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To Illustrate Dr. Doran's Report of "A Case of Mammary Cancer with Metastatic Involvement of Bones." Albany Medical Annals, March, 1900.

the axillary artery and external cord of the brachial plexus immediately underneath the clavicle. This origin was about one centimeter wide. The muscle then formed a ribbonshaped fasciculus eight centimeters long and five millimeters thick at its thickest part, which was directed outwards, forwards and downwards, passing in its course between the fibres of the outer cord of the brachial plexus, to the outer side of the artery and between the two pectoral muscles. As this muscle passed over the tendon of the subscapularis its fibres were in part attached to the walls of the bursa usually found between the tendon of that muscle and the coronoid process of the scapula. The muscle was finally inserted into the deep fascia and the shaft of the humerus immediately underneath the large of the tuberosities.

Second, Nerve.-The lateral cutaneous branch of the third intercostal nerve was very much enlarged. The costohumeral nerve was of the usual size while the lesser internal cutaneous (Wrisberg) was missing and the internal cutaneous small in size. The lateral cutaneous nerve of the third intercostal evidently took the place in part of the two cutaneous branches from the inner cord of the brachial plexus and assisted in an unusual degree in furnishing sensory filaments to the upper and inner humeral region.

JOSEPH D. CRAIG.

Nephritis of Pregnancy.-History of Two Neglected Cases.Case I. Mrs. F. R., age 24; married; housewife; mother of two children, both labors having been natural and uneventful; youngest child six years of age; patient grown very fleshy since birth of last child.

Present Pregnancy was uneventful until about the seventh month when the patient was taken with severe gastric disturbance, associated with almost constant nausea and vomiting, complete anorexia and some oedema of legs. She had noticed a peculiar waxy appearance of the skin. Her family physician gave hypodermics of morphine from time to time and after examination of the urine told her the "kidneys were in bad condition." The gastric symptoms continued, œdema

of legs increased, œdema of eyelids occurred in the morning and she had "spells of blindness." Pregnancy was allowed to go on uninterruptedly.

At about the thirty-fifth week she had some mild labor pains through the night followed by rupture of the membranes.

The physician who was called found the patient in a comatose condition with scarcely perceptible pulse, complete loss of vision and oedema. She had voided no urine for fortyeight hours, Stimulants were administered and I was called in consultation and found the patient as above described.. The pulse could not be counted at the wrist; over the heart it was about 190 as nearly as could be estimated.

Examination revealed no foetal heart sound, vertex presentation, R. O. A. The cervix admitted two fingers. There was slight oozing and the head was not firmly engaged. With catheter about four drachms of urine were obtained which coagulated on addition of heat and acid. (A small specimen obtained next morning contained small and large granular casts in abundance.) She improved during the night under hypodermatic stimulation until 7 A. M., when the pulse was 140 and much stronger, and vision had improved until she could see people in the room but could not recognize faces. Ether was administered and after careful preparation of the patient the cervix was dilated with steel dilators and hand until the forceps could be applied and delivery was effected. The patient soon recovered consciousness and three hours after operation the pulse was 140 and temperature 99.4°. The urine was loaded with albumen and abundant casts. Various diuretics were tried and given up as no medication would be retained. The catheter was used twice daily and Betz dry hot air bath was employed; the bowels were freely opened after the first day. Vision steadily improved, the pulse gradually grew weaker and more rapid, oedema in legs increased and oedema of back began until patient was practically "waterlogged." On the fifth day after the operation she died in condition of coma. Her apparent improvement after delivery with no increase of urine and constantly increasing appeared unusual.

dema

Case II. Mrs. W. C., aet. 28; housewife. History of three previous pregnancies with only one living child. Two instrumental deliveries in which children were "still born." In present pregnancy gave history of nausea and vomiting extending over a period of five or six weeks. She had grown very weak and anæmic from lack of nourishment. Labor pains began at about the thirty-fifth week. I was called after she had been in labor forty-eight hours. I found vertex presentation, L. O. A., foetal heart sounds indistinct and about 160; cervix almost completely dilated; head not engaged and bag of waters intact. The pulse was 120, weak and irregular. A murmur could be heard at the apex of heart corresponding in time with first sound which it replaced. The urine contained a large quantity of albumen and small granular casts. She had been unable to retain any nourishment for three days and was constantly growing weaker with almost constant vomiting. I prepared the parts at once by scrubbing and douche, enema and use of catheter; introduced my hand and did internal podalic version without anæsthetic or assistant. The child was delivered as rapidly as possible, that is in about fifteen minutes after getting the foot. The child died in about two hours in spite of insufflation and artificial respiration. The mother made a good recovery, without complications, and now at the end of three weeks is up and about. The urine still contains a trace of albumen, but for the last week I have been unable to find any casts.

In conclusion I will say that the test for albumen alone in these cases is of little value, as but few cases go to full term without at some time at least a trace of albumen. Hyaline casts may also be of no special significance, but with the presence of albumen in large quantities and small or large granular casts in any numbers, diminished amount of urine, gastric disturbances (nearly always an early if not the first symptom recognized) and oedema, with patient constantly growing weaker, operative influence is always indicated.

The above I think are fair examples of nephritis of pregnancy and good examples of the mortality in neglected cases. R. H. IRISH,

504 SECOND AVENUE, LANSINGBURGH, N. Y.

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