with pregnancy premature labor should be induced.

2. That the so-called diet-treatment in such cases is pernicious and worse than useless, inasmuch as the diabetes is due to some unknown cause or condition brought about during gestation, and which can not be benefited by the withdrawal of saccharine and starchy substances.

PADUCAH, KY.

TWO CASES OF FATAL INJURY OF
THE BRAIN.*

BY T. B. GREENLEY, M. D. CASE 1. Fitz John Fisher, aged seventysix, of active good health, was, on the night of September 4, 1889, accidentally kicked by a mule while in a stooping posture, the blow being received over the right eye, crushing in the superciliary arch of the frontal bone, and extending backward about two inches, near the coronal suture. The fractured and depressed portion of bone extended from near the median line about three inches to the right. This portion of bone was completely depressed into the brain substance, causing the escape of some brain material.

My friend, Dr. J. S. Lewis, of Tip Top, near whose residence the patient lived, was called immediately; but on account of not being able to get surgical assistance the paRead at the December meeting of the Hardin County Medical Society.

tient remained in the above described condition until the next night, over twenty-four hours.*

Dr. H. M. Pusey, of Louisville, and myself were called, and the depressed portion of bone was raised by the use of the trephine and elevator.

The patient had been unconscious from the time the accident occurred, and complete hemiplegia existed on the left side.

The operation had no favorable effect either in restoring consciousness or relieving the paralysis.

Taking into consideration the age of the patient, the character of the injury, and the time that elapsed before the operation, there was but little hope of his recovery. There was evidently great concussion as well as contusion of the brain, and I am well satisfied that if an operation had been performed immediately no good results would have. followed. The patient died next day after the operation. No autopsy.

CASE 2. Marshall Lester, aged thirty, bridge-carpenter, on November 11, 1889, was thrown from a trestle thirty feet high. It seems, from the history of the accident, that he, with other hands, was on the trestle engaged in moving heavy timbers when some of the machinery gave way, which threw Lester to the ground. He was entangled in a rope and fell about thirty feet from the base of the trestle, which made the distance thrown about forty-five feet. The boss of the work witnessed the accident, and says he fell in a small sink hole where the ground was soft, and immediately after striking raised his head, or rather endeavored to assume the sitting posture. He also says that a large sill of timber twelve inches square slid off the trestle, following Lester, and struck him on the head just as he raised up., He is of the opinion that Lester was not badly hurt by the fall, but the blow from the timber rendered him unconscious and caused his death. By the assistance of a man on each side he walked

* Dr. L. explained to me that one reason why assistance was not sooner obtained was the impression the patient would succumb before help could arrive, but as he lived through the night it was deemed best to give him the chance of an operation.

to his room, a distance of a quarter of a mile. On examination of the patient I found contusion and laceration of the scalp over the vertex, but by manipulation both with the finger and probe I could not detect any fracture or depression of bone. In fact there was not the slightest evidence of either depression of bone or compression of the brain. He was entirely unconscious, but had the active use of all the voluntary muscles. At times he was very restless, requiring several men to keep him in bed. On this account it was necessary to give him hypodermic injections of morphia occasionally in order to keep him quiet. He swallowed nothing, either fluid or solid, from the time he was hurt, although we occasionally applied water to his lips, hoping he might do so by instinct. We administered an enema in order to empty his bowels, which had the desired effect. On account of retention of urine the catheter was twice used, drawing off each time about twenty ounces, and illustrating the fact that functional activity of organs may exist independent of brain power.

In the management of the case I had the assistance of my young friend, Dr. Prewitt, of West Point, and also of Dr. Edward Pearce, of Louisville, the assistant of the railroad surgeon, Dr W. O. Roberts of that city. Dr. P., on examination, agreed with us that there existed no depression of bone or compression of the brain, and consequently no indication for an operation. The patient lived about forty-four hours after the occurrence of the accident. Dr. Prewitt thought there was slight paralysis in some of the muscles of the right arm a few hours before death.

When first seen by the writer, shortly after he got to his rooms, reaction had not entirely taken place, but in a few hours his temperature rose to 2° abnormal heat. He had fever from this time on, amounting toward the last to 103°. On account of the great injury the brain had sustained, the pupils responded but little to the effects of light, varying only slightly from normal.

Autopsy eight hours after death. On removing the calvaria we found some effusion

of blood between the dura mater and the cranium at the site of the scalp injury, which we thought escaped from the longitudinal sinus. Also found fracture running through the right parietal temporal and sphenoid bones. This fracture separated more widely as it descended toward the base, being perfectly closed at the top and the margins in apposition; through the parietal we could. not insinuate the thickness of a pen-knife blade between the margins, but in the sphenoid it was not so completely closed, although at no point was there any displacement.

On looking at the surface of the cerebrum we found sulei of the convolutions pretty well filled with coagulated blood, which no doubt escaped from the pia mater. This membrane was greatly congested. There was some effusion of blood at the base of the brain.

On cuting through the brain substance. we found but little evidence of inflammation, probably on account of the short time the patient lived after the accident. There was no effusion into the ventricles. Dr. Prewitt assisted in the autopsy.

In studying the history of a case of brain injury the question naturally arises: Can any thing beneficial to the patient be done in the way of a surgical operation?

In this case there were no symptoms presenting which tended in the least to indicate a lesion which could be benefited by an operation. Neither were there any conditions found on post-mortem examination which would have justified an operation.

Dr. F. C. Leber said that the observations of the author have not been confirmed by European observers. If the worm is the, cause of pernicions anemia it accounts for the good effects of turpentine in this disease.

Dr. T. P. Satterwhite said that he had never seen tape-worm of any kind associated with pernicious anemia. If the association. of the two conditions can be proved it is a great indication for treatment.

Dr Ouchterlony: The author does not say that all cases of pernicious anæmia are due to the worm, but that in nine out of ten of the cases observed the worm was found. Patients who received the anthelmintic treatment got well.

The second translation was entitled Two Cases of Puerperal Tetanus. (See page 34.)

DISCUSSION.

Dr. Douglas Morton said that the cases reported accentuated the value of antiseptics in labor cases. This measure is too much neglected here. If the vagina be dis infe ted no danger need be feared of puerperal fever. The speaker uses a solution of bichloride of mercury with tartaric acid. Vaginal irrigation is particularly agreeable to the woman. No odor follows when the above combination is used. He applies antiseptics to the womb only after turning or other exigency requiring the introduction of the hand into the organ. Sometimes when he is about to apply the forceps he precedes the measure with an injection. He believes every case of puerperal fever to be preventable. Since he has used antiseptics he has had no milk fever or other puerperal trouble. In one case, however, a month after delivery, the woman developed cellulitis.

Dr. P. Guntermann said he had delivered