I have ventured to record this case somewhat at length, because instances of sudden death in the puerperium, or immediately after labour, are fortunately not every-day occurrences, and the precise cause in many cases is not selfevident. Thrombosis of the pulmonary artery, air embolism, internal (or other) hæmorrhage, heart failure (syncope), cerebral hemorrhage, and shock after difficult labour, are the chief

causes.

In the case I have related I consider I had to deal with gradual (one might call it progressive) failure of the heart There was no evidence of serious hæmorrhage either before or after my arrival. The blood that escaped while I was there was of a venous character. There was no unconsciousness till the last few minutes. There was no rupture of the uterus. The finger-nails and lips were not blanched, but bluish in colour from an early period, for the attendants said they had noticed this ever since the child was born. No "inward examination" by the nurse was confessed to; I asked the patient, and she said none was made. the symptoms were marked before I made a vaginal examination or gave a douche, hence air embolism may be excluded. Nothing suggested cerebral apoplexy. The difficulties of the labour were not apparently of a kind to cause shock. The child was alive and well.

All

The literature to which I have access says comparatively little about sudden death after labour. Herman, in "Difficult Labour," p.

308, says: "When a patient is very prostrate the effect of suddenly emptying the uterus may cause fatal syncope. But here he is referring to "placenta prævia" with loss of much blood. He adds that a patient in whom loss of blood has been stopped may "pass gradually into collapse and die." Leishman (in the 1888 edition, p. 334) says thrombosis and embolism are predisposed to by exhausting hæmorrhage, but he mentions no cases of sudden death within a few hours of delivery from these causes. Goltman (Medical Record, May 8, 1897) remarks on a case of thrombosis secondary to varix which caused sudden death during the puerperium, and says that pulmonary embolism is the cause of most such cases, but adds that prolonged labour or shock may directly cause sudden death (Braithwaite's Retrospect, Vol. CXV.). The most full and interesting account of the subject within my reach I found in "Churchhill's Theory and Practice of Midwifery," though the edition is very old (1872), and, significantly enough, the pages in that portion of the book were uncut. In chapter 22 he deals with sudden death, and details a number of cases. Amongst them is (p. 630) one described by

M. Chevallier thus :-" After the birth of the second child (twins) she appeared a good deal exhausted, and as the discharge of blood was very moderate the accoucheur thought it best to defer the extraction of the placenta. She recovered a little, but about two hours afterwards grew suddenly faint, breathed short, and died in about half an hour." On page 631 is also a quotation from Ramsbotham's "Practical Observations," which describes such cases under the heading of "Idiopathic Syncope," and a similar quotation from Christison page 630. Either of these would serve to describe the case of A.M. almost precisely, and they appear to refer to a class of cases in which death is due to heart failure of more or less sudden occurrence, unassociated with thrombosis, embolism, hæmorrhage, or entrance of air into a vein, and in the absence of organic heart disease.

on

UNUSUAL TYPE AND LOCATION of LupuS ERYTHEMATOSIS.

By W. McMurray, M.D., Physician to the Department for Diseases of the Skin, Sydney Hospital.

IN New South Wales lupus erythematosis is much more common than lupus vulgaris. In 1,000 consequative cases in private practice the proportion was 13 to 4. It is rare to see it occur on mucous membranes. This is the reason of publishing the following case:

S.P., aged 21, farmer.

Family History.-Father, 62, suffers from rheumatism; mother, 63; five brothers, five sisters-all living, in good health. There is no history of phthisis.

Personal History.-At age of 10 suffered from sunstroke; was ill a fortnight. For some time afterwards was subject to headache and vomiting. In cold weather suffers from chilblains. With these exceptions he has always had good health.

History of Present Condition.-Six years ago the lower lip became swollen, painful, and cracked, "just like a cold." This seemed to get better for a time, and then relapsed. Three months afterwards the upper lip became similarly affected. A mucoid secretion forms during sleep, which causes glueing of both lips and great discomfort. When the lips become stretched, as in laughing, they crack, and blood crusts form over the fissures. They are constantly scaling. It is just as active in summer as during the cold season. The lesions on the left side of the nose and lobules of the ear appeared three years subsequently.

Present Condition. He is well built, of a clear complexion, lymphatic temperament, teeth normal, enjoys excellent health. During summer the hands and feet are habitually red, cold, and moist; in winter he has suffered from broken chilblains; there is seborrhoea of the scalp and face; both lips are of a violet red colour, swollen, and everted. The surface is not ulcerated, but exfoliates thin lamellar scales. Here and there it is fissured, covered with crusts; these when forcibly detached have small, bleeding points. At the junction of the skin and mucous membrane on the upper lip a fine line of scar tissue is seen. On everting both lips a highly vascular line marks the junction with normal mucous membrane. On the left side of the nose, near the inner canthus and lobules of the ears, are well marked examples of the sebaceous type of this disease.

The only literature at my disposal bearing on the case is mentioned by Stelwagon* in a paper on Persistent Exfoliation of the Lips," in which he reports Hassler's case of a middleaged adult, who, in addition to well-marked areas of Lupus Erythematosis on the face, presented the disease upon the lips, extending to the mucous membrane, the lips being violaceous-red in colour, with lamellar exfoliation.

*Read at the twenty-fourth annual meeting of the American Dermatological Association at Washington, May 3rd, 1900.— Journal of Cutan, and Gen. Urin. Dis., June, 1900.

CLINICAL AND PATHOLOGICAL NOTES.

METHYLENE BLUE IN SCIATICA.

IN the issue of the Australasian Medical Gazette for June last appeared an interesting note by Dr. Zwar, of Clermont, on the treatment of supraorbital neuralgia by injections of methylene blue. Just after this appeared, a tramp came under my care in the Berrima District Hospital suffering from sciatica. He had suffered from it for two years, but it had become much worse lately, and he said it gave him great pain to walk at all. Seeing that the thigh on the affected side had atrophied to the extent of an inch in circumference, I see no reason to doubt his statement; the nerve could be easily felt and was thickened and tender. A week's rest in bed with administration of iodides and alkalies produced some benefit, but not much, and the case seemed a good one for testing a remedy. I attempted to inject 15 drops of saturated alcoholic solution of methylene blue into the nerve at a point between the ischial tuberosity and the great trochanter, but

the attempt was a failure. Two days afterwards I made a second attempt below the border of the gluteus maximus-the nerve was felt, and steadied with the fingers of the left hand, and the needle could be felt to penetrate the tissue of the nerve. 15 minims of the solution were injected. From that moment the sciatica ceased absolutely, and a week afterwards the man walked out of the hospital declaring himself quite free from pain. Should I meet with another case I should like to try the effect of injecting alcohol alone into the nerve, as the somewhat remarkable result might possibly be due to the alcohol rather than the methylene blue. As far as I know this is the first time the above treatment has been tried in sciatica. ARTHUR S. VALLACK, M.B. et Ch. M. (Sydney), L.M. (Rotunda). Bowral.

GLIOMA OF THE RETINA.

HAVING read in the May number of the Gazette the interesting paper of Dr. Earle Newton on "Glioma of the Retina," it occurs to me to be opportune to place on record another "remarkable family history" to still further emphasise, if necessary, the hereditary character of glioma. Six years ago Mrs. H. consulted me at the Sydney Hospital about her second child James, who was then 18 months old. He had glioma in the right eye, which I enucleated. A few weeks later the left eye became affected in the same way, and I enucleated it also. From her next child, Marion, I removed both eyes for glioma when she was two years of age. She had been under observation for some months before the operation, the mother declining to have anything done, saying she would rather the child die than be like her blind boy with both eyes removed. However, when the gliomatous growths had increased, and the child began to suffer severe pain, she consented, and I enucleated both eyes the same afternoon. few months later glioma appeared in her fourth child's left eye, and I enucleated it. Thus out of a family of four children three suffered from glioma of the retina, and in two of them both eyes were affected. I have recently seen these children, and they are all in excellent health. The eyes were examined at the Pathological department of the Sydney Hospital, and pronounced to be true glioma. Brief summary :—

Α

3. Marion H., present age 5 years; both

eyes removed when 2 years of age. 4. Isabella H., present age 3 years; left eye removed when 1 year old.

W. ODILLO MAHER, M.D., Ophthalmic Surgeon to the Sydney and St. Vincent's Hospitals, Sydney.

PREGNANCY IN THE STUMP OF A
FALLOPIAN TUBE.

THE patient from whom this specimen was taken was twenty-eight years old. She has been married nine years. There were two

When her abdomen was opened, five hours after the onset of the illness, her pulse was barely perceptible. The abdominal cavity was full of blood clot, and blood was trickling from a rupture in a globular dark blue swelling projecting from the right cornu of the uterus.

The left tube and ovary were intact and normal. Whether it was a case of deciduoma malignum or a ruptured pregnancy which had taken place in the stump of the tube I could not say; at all events, there appeared to be nothing for it but to remove the whole uterus, which I did at once, securing the uterine artery on the bleeding side without delay.

children-one seven years of age and the other, who died four months ago, would have been nineteen months old if it had lived. Three years ago the patient underwent operation for a ruptured right tubal pregnancy. At that time, her medical attendant, Dr. Wood, tells me, she was not desperately ill, and she made a good recovery after the removal of the tube. She menstruated last on the 22nd of January. On the 3rd of May she threw some food to the fowls and was immediately seized with severe abdominal pain. Dr. Wood saw her about three hours afterwards, and he was then of opinion that she would not survive the removal to hospital, about a mile distant.

D-Left Ovary.

The patient did not lose more than three drams of blood during the operation, and saline solution to the extent of three pints, distributed over the next three hours, together with hypodermics of strychnine, soon placed her out of danger from hæmorrhage and shock.

I feel bound to add that her recovery was largely due to the care she received from Dr. Wood, who was responsible for her after treatment. I am indebted to Mr. Humphrey for the photograph of the specimen, which Professor Welsh has placed in the University Museum.

H. CRITCHLEY HINDER, M.B., Ch.M. (Syd.) Macquarie Street, Sydney.